title: Health Extension Workers' and Mothers' Attitudes to Maternal Health Service Utilization and Acceptance in Adwa Woreda, Tigray Region, Ethiopia.
abstract: BACKGROUND
  The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs' and mother's attitudes to maternal health services in Adwa Woreda, Tigray Region.
  
  
  METHODS
  In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women's social status and mobility; and women's perceptions of skilled birth attendant's care. All data were analyzed thematically.
  
  
  RESULTS
  There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women's Development Groups (WDGs), and referral by ambulance to health facilities either before a woman's Expected Due Date (EDD) or if labour started at home.
  
  
  CONCLUSIONS
  With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women's groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.
authors.affiliation: Alfred Deakin Institute for Citizenship and Globalisation, Deakin University, Geelong, Victoria, Australia.
authors.forename: Ruth
authors.initials: R
authors.lastname: Jackson
authors.affiliation: College of Health Sciences, Department of Public Health, Mekelle University, Mekelle, Tigray Region, Ethiopia.
authors.forename: Fisaha Haile
authors.initials: FH
authors.lastname: Tesfay
authors.affiliation: Tigray Regional Health Bureau, Mekelle, Tigray Region, Ethiopia.
authors.forename: Hagos
authors.initials: H
authors.lastname: Godefay
authors.affiliation: College of Health Sciences, Department of Public Health, Mekelle University, Mekelle, Tigray Region, Ethiopia.
authors.forename: Tesfay Gebregzabher
authors.initials: TG
authors.lastname: Gebrehiwot
mesh_terms: D000328:Adult; D001294:Attitude to Health; D003150:Community Health Workers; D003695:Delivery of Health Care; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D006801:Humans; D008427:Maternal Health Services; D008428:Maternal Mortality; D011247:Pregnancy; D012959:Socioeconomic Factors