title: Factors that hinder or enable maternal health strategies to reduce delays in rural and pastoralist areas in Ethiopia.
abstract: To document factors that hinder or enable strategies to reduce the first and second delays of the Three Delays in rural and pastoralist areas in Ethiopia.
  
  
  
  A key informant study was conducted with 44 Health Extension Workers in Afar Region, Kafa Zone (Southern Nation, Nationalities and Peoples' Region), and Adwa Woreda (Tigray Region). Health Extension Workers were trained to interview women and ask for stories about their recent experiences of birth. We interviewed the Health Extension Workers about their experiences referring women for Skilled Birth Attendance and Emergency Obstetric and Newborn Care. Data were analysed using thematic analysis.
  
  
  
  Themes related to reducing the first delay, such as the tradition of home birth, decision-making, distance and unavailability of transport, did not differ between the three locations. Themes related to reducing the second delay differed substantially. Health Extension Workers in Adwa Woreda were more likely to call ambulances due to support from the Health Development Army and a functioning referral system. In Kafa Zone, some Health Extension Workers were discouraged from calling ambulances as they were used for other purposes. In Afar Region, few Health Extension Workers were called to assist women as most women give birth at home with Traditional Birth Attendants unless they need to travel to health facilities for Emergency Obstetric and Newborn Care.
  
  
  
  Initiatives to reduce delays can improve access to maternal health services, especially when Health Extension Workers are supported by the Health Development Army and a functioning referral system, but district (woreda) health offices should ensure that ambulances are used as intended.
authors.affiliation: Alfred Deakin Institute for Citizenship and Globalisation, Deakin University, Geelong, VIC, Australia.
authors.forename: Ruth
authors.initials: R
authors.lastname: Jackson
authors.affiliation: College of Health Sciences, School of Public Health, Mekelle University, Mekelle, Ethiopia.
authors.forename: Fisaha Haile
authors.initials: FH
authors.lastname: Tesfay
authors.affiliation: College of Health Sciences, School of Public Health, Mekelle University, Mekelle, Ethiopia.
authors.forename: Tesfay Gebregzabher
authors.initials: TG
authors.lastname: Gebrehiwot
authors.affiliation: Tigray Regional Health Bureau, Mekelle, Ethiopia.
authors.forename: Hagos
authors.initials: H
authors.lastname: Godefay
mesh_terms: D000293:Adolescent; D000328:Adult; D003657:Decision Making; D005002:Ethiopia; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data; D008428:Maternal Mortality; D007744:Obstetric Labor Complications / Q000401:mortality / Q000517:prevention & control*; D011247:Pregnancy; D011295:Prenatal Care; D012307:Risk Factors; D019035:Rural Health Services / Q000706:statistics & numerical data; D013997:Time Factors; D014187:Transportation of Patients; D055815:Young Adult
keywords: Ethiopia; Health Extension Workers; maternal health services; referral; skilled birth attendance; three-delays model