Factors Associated with Readiness of Front Line Workers in Pregnancy care, Delivery and New-born care in four regions of Ethiopia

Factors Associated with Readiness of Front Line Workers in Pregnancy care, Delivery and New-born care in four regions of Ethiopia


MSc Project Report

2015 – 2016


 Factors Associated with Readiness of Front Line Workers in Pregnancy care, Delivery and New-born care in four regions of Ethiopia





Candidate number: 109179

Word count: 10,000

Project length: Standard


Submitted in part fulfilment of the requirements for the degree of MSc in Public Health in Developing Countries


September 2016





Table of Contents





  1. Introduction. 7

1.1 Country situation (ETHIOPIA) 7

1.3 Maternal Mortality. 8

1.4 Pregnancy and Newborn care. 9

1.5 Institutional delivery in Ethiopia. 11

2.1 The IDEAS 2015 study. 13

2.2 Study design. 14

2.3 Study setting. 14

2.4 Study and sample population. 15

2.5 Sample size and sampling selection method. 15

2.6 Eligibility and exclusion criteria. 15

2.7 Questionnaire/data collection tool 15

2.8 Method of data Analysis. 16

2.9 Ethics Approval 17

  1. Result 18

3.1 Socio demographic characteristics of the FLW (table 1). 18

3.2 Experience and best practices of FLW on pregnancy care, delivery care and newborn care (Table1) 19

3.3 Experience and Best practices for new-born care during the delivery. 20

3.4 Trainings and supportive supervision provided to Front Line Workers (Table1 & 2) 20

3.4 Preparation and best practices of FLWs for delivery care (Table3) 21

3.5 Knowledge and best practices of key components of delivery care (Table4). 23

3.5.1 Focused Antenatal care: 23

3.6 Association between full preparation for conducting delivery care and other selected factors (Table 5A). 26

3.7 Association of Knowledge with other selected factors for conducting delivery of care (Table 5.B) 27

  1. Discussion. 28

4.1 Limitations. 31

4.2 Generalizability. 32

4.3 Implications for policy. 32

  1. Conclusion. 33
  2. References. 34





The research seeks to highlight the measures taken by the government to put the health systems in Ethiopia on a world class pedestal and most importantly the milestones in the medical sphere since time immemorial. It also brings into perspective the various levels of health institution ranging from district, referral to general hospitals. Moreover, the report tables the hospital-patient ratio with respect to their structural setups. It highlights the recommended patient base for every hospital level; for instance, a 5-million patient base for general hospitals. By and large, the report revolves around maternal health: maternal mortality during the actual delivery and the postnatal phase, measures to be incorporated in the medical frameworks in a move to cut on the maternal death toll.


It actually highlights measures have been put in place with a view to reducing unfavorable maternal medical attention and the various health practitioners who take part in the actual delivery. In addition, it highlights the institutional delivery in the Ethiopia rural and urban areas and more generally the public permissibility of the institutions.


It also brings into perspective the sense that Prospective research projects should investigate antecedents of healthcare in Ethiopia. The findings in the report show that the measures geared towards improving on the healthcare may have secondary benefits. The project brings into the picture the health situation in Ethiopia, challenges and the recommended future forecast of the present healthcare situation in the country. The project brings into the picture the health situation in Ethiopia, challenges and the recommended future forecast of the present healthcare situation in the country.


It sheds some light on the importance of the preparedness of the medical practitioners, their educational backgrounds and the admissibility of the professional care by the women folk more so in the upcountry. It wraps up by interpreting maternal mortality records, highlighting determinants of healthcare options, stating the service capacity of the various hospitals in their own elements and introducing the count of women applying contraceptives in family planning albeit to a less extent.



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).















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 organization.
  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













Ethiopia is ranked 99 out of the 103 in the UNDP Human Poverty Index. The country has 45% of its population leaving below the poverty line. Practically, 75% of the people lack the accessibility to potable water and out of five people, only one lives in hygienic conditions. Additionally, Ethiopia is home to approximately 133,000 refugees from the neighboring countries. In the last twenty years’ major national crisis; famine, armed civil conflicts and famine for example, have grossly dogged the country. (Heal Dev, 2010).

The major health concerns in the country include maternal mortality, tuberculosis, malaria and HIV/AIDS which are aggravated by acute malnutrition and inadequate accessibility to clean water and hygienic living conditions. The reasonably scarce number of health institutions, inefficient distribution of medical supplies and discrepancies between rural and urban areas due to severe underfunding of the health sector, consequently compound the access to proper healthcare. The research handpicks the maternal mortality, newborn mortality and measures to avert these menaces. (Ayale B, 2005)

There are various determinants of health in Ethiopia ranging from; educational levels, hygienic environment, wealth distribution, availability of clean water, availability of health centers with a skilled workforce, the cost of healthcare delivery and or the cultural backgrounds and demands. The knowledge and best practices of FLWs staff in health is of paramount importance due to the fact that healthcare services more so the labor service, requires a professional hand to successfully provide; some delivery processes may call for a cesarean section which cannot be achieved by an incompetent health staff. In cases where labor complications occur e.g. haemorrhage, only quick thinking health staff would effectively arrest the complication or a probable maternal or newborn death. (Med Bull, 2011).

The FWLs staff has been put under a training program to enhance their readiness by the government of Ethiopia. In the same breath, they have been exposed to such skills like: the capacity to; provide a comprehensive patient care, perform minor operative procedures, mobilize individuals, families and the community for health campaigns and document and report all primary healthcare unit activities.






