Since the introduction of HEP in 2003 and deployment of HEWs, there has been an increase in the proportion of women who have utilized family planning, antenatal care, and HIV testing. On the other hand their deployment and work have not showed any improvement in utilization of health facilities for delivery, postnatal check up and use of iodized salt. Primary care facilities; particularly health posts, were almost unutilized by women for maternal health services. Women preferred to visit health centers instead of health posts. Women, who were literate, listened to the radio, participated in income generating activities and had been working towards graduation or graduated as model family were more likely to access and utilize comprehensive maternal health services.
Our finding on family planning is in agreement with other studies conducted in Ethiopia [11, 12]. These studies showed HEWs have improved access to family planning. A study conducted in the southern part of Ethiopia found that women who were able to read and write are more likely to access maternal health services, similar to our findings. This study also showed similar to our findings on ANC that the proportion of women who had at least one ANC visit has increased considerably . Nevertheless our study showed the proportion of women who had 4 and more ANC visits as recommended by WHO was still low (48%). Thus concerted effort by HEWs and VCHWs is necessary to educate women about the importance of having four and more ANC visits. Another important achievement observed in our study is the increase in HIV testing. A study on antiretroviral treatment in Ethiopia depicted a similar substantial expansion of access to HIV counselling and testing in Ethiopia . This increase might not be totally attributed to HEWs, because nongovernmental organizations (NGOs) and other stakeholders also play a crucial role in HIV testing and education, through different approaches such as campaigns. HIV programs are highly supported by NGOs and other stakeholders. However, the positive role of HEWs in improving HIV testing and prevention in rural areas is undisputable. In reality, in rural kebeles in Ethiopia, HIV testing and education on HIV prevention is carried out primarily by HEWs. Even HEWs who are not trained for HIV testing organize and coordinate the campaigns for HIV testing. Practically all the health activities including campaigns at rural kebeles in Ethiopia are undertaken and organized by HEWs.
The HEWs did not succeed in improving utilization of health facility delivery, PNC check up and use of iodized salt. This calls for urgent interventions into the HEP. Innovative approaches are needed to improve HEWs effectiveness in relation to these services. Similar to our study, another study also showed no progress in skilled birth assistance and postnatal care coverage in Ethiopia since 1998 . Contrary to the findings of a cross sectional study among 60 households in Tigray region which was conducted at the earlier stages of the HEP implementation, our study revealed the proportion of women who were assisted for birth by trained traditional birth attendants (TTBAs) is much higher than those assisted by HEWs . This might be due to the fact that the number of TTBAs in a kebele is higher than the number of HEWs. It might be also TTBAs are tried and tested by women and seen to be experienced in conducting deliveries. Perhaps they could be closer and accessible to village women. On the other hand low competency and confidence of HEWs in assisting births, less favourable working conditions at the health posts, workload and walking long distances at night to assist births at home might also be attributed to this low performance of HEWs in assisting births .
Though further research is needed to study the HEWs’ performance in birth assistance, we propose several reasons for the present findings of their low participation in this role. First, health facility delivery is demanding in relation to cost, skill and competency. It requires HEWs having the necessary skills and communities having accessible and well-supplied facilities in place. Second, encouraging behavioural change for women to have births at health facility is time consuming work [17–19]. Women’s preference for having birth at home is a deeply embedded cultural belief. Women may believe that it is appropriate to go to a health facility for birth assistance and check up only if there are visible complications during birth . Other determinants like women’s age, education, income, number of children and health seeking behaviour could also influence women’s preference on health facility delivery and birth assistance by skilled birth attendant . Thus focused birth preparedness by pregnant women is necessary to encourage every woman to have birth at health facility or assisted by health professionals. It is advisable for HEWs and other community health workers to have effective discussion on birth preparedness with every pregnant woman when they do home based ANC visit. Third, health posts are not well equipped for providing delivery service which is a disincentive for women to use these facilities. Almost all health posts are a single room only, with no waiting room area, water source or electricity. Hence a strong referral system should be established between health posts and health centers (which are better equipped for birth deliveries) until health posts meet the necessary standards for delivery service. Fourth, HEWs’ low performance in assisting birth also relates to how HEWs are perceived by the community. The community may regard HEWs as less competent to assist birth. Unpublished reports from Tigray regional health bureau on the HEP indicate that the community perceive HEWs’ main task to be health education, sanitation and personal hygiene. Health extension workers were primarily associated with latrine construction. All these reasons and considering HEWs’ present workload and the poor conditions of health posts, it may be unrealistic to expect greater involvement in birth assistance by HEWs or that women would choose to give birth at health posts [16–20].
The 1978 Alma Ata Declaration on Primary Health Care , and subsequent reviews of primary health care reforms, call for intersectoral collaboration to address socio-economic determinants of community health, in which ensuring universal access to health services is one element [22, 23]. In consideration of these other social determinants of women’s health, this study looked at whether participating in IGAs had an association with utilization of maternal health services. Logistic regression analysis revealed women who have been participating in three and more income generating activities were 1.72 times more likely to have good utilization of comprehensive maternal health services. The regression analysis also identified women who were literate, listened to the radio, and had been working towards graduation or graduated as model families for HEP were more likely to have good utilization of maternal health services. Hence these potential social factors could be targets for future intervention and support, as a means of increasing health care utilization. Year of enrolment into the HEP was not associated with good utilization of maternal health services. This may be due to the effect of diffusion of the intervention. Households who were enrolled later into the program may have opportunities to learn and share experience on positive health behaviours and information from households that were enrolled earlier.
Strength and limitation of the study
Our study examined utilization of maternal health services among rural women who are difficult to reach. Our study is a cross sectional study and it may be difficult to attribute all the changes in utilization of maternal health services to the deployment of HEWs. Comparing our findings from a local sample with a national survey has its own limitation as the study population of our survey is small in size and from a specific region of the country while the national survey is large in size and representative for the whole country. Nevertheless, similar findings on improvements on utilization of family planning, antenatal care and HIV testing after the introduction of the HEP were observed by other studies conducted in other regions of the country. Thus the conclusions made in our study are most likely hold true not only for our study area but also for other areas in the country irrespective of the difference in socio-demographic characteristics across the country. It is worthy considering the way the outcome index (maternal health service utilization) is constructed, the variables chosen to construct this index and its categorization into good and poor. Had we chosen different variables and categorization to construct this outcome index, the results might have been different. Recall bias might also influence some of the results such as information on whether a household had been working towards graduation or graduated as model family or not and women’s involvement in IGA or not, because we took women’s word for these variables. Some important determinants of maternal health services utilization, for example distance to health facility, timing and frequency of HEWs visits, and household-decision making practices are not taken into account in our study. We recommend further study on the effect of these factors on utilization of maternal health services by rural women.