 Yn ymgyrch o'r tîm blynedd, rwy'n ymddi'ch gweithio gael y gallwn i'ch gweithio'r bwysig ymddiadau o'r bwysigau i'ch gweithio'r bwysig sy'n gyfnodol yma i'ch gweithio'r bwysig, o'r ddau'r bwysig ymddiannig o'r bwysig. Yn ymgyrch o'u bwysig o'r rhaid i'ch gweithio'r bwysig o'r bwysig, In 2016 it was estimated that 412 women die per 100,000 life births. Ethiopia being one of the six countries that have contributed to 50% of all maternal deaths worldwide. Let's begin with where this study took place. Since 2007, Medecins Sans Frontières has been working in Dolo's own delivering basic and reproductive health care to this pastoral rural population with the regional health bureau. You may recognise the area in the recent food crisis emergency. In 2016 we worked in nine villages in three districts, Wardair, Lailahoe and Danood. Dolo's own is one of the nine zones in the Somali region, Ethiopia. It is bordered on the north and southeast by Somalia. MSF and the regional health bureau and the public health institute wanted to understand the reasons behind low utilisation of reproductive health services it offered at this time. Let's move on to who we involved in the study. We interviewed purposefully 27 women who kindly shared their life stories and their health specific to childbirth. We followed a method where each woman, pregnant women, women with a child under one year and older women, reflected on their memories from childhood up to the point of becoming mothers themselves. But don't worry men, we haven't left you out. Men's ideas were captured through eight group discussions, also selected purposefully according to whether they were fathers with pregnant wives and or young children as well as older knowledgeable men. Before we go into the findings, I want to share one of the participants Amina's story. In her own words for you to get a glimpse of the common realities. Obviously her name has been changed. I am a mother. I have given birth to nine children. I was born in this same district in Ethiopia as I live now. When I was 12 years of age I travelled to Somalia and I grew up there until 17 years. I was married there. It was about the time at the pregnancy of my first baby. It was the time when the previous regime of Somalia was overthrown. I fled Somalia. I delivered my first child as a refugee while on the road back to my place of birth here in Ethiopia. Even though this country was not as peaceful as we know now, there was luck of peace back then. My baby didn't get any care or service, all the other eight children were born here. I'm 29 years of age. I'm a healthy mother. I had bleeding in two deliveries. My children are healthy, although one son of mine has died. Now I am pregnant. I'm in my fifth month of pregnancy. Note how she describes being used to risk. Living with risks and being a healthy mum simultaneously. The findings may help explain such experience. I'm now going to tell you about the results from the whole participant group. Four key findings emerged. First, we identify a social emphasis on barriers to healthcare and understandings of risk and resilience. Second, we explain how responsible adults manage risk. Thirdly, delays in reaching care describe the urgent case and value given to collective decision making. Lastly, we consider how technologies are perceived to enable access to better knowledge and care. The first findings relates to the adversity of social experiences and life for this population. A population used to pregnancy as a normal occurrence, but also used to risk. Like my own title suggests, hoping for life while fearing death describes and explains an acceptance of levels of risk in pregnancy and childbirth. But like Amina's story, the hope or prospect for a better outcome was judged constantly with risk. This finding is important for the health worker with the responsibility to explain the significance of risks and danger signs in pregnancy. We are like newly grown grass subject to the same fragility and vulnerabilities needed to sustain life. Equally, the concentration of health facilities in more populated areas means that perceptions of people towards using health services were outside their day-to-day experience, unfamiliar and unobtainable. Like all of us, they don't know what they cannot see. Faciliters should be established with people in the bush, just like the capital cities or big towns. Second findings, it was apparent from both male and female respondents that living with and managing risk was part of day-to-day life as pregnancy was and giving birth. For this, importance was given to the presence or not of a responsible adult. This could be the husband or it could be somebody in the community or a health worker, but someone there that could respond and be supportive. It is necessary to act in a way that would save the life of a woman. Our habit is that a husband follows the progress of the pregnancy and his wife. Similarly, the survival of mother and child, especially in drought or instability, is related to the presence of responsible support. There are examples of good support during delivery and for childcare, including hygiene and nutrition and protection, young infants were visibly cared for and nurtured and loved. The third findings, most participants' responses state that referral of a pregnant woman who needs emergency care to be reliant on a group decision making. Yes, we work as a group, search for a vehicle or communicate with a man at the health post. Participants recognise the influence of group decision making contributing to delays in reaching skilled assistance once the case requires attention. Negotiation as part of a collective nature of decision making was complex. There are several parts to the decision, each having a unit of time attached to it, leading to delays. While clearly group decisions carried authority, not all were straightforward and sometimes the negotiation was connected to other priorities, for example other children, animals to look after. The fourth finding, the frequent references to technology by participants suggested that to have more access to it would enable them better knowledge and care. The value placed on technology was twofold. It was described, for example, by the importance given to women to a pregnancy test, proving that they were pregnant before it was visible or physically showing. Or that they could find out their red blood cell count from a test if they had low anemia. They'd know that it was severe. Equipment or technology that can measure and make certain biological events visible is potentially useful to prompt action. We are only seeing in modern times when blood and people is being measured and when children are measured in different ways. This quote, in context, is a good example of wanting to measure and see their illnesses, or in the case of pregnancy, the risks. Secondly, a speedier communication was shared by many participants across male and female respondents. The presence of a transmitter so that radios could be used, or more recently the mobile phones with improved networks available in some villages, were essential for better referral systems and information sharing. The best man in rural areas is the one who requests for radio communication and tells them that his wife is about to deliver and needs assistance. As with qualitative research, our findings aren't generalisable to context, but we do think that the concepts in other nomadic populations living in remote areas would be of youth conclusions. I'm now going to talk about the conclusions. When we were looking at the findings, we realised they suggested a community-based approach was needed to help overcome barriers and enable access to care. So we came up with the idea to match them to the health extension worker programme being rolled out by the health bureau in the region, taking advantage to apply our findings to ensure the effectiveness of the health worker. We believed that access could be improved through increased effectiveness of a health worker, for example the responsible person that we discussed earlier, a female to be trained up. When we presented the findings back to the community, they created this tree with four elements, four elements as the roots of the tree to preserve life, as well as the female health worker that would have skills and equipment to carry out their tasks. That person would also be a broker to direct decision-making, an influencer to improve knowledge and recognise earliest dangerous signs and an enabler with screening tools to detect dangerous signs and earlier referral. Other conclusions included, a contextual analysis of delay is needed to understand socio-political aspects influencing access to health care. Technology is important to identify danger signs and increase access to knowledge and care, and community perceptions are key to understand how best to approach health worker and health systems planning. Next steps. There is a high priority and shared momentum to reach the national public health goal to reduce maternal mortality in Ethiopia, and this may be able to contribute to that. The regional health bureau liked the idea to add these components to support prevention and referral activities. The Public Health Institute has recently done a national survey that would like to combine with these findings for new strategies to address improving emergency obstetric care. Community responsiveness has also been positive to the findings. I would like to thank the research team, the women and men of Dolo and the regional health bureau and the Institute of Public Health and MSF teams for their help with study. Thank you.