Maternal health care service utilisation is important for the improvement of both maternal and child health. In a study of six African countries, lower number of maternal and neonatal mortality and morbidity were shown when mothers give birth in a health facility with the help of skilled medical personnel. These study results show the importance of having an increased number of women to give birth in health institutions with the assistance of trained staff/skilled attendant so as to avoid the needless death of mother and child.

As you have seen in the above section, despite the fact that institutional delivery provides a much better and safer service than home delivery, all data indicate that a vast majority of women still not utilise the service.

Among most of the factors you studied in previous sections, a lower educational level of women is the one which could be easily addressed with a much lesser but very effective intervention called health promotion and communication. The fact that a huge number of women still think of institutional delivery as "unnecessary", clearly show you the prevailing high awareness gap among our community and women in particular. This also shows the need to have an immediate and large-scale interventions targeting on improving women's educational opportunities. This can be achieved as a long-term action but could also be achieved in the short term through effective health education programs by addressing more women with no education. DHS study of 2011 also clearly indicates the need to have effective health education and information campaign as an important intervention to dispel the knowledge gap and negative attitudes of women towards institutional delivery.

How to Promote Institutional Delivery?

Hence, as a health extension worker you could play a major role in promoting institutional delivery by applying the principles of health education and communication you learn in Module 2.

As you may remember from Module 2, any community health problem that demands health education intervention is based on the assumption: "that beneficial health behaviour will result from a combination of planned, consistent, integrated learning opportunities and scientific evaluation of programs in different settings."

You will follow the following principles and approaches in the promotion of institutional delivery in your community:

• Identify the factors/gaps for a lower level of institutional delivery in your kebele. This step helps you to understand and analyse the causes of the problem.
• You should set the goal of promoting institutional delivery. Your goal here could be to increase the current institutional delivery to a better level so that all pregnant women under your kebele deliver at a health institution.
• Participate all member of the community in the health promotion activity since it is impossible to increase institutional delivery without their active involvement. Therefore, make sure to involve her families, religious leaders, respected individuals, traditional birth attends development army (in her 1-5 network) and the community as a whole. This will also help for the development of the local partnership.

By principle participation also helps people to identify their need for change and promotes the ability to choose for themselves methods and strategies that will enable them to take action.

• Identifying the target of education is also important. Your targets could be an individual pregnant woman, a group of individuals or the community. There are various opportunities to come in contact with your targets, some of these are your house to house visit which will allow you to get an individual pregnant woman and a 1-5 network of women. Group gathering of any kind like Ekube, Edir and community meetings could also allow you to find your targets/audience. Identifying your target/group will help you to adapt proper health education method and activity that will fit your audience.



Fig. 1.2. Targets of health education could be individual women, a group of individuals and the community.


• You should first set the objective of your health education that will address the identified gaps or factors contributing to lower institutional delivery.

What do you want to address?:

• A knowledge gap on the importance of institutional delivery?.
• The risk of home-based delivery?.
• The risk of delivery without skilled birth attendant?.
• Do you want to address negative attitudes/beliefs of women and the community on institutional delivery?
• Your objective might address one, most or all of these objectives in one or another way based on the gap you identify for your kebele.
• Use credible resource (updated scientific facts) is also critical not to diffuse the information shared and also lose trust.
• Multiple causes/factors will always be found for any given behaviours. For each of the multiple predisposing, enabling, and reinforcing factor identified a different methods or components of comprehensive behavioural change must be provided. The most important teaching methods you could use could be:
  • Talking about the importance of institutional delivery using relevant, local and tangible experience the audience could easily understand. Using local language and way of expression is also important.
  • Experience sharing of some women whose lives was saved because of institutional delivery and also a testimony of traditional birth attendants could influence the community.
  • Invite role models, influential individuals, elders religious leaders to promote the importance of institutional delivery.
  • Role play and drama on the risk of home-based delivery and the importance of institutional delivery.
  • Mass media:
    • Studies suggested the effectiveness of mass media (access to radio) rather than printed media to transmit health information especially in a rural setting where most women cannot read. In addition to that using local language to transmit health education is also found to be very effective.
  • Audio-visual aids like posters.
  • Demonstration.
  • Group discussion in a 1-5 network.
  • Traditional means of communication such as poems, stories, songs, dances and puppet shows.
• Planning and organising health education are very important. It involves deciding in advance the when, who, what, how and why of health education on institutional delivery. It requires the planning of health education objectives, resources, methods and materials to be used and identification of target groups, etc.

