This research examined factors associated with readiness of frontline workers in pregnancy care delivery and new born care in four reasons in Ethiopia. We analysed data obtained from the frontline workers’ module of the 2015 IDEAS study which looked at ‘Change in Maternal and Newborn Healthcare’ in four regions of Ethiopia. The aim of the study was to gather data regarding the equity, frequency, quality of delivery care of pregnant women and newborn babies with 6 weeks after birth. The study was also aimed at estimating the coverage of life-saving interventions delivered by frontline workers to pregnant women and newborns and the need for direct and indirect improvement activities for maternal and newborn care. 80 workers in 80 selected health care facilities who participated in 2015 IDEAS study were interviewed. We predicted that frontline workers would experience various difficulties in providing pregnancy care, delivery care and newborn care services, before and after birth. Poor knowledge, lack of motivation and job satisfaction impair the readiness of frontline workers in providing quality prenatal and postnatal care, suggesting that an enabling environment and improvement of skills and competency of maternal care workers is necessary to achieve international standards for safe pregnancy, delivery and newborn care.

ACKNOWLEDGEMENT

I wish to pass my heart-felt regards to the Ethiopian Government and in particular the ministries of health and the ministerial docket in science and technology for their successfully written approval for the report before the interview. It’s also my pleasure to thank my supervisor for his support which went a long way in making my project a success. Additionally, I sincerely thank the Regional Institutional Review Boards and finally the London School of Hygiene and Tropical Medicine for their cooperation (LSHTM).

ACRONYMS

Various acronyms have widely been used in the report. For the interest of clarity and objectivity, they have been explained below though with some differences to the conventional ones.

1. MDG – millennium development goals.
2. EDHS- Ethiopian Demographic and Health Survey.
3. BEmOC- basic emergency obstetric care.
4. CEmOC – comprehensive emergency obstetric care.
5. HEW –health extension workers.
6. WHO-world health organisation.
7. ANC-meaning antenatal care.
8. FLW – front line workers.
9. ISO -international organization of standardization.
10. TTBA-traditionally trained birth attendants,
11. CHP-community health provider,
12. MMR-maternal mortality rate
13. BCG-is a vaccine against tuberculosis
14. DPT-a vaccine against diphtheria

Major obstacles to good pregnancy, delivery and newborn care in developing countries like Ethiopia include lack of skills and competency. Moreover, the scarce number of health institutions, inefficient distribution of medical supplies and inconsistencies between rural and urban areas owing to severe underfunding of the health sector compound the difficulties to provide proper healthcare. The research carefully selects the maternal mortality, infant mortality and measures to avert these menaces. (Ayale B,2005).

According to USAID (n.d), only about 10% of births in Ethiopia are delivered by professional workers, and more than 10% of those babies die before their 5th birthday. Therefore, there is still much to be done to save the lives of both mother and child.

Maternal health is important to communities due to its profound impact on the well-being of mothers, immediate survival of newborns and long-term health of children. Successful pregnancy care and child birth provides times of joy for both parents and families. However, in many developing countries, these could also be times of anguish as more than 1,500 women die daily due to pregnancy complications in Ethiopia. Over the past 20 years, an estimated 10 million women have died worldwide (De Brouwere, Richard, & Witter, 2010). Most of these deaths can be prevented if skilled birth care, as well as emergency obstetric care, are provided. Strategies to minimise delays in receiving pregnancy care and delivery services must also be considered. Hence, the success of any healthcare system depends on the competency, productivity, responsiveness and availability of frontline workers.

Ethiopia can be found in the Eastern Africa region. Its estimated current population is 104 million, and those living in the rural areas being over 84% of the total population, and 44% of the population earning less than a dollar per day (1). One of the millennium development goals is to reduce maternal mortality, and Ethiopia has not been able to achieve this. By 2015 Ethiopia had reduced the mortality rate from 871 deaths for each 100,000 live births in 2000 to 218 deaths for each 100,000 live births (2). Despite the reduction, the rates are some of the highest in the world and the absence of significant developments in the most recent past is pretty disturbing. Some of the causes of these insistently high maternal death rates comprise ineffective usage of health services, unpredictable delivery services and insufficient professional medical attendants at birth in Ethiopia(4)(5). According to the Ethiopian Demographic and Health Survey (EDHS) 2015, only 15% of females delivered at public health centres (5). Many of those who subscribe to safe motherhood live in the urban areas, especially Addis Ababa. The likelihood of women who live in Ethiopia’s capital city, Addis Ababa receiving professional assistance during delivery is 40:1 compared to those who live in the countryside Mekonnen, (2003) (4). Women who had received professional assistance increased to 86% in the city compared to 10% in the rural areas (5). Difficulties experienced when trying to use health facilities include, mistrust of health facilities, customs and transport. (5)(6). Consequently, the Ethiopian government introduced reforms so that every pregnant woman can access free maternal healthcare services. This was aimed at tackling the twin issues of affordability and accessibility(7).

This project seeks to evaluate the promptness of Frontline Workers (FLWs) in management of pregnancy, delivery and newborn care in the four regions of Ethiopia. Specifically, its objectives include the following:

1. Study the international principles for safe perinatal period, delivery and newborn care
2. Find out how capable, experienced and skilful the FLWs are when it comes to providing pregnancy care, deliveries and newborn care.
3. Anaylse and debate the conclusions for administration policy on quality of care in pregnancy, delivery and newborns.

World Health Organization defines maternal mortality as the death of an expectant woman while giving birth or within 6 weeks after successful delivery irrespective of the duration or place of delivery. Maternal mortality can be as a result of any complication connected to or worsened by the pregnancy or its management, but not from incidental or accidental factors (13). The main causes of maternal deaths are: haemorrhage (severe bleeding) which accounts for about 25% of the deaths, unsafe abortion process, infections/sepsis, hypertension, and an obstructed labour. Other minor causes such as embolism, ectopic pregnancy, and others account for 8% of maternal mortality. Heart disease, tuberculosis, anaemia and malaria are indirect causes and constitutes 20% of maternal deaths (14). Both Ethiopian and global status of maternal mortality levels are comparable albeit of course with some negligible discrepancies, with the same major causes of deaths (15). But 80% of the maternal mortality is avoidable if proper management and treatment is done (13). The forecast of obstetric complications that cause maternal mortality and morbidity as well as provision of delivery care from professional workers such doctors, nurses or midwives are both seen as the most significant interventions in safe motherhood programs. Early medical intervention during obstetric emergencies could save many lives and effectively reduce maternal and neonatal deaths.

It is important to note that poor accessibility due to bad roads makes it hard for pregnant women to seek health care. Consequently, women would seek care from the nearest health facility which may not have adequate facilities and skilled workers to cater for their needs. Health workers in the countryside lack the necessary skills, equipment and experience to properly respond to patient needs (16).

Despite these difficulties, the government has committed to achieve one of the millennium development goals of reducing maternal mortality rate (MMR) by 75% between 1990—2015. This is aimed at improving the overall maternal health across the country. In addition to that, the federal ministry of health (FMOH) has also employed various tactics to cut down the maternal mortality and newborn mortality indices.

