These Health Extension Workers bring preventive care, include family planning services, to the Oromiya Region of Ethiopia's Bale Zone, where the fertility rate is 6.2.

Badiriya Umer was recently offered an alternative many women in Ethiopia never have—with one visit to her local health provider she can stop having children for five years.

Safia Mohamed, a local Health Extension Worker (HEW), granted Badiriya this option by teaching her about long-acting family planning methods and referring her to the village health post. HEWs like Safia provide a package of 16 preventive, basic health services to community members, and refer clients to the local health center for deliveries and curative services.

The Integrated Family Health Program* and the Extending Service Delivery (ESD) Project update the skills of HEWs, like Safia, as well as service providers, so that women like Badiriya can follow the healthy timing and spacing of pregnancy (HTSP) messages and wait at least two years between pregnancies, and six months after an abortion or miscarriage to conceive. Using an expanded method mix— including those that are long-acting—young married women can also more effectively ensure they don’t get pregnant until they are 18.

By training both HEWs and service providers, ESD helps to ensure a strong referral system, ready to counsel clients at both stages of care and broaden family planning options for local women.

Safia was one of the first HEWs trained to counsel women on long-acting family planning methods, as well as HTSP.  Because of Safia, Badiriya can recite the HTSP messages—lessons she will likely pass on to her neighbors and children—if they want to have children when they are adults.

Safia taught Badiriya about Jadelle, Depo Provera, Implanon and Intrauterine Contraceptive Devices (IUCDs). These options give Badiriya, at age 29, a new perspective on her family’s future. Instead of growing her family, Badiriya wants to delay childbearing and finish her education. She wants her children—ages 8, 10, 11, 12, 13 and 14—to get an education too.

Of the methods offered, Badiriya selected Jadelle, a five-year implant.

The June 2009 training was the first of its kind in Bale Zone. Prior to the training, HEWs provided information about pills and injectables and referred clients to health centers for everything from illness to deliveries.

“We didn’t know about long-acting family planning services before the training,” said Safia. “But after the training, I started to explain and refer.”

Because of HEWs like Safia, Badiriya is of a new generation in her rural Ethiopian Woreda, or District, well- versed in family planning. Up to a year ago, not many people in the community knew about how to delay pregnancies using long-acting methods. Most women in the region where Badiriya lives have six children in their lifetime.**

Now, you probably won’t meet an HEW client in Badiriya’s District who doesn’t embrace their choices. In fact, all clients interviewed after the training said family planning is the most valuable service offered to them by HEWs.

A 2008 performance survey of HEWs by ESD, Pathfinder International/Ethiopia, and the Federal Ministry of Health, shows that before HEWs began working in rural areas, pregnant women had to be carried to the health center in hammocks.  Travel sometimes took days, and all too frequently women died or had a stillbirth before reaching the health facility. Among those arriving alive, many suffered complications or died because they sought care too late.

HEWs now follow up with and refer women for medical care, and it is rare to hear about a pregnant woman dying because of delayed care, or children dying from a preventable disease.

“Before the training, I was not clear how to approach and counsel and even how to communicate about family planning,” said Fekiya Kadi, another trained HEW serving a rural health post in Bale Zone. “Now, I (have) received and gained skills and knowledge (about) how to counsel and communicate.” Fekiya Kadi currently counsels 240 clients about family planning services.

* ESD works in partnership with the Integrated Family Health Program (IFHP), a five-year family planning/reproductive health services and maternal and child health project led by Pathfinder International in partnership with John Snow, Inc.

**The Bale Zone is located in the Oromiya Region of Ethiopia, where the fertility rate is 6.2 (2005 Ethiopia DHS).

-By Laurel Lundstrom, ESD’s Communications Officer and Jeanette Kesselman, ESD’s Senior Advisor for Capacity Building and Sustainability