1.1 Country situation (ETHIOPIA)

Ethiopia is situated in eastern part of Africa. In 2007 it’s estimated population was 74 million, with 84% of the population living upcountry and the abject poverty estimated to be at 44%(1). Among the Millennium Development Goal (MDG 5) which Ethiopia has not fully achieved as it were, is to reduce maternal mortality. In 2015 Ethiopia only managed to reduce the mortality by a wide margin. This put the rate at 218 per 100,000 live births (2) down from 871 per 100,000 live births in 2000, 673 in 2005, and  671 in 2010 (3).  These rates are some of the highest cases in the world and the lack of substantial improvements in the recent past is quite demoralizing. The concept of  these persistently high rates of maternal mortality  is mainly due to the inefficient use of health facilities, unreliable delivery services and inadequate professional medical attendants at birth in Ethiopia(4)(5).  In 2014, the Ethiopian Demographic and Health Survey (EDHS) estimated that 15% of women had their delivery at public health facilities(5) Subscription of Safe motherhood services is higher in urban areas than rural areas and highest in Addis Ababa.  According to  Mekonnen, (2003), women living in Addis Ababa were 40 times more likely to have a professional assistance at the time of delivery compared to those in the rural(4), with regards to the EDHS in 2014 the percentage of women who had had assisted delivery by a skilled personnel in the capital city, Addis Ababa, rose to 86% compared to 10% in the  remote regions (5).  The cited impediments in using health facility included transport, customs, and mistrust of health facilities (5)(6).  The Ethiopian Government introduced reforms to provide free maternal healthcare services to every legible woman, principally to address the twin issues of equal accessibility and affordability (7).

The overall aim of this project is to assess the readiness of Front Line Workers (FLWs) for pregnancy, delivery and newborn care in 4 regions of Ethiopia and its specific objectives are:

  1. Outline the international standards for safe pregnancy, delivery and new-born care
  2. Assess the training, knowledge and experience of the FLWs who provide pregnancy care, deliveries and care for the new-born.
  3. Discuss the implications of the findings for government policy on facility delivery



1.3 Maternal Mortality

The World Health Organization (WHO) defines maternal mortality as the death of a pregnant woman during delivery or within 42 days of after a successful delivery  irrespective of the duration and place of delivery, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental factors (13). Usually, the principal causes of maternal deaths are: Severe bleeding (hemorrhage) which accounts for about 25% of the deaths, infections/sepsis, unsafe abortion process, eclampsia/hypertension, and an obstructed labor. The less frequent direct causes such as ectopic pregnancy, embolism and others account for 8% of maternal deaths.  The indirect causes include tuberculosis, heart disease, malaria and anemia which constitute 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).

Mostly, 80% of the maternal mortality is preventable with proper management and treatment (13).  The prediction of obstetric complications that lead to maternal morbidity and mortality and provision of delivery care from skilled attendants such as doctors, nurses, or midwives are both identified as most important interventions in safe motherhood programs. During obstetric emergencies, early medical attendance is live-saving and could effectively prevent maternal and neonatal death. It is pertinent that seeking health care is compounded in Ethiopia by the poor accessibility due to dilapidated road systems.    In seeking care, women will mostly seek it from the nearest health facility which may not be helpful to suffice their needs considering the fact that health workers in remote area health facilities lack appropriate experience, equipment and skills to respond properly to patient calls (16).

The government is however committed to achieve the millennium development goals 5 (MDG5) by reducing the maternal mortality rate (MMR) by 75% in the period 1990-2015 in a move to improve the overall maternal health across the country. Furthermore, the federal ministry of health (FMOH) has also applied a diverse approach to cut on the maternal mortality and new-born mortality indices.

 1.4 Pregnancy and Newborn care

The antenatal care is basically the care accorded to the mother and the newborn after delivery. The ANC focused package has it that mothers ought to essentially make four visits in the health centers to receive some vital interventions. These interventions include: identification and monitoring of obstetric complications such as eclampsia, tetanus toxoid immunization, identification and management of HIV/AIDS and STIs and finally the occasional care and treatment for malaria during pregnancy.

The new-born care is more or less about the antenatal care (ANC). This is a medical procedure for the newly-delivered-women and it begins immediately after curtains are drawn on the delivery process. The utilization of ANC in Ethiopia is 1.2 times higher for the women in the age bracket 20-34 relative to the women in the age group 15-19. Educated women had twice as much likelihood to utilize the ANC services as those with no proper education. In addition, the likelihood of the utilization of the ANC services decreased as the income of the women in question became scarcer.

Essentially the new-born care involves tending to the new born. Immediately the baby is born, the cord is detached from the mother by tying it using the local inset thread and later severed. The healthcare provider puts it in a radiant warmer, dries it, assesses the new-born, wraps the newborn in warmed blankets and places the born on the woman’s abdomen for warmth and closeness. The mother follows suit through the typical breast feeding (Jennifer A Callaghan et al, 2013).

The child weight and size at birth comes in handy when testing the child’s indisposition to various childhood health hazards. Children whose birth is below 2.5 Kg have higher risks of vulnerability to childhood demises. (Jennifer A Callaghan et al, 2013).