Most of the problems experienced by pregnant women can be prevented, detected or treated through Antenatal care. Antenatal Care (ANC) is one of the most important health interventions for preventing maternal mortality and morbidity especially in areas where the general health of women in poor (Wilunda et al., 2015).

ANC involves nutrition counselling, birth preparations, advice on family planning after birth and delivery care. This provides a great opportunity for detecting threats to mother and the unborn child’s health. But most developing countries experience low antenatal care coverage, unlike developed countries where ANC penetration is 97%.In developing countries, only 69% of pregnant women visit healthcare facilities for antenatal care in sub-Saharan.

The consequences of failing to attend Antenatal Care Visits include death, and disability among women in the reproductive age (15-49) bracket in the developing nations. A woman who gives birth in a developing nation is 300 more likely to die as a result of complications during pregnancy compared to her counterpart in developed country (Gela, 2014).

Newborn care is mostly tied to Antenatal Care (ANC). ANC is a medical care given to newly delivered women, therefore, it begins immediately after the delivery process. In Ethiopia, ANC is utilised 1.2 times more by women in the age bracket 20-34 compared to those in the age group 15-19. Educated women are twice as much likely to use ANC as those with no proper education. Furthermore, the less income one has, the less likely, they are to utilise the ANC services.

Essentially, newborn care involves caring for the newborn. After delivery, the baby’s cord is removed from the mother by tying it using the local inset thread and later detached. The healthcare providers places it in a radiant warmer, dries it and looks after the newborn. The newborn is then wrapped in warmed blankets and placed on the abdomen of the mother to receive warmth and be close to its mother where it is breastfed (Jennifer A Callaghan et al, 2013).

When assessing the newborn’s indisposition to various childhood health hazards, its weight and size at birth is checked. Children that weigh below 2.5 kg at birth are more likely to die (Jennifer A Callaghan et al, 2013).

41% of women who delivered in the past 5 years received ANC from skilled health workers, midwives, or nurses during their most recent delivery. This represents a 52% increase over the last 15 years (5). 32% of women attended more than antenatal visits during their pregnancies compared to 10% that did so in 2000 (5). The median duration of pregnancy at the time of the first antenatal visit is 4.9 months. Although there have been only 15% facility births in Ethiopia, there has been remarkable improvement in the past 15 years up from 5%.only 13% of women received postnatal care within the first 48 hours of delivery in 2000 (5). However, this is a big improvement from the last 15 years where only 2% of women received the postnatal care (5).

About 1 in 27 women are at a risk of dying during childbirth or pregnancy (17). Further, more than a half a million women experience pregnancy-related disabilities. Obstetric fistula accounts for 9000 cases of pregnancy-related disabilities each year. The cases of pregnancy-related disabilities are more prevalent in the rural areas because most girls marry at tender ages due to strong sociocultural pressures. There is a 3.2% pregnancy among teenage girls in rural areas compared to only 0.6% in the urban areas. Most teenage girls become pregnant at age 19 years old (17).

Over 90% of total national births take place in the countryside. Unfortunately, 90% of women who need caesarian services lack proper access whereas only 15% of births are. It was estimated that out of 90,311 HIV-positive pregnant women, 14,276 were HIV-positive births (17)(18). As a result, two thirds of expectant mothers were tested and counselled for PMTCT. In an HIV-Positive-woman delivery section, only 24.6% were able to get the full medical attention in 2011(17). Despite the fact that the overall coverage of ITN use has improved at household levels in the recent years, only 35% of pregnant women use ITN (19).

There is a big difference between the level of education for women and regions. The number of women who are currently doing family planning has increased to 29% in the rural areas in a period of 5 years, whereas the increase is only 6% in the urban areas (17). Therefore, there is a need to ensure that health workers are motivated, skilled and knowledgeable to increase deliveries in health facilities.

According to sources from western countries, understanding the factors that influence individual and household factors to increase professionalism in delivery in health facilities is important. Appropriate healthcare must be given during pregnancy and delivery to reduce maternal mortality (Addis Allen Fikre, 2012). However, there is the challenge of accessibility for pregnant women in sub-Saharan Africa. The best way to reduce maternal and infant mortality in remote areas with low accessibility, socio-economic status and subscription to obstetric services is a resourceful approach. There is a risk of aggravated fatal outcomes such as death and disability if obstetric care is not availed. Providing professional assistance during delivery could reduce maternal deaths by an estimated 16-33%. The most prevalent obstacle to accessing proper healthcare is transport to a healthy facility as well as the long journey to health facilities (Warren C, 2010).

Most maternal mortality cases are preventable if healthcare interventions to prevent and check the complications are identified early enough. All women should ensure they have access to the antenatal care during pregnancy and receive skilled care during delivery and newborn care (WHO factsheet). The most effective means of reducing maternal mortality is ensuring pregnant women receive professional care. This can reduce maternal deaths from 33% to 13% (20). Both overall skilled attendance and institutional delivery account for 15% (5).

Skilled attendant is described the World Health Organisation as “an accredited health professionals such as a midwife, gynecologist or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period and in the identification, management and referral of complications in women and new-borns” (21).

Many researchers have concluded that there is a positive correlation between the use of maternal healthcare services and the patient’s place of residence. In other words, people in the urban areas are not only closest to the health facilities, but they also mostly benefit from skilled attendance more than those in the rural areas (22), (23), (24), (25). Maternal education is also another factor that determines the woman’s delivery care seeking behavior (26),(27),(28). Other related factors include maternal age, household wealth, and autonomy of the mother and the physical health of the facility (29). Distinctions are observed among studies on the reported factors. For instance, household wealth is seen as a more noteworthy determinant than access in India (30). Moreover, the level of education of the mother was considered an important factor in several studies (30), (31).

However, the extent of its effects is consistent with those of women’s autonomy, household wealth and access in a different study in Zambia (32). Furthermore, other factors include previous health facility delivery, antenatal follow-ups, quality of service and cost of the healthcare (30), (33), (34), (35), (36).

According to the ministry of Health, there is a low rate of delivery in the facilities despite the fact that institutional delivery is important. Thus, ministry considered priotising it in the National Reproductive health strategy and set to intensify it up to 60% by the year 2015 (37). However, there are only 15% deliveries in health facilities in Ethiopia (5). Hence, the aim of this study is to explore the factors associated with the readiness of front line workers in pregnancy care, delivery and new-born care in 4 regions of Ethiopia.

1.6 Quality of Care at delivery

The essential services required for adequate maternal and newborn care include sanitation, enhanced nutrition, safe water and hygiene facilities and practices, quality reproductive healthcare services, disease prevention and treatment during pregnancy, quality Antenatal Care (ANC), skilled assistance at delivery, comprehensive emergency obstetric services, newborn care services, postnatal care and neonatal care (van den Broek & Graham, 2009).

Globally, at least 850,000 women die annually due to a poor quality of delivery at delivery. In particular, more than two-thirds of all maternal deaths are caused by five major complications: infections, haemorrhage, unsafe abortion, and obstructed labour and hypertensive disorders of pregnancy. The majority of maternal deaths occur in the post-delivery period and within a day of delivery. Another estimated 40% of pregnant women suffer health complications related to pregnancy, before, during and after delivery. As a consequence, two-thirds of infants who die each year is largely due to poor quality of care during delivery as well as insufficient essential care of the newborn. Ethiopia is one of six countries that account for half of world’s maternal mortality with maternal mortality rate being 676 per 100,000 live births (Murray & Pearson, 2006).

