Umeå University, Medical Dissertations

New Series No 1705, ISSN 0346-6612, ISBN 978-91-7601-239-0

Department of Public Health and Clinical Medicine

Epidemiology and Global Health
Umeå University, SE-901 87 Umeå, Sweden

No woman should die while giving life

Does the Health Extension Program improve
access to maternal health services in Tigray,
Ethiopia?

Tesfay Gebregzabher Gebrehiwet

Department of Public Health and Clinical Medicine

Epidemiology and Global Health
Umeå University
Umeå 2015
 Department of Public Health and Clinical Medicine
Epidemiology and Global Health
Umeå University
SE-901 87 Umeå, Sweden

Responsible publisher under Swedish law: the Dean of the Medical Faculty
This work is protected by the Swedish Copyright Legislation (Act 1960:729)
ISSN: 0346-6612
ISBN: 978-91-7601-239-0
Copyright © Tesfay Gebregzabher Gebrehiwet 2015
Cover photo and other photos: Tesfay Gebregzabher Gebrehiwet
Electronic version available at http://umu.diva-portal.org/
Printed by: Print & Media, Umeå University, Umeå, Sweden 2015
This thesis is dedicated to my late (young) brother Mussie Gebregzabher
Gebrehiwet, let his soul rest in peace.
0
Table of Contents

Abstract in Tigringa 3
Abstract 9
Acronyms 12
Terminology 13
Prologue 15
Introduction 17
The global maternal health and health care situation 19
Maternal health care initiatives globally 21
Background 25
Profile of Ethiopia 25
History and geography 25
Socio-economic situation 26
Gender relations in Ethiopia 27
Health status 28
The Ethiopian health system and its organizational 29
structure …
The Health Extension Programme 31
Maternal health care in Ethiopia 35
The Tigray region 37
Regional context 37
Maternal health care delivery system in Tigray 39
The maternal health care situation 41
36
Rationale for this thesis 43
Aim of the thesis 45
The overall aim 45
Specific objectives 45
The conceptual framework 47

1
Methods 51
Study area 51
The research design 52
Quantitative retrospective longitudinal study 53
Quantitative cross sectional study 55
Qualitative, Grounded theory approach 57
Qualitative, Thematic analysis approach 59
Ethical considerations 60
Main findings 61
The association of HEP with the levels and trends of 62
antenatal, delivery and postnatal care utilization from year
2003-2012
Regression analysis 64
Factors associated with antenatal care and delivery services …60
65
Women’s experiences in giving birth 68
Institutional delivery from health workers perspective 71
Discussion 75
Availability 76
Accessibility 77
Acceptability 78
Methodological considerations 81
The role of the researcher 84
Conclusion 85
Implications for further intervention 87
Implications for further research 89
Acknowledgements 91
References 95

2
Abstract in Tigrigna

ሓፂር መግለፂ ፅንዓት

ሽፋን መሰረታዊ ክንክን ጥዕና ምዕባይ ድሕንነት ኣዴታትን ህፃናትን ንኽረጋገፅ

ዝለዓለ ተራ ከምዘለዎ ይፍለጥ፡፡ ይኹንደኣምበር ግልጋሎት ጥዕና ኣዴታት ብማዕረ
ኣብ ምብፃሕን ብምዕሩይ ኣገባብ ኣብ ምሃብን ብዙሓት ሃገራት እናተፀገማ እየን፡፡
ነዚ ዘይምዕሩይን ማዕረ ዘይኾነን ኣዋህባ ግልጋሎት ጥዕና ንምምሕያሽ ኣብ ሃገርና
(ኢትዮጵያ) ብ1994-1995 (ብአቆፃፅራ ግእዝ) ዝተኣታተወ ፕሮግራም ምግፋሕ
ጥሙር ጥዕና ቤተሰብ (Health Extension Program/HEP) 10 ዓመታት
ኣሕሊፉ ይርከብ፡፡

ፕሮግራም ምግፋሕ ጥሙር ጥዕና (HEP)፣ ሕብረተሰብ መሰረት ዝገበረ-ምክልኻል

ሕማማትን ምስጓም ጥዕናን - ምትእትታው ግልጋሎት ሕክምና ቀለልቲ ሕማማትን
ብፍላይ ድማ ንኣዴታትን ህፃናትን ትኹረት ብምግባር ስድራ ቤት ብምሕቋፍ
ዝንቀሳቐስ ፕሮግራም እዩ፡፡

እዚ ፕሮግራም ንምትግባር ኣብ ክልል ትግራይ ልዕሊ 600 ኬላታት ጥዕና

ተሃኒፀን፡፡ ልዕሊ 1200 ሞያተኛታት ጥሙር ጥዕና እውን ሰልጢነን እየን፡፡ ክልተ
ሞያተኛታት ኣብ ሓደ ኬላ ጥዕና ተመዲበን ካብ 5000-7000 በዝሒ ንዘለዎ
ሕብረተሰብ ግልጋሎት እናሃባ ይርከባ፡፡ እንተኾነ ግን ዝተፈላለዩ መፅናዕታታት
ከምዘመላኽትዎ ግልጋሎት ኣዴታት ጥዕና (ወሊድን ድሕሪ ወሊድን) ትሑት ሽፋን
ከምዘለዎ ይሕበር፡፡

ዕላማ እዚ ዝገበርናዮ መፅናዕቲ እውን ኩነታት እቲ ግልጋሎት ብኣሃዝ ንምዕቃንን

ከምኡ እውን ምኽንያታት እቲ ትሑት ግልጋሎት ንምድህሳስን እዩ፡፡

3
ኣብዚ መፅናዕቲ እዚ ምኽንያታት ትሑት ሽፋን ግልጋሎት ክንክን ጥንሲ ወሊድን
ድሕረ ወሊድን እንታይ ምዃኑ ካብ ሕሉፍ ልምዲ (ተሞክሮ) ኣዴታትን ሰብ ሞያ
ጥዕናን ብዝርዝር ብምድህሳስ - ፕሮግራም ምግፋሕ ጥሙር ጥዕና ንቐረብ
ግልጋሎት ኣዴታት ጥዕና ንምምሕያሽ ዘለዎ ኣስተዋፅኦ እንታይ ከምዝመስል
ተተንቲኑ ቐሪቡ ኣሎ፡፡ እቲ ቀረብ ግልጋሎት ጥዕና ሓሙሽተ መዐቀኒታት ብዘለዎ
ፍሬም ዎርክ እዩ ተዳህሲሱ እቶም ሓሙሽተ መመዘኒታት
1. ቅርበት ትካል ጥዕናን ሰብ ሞያ ጥዕናን ንተገልገልቲ
2. ህልውነት ሰብ ሞያ ጥዕናን ናውትን ድሌት ተገልገልትን
3. ሰብ ሞያ ጥዕና ብተገልገልቲ ዘለዎም ተቐባልነት
4. ትካል ጥዕና ንድሌት ተገልገልቲ ንምዕጋብ ዘለዎ ድልውነት
5. ተገልገልቲ ወፃኢታት ሕክምና ንምሽፋን/ንምኽፋል ዘለዎም ድሌትን
ዓቕምን እዮም፡፡

እዞም ሓሙሽተ መዐቀኒታት መሰረት ዝገበሩ ኣርባዕተ ዓይነታዊን አሃዛዊን ሜላታት

ብምጥቃም ዝተኻየዱ መፅናዕትታት ኣብ ኣብ 4ተ ወረዳታት ትግራይ እዮም
ተኻይዶም፡፡

ኣብቲ ቀዳማይ መፅናዕቲ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ቤተሰብ (HEP) ኣብ

ምምሕያሽ ክንክን ጥንሲ-ወሊድን-ድሕረ ወሊድን ግልጋሎት ዘምፅኦ ለውጢ ኣብ
ሰለስተ ወረዳታት (ጋንታአፈሹም፤ ክልተ ኣውላዕሎ፣ ሕንጣሎ ዋጅራት) ንዝሓለፉ
10 ዓመታት ኣብ ዝተዋህበ ግልጋሎት ብምድራኽ እዩ ዳህሰሳ ተኻይዱ፡፡
ትኽክለኛነት እቲ ፀብፃብ እውን ካብ ትካላት ጥዕና ዝተልኣኸ ወርሓዊ ኣብ ወረዳ
ምስ ዘሎ ፀብፃብ ብምንፅፃር ንኽረጋግፅ ተገይሩ እዩ፡፡ እቲ ካልኣይ መፅናዕቲ ኣብ
ወረዳ ሰሓርቲ ሳምረ ካብ 19 ጣብያታት ካብ ዝተመረፃ 30 ቑሸታት ዕድሚአን
ካብ 15-49 ዓመት ምስ ዝኾና 1115 ደቂኣንስትዮ ኣስታት 30 ደቓይቕ ዝወደአ
ቃለ መሕትት ብምኽያድ እዩ ዳህሰሳ ተኻይዱ፡፡

ኣብ ወሊድ ግልጋሎት ዘሎ ልምድን ተሞክሮን ንምድህሳስ 51 ኣዴታት

ዝተሳተፋሉ ሽዱሽተ ጉጅላዊ ምይይጥ በቲ ሳልሳይ መፅናዕቲ ምርምር ዝተፈፀመ

4
እንትኾን ምስ ሸሞንተ ሞያተኛታት ጥሙር ጥዕናን ኣርባዕተ ነርስ መዋልዳንን ቃለ
መሕትት ብምኽያድ እቲ 4ይ ምርምር/መፅናዕቲ ተፈፂሙ እዩ፡፡

ውፅኢት ቀዳማይ መፅናዕታዊ ፅሑፍ

ኣብዚ ቐዳማይ መፅናዕቲ እቶም ዝተአከቡ መረዳእታት ኣብ ሰለስተ ደረጃታት -

ቅድመ ፕሮግራም-ፕሮግራም-ድሕረ ፕሮግራም ብዝብል ዝተመቐሉ እዮም፡፡ እቲ
ቐንዲ ዕላማ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ድሕሪ ምጅማር ዝተራእየ ለውጢ
ንምፍታሽ እዩ፡፡

ኣብ ድሕሪ እቲ ፕሮግራም ካብ 2001-2004 ዓ/ም ብዝተኻየዱ ንጥፈታት ጥዕና

ግልጋሎት ወሊድን ድሕረ ወሊድን ኣብ ኩለን ትካላት ጥዕና ካብ ዓመት ናብ
ዓመት ልዑል ኣዝማሚያ እናርኣየ ከምዝኸደ ብስታቲስቲካዊ መረዳእታ ንምርግጋፅ
ተኻኢሉ እዩ፡፡ ብተመሳሳሊ ኣብዚ ወቕቲ እዚ ኣዝማሚያ ግልጋሎት ክንክን ጥንሲ
ኣብ ጥዕና ጣቢያታት ጥራሕ እናለዓለ ከምዝኸደ ውፅኢት እቲ መፅናዕቲ የረድእ፡፡

እቲ መፅናዕቲ ከም ዘረድኦ ሽፋን ክንክን ጥንሲ ብ1995 ካብ ዝነበሮ 28.2%

ብ2004 ናብ 46.7 ክምዝለዓለ፤ ግልጋሎት ወሊድ ብ1995 ካብ ዝነበሮ 5% ዝነበረ
ናብ 23% ከምዝደየበ ድሕረ ወሊድ ግልጋሎት እውን 11% ዝነበረ ናብ 41%
ከምዝለዓለ ንምርዳእ ተኻኢሉ ኣሎ፡፡

ውፅኢት ካልኣይ መፅናዕታዊ ፅሑፍ

ኣዴታት ግልጋሎት ክንክን ጥንሲ ኣብ ጥዕና ጣቢያ ንኽጥቀማ ቅርበት ትካላት

ጥዕና ንመንበሪ ገዛውቲ፣ ሓዳር ምግባር፣ ልዕሊ 5 ዓመት ስሩዕ ትምህርቲ ምምሃርን
ካብ ሕርሻ ወፃኢ ኣብ ካልእ ስራሕቲ ዝተዋፈሩ ሰብ ሓዳር ምህላው ወሰንቲ
ኣካላት ምዃኖም በቲ ዝተገብረ ካልኣይ መፅናዕቲ ተረጋጊፁ፡፡ ብተመሳሳሊ ኣብ
እዋን ክንክን ጥንሲ ንኣዴታት ምኽሪ ግልጋሎት ምሃብ ቅድመ ታሪኽ ዝንጉዕ
ሕርሲ ወይ ሃልኪ ምንባር እውን ኣብ ትካላት ጥዕና ወሊድ ግልጋሎት ንኽመሓየሽ
ወሰንቲ ኩነታት ከምዝኾኑ በቲ መፅናዕቲ ተረጋጊፁ፡፡

5
ብሓፈሻ ፕሮግራም ምግፋሕ ጥሙር ጥዕና ቤተሰብ (HEP) ቀረብ ግልጋሎት
ጥዕናን ሽፋን ክንክን ጥንሲ ወሊድን ድሕረ ወሊድ ግልጋሎትን ኣብ ምምሕያሽ
ዝተፃወቶ ተራ ትርጉም ዘለዎ ምዃኑ በቲ ዝገበርናዮ መፅናዕቲ ንምርዳእ ተኻኢሉ
ኣሎ፡፡ እንተኾነ ግን ባህላዊን ልማዳዊን ኩነታት (ኣብ ገዛ ክትወልድ ምድላይ-
ነፍሰፁር ዓይኒሰብ ከይረኽባ ኢልካ ምእማን) - ተበቲኖም ዝሰፈሩ ነበርቲ ምህላው -
ኣፀገምቲን ዓቐብ ቁልቁልን ጎቦታትን ዝበዝሖም መንገድታትን እኹል መጉዓዝያ
ዘይምህላውን ቀንዲ ሃልኪታትን ዕንቅፋታትን እቲ ዝወሃብ ግልጋሎት ምዃኖም
ኣብዚ መፅናዕቲ ተገሊፁ እዩ፡፡ ብተወሳኺ ኣብ ላዕለዎት ትካላት ጥዕና ዘይብሩህ
ገፅን ሰሓባይ ኣቀራርባ ሰብ ሞያ ጥዕና ዘይምህላውን ተቐባልነት ዘይብሎም
ባህሪያት ምንፅብራቕን ነቲ ግልጋሎት ዝዓዘዘ ዕንቅፋት ከምዘለዎ በቲ መፅናዕቲ
ንምርዳእ ተኻኢሉ እዩ፡፡ ማይን መብራህትን ዝኣመሰሉ ትሕቲ ቕርፂ ኣብ ኬላታት
ጥዕና ዘይምህላዉ ኣዴታት ኣብ ቀረበአን ዘሎ ትካል ጥዕና ንኽወልዳ ዘየተባብዕ
ከምዝኾነ እውን ተሓቢሩ እዩ፡፡

ውፅኢት ሳልሳይን ራብዓይን መፅናዕታዊ ፅሑፍ

ኣብ ሳልሳይ መፅናዕቲ ምስ ኣዴታት ብዝተገበረ ምይይጥ - ኣደ እትወልደሉ ቦታ

ባዕላ ንኽትውስን ከምእነሓጎታት ዝመሰላ ዕድመ ዝደፍኣ ኣዴታትን ፀቕጢ
(ተፅእኖ) ከምዝግበረላ እቶም መፅናዕቲታት ይሕብሩ፡፡ ዋላ አኳ ኣብ ትካል ጥዕና
ብዛዕባ ምውላድ ኣዎንታዊ ኣረኣእያ ኣዴታት ዝዓዘዘ እንተኾነ ብዛዕባ ድኹም
ኣዋህባ አገልግሎት ጥዕና ኣዝዩ ከምዘተሓሳስበን እቲ መፅናዕቲ ይገልፅ፡፡ ትካል
ጥዕና ናብ መንበሪ ኣዴታት ዘለዎ ርሕቐትን መጓዓዓዚ ዘይምርካብ ዝኣመሰሉ
ፀገማት ከምዘገድስወን እውን እቲ መፅናዕቲ ይሕብር፡፡

