Quality of comprehensive emergency obstetric and newborn care services and associated factors among mothers with obstetric emergencies in public hospitals of west shoa zone,central Ethiopia: A cross-sectional study design

Abstract

Introduction

The obstetric complications remain the leading cause of death in women of reproductive age and their neonates in low and middle-income countries. These deaths are largely preventable through providing quality of care. However, there is limited information about quality of emergency obstetric and newborn care and its associated factors in Ethiopia.

Objectives

This study aims to assess quality of comprehensive emergency obstetric and newborn care and factors associated with mother satisfaction in public hospitals of West Shoa Zone.

Methods and materials

A facility-based cross-sectional study design was conducted at four public hospitals of West Shoa Zone from September 01, 2023 to February 28, 2024. A facility audit was conducted at 04 selected public hospitals, and 348 mothers were randomly selected to participate in observation of care, mother exit interview and their medical record reviews. Then, the input, process and output components of quality care were computed. Furthermore, linear regression analysis was fitted and variables having p-value of <0.05 in multivariate analysis were considered as statistically significant predictors for mother satisfaction with quality care.

Results

The result of the study finding indicates the input, process, and output components of quality care were 81.2%, 78.2%, and 75.9%, respectively. The study also identified mothers’ waiting time for receiving care (B =-2.68, 95% CI: -4.66, -0.70) and duration of hospital stays (B =-0.17, 95%CI:-0.34, -0.01) were significantly associated with mother satisfaction with quality of comprehensive emergency obstetric and newborn care services.

Conclusion and recommendations

The input, process and output dimensions of quality care were acceptable level in the study area. Mother waiting time and duration of hospital stays were significant predictors of mother satisfaction toward quality of care. Therefore, the health system should strengthen facility infrastructures, availability of essential supplies, and enforcing health care providers’ adherence to standards of care.

Keywords

quality of CEmONC services associated factors obstetric emergencies public hospitals west shoa zone central Ethiopia

Introduction

Maternal and perinatal mortality are the crucial indicators used globally to assess, monitor, and evaluate maternal and newborn health,¹ and countries have made improvements toward achieving the Sustainable Development Goals (SDGs), particularly in relation to SDG 3.1 and SDG 3.2, which aim to reduce maternal mortality and end preventable deaths of newborns and under five children.² Despite the global progress, maternal and child mortality remain high, with about 260,000 maternal deaths reported in 2023 and nearly 4.9 million under-five deaths in 2024, almost half occurring in the neonatal period.^3,4 These deaths are largely preventable and are strongly associated with limited access to quality of care during childbirth. Evidence shows that skilled birth attendance and access to emergency obstetric and newborn care can prevent the majority of maternal and neonatal deaths by enabling timely management of the obstetric complications during labor and delivery. Institutional delivery, which ensures the presence of trained health professionals and appropriate medical resources, therefore plays a crucial role in reducing mortality risks and improving the survival outcomes.⁵

The obstetric complications remain the leading cause of death in women of reproductive age and their neonates in low and middle-income countries. But, these deaths are preventable with the implementation of quality emergency obstetric and newborn care (EmONC) services in the healthcare facilities.^6–8 Furthermore, the coverage of institutional deliveries has been significantly increasing over the past few decades. At the same time, a higher proportion of avoidable maternal and perinatal mortality and morbidity has shifted to health care facilities, where poor quality of care has become a major challenge to ending preventable mortality and morbidity.⁹ Recently, a greater focus on quality of care was advocated to achieve the 2030 SDGs, which aim to ensure healthy lives and promote well-being for all at all ages. Poor quality of care is not only harmful but also waste resources that could otherwise be used in other sectors to improve the lives of citizens.¹⁰

The World Health Organization (WHO) defined the quality of maternal and newborn health care as “the extent to which maternal and newborn health services (for individuals and populations) enhance the probability of timely, appropriate care aimed at achieving desired outcomes that align with contemporary professional knowledge and consider the preferences and aspirations of individual women and their families.”⁵ The WHO standards for quality maternal and newborn care emphasize prioritized, evidence-based interventions during critical periods of pregnancy, childbirth, and the early postnatal phase. The vision is to ensure that every woman and newborn receives high-quality care throughout this continuum. Effective prevention and management of obstetric conditions during late pregnancy, childbirth, and the early neonatal period can substantially reduce maternal mortality, stillbirths, and early neonatal deaths.⁹

The EmONC services are effective in treating many obstetric complications and preventing maternal and perinatal mortality and morbidity. However, the availability and quality of EmONC services were found to be insufficient in most low-income countries.¹¹ Globally, more than half of women with obstetric complications do not receive EmONC services, with a significant disparity between low-income (21%), middle-income (32%), and high-income countries (99%). This disparity corresponds to an annual 11.4 million untreated obstetric complications and 951 million women without access to EmONC services.¹² The recent evidence shows that half of all maternal and one million newborn deaths can be prevented by providing high-quality care before, during and after childbirth. However, in low income countries, obstetric mothers receive less than half of the recommended practices in a typical maternity care visit.¹³

According to the Ethiopian EmONC service assessment report in 2016, about 66% of the obstetric mothers gave birth at the health institutions. Regardless of complications, every child birth should occur in a health facility that can readily manage obstetric emergencies. However, only 14% of them gave birth in the EmONC facilities, indicating that most health facilities were not ready to treat the obstetric emergencies adequately.¹⁴ Another recent survey conducted on service provision assessment of EmONC services in Ethiopia from 2021-2022 also reported that from a total of 905 health facilities assessed, only 442 health facilities (49%) were able to provide fully functional Basic EmONC (BEmONC) services and 250 facilities (27.6%) provided fully functional Comprehensive EmONC (CEmONC) services. The national coverage of BEmONC was estimated at 1.5–3.77 facilities per 500,000 populations, and the CEmONC coverage ranged from 0.83–2.1 facilities per 500,000 populations, indicating remains below the WHO recommended standard. The study also revealed significant geographic disparities in service availability, with relatively better access in regions such as Amhara, Southern Nations, Nationalities, and Peoples’ Region (SNNPR), and Addis Ababa, while many rural and remote areas had limited access to life-saving obstetric care services.¹⁵

