Worldwide Wellness of Mothers and Babies (WWOMB): program overview and lessons learned from Ethiopia

Abstract

Background

Despite the progress made in improving maternal and child health in Ethiopia, it still has one of the highest maternal and neonatal mortality rates in the world. This is largely due to inadequate healthcare infrastructure and a lack of comprehensive evidence-based maternal and reproductive health services. To achieve the Sustainable Development Goal targets related to maternal and child health, it is essential to conduct culturally sensitive and policy-relevant research to identify areas for improvement.

Methods

To address these issues, through The University of Newcastle’s increased global focus and investment into funding international research higher degrees, we developed a program on the Worldwide Wellness of Mothers and Babies (WWOMB) and trained Doctor of Philosophy students who conducted cross-cutting research across the reproductive life course. Importantly, the program aimed to bridge the inequality gaps in maternal and child health whilst cultivating a new generation of research leaders in low- and middle-income countries such as Ethiopia.

Results

The WWOMB program has successfully generated a substantial body of epidemiological research in Ethiopia, covering five major themes: family planning and contraception, maternal and child health service utilisation, maternal and child health outcomes, maternal and child nutrition, and health economics. The key findings of the studies conducted in Ethiopia have demonstrated geographical disparities in the use of modern contraception and maternal health service utilisation, high incidence of severe maternal outcomes and neonatal near misses, high prevalence of intimate partner violence during pregnancy and its significant impact on adverse pregnancy outcomes, and the presence of economic disparities in maternal and child health, particularly around service delivery and availability.

Conclusions

Investment in healthcare infrastructure and services, coupled with efforts to reduce economic inequalities, can contribute to improved maternal and child health in Ethiopia. The WWOMB project has focused on delivering evidence-based recommendations for policy and practice that could accelerate the country’s progress towards achieving Sustainable Development Goal targets related to maternal and child health.

Texbox 1. Contributions to the literature
• The synthesis of literature from the WWOMB program revealed significant geographical and economic disparities in maternal health service utilisation, coupled with high incidence of adverse maternal outcomes, neonatal near misses, and the significant impact of intimate partner violence on adverse pregnancy outcomes.
• The literature synthesis demonstrated the effectiveness of the WWOMB program in generating culturally sensitive and policy-relevant epidemiological research, which can inform strategies to improve maternal and child health outcomes and achieve Sustainable Development Goals in low- and middle-income countries.

Background

The United Nations Millennium Development Goals (MDGs) were instigated by a landmark commitment in 2000 by world leaders to free “men, women and children from abject and dehumanizing conditions and extreme poverty” [1]. This commitment was translated into a framework to be used as a road map over the next 15 years to achieve widespread improvements in terms of poverty and hunger, education and gender equality, environmental sustainability, poor maternal and child outcomes as well as communicable diseases such as human immunodeficiency virus (HIV) [1]. Despite substantial progress recorded globally towards these goals, by the end of the MDG era, progress was uneven, and significant inequalities remained [1]. Major concerns were also raised regarding the sustainability of progress, particularly in low-income and developing countries such as Ethiopia [1, 2].

The MDGs gave rise to the Sustainable Development Goals (SDGs) to improve on these inequalities across 17 key areas [3, 4]. Improving maternal and child health outcomes as well as gender equality and empowerment remained important outcomes across the two frameworks given the variability in outcomes across the MDG period. Within the maternal and child health spheres, targets for the SDGs under Goal 3 “Good health and wellbeing” were set to: (a) reduce maternal mortality by two-thirds by 2030 (Target 3.1); (b) end preventable deaths of newborns and children under five years of age (Target 3.2) and (c) achieve universal access to sexual and reproductive healthcare services (Target 3.7). To achieve these targets, a global reduction in maternal deaths below 70 per 100,000 live births was required, with a stipulation that no country should have a maternal mortality ratio greater than twice the global average (i.e., 140 per 100,000 live births). To meet the SDG targets for child mortality, global reductions were required in neonatal and under-five mortalities to at least as low as 12 per 1,000 and 25 per 1,000 live births, respectively. In addition, given that access to, and use of, contraception is a key factor in reducing maternal and infant mortality (and is a marker of gender equality), it was acknowledged that there was a need to increase the proportion of modern contraceptive methods available to women of reproductive age as well as achieve substantial reductions in adolescent pregnancies (Target 3.7).