ኣብቲ ራብዓይ መፅናዕቲ ብወገን ሞያተኛታት ጥሙር ጥዕናን ነርስ መዋልዳንን

ብዝተገበረ ምይይጥ - ኣብ ሆስፒታል ዝዋሃቡ ዝሐሹ ግልጋሎት ኣዴታት ካብ
ታሕተዋይ ትካል ጥዕና ናብ ሆስፒታላት ሪፈር እንትበሃላ ኣብ ምጉዕዓዝ
ብሕብረተሰብ ዝግበር ምትሕግጋዝ ከምኡ እውን እናዓበየ ዝኸይድ ዘሎ ግንዛበ

6
ሕብረተሰብ ኣዴታት ኣብ ትካል ጥዕና ንኽወልዳ መሳለጢ ከምዝኾነ እቲ ፅንዓት
የረድእ፡፡ ዓቕሚ ምንኣስ ሞያተኛታት ጥሙር ሞያተኛታት ጥሙር ጥዕናን ነርስ
መዋልዳንን - ድኹም ኩነታት ትካል ጥዕናን (ሕፅረት ናውቲ ጥዕና ምህላዉ -
ትሕቲ ቅርፂ ዘይምምላእ) ፀገም መጉዓዝያን እውን ኣዴታት ኣብ ትካል ጥዕና
ንኸይወልዳ ዕንቅፋታት ከምዝኾነ እቲ ፅንዓት የመላኽት፡፡

መጠቓለሊ

እቶም ዝተጠቐሱ ዕንቅፋታትን ፀገማትን ብምንካይ ቀረብ ወሊድ ግልጋሎት ጥዕና

ንምዕባይ እዞም ዝስዕቡ ፃዕሪታት ምክያድ ይግባእ፡፡

ኣብ ጎቦታትን ኣዝዩ ርሑቕን ኣፀገምትን ዝሰፈረ ሕብረተሰብ ካብቲ ልሙድ

ዝተፈለየ ቀረብ ግልጋሎት ጥዕና ምሃብ (ንኣብነት ካብ ጥዕና ጣቢያ ኣዝየን
ዝርሕቓ ኬላታት ጥዕና ክእለት ዘለወን ነርስ መዋልዳን (midwives) ምምዳብ -
ኣደ ማእኸል ዝገበረ ግልጋሎት ንኽወሃብ ሰብ ሞያ ጥዕና ብዓቕሚ ንኽዓብዩ
ምግባርን ነቶም ሓሙሽተ መዐቀኒታት ቀረብ ግልጋሎት ብምምላእ ኣብቲ
ሕብረተሰብ ተቐባልነት እቲ ግልጋሎት ክዓቢ ምግባርን፡፡

7
8
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.

9
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.

10
Original papers
This thesis is based on the following papers:

I. Gebrehiwot T, San Sebastian M, Edin K, Goicolea I: Health

Extension Program and its association with change in
utilization of selected maternal health services in
Tigray region, Ethiopia: a segmented linear
regression analysis. Submitted to PLOS one.

II. Tsegay Y, Gebrehiwot T, Goicolea I, Edin K, Lemma H, San

Sebastian M: Determinants of antenatal and delivery
care utilization in Tigray region, Ethiopia: a cross-
sectional study. International Journal for Equity in Health
2013, 12:30.

III. Gebrehiwot T, Goicolea I, Edin K, San Sebastian M: Making

pragmatic choices: women's experiences of delivery
care in Northern Ethiopia. BMC Pregnancy Childbirth
2012, 12:113.

IV. Gebrehiwot T, San Sebastian M, Edin K, Goicolea I: Health

workers’ perceptions on facilitators and barriers for
institutional delivery in Tigray, Northern Ethiopia.
BMC Pregnancy and Childbirth 2014, 14:137.

Reprints were made with permission from the respective publishers.

11
Acronyms
ACRMMA Accelerated campaign to reduce maternal mortality in Africa
ANC Antenatal care
BEmNOC Basic emergency and neonatal obstetric care
CBHC Community based health services
CBPHC Community based primary health care
CEmNOC Comprehensive emergency and neonatal obstetric care
DC Delivery care
DHO District health office
EDHS Ethiopian demographic and health survey
FGD Focus group discussion
GTP Growth and transformational planning
HEP Health extension program
HEW Health extension worker
HF Health facility
HSDP Health sector development program
ICPD International conference on population and development
IMF International monetary fund
MDG5 Millennium development goal 5
MHTF Maternal health thematic fund
MMR Maternal mortality ratio
MoH Ministry of health
NHP National health policy
PASDEP Plan for accelerated sustained development to end poverty
PHC Primary health care
PHCU Primary health care unit
PMNCH Partnership of maternal, neonatal and child health
PNC Postnatal care
PPC Postpartum care
PPH Postpartum hemorrhage
RH Reproductive health
SMI Safe motherhood initiative
SSA Sub-Saharan African countries
TBA Traditional birth attendant
THB Tigray health bureau
UN United nations
VCHW Volunteer community health workers
WHO World health organization
WDA Women development army
WHDA Women health development army

12
Terminology
Antenatal care coverage: Number of pregnant women examined
at least once during the current pregnancy, by a skilled health worker
(nurse, midwife, health officer, doctor) and by HEWs for reasons
related to pregnancy divided by the total number of live births.
Skilled attendance delivery coverage: Number of pregnant
women assisted by a skilled attendant/accredited health professional
(nurse, midwife, health officer, doctor) who is trained to be proficient
in the skills necessary to manage normal pregnancies, childbirth and
the immediate postnatal period including the identification,
management and referral of complications in women and newborn
divided by the total number of live births.
Postnatal care coverage: Number of women who seek care, at
least once during the postpartum period (42 days after delivery) from
skilled health workers (nurse, midwife, health officer, doctor) and by
HEWs, for postpartum related reasons, divided by the total number of
live births.
Clean and safe delivery coverage: Deliveries assisted by HEWs
divided by the total number of live births. This singles out the
activities of the national HEP in which clean and safe delivery service
by HEWs is included as one of their tasks.
Basic emergency obstetric and neonatal care (BEmONC):
The signal functions of BEmONC include: a) remove retained
products after miscarriage/abortion (e.g. manual dilation, extraction
and curettage), b) administer parenteral antibiotics, c) administer
parenteral anticonvulsants for pre-eclampsia and eclampsia (such as
magnesium sulphate), d) administer uterotonic drugs (such as
oxytocin), e) perform assisted vaginal delivery (including vacuum
extraction and forceps delivery), f) perform basic neonatal
resuscitation (with ambu bag and mask) and g) manually remove the
placenta.
Comprehensive emergency obstetric and neonatal care:
Perform all BEmONC signal functions (a-g) plus: perform surgery
(cesarean section) and blood transfusion.
Health Sector Development Program (HSDP): The strategic
plan of the country designed to improve the health status of the
Ethiopian society implemented through a series of five years
programs since 1997/98. It emanated from the national health policy
and is aligned with international commitments such as the MDGs.

13
Volunteer community health workers (VCHWs): Members of
the community who are selected as the best persons for implementing
HEP tasks subsequent to the training by HEWs. They are role models
by being fast learners and acceptors to help HEWs to diffuse health
messages leading to the adoption of the desired practices and
behaviors by the community.
Women development army/group (WDA): An approach of
mobilization within a cluster of thirty households which is further
subdivided into one to five networks of women. These women are
trained and engaged in their localities to mobilize their peers (women
of child bearing age) in the nearby community to be enhanced for
increased health care seeking, particularly for ANC and institutional
delivery.
Service hours: Hospitals and health centres are open to provide
health services 24 hours a day and seven days a week, whereas health
posts are open only working days (from Monday to Friday) from
8:00-12:30 in the morning and 1:30-5:30 in the afternoon. HEWs are
on call for any emergency situations such as referrals or for any first
aid measures.

14
Prologue
My years of work at health centres and hospitals as a registered nurse
has given me the experience of providing skilled attendance to
birthing women and resuscitating newborns. During my internship,
in the delivery unit, I couldn’t believe my eyes when women were
pinched and slapped by health workers during delivery. On top of the
excruciating labor pain, the humiliation and grief that those women
were subjected to by health workers was unbearable. Since then I
have been touched and affected by the dehumanizing nature of
treatment and as a professional I promised myself to provide
compassionate care.
I graduated from Asmara School of Nursing, Eritrea (former
Ethiopia) as a registered nurse with a diploma certificate. After
working a few years there I came to Tigray, Ethiopia. This was 1991
and after the military regime was defeated by Ethiopian Proletarian
Revolutionary Democratic Front (EPRDF) and the leadership had
been taken over by the transitional Government of Ethiopia. The
freedom fighters who struggled 17 years for peace, accountability,
justice and democracy were on their way to implement the strategies
and policies which had been designed and developed during the
period of the armed struggle. I was extremely glad to apply my
knowledge and skills with people who were thirsty for health service
access and I also felt like I was contributing to health sector
development.
To be honest, while I was working in Northern Tigray (Zalanbesa), I
saw that the commitments of the health centre teams in dealing with
various communicable diseases (such as malaria, measles and
whooping cough) and provision of pregnancy and delivery care
resulted in improving the wellbeing of the community.
There were hard moments during outreach services in the villages. It
was an unforgettable event when I struggled to save my own life
during a flooding after sensitizing a community about the importance
of institutional delivery. I suffered only minor cuts and bruises and
the community’s respect towards professionals was encouraging and
motivated me to want to build a strong connection with public health
and research.
Being from a low income family may also have motivated me to face
challenges and struggle for better attainment in life. As part of
improving my future carrier, I graduated as a BSc in public health

15
(health officer), from Gondar University and was assigned at Adi-
remets, Wolkayt which is one of the most remote districts in Tigray.
This was a time where I was challenged to deal with three main roles
of the health service delivery. Providing clinical activities as a non-
physician clinician, coordinating health promotion and disease
prevention of the district and dealing with administrative issues of the
health centre. However, the collaborative effort of internal and
external stakeholders and the love and care of the community taught
me how to harmonize the tasks. I was very inspired by the
coordination and organized movement of the health centre team. We
were following the principle of many as one and one as many in
solving emergency problems. These memories are all shined brightly
into my mind. On the other hand, falling down from a mule, travelling
a long journey (48 kilometres) to reach a place where a vehicle is
available and escaping a furious camel were some of the accidental
events also in my memory.
In the period of 2002-2003, I accomplished a MPH at Umeå
University Sweden and soon after I was re-assigned to be head for the
district health office (DHO) and then transferred to Tigray Regional
Health Bureau as a HEP coordinator. My connection with Umeå
ignited new ideas about research and community service in my mind.
Due to my interest of research and community service, I applied to
work in the University. In the meantime, I also worked for the World
Health Organization (WHO) and United Nations International
Children’s Fund (UNICEF) through contractual agreement for some
months. After working for one and a half years as a lecturer in the
University (2008-2010), I was appointed the head for the department
of public health. It was a nice coincidence when Dr. Miguel San
Sebastian from Umeå University came to visit his former PhD student
in Tigray which also became an opportunity to discuss doctoral
studies.
To be honest, my position as HEP coordinator and the evident
connections between my nursing and public health profession and the
field work at the community level, and my engagement in the
University motivated me to pursue a PhD and choose the topic of my
research.

16
Introduction
In 2000, the United Nations addressed the concern of maternal
mortality reduction with the slogan “No woman should die while
giving life”. In Ethiopia, the slogan captured the interest of the late
Prime Minister Meles Zenawi who constantly repeated it in his
speeches. Moreover, guided by this motto, great efforts towards the
reduction of maternal mortality and morbidity were taken by the
country, the Health Extension Program being the flagship of these
efforts. This thesis aims to explore in which ways the efforts made by
Ethiopia aimed at realizing “No woman should die while giving life”
resulted in better accessibility to maternal health care services for
women.

Ensuring access to universal primary health care is essential to secure

a safe and pleasant motherhood and to provide compassionate care
for mothers and new-borns. However, inequalities in the access to
maternal health services still remain prominent in many countries [1-
2]. The implementation of community based primary health care
programs (CBPHC) is considered one of the best strategies to improve
the access of populations to health services. CBPHC is an approach to
identify health care problems and subsequently to design, implement
and evaluate health intervention activities aimed to address such
problems. The process is led by the community, and involves key
actors, such as government agencies, non-governmental
organizations, donors and private stakeholders [3-6].

CBPHC is believed to address the major health problems of the

society providing promotive, preventive and curative services based
on the socio-cultural, political and economic context of the country.
The CBPHC strategy is enhanced through principles such as
community participation, self-reliance, social awareness and
decentralization of the health system to lower administrative units.
The long term goal of CBPHC is to achieve universal access to health
care to the larger community, through the provision of acceptable,
accessible, available, well organized and appropriate and affordable
health care, including maternal and child health care [7-9].

Ethiopia was one of the four African signatory countries for

implementation of the primary health care (PHC) strategy in the late
1970’s [10]. However, poor governance, a centralized top down
management and a fragmented health service delivery affecting the

17
country for decades, among other factors, hindered the real
implementation of PHC until 1993 [11-13].

That year, the government of Ethiopia developed the National Health

Policy (NHP) emphasizing the democratization and decentralization
of the health structures and aiming for universal access and equity of
health care to the population. To achieve these goals, the government
formulated a 20 year plan (1997/8-2014/5) under the name of Health
Sector Development Program (HSDP). Along these years, the HSDP
has been performing continuous interventions in policy and programs
to strengthen the country’s health care system. In 2003, as part of the
community based primary health care intervention, the Health
Extension Program (HEP) was established as the flagship of the
HSDP.

The HEP is a new program designed with a defined package of

essential promotive, preventive and basic curative services targeting
households, particularly mothers and children in a community.
Improving access to maternal and child health services was among
the major objectives of the HEP [13-15]. Despite the empowerment
and involvement of the community in implementing the HEP, the
access to curative services remains low. The limitations in fulfilling
the communities’ expectations in terms of access to curative services
might be a challenge to the HEP strategy which focuses mainly on
promotive and preventive services.

The northern state of Tigray has been the leading region in the
country in creating a solid platform for delivering the HEP. In 2005,
600 health posts, staffed with 1200 Health Extension Workers
(HEWs) were working in the region. This was possible due to the
coordinated effort between the leadership at the regional level and a
strong commitment of the district level officials together with the
rural communities. However, many challenges were encountered
during the initial stage of the program implementation. Some of these
main challenges included: 1) incompleteness of equipment, supply
and furniture at health posts, 2) absence of clear guidelines on career
structure of HEWs and their relation with other health workers, 3)
weak transport and communication services and 4) absence of
reading and reference materials in the local language [13, 16].

When this thesis was planned, despite the government’s effort in

implementation of the HEP, maternal health care utilization

18
remained poor and the reasons for the low coverage of services were
not sufficiently clear.

This thesis consists of ten chapters and gives a comprehensive

description regarding the endeavor of the HEP in improving the
access of the maternal health care services to the rural population of
Tigray. The global maternal health situation, maternal health
initiatives including the safe motherhood initiative and other global
strategies to improve maternal health are presented in chapter 1. The
socioeconomic context, the health system and its organizational
structure, both at national and regional level, with a focus in the
health extension program are described in the second chapter. Then,
the rationale of the thesis is included in chapter 3.

The next chapters of the thesis focus on the four studies that
constitute the core of this thesis. The aim and the four specific
objectives are presented in chapter 4 while the conceptual framework
linking the four objectives with the concept of access is elaborated in
chapter 5. The research design, consisting of a combination of
different methods, and the ethical considerations are described in
chapter 6. The major findings of this thesis are then presented in
chapter 7. The discussion in chapter 8, the conclusion in chapter 9
and the implications of the results for practice and future research in
chapter 10 are considered in the last section of the thesis.