Forty-one percent of women who gave birth in the past 5 years received antenatal care from skilled health practitioners, nurses, or midwives during their most recent delivery. This is a 52% increase over the last fifteen years (5).  One in three women (32%) attended more than four antenatal visits during the course of her pregnancy compared to 10% in 2000(5). The median duration of pregnancy is 4.9 months at the time of her first antenatal visit (5).   Even though the percentage of facility births continues to be as low as 15% in Ethiopia, there has been significant progress in the last 15 years, up from 5%. In 2000 (5)  only 13% of women received postnatal care within the first two days of delivery. However, this is an improvement from 15 years ago when only 2% got postnatal care (5).

The risk of a women dying during pregnancy and or childbirth is 1 in 27 (17).  More than 500,000 women go through pregnancy related disabilities. Only Obstetric fistula as part of pregnancy related disabilities accounts nearly 9000 cases each year.  The scale of disability is significantly enormous in rural areas because there are strong sociocultural motives for the girls to marry at the tender ages. There is a rate of 3.1% teenage pregnancy in the rural and 0.6% in the urban. The highest rate was reported at the age of 19 years old for teenage pregnancy(17).

Overall, 90% births at national level happen in rural areas. Over 90% of women who require caesarean section lack access to proper healthcare services and only 15% of deliveries are conducted by professional health workers.   In 2010, the estimate of HIV-positive pregnant women was 90,311 with 14,276 HIV-positive births (17)(18), 66% of pregnant women were tested and counseled for PMTCT. In a HIV-positive-women delivery, only 24.6% received full course of proper medical attention  in 2011(17).  Despite reported improvement of overall coverage of ITN use at household levels in the recent years, only 35% pregnant women sleep under ITNs (19).

There is a significant difference between the regions and the level of education for women. The count of married women  currently  using contraceptives for family planning has significantly raised to 29% in rural areas in a period of five years, while the increase in urban areas is negligible and stands at 6% (17). Hence, addressing in all these gaps demands professionally knowledgeable and motivated health workers and shift to increase deliveries in health facilities.

1.5 Institutional delivery in Ethiopia

Sources from developed countries shows that for the plans of institutional delivery to be effective, it’s important to understand the factors that influence individual and household factors to utilize professional attendance and institutions for delivery. Maternal mortality can be reduced by availing appropriate healthcare during pregnancy and delivery (Addis Allen Fikre, 2012). In Sub-Saharan Africa however women face the problem of inadequate accessibility to such services. To reduce maternal and infant mortality more so in areas with low socio-economic status, accessibility and subscription to obstetric services is a resourceful approach. When there is absence of appropriate obstetric care, the pregnant women run the risk of aggravated fatal outcomes such as death and or disability. Professional attendance during the time of delivery could reduce an estimated 16-33% of maternal deaths. The most prevalent hurdle to access proper healthcare that Ethiopian women mention is taking transport to a health facility, lack of money and the long distance to health facilities (Warren C, 2010).

Most maternal mortality cases are preventable as the healthcare interventions to prevent and putting the complications in close tubs are identified and offered in due course. All women need access to antenatal care in pregnancy, skilled care during childbirth and care and support after childbirth (WHO factsheet). Professional attendance is the most viable services in reducing maternal death and the related complications. The conventional attendance during labor, delivery and early postpartum period reduces the maternal deaths from 33% to 13% (20).  In Ethiopia, both institutional delivery and overall skilled attendance at birth both account for about 15%(5).

The World Health Organization defines skilled attendant 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).

Several studies discovered that there is favorable association between the use of maternal healthcare services and the patient’s place of residence; people in urban are more often than not closest to facilities but also mostly benefit from the skilled delivery services more than those in rural areas(22), (23), (24), (25).  The level of maternal education is also measured as the most significant factor in determining women’s delivery care seeking behavior (26),(27),(28).  Other associated factors included household wealth, maternal age, autonomy of the mother and physical access to the health facility (29).  Variations are noticed among studies on the reported factors. For example, household wealth is accepted as a more significant determinant than access in India (30). In addition, education level of the mother was considered  the most important factor in numerous studies (30), (31). However, the level of its effects is consistent with those of household wealth, women’s autonomy and access in another study in Zambia (32).  In addition to these, other factors are the antenatal care (ANC) follow ups, previous health facility delivery, quality of the service and the cost of healthcare (30), (33), (34), (35), (36).

Ministry of health of Ethiopia recognized the importance of institutional delivery, identified the low rate of delivery in the facilities and prioritized it in the national Reproductive Health Strategy and set to increase it up to 60% by the year 2015 (37). Nevertheless, only 15% of births are delivered at the health facility in Ethiopia (5). Thus, the aim of this study is to assess 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

There are many definitions with respect to quality health care during delivery. This may essentially vary from one field to the other. However, it should be appreciated that the provision of effective health care could almost be impossible without proper understanding of what is basically meant by the phrase ‘quality health care’. Moreover, the health care providers should be well versed in the medical field as a whole. They ought to have gained enough knowledge and more importantly the prerequisite experience by the time they set to deliver such services. This means that the quality of healthcare partially depends on the training of the Medicare providers.

