Community-based delivery of lifesaving maternal and newborn health interventions in vulnerable Ethiopian communities: Lessons from implementation research

Introduction In Ethiopia, women in remote agrarian and pastoralist regions face major barriers to accessing timely, quality maternal and newborn health (MNH) services, leading to high rates of home births and preventable mortality. This study assessed the implementation of the Village Health Leader (VHL)-led community-based MNH package in vulnerable agrarian and pastoralist communities in Ethiopia. Methods Implementation research deploying a mixed-methods process evaluation across seven health centers and 38 vulnerable communities in the Afar, Somali, and Oromia regions was carried out from December 2023 to July 2025. VHLs were trained to deliver community-based MNH interventions that included misoprostol for the prevention of postpartum hemorrhage, chlorhexidine for umbilical cord care, iron-folic acid for the prevention of anemia, and postpartum family planning counseling and services. Quantitative program monitoring data were collected from 3,980 pregnant women and analyzed descriptively. Qualitative data were collected through 90 in-depth interviews and 14 focus group discussions with VHLs, health workers, postpartum women, community members, and supervisors. Qualitative data were coded in ATLAS.ti using both deductive and inductive approaches. Findings from the quantitative and qualitative components were integrated to provide a comprehensive assessment of implementation. Results The intervention reached about 4,000 pregnant women, with high rates of uptake for lifesaving MNH services. Among women who gave birth, 35% delivered at home, 92% used misoprostol, and almost all applied chlorhexidine to the umbilical cord stump. Qualitative findings indicated generally positive perceptions of the intervention and highlighted its acceptability and feasibility. VHLs demonstrated strong adherence to protocols and timely referrals to health facilities. Challenges included supply shortages, lack of incentives for VHLs, and weak referral feedback systems. Despite these constraints, the intervention improved access, enhanced equity, and did not disincentivize facility-based deliveries. Conclusions Community-based delivery of lifesaving MNH interventions by VHLs is both feasible and acceptable in most underserved communities. The model strengthens the primary health care system by extending its reach, improving the continuum of care, and addressing persistent access barriers. However, sustainability requires reliable supply chains and tailored approaches for pastoralist populations. The findings support the integration of trained community volunteers into national MNH service delivery strategies to reduce preventable maternal and newborn deaths.