The global maternal health and health care situation

The global community started to pay significant attention to women’s
health when the United Nations (UN) charter was signed during the
establishment of the World Health Organization (WHO) in 1948 [17].
Later, maternal health was recognized as one of the core elements of
primary health care (PHC) during the international conference of
Alma Ata in 1978. Consequently, improving access to maternal health
services in low and middle income countries continued to be a
concern of governments and international agencies [7, 18]. This can
be illustrated by the growing attention that safe motherhood has
received at international conferences and summits over the last two
decades.
Despite being prioritized on the international agenda, more than
289,000 women around the globe still die because of pregnancy and
delivery related complications. Maternal mortality has continued to
decrease in south and east Asian countries and southern and central
Latin America [19-20]. Almost all (99%) maternal deaths occur in

19
developing countries. The overwhelming tragedy is particularly
evident in sub-Saharan African (SSA) countries, accounting for
around two thirds of the global burden (62%) (Figure 1). The
estimated risk of women dying due to pregnancy and childbirth is 1 in
38 in SSA in comparison to high income countries where the risk is 1
in 3400 [19-24]. Due mainly to the burden of communicable diseases,
such as HIV, the number of maternal deaths in SSA from 1990-2000
showed an increased trend hence, an evidence of decline was
observed later (till 2013) due to enhanced anti-retroviral uptake [19-
20]. These statistics might underestimate the number of maternal
deaths in the region due to the absence of vital registration system
and we most certainly have unrecordable cases which were supposed
to capture maternal deaths.

Figure 1. Maternal mortality ratio by countries, trends 1990-2013

[19].

Several factors related to culture, context and health systems

contribute to the overall maternal mortality situation and include:
poverty, gender inequality, low utilization of services, absence of
social pressure to improve access, lack of coordination, weak
information and fragile health systems. At the individual level,
women’s socio-demographic characteristics such as: older age, parity,
not being married (single, divorced, separated), poor access to health
services and low economic and educational status - have been
commonly identified as major risk factors for the low utilization of
maternal health care that leads to increased maternal mortality [25-
31].

20
Besides death due to unsafe abortion, most maternal deaths occur
during labor, delivery, or 24 hours after birth because often serious
complications during these stages cannot be reliably predicted. The
medical causes of maternal mortality are mainly hemorrhage,
obstructed labor, eclampsia, severe pre-eclampsia and sepsis. Beyond
the preventable medical causes, three types of delays, which mainly
focus on the social determinants of maternal deaths, have been
mentioned as explanatory causes throughout the literature for many
decades [22].

The first delay refers to delay in deciding to seek appropriate medical

care and socio-cultural norms and traditions are influential in this
delay. These may include religion, influence from elderly, the
consideration of delivery as a natural event, fear of the health facility
setting, poor decision making power of women and low levels of
education among women. Besides, poor access to information for
women about the place of delivery, failure to identify different
barriers (cost and geographical challenges) and poor community
involvement are also aggravating factors [22, 32-33].

In addition, there are delays in reaching appropriate obstetric

facilities (second delay) and delays due to lack of adequate care after
reaching the facility (third delay). Both delays are connected to the
supply factors which are mainly related to health policies and health
system organization. The most frequently mentioned factors in the
literature regarding the second delay include the unavailability of
transport, poor quality and delay of referral. Long waiting time at
health facilities, shortage of supplies, absence of skilled health
workers, unfriendly approach of health workers, poor responsiveness
and poor quality of care are usually part of the third delay [22, 32, 34-
35]. Health care providers’ lack of sensibility towards traditional
norms of the society on the process of childbirth – as promoted in the
CBPHC approach is also reported as a key barrier for institutional
delivery [36-37]. Overall, the primary bottleneck of the supply factors
in poorly resourced countries are due to the overwhelming failure of
health systems, lack of good governance, poor political commitment,
lack of attention to the ethos of CBPHC, lack of donor coordination
and lack of harmonization between stakeholders [28, 31-34, 38].

Maternal health care initiatives globally

As part of the ongoing effort to improve maternal health and reduce
maternal mortality, numerous global initiatives have been
implemented in the past decades. The main aim of the global Safe

21
Motherhood Initiative (SMI) conference in Kenya (1987) was to cut
down maternal mortality by 50% by the year 2000. The SMI blended
the major components considered to be key for maternal mortality
reduction - family planning, access to quality care during pregnancy
and throughout the process of child birth and early postnatal care
[39-42].

The SMI with its successive initiatives has been influenced by

different emerging evidence and competing interests over the years
[43-44]. In the 1970s-1980s, screening for risk factors during
pregnancy and training of traditional birth attendants (TBAs) were
considered useful approaches to improve maternal health services
and were implemented in low income countries as core strategies.

Despite the fact that donors dispensed their cash on TBA training and
screening pregnant women (for high risk factors such as pregnancy
induced hypertension or gestational diabetes), such strategies were
not effective enough to curb maternal mortality [45-46]. As a result,
community-based actions and training programs for TBAs were
criticized and often discontinued.

Immediately, the focus of the programs shifted towards increasing

access to skilled delivery attendance and emergency obstetric care.
The assumption was that since it was not possible to predict obstetric
complications during child birth, women should deliver close enough
to health care facilities that could manage these complications. This
meant focusing on implementing Basic Emergency Obstetric and
Neonatal Care “BEmONC” and Comprehensive Emergency Obstetric
and Neonatal Care “CEmONC”, (see pages 13-14 for definitions) [42,
47-48]. The availability of these services is measured by the number
of facilities that perform the complete signal functions in relation to
the size of the population. According to the WHO, the minimum
acceptable level for a population of 500,000 is five BEmONC facilities
with at least one providing comprehensive care [49].

Parallel to these events, a series of international conferences and

summits focusing on sexual and reproductive health and gender
equality were held where the issue of enhancing safe motherhood and
reducing maternal mortality were also addressed [50-53]. For
instance, the International Conference on Population and
Development (ICPD) in 1994 appealed to the concerned global bodies
to focus their attention on reducing maternal mortality and
improving women’s health through ensuring access to: family

22
planning and reproductive health services, maternal health-care
services, skilled attendance at delivery and emergency obstetric care
[54].

In 1995, the Beijing World Conference on women reaffirmed that the

universal access of health care, women’s empowerment and their
right to health needs to be ensured as a priority action. It further
emphasized the position of women to be considered beyond
motherhood, the importance of gender equality for improving
women’s health and education, and the contribution of women to the
welfare of the family and to the development of the society [51].

Lastly, improving maternal health and reducing maternal mortality

was adopted by all United Nations (UN) countries in 2000 as one of
the eight Millennium Development Goals (MDGs) aiming to reduce
the maternal mortality ratio (MMR) by three quarters between 1990
and 2015 [55].

The most recent global Partnership of Maternal Neonatal and Child

Health (PMNCH) was established in 2005. It advocates for an
integrative and life cycle approach to maternal health care, focusing
on ensuring access to maternal health care at the institutional level,
but coordinated with care provided at the household and community
levels [56, 57]. As part of strengthening PMNCH, the 194 UN member
states and several partners renewed their commitment to save women
and newborns lives during the 67th WHO assembly in 2014 [42, 57-
61].

In Africa, various programs are currently being introduced aiming to

strengthen women’s sexual and reproductive health rights through
empowering and enabling women to decide whether and when to get
pregnant and improving access to quality care through pregnancy and
child birth. Since 2009, the Maternal Health Thematic Fund (MHTF)
under The African Union Commission (CARMMA), an accelerated
campaign to reduce maternal mortality in Africa, supports more than
43 African countries in reducing maternal mortality through building
the national capacity for strengthening and sustaining emergency
obstetric care. The share of expenditures allocated to African
countries by MHTF in 2012 amounted to 62% compared to 57% in
2011 [62].
Despite the efforts made in SSA countries, including Ethiopia, to
improve access of maternal health services utilization, the reduction

23
of maternal mortality remains insufficient - from 990/100,000 live
births in 1990 to 510/100,000 live births; a 49% reduction in 2013
compared to the MDG5 goal that aims for a reduction of 75% [19].

24
Background
Country profile of Ethiopia
History and geography
Ethiopia is an ancient country recognized as Abyssinia, the initial
origin of human being [63]. The Axumite Empire during 1st year after
death of Christ (AD) in Ethiopia was predominantly Christian. It was
one of the great powers of his time along with Persia, Rome and
China. The Islam religion was introduced around 615 AD when the
country offered shelter to followers of the prophet Mohammed [64-
65].

The country has a rich cultural diversity and is home to more than 80
ethnic groups and 83 different languages. The country has
maintained the status as an independent nation free from
colonization and preserves its unique calendar, timing and script.
Ge’ez is an exclusive script which is still used by the Ethiopian
Orthodox Tewahedo Church at present. Amharic and Tigrigna
languages are derived from the Ge’ez script, where the former is the
official national language of the country [66].

Ethiopia is, after Nigeria, the second most populous country in Africa
with 84,320,987 inhabitants. It is situated in the horn of Africa and is
bordered by Djibouti in the east, Sudan in the west, Somalia in the
southeast, Eritrea in the north and northeast, and Kenya to the south
[67-68]. Ethiopia’s total surface area is about 1.1 million square
kilometres (Figure 2).

Around 84% of the country’s population lives in rural areas and it is

recognized as one of the least urbanized countries in the world. The
average annual growth rate is 2.6%. Nearly one quarter of the
population (23.4%) are women of reproductive age (15-49 years). The
average lifetime fertility has declined from 6.4 births per woman
(1990) to 5.4 births in 2005 and 4.8 births in 2011 [69-70].

25
 Nine
regional
states
- Oromia
- Southern
nations and
nationalities
- Amhara
- Tigray
- Afar
- Somali
- Benshangul
- Gambella
- Harari
Two admin.
cities
- Addis Ababa
- Diredawa

Figure 2. Ethiopian map with nine regions and two administrative

cities [69].

Socio-economic situation
Prior to 1993, the centralized nature of the political structure led to
Ethiopia having low socio-economic and technological development.
Since 1993, the transitional government of the country introduced a
decentralization system of administration where decision making
power is shared at all levels -federal government, regional states and
district administrative units [13, 70]. At present, the country is a
federal state with nine regions and two administrative cities (Figure
2).

The regions are divided into 80 zones, 551 districts (woredas) and
about 12,000 villages (kebeles/tabias) [67-69]. A district is the basic
decentralized administrative unit whereas the village is the smallest
administrative unit in the governance structure.

Farming is the major source of livelihood for the population in

Ethiopia and the country’s economy is agriculture centred. Agri-
business accounts for 43% of the gross domestic product and 80% of
exports.

26
Coffee, livestock, gold, leather products, dried legumes, vegetables,
flowers and oil seeds are the major export items of the country. The
plan for accelerated and sustainable development to end poverty
(PASDEP) and the Growth and Transformational Planning (GTP)
have been strategies designed to attain the MDGs and to maintain
rapid economic growth and ultimately to end poverty [69, 71-74].
The country has achieved an effective and efficient utilization of
resources by introducing sector wide approach programs. These
programs have aimed at improving health care planning and
implementation through harmonization and alignment -one budget,
one plan, and one report and all donors are obliged to align their
budget program along with the governmental goals. Poverty head
count index in the country has reduced from 49.5% in 1994/95 to the
level of 29.2% in 2009/2010. Recently, the World Bank announced
Ethiopia as among the five African countries with the fastest growth
of economy [75]. However, socio-economic inequality is still of major
concern in the country. Ethiopia is ranked at 173 of 188 countries on
the human development index (HDI) based on the last human
development report [76-77]. The initiatives that have been
implemented in the economic sector only contributed to increase the
HDI value from 0.284 in 2000 to o.435 in 2013. Despite the efforts,
Ethiopia couldn’t cross the HDI value beyond 0.550 which is the cut-
off point for low human development [75, 78].

Gender relations in Ethiopia

Gender can be described as a set of expected and incorporated
features, characters, and behavior patterns that differentiate women
from men socially and culturally and relations of power between
them. The power relationship and decision making in the Ethiopian
context have been dominated by men [79-81].
Traditionally, the patriarchal and cultural norms of the country have
considered men as breadwinners and responsible for satisfying the
needs of the household members. Women have only been considered
responsible for domestic work and as caretakers of their husbands
and children. Despite women’s involvement in all aspects of society,
their position has not always been recognized. Instead, their poor
decision making power, lack of economic stability and low level of
education has been contributing to low social status.
In response to the existing gender inequalities, a women’s national
policy was formulated in 1993 in order to promote gender equity.

27
Later on, in 2005, the government re-established the women’s affairs
office at the Ministry level. The main aim of the Ministry is to
strengthen gender development and to reduce gender inequality, to
set up strategies for the improvement of women’s access to health and
education, and to empower their socio-economic positions. Partly and
probably due to these policies, a significant number of women, mostly
from urban areas (some but fewer from rural areas) are taking a
major part in all kinds of employment and men are also starting to
take a greater part in domestic life mainly in towns and cities [79, 82].
One Ministerial and three state Minister positions are currently
headed by women [79-81]. The proportion of women who shared the
labor participation increased to 78.2%, and 25.5% of the seats in the
parliament are held by women as reported in the gender gap
development report in 2014 [82].
However, the country still needs to work more on sharing the power
relations between men and women to reduce the gender inequality,
for instance: the prevalence of life-time intimate partner physical
violence against women is reported to be 39%, and 12.5% during the
last three months, in 2013 [79]. Ethiopia is ranked 121 and 126 for
gender inequality index and gender development index respectively of
178 countries.

Health status
Tuberculosis, malaria, HIV/AIDS and non-communicable diseases
such as cardiovascular diseases, diabetes mellitus and cancers along
with injuries are among the major contributories of high morbidity
and mortality in Ethiopia [71, 83].
The country has made good progress towards children’s health. Infant
mortality rate (IMR) has been reduced from 88/1000 in 1990 to
59/1000 live births in 2012, respectively. Child mortality has been
decreased from 184/1000 live births to 88/1000 in the same period.
More than 90% of child deaths are due to pneumonia, diarrhea,
malaria, neonatal problems, malnutrition and HIV/AIDS, or
combinations of these conditions [71].
In terms of sexual and reproductive health, the prevalence of new
HIV infections has dropped from 12.4% in 2003 to 1.3% in 2012.
Maternal mortality has also been reduced from 871 in 2000 to 471 per
100,000 live births in 2012 [71, 84]. More than 80% of maternal
deaths are due to direct obstetric causes: infections/sepsis 47.1%,
hemorrhage 29.4%, severe pre-eclampsia/eclampsia 7.6%, obstructed
/prolonged labor and ruptured uterus 2.9%; and complications from

28
unsafe abortions 2.9%. Indirect obstetric causes such as malaria, HIV,
anemia and cardiac problems account for the remaining proportion
[71, 84]. Selected health indicators of the country are presented in
Table 1.

Table 1. Basic health indicators of Ethiopia for years 2011/2012

[69, 84].
Health indicators Value
Total fertility rate 4.8 per woman
Contraceptive prevalence use rate 40.4 %
Antenatal coverage first visit 89.1 %
Deliveries attended by skilled attendants 20.4 %
Postnatal coverage 44.5 %
Maternal mortality ratio 471/100,000 live births
Infant mortality rate 59/1000 live births
Under five child mortality 88/1000 live births
Pentavalent three immunization coverage 84.9 %
Full immunization coverage 71.4 %
Life expectancy for males 60 years
Life expectancy for females 62 years

The Ethiopian health system and its organizational

structure
Due to a fragile health policy and shortage of resources, the health
access for the majority of the population has been very limited for
decades. The few health institutions have been poorly equipped and
budgeted with a health system dominated by curative services and
with more than 50% of health facilities located in urban areas. A
critical and prolonged shortage of human resources has been another
major challenge [13, 85-87].
In 1993, the transitional government of Ethiopia developed a National
Health Policy (NHP) aimed at addressing the health rights, values
and the needs of the less advantaged population. The NHP
emphasized the principles of democratization and decentralization to
strengthen the health system and to ensure health promotion, disease

29
prevention and equitable, efficient and effective health care delivery.
Health system strengthening was considered as an instrument of
social justice and equity as well as central for social and economic
development. As part of the NHP implementation, the HSDP was
developed during 1997/1998-2014/2015 rolling with five-year
program periods. The HSDP gives attention to harmonizing the goals,
objectives and targets set by all stakeholders (governmental and non-
governmental organizations, donors, private partners and the
community). Thus, the objective of HSDP focuses on attaining
universal access to PHC for the whole population and eventually
achieving the MDGs [12-13]. The successive implementation
conducted to achieve MDG5 is illustrated in Figure 3.