A high-quality care requires health facility readiness (physical infrastructure, medicines, equipment and medical supplies); adherence to the guidelines for providing care; and the availability of human resources with adequate knowledge, and skills to effectively manage the uncomplicated and complicated childbirth events.¹⁶ The research evidence also revealed that healthcare delivery is inadequate and of poor quality in low- and middle-income countries, characterized by issues like shortage of resources, poor infrastructures, lacks of political will, and insufficient management and governance, all of which undermine patient safety and health outcomes. The study highlights poor quality of care often prevents better outcomes, with factors like inadequate training, poor adherence to guidelines, and weak health system support contributing to deficiencies in health facility care.¹⁰ According to the estimates, about six out of ten neonatal problems and 50% of maternal deaths are due to inadequate quality of care in low- and middle-income countries. This finding highlights that poor quality is a primary driver of preventable mortality.¹⁰

Quality care is crucial in ensuring that women and newborns receive interventions that may prevent and treat birth-related complications. As health facility deliveries increase in developing countries, measurement of quality services is essential in ensuring the delivery of appropriate interventions to reduce preventable maternal and child mortality.¹⁷ One of the most widely used frameworks for assessing healthcare service quality is Donabedian’s model, which is based on three interrelated components: structure, process, and outcomes. In this framework, ‘structure’ refers to the settings in which care is delivered, including infrastructure, provider qualifications, and organizational systems; ‘process’ denotes the actual delivery of care; and ‘outcomes’ refer to the effects of care on patient health, including recovery and survival. These components continue to form the foundation of contemporary quality assessment in healthcare These concepts, therefore, remain the foundation of quality assessment today.^18,19

Donabedian’s framework was selected for this study due to its comprehensive and systematic approach to assessing the healthcare quality across three interrelated domains: structure, process, and outcomes. This framework is particularly well suited for evaluating EmONC services, where infrastructure, clinical practices, and maternal and neonatal outcomes are closely interconnected. Moreover, it has been widely applied in both low- and middle-income country settings, facilitating comparability across studies and alignment with global standards for quality of care assessment. Its adaptability to diverse healthcare contexts further supports its use in evaluating the maternal and newborn care health services in Ethiopia.¹³

In Ethiopia, notable efforts have been made to improve access to basic and comprehensive emergency obstetric and newborn care such as expansion of health facilities and availing BEmONC and CEmONC services.²⁰ However, increasing access to and utilization of services alone does not guarantee improved maternal and newborn health outcomes. Along with expanding coverage of the services improving quality and evidence-based care during critical periods will have the greatest impact on the survival of the mother, fetus and newborn.⁵ The global efforts to reduce maternal and child mortality are also guided by the SDGs, particularly target 3.1, which aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births, and target 3.2, which seeks to end preventable deaths of newborns and children under five by 2030.²¹ Achieving these targets will therefore require scientific evidence that aiming to improve quality of care in order to reduce preventable deaths from complications.²²

Furthermore, studies conducted in Ethiopia have primarily focused on the availability and utilization of EmONC services,^23–25 with limited evidence addressing the quality of these services.^26–28 In addition, existing research lacks comprehensive assessments that integrate the structural inputs, process measures, and outcome indicators. West Shoa Zone was purposively selected due to its high epidemiological relevance to the study objectives, characterized by its substantial burden of severe obstetric complications and experiences a substantial referral burden from rural areas. Evidence indicates that factors such as low service utilization and delays in accessing care contribute to maternal near-miss events, making the area an appropriate setting for evaluating quality of EmONC services and informing targeted interventions.²⁹ Therefore, this study aims to assess the comprehensive quality of CEmONC services and its associated factors using Donabedian’s framework in public hospitals of the West Shoa Zone, Oromia region, Central Ethiopia.

Method and materials

Study setting and period

The study was conducted in four purposively selected public hospitals found in West Shoa Zone, Central Ethiopia. The purposive selection of these four hospitals for inclusion in the study was based on the need to ensure that the included hospitals were most relevant to the study objectives, sufficient patient loads, were capable of offering comprehensive EmONC services, and feasibility of data collection within time and resource constraints. However, the specific criteria for excluding the other five hospitals were having low obstetric case loads, recent establishment of the health facility, logistical and accessibility challenges that could compromise the effective data collection. But the purposive selection of study sites was made cautiously through including different types of health facilities that may capture the cases from multiple districts for increasing population coverage and representativeness. According to the report of the West Shoa Zone health office, there were a total of 2,821,589 people living in the west shoa zone at 2023/2024GC. There are a total of 9 public hospitals, 92 health centers, and 529 health posts that are providing health care services for over 2.8 million people living in the zone. The hospitals are the only facilities mandated to provide CEmONC services, and the services are provided 24 hrs a day in all public hospitals of the West Shoa Zone. Finally, the study period was from September 01, 2023, to February 28, 2024.

Study design

A facility-based cross-sectional study design was conducted to address the research objectives and the quality of CEmONC services were measured using the input, process, and outcome components of the three quality dimensions.

Population

The source population for this study included all public hospitals within the West Shoa Zone, as well as all obstetric emergencies admitted to these facilities. The study population consisted of selected public hospitals and selected obstetric emergency cases that were admitted to the selected public hospitals during the study period.