We used secondary analysis of data obtained from the frontline workers’ module of the 2015 IDEAS study which looked at ‘Change in Maternal and Newborn Healthcare’ in four regions of Ethiopia.

IDEAS (Informed Decisions for Actions) is a 5-year project that is sponsored by Bill & Melinda Foundation. Its main objective is to improve the survival and health of mothers and babies by gathering evidence to inform policy and training. This project is currently underway in Nigeria, India, and Ethiopia, and uses measurement, evaluation and learning to discover maternal and newborn practices and ideas that work. A team of experts from London School of Hygiene & Tropical Medicine leads the practice (38). There are three survey components in the IDEAS project: (i) The facility module (ii) household module, and (iii) The front line workers’ module. This study specifically studies data on the FLWs module of 2015.

Ethiopia’s ministry of health has modified policy on deliveries to take place in health facilities instead of home deliveries. As a result of these changes, that has been a remarkable workload pressure on the skilled FLWs as the demand for adequate skills and readiness of the frontline workers has increased.

This is a multidimensional survey data collected in the last 10 kilometres (LK 10) worked in the last 5 years. It was gathered from two comparison and intervention areas to assess the impact of change between the baseline and the follow-up using difference-in-difference approach.

There are three levels of health system in Ethiopia; the first level is the district based (Woreda as Ethiopian administrative structure), which is the central hospital that can serve around 100,000 population. Health centres can serve a population of around 25,000 and health posts serves approximately 5,000 people. In Ethiopia, primary healthcare system is provided by the health centres and heath posts. The second level is the General hospitals that cater to about one million people. The tertiary level is the specialized hospitals that serve 5 million people. Each of these levels are linked to one another through a referral system. However, there are concerns regarding the speedy growth of the country’s health systems as well as its future sustainability (1).

The government has been able to achieve free maternal and child care and the health centres are basically able to provide basic emergency obstetric care (BEmOC) while hospitals provide Comprehensive Obstetric Care (CEmOC). However, due to differences in skills, knowledge and experience of the healthcare workers, the quality of care varies. While 51% of health practitioners within the hospitals are able to provide CEmOC, only 14% can provide BEmOC (8).

The ministry of health introduced Health Extension Workers (HEW) in a bid to achieve universal coverage. These health workers were selected from the local community (9)(10). In order to qualify as an HEW, one must have completed at least the 10^th grade in school. HEWs are trained for 9 months in the area of provision of basic healthcare services in the health posts(11) and offer simple and non-complicated deliveries. A month-long training known as “Clean and Safe Delivery” is also offered. HEWs had little prior experience, yet families accepted and trusted them. However, their skills and integrity has already been put to doubts (12).

In this context, FLW consist of Women’s Development Army (WDA) who are HEWs, community volunteers, auxiliary nurses, nurses and doctors who work in primary health centres.

This secondary data analysis assesses the knowledge and readiness of 320 front line workers who were selected from health facilities in four regions where IDEAS project conducted their evaluation and collected this data. The staff in health facilities who attended the recent deliveries in 80 health centres and 80 health posts were interviewed.

A normal questionnaire was created to measure the preparedness and knowledge of frontline health workers. The questions were designed to assess four categories of information:

1. The knowledge part of the questionnaire had seven parts of spontaneous questions such as need for special care plan for mothers, focused antenatal care, type of observations to make during labour , where to report the observations, what to do when women start bleeding heavily, special care to provide to underweight babies, and how to manage newborn infections.
2. The part on the preparedness had 13 questions to find out how FLWs prepared important drugs and equipment to conduct quality delivery care.
3. The frequency and type of training received by FLWs designed to improve their knowledge and skills during the last 12 months.
4. Whether the FLWs received any supportive supervision and who supervised them in the last 12 months.

As mentioned in the IDEAS report, all the questions in the initial assessments were informed by large-scale survey tools like the Demographic and Health Surveys (DHS), Averting Maternal Death and Disability and Safe Motherhood and the Service Provision Assessment (SPA).

Data was received in a STATA form and tested for errors, inconsistencies and using values to be able to do thorough analysis. We conducted descriptive summaries between the group proportions and made comparisons between them.

Demographic variables and background characteristics were produced. The predicting factors and explanatory variables selected in this study to test the connection with the results included supportive supervision, training of FLWs and years of service by the FLWs

Knowledge of care givers at the delivery, full preparation of key components in providing quality of delivery and quality of care were the primary and secondary outcome variables of interest in this study. A binary outcome variable was created for preparation and knowledge and studied various scoring patterns like the Ethiopian university education scoring system. Lastly, all the FLWs wore were found to be prepared for more than 60% of the items (>8 out of 13 items) were accorded full preparations while their counterparts who responded to less than 60% of the thirteen items were assigned poor preparations. Similarly, the knowledge variable was also divided into good and poor knowledge, with 0 being coded poor knowledge and 1 for full or good knowledge. Cross tabulations of each exposure of variable with the main outcomes of individual interest was used to examine the effects of different exposures of outcomes.

The studies examines the null hypothesis that FLWs who have had supportive supervision, full training and had over 12 months of working experience are not ready and not well prepared to conduct quality of care at pregnancy, delivery and care for newborns.

We used a single variable logistic regressions to study the connexion between each expression and outcomes of variables independently.

The association was measured using the odds ratios and matching confidence intervals as well as the likelihood ratio test. Confidence interval, crude odds ratio and p-value were achieved. This being a cross-sectional survey data, all associations were tested using the 10% and 90% confidence intervals.

Figure 1: Logical flow of the priority for the analysis

Multivariate logistic regression analysis was done to modify for confounding affected by the FLWs’ age, years of service, and nature of training and identity factors linked with the readiness of the FLWs. In order to examine the level of correspondence between the outcome and explanatory variables, test of mult-collinearity was conducted. No collinearity of more than 0.5 was detected.

Informed Decisions for Action in maternal and newborn health (IDEAS) got nationwide backing for the initial survey statistics gathering from Ethiopia’s Ministry of Health, and ethical authorisation was gotten from the Ministry of Science and Technology.

London School of Hygiene Ethics Committee (LSHTM Ethics Ref: 6088), Regional Institutional Review Boards in Amhara Oramia and Tigray approved consent forms used for the project and the study protocol. All interviewees gave their formal, written consent in advance of being quizzed.

A total of 320 FLWs were sampled from 160 health amenities in the 4 provinces of Ethiopia.

Their accumulated mean age was 31.8 with a standard deviation of 0.57. 30.6% of the respondents were aged between 18-25 years while those who were aged over 56% represented only 1.3% of interviewees. 48.1% of the respondents had attended college or university while 24% of the respondents didn’t have any formal education.

