Factors Affecting Provisions of Emergency Obstetric and Newborn Care

TABLE OF CONTENTS

Acknowledgement

DEDICATION

Abstract

TABLE OF CONTENTS

LIST OF TABLES

LIST OF FIGURES

LIST OF ACRONYMS AND ABBREVIATIONS

Chapter One
INTRODUCTION
1.1. Background of the Study
1.2. Problem Statement
1.3. Significance of the Study

Chapter Two
LITERATURE REVIEW
2.1. General population characteristics
2.2. Providers Knowledge, skills and confidence
2.3. Facility Readiness for EmONC service provision
2.4. Factors affecting provisions of quality EmONC services
2.5. Other factors
2.6. Conceptual framework

Chapter Three
Objectives
3.1. General Objective
3.2. Specific Objectives

CHAPTER FOUR
METHODS AND MATERIALS
4.1. Study Area
4.2. Study Design and Study Period
4.3. Source Population and Study Population
4.4. Eligibility Criteria
4.4.1. Inclusion Criteria
4.4.2. Exclusion criteria
4.5. Sample Size Determination and Sampling Methods
4.5.1. Sample size
4.5.2 Sampling methods
4.6. Study Variables
4.6.1. Independent Variables
4.6.2. Dependent Variables
4.7. Data Collection tools and approaches
4.8. Data Collection process and Quality Control
4.9. Data management and analysis
4.10. Operational Definitions
4.11. Ethical Considerations
4.12. Dissemination of Results

CHAPTER FIVE
RESULTS
5.1. QUANTITATIVE RESULTS
5.2. QUALITATIVE STUDY RESULTS

CHAPTER SIX
DISCISSION
STRENGTH AND LIMITATION OF THE STUDY

Chapter SEVEN
Conclusion AND RECOMMENDATIONS
7.1. CONCLUSION
IMPLICATION OF THE STUDY
7.2. RECOMMENDATIONS

APPENDIX-I: REFERENCES

APPENDIX-II: INFORMED CONSENT SHEET AND QUESTIONNAIRE
1. INFORMATION SHEET AND INFORMED CONSENT
2. QUESTIONNAIRE

Appendix-III: Interview guide Checklists

APPENDIX IV: FGD GUIDE CHECKLIST

APPENDIX V: HEALTH FACILITY SURVEY CHECKLIST

Acknowledgement

First and foremost, my thank goes to my almighty God for giving me capacity and health during the whole period of my research work.

I am deeply indebted to express my sincere gratitude to my supervisors Prof. Oladapo Olayemi and Dr. Onoja M. Akpa for their committed supervision, advice and comments. I appreciate them for their constructive criticism, guidance and encouragement starting from the time of topic selection until completion of my dissertation paper.

I would like to acknowledge African Union Commission (AUC) and PAN African University, Life and Earth Science Institute (PAULESI), University of Ibadan, Ibadan, Nigeria for their financial support and provision of an entail opportunity to conduct this study in line with this scholarship scheme.

Further, I would like to extend my acknowledgement to Ethiopian Federal Ministry of Health (EFMOH) for giving me a letter of support to Dire Dawa Regional Health Bureau (DDRHB) and DDRHB for giving me a letter of cooperation to respective health facilities and for their exhaustive support in giving me a transportation services to reach at all the networked health facilities mainly those located in the rural, and technical assistance in the whole period of my data collection.

In addition, all health facilities on which study was conducted, respective Hospital Managers, Medical Directors and all staffs of Maternal, Neonatal and Child Health, mainly providers, who helped me to accomplish my study.

Lastly but the most; I would like to acknowledge my parents and friends for their enthusiastic encouragement and contributions to my work.

DEDICATION

My dedication is belongs to all Maternal, Neonatal and Child Health (MNCH) Care Providers, mainly to EmONC service providers.