In Ethiopia, during the MDG era, concerted efforts were made to address disparities in maternal and child health, including the integration of the MDGs within the national development framework [5]. Ethiopia was added as a country to the global Demographic Health Survey (DHS) initiative which is mainly funded by the United States Agency for International Development. The initiative was designed to collect and monitor the progress of the MDGs through periodic assessment of large and complex cross-sectional surveys focused on demographic and various health parameters (which have been added over time, including those related to maternal and child health) [6]. In addition, the Ethiopian government also implemented various initiatives related to maternal and child health including the implementation of the Health Extension Program to increase access to primary healthcare services [7, 8]. The Health Extension Program delivers cost effective basic services to all Ethiopians, particularly women and children, and is implemented by Health Extension Workers who have been trained on 18 health extension packages. These packages are broadly grouped into five major components: maternal and child health, disease prevention and control, hygiene and environmental sanitation, curative services (specifically pneumonia and diarrhoeal disease management), and an expanded immunisation program [9, 10]. In addition, initiatives such as mobilising the Women’s Development Army (a structural arrangement that connects one-to-five household together and is led by a female resident who is informed of, and adheres to, the health extension package guidelines) to increase community awareness [11] and rapid expansion of health services through increasing health financing [12, 13] have also been used by the Ethiopian government to improve health outcomes of communities.

Despite this commitment by the Ethiopian government and significant gains being made in the area, challenges remained. Importantly, while a reduction in maternal mortality from 950 per 100,000 live births in 1990 [14] to 412 per 100,000 in 2016 was achieved by the beginning of the SDG era, the maternal mortality ratio was still exceptionally high and had stagnated [1]. Ethiopia’s report card relating to infant and neonatal mortality was similar. Although Ethiopia met MDG targets by reducing under five deaths by two-thirds between 1990 and 2015 [15], targets related to infant and neonatal mortality were not met [16]. As such, at the beginning of the SDG era Ethiopia still had the highest maternal and child mortality rates in sub-Saharan Africa [17]. In addition, access to sexual reproductive health services remained inadequate, with unmet needs for family planning reported at 22.0% in 2016 [18].

Due to the unacceptably high mortality rates, greater investment into research was required to create an evidence-base around the multidimensional factors that contribute to poor maternal and infant outcomes including access to family planning, antenatal, delivery and postnatal care to facilitate informed health care and policy decision-making. However, at the beginning of the SDG era, there was a significant lack of appropriately trained researchers in Ethiopia to undertake this important task. Importantly, there was a lack of highly skilled researchers to analyse the existing DHS data which had the potential to provide critical epidemiological groundwork for service and policy change in the country as well as sufficient expertise in methods that would allow researchers to understand specific conditions on the ground [19]. This is despite previous calls from the World Health Organization (WHO) for renewed efforts around strengthening health research capacity in Africa [20]. During 2016–2018, The University of Newcastle offered an unprecedented number of international Doctor of Philosophy (PhD) scholarships. Research higher degree training for those from low-and-middle-income countries (LMICs) has the ability to not only strengthen the research capacity of individuals and universities but has widespread implications for the candidate’s home country. However capacity within Ethiopia has been limited. At the beginning of the SDGs era, only 24.5% of PhD holders completed their studies in Ethiopian universities and only around 7% were trained in the field of medical and health sciences [21]. Given this human-resource crisis at the beginning of the SDG era, it provided a significant barrier to implementing within-country training in Ethiopia [22]. Through The University of Newcastle’s investment and strategic global focus, we developed a program on the Worldwide Wellness of Mothers and Babies (WWOMB). This program was guided by the principles that promote a holistic approach to research and health and had a vision of eliminating preventable maternal and infant mortality and morbidity at its core. Given cultural diversity is recognised as a potential asset for effective primary health service delivery and improving health outcomes, we aimed to create a critical mass of PhD students conducting policy-relevant and culturally sensitive research that would make substantial contributions to the inequality gaps in maternal and child health and produce a new wave of research leadership in LMICs such as Ethiopia. In this paper we describe the WWOMB program and its strengths and challenges, through the lens of a case study. To date, the majority of the WWOMB program alumni have come from Ethiopia and studied maternal and infant mortality in the Ethiopian context. To exemplify the WWOMB program approach, we will present a synthesis of findings for Ethiopia, and make a clear set of recommendations that could contribute to meeting SDG targets across this footprint.

