Background: In recognition of the critical shortage of human resources within health services, community health
workers have been trained and deployed to provide primary health care in developing countries. However, very
few studies have investigated whether these health workers can provide good quality of care. This study
investigated the knowledge and performance of health extension workers (HEWs) on antenatal and delivery care.
The study also explored the barriers and facilitators for HEWs in the provision of maternal health care.

Methods: In conducting this research, a cross-sectional study was performed. A total of 50 HEWs working in 39
health posts, covering a population of approximately 195,000 people, were interviewed. Descriptive statistics was
used and a composite score of knowledge of HEWs was made and interpreted based on the Ethiopian education
scoring system.

Results: Almost half of the respondents had at least 5 years of work experience as a HEW. More than half (27
(54%)) of the HEWs had poor knowledge on contents of antenatal care counseling, and the majority (44 (88%)) had
poor knowledge on danger symptoms, danger signs, and complications in pregnancy. Health posts, which are the
operational units for HEWs, did not have basic infrastructures like water supply, electricity, and waiting rooms for
women in labor. On average within 6 months, a HEW assisted in 5.8 births. Only a few births (10%) were assisted at
the health posts, the majority (82%) were assisted at home and only 20% of HEWs received professional assistance
from a midwife.

Conclusion: Considering the poor knowledge of HEWs, poorly equipped health posts, and poor referral systems, it
is difficult for HEWs to play a key role in improving health facility deliveries, skilled birth attendance, and on-time
referral through early identification of danger signs. Hence, there is an urgent need to design appropriate strategies
to improve the performance of HEWs by enhancing their knowledge and competencies, while creating appropriate
working conditions.