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'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',
Woman Extension Worker, Logyia, Afar Region, Ethiopia, 25 March 2014.
We are sitting in the shade at the Afar Pastoralist Development Association (APDA) training facility with 19 Women 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 where 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 sari (pronounced 'ari). Aris are dome shaped and made of shaped bent sticks and covered with leaf mats. They are light and portable and easily dismantled - a job usually done by women.
While the Women 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 Woman Extension Worker explained that they had to help their husband's 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 northeastern 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 over 50 degrees celsius in the summer. Around 90 percent of the regional population in Afar 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 deliveries assisted by qualified health personnel is 6.2 percent compared to the national average of 18.4 percent. Antenatal coverage is 25.3 percent compared to the national average of 71.4 percent. Clean and safe delivery coverage is 0.5 percent compared to the national average of 17 percent and the contraceptive acceptance rate is 13 percent compared to the national average of 61.9 percent.
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 Extension Workers to mobilise communities in hygiene, sanitation, nutrition, mother/child care, safe motherhood, HIV prevention, and stopping harmful practices. Women 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 Extension Workers discuss the problems women have during pregnancy and childbirth. The first problem they mention is anemia 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 live a long way from the roads - some people walk 30 to 40 kms to reach the road. There are many difficulties for the woman giving birth but now with APDA's health programs, the Women Extension Workers and HEWs can check women for anemia 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 Extension Worker knows that there will be problems and that the woman shouldn't deliver at home, they refer her to the health centre.
Trained TBAs and women extension workers can refer women by ambulance to the recently opened Barbara May Hospital in Mille which is APDA's obstetrics and gynaecology hospital for Afar women with a 250 km radius. The hospital also built a number of aris which 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. According to staff at the hospital, 20 percent of women who attend ANC 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 phone network, people have to go to the top of hills or mountains to make the call. This means it can take three or four days to get the woman to the hospital. Women 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".
If the community is far from the hospital they call someone at the closest health centre.
Another difference between the APDA Barbara May Hospital and the government hospitals is that APDA employs women at the hospital -
"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 newborn during delivery. One 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 Extension Workers teach exclusive breastfeeding and not to give the baby water and sugar to drink. In the past the TBA tied the woman's legs together and did not allow her wash for a week but now Women 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 Extension Workers extraordinary. Nothing changes overnight and one Woman 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 Woman Extension Worker insisted on calling for a car and driving the whole night to the hospital. The woman had a Caesarean Section and so she survived. Now this Woman Extension Worker is remembered by the whole community:
"once you do something good - people will trust you … Increasing the number of Women 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".
Dr. Ruth Jackson is a Research Fellow at the Alfred Deakin Research Institute. Her research is about developing and implementing the peer ethnographic approach to improve the skills and capacity of Health Extension Workers (HEWs) and Non-government Organisations (NGOs) to encourage women in rural and pastoralist Ethiopia to give birth with skilled birth attendants. This project has been funded by the Australian Development Research Award Scheme.
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