Out of the 320 FLWs that were questioned, 48.1% form part of the Health Development Army while 25.6% are nurses or midwives. Others were, Trained Traditional Birth Attendants (TTBAs) (1.3%) and Community Health Providers (CHPs) (0.6%). The results show that all but one health facilities were owned by the government. The results also indicate that 99.4% of the 160 health facilities under the study were run and managed by the government while 0.63% of the health amenities were managed by non-governmental organizations. There were no mission health facilities in the area of study. 38.8% of the 160 health facilities under study are from the Amhara region while 11.3% come from the Tigray region.

From the study, 71.9% representing 230 respondents out of 320 FLWs who were interviewed had between 1 and 5 years’ work experience. 24.5 of respondents worked between 1 and 5 years while those who had less than 12 months job experience represented 3.8% of the interviewees.

FLWs spent on average 11.50 hours per week in the provision of ANC services in health services, with a standard deviation of 16.06. About 54.1% reported having provided pregnancy care in the last 12 months with 40.6% claiming they gave delivery services and 60% reporting not providing birth services.

Of the births that were done, 98.3% were those that were vertex in nature, meaning that they needed one vacuum extraction while 40% of the vertex was noticed during the initial first stage of the pregnancy and 35% during the second stage and 35% at the second stage and 19.7% at third.

On average, those who received assistance were aged 28 with standard deviation of 1.2, with confidence interval of between 25.7 and 30.3. More than ¾ of the 117 assisted mothers had delivered at least once in the past and 93.2% of the interviewee said that mothers lived after giving birth. However, 95.7% said that they experienced still birth while giving birth.

More than 74.4% of the interviewees reported that infants that weighed less than 2.5 kg were 8% while 23.1% of the respondents said they experienced early deliveries of less than 37 weeks. Only 3.4% of mother and 1.7% of children were referred to other health centres.

The percentage of respondents that reported watching the labour process was 84% but only 19.4% recorded their observations on the pantograph. The percentage of FLWs that provided rgometrine/syntometrine/ oxytocin/misoprostol—uterotonics was 54.7% while those who provided active management of the third stage of labour was 82%. 22% of the respondents provided oxytocin while only 5% provided egometrine with 1-2 minutes.

25.1 of the FLWs claim to have conducted uterine massage and 25% say to have controlled cord traction. Out of 117 FLWs, 20.5% said they called for emergency intervention while 34.2% said they were compelled to manually remove the placenta. 19.7% administered oxytocin while 14.5% had to give antibiotics.

17.2% of the 320 FLW surveyed said they cleaned the baby’s mouth before the rest of the shoulders came out while 29.7% washed the baby’s face, nose and mouth. 26.3% ensured that the baby was breathing and 25.9 checked to see if the baby was dry. 18.1% ensured the baby was warm and 14.1% examined the colour of the baby. 20.6% checked the weight of the baby and 14.7% administered prophylaxis for the eyes. Lastly, the newborn was observed within the first hour after birth by 22.5% of the respondents. Regarding resuscitation, the deliveries that required resuscitation were 10.3% and 24.1% of 117 interviewees said they did not apply anything during the treatment of cord.

Supportive supervision is simply the practice assisting the staff to improve their work performance. This research examined a diverse types of training for example offering normal deliveries services, antenatal care, and active managing of the third stage of labour, newborn care, postnatal care and basic emergency obstetric. Health extension workers were represented by 54 (37.5%) of the FLWs. 52 (36.1%) of the respondents represented Nurses and Midwives and 38 (26.4) of the respondents were from Health Development Army. None of the Community Health Providers and Trained Traditional Birth Attendants said they received training.

The aim of supportive supervision is to improve the skills and knowledge of the health workers. 7.3% of the FLWs interviewed said they received supportive supervisory visits in the last two months. TTBAs reported higher average of 8.5 supportive supervisory visits with a standard deviation of 4.9 compared to other cadres. Community Health providers, on the other hand, did not receive any supportive supervision in the last 12 months.

This study examines the methods employed by the FLWs while doing delivery care. It also aims to understand whether FLWs were able to get ready with critical and lifesaving items that were important when conducting deliveries. The study further aims at identifying any gap in the preparedness level. Some respondents claimed to have lack of or limited supplies of sterile gloves, gauze, disinfectant, clean clothes or towels, sterilized razor blades/scissors, ligators, misoprostol, oxytocine, ergometrine, chlorhexidine and eye ointment. 94% of the 117 respondents were prapered with gloves as part of delivery preparedness. 81.2% got access to disinfectant while gauze was available for 93% of the respondents; clean towels or cloths was available to 68.4% of the interviewees. Only one respondent did not have a sterilized pair of scissors for cutting the cutting cord. 97% of the 117 respondents said the prepared ligatures, 65% were prepared with oxytocin, but 77.8% of the respondents who didn’t have oxytocin blamed the limited supply while the rest (9%) alleged that policy issues was the main concern. Among those who did not claim unavailability, 68.4% prepared for ergometrine. Only 27% prepared for Misoprostol, and those who did not have it claimed that lack of supply was the reason. 72.7% of the respondents prepared for eye ointments. Syntometrine and chlorhexidine was prepared by only 10% and 11% of the 117 respondents respectively. No reason was provided by those who did not have syntometrine and chlorhexidine.

3.5.1 Focused Antenatal care:

Seven components essential for studying the knowledge of the service providers was studied, and this included the primary aspects of focused antenatal care, monitoring observation during labour, special care plan for women, registration of observations, actions to be taken when women start bleeding heavily and the nature of special care to be given to newborns who weigh less than 2.5 kg. Lastly, what are the initial steps taken when newborns show signs of antibiotics?

Regarding the knowledge test for the focused antenatal care, 47.2% of the 320 respondents, claimed at least four consultations as part of the primary part of focused ANC. 34.1% of the respondents said they ensured women had a birth control plan while 47.2% said they promoted health by providing preventive services like iron tablets, tetanus toxoid vaccines and protection against malaria. In addition to tat, 37.2% of the 320 FLWs respondents claimed that they detected illness and had the ability to manage HIV and other STIs complications. 35.3% and 33.2% of the respondents said educating women about signs of pregnancy, delivery and postpartum and promotion of breastfeeding respectively.

3.5.2 Special Care Plan

43.2% of the 320 interviewees alleged that females who experience caesarean need special care plan, whereas 29.1% thought that females who have had at least 5 deliveries require special care plan; 8.2% claimed that women who have had birth intervals of less than 2 years or more than 5 years require special care plan. 29.7% of the respondents said that women who previously had still births need special care plan, while 22.5% were of the opinion that women who previously experienced neonatal death required special care plan. 13.1% felt that women who had experienced instrumental delivery processes such as forceps or vacuum extraction require special care plan. 15.9% and 22.5% of respondents felt that women with a history of obstetric fistula repair and severe obstetric complications needed special care plans respectively. Lastly, 20.6% of the respondents thought that underage/teenage pregnant girls needed special care plan.

3.5.3 Monitoring Labour Progress

Once it comes to observing labour processes, 35.6% of the 320 FLWs respondents examined the heartbeats, 21.3 monitored the degree of moulding, 17.8% watched the colour of amniotic fluid, 28.4 watched cervix dilation, 24.7 observed uterine reductions, 20.9% checked the descent of the head and 24.1% observed maternal pulse.