- Decentralization of the health care

system at all levels (1993 and
beyond). Changing health care tier
system (1996, 2012), establishing new
programs and designs (2003 and
beyond)
- Provision of transportation facilities,
strengthening referral and outreach
services, strengthening the national
medical supplies and equipment and
maintenance system (1998-2014).

- Accelerated expansion of PHC service from 2003-

2014 (construction of new health posts, health centres
and upgrading of health facilities).
- Accelerated training of health officers, midwives,
health extension workers, integrated emergency surgery
and obstetrics graduates and other health professionals
from 2003-2014.

Figure 3. Successive implementation of strategies for achieving

MDG5.

As part of the ongoing efforts to improve the package of PHC services

across the country, the structure of the health delivery system was
reorganized from six to four and then to a three-tiered system [12-13,
88]. The current system involves three levels comprised of primary
health care units (PHCU), general hospitals and specialized hospitals.

A PHCU consists of five satellite health posts, one health centre and
one primary hospital serving populations of 5,000, 25,000 and
100,000 respectively. The secondary level -general hospital- serves

30
1,000,000 and the tertiary hospital serves 5,000,000. The health
centre is the immediate referral health facility for the health posts and
it is usually staffed with health officers, midwives, nurses, medical
laboratory technologists, pharmacy professionals, and administrative
staff. Nurses and midwives are trained for two and four years
respectively after finishing high school and are granted diploma and
degree certificates.
To promote decentralization and ensure community participation,
decision making power is shared among regions and districts [12-13].
The Federal Ministry of Health plays a role on designing policy
matters, guidelines, setting forth frameworks and high level capacity
building issues. The Regional Health Bureaus are proactively involved
in establishing the policies and operating guidelines and play
facilitating, coordinating and mentoring roles. The fundamental roles
of managing, coordinating and decision making activities at the
PHCU level are made by the district health offices (DHOs). They are
in charge of supervising and coordinating the primary health care
units. The authority and decision making power of the districts is up
to the level of recruiting and employing health workers, building
infrastructures, procuring essential supplies for health facilities
through fair allocation of resources to the lowest administrative units.
This practical implementation is aligned with community based PHC
principles.

The Health Extension Program

In an effort to increase the access to the health care system and
improve the health status of the most vulnerable rural population, the
government of the country started the implementation of the health
extension program (HEP) in 2004 [15, 71]. The fundamental
philosophy of the HEP is to transfer ownership and responsibility for
preserving people’s own health to households by conveying health
knowledge and skills to them [71, 89]. Model households assist to
diffuse information aimed to encourage adaptation of desired
practices and behaviors in the community. HEP assumes that health
behavior can be enhanced in communities by creating model families
that share their best experiences and encourage their neighbors to
learn and practice similar behavior [71, 90]. It is designed to improve
equitable access to preventive essential health interventions through
community-based health services. It is also intended to achieve
significant basic health care coverage through the provision of a
staffed health post to serve an area of approximately 3,000 to 5,000

31
people - a kebele. Each kebele has one health post and two health
extension workers (HEWs). Health posts receive technical support
from a closer health center and they are located nearest to other
public institutions to facilitate coordination among public service
providers.

The HEWs are the community members’ first point of contact with
the health system providing integrated promotive, preventive and
basic curative health services. They aim to ensure the continuity of
care throughout pregnancy, child birth and postnatal care [14, 91].
Influential members (such as women associations, civil society
organizations and religious and clan leaders) of the community and
district offices representatives (health, education, agriculture,
women’s affair and capacity building) select the HEWs. The criteria
for recruitment include: being female, to be known to respect societal
norms and values, to be known for community participation,
knowledge of the local language and enthusiasm to serve the
community after training. Three reasons can be mentioned for
selecting females to be HEWs: 1) most of the HEP packages are
related to issues affecting mothers and children in the setting, 2)
contextually, in the absence of husbands at the household,
communication between female HEWs and the women was thought
to be easier and culturally acceptable, 3) employing salaried female
health workers by the government at village level was also considered
to empower women.

The HEWs are recruited from their own village and are trained for
one year after they completed high school. Soon after their
graduation, HEWs are usually further mentored about midwifery
services for one month at health centres and hospitals under the
supervision of nurses and midwives. They also receive refresh
training once a year. The HEP has been implemented throughout
Ethiopia, with more than 34,000 HEWs already trained and deployed
in over 14,000 health posts since 2004 (Figures 4 and 5).

Immediately after HEWs are deployed, they provide training to

members of the community for 96 hours during a period of six
months. During the training HEWs are engaged in selecting model
families who are considered to have best performance. Afterwards,
the selected model families are recruited as volunteer community
health workers to collaborate with HEWs to mobilize the community
[13, 71, 89].

32
Figure 4. Trends of health posts construction by consecutive years
(2004-2010) (Source HSDP III, document of 2010/2011).

Figure 5. Trends of graduated and employed HEWs by consecutive

years (2004-2010) (Source HSDP III document of 2010/2011).

Initially the HEP was developed for agrarian inhabitants, and then
subsequently, it has been tailored and scaled up into urban and
pastoral communities. In rural areas, the HEP is composed of 16
intervention packages categorized into four areas: “hygiene and
environmental sanitation" (seven packages), "family health" (five
packages), "disease prevention and control" (three packages), and
"health education and communication" (one package), for details
please refer to Figure 8 [14-15, 71]. The role of HEWs and operational
definition of health post are described in Boxes 1 and 2.

33
 Image 1. A standard health post. Box 1. Health post organization
- Operational centre of the HEP. It
functions under the supervision of the
Woreda Health Office, kebele
administration with technical support
from the nearest health centre.
- Built and owned by the community
with support from the regional
government.
- One of the HEWs is elected as a
cabinee member of the local
community (kebelle), for empowering
the decision making of the health unit.

Box 2. Selected tasks of HEWs

- Conduct home visits and outreach
Image 2. HEWs at a health post. services.
- Provide referral services to health
centres.
- Identify, train and collaborate with
VCHWs.
- Provide reports to Woreda Health
Offices.
- Provide health promotion and
preventive services related to the 16
components of the health packages.
- Provide preventive services such as
immunization, antenatal care and
family planning distribution.
- Provide basic curative services, treat
for malaria after rapid diagnostic
tests, provide oral rehydration salts
for children with diarrhoea and
perform first aid measures.

Despite the fact that stretched efforts have been made through
effective implementation of HEP at the grass root level, it is still hard
to reach rural families. In response to this, the government
established the Women Health Development Army (WHDA) network
in 2011. This network was required to create community ownership
by coordinating various sectors and mainly involving the community
from the planning up to the evaluation stages of the health sector and
other divisions. A total of 257,153 WHDA have been formed all over

34
the country. Prior to this network, volunteer community workers have
been recruited and trained to support HEWs in mobilizing the
community for preventive health programs such as immunization and
delivering key health information messages designed by the HEWs.
The volunteer community health workers (VCHW) and TBAs are
combined with the WHDA and some of the active members of
VCHWs hold a leading role in the WHDA. Currently the majority of
women in the villages are accessing information about birth
preparedness and benefits of institutional delivery from WDAs at
their locality [92-94].

Maternal health care in Ethiopia

Antenatal, delivery and postnatal care activities are provided at all
levels of health facilities. Antenatal care (ANC) is provided by nurses
and midwives (skilled professionals) at health centres and hospitals
and by HEWs at health posts. Women are assisted by skilled health
attendants for labor and delivery only at health centres, hospitals and
private clinics, whereas, clean and safe delivery is provided by HEWs.
Similarly, women receive postnatal care at home by HEWs, and by
midwives and nurses at health centres and hospitals.
The maternal health components of a PHC unit include service
performed at both health centres and health posts: immunization,
hygiene and sanitation, family planning, antenatal care, health
information provision and counselling service and referral linkage to
higher health facilities. Apart from these services, health centres
provide skilled delivery attendance, basic emergency obstetric and
neonatal care (BEmONC), safe abortion and post abortion care
services, whereas, health posts occasionally deal with clean and safe
delivery services. HEWs also provide postnatal care services at the
household level.
The primary hospital is the higher level referral centre of the primary
health care unit which deals with all preventive and curative type of
services including basic and comprehensive emergency obstetric and
neonatal care [13-71].
As indicated in Figure 6, the Annual Ethiopian Health Indicator
Bulletin shows an increasing trend of users flow for the three types of
services in the last eight years, although not very notorious for
delivery care [69, 84].

35
Figure 6. Trends of ANC, DC and PNC at national level year 2005-
2012.

According to the national surveys, the trends of ANC, DC and

PNC have increased from 46%, 13% and 15% in 2005 to 89%,
20% and 45% in 2012 respectively. Similar figures regarding
ANC visits (85%) have been reported in different studies. In
terms of the prevalence of institutional delivery, studies provide
different figures: i.e. Abera et al. in 2011 reports a 16%
prevalence of institutional delivery, whilst the Bulletin and
UNDP report it to be 20% (20.4%) [26-27, 30-31, 95-100].
Despite this increase, the prevalence of institutional delivery is
still low when compared to the country’s target of 62% for 2010-
2015. The reasons reported for the low coverage of this services
by the annual HSDP bulletin of 2011/2012 include: a) absence
of services 24 hours a day and seven days a week in most health
facilities, b) inadequate numbers and high turnover of
experienced and senior midwives, c) shortage of drugs, supplies
and equipment forcing mothers to buy gloves, drugs and
intravenous fluids, d) poor delivery room environment, e)
absence of neonatal unit and f) weak referral system [93, 101].
According to the Ethiopian Demographic Health Survey
(EDHS) 2011, lack of transport (71%), lack of money (68%) and
distance (66%) were the major reasons mentioned by women
for not accessing postnatal care services [95].

36
The majority of women still utilize the traditional model of child
birth at home where they are assisted by traditional birth
attendants (TBAs), grandmothers, mother in-laws, or
neighbors. TBAs continue to assist home deliveries due to the
fact that they are culturally accepted and trusted by the
community. However, nowadays, TBAs formally collaborate
with the WDAs and work under supervision of HEWs to counsel
and refer women to nearby health centres for delivery [12, 13,
71, 93, 101-102].

The Tigray region

Regional context
Tigray is one of the nine regional states in Ethiopia. It is
bordered by Eritrea to the North, Sudan to the west, Afar region
to the East and Amhara region to the south and south west. The
total area of the region is about 54,569 square kilometers. The
total population is 4,806,843, and almost 80% are rural
inhabitants. The proportion of males and females is 49.2% and
50.8% respectively and the majority of the inhabitants are
Christians. The Tigray region is divided into seven zones and 47
districts of which 35 are rural and 12 urban. There is one
specialized referral hospital as well as six zonal hospitals, seven
district hospitals, 214 health centres and more than 613 health
posts in the region [67, 94]. Figure 7 shows the map of Tigray
and the regions where the different sub-studies in this thesis
were conducted.

37
 Study
districts for
paper I, III
and IV

Study district
Study district for paper I
for paper II

Figure 7. Map of Tigray region.

Like the national health status, the most common health

problems of the region are communicable diseases, such as
pneumonia, diarrhea, malaria, tuberculosis and HIV/AIDS.
Childhood problems are mainly aggravated due to malnutrition.
Low awareness of communicable diseases, poor personal
hygiene and lack of environmental sanitation are among the
major problems identified by the TRHB annual report. A recent
study from the demographic surveillance site in Tigray has also
reported the emergence of non-communicable diseases in the
region [83, 94].
Although some studies indicate a positive impact from HEP in
some of its sub-components such as community participation,
community health awareness, immunization coverage, and
hygiene and sanitation, still the impact in access to maternal
health services is low. Studies reveal the existing poor
infrastructures of health posts in the region: electricity, tap
water supply, and fixed telephone line (all HEWs have mobile
phones but the connection is poor) were only available in 5%,
8%, and 21% of the health posts respectively [90, 99, 103-105].

38
The basic health indicators of the region are indicated in Table
2.

Table 2. Basic health indicators of the Tigray region year 2011/2012

[69, 84].

Health indicators Value

Total fertility rate 4.6 per woman
Contraceptive prevalence rate 28.6 %
Antenatal coverage first visit 50.1 %
Deliveries attended by skilled attendants 26.3 %
Postnatal coverage 49.6 %
Maternal mortality ratio 266/100,000 live births
Infant mortality rate 64/1000 live births
Under five child mortality 85/1000 live births
Pentavalent three immunization coverage 86.3 %
Full immunization coverage 74.6 %
Life expectancy for males 60 years
Life expectancy for females 62 years

Maternal health care delivery system in Tigray

The organizational health system in Tigray is more decentralized
compared to the other regions of Ethiopia. The health bureau
communicates directly with the district health offices, after the zonal
health structure was eliminated in 2002. Assisting and supervising
the PHC units (health posts, health centres and hospitals) is the
primary role of the regional health bureau staff.
The health posts are staffed with two HEWs enrolled in providing
health care services both at the health post and in the community,
focusing on the 16 HEP components that include maternal and child
health. The Tigray Health Bureau (THB) designed the sub-divisions of
the HEP in a star form which is thought to be easily understandable
(Figure 8).

39
Figure 8. Rural HEP’s components simplified around a star
structure.

Regarding maternal and child health, HEWs provide family planning,

immunization for children, antenatal, and postnatal care and may
attend deliveries. They also give health education on maternal
nutrition, hygiene and sanitation. HEWs work in collaboration with
the WDAs, TBAs and other voluntary community health workers are
expected to support health education activities in the communities
through house to house visits [14, 46]. HEWs use a family folder
which helps them identify the maternal health service needs of the
family when they visit their households [106].

Though, HEWs were supposed to assist labor either at health posts or

at home during the initial phase of HEP, their work pattern now is
shifting towards referring to health centers and hospitals. The reasons
for the change include: 1) increased community awareness regarding
benefits of health facility delivery, 2) improved accessibility through
organized community effort in transportation, and 3) enhanced
acceptability of services at the health center and hospital due to the
implementation of humanized approach to childbirth in these
settings. They use the family folder to trace women who reached their

40
expected date of delivery and refer them to nearby health centres.
WDAs work closely in collaboration with HEWs in mobilizing and
convincing the community on the health facility benefits in general
and institutional delivery in particular.

The health centres and primary hospitals need to have well equipped
and staffed facilities to provide BEmONC and CEmONC for saving
women with obstetric complications. Currently, the staffing pattern of
nurses and midwives at health centres is increasing in number and
BEmONC has been introduced in the majority of the health centres.
Some remote health centres in Tigray are staffed with integrated
emergency obstetrics/surgery clinicians for provision of CEmONC
services.

Hospitals are facilities where BEmONC and CEmONC services are

provided and they are staffed by skilled health attendants (physicians,
midwives and nurses) and integrated emergency surgery clinicians.
Maternal and child health services are free of charge through the
health care financing strategy; however the costs such as transport
and other charges are expected to be covered by users.
Despite the significant effort of the Tigray regional health bureau and
the government to improve maternal health care, a high proportion of
home deliveries are still practiced in the region which is a barrier to
maternal mortality reduction and a major reason for not achieving
MDG5 [94].

The maternal health care situation

The last national survey report indicates that 50.1% of all pregnant
women in Tigray received at least one ANC visit at health centres and
hospitals (45.6% by nurse or midwife and 4.3% by a doctor) whereas
14.4% were at health posts by HEWs [69]. During ANC visits, health
professionals’ will check the position and presentation of the baby
and fetal heartbeat. The components of ANC services also include: 1)
blood pressure measured (86%), 2) blood sample taken for
hemoglobin, HIV testing, blood group and RH factor (66.9%), 3)
urine sample taken for bilirubin, sugar and other microscopic
investigations (48%), 4) iron tablets provided (33.6%) and 5)
information conveyed on complications and danger signs during
pregnancy (27.5%) [93].