Methods

The WWOMB program was established as part of The University of Newcastle’s investment and increasing global focus. In particular, it was designed to meet key strategic goals of the University at the time of its implementation around ‘engaging across the globe’, ‘driving global and regional impact’ and developing ‘graduates who make a difference’. The WWOMB program subscribed to the philosophy that women and girls should be able to determine their own future, no matter where in the world they were born and was guided by principles that promote a holistic approach to research and health as well as applying a gendered lens to all WWOMB research. Given the global focus and the interest in improving outcomes in LMICs such as Ethiopia, cultural diversity was viewed as a key asset. As such, a core focus was to partner with people in and of the culture in which the research was being conducted.

The overarching vision of the WWOMB program was to eliminate preventable maternal and infant mortality and morbidity. The program focused on addressing maternal and child health issues across the reproductive life course (preconception, pregnancy, intrapartum and postpartum period) under three major themes: family planning, maternal health, and infant health (Fig. 1). The WWOMB program also extended its focus to addressing related issues that influence maternal and infant outcomes including violence against women, chronic health conditions (including mental health) and access to, and use of health services.

Fig. 1

Worldwide Wellness of Mothers and Babies (WWOMB) major, and key cross-cutting themes

Given the intricate interplay of various factors influencing maternal and child health, the majority of WWOMB studies adapted and integrated the socioecological model to investigate issues surrounding maternal and child health in Ethiopia (Fig. 2). The socioecological model of health is a comprehensive framework that recognises that health outcomes are influenced by the dynamic interaction among individuals and their broader social, cultural, and environmental contexts [23]. This model emphasises multiple levels of influence, ranging from individual factors to interpersonal relationships, community dynamics, and societal structures. By considering these interconnected layers, the socioecological model provides a holistic understanding of health determinants and informs interventions that address health issues at various levels, promoting a more comprehensive and effective approach to public health [23].

Fig. 2

Socioecological model of health

A key goal of the WWOMB program was to produce work ready graduates who are upskilled to take on research leadership roles within their own cultures and communities. We aimed to achieve this by ensuring adequate skill acquisition, a commitment to ongoing development, modelling academic excellence and integrity, movement towards independence, leading to a well-rounded graduate with expertise in research, dissemination and translation, stakeholder engagement and analysis of the policy environments they seek to influence.

As such, students completing their PhDs within the WWOMB program went through the same scholarship and admission process for all The University of Newcastle international PhD candidates and were required to achieve the same requirements throughout their candidature as all PhD candidates (e.g., undergo a confirmation of candidature within the first 12 months (where students are required to provide a document encompassing a current review of the literature on their topic, a proposed research plan and timeline for completion to be assessed by an expert panel, undertake a 20-minute presentation on their proposed research and undergo a verbal defence with their panel). The difference for WWOMB PhD candidates however was the targeted approach to learning throughout the candidature. As the WWOMB initiative was designed to study global maternal and infant health conducted by people who are in and of the cultures concerned, a cohort approach was taken to student supervision and support (in addition to their individual supervision sessions). Cohort student supervision was designed using a community of praxis framework focused on four stages: (i) supervision and training; (ii) writing for specific audiences (e.g., publications, policy briefs and lay summaries); (iii) training and facilitation of policy and practice translation (e.g., developing reciprocal relationships with health policy makers, clinicians, and community member); and (iv) work-preparedness (e.g., Curriculum Vitae writing and review, interview advice and practice).

Using this cohort approach, students undertook fortnightly classes during Year 1 focused on key activities (e.g., confirmation preparation, skill development in systematic reviews, using statistical packages and various research methods). In the second year, the students determined their own class needs with guidance and content provided by the three core supervisors (MLH, DL and CC). In Year 3, the class evolved into a peer support program, fully controlled by the students, with supervisor support and guest speaker input (on a needs basis). The class-supervision structure provided the benefits of a peer environment complemented by individual supervision. In addition to training in these areas, WWOMB candidates received additional supports which included: dedicated English language support (through regular language classes and one-on-one support), statistical consultations, as well as manuscript, and thesis editing support.

