by Jenny Dyer, PhD

Over the last ten years, Ethiopia has implemented their Health Extension Worker (HEW) program building Health Posts with HEWs throughout the country. To date, there are some 38,000 HEWs; two at every post. This has amazing reach to communities whose individuals might otherwise have to walk for miles and miles just to have basic services for a sick child, contraception, or antenatal care. This being said, the Health Post does have limitations. The HEW cannot provide a high level of skilled care. For instance, women in Tigray are highly encouraged to take a “mobile ambulance” (i.e. stretcher) to the Health Center where they can have access to skilled health workers that are better prepared to manage complications during birth.

Agulae health center_ethiopia

We visited Agulae Health Center in Tigray which won the award for the best Health Center in the country a couple of years ago. The sign outside reads “Healthy Mom, Happy Child.” The Center focuses on maternal and child health , ART treatment, TB treatment, family planning, and youth friendly services, providing a holistic approach for development of identity for teens in the area. Ethiopia is serious about improving maternal health, or conversely, reducing maternal mortality. And, one step to do this is by encouraging moms to have their babies in the health center, not at home.

Healthy Mom happy child_ethiopia

Inside, patients waited for services including anti-retroviral treatment, immunizations, contraception, antenatal care, and pediatric care. The Health Center Director, Tirete Zeleke, shared with us the progress particularly in delivery services over the last five years. See the chart below. Note that Ethiopia’s calendar is eight years behind ours, so it is 2006 currently. In 2001 (Ethiopian calendar – so 2009), they record that only eight percent of mothers were coming to Agulae to have their newborns. But by 2005 (2013), they note 95 percent were choosing to come to the Center to take advantage of the services and resources for a safer delivery. This is an unbelievable change.


There has been much resistance from Ethiopian women to give birth outside her home. First, the “stretcher” that some communities in Tigray have developed to  carry the pregnant women from their community to the Center, or at least to a paved road to get transportation, has been stigmatized. It was said if you left on the stretcher, you never would return. To destigmatize the stretcher, they now call it a “traditional ambulance.” Secondly, there are rituals to be performed immediately after birth to drive away the evil spirits that might take your life or the life of your newborn. This involves a coffee ceremony and the partaking of porridge. Family and friends in the community join in these rituals, partaking together. The Center has recognized this void for the community, and it has created a space for performing the coffee ritual.

coffee ritual_ethiopia

Also, it has required all farmers in the region to donate 1 kilo of teff (an ancient grain) from their harvest to the Center to make the porridge. This attention to community beliefs and ritual has helped break down the cultural barriers that were impeding the women to leave her home during labor.

Lastly, as a final incentive, they have started to create beautiful, laminated birth certificates after one year of postnatal care and infant care. These special documents serve as birth registries and include a photo of the child and all the necessary health care information. Birth registration is so important for establishing name, nationality, and providing the dignity of identity for citizens.

brith certificates

Finally, they have pursued religious leaders to join them in encouraging couples to seek out both family planning options as well as to encourage women to deliver in the Health Centers. The synergy of religious, social, cultural, and governmental forces working together in Tigray has made Agulae Health Center a model for progress in Ethiopia, particularly for maternal health.