It is estimated around 358,000 maternal deaths from complications of pregnancy and child birth occurred worldwide in 2008. Of these, developing countries accounted for 99% (355,000) of deaths[1]. The vast majority of maternal deaths are due to direct obstetrical complications, including hemorrhage, infection, eclampsia, obstructed labor, and unsafe abortion. Most obstetric complications occur around the time of delivery and cannot be predicted, but can be prevented with proper medical care[2]. In 2008, Ethiopia was among the six countries that contributed for more than 50% of maternal deaths in the world[3]. There is no evidence suggesting maternal mortality in Ethiopia is declining. In Ethiopia, 673 and 676 maternal deaths occurred in every 100,000 live births in 2005 and 2011, respectively[4, 5].

Ethiopia is a signatory to the millennium development goals. Goal 5 targets the reduction of maternal mortality by 75% between 1990 and 2015 and calls for a target of 80% of births assisted by a skilled attendant by the year 2015[6]. Skilled birth attendance is advocated as the ‘single most important factor in preventing maternal deaths’ and the ‘proportion of births attended by skilled health personnel’ is one of the indicators for millennium development goal 5[6, 7]. The World Health Organization (WHO) defines a skilled birth attendant as ‘an accredited health professional - such as a midwife, doctor or nurse - who has been educated and trained to be qualified in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns’[7].

Since the Alma-Ata Declaration on primary health care in 1978, community health worker cadres have been occurring in many countries across the globe[8]. Nowadays, the potential roles of community health workers within primary health care have received renewed attention as a result of the HIV pandemic and due to the increasing acknowledgement of the critical shortage of human resources within health services[9–11].

Similar to other developing countries, Ethiopia has been training and deploying volunteer community health workers. With the aim of accelerating primary health care coverage and ensuring access to basic health services to the underserved rural population, the country launched a new community-based initiative called the Health Extension Program (HEP) in the year 2003[12]. Under the umbrella of this program, cadres of community level health workers trained for 1 year, named health extension workers (HEWs), were deployed to rural areas. In relation to reducing maternal mortality, HEWs are trained on how to provide care to pregnant mothers through pregnancy, birth, and postnatal care. They are part of the formal health structure and receive a monthly salary.

Very few studies have been published on the effectiveness of these HEWs since their deployment[13]. These studies have shown that HEWs are effective in improving immunization, family planning utilization, and antenatal care visits, but not in health facility deliveries and skilled birth attendance coverage[13–15]. Reviews have been published concerning the role of community health workers, highlighting successes and problems in other developing countries[16–19]. A systematic review done to assess the effectiveness of lay health workers showed promising benefits in promoting immunization uptake and improving outcomes for acute respiratory infections and malaria. However for other health issues such as birth attendance, there is insufficient evidence to justify recommendations which can guide policies and practices[10].

Considering that HEWs are not skilled birth attendants, it is recommended that the HEWs task should focus on the early identification of danger signs, danger symptoms, and complications in pregnancy and facilitating immediate referrals of pregnant women when needed. However, it is not known whether the knowledge of HEWs is adequate. Therefore, we examined the knowledge of HEWs on contents of antenatal care, danger signs, danger symptoms, and complications in three districts of Tigray region in Northern Ethiopia. In addition, we explored barriers and facilitators for HEWs in the provision of antenatal care, delivery care, and referral services.

The HEWs of Ethiopia play a rather small role in assisting births. On average, a HEW assisted approximately six births per 6 months. Most deliveries took place at home without the necessary professional help or the necessary facilities. The HEWs knowledge on danger symptoms, danger signs, and complications in pregnancy was poor. In relation to this, it was indicated that HEWs rarely referred a pregnant woman to a health center. Very few HEWs received professional support on obstetric care from a midwife.

