Abstract
BackgroundIn 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care. Despite enormous effort, utilization of maternal health services remains limited, and the reasons for the low utilization of the services offered through the HEP previously have not been explored in depth.This study explores women’s experiences and perceptions regarding delivery care in Tigray, a northern region of Ethiopia, and enables us to make suggestions for better implementation of maternal health care services in this setting.MethodsWe used six focus group discussions with 51 women to explore perceptions and experiences regarding delivery care. The data were analysed by means of grounded theory.ResultsOne core category emerged, ‘making pragmatic choices’, which connected the categories ‘aiming for safer deliveries’, ‘embedded in tradition’, and ‘medical knowledge under constrained circumstances’. In this setting, women – aiming for safer deliveries – made choices pragmatically between the two available models of childbirth. On the one hand, choice of home delivery, represented by the category ‘embedded in tradition’, was related to their faith, the ascendancy of elderly women, the advantages of staying at home and the custom of traditional birth attendants (TBAs). On the other, institutional delivery, represented by the category ‘medical knowledge under constrained circumstances’, and linked to how women appreciated medical resources and the support of health extension workers (HEWs) but were uncertain about the quality of care, emphasized the barriers to transportation.In Tigray women made choices pragmatically and seemed to not feel any conflict between the two available models, being supported by traditional birth attendants, HEWs and husbands in their decision-making. Representatives of the two models were not as open to collaboration as the women themselves, however.ConclusionsAlthough women did not see any conflict between traditional and institutional maternal care, the gap between the models remained and revealed a need to reconcile differing views among the caregivers. The HEP would benefit from an approach that incorporates all the actors involved in maternal care, at institutional, community and family levels alike. Reconsideration is required of the role of TBAs, and a well-designed, community-inclusive, coordinated and feasible referral system should be maintained.
Highlights
In 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care
Despite the international emphasis since the 1990s on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is worrying in sub-Saharan Africa where more than 300,000 women still die each year during pregnancy and childbirth; most
The Ethiopian HEP builds on the principles of primary health care, and aims to network volunteer community health workers, including traditional birth attendants (TBAs), with health extension workers (HEWs) and higherlevel health facilities [8]
Summary
In 2003, the Ethiopian Ministry of Health launched the Health Extension Programme (HEP), which was intended to increase access to reproductive health care. After many studies confirmed that training TBAs was not cost-effective when compared with the provision of professional skilled care [7,8], training programs for TBAs were discouraged, as well as other community-based actions Instead, programmes modified their focus to skilled delivery care and the implementation of emergency obstetric care services within health facilities [4,6,9,10]. Despite noteworthy achievements, focusing on the implementation of emergency obstetric care did not automatically result in women’s better access to services [6,9,11]. In order to reduce maternal mortality all these actors should be mobilized to work together [12,13]
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