Five Ways USAID is Transforming Safe Motherhood in Yemen through Social and Behavior Change
Yemen’s ongoing political conflict, food insecurity, and deterioration of essential public services present overwhelming challenges to the health and well-being of the population of Yemen. The maternal mortality ratio is one of the highest in the region at 183 maternal deaths per 100,000 live births. Some of the greatest barriers that women face in accessing reproductive, maternal, and child health services are a lack of health education, limited and costly transportation, distance, lack of support from their husbands, reluctance to see male service providers, and low quality public services that engender mistrust. Additionally, rumors and myths about vaccines persist, lowering public confidence in immunization for children.
Findings from a mixed methods study conducted by the USAID-funded Systems, Health and Resiliency Project in the districts of Aden, Lahj, and Ta’izz have deepened the understanding of beliefs, attitudes, and factors influencing the uptake of reproductive, maternal and child health services. The study also identified the key barriers affecting access to essential services and shed light on the preferred communication channels and trusted sources of health information. The study’s findings informed the development of an evidence-based strategy to improve health-seeking behaviors and service uptake in order to decrease morbidity and mortality rates in Yemen. Utilizing multiple, mutually reinforcing messaging approaches have contributed to the effectiveness of the project’s social and behavior change activities.
Interpersonal Communication
The study found that women prefer face-to-face, interpersonal communication, and that their trust in community midwives and community reproductive health volunteers is high. Volunteers meet women where they naturally gather and initiate small group discussions. Community midwives visit women in their homes one-on-one, and when possible, engage in family or couples’ discussions. Visual aids and other print materials enhance their communication with pregnant women and new mothers. Between November 2022 and April 2023, the project’s trained community midwives and volunteers provided health education to more than 190,000 women.
Radio Campaigns
Radio has high listenership in Yemen, particularly in rural areas where literacy rates are low, and internet access is limited. To reach rural audiences, the project produced and aired 22 radio spots promoting key health behaviors, such as the importance of early and exclusive breastfeeding, antenatal care, postnatal care, immunization, family planning, and other topics. These radio spots aired on four channels for six months, reaching an audience of approximately 5.7 million people, with crucial information to keep families safe and healthy.
Primary TextI got health information from the community health volunteer and she saved my life. Many other women lack awareness, so health awareness is important in the community.” –Mona, a mother from Aden Governorate.
Engaging Religious Leaders to Reach Men
In Yemeni communities, imams (religious leaders) are trusted and respected figures and key influencers. Religious leaders play an influential role in the construction of social and gender norms, and have the potential to foster positive norms that support healthy reproductive, maternal, newborn, and child health behaviors. According to the research, husbands are commonly the decision makers for family planning, antenatal care, and other health services. As such, reaching men with critical health information during Friday prayers acts is an important approach. Working with the project, the imams helped clarify misperceptions related to religion that led community members to carry out unhealthy behaviors, and highlighted healthy practices, like birth spacing and breastfeeding, that are affirmed by Quranic verses. USAID/SHARP conducted a three-day training for 42 imams from Aden, Ta’izz, and Lahj Governorates to increase their knowledge on the importance of family planning, vaccination, antenatal care, and foods that improve the health of mothers and children, as well as clarification of religious perceptions of reproductive and maternal health. After the training, the Imams dedicated time in two Friday speeches at their mosques to address issues like child spacing and contraceptive use and to advocate for change. These speeches were attended by hundreds of people. The imams also discussed these issues during small interactive gatherings where trust could be built more intimately. Between January and April 2023, the Imams reached over 56,000 people, equipping them to make better decisions about their families’ health. Based on this experience, the Imams expressed interest in expanding the program to other districts and to engage female religious leaders. They also requested training on additional health topics to add to their sermons and discussions.
School Health Clubs
To engage young people as advocates for healthy behaviors, the project prioritized reaching adolescent female students in secondary schools. The average age of marriage for a woman in Yemen is 18, so these students will be wives and mothers soon. They can also share information with their peers and families. In close coordination with the school health unit at the Ministry of Public Health and Population, USAID/SHARP established school health clubs in six secondary schools in Aden, Lahj, and Ta’izz. The clubs received equipment to help them to engage fellow students in health-related discussions by creating wall coverings, acting out puppet theater performances, and creating quiz games.
Immunization is health and life.” - A school student during roleplay.
Each club consists of ten members and a teacher, who supervise and help plan activities. The school health clubs not only raised awareness among female students, but provided essential first aid materials. The awareness activities reached almost 17,000 female students and will help prevent future maternal health problems in the community. Involving students in these awareness raising activities has helped to strengthen knowledge and healthy practices in schools and their surrounding communities. Female secondary school students also have the ability to influence their peers and families, leading to the transfer of knowledge from schools to households and communities.
Digital Communication and Mobile Vaccine Reminders
Almost a third of infants under the age of one in Yemen are missing at least one routine immunization for preventable diseases. To increase vaccination uptake, The USAID SHARP project pilot-tested an automated text message vaccination reminder system in Al Buraiqa District in Aden Governorate. The system sends reminders to parents and caregivers about vaccination appointment dates for their children under the age of 18 months. A message is sent two days before an appointment, encouraging timely vaccination. Studies have shown that a behavioral nudge delivered through text reminders can increase adherence to vaccination schedules. Additionally, trained community midwives follow up with caregivers who do not receive the reminders due to network connection issues.
Outcomes
The use of these varied and multi-level social and behavior change approaches has helped to change the health-seeking behaviors of individuals and communities in Yemen, and improved the norms that underpin those behaviors. By understanding family and gender dynamics, community norms, economic realities, and perceived risks, the project was able to employ interventions that were accepted by the community, increasing the uptake of health services and leading to better health outcomes for mothers and children.
To read another story about community midwives, click here. To read more about USAID's support to the health sector in Yemen, click here.