Inclusion and exclusion criteria

The inclusion criteria were mothers admitted with selected obstetric emergencies (antepartum hemorrhages, pre-eclampsia and eclampsia, prolonged/obstructed labor, and postpartum hemorrhages) after 28 weeks of gestational age and getting at least one of CEmONC signal functions in selected public hospitals of the West Shoa Zone. The exclusion criteria were mothers with selected obstetric emergencies but referred to another health facility for further management of their obstetric complications.

Sample size determination and sampling procedure

The sample size determination for the first objective was using the single population proportion formula, considering the quality of BEmONC services as 66.7%, from a previous study conducted in Adigrat town, Eastern Tigray, Northern Ethiopia.²⁷ So, using a 95% confidence interval and 5% marginal errors between the sample size and the population parameter;

n = \frac{{(Z á / 2)}^{2} P (1 - P)}{d 2} = \frac{{(1.96)}^{2} * (0.667) * (1 - 0.667)}{(0.05)} = 341; and 10 % non - response (34) = 375

The sample size for the second objective was calculated for each predictor variable was also using the previous study conducted on the quality of BEmONC services in Adigrat town of Eastern Tigray, Northern Ethiopia,²⁷ as summarized in the following table below (Table 1).

Table 1.

Sample size calculation for predictors on quality of CEmONC services from study conducted on quality of BEmONC services in Adigrat town, Eastern Tigray, Ethiopia.

Articles	Variables	CI	Margin of error	Power	% of outcome among un-exposed	% of outcome among exposed	AOR	Non -response rate	Final sample size
Quality of EmONC services in Adigrat town, Tigray Region	Residence (urban vs. rural)	95	5	80	30.2	47.5	0.273	27	297
	ANC follow up (Yes vs. No)	95	5	80	32.8	50	0.004	28	306
	partner presence during delivery (Yes vs. No)	95	5	80	12.3	47.3	2.259	6	70

Therefore, considering the larger sample size, a total of 375 study participants were used for conducting this study to ensure the findings are reliable enough to support the conclusions.

Sampling and sampling procedures

First, four public hospitals (Ginchi Hospital, Gedo Hospital, Ambo General Hospital and Ambo University Referral Hospital) were selected purposively from nine public hospitals found in the West Shoa Zone based on the relevance to the study objectives, the emergency obstetric caseloads in the facilities, availability of study resources, and time limitations. Next, the total sample size allocation for each hospital was made proportionally based on the expected number of selected obstetric emergency case loads from the previous 6-month report. A total of 698 mothers with selected obstetric emergency cases were expected to attend all the included health facilities during the study period and a total of 375 study participants were estimated as sample size of the study (65 participants from Ginchi Hospital, 74 participants from Gedo Hospital, 106 participants from Ambo General Hospital and 130 participants from Ambo University Referral Hospital). Then, those mothers who fulfilled the eligibility criteria were recruited through systematic sampling by including every other mother (selecting one mother, skipping the next, then selecting the third one, and repeating this pattern) until the required sample size for each hospital was obtained. The client on number two was randomly selected as the starting point by the lottery method, and if the selected mother didn’t fulfill the eligibility criteria, the next mother was included. Finally, 348 participants were fully responded and included in the data analysis. Where as, about 27 study participants were excluded due to refused to participate or incomplete information on their medical records during the data collection process.

Data collection tools and procedures

The data were collected by using structured and adapted questionnaires from relevant studies^{18,26,27,30–36} to answer the study objectives. The prepared questionnaires were typically structured with the triad of inputs, process, and outputs of health care quality assessment for EmONC services, and this framework guides to improve the quality of service delivery to reduce maternal and newborn mortality,¹⁸ as filed attached below (S1 File). Additionally, data collection tools (facility audits, observation of care and medical record reviews, and mothers’ exit interviews) were used to gather the necessary data. Related to the data collection process, health facility audit using a structured check list on the availability of essential medicines, equipment, supplies, and provision of signal functions of CEmONC services were conducted to assess the structural quality of CEmONC services. Additionally, observation of care and medical record reviews and mothers’ exit interviews were conducted to collect the process and output-related quality of CEmONC services, respectively. The Cronbach’s alpha coefficient for all components of quality measurement items were scoring of 0.88 in a combined analysis. Finally, a total of eight BSc nurses and four medical doctors were involved as data collectors and study supervisors after getting appropriate training about the study.

Study variables and measurements

The primary outcome variables were the input, process, and output quality of CEmONC services. It was measured as a continuous variable using 50, 20, and 25 items for assessing the input, process and output quality of CEmONC services, respectively. The results were analyzed by calculating the mean of each component. The independent variables were socio-demographic characteristics including age, address, marital status, religion, educational level, occupational status, and family monthly income; obstetric factors including number of gravidities, number of parties, history of abortion, and history of stillbirth; and health service-related factors including history of ANC service, frequency of ANC services, gestational age at admissions, mode of delivery, types of admissions, types of referring facility, mode of transportation, distance from health facilities, duration of hospitalization, and payment for health care services.

