Project Zero Pilot Program Update

First two Project Zero pilots a great success

Hamlin Fistula Ethiopia is determined to accelerate the rate of change for women in Ethiopia.

In late 2023, the groundbreaking program, Project Zero was launched to find every woman living with obstetric fistula, house by house, woreda (district) by woreda. The key objectives of Project Zero are to:

• increase awareness of maternal health and birth injuries
• mobilise the community to improve maternal health care
• support the woreda to improve and sustain improvements in maternal health care
• find and treat all obstetric fistulas (and where possible treat all advanced stage pelvic organ prolapse cases) in the woreda.

Each Project Zero pilot is designed to be carried out over 3-4 years, the first phase with a team working intensively in a woreda for around 6-8 months. For the pilot a team of 6 individuals including 4 Hamlin trained midwives (three as mentors, one as Team Leader), a Patient Identification Officer and a Monitoring and Evaluation Officer is needed.

Outcomes from Pilot 1 – Ale Woreda

The first pilot took place in late 2023 in Ale Woreda located around 540km from Addis Ababa and 18km from Hamlin’s Metu Fistula Hospital. There are 24 kebeles (neighbourhoods), most of which rural, with an officially estimated total population of 85,408 and 2,966 expected deliveries. The local economy is primarily based on agriculture with most of the population engaged in farming activities.

The surveys were effective both in finding women with obstetric fistula or pelvic organ prolapse (POP) and in raising the level of understanding both of birth injuries and maternal health care. It is reported that attendances in ante-natal clinics have increased substantially.

Teams of Hamlin-trained community volunteers known as Health Development Armies (HDAs) are vital to the ongoing success of Project Zero. Their commitment and enthusiasm is extraordinary. Together with some 343 health extension workers they carried out a total of 14,664 house-to-house surveys in 24 weeks.

As a result of the house-to-house survey, 64 women with long term childbirth injuries were found. All but one of these women were treated at Hamlin’s Metu Fistula Hospital.

The Project Zero intervention was run as a partnership with widespread and committed involvement from officials, local leaders/elders, health professionals and particularly the community.

Hamlin Midwife mentors played a crucial role in supporting and guiding healthcare staff working in the Maternal and Child Healthcare (MCH) Units of both health centres found in the woreda. Their activities were aimed at empowering healthcare providers, improving the quality of care, and ultimately reducing maternal and child morbidity and mortality. Their expertise and support were invaluable in ensuring that healthcare providers have the necessary skills and knowledge to provide optimal care to mothers and children in need.

Outcomes from Pilot 2 – Dedesa Woreda

The second pilot took place in Dedesa Woreda, commencing in February 2024. There are 33 kebeles, most of which are rural with an estimated total population of 130,079 with 4,513 expected deliveries. Like Ale Woreda, the local economy is primarily based on agriculture, with most of the population engaged in farming activities.

The challenge for Dedesa Woreda was to replicate the house-to-house surveys but for 40% more households across more kebeles in a more rural area in less time. Local leaders and literate women in the woreda were engaged as extra volunteers to supplement the health extension workers, which proved successful.

With these extra volunteers the house-to-house surveys proved to be very effective in finding women with obstetric fistula or pelvic organ prolapse and in raising the level of understanding both of birth injuries and maternal health care.

A total of 156 women with childbirth injuries were identified and most have been referred to a Hamlin fistula hospital for treatment. Some women have refused treatment for fear of being away from home for an extended period.

Raising community awareness of birth injuries and seeking treatment is a high priority. The Project Zero team attended 25 markets to hand out leaflets in local languages, engage in discussions with those in attendance and broadcast through loudspeakers across the kebeles.

Schools and other community gatherings were also targeted through speaking engagements and workshops explaining the causes and consequences of obstetric fistula and how it can be prevented. Harmful traditional practices as well as general reproductive health issues were also discussed. Local FM radio and social media were also extensively used to support these group events.

The embedding of quality maternal health care into the woredas through Project Zero is a key component of the work and, as in Ale Woreda, this has provided positive change to the delivery of maternal health care.

The numerous benefits of Project Zero

The benefits of these two Project Zero pilots are numerous:

• Raising awareness of maternal health care issues and obstetric fistula throughout communities
• Increased community engagement, with Health Development Armies being extremely active and engaged and offering to do more in the future
• Establishment of standards for the delivery of maternal health care and agreement of an action plan to meet those standards
• Improvements in quality midwifery practice and standards of care and enhanced processes to support the effective, client friendly delivery of care
• Mentoring of maternal health staff and future development of Personal Development Plans to sustain and continue improvements
• Improved physical facilities and equipment
• Provision of additional Hamlin Midwives and new partner health centres where needed.

Pilot 3 has commenced in Seharti Woreda

The third Project Zero pilot has begun in Seharti Woreda. A team leader, a Monitoring and Evaluation officer, two Hamlin Midwife mentors and a Prevention officer all received interactive training on every aspect of Project Zero including patient identification and screening.

The four health centres in the woreda have each undergone a thorough assessment, along with the woreda maternal healthcare system using the Hamlin standard checklist.

As part of the preparation, key individuals in the woreda were communicated with, office furniture and equipment was purchased and marketing materials were printed in the local language.

The first two Project Zero pilots have already made the future incidence of obstetric fistula far less likely and served to galvanise the efforts of the local community to make sustainable improvements in maternal health care.