Quality healthcare can be defined based on some five pillars as it were. To start with, quality health care should be effective in the sense that its delivery should result into improved health outcomes for individuals and the community at large. Secondly it should be efficient in such a manner that there is maximum use of resources with minimal wastage. Third, it should be safe to ensure that any risks or harm are ruled out on the part of patients. Next a quality healthcare system should be palatable in that it should prioritize the preferences, aspirations and culture of patients at personal levels. Finally, quality healthcare should be equitable by ensuring that the provision of health services would not vary relative to the gender, race, economic muscles and or the geographical location of the patients. However worth to note is that the community also play a role in the provision of quality care; the care would otherwise be farfetched if the immediate community would not cooperate.

  1. Methods

This study is based on the secondary analysis of data obtained from the open interview with the frontline workers with respect to their module of the 2015 IDEAS study which holistically covered the broad topic on the ‘Change in Maternal and Newborn healthcare’ in the four regions of Ethiopia.

2.1 The IDEAS 2015 study

IDEAS (Informed Decisions for Actions) is a five-year project, funded by Bill & Melinda Gates Foundation that aims to improve the health and survival of mothers and babies through generating evidence to inform policy and practice. This project works in Ethiopia, North-Eastern Nigeria and the state of Uttar Pradesh in India. IDEAS uses measurement, learning and evaluation to find out what works, why and how in maternal and newborn health programs. The project is led by team of experts who are based at the London School of Hygiene & Tropical Medicine(38).

There were three survey modules: (i) household module, (ii) The facility module and (iii) The front line workers’ module.  This analysis specifically examines data on the front line workers’ module of 2015.

Ministry of Health, Ethiopia has changed policy for deliveries to happen in health centres instead of home delivery or delivery in health posts.  This change involves increased workload for the health centres and also created higher demands for adequate skills and readiness of the front line workers to perform pregnancy care, skilled delivery and care for newborns.

2.2 Study design

This is a cross-sectional survey data collected in areas where LK10 (Last 10 Kilometers) worked in the last five years. It is collected from two intervention and comparison areas to estimate the magnitude of change between the baseline and the follow-up using difference-in-difference approach.

2.3 Study setting

The Ethiopia’s health system comprises of the three levels; First level is district based (Woreda as Ethiopian administrative structure) which is a main hospital with a capacity to serve a 100,000 population estimate. The health centers which has a population base of 25,000 each and health posts cover approximately 5,000 people. The health centers and health posts constitute the primary health care system. In the second level are the General hospitals that cover a one million population estimate while the tertiary level is defined to be specialized hospitals that could serve a population of 5 million.  Each level is linked to the other through a referral system. However, concerns remain on the rapid expansion of Ethiopia’s health systems and its future sustainability(1).

Government of Ethiopia made the Maternal and Child Healthcare free and the health centers are practically able to provide basic emergency obstetric care (BEmOC) while hospitals offer Comprehensive Obstetric care (CEmOC).  However, the quality of care varies due to knowledge, skills, experience and the training given to health workers. Within the health practitioners in the hospitals, essentially 51% are in a position to provide CEmOC services and only 14% can offer BEmOC (8).

In an attempt to achieve universal coverage, Ministry of Health introduced Health Extension Workers (HEW) selected from the local community (9)(10). It’s mandatory that they should be females and must have completed at least the 10th Grade in school.  HEWs are initially trained for nine months to be able to: master provision of basic healthcare services in the health posts (11) and offer simple and non-complicated deliveries. They also received a 30-day training package called “Clean and Safe Delivery”.  However, they had no prior health experience. The families accepted and trusted the health extension workers although the integrity of their practice and skills have since been questioned (12).

In the context of this study, front line workers consist of Women’s Development Army (WDA) who are community volunteers, Health Extension Workers (HEWs) in health posts, auxiliary nurses, nurses and doctors working in primary health centers.

2.4 Study and sample population

Basically the sample population cut across the entire cadre of the FLWs and especially those situated in the Amharic region. The study entails administration of questionnaires coupled with the candid interviews with the FLW staff.


2.5 Sample size and sampling selection method

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 centers and 80 health posts were interviewed.

2.6 Eligibility and exclusion criteria

Only the FLW staff who had in one or the other taken care for patients at least once in their professional journey were eligible for the interview due to the nature of the hypothesis projected. Otherwise, any of such staff who had semi skills about or who was on training on the proper provision of health care was excluded from the shortlist of interviews.



2.7 Questionnaire/data collection tool

A standard questionnaire was designed to assess the knowledge and preparedness of frontline health workers; the questions were modified to obtain four categories of information:

  1. The knowledge section of the questionnaire contained seven components of unprompted questions such as focused antenatal care, need for special care plan for mothers, kind of observations to make during labor, where to register the observations, things to do when women develop heavy bleeding, special care to provide low birth weight babies, and how to manage when newborns present infections.
  2. The section on preparedness consisted of thirteen questions to assess how the front line workers prepared the essential drugs and equipment to conduct quality delivery care.
  3. The type and frequency of the trainings received by front line workers aimed to improve their skills and knowledge during the last twelve months.
  4. And whether the front line workers received any supportive supervision and who supervised them in the last twelve months.

As stated in the IDEAS report, all the questions in the original surveys were informed by large scale survey tools such as the Demographic and Health Surveys (DHS), the Service Provision Assessment (SPA), Averting Maternal Death and Disability and Safe Motherhood.


2.8 Method of data Analysis

Data was received in a STATA form and checked for inconsistencies, errors and missing values to be able to conduct proper analysis. Descriptive summaries between the group proportions were conducted and comparison between them were made.