Studies[13–15] showed that the deployment of HEWs has improved some aspects of maternal and child health such as family planning utilization, immunization uptake, and the number of antenatal care visits but not in health facility deliveries and skilled birth attendance coverage. Nevertheless, these studies did not explore the reasons for HEWs’ low performance in promoting health facility deliveries and skilled birth attendance. Our study showed that one possible reason for the low performance of HEWs in stimulating behavioral change among the community and facilitation of referrals could be their poor knowledge on contents of antenatal care, danger signs, danger symptoms, and complications in pregnancy. Because of their poor knowledge, HEWs may not convince pregnant women to have birth planning and preparedness to give birth at health facilities and assisted by skilled birth attendant. In addition, the HEWs may experience that the public still prefers to give birth at home; despite the fact that the importance of institutional delivery has been discussed with the clients. This choice might be preferable considering the poor knowledge of the HEWs and lack of basic infrastructures at health posts, but it may be also due to a deep-rooted behavior and preference of the community to give birth at home. Given the HEWs are the key and main provider of primary health care services to the rural community in Ethiopia, improving their competency and effectiveness on maternal health care is urgently needed. A study conducted among community health extension workers in Nigeria showed that community health workers, who were backed by telephone consultations and working under the direct supervision of doctors, can improve quality of care to the satisfaction of most of their patients[16]. The recent introduction of mobile phones could provide new opportunities for two-way communication between front-line health workers such as HEWs and skilled birth attendants such as midwives in health centers[22]. However, further researches are needed to investigate the potential impact of mobile phone-based applications in improving the performance of HEWs.

Looking from the HEWs’ perspective, our study showed the absence of further education to improve their career and knowledge, earning low salary, and work load were noted to be the main factors that hindered the HEWs from providing good quality of care. Therefore, it may be unrealistic to expect HEWs to play a key role in the improvement of maternal health care without addressing their needs in career promotion and other monetary incentives. Similar findings were observed in other studies on similar initiatives[18, 19, 23]. These studies showed that continuous training, transport means, adequate supervision, and motivation of community health workers through the introduction of financial incentives are among the key factors to improve the work of community health workers. Nevertheless, more studies are needed before we can be sure what the best and most cost-effective strategy is to improve the quality of care provided by the HEWs.

Some limitations of this study deserve attention. Although this study was carried out in rural districts, these districts were relatively near to urban towns. We also did not investigate actual care given by HEWs for example by non-participant observation. Presumably the situation is more severe in very remote areas and a similar study[17] like ours, which included non-participant observation, showed that HEWs performed less well when compared to their reported knowledge. Therefore, although the situation observed in our study was far from ideal, we assume that the knowledge and performance of HEWs might be poorer in reality.

We adapted the Ethiopian university scoring system to interpret HEWs’ knowledge on contents of ANC counseling, danger signs, danger symptoms, and complications in pregnancy. Although it might seem illogical to use the university scoring system for HEWs, it has no influence on the description we made, because basically we adapted the knowledge questions in the assessment from the guidelines, manuals, and log books of HEWs. All the knowledge questions were about the contents of ANC counseling, danger symptoms, danger signs, and complications that are expected to be known by HEWs.

Eighteen (26.5%) of the 68 HEWs who were working in the 39 health posts were not present in their working place or kebele during the period of data collection. They moved away from their working place for meetings, training, maternity leave, or social reasons. Their absence was not because they had different characteristics from the HEWs who were interviewed. Hence their exclusion from our study is not likely to influence the findings in this study.

In this study we explored the barriers and facilitators for HEWs in the provision of maternal health services through a questionnaire. However qualitative assessment either through focus group discussions or in-depth interviews with the HEWs might have been preferable approach to explore these barriers and facilitators. Hence, we recommend further qualitative studies in this regard.

HEWs knowledge on contents of antenatal care counseling, danger symptoms, danger signs, and complications in pregnancy was poor and there was no good referral system. Hence, there is an urgent need to design appropriate strategies to improve the performance of HEWs by enhancing their knowledge and competencies, while creating favorable working conditions for HEWs in the rural areas.