Different figures for institutional delivery have been reported for

Tigray, ranging between 11.6% [84] (estimates from the national

41
report) and 32.2% [94] (estimates from the regional report). The
reason for the variation might be different sampling methods and
periods; EDHS collected data from the 2006-2010, whereas, the
regional estimate included the recent progress of the implementation
from the years 2010-2012.

The majority of rural women (83.3%) do not receive postnatal care in

the region. In 2011, the Ethiopian Demographic Health Survey
(EDHS) reported that only 16.7% of women received one PNC visit of
which, only 12.3% were seen by doctor/midwife or nurse and 0.8% by
HEWs in the first two days after birth. In 2012, the THB bulletin
reported an increased proportion of PNC use by women, from 5% in
2000 to 49.1% in 2012 [94]. The reason for the increased proportion
might be the cumulative effort of the health work force, mainly
HEWs, women development groups and the community.

42
Rationale for this thesis
The HEP is a community based health care approach that has been
implemented since 2004. The THB has been investing in building
over 600 health posts and deploying more than 1200 HEWs. UN
agencies and other international stakeholders have also been
committed to support this process. However, the mere presence of
health posts and availability of HEWs within the rural areas is not
enough to ensure the fulfilment of community expectations and their
access to health services.

In 2010 (when this research project began), few studies assessing the
HEP had been conducted. The findings of existing studies indicated a
positive experience of the program by the population, but also poor
working conditions [107, 108].

Despite the continuous effort of the THB in improving access to

health care services for the population, especially since 2004,
preliminary data pointed out a low utilization of maternal health care
services. This thesis therefore emerged to understand on the one
hand, the impact of the HEP regarding women’s access to maternal
health care, and on the other hand, the reasons for the low use of
maternal health care services from the perspectives of the involved
actors. A final goal of the thesis was to be able to suggest possible
approaches for policy makers to develop appropriate responses to
increase the access to these services.

43
44
Aim of the thesis
The overall aim
The overall aim of this thesis is to assess if the Health Extension
Program is improving maternal health care services’ utilization in
Tigray region, Northern Ethiopia.

Specific objectives

1) To evaluate the association of the HEP with the levels and trends
in utilization of antenatal, delivery and postnatal care services
during the period 2003-2012 (sub-study I).
2) To determine the prevalence of maternal health care utilization,
particularly antenatal and delivery care, and to explore its
determinants among rural women aged 15-49 years (sub-study
II).
3) To explore women’s experiences and perceptions regarding
delivery care (sub-study III).
4) To explore health service providers’ perceptions on factors
influencing utilization of institutional delivery (sub-study IV).

45
46
The conceptual framework: Access to
Community Based Primary Health Care
In 1978, the Alma-Ata declaration on PHC recognized that the world’s
health issues required more than just hospital-based and physician
centered policies. The declaration called for a paradigm change that
would allow governments to provide essential care to their population
in a universally acceptable manner [7]. One key focus of the strategy
was how to increase the access to the health services for the most
vulnerable groups in the society in an affordable and effective way.
The issue of access was considered again as a key dimension by the
2000 WHO Health Report on health systems performance when
discussing how to achieve the goals of a health system: to improve the
health of the population, to establish a fair share of financing and to
ensure the responsiveness of the system.

Penchansky & Thomas have defined access as “the fit between the
user and the health care system” [cited in 109]. They proposed five
dimensions that the concept of access should include: a) availability,
namely -the relationship between the existing services in volume and
type, and the clients demand, b) accessibility refers to the physical
location of providers and health facilities versus setting of the users,
c) accommodation relates to the extent the resources of the health
care system are organized in a manner to meet users expectation, d)
affordability is measured by the users’ ability and willingness to pay
for the services and e) acceptability, how the users feel satisfied
receiving health service from the providers and vice versa [109].

This framework has been used in different studies to assess access to

health care in low-income settings such as in the case of malaria
treatment in Tanzania and Ethiopia or the use of maternity waiting
homes to promote institutional delivery in Liberia [109-110]. Figure 9
represents the application of the access model of Penchansky &
Thomas as have been applied in this thesis (Figure 9).

47
 Health Extension Programme

1. Excellence in health care

Core values of the health sector
delivery
development program: community first,
2. Excellence in leadership and
collaboration, commitment, change,
governance
om trust, professional development
3. Excellence in health
infrastructure
and resources

Primary health care

unit

- Women
Hospital - Family
- Volunteer community
Access health workers (VCHWs)
Health centre - Women development Army
- Communities
Health post

Increased utilization and coverage

Improved status of women’s health

Figure 9. Conceptual framework of access modified from Thomas

and Pechansky [109].

The HEP and its association in utilization of ANC, DC and PNC was
assessed in the first sub-study capturing mainly the dimensions of
accessibility and availability. Prevalence of ANC and institutional
delivery and its determinants, analyzed in the second sub-study,
focused on accessibility, availability and acceptability. The experience
of users’ regarding institutional delivery (sub-study III) explored
three dimensions of access (accessibility, availability and
acceptability) from a qualitative perspective. The perceptions of
health workers in relation to women’s place of delivery (sub-study IV)
mainly reflected the accessibility, and acceptability domains of the
access concept. A summary of the relations between the objectives of
this research and the three dimensions of access is presented in Table
3.

48
 Table 3. Sub-studies, level of health care and framework of access to
maternal health service utilization.

Sub-studies I-IV Level of Research Dimensions

primary question of access in
health focus
care unit

I. The association of How does the trend of Accessibility

Health post
HEP with the levels ANC, delivery and Availability
and trends in postnatal care look?
Health
utilization of selected centre What is the impact of HEP
maternal health in improving access to
services from year maternal health care
utilization?
2003-2012

II. Determinants of Health post What is the prevalence of Accessibility

antenatal and delivery Health antenatal and delivery Availability
care utilization centre care?
Acceptability
What are the determinants
of institutional delivery?

III. Women’s Health post Why women give birth at Accessibility

experiences and Health home or at a health Availability
perceptions regarding centre facility?
Acceptability
delivery care What factors influence
Hospital
women when choosing the
place of delivery?

IV. Health workers Health post What is the perception of Accessibility

perceptions of Health health workers on Availability
facilitators and centre institutional delivery?
Acceptability
barriers to What are the facilitators
Hospital
institutional delivery and barriers to
institutional delivery?

49
50
Methods
Study area
The contextual description of Tigray can be found under Regional
context (page 37-38). Of the 35 rural districts in Tigray, ten were first
selected purposively from different geographic areas. Then, three
districts were excluded for inaccessibility reasons and another three
were not included due to large missing data. Finally, a total of four
districts (Saharti-Samre and Hintalo-wajirat from south east zone
and Kilte-Awlaelo and Ganta-Afeshum from eastern zone) were
included in the study. The longitudinal data was extracted from Kilte-
Awlaelo, Ganta-Afeshum and Hintalo Wajirat districts. Saharti-Samre
is a rural and remote district where the second study was conducted.
Kilte-Awlaelo and Ganta-Afeshum are districts where the voices of
women and health workers were captured.

These four districts have an estimated population of 526,130 of which

50.2% are females. According to the year 2012 THB report, women of
reproductive age (15-49 years) constitute approximately 121,010
(23%) of the population and the number of deliveries in 2011-2012
was estimated to be 19,993. The first visit of ANC coverage was
reported as 76.4%. The skilled delivery attendance, clean delivery and
postnatal care (PNC) proportions in the districts were reported 23%,
12.7% and 46.7% respectively (Table 4). (See page 13 for definitions of
skilled delivery and clean delivery).
Table 4. Maternal health services coverage in the study districts,
2011-2012 (annual report).
Name of Distance Population Eligible* ANC Skilled % of PNC
district from 1st visit delivery clean visit
Mekelle in % in % delivery in %
Ganta 120 Kms 100,261 3810 57.2 12.3 13.6 30.3
Afeshum
Hintalo 35 Kms 172,222 6544 94 29.2 10.2 69.4
Wajirat
Kilte 45 Kms 112,788 4286 60.2 34.7 14.7 40.3
Awlaelo
Samre 55 Kms 140,859 5353 94 15.9 12.2 47.9
Saharti
Total 526,130 19,993 76.4 23 12.7 46.7
* Eligible: Number of women expected to receive the services based on the Federal Ministry of
Health data

51
The total number of health posts and health centres in the four
districts is 71 and 24 respectively. In average, the ratio of nurses and
midwives (diploma level) to the population ranges from 1:4,200
(nurse), 1:21,527 (midwife) of Hintalo Wajirat to 1:3,342, 1:5,276 of
Ganta-Afeshum, respectively. All health posts are staffed with two
HEWs, the details of human resources in each district is illustrated in
Table 5.

Table 5. Number of health facilities in the districts with type and

number of health workers (for level of diploma-12+2 and BSc degree
12+4, please read page 31), [12, 13].
District HPs HEWs HCs Type and number of health workers at health No. of
centres HCs with
BEmONC
Nurses Midwives Health
officers
12+2 12+4 12+2 12+4
Ganta 16 40 5 30 3 19 0 3 5
Afeshum
Hintalo 18 40 7 41 2 8 3 4 7
Wajirat
Kilte 17 32 5 34 0 15 0 5 5
Awlaelo
Samre 18 28 5 35 1 10 2 5 5
Saharti
Total 69 140 22 140 6 52 5 17 22

The research design

For this thesis, quantitative and qualitative methods were applied in
an attempt to answer each of the four objectives using the most
appropriate methodology [111]. The combination of both methods
enhanced the trustworthiness of the findings. Longitudinal
retrospective and cross sectional study designs were employed for
sub-studies I and II respectively. The qualitative approaches utilizing
grounded theory and thematic analysis were used for sub-studies III
and IV (Table 6).

52
Table 6. Study objectives, methodological approaches and analytical
methods used.
Specific Research Data collection Analytical
objective design techniques approach
I. To assess the Quantitative Documents Segmented linear
change in retrospective review carried out regression
utilization of longitudinal study in three districts; analysis
selected maternal ANC, DC and
health services PNC data
and its retrieved from
association with 2002-2012
the HEP
II. To determine Quantitative cross 1115 women Multivariate
the prevalence of sectional study interviewed logistic regression
maternal health through a analysis
care utilization structured
particularly questionnaire
antenatal and
delivery care and
explore its
determinants
among rural
women aged 15-
49 years
III. To explore Qualitative study Six focus group Grounded theory
women’s discussions with
experiences and 51 women in two
perceptions districts
regarding delivery
care
IV. To explore Qualitative study In depth Thematic analysis
health service interviews with 12
providers’ health workers (4
perceptions on midwives and 8
facilitators and HEWs) in two
barriers for districts
utilization of
institutional
delivery

Quantitative retrospective longitudinal study

For sub-study I, a rapid assessment to check the availability of the
necessary information in district health offices was first carried out.
Eight out of 34 districts of the region were visited. Health profiles and

53
reports were reviewed for checking data availability. A checklist which
answers the research question was prepared. Then, three districts
which fulfilled the requirement of the check list were chosen. The type
of services provided (AND, DC and PNC) and variables such as: name
of the district, health facility, date, facility code, and total population
of the catchment area were included in the checklist.

Due to absence of electronic monitoring recording system and poor

health management information system in the archive office of the
districts, the process of data collection was lengthy. Data collection
was carried out by two pairs of people at each district. From the
district health office, the person in charge of the archive office and the
maternal health expert were fully engaged in sorting the relevant
documents and handing over to the researchers. Then, the data was
labelled and recorded after a proper check for its completeness and
accuracy.

Retrospective longitudinal data from 10 years was extracted from the

three selected districts (61 health facilities of which 16 were health
centres and 45 health posts) and checked for accuracy. Then it was
aggregated on a quarterly basis and exported to the Stata software for
analysis after being cleaned in an excel spreadsheet. The analysis was
performed independently (by HC, HP and as total) under the three
phases of the intervention periods named as pre (the period before
the program started, July 2002-June 2005), immediate (initiation of
HEP, July 2005-June 2008) and late intervention (when the program
runs smooth, after July 2008). Because July 2005 was the time where
HEP implementation in the study districts started with minimum
resources, it was selected as the starting point of the HEP.

Since the nature of the longitudinal data is prone to bias, segmented

linear regression technique was used to control the secular trends
adjusted for correlation of the data [112-114].

The linear regression employed in the analysis was:

Yt = βo+β1*time+β2*intervention+β3*postslope+et

Yt indicates ANC, DC or PNC variables at time t where time is a

continuous variable which was subdivided in three periods of the
intervention named as pre-intervention (July 2002–June 2005),
early intervention (July 2005–June 2008) and post-intervention
(after July 2008). Two models were designed for running the analysis

54
in Stata. To estimate the level and trend of changes related to the
duration after July 2005, Model 1 was used. The changes during the
post intervention period were estimated by Model 2. Autocorrelation
was considered using the Prais Winston estimator.
In this model, the base line level of the outcome variable and the
estimated value of the structural trend in utilization are represented
by βo and by β1 respectively. Whereas, the estimated level of the
immediate impact after intervention is denoted by β2 and the change
in trend after the intervention by β3.

Quantitative cross sectional survey study

To determine the prevalence of ANC and institutional delivery
and to explore its determinants a cross-sectional study was
conducted. Women aged 15-49 years (n=1115) who had given
birth within five years prior to the survey period participated in
the study. The sample size was determined using a single
population proportion formula. Multi-stage cluster sampling
technique was employed. Of a total of 23 tabias (lowest
administrative unit), four were excluded due to difficult roads
(Images 3 and 4 illustrate the mountainous and hard to reach
localities).

Image 3. Hard to reach areas.

55
Image 4. Mountaineous landscape.

Random sampling was carried out among the remaining 19 tabias for
sorting the respected villages. Population proportion allocation to size
sampling was employed to select 30 clusters. A random selection
method was used to identify the first house for beginning the data
collection.

The questionnaire was developed based on national and international

literature, national guidelines, field observations and common local
practices in order to better respond to the research question of the
study. The data was collected by 15 HEWs through administered
interview and supervision was performed by four experienced nurses.
The two outcome variables were ANC use and place of delivery. ANC
use was defined as at least one ANC visit to a health facility (HF) by a
pregnant woman. For place of delivery, the home and health facility
options were available. Socio-demographic and obstetric
characteristics such as respondent’s age, marital status, education,
occupation, presence of health facility in a village, gravidity, previous
ANC use, history of obstetric problems and counselling and
information provision on benefits of institutional delivery during ANC
were included as predictor variables. The quality of the data was
ensured by training the enumerators, pre-testing the questionnaire
and performing close follow up and supervision. Data collection was
carried out from August to September 2009.

56
Data was entered into EPI-info after meticulous revision by the
supervisors and the principal investigator. Then it was coded, cleaned
and imported into the software Stata version 10 [115]. Cross
tabulations were performed to assess the relationship and the
significance between the outcome and predictor variables. Then, after
executing univariable analysis, the significant predictor variables
were included in a multivariable logistic regression analysis. Odds
ratio was used to explain the association between the outcome
variable and the risk factors. The presence of collinearity among
predictor variables was also checked.

Qualitative, Grounded theory approach

Women’s experiences and perceptions about giving birth at home and
at a health facility were explored in two rural districts. Initially, two
FGDs were conducted and a preliminary analysis carried out. Then,
six additional FGDs were carried out and analyzed. The data
collection was carried out from September 2010 to January 2011.
Potential participants were identified by HEWs and invited to the
health posts. A total of 51 married women with age range of 15-40
years were invited, 27 who experienced giving birth at home and 24
who were assisted by health workers during delivery at health
facilities. To obtain adequate disclosure of opinions and to include
maximum number of eligible participants’ women who gave birth
three years prior to the research participated in the FGDs. For
capturing various experiences, women who lived close to urban
centres and those residing in remote areas were equally invited. Only
women who had never been serving as part of VCHWs were selected
in the FGDs to avoid social desirability bias.

The FGDs were conducted in a setting chosen by the participants, and

the moderator tried to ensure a friendly environment. An interview
guide to capture reasons for women seeking and not seeking ANC and
delivery care was developed, and additional issues emerging during
the first discussions were further explored during the subsequent
FGDs following an emergent design. (Image 5 illustrates the FGD
conducted with women).