Background characteristics and demographic variables were produced. In this study, supportive supervision, training of health workers (FLWs) and years in service by the front line workers were selected as the explanatory variables and predicting factors to test the association with the outcome of interest.

The primary and secondary outcome variables of interest in this study are full preparation of key components in conducting quality delivery, knowledge of care providers at the delivery and Quality of Care.  We created binary outcome variables for preparation and knowledge and reviewed different scoring systems such as Ethiopian university education scoring system.  Finally, all FLWs who were prepared more than eight (>60%) out of thirteen items, were assigned full preparation and poor preparation for those responded to less than eight (<60%).  Likewise, the knowledge variable was also classified into good knowledge and poor knowledge.  For both variables, zero was coded to the poor and one for those of good or full category.  Effects of different exposures on the outcomes were assessed using cross-tabulations of each exposure variable with the main outcomes of interest individually.

The study is testing the null hypothesis that front line workers who received training, supportive supervision and had over one year working experience are not ready and not well prepared to conduct quality of care at pregnancy, delivery and care for newborns.

Univariate logistic regression was used to examine the relationship between each exposures and outcome variables individually. Odds ratios and corresponding confidence intervals were estimated and the likelihood ratio test was used to measure the association. Crude Odds ratio, confidence interval and P-value were obtained.  As this is a cross sectional survey data, all associations were tested for significance at the 10% level and 90% confidence intervals.

Multivariate Logistic regression analysis was conducted to adjust for confounding caused by the age of front line workers, years of services, type of trainings and identify factors associated with FLWs’ readiness.

Test of multi-collinearity was conducted to check the level of correlation between the explanatory and outcome variables and found no collinearity level greater than 0.5 detected.

2.9 Ethics Approval

Informed Decisions for Action in maternal and newborn health (IDEAS) obtained National level support for the original survey data collection from Ministry of Health, Ethiopia and ethical approval from Ministry of Science and Technology.

The study protocol, consent form and other forms used for the project were approved by the London School of Hygiene Ethics Committee (LSHTM Ethics Ref: 6088)) and Regional Institutional Review Boards in Amhara, Oramia, SNNP and Tigray. All respondents provided written informed consent before they were interviewed.

3. Result

3.1 Socio demographic characteristics of the FLW (table1).

In total 320 front line workers were drawn from 160 health facilities in 4 regions of Ethiopia. From the analysis, the accumulated mean age (in years) of the respondents is 31.8 with a standard deviation of 0.57. The front line workers with ages between 18-25 years represented 30.6% of the respondents, while respondents who are 56 years and above recorded an insignificant percentage of 1.3% of the total respondents. The educational status of the respondents recorded that 48.1% of the respondents had acquired higher education (college, university), while 24.4% of the respondents lacked formal education.


Of the 320 front line workers interviewed, 48.1% are part of the Health Development Army (HDA), and 25.6% are midwives/nurses. Trained Traditional Birth Attendants (TTBAs) represented 1.3% of the respondents while the Community Health Provider (CHP) had the least percentage of 0.6%. The findings indicate that all except one (1) health facility are owned by the government. The results show that 99.4% of the 160 health facilities are run by the government and 0.63% of the health facilities are run by Non- Governmental Organizations. There are no mission health facilities in the target areas. Out of the 320, 38.8% are from the Amhara region while 11.3% are from the Tigray region.

3.2 Experience and best practices of FLW on pregnancy care, delivery care and newborn care (Table1)

From the analysis, 71.9% (i.e. 230 respondents) of the 320 front line workers interviewed have 1 – 5 years of work experience. Respondents who have worked for 1-5 years represented almost 24.4%.  Those with less than one (1) year working experience represented 3.8% of the respondents.

The weekly average operating hours spent in the provision of ANC services in health facilities is 11.50 hours with a 16.06 standard deviation. At least, 54.1% of the respondents report to have offered pregnancy care to women in the last 12 months.  40.6% (130) of the respondents reported to have provided delivery services, while 60.4% (290) claimed not to have attended birth deliveries. From the deliveries conducted, 98.3% were vertex (one vacuum extraction) and 40.2% of the vertex was seen at the first stage, 35% at the second stage and 19.7% at third.

The mean age of 117 assisted mothers is 28± SD 1.2 with a 95% Confidence Interval 25.7 – 30.3. 75% of the 117 (assisted mothers) had given birth more than once. 93.2% of the respondents reported that mothers survived after delivery; however, 95.7% claimed still births during labour. At least 74.4% of the respondents said that the babies were weighed and only 8% weighed less than 2.5kg and 23.1% of the respondents reported to have observed premature births of less than 37 weeks. From the responses, only 3.4% of the mothers and 1.7% of the newborn babies were referred to other health facilities.

About 84% of the respondents claim to have monitored the labour process with only 19.4% registering their observations on the pantograph. In addition, 54.7% of the frontline workers interviewed reported to have provided ergometrine/syntometrine/ oxytocin/misoprostol – uterotonics and around 82.9% of the respondents’ stated to have practiced active management of the third stage labour. Immediate oxytocin was provided by 22.2% of the respondents while the ergometrine was provided within 1-2 minutes of delivery by 5% of the respondents.

25% of the front line workers claim to have controlled cord traction and 25.1% say to have conducted uterine massage. Emergency intervention was called for by at least 20.5% of the 117 respondents with 34.2% forced to remove the placenta manually, while 14.5% administering antibiotics and 19.7% had to give oxytocin parentally.