Abstract

BACKGROUND - Emergency Obstetric and Newborn Care (EmONC) is a life saving approaches of care for mother and newborn experiencing complications during pregnancy, childbirth and postpartum period. Like other developing countries, Ethiopia has high maternal and neonatal mortality (353/100,000 live births and 28/1000 live births respectively by 2015) where majority of them are due to lack of timely, effective and accessible EmONC services. Even though Addis Ababa, Harar and Dire Dawa have met the WHO minimum requirements of EmONC service in terms of availability and accessibility unlike other regions, the report shows that the quality of care provided was highly compromised.

OBJECTIVE : Assessment of factors affecting provisions of Quality Emergency Obstetric and Newborn Care services in Public health facilities in Dire Dawa, Ethiopia

METHODS AND MATERIALS - A mixed method design (MMD) was employed in purposively selected health facilities in Dire Dawa city to assess factors affecting provisions of Quality Emergency Obstetric and Newborn Care. Quantitative study includes self-administered standardized questionnaire and health facility survey checklist, an observational checklist. Information letters, consent forms and questionnaires was handled to potential participants by research assistants. Data was coded, cleaned and entered using Epi Info 7 (7.0.9.34) and Analyzed using SPSS version 20 for descriptive and inferential statistics. Qualitative study which includes Key Informant In-depth Interviews and FGDs was cleaned, coded and analyzed using thematic analytic approach, and some important findings was reported with the associated quotations from the extracted discussions.

RESULTS : Of the nine surveyed EmONC facilities in Dire Dawa, 73.9% of health centers and 91.7% of hospitals shows readiness for provision of EmONC services. Of the seven BEmONC facilities designed to provide all signal functions of BEmONC, only six (85.7%) were providing all the eight signal functions of BEmONC; and 95.0% of CEmONC facilities were found to deliver all the ten basic signal functions of CEmONC. Majority (67.35%) of providers were untrained, where large numbers (38.5%) were reported from Health centers. Forty-five (86.04%) were reported of having sufficient knowledge of EmONC; while only 31 (59.4%) reported of having adequate skills and 46 (88.45) reported of having adequate confidence in performing major EmONC procedures.

CONCLUSION : The gaps in trained and specialized MNCPs, basic infrastructural installments/amenities, drugs and supplies backed by low educational level of clients contributing to lack of improvements in quality of EmONC services in the region. Thus, the findings bear considerable implications for policy and local priorities.

Keywords: Factor(s), Quality, Provision(s), Emergency obstetric and newborn care, Knowledge, Ethiopia

LIST OF TABLES

Table 1: Number of Maternal and Newborn Health Care providers in the networked EmONC providing facilities, Dire Dawa, Ethiopia,

Table 2: Socio-demographic characteristics of MNHC providers in surveyed health care facilities in Dire Dawa, Ethiopia,

Table 3: Maternal and newborn health care providers’ current level of knowledge in performing a major EmONC procedure in surveyed health care facilities in Dire Dawa, Ethiopia,

Table 4: Proportions of MNHC provider’ took in-service training on specific components of EmONC in surveyed health care facilities in Dire Dawa, Ethiopia,

Table 5: Shows percentages of MNCH providers’ performing major EmONC procedures in surveyed health care facilities in Dire Dawa, Ethiopia,

Table 6: Criteria for categories comprising providers’ level of confidence in surveyed health care facilities in Dire Dawa, Ethiopia,

Table 7: Criteria for categories comprising emergency obstetric and newborn care readiness scores by facilities in Dire Dawa, Ethiopia,

Table 8: Shows availability of EmONC and FP services in surveyed health care facilities in Dire Dawa, Ethiopia,

Table 9: Shows predictors of EmONC quality in purposively selected facilities in Dire Dawa, Ethiopia, 2016 (Chi-square/Fisher test, binary and multinomial logistic regression results)

Table 10: Theme, Categories and Codes identified and used for qualitative data analysis

LIST OF FIGURES

Figure 1: Conceptual framework

Figure 2: Schematic representation of sampling methods

Figure 3: A pie chart showing the current knowledge level of MNHC providers in purposively selected health care facilities in Dire Dawa, Ethiopia,