3.5.4 Registration of Observations

25.3% of the respondents said they recorded observation on the pantograph while 7.8% said they entered their observations on the clinical cards of the patients. 4.1% recorded their notes on the pantograph in the postnatal card. However, 5% said they recorded their observation a white piece of paper while 11% did not keep any records.

3.5.5 Management of Heavy Bleeding

If heavy bleeding occurs during or after delivery 20.6% massaged the fundus, 23.8% claimed they gave either oxytocin (IV or IM) or ergometrine while 23.8% claimed that they gave IV fluids. 7.5% of the respondents check blood for the presence of haemoglobin and cross-matching and 12.2% emptied the bladder. Those who examined women for tears were 15% while 12.8 detached the reserved products by hand while 71.3 referred the women.

3.5.6 Care for Low Birth Weight

For the 117 conducted deliveries, front line workers were asked how well they were able to prepare the essential items (Table 3) for use during the delivery. Univariate logistic regression established that front line workers who received all training were almost 1.3 times more likely to be well prepared (OR: 1.26; 95% CI: 0.57-2.75; P=0.56) than those who were poorly prepared. Health workers who received the antenatal training had 25% less preparation for delivery care (OR: 0.75; 95% CI: 0.23-2.42; P=0.64) compared to those who did not receive that particular training, whilst workers who served in same role between one to five years were twice more likely well prepared (AOR: 2.11; 95% CI: 0.16 -27.58; P=0.56) compared to those who remained in service < 1 years.

Multivariate logistic regression analysis, all types of trainings received in the last 12 month by front line workers or providers, supportive supervision and years of services showed no evidence to be associated with the full preparation for delivery care (OR:0.99, 95% CI: 0.37-2.66, P=0.99 for training; OR:0.59, 95%CI:0.19-1.85, P=0.37 for supervision; and OR:0.42, 95CI:0.03-6.27, P=0.63 for those in service over five years).

Measuring the connection between the knowledge of the FLWs and other independent variables like supervision, training and years of experience of service the FLWs remained as service provider. It was found that significant supportive supervision is strongly correlated to the knowledge of the health workers when it comes to providing quality of care (AOR: 4.4; 95% CI: 2.16 – 8.97; P<0.001).

The FLWs who got the requisite training are 3 times more likely to have full knowledge (AOR: 2.54; 95% CI: 1.35–4.77; P=0.004) compared to those who did not acquire any form of training. The surprising thing is that the analysis show that there is no correlation between knowledge and training of those who received antenatal care (AOR: 1.0; 95%CI: 0.34-2.98; P=0.99) and who did not. Those with at least 5 years of experience are more than likely to be more knowledgeable (AOR: 1.38; 95%CI: 0.23–8.97; P=0.72) than those with less than 12 months of experience.

Finally, a fully adjusted OR between age, preparedness and knowledge was tabulated using the logistic regression. It was discovered that is age is strongly correlated with knowledge, but not preparedness variable (OR: 0.44; 95% CI: 0.30-0.64; P<0.001; and OR: 1.04; 95% CI: 0.57-1.90; P=0.89) respectively.

After monitoring for identified confounder, the FLWs who received training were three times more knowledgeable than those with no training. There was a very low p-value associated with the fully adjusted OR, making it not likely that the finding was an accident. Furthermore, evidence suggests that those FLWs who received supportive supervision were 5 times more knowledgeable than those who did not. However, the likelihood or residual confounding is real. For instance, it is possible that the knowledge and practice of FLWs in urban settings is different to the FLWs in the rural areas. So it is important to have this knowledge at an individual level for one to know whether there is any difference in odds between the two groups of FLWs. Ccording to a study by Gilles Dussault, et al., wealthier, urban areas attract more skilled workers compared to rural, poor areas. Apart from financial gain, a qualified physicians may consider social, cultura and professional advantages (39). This feelings makes people living in the rural areas to lack quality of healthcare services.

According to a systematic review involving 95 quasi-experimental studies by Michael J. Burke, et al, a positive association exists between training and improvement of knowledge and skills for health outcomes. The study suggests that training can enhance the knowledge of health workers if it is conducted in a way that suits the needs on the ground and is properly implemented. In addition to that, an interactive training that involves in substantial practice results in more effective behavioural modelling and dialogue than passive, computer based distance learning forms of training (40). We understand from this data analysis that only 45% of the 320 FLWs (144) from the 160 sampled health facilities had received training in the last one year. No information can be found that is related to the quality, content and methodology of the training was conducted.

Another critical aspect of intervention to improve the performance of FLWs as well as the quality of services is supervision. If done correctly, it could provide workers with a chance to develop professionally and also reassure and motivate the health workers (41). However, it is rarely challenged by impractical plans, weak accountability and unavailability of resources, lack of follow-up and health workers feedback in developing setting (41). The result of the supervision is normally affected by the performance of the supervisors and the extent to which supervisory tools are utilised in the given facility. Therefore, the performance of the supervisor should be understood in this regard. This analysis did not study the determining factor of quality supportive supervision that is aimed at improving the satisfaction levels of health workers including the performance and motivation of the supervisors.

Similarly, the analysis also examines the connection between experience by the FLWs and their preparedness and knowledge in engaging in quality of care at delivery. The variable, years in service, was then divided into three: those with less than 12 months of experience, those FLWs who served between 1-5 years and those with over 5 years of experience. Hence, the regression analyses shows that there is no significant correlation between the numbers of years of experience of health providers and their preparedness and knowledge in serving patients. According to research report by NHS England, Dr Jeremy Dawson of Sheffield University Management School, has examined, in many studies, the effects of health workers experience over the outcomes of the patient in various nations. He concluded that the experience of the staff has a strong association with the outcome of patients, quality of care and patient satisfaction (42).

It was revealed that the health workers had very poor knowledge of their normal tests when spontaneous questions were asked. Seven components of health care workers’ knowledge were included in the test questions. The seven parts included the following: focused antenatal care, what to observe during labour process, special care for pregnant women, recording of observation and controlling of heavy bleeding after delivery. Other are, low weight of the newborn (below 2.5kg) at birth and main steps to take to manage newborn infections.

None of the interviewees met the standards of safe motherhood because none of them passed all the above mentioned 7 criteria. According to a certain study done on the knowledge and performance of Ethiopian HEWs on antenatal and deliver (Medhanyie , et al, n.d), policies for improving the performance and knowledge of HEWs need to be implemented as well as create an enabling environment particularly in the rural areas. (43).

The research explored the knowledge of the HEWs and concluded that there is a knowledge between those HEWs in rural areas and urban areas. In this study, it is impossible to separate the data into rural and urban to study the difference between these two groups. Nonetheless, there is no clear difference that exists between health extension workers and nurses/midwives where their knowledge was tested. In conclusion, heath extension workers shouldn’t perform better than nurses/midwives; therefore, the fact that there is a striking similarity between the HEWs and nurses is a subject for further studies.

There is a possibility of selection bias because data is collected from FLWs in a sample of health facilities. For example, it is not possible to tell what percentage of respondents come from the intervention Woredas and the comparison ones. It is also not possible to know how these frontline workers were chosen among several others. No specific detailed selection formula has been discussed because, for instance, we are simply told that out of the 130 FLWs who ever attended delivery, only 117 were selected. It mentions that each family produced two member.