Results

The following outlines key findings from the WWOMB program in Ethiopia.

Study characteristics

A total of 44 papers were published by the WWOMB research team between 2017 and 2022 that focused on improving maternal and infant outcomes in Ethiopia. Of these, one involved the systematic review of current literature [24], nine involved a systematic review with meta-analysis [25,26,27,28,29,30,31,32,33,34], one focused on geographic linkage methods [35] and 37 were original research articles. Of the original research articles, 17 studies analysed national Ethiopian Demographic Health Survey (EDHS) datasets including two that were linked to Ethiopian Service Provision Assessment (ESPA+) survey data, four studies utilised hospital-based emergency obstetric and neonatal care registry data, one study used longitudinal surveillance system data (Health and Demographic Surveillance System; HDSS) and one utilised panel data from the World Bank Development Indicators database. Ten studies involved primary collection of quantitative data (including two prospective studies) and three involved qualitative data collection.

Identified topics

Five overarching topics based on the study outcomes were identified: (a) family planning and contraception (n = 7); (b) maternal and child health service use (n = 14); (c) maternal and child health outcomes (n = 20); (d) maternal and child nutrition (n = 5); and (e) health economics (n = 2). To synthesise the findings, information related to first author, year of publication, study aim(s), study design and setting, participant characteristics, main findings and policy and practice implications were extracted. The major findings for each of the identified topics are presented below as a narrative synthesis, with case studies highlighted.

Family planning and contraception

Seven studies focused on specific aspects of family planning across the reproductive life course including the relationship between Intimate Partner Violence (IPV) and unintended pregnancy (n = 2), the population-level examination of geographical differences in the use of modern contraception (n = 1) and contraceptive use, contraceptive counselling, and fertility among women with HIV (n = 4) (see Table 1). In particular, Tegene et al. [36] provided the first population-level evidence in Ethiopia on the geographic identification of concentrated high use of modern contraception (i.e., hot spots) and those with low use (i.e., cold spots) through geospatial mapping. While only one-third of married women were found to be overall users of modern contraception, utilisation varied across different regions and city administrations (Global Moran’s I = 0.24; Z-score = 8.09; p < 0.0001). The highest contraceptive prevalence was reported in the Amhara region (52%) and Addis Ababa (50%). In contrast, the prevalence of contraceptive use in the Somali, and Afar regions were low (< 10%). Area of residence was found to account for around 25% of the variance in the use of modern contraception among married women. Of the other individual- and regional-level factors examined, the strongest predictor of modern contraceptive use was health facility readiness to provide short-term modern contraceptives, where a one-unit increase in health facility readiness to provide short-term modern contraceptives in a given area was found to increase the odds of modern contraceptive use by more than 20-fold (95% CI 1.44 to 29.54).

While this topic included research across the family planning space (i.e., from preconception to conception), the most comprehensive body of work to date has focused on women of reproductive age living with HIV [37,38,39]. Using facility-based cross-sectional surveys, Feyissa and colleagues demonstrated that of women who gave birth in a three-year period, 18% of births were reported as mistimed and one-quarter were unwanted at conception [40]. In addition, a quarter of women living with HIV who reported being fecund and sexually active within the previous six months and were at risk of an unintended pregnancy were found to have an unmet need for contraception [40]. When contraception was used, only 29% of women used highly effective contraception (e.g., progestogen-only implant). This is particularly important given that previous research has shown that engagement in reproductive discussions between healthcare providers and sexually active women living with HIV is lacking. Less than one-third of women reported having general reproductive discussions and even fewer (17%) reported having personalised reproductive discussions [41].

Table 1 Studies on family planning and contraception in Ethiopia (2017–2022)

Maternal and child health service use

Table 2 summarises the studies which focused on maternal and child health service utilisation. Two studies investigated emergency obstetric care (EmOC) [24, 43], six studies focused on antenatal care [25, 27,28,29, 35, 44], four focused on institutional delivery [26, 45,46,47], one study focused on postnatal care utilisation [47], and one study assessed maternal health service utilisation in general [48].