• Observes rules and norms of culture as appropriate. You have to understand the culture of the community and introduce new ideas with a natural ease and caution. Learns about traditional practices of the locality and recognise the richness and spiritual significance of the community and culture that could contribute to better utilisation of health institutions. This means you should be aware of the traditional beliefs regarding pregnancy and childbirth and cooperates and liaises with traditional healthcare system when possible so that you could promote or build on positive traditional practices. For instance, you could start from some of the positive aspect of the traditional practices done in the community like that of the traditional birth attendants good practice of allowing the presence of relatives, encouraging walking around, allowing free position in delivery, placing the baby on the mother's breast even before umbilical cord is cut.

  You should also identify cultural attitudes and practices that prevent the utilisation of health service. Instead, you need to offer sound alternatives in place of the harmful practices. You must avoid using dogmatic statements contrary to existing belief, culture and practices since such approach will result in rejection and hatred. Therefore, your health educations should start from where people are (their existing reality) and slowly build up the discussion to allow them to understand, appreciate and internalise fresh ideas.

• Provide positive reinforcement for women who previously delivered at health institution and continue to use this approach. Expanding such best practices to other women, families and community members through a 1-5 networking system should be practised so that it could be replicated. To do this, you could use model families who implemented all the packages of health extension program which probably includes better utilisation of healthcare institutions for ANC, delivery, etc. Providing various rewards for mothers who deliver in healthcare facility could also motivate other mothers in the community.
• Follow pregnant women in your kebele after providing a serious of health education sessions so that you could witness and give feedback for any change in behaviour/ practice that occurs. Look for any change in health seeking behaviour and also utilisation of the health care facility.
• Use the various setting you could get like the house to house visit, "Edir", "Ekube" coffee drinking ceremonies, religious places, market places, schools, a community gathering of any kind, etc., to teach the community and get your message out.

N.B. When you provide health education, you must also apply the principle and features of communication that you learn in Module two.

The role, relationship and responsibilities of Traditional Birth Attendants (TBA's) as an advocate for women and families to support safer birthing

Traditional Birth Attendants' (TBAs) assist 60% -80% deliveries throughout the world and are called by different names. Therefore, considering a large number of the community they serve, the positive perception of the community towards them and their ability to identify some level of obstetric problems compared with other community members, the need to involve TBAs in the promotion of institutional delivery is unquestionable. TBAs could be an important and helpful agent in advising and referring mothers during pregnancy and delivery. However, it is also equally important for you to respect them and their effort, acknowledge their contribution and make them an active participant (even a lead person) in the 1-5 household networks and the health development army. It is only through these partnerships you could make them an ally/partner in improving the health outcome of mothers and children. Studies show that establishing a partnership with TBAs will increase a healthy collaboration with TBAs which consequently results in an improved maternal and neonatal health outcome. So, being an important partner, TBAs should be actively involved at each step of your health promotion and communication practice.

Involve families, relatives, friends and the community in the development of institutional delivery

The health extension program support start from single families' to the community, making sure that there is no one left behind. So you have an excellent opportunity to come in direct contact with the whole family members (the mother, husband, relatives, etc.neineighbours, community leaders, religious leaders and the community. Therefore, you should use these opportunities to promote the importance of institutional delivery.

The 1-5 network, the existing community development groups, development armies are also another opportunity though which you could teach the community about the benefits of having a delivery with the assistance of a skilled health professional.

You could also inform the community that the service provided in the healthcare facility is women friendly: which respect the belief, culture and religion of the mother and the community. You could also use these opportunities to explain any myth the community have towards institutional delivery.