3.3 Experience and Best practices for new-born care during the delivery.

Of the 320 front line workers interviewed, 17.2% cleaned the baby’s mouth before the shoulders came out and 29.7% cleaned the baby’s mouth, face and nose. 26.3% of the respondents checked to ensure that the baby is breathing, 25.9% ensured that the baby is dry, 14.1% checked and observed the baby’s colour, 18.1% ensured that the baby was kept warm by skin to skin method, 14.7% administered prophylaxis for the eyes, 20.6% weighed the baby and lastly, 22.5% examined the new-born within the first hour. With regard to resuscitation, only 10.3% of the 117 deliveries needed resuscitation and 24.1% of the 117 respondents claimed to apply nothing during cord treatment.


3.4 Trainings and supportive supervision provided to Front Line Workers (Table1 & 2)

Supportive supervision is a process of helping staff to improve their own work performance continuously. This study investigated different types of trainings such as the antenatal care, attending normal deliveries, active management of third stage labour, postnatal care, new-born care and basic Emergency Obstetric and New-born care. 37.5% (54) of the front line workers trained represented health extension workers (HEWs), 36.1% (52) of the respondents are Nurses and Midwives and 26.4 (38) of the workers from Health Development Army.  None of the Trained Traditional Birth Attendants and Community Health Providers claimed to have received training during the interview.

Supportive supervision aims at improving skills and knowledge of the health workers. From the study, an average 7.3 of the front line workers interviewed claimed to have received supportive supervisory visits in the last two months. TTBAs reported higher mean 8.5 with SD 4.9 of supervisory visits compared to other cadres. CHPs claimed that they have not received any supervision in the last twelve months.

3.4 Preparation and best practices of FLWs for delivery care (Table3)

The study seeks to determine the methods used by front line workers while conducting delivery care and also aims to understand whether front line workers were able to adequately prepare critical and lifesaving items that are essential when conducting deliveries. In addition, the study intends to identify any gap in the preparedness level. From the findings, a number of respondents stated among other reasons to have limited or lack of supplies for sterile gloves, disinfectant, gauze, clean clothes/towels, sterile scissors/razor blade, ligatures, oxytocine, ergometrine, misoprostol, syntometrine, eye ointment and chlorhexidine. 94% of the 117 respondents prepared sterile gloves as part of the essential items in the delivery process; 81.2% of the respondents had disinfectant; gauze was available for 93% of the respondents; 68.4% of the respondents had clean clothes/towel. Only one respondent did not prepare for sterile scissors, while 99.2% (116 respondents) prepared sterile scissors/blade for cutting the cord. 97% of the respondents prepared ligatures, 65.8% had oxytocin but 77.8% of the 40 respondents who failed to prepare for oxytocin claimed limited supply, while the remaining 9% alleged policy issues. 68.4% had prepared for ergometrine those who did not claimed unavailability among other reasons. Misoprostol was prepared by only 27.4% of the front line workers, and those who did not use it claimed lack of supply among other reasons. Eye ointment was prepared by 72.7% of the respondents. Out of the 117 respondents, only 10% and 11% of the front line workers prepared for syntometrine and chlorhexidine respectively, and those who failed to prepare for syntometrine and chlorhexidine did not provide any reason in the interview.




3.5 Knowledge and best practices of key components of delivery care (Table4).

3.5.1 Focused Antenatal care:

The study focused on the seven components necessary for examining the knowledge of the service providers, which included the primary aspects of focused antenatal care, special care plan for women, monitoring observations during labour, registration of the observations, actions to take when women develop heavy bleeding and the type of special care given to new-borns who weigh less than 2.5 kg. Lastly, are the initial steps taken when the new-borns present signs of antibiotics.

On knowledge test for the focused antenatal care, 47.2% of the 320 front line workers interviewed stated minimum of 4 consultations as part of primary aspect focused ANC; 34.1% responded ensure that women had a birth plan and 47.2% said to promote health by the provision of preventive services that include tetanus toxoid vaccines, iron tablets, and protection against malaria. In addition, 37.2% of the 320 respondents said detecting illnesses and ability to manage STI/HIV complications among others. Moreover, 33.2% and 35.3% of the 320 FLW responded promotion of breastfeeding and educating women about the danger signs in pregnancy, childbirth and postpartum respectively.

3.5.2 Special Care Plan

43.2% of the 320 respondents said that women who undergo caesarean require special care plan, while 29.1% said that women who have had 5 or more deliveries need special care plan; 8.2% said that women who have had birth intervals that are less than two years or exceed 5 years require special care plan; 29.7% considered women who had previous still birth are in need of special care plan, 22.5% said that women who had previously experienced neonatal death needed special care plan; 13.1% felt that women who had previously undergone instrumental delivery process such as vacuum extraction or forceps require special care plan. 22.5% and 15.9% were of the view that women with a history of severe obstetric complications and women who have previously undergone obstetric fistula repair respectively, need special care plans. Lastly, 20.6% felt that under-age pregnant girls need special care plan.

3.5.3 Monitoring Labour Progress

When monitoring labour progresses, of the 320 respondents; 35.6% monitored foetal heartbeat, 17.8% monitored the colour of amniotic fluid, 21.3% monitored the degree of moulding, 28.4% monitored cervix dilation, 20.9% monitored the descent of the head, 24.7% monitored uterine contractions, 31.9% monitored maternal blood pressure, 26.9% monitored maternal temperature and 24.1% monitored maternal pulse.