Operational definition and definition of terms

Quality of Emergency Obstetric and Newborn care: The provision of quality services to the obstetric mother and their newborns as per the standards of CEmONC services to improve the desired health outcomes.⁵

Comprehensive Emergency Obstetric and Newborn Care (CEmONC) services: are provision of seven expected services (parenteral antibiotics, parenteral uterotonics, parenteral anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal delivery, and neonatal resuscitation) to be provided by BEmONC facilities and the additional two services, namely, caesarian section and blood transfusion services.³⁷

The input dimension of Quality CEmONC service: was measured using an index created by calculating the mean of all questions assessing the facility infrastructures, drugs and medical equipments, signal functions of CEmONC services, staffs availability and quality improvement programs in health facilities by using 50 items and computed out of 100%.^14,26,38

The process dimension of Quality CEmONC service: was measured using an index created by calculating the mean of all 20 assessing the compliance of healthcare providers to clinical standards during the obstetric emergencies treatment and computed out of 100%.^26,39

The output dimension of Quality CEmONC service (Mother satisfaction): was assessed by using the woman’s satisfaction with CEmONC services she utilized, each containing a five-point likert scale (1=very dissatisfied, 2 = dissatisfied, 3 = neutral, 4 = satisfied and 5 = very satisfied), and the magnitude of care “very satisfied” and “satisfied” were categorized as Satisfied, while “very dissatisfied”, “dissatisfied” and “neutral” were categorized as Dissatisfied and a total of 25 items using a 5-scale likert scale tool (ranging from “very dissatisfied” to “very satisfied”) were used to assess the woman satisfaction with the CEmONC services in the health care facilities and computed out of 100%.⁴⁰

Selected obstetric emergencies: In this study, the mothers were included if they had at least one of the following obstetric emergencies; such as antepartum hemorrhages, pre-eclampsia and eclampsia, prolonged/obstructed labor and postpartum hemorrhages.^14,41–43

Data quality controls

To ensure the data quality, the prepared questionnaires were translated to Afaan Oromo and pre-tested on 5% of the total sample size at Inchini hospital to ensure the validity and reliability of the prepared tool. Then, necessary modifications were made based on the pre-test results. The developed items were based on the Donabedian model of three quality assessment components; including the structure, process, and outcomes on quality of CEmONC services. Additionally, all data collectors and study supervisors were trained for two days on the data collection tools and data collection process to ensure consistent understanding of data collection tools, study protocols, and standardized observation and data abstraction form. Additionally, all observers were involved in pilot observations to help the observers become familiar with the procedures and ensure to interpret the observation criteria similarly. During the data collection activity, observer bias was addressed by using standardized observation check list, adhering to predefined criteria, and limiting to needed information to maintain data consistency. Furthermore, inter-rater reliability across data collectors was ensured through providing standardized training, the use of uniform and pre-tested data collection tools, provision of a detailed data collection guideline, and close supervision during fieldwork. Finally, the overall data collection activities were monitored and controlled by the supervisors and principal investigators.

Data processing and analysis

The collected data was first checked for completeness, then coded and entered into SPSS version 27 for data analysis as the file attached below (S2 file). After categorizing and defining variables, descriptive statistics were carried out and summarized using frequency, percentage, and tables for categorical variables. Then, assumptions of linear regression such as normality (Shapiro–Wilk p > 0.05), multicollinearity (VIF-2), and homoscedasticity (Breusch–Pagan p > 0.05) were checked and fulfilled as reported. Finally, simple and multiple linear regressions were conducted to identify the candidate and predictor variables for mother satisfaction toward the quality of CEmONC services while controlling for potential confounders. Furthermore, variables that showed a p-value ≤ 0.25 in the bivariable analysis were included in the multivariable regression model to control for potential confounding and to ensure that potentially important predictors were not excluded prematurely, as some variables may show weak or non-significant in bivariate analyses become significant after adjusting for other factors in the final multivariable model. Additionally, it helps to minimize residual confounding, and ensure a more comprehensive and well-specified regression model, as recommended in standard regression. Finally, those variables with a p-value < 0.05 in the final model were reported as predictors for mothers’ satisfaction toward the quality of CEmONC services.

Ethical clearance and approval considerations

The ethical clearance and approval were obtained from the ethical review board of Wallega University, with IRB reference No.WU/RD/718 in a serial number of 718/2023. Then, an official letter written from Wallega University was submitted to the concerned bodies of selected public hospitals to attain their approval. Next, a written informed consent was obtained from all study participants or from the legally authorized representative of minor subjects after providing adequate information on the benefits of the study, the study objectives, and data confidentiality. Participants who were unable to sign the consent form due to illiteracy were asked to mark the consent form with a thumbprint. Furthermore, the study participants were also informed that they had full right to participate or not to participate in the study. Finally, all types of data collection were conducted in a private room to collect the necessary research data, securing confidentiality.

Result

The socio-demographic characteristics of study participants

From a total of 375 sampled study participants, about 348 study participants were involved, yielding a response rate of 92.8%. Related to the age category, about 135 (38.8%) of the study participants were 25-29 years in the age category, with the mean age of 28.3 ± 4.9 years. About 221 (63.5%) and 313 (89.9%) of the study participants were from rural residences and Oromo by ethnicity, respectively. More than nine out of ten participants (97.4%) were married and more than half (58.9%) of the study participants were protestant religion followers, respectively. Related to their educational status and occupation, one third (30.2%) of the participants had no formal education, whereas about 199 (57.2%) of the participants were farmers by occupation. Regarding their family monthly income, about 151 (43.4%) of the study participants were earning a family monthly income of ≤4,000 EBR per month as described below (Table 2).

Table 2.

Socio-demographic characteristics of study participants in selected public hospitals of west shoa zone, central Ethiopia.