57
Image 5: FGD with women.

An explanation on the purpose of the study was given to all

participants by the researcher. Afterwards oral informed consent was
obtained from women to participate in the FGDs. The local language
(Tigrigna) was used for carrying out the FGDs. The discussions were
digitally recorded and transcribed verbatim. Notes were also taken for
complimenting the data. All FGDs lasted between 90 and 120
minutes. The researchers continued to undertake the FGDs until
saturation was reached, that is new information relevant to our
research questions was no longer emerging [111].
The process of transcription was done verbatim, word by word, which
contributed to capturing the pronounced feelings, opinions and
expressions of the participants. The transcribed records were
translated from Tigrigna to English and the texts were read very
carefully several times for grasping the meaning of the respondents.
The translated transcriptions were imported into the Open Code
software [111] for managing the data during the analytical process.
Texts were separated line by line and open coding was conducted.
Codes were generated in two ways: translating ordinary terms into
concepts, where expressions were chosen up directly from the data
and used as open codes (“in-vivo”) and also by constructing codes
from the texts (“in-vitro”) [111]. The team of researchers reviewed the
data repeatedly and negotiated to select the codes, meanwhile,

58
moving back and forth to the data was executed to advance the
coding, then similar codes were clustered together to form
subcategories and categories that were refined, until a core category
emerged. A constant comparison method was applied during the
analysis.

Qualitative, Thematic analysis approach

To capture the health workers’ perspective on access to maternal
health care services by women in Tigray, HEWs and midwives were
invited to participate in interviews. All potential participants were
selected by district health officials from various categories of health
facilities (health posts, health centres and hospitals) in order to enrich
the findings. Informants with different training backgrounds (ranging
from 1-4 years after high school) were included aiming to explore a
variety of experiences from different perspectives. Four midwives and
eight HEWs participated in the interviews. This study shared similar
study setting, duration of the study, steps and procedures of
participants’ selection as described in the previous section about
FGDs. An interview conducted with a midwife is shown in Image 6.

Image 6: An interview with a midwife.

The researcher requested permission from the participants for the

interview as well as for digitally recording it. All participants agreed to

59
the request. Then, for each interview comfortable places that
encouraged interactive discussions were chosen based on informant
preferences. The research interview guide for these informants
included semi-structured open ended questions covering various
issues focusing on enabling and hampering factors for institutional
delivery. These included: the role of decision making processes (by
elderly women, family, husband) during delivery and what factors
encouraged women to give birth at home or at health facility. Careful
verbatim transcription of the recorded interviews in Tigrigna was
conducted by the principal researcher and then translated into
English and organized with the help of the Open Code software [111].
The analysis was guided by the framework of the three delays model
[22, 116]. Firstly, the parts of the interviews linked to each delay were
identified and coded. Secondly, for each delay codes referring to
facilitators and barriers were identified and grouped in two different
clusters. Thirdly, through revising the emerging codes, the initial
three delays themes were fine tuned in the light of the new
information.

Ethical considerations
This study was approved by the University of Mekelle, Research
Ethical Review Committee of the College of Health Sciences,
Northern Ethiopia. A permission letter was received from THB and
district health authorities. Participants were informed about the
purpose and procedures of the study. Written or verbal informed
consents were obtained from all participants. Confidentiality and
privacy of participants were guaranteed and they were assured that
they had the right to withdraw from the interview or survey at any
time.

60
Main findings
This chapter is structured according to the four objectives of the
thesis and a summary of the main results is presented in Table 7.

Table 7. Summarized findings of the four objectives.

Objective Summarized findings

Association of the - A statistically significant upward trend found for DC
Health Extension and PNC in all facilities during the HEP late
Program with the implementation period (July 2008-June 2012).
levels and trends - The flow of first ANC visit increased by 6.4 fold in
of antenatal, health posts during the late implementation period but
delivery and not in health centres.
postnatal care
utilization
Prevalence and - 54% of the respondents visited ANC once. Women
determinants of close to health posts used the services more frequently.
ANC and - 4.1 % of women delivered institutionally.
institutional - 3.6% births were delivered by skilled delivery
delivery attendants.
- 7% of women of those who gave birth at home were
assisted by HEWs.
- Women who received information about institutional
delivery used more often health facilities.
Women’s - Women are in favor of home delivery due to cultural
experiences on tradition and faith.
delivery care - Elderly women influenced the decision making
process, preferring home delivery.
- Positive opinion about delivery at health facility, but
concerned about the poor quality of care,
inaccessibility and unavailability of transport.
- HEWs, TBAs and husbands supported women on
their struggle for a safe delivery.
Perception of - Women development group efforts have a positive
health workers on effect on increased community awareness (F).
facilitators (F) and - Community willingness to solve transportation
barriers (B) of problems (F).
institutional - Poor decision making power for women to choose
delivery institutional delivery (B).
- Poor competence of HEWs and some midwives in
delivery (B).
- Poor conditions of health facilities, lack of electricity
and water facility in the delivery room (B).
- Inaccessibility of transportation (B).

61
The association of HEP with the levels and trends of
antenatal, delivery and postnatal care utilization from year
2003-2012
During the ten year period (July 2002-June 2012), the consultations
on the three types of services - ANC, DC and PNC- increased
constantly, particularly after the late-intervention period (July 2008-
June 2012). Increases were higher for ANC and PNC at health post
level whereas for DC at health centers. The trend of ANC, DC and
PNC increased from 28% to 47%, 5% to 23% and 11% to 41%,
respectively (Table 8).

Table 8. Frequencies of ANC, DC and PNC users in both HFs (HCs

and HPs) July 2002-June 2012

Year Eligible % ANC % DC % PNC

July 02-June 03 22,501 28.2 5 11
July 03-June 04 23,096 25.5 3 5
July 04-June 05 21,219 29.5 4 10
July 05-June 06 (early 20,145 28.3 4 7
intervention)
July 06-June 07 17,670 46.1 7 18
July 07-June 08 18,112 40.9 6 14
July 08-June 09 (late 18,564 49.5 9 19
intervention starts)
July 09-June 10 19,029 52.0 13 29
July 10-June 11 19,505 57.5 16 27
July 11-June 12 19,993 46.7 23 41

NB: Population: Total population of three study districts based on

population census (1994 to 2006 and then census of 2007),
*ANC=antenatal care, DC=delivery care, PNC=postnatal care
Eligible: Number of women expected to receive the services based on
the Federal Ministry of Health data.

The flow of ANC visits in health posts increased by 2.85 and 6.4 fold
immediately after the intervention (July 2005-June 2008) and during
the late intervention period (July 2008-June 2012) respectively
compared to the pre-intervention period (July 2002-June 2005). This
pattern however was not observed at the health centres (Figure 11).

62
Figure 11. ANC visits of women in both health facilities, Years 2002-
2012.

The number of women assisted at health centres and those assisted by

HEWs at health posts for delivery were three times higher and 11.9
fold respectively in the late-intervention period when compared to the
pre- and early intervention stages (Figure 12).

Figure 12. Women assisted for DC in both health facilities, Years

2002-2012.

63
Attendance to PNC services in health posts increased by 2.7 and 6.4
fold immediately after the intervention and during the late
intervention period respectively compared to the pre-intervention
period. But that pattern was not seen at health centres (Figure 13).

Figure 13. PNC visits of women in both health facilities, Years

2002-2012.

Regression analysis
During the early intervention, the number of ANC consultations
increased by 116.88 visits per quartile (period of three months) at
health posts which was not significant, hence, a decrement was
observed at health centres. A substantial change in trend was
observed at health centres after the intervention (p=0.009), but this
pattern was not seen in health posts (p=0.76) (Model 1, it can be
found on Paper 1, Table 3). Regarding delivery care, Model 1 indicates
a decrement of consultations per quartile in both health facilities
(non-significant trend), whereas for postnatal care an increased
number of consultations in both health facilities was observed,
though this trend was also non-significant.
Model 2 was built to detect the changes related to the late
intervention period. Overall, a positive statistically significant upward
trend was found for DC and PNC in both (health centres and health
posts) facilities (p=<0.01). An increase by 122.75 and 326.47 of ANC
consultation visits per quartile of the year (period of three months) at
health centres and health posts was observed respectively. A positive

64
trend was shown in ANC at health centres (p=0.04), but not at health
posts (Table 9).

Table 9. Model 2 regression analysis (corrected for auto correlation)

of attendants for ANC, DC, PNC at health centres, health posts and
both, July 2002−June 2012.
Service B0 B1 (Time) B2 B3
ANC Total 1412.00 19.50 (0.11) 456.78 (0.07) -2.74 (0.90)
HC 1400.04 -18.70 (0.04) 122.75 (0.05) 37.18 (0.04)

HP 9.85 38.41 (0.00) 326.47 (0.006) -39.54 (0.01)

Delivery Total 321.62 -15.82 (0.52) -160.97 (0.21) 54.50 (0.038)

care
HC 208.56 -3.67 (0.46) -139.03 (0.11) 49.60 (0.000)

HP -6.83 6.18 (0.001) 91.55 (0.01) 11.46 (0.001)

Post Total 315.37 14.08 (0.28) -41.19 (0.84) 84.38 (0.002)

natal
HC 333.10 -4.03 (6.0) -148.88 (0.21) 45.65 (0.003)
care
HP -21.92 18.50 (0.01) 107.78 (0.37) 37.26 (0.007)

NB: for comparison the analysis with Model 1, please refer to Paper IV in the
appendix. For an explanation of Bo, B1, B2 and B3 please refer to page 54-55.

The number of consultations for delivery care at health posts during

the early intervention period increased by 91.55 visits per quartile
(p=0.01), but decreased at health centres, though not being
statistically significant. The trend (post slope) for both (health centres
and health posts) in the late intervention period, was positively
significant (p=<0.01) (Table 9).
Finally, in the early intervention, the model showed a non-significant
decrease of consultations to PNC services in both health facilities.
However, a positive significant change in an upward trend was
observed in health centres and health posts during the late
intervention period (HC: p=0.003), (HP: p=0.007).

Factors associated with antenatal care and delivery services

Of 1115 women, 1113 (99%) responded to the survey. The mean age of
the participants was 30.4 years. Only 3.3% of the participants had
completed secondary education. Fifty four percent of women reported

65
at least one ANC visit during last pregnancy (Table 10). The main
reasons for women not using ANC were: being apparently healthy
(32.7%), lack of awareness of the benefits (28.2%), feeling shame
(16.7%), work load (13.4%) and health facility too far (12.5%).
Regarding ANC services, women mentioned that abdominal
examination and checking blood pressure and fetal heart beat were
the most valuable components of pregnancy check-ups.

Table 10. Socio-demographic characteristics of women in the sample

- Saharti-Samre district (n=1113).

Individual variables Number of women (%)

Age groups
16-29 473 43
30-39 482 43
40-50 158 14
Marital status
Single 31 2.8
Widowed 29 2.6
Married 986 89
Divorced 67 6
Education
Illiterate 880 79
1-4 Grade 126 11
5-12 Grade 107 10
Parity
1-4 593 53
5-7 371 33
8-11 149 13
Husbands’ Occupation
Farmer 981 88
Government employee 31 3
Daily laborer 50 4
Merchant 51 5
Health facility in village
No 687 62
Yes 426 38
Total deliveries
Home 1067 96
Health facility 46 4
Health center 41 3.6
Health post 5 0.5
ANC use
No 511 46
Yes 602 54

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Table 11. Women’s characteristics and its association with ANC and
DC for their recent birth in Saharti-Samre district (n=1113).

Individual Received Adjusted Place of Adjusted

variables ANC Odds Ratio delivery Odds Ratio
n (%) (95% CI) Home n (95% CI)
(%)
Marital status
Single+Wido 19 (1.7) 1 55 (4.9)
wed
Married 546 (49.0) 2.57 945 (84.9)
(1.44-4.58)
Divorced 37 (3.3) 2.78 67 (6.0)
(1.31-5.89)
Education
No education 452 (40.7) 1 854 (76.7) 1
1-4 Grade 64 (5.8) 0.96 123 (11.1) 0.72
(0.65-1.42) (0.20-2.55)
5-12 Grade 86(7.7) 3.18 90 (8.1) 2.56
(1.85-5.47) (1.08-6.01)
Parity
1-4 320 (28.8) 1 560 (50.3) 1
5-7 202 (18.1) 1.16 361 (32.4) 0.39
(0.88-1.55) (0.17-0.93)
8-11 80 (7.2) 1.28 146 (13.1) 0.40
(0.87-1.88) (0.11-1.48)
Health facility in village
No 325 (29.2) 1 666 (59.8) 1
Yes 277 (24.9) 1.83 401 (36.0) 1.59
(1.41-2.38) (0.77-3.27)
Husbands Occupation
Farmer 499 (44.8) 1 957 (86) 1
Others 103 (9.2) 2.26 109 (9.8) 3.84
(1.43-3.58) (1.78-8.29)
Attended ANC
No 504 (45.3) 1
Yes 563 (50.6) 1.45
(0.48-4.34)
ANC advice
No 634 (57.0) 1
Yes 433 (38.9) 3.08
(1.21-7.84)
Difficult/prolonged labor
No 837 (77.4) 1
Yes 200 (18.5) 10.0
(4.87-20.6)

67
The factors associated with a first ANC visit after running a
multivariable logistic regression were: to be married (OR=2.57, 95%
CI: 1.44-4.58) and divorced status (OR=2.78, 95% CI: 1.31-5.89),
having accomplished 5-12 years of education (OR=3.18, 95% CI: 1.85-
5.47), closeness of the health facility to women’s village (OR=1.83,
95% CI: 1.41-2.38) and having husbands with a non-farming
occupation (OR=2.26, 95% CI: 1.43-3.58) (Table 11).
Of the whole sample, only 46 (4.1%) gave birth at health facilities,
whereas, the remaining reported giving birth at home. The most
frequent reasons for home birth were: easy labor (64%), health
facility too far (4.7%), and transport problems (4%).
Of those women who gave birth at home, 53.2%, 40% and 6.8% were
assisted by non-qualified persons (elderly women, mother-in-law,
relatives, neighbors), TBAs and HEWs, respectively. Among a few
women who gave birth at health facilities, their reasons were: saves
mothers life (31.2%), health facility is clean (30.6%), bleeding will not
occur (21%), retained placenta will not be encountered (12.5%) and
health facility supports labor (10%).

Women’s experiences in giving birth

From the FGD’s with women, “making pragmatic choices” emerged as
a core category linked to three other categories. Women in this region
were aware that complications might emerge during delivery and they
“aim for safer deliveries” (category one). In their struggle to deliver as
safe as possible, they have to choose between home delivery -
exemplified by the category “embedded in tradition”- and the modern
institutional delivery - represented by the category “medical
knowledge under constrained circumstances”. The latest was
considered more useful for handling complications, but the poor
quality of the medical services provided hindered women’s access to
them for delivery. In this struggle, TBAs, husbands and HEWs were
supportive to women and facilitate their access to certain services
(TBAs advocated for home delivery, whilst husbands and HEWs
advocated for institutional deliveries). The model is illustrated in
Figure 14.

68
 Making pragmatic choices

Figure 14. Model showing the core category, categories and sub
categories emerged from the analysis on the experiences of delivery
care in Tigray, Ethiopia.

Category one reflects how women were aware of the risks of giving
birth while recognizing the benefits and drawbacks of home and
institutional deliveries, as one participant conveyed:

‘Unless, the labor is soon, it is not good to give birth at home.

Because consequences like much bleeding cannot be treated on
time. I get afraid of bleeding and narrow pelvis if the labor is
at home. There is a good care in the hospital, when there is
bleeding they give injections’. (FGD2)

For services such as antenatal check-ups, participants visited health

facilities because they wanted to know the fetal health status as well
as their own. Usually the positive feedback given by health workers
during ANC created a sense of safety that often prevented women for
going back to the health facility for delivery. Another factor that
hindered women’s access to health care facilities for delivery was their
lack of control in the decision making process, both in terms of
delivery being an event that can happen any time and because of
women’s subordinated position. However, when complications such
as bleeding, prolonged labor and retained placenta occurred, care
from health care facilities was sought, usually with the support from
relatives, and especially from their husbands.