One meta-analysis of antenatal care attendance in Ethiopia identified a point prevalence of 63.8% [27], while another meta-analysis by Tesfaye et al. (2017) found significant delays in antenatal care seeking with a pooled prevalence of 64% identified [29]. Importantly, among women who died, only 26% had attended at least one antenatal care visit. This is particularly important as research by Tekelab et al. (2019) found that at least one antenatal care visit by a skilled provider during pregnancy reduced the risk of neonatal mortality by 39% [28].

Our research also demonstrated significant geographic variations across various maternal health services such as antenatal care ( Global Moran’s I = 0.18, z-score = 6.11, P-value < 0.0001) [35], health facility birth (Global Moran’s I = 0.028; Z = 3.41; P < 0.0001) [45], and caesarean delivery (Global Moran’s I = 1.15, Z-score = 38.26, P-value < 0.0001) [46]. Importantly, Musa et al. (2019) documented the association IPV and maternal health service utilisation, with women who experienced IPV having 25% decreased odds of using adequate antenatal care (having four and above antenatal care visits) and 20% decreased odds of using skilled delivery care compared to women who did not experience IPV [25]. Moreover, Geleto et al. (2018) found that barriers to the provision of quality obstetric services included poorly designed infrastructure, an inadequate number of midwives working at hospitals, language barriers, a lack of treatment protocols and poor supervision support and staff motivation [24].

Table 2 Studies on maternal and child health service utilisation in Ethiopia (2017–2022)

Maternal and child health outcomes

In all, 21 studies focused on maternal and child health outcomes (see Table 3). One study investigated severe maternal outcomes [50], one study focused on obstetric danger signs [30], three studies focused on hypertensive disorder of pregnancy [32, 33, 51], five studies focused on IPV [52,53,54,55,56], and three studies reported on short birth interval [57,58,59]. Additionally, two studies investigated maternal and neonatal near miss [60, 61], two studies researched perinatal and infant mortality [31, 62], one study focused on obstetric case fatality [63], and two studies investigated maternal mortality outcomes [64, 65].

Key findings on adverse child health outcomes has indicated that perinatal mortality in Ethiopia is around 16% [51] and neonatal near miss occurred in 45.1 per 1,000 live births [61]. Leading causes of neonatal death included prematurity (47.5%) and asphyxia (20.7%) [62]. When examining specific maternal health exposures and neonatal outcomes, Musa et al. 2021 found that the experience of IPV increased the odds of a preterm birth by 62% and low birthweight by 37% [56]. Additionally, Tiruye et al. (2021) found that maternal exposure to IPV (a composite measure of physical, sexual, and emotional abuse) and three or more partner controlling behaviours were associated with increased odds of neonatal mortality by 158% and 175%, respectively [54].

When focused specifically on adverse maternal outcomes our program has identified that severe maternal outcomes occur in 37.5 per 1000 live births and maternal near miss occurs in 31.3 per 1000 live births [50]. In addition, a direct obstetric case fatality rate of 0.64% [63], and a maternal mortality ratio of 324 per 100,000 live births [65] were identified. Our research has identified that around 40% of Ethiopian women experience IPV when asked about their most recent pregnancy [55] and the odds of pregnancy loss were 54% and 72% higher among women who had experienced any form of IPV and multiple partners controlling behaviours, respectively (compared to women who had not experienced any form of IPV) [52].

Table 3 Studies on maternal and child health outcomes in Ethiopia (2017–2022)

Maternal and child nutrition

A total of five studies reported on maternal and child nutrition (see Table 4). Two studies examined the relationship between dietary patterns and the risk of adverse pregnancy and birth outcomes [34, 66], two studies focused on anaemia among women of reproductive age [67, 68], and one study reported on undernutrition status (i.e., wasting, underweight and stunting) of children [69].

Importantly, adherence to a healthy dietary pattern (intake of vegetables, fruits, legumes, and whole grains) was found to reduce both adverse pregnancy and birth outcomes (pre-eclampsia, gestational diabetes mellitus, and preterm birth) [34]. Additionally, a causal analysis performed by Shifti et al. (2021) showed the sequential mediation effects of maternal anaemia and baby birth size on the relationship between short birth interval with stunting and underweight. A mediating effect of 4.2% and 4.6% on stunting and underweight, respectively was identified [69].