Variable	Frequency	Percentage
Age (Years)
15-24	76	21.8
25-29	135	38.8
30-34	77	22.1
≥35	60	17.2
Residence
Rural	221	63.5
Urban	127	36.5
Ethinicity
Oromo	313	89.9
Amhara	35	10.1
Marital status
Married	339	97.4
Single	9	2.6
Religion
Orthodox	120	34.5
Protestant	205	58.9
Musilim	18	5.2
Catholic	5	1.4
Educational status
No formal education	105	30.2
Primary education	88	25.3
Secondary education	75	21.6
College and/or Above	80	23.0
Occupational status
Government workers	37	10.6
Farmers	199	57.2
Marchents	55	15.8
House wives	53	15.2
Private work	4	1.1
Family monthly income (EBR)
Upto 4,000 EBR	151	43.4
4,001 – 7,000 EBR	130	37.4
Greater than 7,000 EBR	67	19.3

The obstetric and health service related factors of the study participants

Regarding obstetric history, more than half of the participants were multigravida (56.6%) and multiparous (59.5%). A notable proportion reported prior adverse outcomes, with 17.2% having a history of abortion and 17.5% a history of stillbirth. Antenatal care utilization was high, as 91.7% had attended ANC follow-up, and among these, 61.4% completed four or more visits. In terms of current obstetric conditions, one-third (33.3%) were admitted due to pre-eclampsia/eclampsia, and over half (56.6%) were referred from other health facilities. Most participants (85.1%) were admitted at term (37–42 weeks of gestation), and cesarean section was the mode of delivery for slightly more than half (52%) of the mothers.

Regarding access to healthcare, 121 (34.8%) of the study participants traveled more than 50 km to reach a health facility, and over half (56%) relied on public transportation. In terms of service delays, 46 (13.2%) participants waited 60 minutes or longer to receive EmONC services, while 127 (36.5%) remained hospitalized for more than seven days. Concerning fetal outcomes, a notable proportion of participants experienced adverse events, including NICU admissions (13.8%), stillbirths (7.8%), and neonatal deaths (1.1%) as indicated in the table below (Table 3).

Table 3.

Obstetric and health service related characterstics of study participants in selected public hospitals of west shoa zone, central Ethiopia.

Study variables	Frequency	Percentage
Number of Gravida
Primigravida	57	16.6
Multigravida	197	56.6
Grand multigravida	94	27
Number of Parity
Primiparous	67	19.3
Multiparous	207	59.5
Grand multiparous	74	21.3
History of abortion
Yes	60	17.2
No	288	82.8
History of still birth
Yes	61	17.5
No	287	82.5
History of current ANC service
Yes	319	91.7
No	29	8.3
Number of ANC follow up
Less than four times	123	38.6
Great or equal to four times	196	61.4
Types of pregnancy
Single pregnancy	334	96.0
Multiple pregnancy	14	4.0
Types of obstetric emergencies
Pre-eclampsia/Eclampsia	116	33.3
Antepartum hemorrhage	94	27
Obstructed labour	87	25
Postpartum hemorrhage	51	14.7
Ways of mother admissions
Referral from other health facility	197	56.6
Mother direct admission	151	43.4
Types of referring health facility
Public health centers	120	60.9
Public hospitals	61	31.0
Private clinic	16	8.1
Gestational age at admission
<37 weeks	52	14.9
37-42 weeks	296	85.1
Mode of delivery conducted
Normal vaginal delivery	167	48.0
Cesarian section delivery	181	52.0
Provider conducting the delivery
Obstetrician and Gynecilogist	170	48.8
Integrated emergency surgical officers	40	11.5
Midwives	138	39.7
Distance from this facility
Within 50 KM	227	65.2
More than 50KM	121	34.8
Way of transportation
Ambulance	146	42.0
Public transport	202	58.0
Waiting time for getting services
< 60 minutes	302	86.8
≥ 60 minutes	46	13.2
Duration of hospital stay
1-7 days	221	63.5
> 7 days	127	36.5
Payment for getting obstetric care services
Yes	102	29.3
No	246	70.7
Pregnancy (fetal) outcomes
A live and normal baby	269	77.3
NICU admissions (due to complications)	48	13.8
Still births	27	7.8
Neonatal deaths	4	1.1

The input dimension quality of CEmONC services in selected public hospitals of west shoa zone, Central Ethiopia

The finding indicates the mean input value for quality of CEmONC services was 81.2% (95% CI: 73.0, 90.5%). This result met the minimum national/WHO benchmark of ≥75% for health facility assessments, although nearly 19% of the required facility inputs were missing or did not meet the expected quality standards, which should be fully available at health care facilities. Related to the health facility infrastructures, all hospitals had continuous electricity supply with backup generators. But some facility infrastructures, such as functional water supply in the ward, availability of functional latrines in the ward, and functional a liaison office for client referrals, were only available in half (50%) of the studied health facilities. Most of the hospitals were providing all signal functions of CEmONC services. But only one fourth of the hospitals (25%) had adequate operating tables for C/S services. Regarding human resources and quality improvement activities, about half (50%) of the health facilities did not have enough obstetric care providers according to the standard, and they lacked quality improvement activities, as summarized in the following figure below (Figure 1).

Figure 1.

The average mean input dimension for quality of CEmONC services in selected public hospitals of west shoa zone, Central Ethiopia.

The process dimension quality of CEmONC services in selected public hospitals of west shoa zone, Central Ethiopia

The study findings indicate that the mean process value for the quality of CEmONC services was 78.2% (95% CI: 71.0–83.9%), indicating moderate adherence to clinical protocols but remaining below the optimal national/WHO benchmark of full compliance with standard guidelines. From a total of 348 study participants, 316 (90.8%) had their client history fully taken, while a full physical examination and vital sign checkups were performed for only 214 (61.5%) and 220 (63.2%) participants, respectively. All laboratory investigations (urine analysis, hemoglobin checkup, blood group, and coagulation tests) were performed for the majority (95.7%) of the study participants, but only 258 (74.1%) of the study participants were tested for HIV/AIDS. Related to the client’s clinical monitoring, only half (50.6%) of the study participants were fully monitored as per protocol. Furthermore, the majority (87.9%) of pre-eclampsia mothers had taken MgSo4, and the majority (86.3%) of PPH mothers had taken oxytocin medication as protocol in the figure below (Figure 2).

Figure 2.

The process dimension quality of CEmONC services in selected public hospitals of west shoa zone, central Ethiopia (n=348).