3.5.4 Registration of Observations

25.3% of the 320 respondents reported to register observations on the partograph, 7.8% registered observations on the patients’ clinical record and 4.1% claim to register observations on the partograph in the prenatal card. Nonetheless, 5% of the respondents stated that they register observations on a piece of white paper and 11.6% did not keep any registration records.

3.5.5 Management of Heavy Bleeding

In event of heavy bleeding after delivery, 20.6% of the respondents claim to massage the fundus, 23.8% said that they give either ergometrine or oxytocin (IV or IM), 23.8% report that they offer IV fluids, 12.2% empty the bladder, 7.5% test blood for haemoglobin and cross-matching, 15% examined women for lacerations while 12.8% removed the retained products manually and 71.3% referred the mothers.

3.5.6 Care for Low Birth Weight

The study evaluated and assessed the knowledge of the front line workers with regard to special care provided to new-borns who weigh less than 2.5 kg. 30% of the respondents ensured that the baby was kept warm by either the kangaroo technique or using skin to skin, 22.5% gave extra support to the mother for efficient breastfeeding, 23.1% checked and monitored the breastfeeding ability of the new-born, 9.4% monitored the baby for the first 24hours, 7.5% ensured prevention for any infection and 62.2% referred the babies. In case of any infection signs on the new-born, 11.6% of the respondents alerted and informed the mother/caregiver, 7.8% encouraged breastfeeding or if necessary, provided milk expressed with a nasogastric tube. 5.3% ensured that the airway was open, 18% prescribed antibiotics while 62.5% referred the infected babies.


3.6 Association between full preparation for conducting delivery care and other selected factors (Table 5A).

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 found that front line workers who received all trainings were nearly 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 months 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).


3.7 Association of Knowledge with other selected factors for conducting delivery of care (Table 5.B)

Assessing the association between the knowledge of the front line workers and other independent variables such training, supervision and years of services the front line workers remained as service provider. We found significant evidence that supportive supervision is strongly associated with knowledge of health providers in conducting quality of care at delivery (AOR: 4.4; 95% CI: 2.16 – 8.97; P<0.001). The front line workers who received all trainings are nearly 3 times more likely to have full knowledge (AOR: 2.54; 95% CI: 1.35–4.77; P=0.004) than those who did not receive any training.  Surprisingly, analysis show that there is no association of knowledge and training between those who received training on antenatal care (AOR: 1.0; 95%CI: 0.34-2.98; P=0.99) and those who did not receive it, whilst those who served over 5 years are nearly one and half times more likely to have knowledge (AOR: 1.38; 95%CI: 0.23–8.97; P=0.72) than those who worked less than a year experience or service.

Finally, a fully adjusted OR between age, preparedness and knowledge was calculated using logistic regression. We found that age is strongly associated with knowledge but not with 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.

4. Discussion

After controlling for the identified confounder, the trained front line workers are nearly three times more knowledgeable compared to those who did not receive any training. With such a low p-value associated with the fully adjusted OR it is unlikely that this finding was due to chance.  In addition to that, there is strong evidence that the front line workers who were supervised in the last twelve months have almost 5 times more knowledge as much as those who were not.   However, there is the possibility of residual confounding. For example, it may be possible that the practice and knowledge of front line workers in an urban setting is different to that of front line workers in rural health facilities. Having this knowledge at an individual level would allow for an assessment of the difference if any, between the two groups (urban versus rural).  A Study by Dussault & Franceschini, (2006), finds that mostly the urban and wealthier areas attract the most skillful health workers.  The preference of the qualified physician is not only for financial gains but also social, cultural and professional advantages(39). This development would mean that the people living in rural areas would have limited or no access to quality health service. If they may be fortunate to have health care provision, it would definitely be the kind that doesn’t meet the standards for quality healthcare.

A systematic review involved in 95 quasi-experimental studies by Michael J. Burke, et al, found that there is positive relationship between training and increase in knowledge and skills for health outcomes. The study confirms that if training is conducted in a manner that suits the needs in the ground and implemented properly, it would enhance the knowledge of the health providers and eventually the quality of care. Furthermore, If the training is more interactive and involves substantial practice, behavioral modelling and dialogue then it would generally be more effective than those passive computer-based and distance learning training packages(40). We learnt from this data analysis that only 144 (45%) out of 320 front line workers from 160 sampled health facilities have received trainings in the last twelve months. There is no information related to the content, quality and methodology of how these trainings were conducted.

Supervision is another important aspect of intervention to improve the performance of the health workers and also the quality of services. If correctly done, it could provide opportunity for health workers to professionally develop and has also proven to be reassuring in boosting the health workers’ satisfaction and motivation(41). However, it is seldom challenged by unrealistic plans, availability of resources and weak accountability, lack of follow-up and feedback of the outcome to the health workers themselves in developing settings(41). The supervision outcome is usually also affected by the performance of the supervisors and the extent to which supervisory tools used address issues in the visited facility.  Thus, the determinant of the supervisor’s performance need to be understood in this regard. This analysis did not investigate the determinant of quality supportive supervision that improves the health workers’ job satisfaction and motivation as well as the performance of the supervisors, but rather assessing the positive impact of supervision, training received by health workers and the experience gained over the years of service, with knowledge and prowess in conducting quality care at childbirth.