Table 4 Studies on maternal and child nutrition in Ethiopia (2017–2022)

Health economics

Only two studies have been published to date that reported on economic outcomes (Table 5). Using World Bank Development indicators, Kiross et al. (2020) examined the impact of health care expenditure on infant mortality. While the study’s focus was inclusive of sub-Saharan Africa, it found that overall health expenditure per capita was associated with both neonatal and infant mortality. Importantly, a 1% increase in health expenditure per person irrespective of the source reduced these mortality outcomes by approximately 0.1% [70]. In addition, using decomposition analysis, Shifti et al. (2020) found that short birth interval (a factor associated with poor maternal and infant outcomes) was disproportionately concentrated among the poor, with wealth quintiles as its major contributing factors (along with administrative regions, and not listening to the radio) [71]. This finding suggests that a pro-poor inequality exits in Ethiopia.

Table 5 Studies on health economics in Ethiopia (2017–2022)

Discussion

Maternal and child health is a paramount concern in global public health, and it is particularly significant in low resource countries like Ethiopia. Through a strategic investment by The University of Newcastle, we have been able to create a critical mass of epidemiological work under the WWOMB program in maternal and child health and make clear recommendations for policy and practice in the country to help support the meeting of the SDGs related to maternal and child health.

The epidemiological work under the WWOMB program in Ethiopia spanned across five major themes; family planning and contraception; maternal and child health service use; maternal and child health outcomes; maternal and child nutrition; and health economics. Family planning and contraception are critical components of maternal and child health care. The key findings from the WWOMB studies in this area indicated an association between IPV and a higher risk of unintended pregnancies. The observed link between IPV and unintended pregnancies could be attributed to the fact that women facing such violence often have limited autonomy in making decisions about their fertility [72, 73]. Women in relationships with abusive or controlling partners may encounter barriers that prevent them from accessing and using contraception. Geographical disparities in modern contraception use were also demonstrated. In addition, one in four women living with HIV and who were at risk of an unintended pregnancy were found to have an unmet need for contraception. This underscores the importance of comprehensive family planning strategies and the need to support women who are at greater risk of experiencing unintended pregnancies to reduce the vertical transmission of HIV in Ethiopia. In this regard, understanding regional variations in contraceptive use and the impact of health facility readiness on modern contraceptive use is vital for designing effective family planning programs.

Access to health care is a fundamental determinant of maternal and child health outcomes [74]. Our studies revealed significant variations in health care service utilisation across Ethiopia. Geographic disparities were evident, impacting on antenatal care attendance, health facility-based deliveries, and access to caesarean deliveries. These findings are in agreement with previous Ethiopian studies which showed disparities in the use of antenatal care services [75] and geographical variation in utilisation of health facility delivery [76]. In particular, Yesuf and colleagues found that while antenatal care increased in general over the study period, evidence of widening gaps between Addis Ababa/Dire Dawa regions and the Amhara region was identified [75]. These findings highlight the need for targeted interventions to ensure equitable access to health care services, particularly in underserved regions.

The studies conducted as part of the WWOMB program also identified important factors affecting maternal health service utilisation. For example, the findings of our meta-analysis indicated that women who experienced IPV were less likely to receive adequate antenatal care and skilled delivery care. This could be attributed to the potential impact of IPV on women’s capacity to access healthcare services by impairing their decision-making autonomy, reducing freedom of movement, and increasing economic dependence [77, 78]. Our finding is supported by other Ethiopian research that has found a strong association between lifetime emotional or physical abuse, as well as recent sexual abuse and late entry into antenatal care, particulary for multiparous women [79]. Late entry into antenatal care is a major challenge in Ethiopia and other LMICs and as shown from our research, has flow on effects for engagement in the uptake of skilled delivery, postnatal care [25], and post-partum contraceptive use [80]. Given IPV is emerging as a critical factor impacting maternal health service utilisation [81, 82], there is a need to develop both IPV prevention strategies and strategies to support women experiencing IPV to improve maternal and infant health outcomes.

Accessible and affordable evidence-based quality emergency obstetric care has been found to reduce adverse pregnancy outcomes including maternal mortality [83]. Our studies identified factors such as poor infrastructure design, inadequate staffing, and a lack of clinical practice guidelines as important barriers for accessing and utilising quality obstetric services in Ethiopia. Overcoming these barriers is vital to enhance the accessibility of emergency obstetric care and improve pregnancy outcomes.