The output dimension quality of CEmONC services in selected public hospitals of west shoa zone, Central Ethiopia

The study finding indicates the mean output value for quality of CEmONC services was 75.9% (95% CI: 75.3, 76.5%). The result suggests that maternal satisfaction with the quality of CEmONC services was only slightly above the minimum threshold of national/WHO benchmark that indicating service delivery could be further improved to enhance the client satisfaction. Among the studied variables, consent taking before doing procedures (95.1%), client involvement in decision-making (93.7%), cost of getting services (92.8%), taking physical examination (91.7%), and number of obstetric care providers in the maternity ward (90.2%) were the major contributing factors reported for mother satisfaction toward quality of CEmONC services. Whereas; lack of functional toilet in the maternity ward (27.3%), shortage of obstetric drugs and medical supplies (24.4%), lack of functional running water in the ward (23.9%), poor sanitation in the ward (22.4%), and inadequate availability of laboratory investigations (19%) were the major contributing factors for mother dissatisfaction toward quality of CEmONC services as shown in table below (Table 4).

Table 4.

The output dimension reported quality of CEmONC services in selected public hospitals of west shoa zone, central Ethiopia (n=348).

Study variables	Satisfied	Dissatisfied
1. Satisfiction toward consent taking before procedures	331 (95.1%)	17 (4.9%)
2. Satisfiction toward involvement in clinical decision-making	326 (93.7%)	22 (6.3%)
3. Satisfiction toward cost of getting obstetric care services	323 (92.8%)	25 (7.2%)
4. Satisfiction toward the physical examination conducted	319 (91.7%)	29 (8.3%)
5. Satisfiction toward number of obstetric care providers	314 (90.2%)	34 (9.8%)
6. Satisfiction toward the functionality and cleaness of toilet in maternity ward	253 (72.7%)	95 (27.3%)
7. Satisfiction toward the availability of adequate drugs and medical supplies in maternity ward	263 (75.6%)	85 (24.4%)
8. Mothers satisfiction toward the functionality of running water in maternity ward	265 (76.1%)	83 (23.9%)
9. Mothers satisfiction toward the sanitation condition in the maternity ward	270 (77.6%)	78 (22.4%)
10. Mothers satisfiction toward the availability of adequate laboratory investigations for the obstetric care	282 (81%)	66 (19 %)

Factors associated with mother satisfaction toward quality of CEmONC services in selected public hospitals of west shoa zone, Central Ethiopia

A simple and multiple linear regression analysis were conducted to identify the predictors of mother satisfaction toward the quality of CEmONC services. Non-significant variables were retained in the multivariable analysis to control for potential confounding, as variables meeting the predefined bivariable inclusion threshold (p ≤ 0.25) were included in the model. Then, the result of the analysis reported that the time of waiting for receiving care and the duration of hospital stays were statistically significant predictors for mother satisfaction toward the quality of CEmONC services in the final multivariate analysis. Accordingly, each additional one-minute delay in receiving emergency obstetric care is associated with a 2.7% decrease in maternal satisfaction with the quality of CEmONC services (B = −2.68, 95% CI: −4.66, −0.70), and each additional day of maternal hospital stay was associated with a 0.2% decrease in maternal satisfaction with the quality of CEmONC services (B = −0.17, 95% CI: −0.34, −0.01). Therefore, both waiting time and duration of hospital stay had a negative correlation with mother satisfaction toward quality of CEmONC services as described in the table below (Table 5).

Table 5.

Multiple linear regression on predictors of maternal satisfaction about quality of EmONC services in selected public hospitals of west shoa zone, central Ethiopia (n = 348).

Variables	Unadjusted coefficient		Adjusted coefficient
	B	P-value	B	P-value	95% C. I for B
	B	P-value	B	P-value	Lower	Upper
Age	0.10	0.202	0.15	0.149	-0.06	0.36
Number of Parity	0.22	0.236	-0.47	0.152	-1.12	0.17
Number of ANC follow up	-1.44	0.038	-0.74	0.302	-2.16	0.67
Ways of mother admission	-2.48	0.001	-0.53	0.609	-2.58	1.51
Estimated distance in KM	1.70	0.001	1.21	0.059	-0.05	2.48
Type of transportation	-1.69	0.020	-0.07	0.936	-1.84	1.70
Time of waiting for care	-3.28	0.001	-2.68	0.008	-4.66	-0.70
Ways of mother delivery	-1.07	0.166	-1.08	0.183	-2.67	0.51
Duration of hospital stay	-0.17	0.034	-0.17	0.038	-0.34	-0.01

Discussion

Overall, the findings suggest a gradual decline in quality from input to output performance, indicating that while resources are relatively adequate, gaps in implementation and service delivery may be affecting outcomes. This disconnect implies that the available inputs are not fully translated into optimal service delivery and desired maternal and neonatal health outcomes. The mean quality scores for input, process, and output components of CEmONC services were 81.2%, 78.2%, and 75.9%, respectively. According to the Ethiopian national guideline, CEmONC services require high-quality inputs, strict adherence to clinical protocols, and positive client outcomes across key quality standards to achieve the Sustainable Development Goals for maternal and newborn health.

The study finding was lower than that of a study conducted at Gondar University’s Comprehensive Specialized Hospital, where the availability, care providers’ compliance, and acceptability of services were reported as 88.9%, 74.8%, and 81%, respectively.⁴⁴ The possible difference might be due to variations in of study participants socio-demographic factors, study settings, study populations, availability of hospital resources, and availability of skilled health care providers. This is attributed to the fact that tertiary-level health facilities were in a better position to have adequate facility infrastructures, obstetric drugs and medical supplies, and skilled health care providers to provide quality CEmONC services when compared to the primary-level health facilities found in semi-rural areas.