Figure 4: Percentages of MNHC providers received EmONC training in the past one year in purposively selected health care facilities in Dire Dawa, Ethiopia,

Figure 5: Confidence level of MNHC providers in surveyed health care facilities in Dire Dawa, Ethiopia,

Figure 6: Facility readiness for emergency obstetric and newborn care provision among surveyed health care facilities in Dire Dawa, Ethiopia,

Figure 7: Number of mothers took ANC, and number of mothers attended delivery within the last one month preceding the survey in surveyed health care facilities in Dire Dawa, Ethiopia,

Figure 8: Provider’s perceived level of EmONC quality in their respective facilities in Dire Dawa, Ethiopia,

LIST OF ACRONYMS AND ABBREVIATIONS

Abbildung in dieser Leseprobe nicht enthalten

Chapter One

INTRODUCTION

1.1. Background of the Study

Mahavir Medical Centre a ‘Better-care together group’ define Emergency Obstetric and Newborn Care (EmONC) as “a package of medical interventions to treat life threatening complications during pregnancy and childbirth” (UNFPA, 2014). It is an “effective approach to reduce maternal and neonatal morbidity and mortality in resource limited settings” (Accorsi s, 2010). These services can save the lives of the estimated 280,000 women and 3 million newborns lost in the process of pregnancy, childbirth, and the postpartum period every year. Millions of disabling conditions can also be prevented through timely and effective EmONC (WHO, 2012b, WHO, 2015). Most life threatening complications are not predictable but prevention of death and disability is possible with the availability of effective and timely emergency obstetric and newborn care services (WHO, 2013). EmONC services recognises the paradigm shift from the care of mother and newborn independently to a package of services provided to the maternal-infant dyad (UNFPA, 2014, WHO, 2013).

Essential components of EmONC have been widely accessible in developed countries for decades. However, in low-income countries where 99% of maternal and neonatal deaths occur, health systems may not have the capacity to provide such emergency services (Accorsi s, 2010, WHO, 2009b). With Quality EmONC services in place, 60% of maternal death, 45-75% of intra partum stillbirths and 40% of intra partum related neonatal death can be averted. Basic Emergency Obstetric and Newborn Care only can reduce 40% of intra-partum neonatal deaths and a significant proportion of maternal mortality (WHO, 2009b). The minimum recommended ratio for facilities providing Basic EmONC to Comprehensive EmONC is 4:1 serving about 500,000 people (WHO, 2009b, Pattinson R, 2011). Therefore, EmONC is seen as human right in health system preparedness and very important in the maternal health community for the post-2015 global agenda (UNFPA, 2014).

In order to reduce maternal and neonatal morbidity and mortality; international donors and agencies have played a great role by increasing funding from time to time for support (Pattinson R, 2011, WHO, 2010, Grady K, 2011). Adequate purchase and supply of emergency drugs, supplies and equipment in maternal and neonatal care system infrastructures and strengthening supply chain are the major goals of health care strengthening program (Admasu K, 2008, Alemnesh H Mirkuzie, 2014, FDREMOH, Oct 2010).

Ethiopia follows a three tier health care delivery system. Level one is primary health care unit (Comprises health posts, health centers and primary/local/district/ hospitals). Primary hospitals serve 60,000-100,000 people, health centre serve 15,000-25,000 people and their satellite health posts (for 3000-5000 population), connect to each other by referral system. Level two, general hospitals serve up to 1.5 million people. Level three, specialised/tertiary hospitals serve 3.5 to 5 million people (EFMOH, 2015). Health care facilities have been improved and service coverage increased overtime even with uneven performance across the programme. Owing to economic, socio-cultural and geographical factors, there is 0.03% health care utilisation which is still very low (WHO, 2012a).