69
Religious and cultural factors acted as barriers for institutional
delivery. Religious rituals, the ascendancy of elderly women, and
considering home as a familiar environment were perceived as pulling
factors towards home delivery, as one participant described:

‘Women were not used to going to the HF before getting sick, it

was not taken as a tradition, the more you get sick you go to
HF. Elderly women have been giving birth at home in past
times and they insist their daughters to give birth at home, It’s
because there is a faith that St. Mary and God supports women
during labor at home’. (FGD5)

However, as another participant put it, faith did not need to conflict
with institutional delivery:

‘Hikiminaa [health facility] is good with God’s help. Health

professionals cure you from pain, exhaustion delay of
placental expulsion and bleeding. Women die due to bleeding.
So I think health professionals could help a lot with God’s help’.
(FGD4)

Women were well aware of the benefits of institutional delivery. They

valued the information provided by health workers and were satisfied
with the health care. Various procedures performed at the ANC visits
such as checking fetal heartbeat, measurement of blood pressure and
abdominal examinations were admired. The care provided by HEWs
and the information they provide during ANC visits, were especially
appreciated by women, as one participant expressed:

‘HEWs have a good hospitality. Whatever, how we behave,

they treat and follow us during ANC at health post. They visit
our houses, advise us to check our self during pregnancy and
to give birth at HF. They inform us about issues about
pregnancy, birth and after birth situations’. (FGD4)

However, when it came to delivery, unlike pregnancy, the difficulty to

forecast exact timing prevented them from planning their
transportation in advance. In addition, despite women acknowledging
the benefits of institutional delivery they also pointed out that the
poor quality of care provided further prevented them from seeking
institutional delivery. Long waiting times, unavailability/delay of
health workers during night’s weekends, delay in referral to higher

70
health institution and offering incomplete of health services were
among the critics mentioned by women.
Women considered that health professionals lacked the skills, were
not always available and had disrespectful attitudes towards them.
Women were disappointed when relatives were not allowed to enter
into the delivery room. The poor treatment, insults and
embarrassment during delivery discouraged women to seek
institutional delivery.

Institutional delivery from health workers perspective

Three themes emerged from the analysis of interviews with midwives
and HEWs: “struggling between the tradition and newly acquired
knowledge”, “community willingness to deal with geographical
barriers” and “striving to do a good job with insufficient resources”
(Figure 15). Both groups agreed on the important role of the HEP to
increase communities’ awareness regarding the benefits of maternal
health services utilization. Midwives acknowledged that the proximity
of health posts and HEWs to the communities, the relentless effort of
the volunteer community health workers and the newly created
women development groups were major factors to increase
community awareness on the benefits of institutional delivery. At the
same time, they considered that the main reasons for poor
institutional delivery included cultural traditions - such as the belief
on catching evil eye - and the strong influence of elderly women on
decision making.

In the second theme, geographic inaccessibility emerged as a key

barrier. HEWs expressed how the difficulties of mountainous
topography and scattered localities challenged the communities
endeavour. As a HEW mentioned:

‘Most of the localities of this kebele are with topography of

terrains and mountainous. The shortest walking distance to
reach the main road is 2-3 hours. Women prefer to give birth
at home rather than troubling with the difficult roads’. (HEW
6)

Despite the poor network connection of the rural localities, the joint
commitment of the community members and HEWs in searching for
transportation for referrals was considered as remarkable by the
midwives.

71
In the final theme, midwives admired the dedication of HEWs in
striving to provide health promotion and preventive services such as
immunization, ANC and family planning with the scarce available
resources. However, midwives were concerned regarding the poor
capacity of HEWs to detect women who needed early referral. At the
same time, HEWs recognized their own limitations on assisting
women during labor, and considered the one month midwifery
training they receive as inadequate.

In general, HEWs mentioned the availability of competent health

professionals, and the provision of services without fees for 24 hours
a day and seven days a week in hospitals as promoters of institutional
delivery. Both, HEWs and midwives acknowledged the hospital
setting as the best place for deliveries and for dealing with obstetric
emergencies. However, they also expressed their criticisms regarding
the poor quality of care provided by certain professionals at the
hospitals.

Most of the HEWs commended the contribution of the HEP for

improving preventive activities at the household level. However, they
were concerned regarding communities’ increased demands for
essential curative services. The large amount of time spent by HEWs
for household visits prevented them from engaging in the provision of
curative services within the health post. In addition, the poor
infrastructure of the health posts in terms of electricity, water
facilities and shortage of infection prevention materials (masks,
goggles and shoes for the delivery room) were mentioned by HEWs as
major barriers to provide adequate care.

‘An electric power is also necessary to offer services during the

night time. When we assist delivery during night time we have
to prepare kerosene or candle’. (HEW 2)

72
Figure 15. Health workers perspective on facilitators and barriers for
institutional delivery.

73
74
Discussion
This section is structured around the dimensions of access previously
described in the conceptual framework (pages 47-48), namely
availability, accessibility, acceptability, accommodation and
affordability. We mainly focused on the first three, however the
dimensions of access are interconnected and it is difficult to consider
them as separate entities. For instance, accommodation was reflected
in the data alongside with acceptability, and some aspects that we
consider refer to acceptability might be perceived as referring to
accommodation by other researchers.

The findings of this thesis indicate an overall positive outcome of the

HEP in improving different domains of access to maternal health care
services but revealed also numerous challenges ahead.

The increased trend of health services utilization after the

intervention period (ANC from 28% to 47%, delivery care 5% to 23%
and postnatal care 11% to 41%) indicates an improvement of the
accessibility and availability dimensions of access. Findings from sub-
study II showed a moderate coverage of ANC, but very low
institutional delivery utilization by women in rural Tigray. ANC and
delivery care use were associated to higher education of women (> 5
years) which is related to acceptability to the services. The provision
of health information during ANC was associated with the use of
institutional delivery that might be mediated through enhancing the
acceptability of the services.
In sub-studies III and IV, women and health workers referred to the
influence of cultural factors, ascendancy of elderly women, unreliable
transport, and poor quality of care as promoters of home delivery.
Participants acknowledged the efforts that were being carried out in
the region to improve the access dimensions of health care (Figure 9).
Aspects that were mentioned included the presence of human
resources, drugs and supplies at health facilities (availability), the
community efforts to solve transportation problems in case of
obstetric complications (accessibility), as well as the increased
awareness on benefits of institutional delivery (acceptability).
In this thesis, issues of affordability –users’ ability and willingness to
pay for the services, and accommodation - the extent the resources of
the health care system are organized in a manner to meet users
expectation- did not emerge strongly. On one hand, the provision of
free maternal health care services which was introduced by the HEP,

75
has contributed to make health services more affordable. On the
other, the economic growth that the country has experienced in the
last decade allowing to increase the health budget and the effort of the
government to improve the organizational set up of the health service
delivery system might have contributed to enhance accommodation
[84].

Availability
Availability refers to “the relationship between the existing services in
volume and type, and the users’ demand” [109]. In the last decade,
both national and regional governments, through the HEP, have
invested in building infrastructure, expanding trained human
resources and providing an adequate stock of supplies at health
facilities to enhance availability. The availability of various medical
equipment (i.e. sphygmomanometers, weighing scales and
stethoscopes) and the presence of HEWs at health posts might have
been perceived as a precondition for providing credible health care by
users.

The improved flow of ANC users was observed during the late
intervention period of HEP which might be the effect of increased
availability of health services. It seemed that the availability of
midwives/nurses at health centres might have been more important
for women than the availability of HEWs in health posts, since the
trend of ANC increased significantly only at HC level. The preference
of ANC offered in HC might be due to the fact that such facilities also
offered other services valued by women such as laboratory testing
investigations, diagnostic and curative services for common diseases
and outpatient therapeutic feeding for malnourished children. Other
studies reveal similar findings where maternal health care utilization
is linked to availability of infrastructure, supplies, and human
resources, and not merely to the presence of the health facilities [117-
118]. Such strong associations between availability of supplies and
human resources and utilization of ANC has been reported for
instance in one study conducted in Tanzania [119].

Conversely, the availability of HEWs in HPs did not improve access to

delivery care services, since the health posts were mainly focused on
promotive and preventive services and were not supposed to provide
skilled delivery services after 2011-2012. In line with the country’s
development and economic growth the Ethiopian news agency have
broadcasted increased per capita income of some communities in the

76
rural population: as a result; women might skip the HPs to overcome
the deficiencies and seek delivery services directly at health centres
where nurses and midwives are available.

This thesis also shows the perceived women’s benefits for maternal
and newborn care derived from the availability of skilled
professionals, equipment and supplies in the surrounding health care
facilities (sub-study III). Another study conducted in western
Ethiopia also reported a significant association between respondents’
awareness on benefits of skilled attendance and institutional delivery
[120]. However, women were also aware that the availability of such
resources in health posts and health centres was erratic. This
uncertainty regarding which resources would be actually available
when needed, discouraged women from seeking care from such
facilities.
Despite the continuous efforts to improve the services, poor
availability of essential supplies and human resources remains as a
major gap in remote localities in Tigray. The sub-optimal supply
chain of some essential drugs such as iron sulphate (to treat anemia)
and misoprostol (for prevention of post-partum hemorrhage) has
contributed to HEWs frustration and created mistrust of HEWs’
capabilities. Furthermore, the absence of infection prevention
materials (masks, eye goggles and shoes) was also another major
barrier for HEWs to practice clean and safe delivery. Consistent with
our findings, a study in Tanzania revealed the reduced motivation of
health workers when the curative services are insufficient or sub-
optimal due to the unavailability of drugs [119].

Accessibility
Accessibility can be defined as: when the location of health facilities
and supply of services is close to the users’ locality [109]. Sub-study I
showed an increased trend on ANC, delivery care, and PNC services’
utilization. Such an increase might be partly attributed to the
proximity of over 600 health posts (including the placement of HEWs
and resources) and the upgrading number of clinics to health centres
in the region under the HEP program [26-27, 46, 104].

Accessibility was closely linked with ANC utilization: living in the

close proximity to a health post was a major predictor of ANC use.
Consistent with our results, local and national studies have indicated

77
the benefit of living nearby to both ANC and institutional delivery
services [26-27, 46, 104, 121-127].
Despite the moderately high rate of ANC coverage, institutional
delivery in rural Tigray remained quite low (sub-study II) which is
similar to findings from other national studies [19-22]. This result
points out that even though accessibility is necessary, other relevant
factors strongly influence the place of childbirth.

Acceptability
Acceptability refers to “how the users feel satisfied receiving health
service from the providers and vice versa”. The users level of
education, to receive advice and counseling, the degree of
communication (by health workers) and the clarity of the messages
conveyed, the respect received from health professionals and their
knowledge and skills, are among the factors which are important for
enhancing the acceptability of the services [109]. Besides, how health
facilities are organized to accommodate users and their families with
a friendly and comfortable approach plus cleanliness of health
facilities, ensuring ease of use of drugs, and modern equipment and
the overall quality of care are also determinant factors for
acceptability [33, 128].

The role of HEWs, VCHWs and women development groups is central

to enhance services’ acceptability. HEWs at health posts play a major
role in establishing the linkage between the community and modern
health care practice. The HEWs also serve to give voice for the
demands of women in order to make health services more responsive
to their needs. The WDA which mobilizes women for pregnancy
check-ups and institutional delivery also promotes awareness of the
community on the importance of the services. Moreover, the effort of
skilled health workers for saving women and newborns lives; and the
provision of 24 hours services in these health facilities have improved
the acceptability of the services (sub-study IV). The Lancet series on
midwifery highlights that effective practices related to maternal and
child health along with respectful and responsive care optimizes
acceptability of the services [129-130].

Sub-study III pointed out that women in Tigray aspire for safer child
birth and were conscious of the possible complications during
delivery. However, the decision of where to give birth was influenced
by many aspects including cultural beliefs and traditions. The

78
ascendancy of elderly women, religious beliefs and socio-cultural
aspects influenced women’s decision-making, presenting home
delivery more acceptable than institutional delivery. This finding is in
line with other studies [57, 96, 131]. On the other hand, HEWs and
husbands, were advocates for institutional delivery (sub-study III)
and they might try to convince the relatives and elderly women that it
is the best option.

When women get an opportunity to reach the health facility, the

perceived low quality of services might be a strong factor hindering
the acceptability of services. Among the issues found to diminish
health care service acceptability for childbirth (sub-studies III and IV)
were: 1) poor and slow referral system, 2) unavailability of curative
services due to the focus on promotion, 3) communities’ perception
that their services have been downgraded and 4) verbal abuse and
arrogance of health workers during the service provision. These
findings align with results from other studies where health care
facilities that disregard of the traditional norms of the community is
shown to reduce the acceptability of the services [132-137].

The child birth humanization approach is one that enhances the

acceptability of institutional delivery. Such an approach is currently
being introduced by THB and some changes on the way child birth is
assisted in the facilities have been implemented; i.e. women can
choose the position to give birth, porridge is served after birth and
husbands are allowed to enter the delivery room. These interventions
may contribute to improving the acceptability of the health facilities
by the community.
In sub-study II factors that enhance acceptability were shown to
increase the use of maternal health care services. Educated women
had higher use of ANC and institutional delivery compared to non-
educated women. Extensive evidence shows how increasing women’s
education might enhance their acceptance of maternal health care
services [26-27, 121, 131, 136-137]. On the other hand women with
higher education are more empowered to give voice to their needs
and might be reluctant to accept the service when professionals treat
them without empathy and respect.

Apart from literacy, women receiving proper counseling service were

found to be more likely to use institutional delivery. The positive
effect of counseling on acceptability of ANC and institutional delivery
has also been reported by other studies [126, 135-137]. A possible

79
explanation for this is that: 1) informed women are more likely to
break misconceptions and opt for institutional delivery and 2) women
might develop a sense of trust on the health workers capacity when
they receive proper counseling service and physical examination
during ANC. In addition, village councils have involved HEWs in their
boards which may enable HEWs to better reach the community with
their messages, which in turn can enhance service acceptability [123].

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Methodological considerations gling ween
Various efforts were made to strengthen the research regarding both
the quantitative and qualitative criteria considering the truth value,
applicability, consistency, and neutrality [111, 138].

Truth value refers to the ability of the study to measure what it aimed
to measure. In quantitative studies is defined as internal validity, and
refers to minimizing bias [139-140]. Selection bias could have
occurred in the cross sectional sub-study, for instance: due to flooding
some remote communities might have been excluded from the study.
In the longitudinal sub-study, only the districts with complete data on
their record were included, so selection bias could have occurred due
to the poor data handling of the districts. Regarding qualitative
standards, truth value is defined as “credibility” and refers to how
well the findings had captured the reality being explored [138]. In the
two qualitative studies triangulation of researchers with different
knowledge on the setting enhanced credibility. Triangulation of
participants was done by involving both users and providers
perspectives (sub-studies III and IV). In order to have a deep
understanding and stay closer to the participants’ perceptions, the
local (Tigrigna) version was used along with the translated English
version until the end of the write up. The PI being originally from
Tigray enabled prolonged engagement. The risk of naivety was
minimized by discussion with the other researchers who were not
familiar with the area.

Applicability is important in public health research since it refers to

what extent results can be generalized to other settings. Quantitative
studies seek external validity by appropriate sample procedures [139-
140]. In the cross sectional survey, we ensured that communities and
participants were randomly selected, thus enhancing their likelihood
of representing the situation in Tigray in terms of socio-demographic
characteristics. However, due to the diversified ethnic and cultural
differences representativeness needs to be carefully handled.

Qualitative studies seek transferability, since generalizations from

those studies are theoretical and not statistical [138]. In both our
qualitative studies, transferability was enhanced by purposely
selecting participants based on their ability to contribute to the study
question. We also made an effort to contextualize the results in order
to help readers evaluate to what extent our results were applicable in
other settings.

