Cabinet member responsible for the pregnant mother, and name of the GSK1363089 web individual who will be responsible during when labour starts. WDG leaders now meet weekly or fortnightly with HEWs. According to the Road Map, ambulances should link health posts in rural kebeles with health centres (at the woreda level), and health centres with hospitals (at the zonal and regional level) through a referral system so that women can be transferred if they need EmONC [6]. This referral system is considered to be the key to reducing delays that currently contribute to maternal and neonatal mortality and morbidity [42, 43]. We found that there was strong commitment from Adwa Woreda Health Office to ensure the availability of ambulances at all times and in all localities. There were times when HEWs stated that the ambulance was delayed but this appeared to be because it was in another part of the woreda. Some health centres have put aside space for mothers to wait in the final week of pregnancy. HEWs and health centre staff have identified a number of incentives that have improved women’s likelihood of delivering in a health centre. Based on the health worker’s perceptions, these incentives might be considered as trivial, but they appear to be cost-effective enticements. They include allowing women to wear perfume and to burn etan during labour, putting pictures ofPLOS ONE | DOI:10.1371/journal.pone.0150747 March 10,11 /Maternal Health Service Utilization and Acceptance in Adwa Woreda, EthiopiaMariam on the wall of the labour ward, providing gunfo for the woman to eat straight after delivery, providing a celebratory coffee ceremony, and providing clothes for the newborn baby. Women, HEWs and other health 1471-2474-14-48 workers identified the need for Rocaglamide A site skilled birth attendants to be scan/nsw074 respectful because many women are fearful of giving birth in a health facility–and especially fearful of being referred to the hospital for a Caesarean Section. Some women identified abusive care as a disincentive to attend health facilities. The Adwa Health Office has scheduled regular meetings to ensure that skilled birth attendants treat women from rural areas with respect. Other studies have also found that disrespectful care can be a deterrent to skilled birth attendance as women prefer a health provider that shows respect for their patients [44?6]. A combination of political commitment and resources to health facilities along with the WDGs has seen an increased number of women giving birth in health facilities in Adwa Woreda. WDGs are mobilizing communities to ensure early referral of women to health centres for delivery–thus reducing the first delay. To reduce the second delay, especially the shortage of transportation in rural areas, the introduction of ambulances to each woreda reflects the commitment and multi-sectoral response to improving maternal health care. The TRHB is currently working with health centres and hospitals on a maternal death review to determine why women die in childbirth [30, 46]. The combination of these factors could help ensure that the motto “No woman should die while giving life” becomes a reality for all women in rural Adwa Woreda and in Tigray Region.Study limitationsThere were limitations in our study as our data and conclusions are based on a small number of HEWs and women’s responses from one woreda in Tigray Region. Although HEWs are under considerable pressure to refer all women to health centres for ANC and delivery we occasionally felt that their re.Cabinet member responsible for the pregnant mother, and name of the individual who will be responsible during when labour starts. WDG leaders now meet weekly or fortnightly with HEWs. According to the Road Map, ambulances should link health posts in rural kebeles with health centres (at the woreda level), and health centres with hospitals (at the zonal and regional level) through a referral system so that women can be transferred if they need EmONC [6]. This referral system is considered to be the key to reducing delays that currently contribute to maternal and neonatal mortality and morbidity [42, 43]. We found that there was strong commitment from Adwa Woreda Health Office to ensure the availability of ambulances at all times and in all localities. There were times when HEWs stated that the ambulance was delayed but this appeared to be because it was in another part of the woreda. Some health centres have put aside space for mothers to wait in the final week of pregnancy. HEWs and health centre staff have identified a number of incentives that have improved women’s likelihood of delivering in a health centre. Based on the health worker’s perceptions, these incentives might be considered as trivial, but they appear to be cost-effective enticements. They include allowing women to wear perfume and to burn etan during labour, putting pictures ofPLOS ONE | DOI:10.1371/journal.pone.0150747 March 10,11 /Maternal Health Service Utilization and Acceptance in Adwa Woreda, EthiopiaMariam on the wall of the labour ward, providing gunfo for the woman to eat straight after delivery, providing a celebratory coffee ceremony, and providing clothes for the newborn baby. Women, HEWs and other health 1471-2474-14-48 workers identified the need for skilled birth attendants to be scan/nsw074 respectful because many women are fearful of giving birth in a health facility–and especially fearful of being referred to the hospital for a Caesarean Section. Some women identified abusive care as a disincentive to attend health facilities. The Adwa Health Office has scheduled regular meetings to ensure that skilled birth attendants treat women from rural areas with respect. Other studies have also found that disrespectful care can be a deterrent to skilled birth attendance as women prefer a health provider that shows respect for their patients [44?6]. A combination of political commitment and resources to health facilities along with the WDGs has seen an increased number of women giving birth in health facilities in Adwa Woreda. WDGs are mobilizing communities to ensure early referral of women to health centres for delivery–thus reducing the first delay. To reduce the second delay, especially the shortage of transportation in rural areas, the introduction of ambulances to each woreda reflects the commitment and multi-sectoral response to improving maternal health care. The TRHB is currently working with health centres and hospitals on a maternal death review to determine why women die in childbirth [30, 46]. The combination of these factors could help ensure that the motto “No woman should die while giving life” becomes a reality for all women in rural Adwa Woreda and in Tigray Region.Study limitationsThere were limitations in our study as our data and conclusions are based on a small number of HEWs and women’s responses from one woreda in Tigray Region. Although HEWs are under considerable pressure to refer all women to health centres for ANC and delivery we occasionally felt that their re.