Acquaintance could be another possible source of bias. FLWs may be tempted to make their supervisors happy by preparing and implementing all items. So it is suggested that an inventory taking execrises could remove some of these biases.

There is also the possibility of recall bias because FLWs were asked about several past activities. This, observing FLWs’ practices in relation to conducting quality care would result in a more robust and accurate information about their sills and knowledge.

In the fact that the front line workers were asked about the past activities about the deliveries conducted, there is a greater possibility of recall bias. As said above, observing the practices of the front line workers in relations to conducting quality delivery care would generate more robust and precise information about their skills and knowledge.

Sample size:

According to World Health Organization (WHO) manual, all health institutions in the area should be used if less than 100 in number in the evaluation of maternal care performances (van den Broek & Graham, 2009). However, if there are more, a suitable sample is selected. The quantitative survey was conducted on 80 health care facilities in 4 regions in Ethiopia: Amhara, SNNP, Oromia, Tigray. A multi-stage sampling technique was used to select study participants. A total of 80 participants were selected, two from each health centre. Census was conducted to identify health facilities with qualified frontline workers who have been giving prenatal and postnatal care to pregnant women and newborn babies. During the census, it was discovered that there are more eligible health workers than the needed sample size, hence, a proportional allocation of the four regions was done. Lastly, to select participants to be included in the study, simple random sampling technique was used. If more than two eligible persons were identified in a given health centre, one responded was chosen using a coin toss.

This date was collected from 160 health facilities in the four regions of Ethiopia. This could affect the generalizability of the results because the respondents come from different parts of the country. Moreover, the representation of the rural versus urban localties could affect the generalizability of the results

This data was collected from 160 health facilities in 4 regions in Ethiopia, which although typical for the area but may reduce the generalizability of the results.

In order to achieve quality of care for the mothers and newborns, there are few important things that needs to be considered in the four regions of Ethiopia. They include the following:

• The government should concentrate on the quality improvement of the maternal and newborn services by making substantial improvements instead of expansion only. This study shows that FLWs still need training in order to produce the desired levels quality care.
• There should be an increase in the number of good quality refreshers courses for FLWs in the said health facilities with enough duration.
• District Health management should be given capacity to engage in quality supportive supervision to the health facilities. The supportive supervision sessions should be frequent and regular and use uniform reporting indicators for feedback purposes.
• Staff turnover should be reduced to a minimum. Attraction of qualified staff to the areas should also be encouraged. More support supervision should be encouraged to attract qualified health workers. Many infant and maternal mortality is caused by disabilities or difficulties encountered in the rural areas to access health facilities.

Although the quality of maternal care provided to clients regarding early detection of potential pregnancy complications, prevention and treatment of common maternal and neonatal complications seems to have improved slightly, the quality of overall care falls below the world health organisation recommended standards. It is difficult for frontline workers to provide quality care to pregnant women and newborn babies because they lack sufficient competencies and skills. Poor quality care was observed in all healthcare facilities, meaning a lot still needs to be done.

1. USAID. 1 – Ethiopia_Health_Care_Reform_Brief1. In: USAID, editor. Health Systems 2020. First. Ethiopia; 2012. p. 12.

2. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet [Internet]. 2010;375(9726):1609–23. Available from: http://dx.doi.org/10.1016/S0140-6736(10)60518-1

3. Van Den Broek NR, Falconer AD. Maternal mortality and Millennium Development Goal 5. Br Med Bull. 2011;99(1):25–38.

4. Mekonnen Y MA. Factors influencing the use of maternal healthcare services in Ethiopia. Int J Equity Health. 2003;14(1):7.

5. Central Statistical Agency. 2014 Ethiopia Mini Demographic and Health Survey (EMDHS). 2014;(August):111.

6. Warren C. Care seeking for maternal health: Challenges remain for poor women. Ethiop J Heal Dev. 2010;24(SPEC. ISSUE 1):100–4.

7. Banteyerga H. Ethiopia’s Health Extension Program: Improving Health through Community Involvement. MEDICC Rev. 2011;13(3):46–9.

8. Admasu K, Haile-Mariam A, Bailey P. Indicators for availability, utilization, and quality of emergency obstetric care in Ethiopia, 2008. Int J Gynecol Obstet [Internet]. 2011;115(1):101–5. Available from: http://dx.doi.org/10.1016/j.ijgo.2011.07.010

9. Koblinsky M, Tain F, Gaym A, Karim A, Carnell M, Tesfaye S. Responding to the maternal health care challenge: The Ethiopian Health Extension Program. Ethiop J Heal Dev. 2010;24(SPEC. ISSUE 1):105–9.

10. Kitaw Y, Ye-ebiyo Y, Said A, Desta H, Teklehaimanot A. Assessment of the Training of the First Intake of Health Extension Workers. Ethiop J Heal Dev. 2007;21(3):232–9.

11. Continent D. Yes Africa Can. Africa.

12. Negusse H, McAuliffe E, MacLachlan M. Initial community perspectives on the Health Service Extension Programme in Welkait, Ethiopia. Hum Resour Health [Internet]. 2007;5:21–5. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=28747967&site=ehost-livenhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000465/pdf/1478-4491-5-21.pdf

13. WHO, UNICEF, UNFPA TWB. Maternal Mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and The World Bank. Bull World Heal Organ. 2007;79:657–64.

14. Say L, Chou D, Gemmill A, Tun??alp ??zge, Moller AB, Daniels J, et al. Global causes of maternal death: A WHO systematic analysis. Lancet Glob Heal. 2014;2(6):323–33.

15. Berhan Y, Berhan A. Review of maternal mortality in Ethiopia: a story of the past 30 years. Ethiop J Health Sci [Internet]. 2014;24 Suppl:3–14. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4249207&tool=pmcentrez&rendertype=abstractnhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4249207/pdf/EJHS240S-0003.pdf

16. Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Soc Sci Med. 1994;38(8):1091–110.

17. WHO. Ethiopia: Analytical summary – Maternal and newborn health [Internet]. WHO Country profiles – Ethiopia. 2014 [cited 2007 Jun 20]. p. 1–4. Available from: http://www.aho.afro.who.int/profiles_information/index.php/Ethiopia:Analytical_summary_-_Maternal_and_newborn_health#cite_ref-twelve_0-1

18. FMOH. Federal Democratic Republic of Ethiopia Ministry of Health: Health Sector Development Programme IV 2010/11 – 2014/15. 2010;IV(October 2010):114.

19. Usaid. PRESIDENT ’ S MALARIA INITIATIVE Zambia Malaria Operational Plan FY 2015. 2013;1–45. Available from: http://www.pmi.gov/countries/mops/fy13/liberia_mop_fy13.pdf

20. Baral YR, Lyons K, Skinner J, Van Teijlingen ER. Determinants of skilled birth attendants for delivery in Nepal. Kathmandu Univ Med J. 2010;8(31):325–32.