But this finding was higher than a study conducted in the Wolaita Zone of Southern Ethiopia that revealed the mean values for input, process, and output components of quality EmONC services were 74.2%, 69.4%, and 79.6%, respectively.²⁶ The possible difference might be due to variations in socio-demographic characteristics of study participants, study settings, study populations. Additionally, factors such as local healthcare infrastructure and resource availability and healthcare providers’ training could further influence the observed outcomes in different regions. This discrepancy highlights the potential variations in healthcare quality across different regions and underscores the need for targeted interventions to enhance quality of emergency obstetric and newborn care services in areas where they are inadequate.

The findings of this study highlight there was a gap in health facility infrastructure, including inadequate access to functional water supply, latrines, obstetric beds, and operating tables, which reflect broader systemic challenges within the health system. Such deficiencies not only compromise the readiness of facilities to deliver CEmONC services but also undermine the quality of care provided to mothers and newborns. This finding is supported by studies conducted at Shenan Gibe of Jimma Town⁴⁵ and Gondar University Specialized Hospital⁴⁴ reported shortages of water supply, linen sets, delivery couches, operation tables, maternity beds, and blood units were observed. The unavailability of these basic infrastructures and other medical supplies were factors hindering the deliver of quality of CEmONC services.

The study finding also reported that the process quality of care (adherence to the national guideline) for CEmONC service was 78.2%. The finding reported only half of the study participants has fully measured their vital signs during their admissions. This finding is clinically significant, as it suggests that a substantial proportion of patients did not receive complete monitoring according to protocol, potentially leading to delayed identification of complications and increased risk of adverse maternal and neonatal outcomes. Moreover, substantial study participants who underwent cesarean section did not have a surgical safety checklist completed, and one-fourth of the study cohort did not receive antibiotic prophylaxis in accordance with the guideline protocol. Significant mothers with pre-eclampsia and PPH didn’t receive MgSO₄ prophlaxis and oxytocin loading doses according to the protocol. But this finding contrasts with the requirements of the WHO standard, which recommends that the management of all obstetric complications should adhere to the protocol.⁴⁶

This study was supported by a study conducted on the implementation fidelity of comprehensive emergency obstetric and newborn care at the comprehensive specialized hospital of Gondar University, Northwest Ethiopia, which reported the overall score of the fidelity adherence dimension was 77.2%. The proportion of clients with parenteral antibiotics administered based on the recommended protocols was 60%. Moreover, parenteral anticonvulsants and uterotonic drugs were administered properly for 85% and 89% of the included clients. Moreover, according to the guideline, healthcare providers performed manual removal of the placenta, removal of retained products, and cesarean delivery for 86%, 69%, and 75% of the clients, respectively.⁴⁷

The finding of this study indicates notable gaps were observed in adherence to recommended care. Although clinical guidelines outline essential procedures that should be performed during obstetric care, the results suggest that these standards are not consistently applied in routine practice. This inconsistency reflects a common challenge in many health systems, where the presence of protocols does not automatically translate into their full implementation during patient care. A study emphasize the effectiveness of service depends not only on access but also on whether providers follow evidence-based practices throughout the care process.⁵

This study also reported that the mean value of mother satisfaction toward the quality of CEmONC services was 75.9% (95% CI: 75.3, 76.5). This finding implies that mothers’ satisfaction levels are acceptable but not yet optimal and need further coordinated efforts from the government to improve client satisfaction toward the quality of CEmONC services. This finding was lower than the study conducted in the Jimma Zone of Oromia region, which indicated the overall mean satisfaction with EmONC services was 79.4%, with a 95% CI (75%, 83%).⁴⁸ But higher than the study conducted in the Gedeo Zone of Southern Ethiopia, which indicated the overall mothers’ satisfaction with BEmONC services was 44.8%, with a 95% CI (39.7%, 49.4%),³¹ higher than the study conducted at comprehensive Specialized Hospital of Gondar University, Northwest Ethiopia, which reported the overall clients’ satisfaction with CEmONC services was 65.1% with (95% CI: 60.9, 69.8).³⁰ The variations might be due to difference in socio-demographic characteristics of study participants, such as educational level, expectations, and previous experiences with healthcare services; the availability of essential facility infrastructure and resources; training of healthcare providers on respectfulness care toward ensuring clients’ satisfaction; and the timing of study conducted.

The findings of the study indicate a declining trend in the mean quality scores across the three components of CEmONC services. The input component had the highest mean quality score (81.2%), followed by the process component (78.2%), whereas the output component had the lowest score (75.9%). The higher score (81.2%) in the input component of quality CEmONC services suggests that the facility infrastructures, medical equipment, emergency obstetric drugs and supplies, and human staff are relatively more available than the process and output components of quality CEmONC services. This indicates there may be more gaps in adherence to the clinical guidelines, provider competency, or consistency of providing quality care.

This study also reported that a significant proportion of the study participants were encountered adverse fetal outcomes, including NICU admissions (13.8%), stillbirths (7.8%) and neonatal deaths (1.1%), underscoring potential deficiencies in the quality of care, especially in clinical monitoring, timely intervention, and adherence to established protocols. This study finding was lower than study conducted on maternal and perinatal outcomes in obstetrical emergencies at Lal-Ded hospital of Srinagar that revealed that the maternal and perinatal outcomes of obstetric emergencies were perinatal mortality in 29% and the maternal mortality in 10.5% of the study participants.⁴⁹ Another study conducted at Tertiary care center in Ahmedabad among 100 cases of obstetric emergencies were also reported the feto-maternal outcomes were perinatal mortality (28%) and maternal mortality (11%) of the cases.⁵⁰ This difference could be due to the differences in socio-demographic status, study settings, improvement in access to health services and improvement of quality services now adays due to the government quality intiatives and commitments for improving maternal and child health care.

