In 2003, the Ethiopian government launched the Health Extension Program (HEP) to ensure universal health care. The approach here in my country, one with a large rural population with minimal access to quality health services, is to bring primary health care down to the grassroots community level. The approach has proven successful. Through my work with the Bill & Melinda Gates Foundation-funded Last 10 Kilometers Project (L10K), I have focused on examining how the quality of services can be improved for communities seeking care. L10K has focused on exploring ways to improve health-seeking behavior in communities, in short, to generate demand for higher-level health services.
In 2014 it was estimated that only 15% of Ethiopian women deliver in a health facility. In order to engage the community in improving the quality of healthcare, participatory community quality improvement (PCQI) was implemented. As facility delivery was discussed in PCQI meetings, it became clear that quality of care was a significant concern in the community. Women said that they felt they were not treated respectfully when they went to health facilities; though at home, traditional birth attendants — who know the community and its culture — treated them much better. Of course, the health outcomes are worse when women deliver at home, especially when women require emergency obstetric care. Our goal, in collaboration with the government, is to increase the number of women delivering with trained health care workers in facilities.
Our research in rural health facilities revealed many issues women face: they were often left alone for hours during labor and/or delivery, their privacy was not assured, facilities were unclean and in general women did not feel they were treated with respect. Men and families also felt neglected.
I remember this well when my wife had our first child five years ago. She was giving birth at a private hospital, but I was not allowed into the labor ward. No one told me what was going on and I waited nervously for hours. That was in a private hospital in Addis; typically it was worse in community health facilities.
Once the project identified that disrespect was a critical issue to service utilization, we realized we needed to do something. We partnered with the Hansen Project, of the Women and Health Initiative at Harvard T.H. Chan School of Public Health, to learn more about what disrespect and abuse actually means.
Together in 2013, we conducted a baseline survey in four primary health care units in Ethiopia to measure disrespect and abuse. The results were clear: more than one in five women reported that they have been disrespected and abused when giving birth at health care facilities. Among others, these experiences included non-consented care, lack of privacy, non-confidential care, and abandonment of care, when a woman was left alone during labor.
When we discussed the issues with health care workers at facilities, it quickly became clear that they were not aware that their behavior and the poor facility infrastructure were driving people away. Many felt that their job was to focus on the medical component of care — childbirth, cord care, etc. — but they admitted that they didn’t really think about the needs of women. They just saw that women didn’t come to facility without knowing why.
Today universal health care has taken hold with the strong leadership of the government. L10K has recognized the issues related to respectful care and is working with health facilities to address those issues. As a result, assisted delivery in the L10K areas is now much higher than the national average. More and more women are delivering at facilities and infant and maternal mortality rates are decreasing. In short, Ethiopia is on the right track. And for me, I trust that when my wife has our next child, I will be able to be right with her throughout her entire delivery.
Learn more about L10K’s work in respectful care.