WWOMB studies related to maternal and child health outcomes identified a range of key issues such as higher rates of severe maternal outcomes and adverse pregnancy outcomes, consistent with the previous studies [84]. The findings indicated that there are alarming rates of severe maternal outcomes and maternal near misses in Ethiopia, underscoring the need for improved maternal healthcare services and emergency obstetric care. Additionally, the high prevalence of IPV among Ethiopian women, particularly during pregnancy, calls for comprehensive interventions to address IPV and support victims, given its negative impact on maternal and child health outcomes.

The findings also indicated unacceptably high adverse perinatal outcomes including neonatal mortality and neonatal near miss, in line with previous studies in Ethopia and other African countries such as Rwanda and Nigeria [85,86,87]. This suggests that in the presence of inadequate access to, and use of, maternal healthcare services and maternal near miss, poor perinatal outcome are inevitable. Identifying and addressing the leading causes of neonatal death and neonatal near miss, particularly prematurity and birth asphyxia, is crucial in this regard. On the other hand, the observed link between maternal exposure to IPV and adverse neonatal outcomes underscores the need to provide support for pregnant women facing IPV.

Nutrition is a foundational aspect of maternal and child health [88]. The WWOMB program identified geographical disparities in maternal anemia in Ethiopia with a high prevalence observed in Eastern and north-eastern part of the country. These geographical disparities might be attributable to factors such as the regional variation in food consumption preferences [89, 90] and variation in the availability of healthcare facilities between regional states [91]. Studies on maternal nutrition also demonstrated the positive impact of healthy dietary patterns on reducing adverse pregnancy and birth outcomes including pre-eclampsia, gestational diabetes mellitus, and preterm birth [92, 93]. Thus, promoting the intake of vegetables, fruits, legumes and whole grains is a key strategy for enhancing maternal health and reducing complications during pregnancy and childbirth.

WWOMB studies focusing on health economics provided insights into the economic aspects of maternal and child health. Congruent with most of previous studies in Ethiopia [94, 95], one of the WWOMB studies found that increased health care expenditure per person was associated with reduced neonatal and infant mortality, underscoring the importance of investment in healthcare infrastructure and services. Addressing economic disparities in maternal and child health was also highlighted, particularly in the context of short birth intervals. The finding indicated that a pro-poor inequality of short birth interval in Ethiopia exists. This signals the need to strengthening implementation of poverty alleviation programs to improve the socioeconomic status and reduce the associated inequality in short birth interval.

Core outcomes of the WWOMB program were two-fold. We aimed to address the SDGs including those around gender equality and good health and wellbeing as well as addressing the gap in research leadership in Ethiopia. By developing a critical mass of Higher Degree Research students conducting studies across the reproductive lifespan that would improve outcomes for women and girls in Ethiopia, we have assisted in creating a new generation of research leaders that have the capacity to influence policy and practice decision-making in and outside their home country. Importantly, the alumni and their supervisors were recognised twice by the Ethiopian Ambassador to Australia and by the Ethiopian government for providing much needed information that was used to inform policy development. Additional key strengths of this program, include the invaluable benefit of peer support garnered by not only students focused on a common topic but also cultural similarities. The cohort nature of the program also allowed us to provide group supervision on common learning outcomes such as preparing for confirmation, thesis structure and write up, how to write manuscripts for publication and use of common statistical packages and to the ability to make meaningful engagement with policy-makers due to increased capacity in the area.

Despite having a dedicated cohort of PhD students who were able to work together to build an evidence-base on a focused research area (in this case maternal and child health), we have faced some expected as well as unexpected challenges in generating research impact. In preparing to conduct a program of work driven by a critical mass of PhD students, we anticipated that there would be a need for language support provision so that the supervision team could focus on the content of the student’s work rather than teaching academic English to students through grammatical reviews of written work. We also anticipated the need for statistical support which was provided by our research centre and the need to manage supervisor time to ensure that workload from the cohort was manageable and that all students received the individual attention they required. We however had not expected members of the cohort to arrive at different times due to differences in Visa provision and other administrative delays. While this interfered with our desire to present the classes in a sequential manner, we met this challenge by making most classes independent of previous sessions. As such, while the program was hugely successful, limitations of implementing such programs at scale include the additional costs associated with the provision of support structures and the need to be flexible in the planning and delivery of key learning outcomes across the period of candidature for the cohort.