On the same note, the analysis also assesses the association between the years in services (experience) by the front line workers and their preparedness and knowledge in conducting quality of care at delivery. The variable, years in service, was then categorized into front line workers who remained in service in less than a year, one to five years and those over five years. Thus, the regression analysis reveals no significant association between the years of experience for the health workers and their preparation and knowledge in dispensing their duties. A research report commissioned by NHS England, by Dr. Jeremy Dawson of Sheffield University Management School, has assessed many studies on the impact of health workers experience over the patient’s outcome in different countries.  He concluded that staff experience has strong association with patient outcome, patient satisfaction and quality of care provided to the patients(42).


Knowledge tests among the care providers in their usual practice using unprompted questions had very poor results. The test questions covered in the seven components of provider knowledge such as focused antenatal care, women’s need for special care plan, observations to make during progress of labor, registration of observations, and management of hemorrhage after delivery, low birth weight care and initial steps to take when new-born presents signs of infection. None of the providers in this cohort passed the criteria on all themes of the test which means that none of the front line workers met the standard of safe motherhood for pregnancy care, delivery care and postpartum care. A study on knowledge and performance of the Ethiopian HEWs on antenatal and delivery Medhanyie A, et al, concluded that there is need to develop strategies for improving the HEWs’ knowledge and performance and creating favorable working conditions, especially in the rural areas(43). The study assessing the knowledge of HEWs eludes the difference in knowledge between those HEWs in urban towns and those in rural.  In these analysis, we are unable to segregate data into rural and urban to ascertain whether there is difference in this group of health workers.  However, there is no significant difference between nurses/midwives and health extension workers (HEWs) when compared on the basis of their knowledge.  Nurses/midwives should by far perform better than the HEWs. This similarity between the two categories poses bigger question and demands further investigation.


In the usual practices of front line workers during delivery, FLWs were asked how they prepared the essential items and equipment to conduct the quality care at the childbirth.  In the health sector strategic plan, government stated commitment to ensure access of medical and essential supply to the communities through the health system. Generally, preparation of essential supply relies on the performance of the health workers and the health system in terms of logistical arrangement and availability of resources to deliver. In this analysis, 73 (62.7%) out of 117 front line workers were able to use and prepare all the listed items. Out of those who did not prepare and use, close to 18% (5) said they did not prepare and use due to availability of the supplies. Kruk ME, et al, investigated women’s choice for obstetric care in rural Ethiopia, it was discovered  that women value high technical quality services with attributes such as: availability of drugs, equipment and physician providers(44).  The importance of supply availability and technical knowledge of the health workers are amongst the highest attributes mothers would choose for their place of delivery.

4.1 Limitations

The fact that the data is collected from front line workers (health providers) in a sample of health facilities means that there is a possibility of selection bias. For instance, it is not clear what proportion of the interviewed front line workers is from the intervention Woreda and the comparison ones.  It is not also explained how these workers were selected among others in same facility attending the delivery in the methodology of the original IDEAS survey.  Out of 130 FLWs who ever attended delivery, only 117 of them were selected.  It is mentioned that two staff members were selected from each health facility. Thus, there is no detailed selection criteria specific for front line workers in IDEAS 2012-2015 survey report from Ethiopia that had done the original data collection.


There is possibility of another source of bias which would be that of acquaintance, front line workers may have wanted to please the interviewer about whether they have prepared and used all supply items and equipment listed.  A better method would be to observe what items they prepared, how they conducted the delivery and supply items they planned to use. Likewise, an inventory-taking exercise to confirm the availability of supply items would also increase the reliability and validity of the outcome of this analysis.


In the fact that the front line workers were asked about the past activities in relation to 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.



4.2 Generalizability

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.  The other factors that may affect the generalizability of the results of this analysis could be about the representation of the rural versus urban localities. Out of more than 2,600 health centres and over 14,000 health posts.


4.3 Implications for policy


There are few things important for ensuring quality of care at delivery needed to achieve for the mothers and newborns in these four regions of Ethiopia in view that government has sanctioned policy change from home delivery and delivery at health post to health centres.  These are:


  • Government need to focus on quality improvement of maternal and newborn services substantially rather than expansion only. This analysis finds that there is a gap of knowledge among the front line workers without which they cannot produce the admired level of quality of care.
  • Increase in a good quality refresher and basic thematic training sessions organized for front line workers in these health facility with adequate number of duration.
  • District Health management team should be capacitated to conduct quality supportive supervision to the health facilities. These supervision sessions should be regular and use standardized national supervisory tools with clear indicators to report to. Feedback mechanism of the supervision outcome must be established.
  • Staff retention policy need to be sanctioned that reduces turnover and improves attraction of qualified staff into the rural areas. Additional supervision and support need to be given to the staff in rural health facilities as rural areas hardly attract the qualified staff. Majority of maternal and newborn deaths or disabilities occur in rural and difficult to access areas.

5. Conclusion


Considering the poor knowledge and preparedness of the front line workers, it would be difficult for FLWs, at their current level of knowledge as it has been discovered in this analysis, to conduct quality health care for pregnancy, delivery and care for newborns. Hence, there is an urgent need to design strategic plan of action to improve the knowledge and competency of front line workers, while creating proper working conditions to bolster their motivation and job satisfaction. Furthermore, it is recommended to undertake more focused investigation, focusing on the knowledge, skills, motivation and job satisfaction of this cadre.

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