By Nazrawit Ashenafi, Knowledge Management & Communication Specialist & Mary Phillips, Technical Advisor, PSI

In Ethiopia, PSI’s flagship adolescent sexual and reproductive health program, A360’s Smart Start, learned that across agrarian regions of Ethiopia, introducing contraceptive counseling through financial planning resonated with young, rural couples.

But in Afar, a pastoralist region with its own traditions, culture, and beliefs, the team’s human-centered design approach unveiled a different insight: financial planning missed the mark for a community that believes wealth derives from the blessing of children.

To support young couples in Afar to plan for the lives and families that they want, the A360 team would have to pivot its approach. With partners at the Afar Regional Health Bureau the A360 team set out to speak with married adolescent girls and those closest to them.

According to research from the Gender and Adolescence Global Evidence in 2019, (Adolescent health, nutrition, sexual and reproductive health in Ethiopia) young adolescents living in rural Afar had very little knowledge of contraception, with only 7 percent able to correctly identify a method (compared to 40 percent in Amhara and 14 percent in Oromia). Per the traditional absuma marriage custom, girls in Afar typically marry between ages 13–15 to a maternal cousin chosen by their parents. Girls do not have a say in whom, or when they marry. They must marry as their parents wish and immediately start a family.

Among married women and girls aged 15-49 in Afar, only 12 percent use contraception, compared to 47 and 28 percent in the agrarian region of Amhara and Oromia. (EDHS 2016). For married girls, whose social standing and personal goals often center on having many children, Smart Start’s financial planning framing for contraceptive counselling would not work.

Leading with the health benefits to mother and child, however, could.

When it comes to childbirth, we learned that girls and communities trust ullatinas (traditional birth attendants) in Afar. Could these birth attendants support girls to understand the health benefits of contraceptive use? We prototyped to find out.

First we tested the messaging, then we refined it before supporting ullatinas to test it with girls.

We gauged ullatinas’ willingness to speak to married girls about contraception. To our surprise, ullatinas expressed support for contraception. They knew, from witnessing births in the community, that married adolescent girls often experience health complications as a result of recurrent pregnancies. When girls experience excessive bleeding after birth, traditional birth attendants are the first responders. For this reason, ullatinas gravitated toward a visual aid – an illustrated, flip book called the “Motherhood Coaching Club” used by A360’s young designers to guide couples through the contraceptive conversation. For ullatinas, many of whom are illiterate, the aid provides a visual, low-literacy tool that combines information on the health and financial benefits of spacing children.

Based on the interest in this tool, we tested a “Motherhood Coaching Club” where ullatinas could discuss and learn about sexual and reproductive health (SRH). On the second round of prototype, the solution evolved to a concept where ullatinas talk to married adolescent girls to discuss health complications of rapid, repeat pregnancies using the visual tool. During this round of testing, ullatinas received training on how to work with young women and refer them to care.

We learned that the ullatinas who partook in the prototype process were:

• Willing to speak and give married adolescent girls referral cards for contraceptive counseling.
• Quick to understand the challenges facing young mothers in Afar and wanted to help break down around contraceptive use.
• Urged girls to speak with husbands and the health workers about spacing their next child

It is important to note that in Afar, ullatinas aren’t the only gatekeepers for contraceptive methods, and married girls often lack the autonomy to decide whether or not to use contraception on their own. Tribal leaders and religious leaders also play a pivotal role in the community’s opinion of modern contraception. Other prototypes being tested involve husbands and community leaders who can be activated for contraceptive support. Moving forward, we’re bringing together our prototypes in a holistic, community-level intervention called the “family circle.” The “family circle” creates spaces in which ullatinas and husbands, alongside community leaders, can support girls to plan the families they want.