No woman should die while giving life : Does the Health Extension Program improveaccess to maternal health services in Tigray, Ethiopia?

Abstract: Introduction: Ensuring access to universal primary health care is essential to secure a safe and pleasant motherhood and to provide compassionate care for mothers and newborns.However, inequalities in the access to maternal health services still remain a prominent problem in many countries. As part of reducing inequalities, Ethiopia launched the Health Extension Program (HEP) in 2003. The HEP is a community based program designed with a defined package of essential promotive, preventive and basic curative services targeting households, particularly mothers and children. Despite the construction of over 600 health posts and deploying more than 1200 Health Extension Workers (HEWs), preliminary data suggests a low utilization of maternal health care services. This thesis explores the HEP contribution in improving women’s access to maternal health care, and the reasons for the low use of maternal health care services from the perspectives of the involved actors in the Tigray region in Ethiopia. The five dimensions of access were used as a framework to explore the access to maternal health care utilization in this setting.Methods: A total of four districts were included in the study. Both quantitative and qualitative methods were applied. In the first sub-study, we assessed the HEP and its association with change in the utilization of antenatal, delivery and postnatal care services. Retrospective longitudinal data for 10 years was extracted from three selected districts and checked for accuracy. Segmented linear regression technique was used to control the secular trends adjusted for correlation of the data. For the second sub-study, we conducted a cross sectional survey with 1115 women (aged 15-49 years who had given birth within five years prior to the survey period) to determine the prevalence of antenatal care and institutional delivery utilization and explore their determinant factors of low utilization. For the third sub-study, we conducted six focus group discussions (FGDs) with a total of 51 women to explore women’s experiences of childbirth and maternal care. An interview with eight HEWs and four midwives were carried out to capture health workers’ perspective on access to maternal health care services in the fourth sub-study. Grounded theory for the former, and thematic analysis for the latter were used for the analysis.Main findings: The finding of the first sub-study showed a statistically significant upward trend for delivery care (DC) and postnatal care (PNC) in all facilities during the HEP late implementation period (July 2008-June 2012). In addition, a substantial trend of antenatal care (ANC) service use was observed at health centres after the intervention. In the second sub-study, the determinant predictors for ANC utilization were: proximity to health facilities, to be married, ≥5 years of education and having non-farming husbands. The last three factors were also significantly associated with institutional delivery, but also lower parity, previous history of obstructed/prolonged labour and ANC counselling. Findings from the qualitative studies pointed out that elderly women influenced women’s decision making about where to give birth. Women were mostly positive about giving birth at health facilities, but were concerned about the poor quality of care, inaccessibility and unavailability of transport. From the health workers’ perspective: specialized performance of hospital services, community assistance during referral and an increased awareness among women regarding the benefits of giving birth at a health facility were perceived as facilitators for institutional deliveries. Poor perceived competence of HEWs, poor conditions of health care facilities and inaccessibility of transportation, among others, were perceived as barriers for giving birth at health facilities.Conclusion: Overall, this research revealed a considerable contribution of the HEP in improving the access and coverage of maternal health services (ANC, DC and PNC). However, cultural traditions, scattered localities, mountainous roads without adequate transportation and low quality of care are still the major obstacles to accessing the services. Mechanisms need to be designed to enable health facility access of safe delivery for women in hard to reach areas, improving the proficiency of health workers and introducing a women centered approach that enhances acceptability of the services.