The role of health extension workers in improving utilization of maternal health services in rural areas in Ethiopia: a cross sectional study

In response to inadequate numbers of health personnel, many countries have focused on increasing production and distribution of personnel. This occurred in 1980s particularly in the community health worker cadre although in the 1990s many such programmes faltered [1]. Community health workers (CHWs) are widely used to provide care for a broad range of health issues. However, there is insufficient evidence about the effectiveness of their work in implementing comprehensive primary health care [2]. This lack of knowledge makes it difficult for policy makers to decide how CHWs can best improve the effectiveness of primary health care.

Like in many resource constrained countries, Ethiopia has been training and deploying different categories of volunteer community health workers (VCHWs) in the past decades. These CHWs include trained traditional birth attendants (TTBAs), community based reproductive health agents (CBRHAs) and community health agents (CHAs). However, to accelerate the expansion of primary health care coverage and to ensure equitable access to health services, the government of Ethiopia started deploying specially trained new cadres of community based health workers named Health Extension Workers (HEWs). This initiative has been called the Health Extension Program (HEP). The HEP has been introduced in recognition of the failure of essential services to reach the people at the grassroots level in particular to underserved rural population. It was designed based on the concept and principles of comprehensive primary health care [3–6].

The health system of Ethiopia is a four level health system, characterized by a primary health care unit (PHCU), and then the district hospital, zonal hospital and specialized hospital. A PHCU has been planned to serve 25,000 people, while a district and a zonal hospital are each expected to serve 250,000 and 1,000,000 people, respectively. Specialized hospitals are planned to serve a catchment area with 5 million people [7].

The lowest level in the Ethiopian health system is a PHCU, comprising one health center and five satellite health posts. Health centers are staffed with a health professional team including midlevel health professionals for instance health officers, nurses, midwives, sanitarians and laboratory technicians. A health center provides comprehensive primary health care which includes promotive, prevention, curative and rehabilitative services. One health center supervises and receives referrals from five satellite health posts. A health post is the operational center for two HEWs. On average, a health post serves a kebele which comprises approximately 1000 households or 5000 people.A kebele is the smallest administrative unit in Ethiopia, but it can include several small villages. By the year 2010, a total of about 34,000 HEWs were trained and deployed throughout the country. In addition about 15,000 health posts were constructed in the country. HEWs are required to spend 75% of their time conducting outreach activities by going from house to house in their respective kebele, while the rest of their time they are supposed to be at the health post. All HEWs have completed high school and received additional training for 1 year at an undergraduate level. The HEWs are also different from the VCHWs in that they are employed in the government health system structure and get monthly salary. They receive more advanced and comprehensive training when compared to VCHWs [3–6].

With the aim of reducing maternal mortality, HEWs are trained on how to provide care to pregnant mothers through pregnancy, birth and postnatal period. HEWs inform pregnant mothers on safe motherhood when they provide antenatal care (ANC), birth and post natal care (PNC). HEWs also provide family planning services and are trained on how to educate women on the use of iodized salt and HIV testing.

Since the implementation of the HEP, few studies have published findings on the effectiveness of HEWs [8]. These studies have shown their effectiveness in improving utilization of family planning and immunization services. However, none of them investigated the HEWs role in improving utilization of comprehensive maternal health services.

This study focuses on the extent to which these specially trained community health workers have contributed to the improvement of utilization of maternal health services by rural women in Ethiopia. We compare current utilization of maternal health services with the Ethiopian Demographic Health Survey 2005(EDHS 2005) and investigate which variables may be related to good utilization of maternal health services.

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 [13]. 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 [14]. 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 [12]. 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 [15]. 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 [16].

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 [18]. 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 [13]. 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 [21], 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.

This study has shown HEWs have brought essential maternal health care closer to the rural population in Ethiopia. Nevertheless their success is not for all components of maternal health services. HEWs brought improvement in utilization of family planning, ANC and HIV testing but not in assisting births. The perception that HEWs’ may be less competent in assisting births, the huge workload they already have, poorly equipped health posts and strong cultural beliefs supporting home births, make it unreasonable at the present time to expect substantial change in where and how women give birth. These challenging factors call for innovative strategies to support the efforts of HEWs in identifying risky mothers, birth preparedness and to improve their referral to health centers where midwives and better facilities for assisting births are available.