21. World Health Organization department of reproductive health and research. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva, Switz WHO [Internet]. 2004;1–18. Available from: http://whqlibdoc.who.int/publications/2004/9241591692.pdf

22. Ayale B. What Factors Determine Delivery Practices of Pregnant Women ? School of Graduate Studies. 2005;(May).

23. Hiluf M, Fantahun M. Birth preparedness and complication readiness among women in Adigrat town, north Ethiopia. Ethiop J Heal Dev. 2008;22(5):1–7.

24. Bhatia JC, Cleland J. Determinants of maternal care in a region of South Asia. Heal Transit Rev [Internet]. 1995;5:127–42. Available from: https://digitalcollections.anu.edu.au/bitstream/1885/41182/2/Bhati1_1.pdf

25. Mekonnen Y. Patterns of maternity care service utilization in Southern Ethiopia : Evidence from a community and family survey. Ethiop J Heal Dev. 2003;17(1):27–33.

26. Moore M, Copeland R, Chege I, Pido D, Griffiths M. A behaviour change approach to investigating factors influencing women’s use of skilled care in Homa Bay District, Kenya. Washingt DC Chang Proj [Internet]. 2002;(December). Available from: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:A+Behavior+Change+Approach+to+Investigating+Factors+Influencing+Women?s+Use+of+Skilled+Care+in+Homa+Bay+District,+Kenya#0

27. L10K. Baseline Household Health Survey: Amhara, Oromiya, SNNP, and Tigray. 2009;1–64.

28. Abebe F, Berhane Y, Girma B. Factors associated with home delivery in Bahirdar, Ethiopia: a case control study. BMC Res Notes [Internet]. 2012;5(1):653. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3554461&tool=pmcentrez&rendertype=abstract

29. Hagos S, Shaweno D, Assegid M, Mekonnen A, Afework MF, Ahmed S. Utilization of institutional delivery service at Wukro and Butajera districts in the Northern and South Central Ethiopia. BMC Pregnancy Childbirth [Internet]. 2014;14(1):178. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4047000&tool=pmcentrez&rendertype=abstract

30. Kesterton AJ, Cleland J, Sloggett A, Ronsmans C. Institutional delivery in rural India: the relative importance of accessibility and economic status. BMC Pregnancy Childbirth [Internet]. 2010;10(1):30. Available from: http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-10-30

31. Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health [Internet]. 2011;10(1):31. Available from: http://www.equityhealthj.com/content/10/1/31

32. Gabrysch S, Cousens S, Cox J, Campbell OMR. The influence of distance and level of care on delivery place in rural Zambia: A study of linked national data in a geographic information system. PLoS Med. 2011;8(1).

33. Adamson PC, Krupp K, Niranjankumar B, Freeman AH, Khan M, Madhivanan P. Are marginalized women being left behind? A population-based study of institutional deliveries in Karnataka, India. BMC Public Health [Internet]. 2012;12(1):30. Available from: http://www.biomedcentral.com/1471-2458/12/30

34. Gabrysch S, Campbell OMR. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9:34.

35. Teferra A, Alemu F, Woldeyohannes S. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of Ethiopia: A community – based cross sectional study. BMC Pregnancy Childbirth [Internet]. 2012;12(1):74. Available from: BMC Pregnancy and Childbirth

36. Wanjira C, Mwangi M, Mathenge E, Mbugua G, Ng’ang’a Z. Delivery practices and associated factors among mothers seeking child welfare services in selected health facilities in Nyandarua South District, Kenya. BMC Public Health. 2011;11:360.

37. Ethiopia Ministry of Health. National Reproductive Health Strategy 2006 – 2015. Fed Democr Repub Ethiop Minisrty Heal. 2006;(March):1–46.

38. http://ideas.lshtm.ac.uk/news/ideas-welcomes-new-country-coordinators. LSHTM: http://ideas.lshtm.ac.uk/news. London: LSHTM; 2015.

39. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. 2006;16:1–16.

40. Burke MJ, Sarpy SA, Smith-crowe K, Chan-serafin S, Salvador RO, Islam G. Relative Effectiveness of Worker Safety and Health Training Methods. 2006;96(2):315–24.

41. Rowe AK, Savigny D De, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings ? 2005;366.

42. Jeremy A. STAFF EXPERIENCE AND PATIENT OUTCOMES : WHAT DO WE KNOW ? A report commissioned by NHS Employers on behalf of NHS England. 2014;(July).

43. Medhanyie A, Spigt M, Dinant G, Blanco R. Knowledge and performance of the Ethiopian health extension workers on antenatal and delivery care : a cross-sectional study. 2012;1–8.

44. Kruk ME, Paczkowski MM, Tegegn A, Tessema F, Hadley C, Asefa M, et al. Women’s preferences for obstetric care in rural Ethiopia: a population-based discrete choice experiment in a region with low rates of facility delivery. J Epidemiol Community Health. 2010 Nov;64(11):984–8.

45. De Brouwere, V., Richard, F., & Witter, S. (2010). Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn. Tropical Medicine & International Health, 15(8), 901-909. http://dx.doi.org/10.1111/j.1365-3156.2010.02558.x

46. Gela, B. (2014). Antenatal Care Utilization and Associated Factors from Rural Health Extension Workers in Abuna Gindeberet District, West Shewa, Oromiya Region, Ethiopia. American Journal Of Health Research, 2(4), 113. http://dx.doi.org/10.11648/j.ajhr.20140204.12

47. Murray, S. & Pearson, S. (2006). Maternity referral systems in developing countries: Current knowledge and future research needs. Social Science & Medicine, 62(9), 2205-2215. http://dx.doi.org/10.1016/j.socscimed.2005.10.025

48. van den Broek, N. & Graham, W. (2009). Quality of care for maternal and newborn health: the neglected agenda. BJOG: An International Journal Of Obstetrics & Gynaecology, 116, 18-21. http://dx.doi.org/10.1111/j.1471-0528.2009.02333.x

49. Wilunda, C., Quaglio, G., Putoto, G., Takahashi, R., Calia, F., & Abebe, D. et al. (2015). Determinants of utilisation of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study. Reproductive Health, 12(1). http://dx.doi.org/10.1186/s12978-015-0067-y

1. USAID. 1 – Ethiopia_Health_Care_Reform_Brief1. In: USAID, editor. Health Systems 2020. First. Ethiopia; 2012. p. 12.

2. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet [Internet]. 2010;375(9726):1609–23. Available from: http://dx.doi.org/10.1016/S0140-6736(10)60518-1

3. Van Den Broek NR, Falconer AD. Maternal mortality and Millennium Development Goal 5. Br Med Bull. 2011;99(1):25–38.

4. Mekonnen Y MA. Factors influencing the use of maternal healthcare services in Ethiopia. Int J Equity Health. 2003;14(1):7.

5. Central Statistical Agency. 2014 Ethiopia Mini Demographic and Health Survey (EMDHS). 2014;(August):111.

6. Warren C. Care seeking for maternal health: Challenges remain for poor women. Ethiop J Heal Dev. 2010;24(SPEC. ISSUE 1):100–4.

7. Banteyerga H. Ethiopia’s Health Extension Program: Improving Health through Community Involvement. MEDICC Rev. 2011;13(3):46–9.