Further, although a needs assessment was conducted through consultations with representatives from the Ethiopian Embassy to Australia to broaden the scope of the program in Ethiopia as well as numerous consultations with the Ethiopian Ministry of Health, these efforts were hampered by the COVID 19 pandemic which caused widespread disruption to essential health service provision, including those related to sexual and reproductive health as well as maternal and child health. This also impeded the ability for candidates to return to Ethiopia following submission of their thesis, as a large number submitted during the peak of COVID when travel restrictions were in place. As such, some of our alumni are now located outside of Ethiopia, having taken up postdoctoral fellowships in Australia. Despite this, the wealth of findings to date and the diaspora of postdoctoral fellows with an interest in Ethiopian maternal and child health have the potential to make major improvements in meeting the SDG targets in Ethiopia. In addition, given that the global emergency as a result of COVID has come to an end, linkages with the Ministry of Health will be re-established to not only identify areas for intervention but also garner support for the development of a longitudinal women’s health study in Ethiopia to help address the burning issues for women and girls as we move into a post-COVID era. In addition, we are in the process of establishing Memoranda of Understanding with Ethiopian universities (e.g., Wollega). Our Ethiopian student alumni will be instrumental in achieving these key outcomes.

While Ethiopia continues to make progress towards meeting SDG targets, the WWOMB program has been able to make clear recommendations for priority areas of improvement. For example, with regards to family planning and contraception, our work has shed light on critical areas that warrant immediate attention including presence of geographical disparities. Notably, our findings underscore the pressing need to improve healthcare services for marginalised groups such as women living with HIV. It is imperative to develop strategies that address the specific challenges faced by these individuals to ensure their access to quality reproductive health services and contraception options. In addition, improvements in the provision of preconception care are required, including a focus on the need for healthy dietary choices to not only optimise not only reproductive outcomes but also maternal and infant health outcomes.

Our studies have also exposed geographical disparities in maternal health service utilisation, prompting the call for targeted interventions in regions where access to healthcare is limited. We have also identified the pervasive issue of PV, emphasising the necessity of comprehensive programs and policies to combat this problem, creating a safer environment for women and children. In addition, economic and poor health infrastructure were noted as important factors affecting to access to emergency obstetric services, indicating the need for policy and practice changes to overcome these challenges. For example, health insurance should be made available for women to improve the effect of economic liability on health service utilisation. Direct out of pocket payment is found to be a key deterrent of healthcare service use in LMICs in general [96]. A recent study found health insurance coverage in Ethiopia was only 28% despite formal community-based health insurance programs being implemented since 2011 in rural areas [97, 98]. Importantly, Merga and colleagues found that geographical location, age and gender of the household head were associated health insurance coverage, with older, male headed households and those living in rural areas more likely to have health insurance [98]. We agree with Merga et al. that the Ethiopian community health insurance scheme should reconsider its implementation strategies in order to increase health insurance uptake among younger and female headed households. Such efforts would go a long way towards improving access to, and use of, reproductive and maternal health services, thereby improving health outcome for women and children. There is also a need for more investment in healthcare infrastructure. Furthermore, our research highlights the critical issue of undernutrition among mothers and children. This underscores the importance of strengthening policies and developing interventions that address this fundamental aspect of health, ensuring that adequate nutrition is accessible to all, thus promoting healthier outcomes for mothers and babies. For example, national initiatives such as the Early Childhood Development (ECD) Strategic Plans (2020/21–2024/25) should be strengthened and monitored for their implementation to ensure that all children grow and thrive in a safe and nurturing environment.

Conclusions

Our findings show that investment in healthcare infrastructure and services, coupled with efforts to reduce economic inequalities, can contribute to improved maternal and child health in Ethiopia. The WWOMB project has focused on delivering evidence-based recommendations to policy and practice to improve maternal and infant health in Ethiopia. There is a need to strengthen and monitor maternal and child health-related strategies, such as the Ethiopian Government 2030 Family Planning Commitment, the Reproductive Health Commodity Security Strategic Plan, and the ECD strategic plans to improve the maternal and child health outcomes in the country.