A lot of factors contribute to increased maternal mortality in Ethiopia. These may include but not limited to low facility-based delivery rates, lack of skilled and trained health personnel, unavailability of emergency obstetric care services at facilities, inadequate and inefficient referral systems for obstetric emergencies were the key weaknesses of health care system (Alemnesh H Mirkuzie, 2014, FDREMOH, Oct 2010, EFMOH, 22 Aug 2011). EmONC initiative implementation in Ethiopia was begun in 1998 but the services are not widely accessible. Except for Addis Ababa, Dire Dawa and Harar; almost all of the regions do not meet the WHO minimum requirements in terms of availability and accessibility. Even though Addis Ababa, Dire Dawa and Harar meet the WHO requirement; a report shows that the quality of care is highly compromised (EFMOH, 22 Aug 2011). Thus, this study aims at assessing factors affecting the provisions of quality emergency obstetric and newborn care service in Dire Dawa, Ethiopia.

1.2. Statement of the Problem

Globally, about 800 women die of pregnancy and childbirth- related complications everyday and an estimated 287,000 maternal deaths occur annually (WHO, 2014b). By the year 2013, only about 289, 000 women and 3 million newborns died in the process of pregnancy, childbirth and after birth globally (WHO, 2015, WHO, 2013, WHO, 2014a). More than 90% of these cases took place in developing countries where there were limited resources. Majority are avoidable and preventable with timely and effective emergency obstetric and newborn care services (WHO, 2014a).

Save the children 2014 reports that about 40 million mothers give birth at home without the help of trained health workers every year. As a result, most of the maternal and neonatal morbidities, mortalities and disabilities occur at the community level where there is no quality of care during labour and birth (International, 2014).

According to new ANC approaches, all pregnant women are considered to be at high risk and are to go for timely checkup and get skilled attendance in their prenatal, intra and postnatal periods. Thus, all pregnant women need access to ANC during pregnancy in the presence of skilled attendant during labour and delivery, and holistic medical care support at least up to her first week after delivery to make pregnancy safer (WHO, 2014b, WHO, 2014a). A woman’s benefit from skilled medical care during childbirth in poor resource and low income countries only accounts for 46% which implies that majority of the delivery is not carried out by skilled or trained health professionals as indicated by increased home delivery (WHO, 2014a).

Access to essential maternal health services which includes focused antenatal care, skilled attendant during pregnancy, delivery and post-delivery, appropriate and timely referral service system and Emergency Obstetric Care (EmOC) services can greatly avert maternal deaths and disabilities by 99% (Essendi H, 2011). However, Sub-Saharan African women have limited access to skilled delivery services and continue suffering (Essendi H, 2011). Sub-Saharan African countries alone accounts for more than 62% of all deaths globally. Sub-Saharan Africa together with Southern Asian countries accounts for 99% (286,000 out of 287,000) of total maternal deaths across the globe (Essendi H, 2011, UN, 2015).

The report of a survey of purposively selected health facilities in African and Asian countries shows that majority of the primary health care facilities where Basic EmONC services were expected to be given were not providing the services as some were deliver incomplete services while others simply refer patients to tertiary hospitals. More than half of surveyed facilities in selected African countries (65-100%) were observed as they provide incomplete and inconsistent basic signal functions of BEmONC services. Similarly, 63- 87% of facilities designed to provide Basic EmONC in selected South Asian countries were not fully functional (Lai, 2013).The study also depicts that there were high unmet-needs as evident by population based cesarean section rate which is < 1% to 3% is below the recommended levels (5-15%) of all pregnancies (WHO, 2009b). Even in African and Asian countries where a number of facilities were designed to provide adequate Basic and Comprehensive EmOC, high maternal and neonatal mortality have been recorded (Lai, 2013, Pearson L, 2005).

Like Ethiopia, India has a three tier health care system and accounts for the largest number of global neonatal deaths with 900,000 of 3.3 million neonatal deaths in 2010. Even though the economic growth of India improved over the last two decades, neonatal mortality rates remain high (Anu Rammohan, march 27, 2013).

