This guest post is written by Dr Ruth Jackson of the Alfred Deakin Research Institute. Dr Jackson is working on a project focused on improving the use of maternal, neonatal and child health services in rural and pastoralist Ethiopia. The project is funded by the Australian Development Research Awards Scheme. Dr Jackson has been learning from the experiences of Women’s Extension Workers who work with the Afar Pastoralist Development Association, a partner in The Road Less Travelled project.
“You won’t believe us – we start walking in the morning up til night time to collect water. Then we grind the wheat, collect sticks for firewood and take water to the animals. Sometimes if we have to sleep where we collect water, we take our baby with us, otherwise we leave the baby in the house.”
– Women’s Extension Worker, Logya, Afar Region, Ethiopia, 25 March 2014
We are sitting in the shade at the Afar Pastoralist Development Association (APDA) training facility with 19 Women’s Extension Workers. The women, many with young children and babies, are attending their annual refresher training. It’s too hot to sit inside the training centre but relatively cool in the shade of the building.
Along the fence line are the rooms in which the women stay for the month. Although they are square and joined together they are built of the same materials as the Afar huts or aris. Aris are normally hemispherical and made of palm ribs covered with matting. They are light and portable and easily dismantled – a job usually done by women.
While the Women’s Extension Workers are away from home attending training their husband or mother has to collect water. Men don’t like collecting water as it’s “women’s work”. But one Women’s Extension Worker explained that they had to help their husbands understand that “helping each other is good. Some men joke about doing it while others don’t like doing it … in the past, some men even refused to allow their wives to come to training.”
Afar Region in north-eastern Ethiopia is dominated by the Danakil depression in the north, which is largely desert scrubland with shallow salty lakes and long chains of volcanoes. In the south, the Awash River flows into the northern lakes rather than to the sea. Much of Afar is below sea level and it is one of the hottest places on earth, with temperatures higher than 50°C in the summer. About 90 per cent of the regional population base their livelihood on livestock rearing – cattle, camels, goats, sheep and donkeys – with limited agriculture along the river basins and low-lying riverine areas.
The Ethiopian Ministry of Health acknowledged in Health Sector Development Program IV (2010/11-2014/15) that there was a lack of appropriate health service delivery packages to address nomadic and semi-nomadic communities in Afar Region.
For example, the percentage of births assisted by qualified health personnel is 6.2 per cent compared to the national average of 18.4 per cent. Antenatal coverage is 25.3 per cent compared to the national average of 71.4 per cent. Clean and safe delivery coverage is 0.5 per cent compared to the national average of 17 per cent and the contraceptive acceptance rate is 13 per cent compared to the national average of 61.9 per cent.
APDA is one of the non-government organisations (NGOs) providing primary health care, health education as well as literacy and non-formal education programs in Afar Region. APDA employs 270 Women’s Extension Workers to mobilise communities in hygiene, sanitation, nutrition, mother/child care, safe motherhood, HIV prevention, and stopping harmful practices. Women’s Extension Workers provide training to Traditional Birth Attendants (TBAs) in clean and safe delivery, and work alongside Health Extension Workers (HEWs) who are the front-line health providers for pastoralist communities. HEWs administer basic treatment, run vaccination clinics and provide health education projects.
As we sit in the heat, the Women’s Extension Workers discuss the problems women have during pregnancy and childbirth. The first problem they mention is anaemia and malnutrition, as many women don’t have enough food. This problem is related to repeated droughts. Many of the animals have died. The environment has totally changed and the benefits women were getting from the animals don’t exist now as there is no milk and meat. People also live a long way from the roads – some people walk 30 to 40 kilometres to reach the nearest road.
There are many difficulties for a woman giving birth but now with APDA’s health programs, the Women’s Extension Workers and HEWs can check women for anaemia and give iron tablets. If the baby is not growing they can take the woman to the hospital. They check pregnant women every month and from the eighth month, every week. If the Women’s Extension Worker knows that there will be problems and that the woman shouldn’t give birth at home, they refer her to the health centre.
Trained TBAs and Women’s Extension Workers can refer women by ambulance to the recently opened Barbara May Maternity Hospital in Mille, which is APDA’s obstetrics and gynaecology hospital for Afar women within a 250 kilometre radius. The hospital also built a number of aris that act as a maternity waiting centre where mothers ‘at risk’ or wanting a safe birth can stay until delivery. Since opening in October 2011, there have been 487 births at the hospital. Hospital staff say 20 per cent of women who attend antenatal care deliver at the hospital, many from Mille town. Most births are unbooked; that is, they arrive as emergencies.
When women go in to labour at home and the baby is not born on the first day, getting the woman to the hospital can be quite a challenge. First, people can live a long way from the road and second, if there is no mobile phone coverage, people have to go to the top of hills or mountains to get enough connection to make a phone call. This means it can take three or four days to get the woman to the hospital. Women’s Extension Workers, TBAs and HEWs can call the APDA or the district (woreda) ambulance. “But sometimes the health office doesn’t have the per diem for the driver so most of the time we call for APDA,” said one of the Women’s Extension Workers. If the community is far from the hospital they call someone at the closest health centre.
Another difference between the Barbara May Maternity Hospital and the government hospitals is that APDA employs women – “we are not afraid of them, we can talk without shame. If we look at the male staff – they speak differently to us.”
APDA has identified a number of traditional practices that are dangerous to women and newborns during delivery. One of these practices was using the knife, the makiita, for many women and newborns – either to make a small incision or to cut the umbilical cord. Now there are clean cord ties for the baby and a clean blade for the woman. Women’s Extension Workers teach exclusive breastfeeding and not to give the baby water and sugar to drink. In the past the TBA would tie the woman’s legs together and did not allow her to wash for a week, but now the Women’s Extension Workers wash the woman, check her and make sure the placenta has come out.
For all the heat and the dust and the difficulties women have in reaching health services if there is a problem during delivery, I found the commitment of APDA employees such as the Women’s Extension Workers extraordinary. Nothing changes overnight and one Women’s Extension Worker I interviewed at the hospital told me that in the past, if an Afar woman had a problem during delivery she was left to die. She related an instance when a pregnant woman was pre-eclampsic (suffering from high blood pressure), and the family refused to allow her to do anything. But the Women’s Extension Worker insisted on calling for a car and driving the whole night. The woman had a Caesarean Section and so she survived. Now this Women’s Extension Worker is remembered by the whole community: “Once you do something good, people will trust you … increasing the number of Women’s Extension Workers and Health Extension Workers is essential. We need to keep teaching and talking as it is very hard to change people’s minds.”
For more information about APDA’s work with women extension workers, visit: http://www.apdaethiopia.org/PWA.html
To learn more about the research being conducted through the Alfred Deakin Research Centre, visit: http://www.deakin.edu.au/alfred-deakin-research-institute/index.php