81
Research consistency, according to quantitative criteria, is defined as
reliability and refers to the likelihood of getting similar results if the
study is repeated [140]. For enhancing reliability the cross sectional
study used questionnaires that had been validated in the country and
they were piloted prior to application. Interviewers were well trained
and supervised, and they were recruited from a similar background to
that of the participants.

In qualitative research, consistency has a different meaning and is

defined as “dependability” or the ability to respond to issues emerging
from the data [138]. In both the qualitative studies an emergent
design was pursued. The interview guides allowed the incorporation
of issues emerging from previous interviews, and we used preliminary
emerging results to refine the design of the studies.

The final issue for methodological considerations refers to neutrality

[111]. Quantitative studies claim neutrality and objectivity by
maintaining distance from the observed phenomenon (for instance,
the data of the survey was collected by others), while qualitative
studies deny the possibility of researcher’s neutrality and seek
neutrality in the data (confirmability). In the quantitative studies,
neutrality was applied by accepting the results of the analysis and not
hiding the ones that did not support our working hypothesis. In the
qualitative studies we strived to capture the ideas and experiences of
informants as we tried to be open-minded and to put our pre-
understanding into “brackets” [141]. For instance: despite the rich
and positive experience of the researcher on HEP, the data was
allowed to emerge by itself to reduce the bias in assumption. That
meant not going in-depth into existing theories until findings were
analyzed, and not excluding contradictory or negative findings. The
main limitations of each sub-study are presented in Table 12.

82
Table 12. Limitations of sub-studies I-IV.
Sub-study I
 Use of retrospective data might be questionable for its validity.
 Validity of data might have been hindered by poor handling of the archives
and an absence of electronic medical recording system in the facilities
which could have affected the interpretation of the results.
 The study design could not detect the causal determinants of the impact
on utilization.
 Because of unavailability of data, the external factors that might have
influenced the outcomes were not controlled. Such as: increase in per
capita income, building roads and infrastructure, strengthening micro and
small scale enterprises.
 Due to the fact that our sample was taken from only a small amount of
districts, the issue of generalizability needs to be carefully handled.
Sub-study II
 The data were collected by HEWs who were familiar to the community,
which could have resulted in reporting bias but on the other hand also
increased the response rate.
 The questionnaire assessed the use of maternal health services in the five
years preceding the survey, which might have introduced recall bias in the
use of services.
 The reasons given by women for attending/not attending might have been
longstanding ideas that could introduce a recall bias, with the outcome
often stated rather than the actual reason.
 The methodological nature of the cross sectional study design limited the
causality inference of the study variables.
Sub-study III
 My position as a former staff member of the THB may have affected
participants’ opinions through social desirability bias.
 The fact that the first author was a man, interviewing women could have
affected the response of respondents (social desirability bias) and the
results. However, the respondents reflected their opinion freely.
 The process of translation of the interviews to English might have led to
some of the original meanings (narrated by the participants) being lost.
Sub-study IV
 The setting and my position as a member of the university’s medical
faculty interviewing health workers, could have affected the results (social
desirability bias).
 Purposive selection of the participants might have affected the results
through social desirability bias, however, much work was done to connect
the results with the actual circumstances of the setting and to detail the
analytic process.

83
The role of the researcher
During the development of this thesis, I have had both an insider and
outsider role in investigating the HEP. I considered myself partly as
an insider due to providing health care services in health facilities and
working in the regional health bureau as a health extension program
coordinator. This position allowed me to gain access to participants.
The participants in the interviews and FGDs were women, and me
(the interviewer) being a man could have influenced their responses.
However, the objective of the study was clearly oriented and
participants were approached to discuss their opinion freely.

I also consider myself as an outsider because when I started this

thesis, I was already working at the University, assessing the HEP
from that position. This position allowed me to be more critical to the
HEP and also to keep my pre-understandings due to my previous
working experience with the HEP “in brackets” during the analysis of
the data.nd

84
Conclusion
Our findings reveal that there has been an overall increase in ANC,
DC and PNC use after the introduction of the HEP, particularly in
ANC and PNC at health post level and DC at health centres. However,
despite the proportion of women who received ANC for their recent
births (54%), those who gave birth at a health facility was only 4.1%.
Factors associated with ANC utilization were marital status, high
education, proximity of health facility to the village and the non-
farming occupation of the husbands. Use of institutional delivery was
mainly associated with parity, high education, having received ANC
advice, to have a history of difficult labor and husbands with a non-
farming occupation.

The results point out that despite the effort of the THB to facilitate the
women access to health facilities several challenges remain,
particularly for child delivery. The women who participated in this
study were actively making choices for a safer delivery. Women had to
decide between (1) giving birth at home, in a known place, sanctioned
by tradition, faith and the ascendancy of the elderly, but where little
could be done to manage complications, or (2) delivering at health
facilities, where medical knowledge could (theoretically) manage
complications, but where services’ availability was on occasion
erratic, the quality of care poor and staff’s attitudes disrespectful. In a
similar line, health workers emphasized three major barriers for
institutional delivery: 1) the perception of delivery as a natural event
by the community which was linked to, cultural, ritual and traditional
values of home delivery, 2) geographical barriers, such as long
distances, mountainous localities and poor referral infrastructure
and, 3) lack of adequate training, poor quality of care and shortage of
supplies at health facilities.

85
86
Implications for further intervention

In terms of enhancing availability

 THB is acknowledged for effectively organizing HEWs and
WDA together towards striving for better service acceptability.
The direction of this movement needs to be reinforced and
sustained in collaboration with all partners and with possible
integrated supportive supervision.
 Research from colleagues in Tigray has shown the feasibility of
mobile health in improving maternal health services [142] so,
enhancing access of the services through mobile health needs
to be strengthened.
 To break the misconceptions on benefits of home delivery and
to create mutual understanding of the different actors
involved, meetings and forums with elderly women, religious
leaders, husbands, women development groups, TBAs and
HEWs need to be conducted frequently.
 The current efforts and commitments of HEWs need to be
recognized and praised in an open forum. Performance based
awards and a certificate that recognizes individual and team
efforts should be prepared on annual or bi-annual bases.
 The integrity and commitment of the regional government
towards advancement of women’s education and their
empowerment; and the willingness to improve access through
organized community effort needs to be enhanced to ensure
its sustainability.
 The recent introduction of humanization approach for delivery
deserves to be evaluated, in terms of its effect on enhancing
acceptability of services.

87
88
Implications for further research

 Action based research that enhances positive provider-user

interaction and strengthens women centered approach for
ensuring effective health service delivery is needed.
 This study only focused on users and health providers’
perspective to explore the issues. It would be useful to conduct
research exploring the perspective of community actors (such
as WDGs) and local policy makers regarding issues of
maternal health services.
 PNC was not well assessed except for levels and trends of its
utilization. It would be very interesting to fill the gap by
conducting operational research on the coverage of PNC and
its determinants from the perspective of various actors using
quantitative and qualitative methodologies.
 The access framework approach would be useful to explore
other issues of maternal and reproductive health related
problems, such as: maternal malnutrition, anemia in
pregnancy, gender based violence, contraceptive use and
HIV/AIDS.

Finally, a strong collaboration between THB, Mekelle University, and

Tigray Science and Technology Commission is needed to:

 Enhance and facilitate the dissemination of PhD thesis and

other research outputs to policy makers and to the
community.
 Coordinate and organize in designing community based
projects that can be implemented based on the main findings
of this PhD as well as other research.

89
90
Acknowledgements
I am very grateful to the many people and organizations who
contributed to this PhD thesis. First and foremost, I sincerely express
my deep appreciation to all women who participated in the focus
group discussion and the quantitative survey. Without their
involvement the experiences of maternal health care wouldn’t have
been explored in this thesis. My profound respect and gratitude goes
to the key informants (health extension workers and nurse midwives)
and to the other groups (nurses and HEWs) who participated as data
collectors and supervisors for the survey. I would also like to
acknowledge to my colleague Fisha Haile (FGD note taker and data
collector) and all participants of this research including the district
maternal health experts as well as archive officers. I have a deep
appreciation for the district health offices, the Regional Health
Bureau and Mekelle University. I am also very grateful to an
American friend Joseph Brew Russel who committed his time and
energy and assisted me the data collection task of the first paper.
I am extremely indebted to my supervisors and their greatness will
forever remain in my heart. It is due to their proper mentorship and
guidance that I built my critical and analytical thinking and reached
to the level of exploring the inlet and outlet of the research process.
I would like to sincerely express my heartfelt gratitude to my main
supervisor Isabel Goicolea, it was not only your technical assistance
and proper advice but also your humor, kindness and respect that
make me feel always welcomed and endured. You also gave me a
freedom and energy to optimally utilize my efforts for effective
implementation of the research project. Your careful listening and
your deep interest to understand the social and cultural context of the
study population have contributed in improving the work of the
research. You were an advisor, a mentor as well as a sister. I am very
grateful to your family Delfin and Peio for their hosting and
welcoming reception all the time.
My candid and deepest gratitude also goes to my co- supervisor
Miguel San Sebastian who accepted me as a PhD student and gave me
an opportunity to work under his guidance and supervision. It was
much privilege for me to acquire and learn academic and research
skills from you over the years. During the whole process, your valid
criticisms, provoking comments, endless guidance and support, and
your prompt responses and suggestions helped me to critically think,
analyze and increase my capacity accordingly. Apart from the

91
mentoring and advising processes, the way you give credit to
community values maximized my curiosity and hard work. I would
like to thank your family (Anna Karin, Emil and Sisa) for their
welcoming reception all the time.
I sincerely admire my co-supervisor Kerstin Edin. I am so grateful for
your talents, skills and your rich experiences which guide me to follow
the standards and procedures and to keep an eye out to make things
in different ways. You taught me how to reconcile contextual entities
with the international arena. The family dinner at your house was also
an extra commitment that builds a strong friendship between me and
all my supervisors.
I highly appreciate Anna Karin Hurtig, for her dedication and
commitment in organizing and coordinating various capacity building
workshops to the PhD students and for encouragment and
reassurance during the PhD process. I am so grateful for Lars
Lindholm for accepting to be my examiner.
It would be impossible to forget the co-authors Yalem Tsegay and
Hailemariam Lemma who had immense contribution on the second
paper. Furthermore, I am very indebted to my good friend
Hailemariam Lemma for being a gate opener to my PhD study by
accompanying my co-supervisor (Miguel) to my work place.
Dear Birgitta Astrom, I totally agree with the wonderful
acknowledgments that have been given by former graduates. I am
highly indebted for your everlasting care, support and motherhood
since my Masters study. It is not only the technical, administrative
and logistical arrangements but also your guidance, kindness and
advice in all aspects that I appreciate. I give you my sincere thanks for
your endless support throughout my PhD process. I would also like to
acknowledge Karin Johnsson, Lena Mustonen, Veronica Lodwicka,
Ulrika, Susanne Walther, Per Gustaffsson, Andreas and other
administrative staffs for their continuous support and reassurance. I
offer my appreciation to Anneli Ivarsson for her open interest and
willingness to discuss my little daughter’s issue.
I am very grateful to Kjerstin Dhalbolm who helped me to prepare my
poster presentation for attending an international conference in
Addis Ababa and for her reassurance all the time.
I am highly indebted to Professor Yemane Berhan, Professor
Misganaw Fantahun, Dr. Yirgu Gebrehiwet, and Dr. Nigusse Deyesa
for their influencing messages and guidance to choose the PhD

92
journey over other competitive priorities. I also thank Dr. Kidist Lulu
for reviewing and forwarding her comments to my last manuscript.
I also acknowledge the various funding bodies that sponsored my
trips back and forth from Ethiopia to Umeå to undertake my research
studies and course work in Umeå. I am grateful to the support of the
Swedish Centre Party donation for global health research. I would like
to thank the Umeå Centre for Global Health Research, for granting
me the support fund from FAS, the Swedish Council for Working Life
and Social Research, as well as the Swedish Research School for
Global Health. I sincerely wish to express my appreciation to the
organization Etiopia-Utopia for covering the expenses of data
collection for the qualitative and quantitative research.
I sincerely express my gratitude to Professor Carmen, Nawi and Karin
for their valuable and constructive comments, suggestions and critics
during the mid-term seminar which helped me improve my work.
I acknowledge the commitment of my opponents (Katrina and
Faustine) on the pre-dissertation, their comments and suggestions
were an immense contribution to my work. I am very thankful to
Göran who was very supportive in uploading important statistical
software and solving my PC problems.
I would also like to pass my deepest gratitude on to all the staff at the
Unit of Epidemiology and Global health, Peter Byass, John Kinsman,
Anna Myleus, Klasse Sahlen, Joakim, Malin Eriksson and others.
Special thanks to Barbara Schumann for her continuous reassurance.
I am very grateful to Vigendra Ignole for his best friendship and
brotherhood all the time while I was in Umeå.
I was very lucky to socialize with people from different parts of the
world and it has been a pleasure to learn from the diversified
experiences by attending various research presentations. I am very
grateful to Mariano, Claudia, Steven Maluka, Lorena, Cynthia
Anticona, Paola, Juan Antonio Cordoba, Raman Preet, Joseph, Ailina
Santosa, Bumi, Tej, Rakal, Dickson, Gladys, Thaddeus, Sewe,
Kanyiva, Moses, Paul, Mellissa, Nathnael Sierili, Kateryna Kharina,
Nyttin, Prasad, Trang, Henduruw, Barnabas, Kim, Osama, Setaria,
Ryan, Fredinah, Ying Lei, Jing Hammersson, Linda Sundberg,
Alirezakhatami, Chaya Utamie, Anna Lundgren, Daniel, Jonas
Hansson and Johanna Sundquvist. My special thanks to Alison
Hernandez for her open interest in helping and sharing her
experiences. I acknowledge my good friends Masoud and Julia for
their reassurance and encouraging discussion all the time. My sincere

93
thanks to Mikkel Quam for your respect, friendliness and
companionship and your open willingness to support.
I am very much indebted to Dr. Yohannes Kiros, Dr. Bisrat and Yodit
Yohannes from Stockholm, for their continuous reassurance from the
beginning to the end of this PhD journey and also for their welcoming
reception all the time.
My wonderful acknowledgment to Abrham Tsegay for his
inspirational encouragement and brotherhood support. My colleagues
Hagos, Ataklti and Tsige, I thank you so much for accompanying me
halfway through the journey. As well as to Eduardo Subero for his
encouragement and reassurance during his short stay in Mekelle.
I am also very grateful to Ethiopian community in Umeå: Adane,
Tekle, Fitsum, Haile, Measho, Mohamed, Abbe and Addis for your
nice reception all the time.
Thanks to my friends from Mekelle, Kahsu Bokretsion, Tadesse
Alemseged, Mulu Atsbha, Tesfay Gebru, Yohannes Tewolde,
Mebrahtom Belay, Awaela Equar, Yemane Ashebir, Solomon
G/Mariam, Birhane Hadera, Habtom Gebrehiwet, Solomon Bezabih,
Asmelash and Daniel for your encouragement and reassurance.
I am so much indebted to Yemane, Tadelech, Mulu, Amaru, Axumawi
and Hani Tewolde for the care, protection and their endless
reassurance to my family while I have been away for my PhD study.
I would like to pass my heartfelt gratitude to my Mom for her
pronounced efforts throughout her life to make me a better man.
Thank you “Destaye” for cultivating the values of solidarity and social
integrity in me.
I appreciate the blessing, prayers and the good wish of my Dad. My
special thanks to my siblings, my sister “Tiebe” and my brother
“Mihure” for your endless support to my family when I am away from
home. Your understanding about my academic career gave me a
courage, confidence and endurance.
I am grateful to my beloved wife Luchia, for sharing my decision from
the outset. Apart from accomplishing your own business, I appreciate
your endless support in bearing the burden of family responsibility
throughout the journey. Congratulations Luci, You are the back of this
success. My lovely kids, Henos and Abseala who were very curious
about my frequent travel to Umeå. My little daughter Arsema, who is
very cute, her melodious words through the phone make me stable
when I am away from home.

94
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