8. Admasu K, Haile-Mariam A, Bailey P. Indicators for availability, utilization, and quality of emergency obstetric care in Ethiopia, 2008. Int J Gynecol Obstet [Internet]. 2011;115(1):101–5. Available from: http://dx.doi.org/10.1016/j.ijgo.2011.07.010

9. Koblinsky M, Tain F, Gaym A, Karim A, Carnell M, Tesfaye S. Responding to the maternal health care challenge: The Ethiopian Health Extension Program. Ethiop J Heal Dev. 2010;24(SPEC. ISSUE 1):105–9.

10. Kitaw Y, Ye-ebiyo Y, Said A, Desta H, Teklehaimanot A. Assessment of the Training of the First Intake of Health Extension Workers. Ethiop J Heal Dev. 2007;21(3):232–9.

11. Continent D. Yes Africa Can. Africa.

12. Negusse H, McAuliffe E, MacLachlan M. Initial community perspectives on the Health Service Extension Programme in Welkait, Ethiopia. Hum Resour Health [Internet]. 2007;5:21–5. Available from: http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=28747967&site=ehost-livenhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000465/pdf/1478-4491-5-21.pdf

13. WHO, UNICEF, UNFPA TWB. Maternal Mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and The World Bank. Bull World Heal Organ. 2007;79:657–64.

14. Say L, Chou D, Gemmill A, Tun??alp ??zge, Moller AB, Daniels J, et al. Global causes of maternal death: A WHO systematic analysis. Lancet Glob Heal. 2014;2(6):323–33.

15. Berhan Y, Berhan A. Review of maternal mortality in Ethiopia: a story of the past 30 years. Ethiop J Health Sci [Internet]. 2014;24 Suppl:3–14. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4249207&tool=pmcentrez&rendertype=abstractnhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4249207/pdf/EJHS240S-0003.pdf

16. Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Soc Sci Med. 1994;38(8):1091–110.

17. WHO. Ethiopia: Analytical summary – Maternal and newborn health [Internet]. WHO Country profiles – Ethiopia. 2014 [cited 2007 Jun 20]. p. 1–4. Available from: http://www.aho.afro.who.int/profiles_information/index.php/Ethiopia:Analytical_summary_-_Maternal_and_newborn_health#cite_ref-twelve_0-1

18. FMOH. Federal Democratic Republic of Ethiopia Ministry of Health: Health Sector Development Programme IV 2010/11 – 2014/15. 2010;IV(October 2010):114.

19. Usaid. PRESIDENT ’ S MALARIA INITIATIVE Zambia Malaria Operational Plan FY 2015. 2013;1–45. Available from: http://www.pmi.gov/countries/mops/fy13/liberia_mop_fy13.pdf

20. Baral YR, Lyons K, Skinner J, Van Teijlingen ER. Determinants of skilled birth attendants for delivery in Nepal. Kathmandu Univ Med J. 2010;8(31):325–32.

21. World Health Organization department of reproductive health and research. Making pregnancy safer: the critical role of the skilled attendant. A joint statement by WHO, ICM and FIGO. Geneva, Switz WHO [Internet]. 2004;1–18. Available from: http://whqlibdoc.who.int/publications/2004/9241591692.pdf

22. Ayale B. What Factors Determine Delivery Practices of Pregnant Women ? School of Graduate Studies. 2005;(May).

23. Hiluf M, Fantahun M. Birth preparedness and complication readiness among women in Adigrat town, north Ethiopia. Ethiop J Heal Dev. 2008;22(5):1–7.

24. Bhatia JC, Cleland J. Determinants of maternal care in a region of South Asia. Heal Transit Rev [Internet]. 1995;5:127–42. Available from: https://digitalcollections.anu.edu.au/bitstream/1885/41182/2/Bhati1_1.pdf

25. Mekonnen Y. Patterns of maternity care service utilization in Southern Ethiopia : Evidence from a community and family survey. Ethiop J Heal Dev. 2003;17(1):27–33.

26. Moore M, Copeland R, Chege I, Pido D, Griffiths M. A behaviour change approach to investigating factors influencing women’s use of skilled care in Homa Bay District, Kenya. Washingt DC Chang Proj [Internet]. 2002;(December). Available from: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:A+Behavior+Change+Approach+to+Investigating+Factors+Influencing+Women?s+Use+of+Skilled+Care+in+Homa+Bay+District,+Kenya#0

27. L10K. Baseline Household Health Survey: Amhara, Oromiya, SNNP, and Tigray. 2009;1–64.

28. Abebe F, Berhane Y, Girma B. Factors associated with home delivery in Bahirdar, Ethiopia: a case control study. BMC Res Notes [Internet]. 2012;5(1):653. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3554461&tool=pmcentrez&rendertype=abstract

29. Hagos S, Shaweno D, Assegid M, Mekonnen A, Afework MF, Ahmed S. Utilization of institutional delivery service at Wukro and Butajera districts in the Northern and South Central Ethiopia. BMC Pregnancy Childbirth [Internet]. 2014;14(1):178. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4047000&tool=pmcentrez&rendertype=abstract

30. Kesterton AJ, Cleland J, Sloggett A, Ronsmans C. Institutional delivery in rural India: the relative importance of accessibility and economic status. BMC Pregnancy Childbirth [Internet]. 2010;10(1):30. Available from: http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-10-30

31. Agha S, Carton TW. Determinants of institutional delivery in rural Jhang, Pakistan. Int J Equity Health [Internet]. 2011;10(1):31. Available from: http://www.equityhealthj.com/content/10/1/31

32. Gabrysch S, Cousens S, Cox J, Campbell OMR. The influence of distance and level of care on delivery place in rural Zambia: A study of linked national data in a geographic information system. PLoS Med. 2011;8(1).

33. Adamson PC, Krupp K, Niranjankumar B, Freeman AH, Khan M, Madhivanan P. Are marginalized women being left behind? A population-based study of institutional deliveries in Karnataka, India. BMC Public Health [Internet]. 2012;12(1):30. Available from: http://www.biomedcentral.com/1471-2458/12/30

34. Gabrysch S, Campbell OMR. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9:34.

35. Teferra A, Alemu F, Woldeyohannes S. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of Ethiopia: A community – based cross sectional study. BMC Pregnancy Childbirth [Internet]. 2012;12(1):74. Available from: BMC Pregnancy and Childbirth

36. Wanjira C, Mwangi M, Mathenge E, Mbugua G, Ng’ang’a Z. Delivery practices and associated factors among mothers seeking child welfare services in selected health facilities in Nyandarua South District, Kenya. BMC Public Health. 2011;11:360.

37. Ethiopia Ministry of Health. National Reproductive Health Strategy 2006 – 2015. Fed Democr Repub Ethiop Minisrty Heal. 2006;(March):1–46.

38. http://ideas.lshtm.ac.uk/news/ideas-welcomes-new-country-coordinators. LSHTM: http://ideas.lshtm.ac.uk/news. London: LSHTM; 2015.

39. Dussault G, Franceschini MC. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. 2006;16:1–16.

40. Burke MJ, Sarpy SA, Smith-crowe K, Chan-serafin S, Salvador RO, Islam G. Relative Effectiveness of Worker Safety and Health Training Methods. 2006;96(2):315–24.

41. Rowe AK, Savigny D De, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings ? 2005;366.

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