Like other African countries, majority of maternal deaths in Ethiopia were due to direct cause and majority were avoidable with timely and effective Quality Emergency Obstetric and Newborn Care services. In Ethiopia, there is 13,000 of maternal deaths annually and 84,437 neonatal deaths in 2013 (Prem K.Mony, 2013). WHO (2015) reports that in Ethiopia there are 353 maternal mortality per 100,000 live births and 28 neonatal mortality per 1000 births. Ethiopia in collaboration with development partners had put substantial efforts to reduce maternal and neonatal morbidity and mortality to at least, half by the end of 2014 (WHO, 2015). As a result, she almost achieved her MDGs5 target to bring MMR from 1400/100,000 live births in 1990 to 350/100,000 live births (reduction by 75%) at the end of 2015 and under-five mortality rate from 204/ 1000 live births in 1990 to 68/1000 live births that had been achieved one year before the end of MDGs plan which is considered to be plausibly high (Charles Ameh, 2012, WHO, 2015, WHO, 2012b).

Ethiopian 2008 national EmONC survey and 2009 EmONC baseline/need assessment in Addis Ababa revealed that inadequate water supply was one of the factors preventing facilities from providing quality EmONC services (EFMOH, 22 Aug 2011, Alemnesh H Mirkuzie, 2014). 2011- EDHS report reveals that 54% of households have access to improved source of drinking water. Larger proportion (95%) of households in urban areas have accessed to an improved water source, compared to 42% of households in rural (CSA, 2012). All of the surveyed health facilities in Addis Ababa have a continuous water supply, reliable access to telephone, logbook and partograph, but poor provider’s competence was one of the factors identified as bringing quality gap in provisions of QEmONC services in 2013 (Alemnesh H Mirkuzie, 2014) whereas lack of transportation and communication infrastructure were identified as a major barriers in 2014 survey (Anne Austin, 2015).

EDHS-2011 report shows that about 81.9% of women in Addis Ababa gave birth in a facility and 58% reported that a medical doctor attended their birth. In comparison, national rates for facility based births were 11% and only 3.6% of births were attended by a physician/ doctor (CSA, 2012). According to national mini-survey report in 2014, the rates of skilled birth attendants were 11.7%, and which was slightly increased to 16.2% by 2015 (CSA, 2014).

In 2014, percentages of pregnant women who received ANC from skilled health care providers in Dire Dawa were about 78.4%; 65.9% got care from nurses and midwives and 34.1% were from physicians. Data from the same year again reveals that 59.2% of women in Dire Dawa city gave birth in the health facility, 36.8% were attended to by nurses and midwives where as 22.4% were attended to by physicians. Skilled health care providers attend an overwhelming majority of births from urban areas as against births delivered elsewhere. Urban births were more than six times more likely to be attended to by skilled health care providers than rural births in Dire Dawa (CSA, 2014).

A recent study in rural Ethiopia reveals that providers had relevant insights into the factors that lead women to seek facility based births (Mekbib T, 2003). Providers’ perspectives are also needed to identify high-impact interventions that address poor quality emergency obstetric services (WHO, 2009a). As rural population health care seeking profiles are markedly different from urban population health care seeking profiles, the knowledge and perceptions of urban maternal health service providers can contribute to affect quality emergency obstetric care service provided in the city. A lot of progress have been made in providing necessary drugs, equipments and supplies, health personnel but still sub-optimal quality services continuously been reported, which pursue an urgent consideration (EFMOH, 2010).

Thus, this study assessed those factors affecting provisions of quality Emergency Obstetric and Newborn Care services in Dire Dawa city; and it further accentuate the current knowledge and practice gap of maternal and newborn health care providers in provision of quality EmONC services as a major indices to take corrective action in a way of combating maternal and neonatal morbidity and mortality.

Research questions (gaps)

1. Do Maternal and Newborn health care providers have adequate knowledge and skills in delivering basic signal functions of EmONC service package?
2. Is there any association between facility readiness, professional qualifications of maternal and newborn health care providers’, and the quality of EmONC service provided?
3. What are those factors affecting Quality EmONC service provision?
4. Is there any association between years of working experience, EmONC training, and quality of EmONC?

