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Background: The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs’ and mother’s attitudes to maternal health services in Adwa Woreda, Tigray Region. Methods: In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women’s social status and mobility; and women’s perceptions of skilled birth attendant’s care. All data were analyzed thematically. Findings: There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women’s Development Groups (WDGs), and referral by ambulance to health facilities either before a woman’s Expected Due Date (EDD) or if labour started at home. Conclusion: With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women’s groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.
The research took place in Adwa Woreda, Central Zone, Tigray Region in northern Ethiopia, 1015 kms from the capital Addis Ababa. Tigray is a land of highland plains, mid-land plateaus, valley bottoms and vast escarpments with mountains ranging from 500 metres in the west to the Tsibet Mountains 3,935 meters above sea level in the south. Adwa is one of the 34 rural woredas located in Central Zone with an estimated population of 107,953 [29]. The research sites were selected in consultation with the TRHB [author HG] and subsequently the Adwa Health Office. All 18 kebeles were invited to send one HEW to attend the workshop in Adwa town but only 16 HEWs attended. At the time of the research one ambulance linked the 18 health posts with seven health centres (at the woreda level), and the health centres with Adwa Hospital through a referral system so that women could be transferred if there was an obstetric emergency. A second ambulance was under repair. The HDA evolved differently in Tigray Region compared to other parts of Ethiopia due to the political leadership and commitment by all levels of health professionals and the community. The community is represented by Women’s Development Groups (WDGs) for maternal health issues. WDGs are seen as the cornerstone of community ownership, making invaluable contributions within the health sector as well as in other development sectors. They are ‘conceptualized as a way to create demand for health, wellness, and improved access to health care services through organized voluntary groups of women’ [30]. According to the FMOH, the percentage of deliveries assisted by skilled health personnel in Ethiopia has shown a steep increase from 23.1% in 2012/13 to 40.9% in 2013/14 [14]. However, there is still no consistent figure of skilled birth attendance—and the 2014 Mini EDHS report indicated that for the five years prior to the survey only 15% of women gave birth in a health facility [31]. According to the TRHB, just over half (54%) of women in Tigray Region were assisted by skilled health personnel [30]. Statistics provided by the Adwa Health Office for the first quarter of 2013/14 show that 29% of women gave birth in a health centre, 4% in a health post and 2% at home. For the first three months of 2014/15 statistics showed that of the 894 women who planned to give birth, 238 received skilled attendance at the health centre and six women were assisted by HEWs through safe and clean delivery at home. An additional 174 women were referred either from home to a health centre, or from health centre to hospital. There was one maternal death in Adwa Hospital [32]. The methods for this project were adapted from Key Informant Monitoring and Participatory Ethnographic Evaluation and Research [33–35]. HEWs were selected because they are generally women who come from the same kebele as the women they were interviewing and because they hold a trusted position as health workers in the kebele. In particular, women appreciate the concern of HEWs whose important role on maternal health services influences women regarding ANC and institutional delivery utilization [27]. We expected that HEWs would encourage a certain level of openness from women they knew that we may not have gained ourselves. In this research, HEWs were both research assistants and informants. On the one hand, HEWs with better understanding to traditional and cultural values of the community can be considered as informants of the study, and on the other hand, they are also considered as gatekeepers to health care and mediators between the traditional and medical model of care which was a good justification for recruiting them as research assistants. HEWs attended a two-day workshop in Adwa town where they were trained how to conduct research ethically; interview techniques; how to develop their own research questions and design an interview schedule; how to recruit participants; and how to identify key issues and incorporate lessons learnt into their practices. We practised asking open-ended questions, probing, and asking for stories; third-person interviewing; how to record findings and identify key phrases and/or events the interviewees gave most importance to. We provided each HEW with a form to record women’s responses with questions listed under the three broad themes agreed to during the workshop in detail: barriers to existing health services and perceptions of quality of care; women’s social status and mobility; and attitudes to childbirth including increasing utilization and acceptance of skilled birth attendants and early referral. Minor modifications were made to the data collection forms during the workshop based on comments by the HEWs and the researchers. This ensured the form was standardized by creating common understanding about what information was to be collected. During visits to the HEWs the research team was able to clarify any questions to further ensure the standardization of the interviews. After the workshop, HEWs returned to their kebeles where they identified and obtained informed consent from three women. HEWs were asked to select women to interview who had had a range of experiences giving birth in the previous two years: at home or in a health facility, and women who had had one or two children or more than two children. As HEWs live and work in the community, it was technically possible for them to identify women who had had positive or negatives experiences. The aim of the study was not generalizability based on a representative sample but to identify and understand the barriers of maternal health care utilization as experienced by women with divergent birth experiences. Women were interviewed by the HEW in the following week. All of the HEW interviews with women were one on one. We conducted semi-structured one on one interviews with HEWs and other health workers to assess their perceptions about the utilization of maternal health services.
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