The multiple linear regression analysis showed waiting time for receiving care and duration of hospital stays were statistically significant predictors for mother satisfaction toward the quality of EmONC services. The finding indicates waiting to receive care for each additional minute lowers the mother’s satisfaction toward quality CEmONC services by 2.7 times. This study is supported by studies conducted at Gondar University Hospital, Northwest Ethiopia,³⁰ and Arba Minch town, Southern Ethiopia,³² that indicate mother waiting time for service was a predictor of mother satisfaction with obstetric care services. This could be because of a long waiting time for receiving obstetric care, and leading to developing adverse feto-maternal outcomes that make the mother less satisfied with the quality of CEmONC services.

The study also revealed that the duration of hospital stay was a statistically significant predictor of mothers’ satisfaction with the quality of CEmONC services. The finding indicates that each additional day of hospital stay reduces mothers’ satisfaction with the quality of CEmONC services by 0.2 units. A possible explanation is that prolonged hospitalization may increase physical discomfort, emotional stress, and financial burden on mothers and their families. Furthermore, longer hospital stays may disrupt family responsibilities and social support systems, contributing to dissatisfaction with the care received. This finding was supported by a study conducted on satisfaction with CEmONC services and associated factors at Gondar University Hospital, reporting the clients’ satisfaction was affected by the mother hospital stay, obtaining a welcoming environment, and getting the provider’s explanation of the examinations conducted.³⁰ This study finding is also supported by a study conducted in the Wolaita Zone of southern Ethiopia, which revealed that the duration of facility stay and health care providers’ experience were independent predictors of quality service.²⁶ This could be prolonged hospitalization, frequently the result of maternal or neonatal complications, such as surgical site infections or a baby requiring NICU services. Therefore, addressing these complications and enhancing the quality of care can significantly improve patient outcomes and satisfaction levels.

In conclusion, this study provided objective framework for assessing quality of EmONC services in public hospitals of West Shoa Zone against established benchmarks. While structural capacity is relatively better, improvements are needed in the implementation of standard clinical practices and quality assurance mechanisms to ensure the available inputs effectively translate into improved maternal and neonatal health outcomes. Therefore, actionable measures to increase mothers’ satisfaction toward the quality of CEmONC services, and reducing time to receiving care and optimizing the duration of hospital stay are vital.

Strength and limitation of the study

As a strength, this study used the Donabedian framework to examine the three quality dimensions of CEmONC services in public hospitals of the West Shoa Zone, Central Ethiopia. This study also used multiple data collections (health facility audit, observation of care, medical record review, and mother exit interview) that enriched the study to yield concrete findings on the comprehensive quality of CEmONC services. As a limitation, the first was that this study used a cross-sectional design, which limited the ability to determine causal relationships between the study variables. Secondly, the current study is not free from social desirability bias, in which some mothers may report the service they have taken as a positive experience while they are in the health care facilities due to fear of reporting abusive care. Thirdly, since the study used purposive sampling to select the hospitals included, this could affect the representativeness and generalizability of the findings to other facilities in the region or in different settings.

Conclusion and recommendations

The study reported that the overall quality (input, process, and output) components of CEmONC services were acceptable level but need further improvement to ensure the overall quality of CEmONC services. The waiting time and duration of hospital stays significantly influenced the mother’s satisfaction toward quality of CEmONC services. This highlights the importance of timely care and minimizes unnecessary prolonged hospital stays for enhancing mother satisfaction toward the quality of CEmONC services. Therefore, the health systems and other stakeholders should emphasize fulfilling all essential facility infrastructure requirements, ensuring the regular availability of obstetric drugs and medical supplies, and promoting healthcare providers’ adherence to standards of care. The health care providers’ adherence to the standard guideline should be improved through health care providers training, supervision, and monitoring activities.

Supplemental Material

Supplemental Material - Quality of comprehensive emergency obstetric and newborn care services and associated factors among mothers with obstetric emergencies in public hospitals of west shoa zone, central Ethiopia: A cross-sectional study design

Supplemental Material for Quality of comprehensive emergency obstetric and newborn care services and associated factors among mothers with obstetric emergencies in public hospitals of west shoa zone, central Ethiopia: A cross-sectional study design by Tolera Gudissa Damme, Sileshi Garoma Abeya and Dereje Bayissa Demissie in Sage Open Medicine.

Footnotes

Acknowledgments

The authors are grateful to Wallega University for financial support of this research work. We would also like to thank the selected public hospitals and their managements for their co-operation, facilitation and support to the activity of this research work. Finally, we would like to thank all data collectors, study supervisors, and the study participants.

ORCID iDs

Tolera Gudissa Damme

Dereje Bayissa Demissie

Author contribution

Conceptualization: Tolera Gudissa Damme. Data curation: Tolera Gudissa Damme. Formal analysis: Tolera Gudissa Damme. Investigation: Tolera Gudissa Damme. Methodology: Tolera Gudissa Damme. Project administration: Tolera Gudissa Damm. Resources: Tolera Gudissa Damme. Software: Tolera Gudissa Damme. Supervision: Silashi Garoma Abaya, Dereje Bayissa Demissie. Validation: Tolera Gudissa Damme, Silashi Garoma Abaya, Dereje Bayissa Demissie. Visualization: Tolera Gudissa Damme, Silashi Garoma Abaya, Dereje Bayissa Demissie. Writing: Original draft: Tolera Gudissa Damme. Review & Editing: Tolera Gudissa Damme, Silashi Garoma Abaya, Dereje Bayissa Demissie

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received financial support from Wollega University to conduct the study and no other fund for this study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data will be available upon reasonable request from corresponding author (tolerag@gmail.com).

Supplemental Material

Supplemental material for this article is available online.

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