1.3. Significance of the Study

This study aimed at assessing the factors affecting provisions of Quality EmONC services and redound a clear picture of those key areas requiring interventions for the benefit of mother and her newborn in the dyad.

The finding has a significant contribution to the knowledge and practice of maternal and newborn health care providers in the provisions of the recommended EmONC service package. It is also a grand input to be used by the surveyed and or other facilities to ensure quality service delivery sought by mother and newborn in emergencies by the spur of providers understanding of quality care services.

Furthermore, the study will help policy makers, administrators, researchers, including governmental, private bodies and NGO’s to uncover those factors resulting in quality gaps and guide them on what should be emphasised when practicing solutions.

Overall, the findings have important implications for health care planning, resource allocation and policy planning mainly pertinent to the study area in the spectrum of the strengthening, support and development of health care system which enhance the achievement of SDGs.

Chapter Two

LITERATURE REVIEW

2.1. General population characteristics

Of 52 local health care providers filled the questionnaires used for the assessment of knowledge and perception of quality obstetric and newborn care in Malawi. Most of them were nurses (42), 5 were medical assistants, 1, a clinical officer and 4 other staff (clinical technician, clinical officer intern and midwife) working in EmONC. 37 of them from BEmOC facilities where 35 from health centers and 2 were from rural hospitals and the remaining 15 from CEmOC (Bayley O, 2013).

A survey in Gambia on the availability and quality of Emergency Obstetric Care in main referral hospital identifies women of five diagnostic groups with different acute Obstetric conditions such as: hemorrhage, hypertensive disorders, dystocia, sepsis and anemia (Mamady Cham, 2009).

Three hospitals and five health centres were part of the 40 health facilities offering delivery services in Malinda district in Kenya. Government hospital facilities were more (Elizabeth Echoka, 2013). Women between 18 and 40 years old were selected for qualitative in-depth interview on barriers to Emergency Obstetric Care services in perinatal deaths in rural Gambia. Almost all the women were attending ANC. Of the 20 women who delivered at study site, only three sought initial care at another health center, 19 had stillbirth while one had an early neonatal death. 30% of the cases were as a result of first delay, 50% second delay and 20% third delay. Most of the interviewed women barely know the dangerous signs of pregnancy and child birth, or they misinterpret or “hope for the best.” As a result of these, many of them do not seek care as they narrated their ordeal. The informed ones among them had an awareness and were better placed to make good decisions in emergency situations while others who did not decide to seek early delivery care at health facility were usually influenced by their mothers-in-law since visiting hospitals early in labour is viewed as unnecessary (Abdou Jammeh, 1 may 2011).

A retrospective study at Olabisi Onabanjo University teaching hospital (OOUTH), Sagamu, Nigeria shows that: 262 (18.5%) of 1420 total deliveries were experienced obstetric emergencies. The most common emergencies were prolonged/obstructed labour, post-partum hemorrhage, fetal distress, severe pregnancy-induced hypertension/eclampsia and ante-partum hemorrhage. Obstetric emergencies were responsible for 70.6% of maternal mortality and 86% of perinatal mortality (Lamina Mustefa Adelaja, 2011).

A retrospective review of three hospitals and 63 health centers in Gamo-Gofa, south-western Ethiopia showed that 6.6% of births were attended by skilled professionals in the health facilities. Though the variation was large, districts with higher proportion of midwives were capable of doing emergency lifesaving services where caesarean sections had higher institutional delivery rates. There were two comprehensive and three basic Emergency Obstetric Care qualifying facilities for 1.7 million people in Gamo-Gofa (Meseret Girma, 2013). A project conducted in Addis Ababa in 10 randomly selected public health centers on providers working in the labour ward for their knowledge acquisition after training was given for 6 months and immediate post-course using standard tools were assessed. Of the total 82 providers who received BEmOC training, 36.6 % were male and 61 (74.4%) were midwives. Working experiences of the providers were ranged between 1month and 37 years (Alemnesh H. Mirkuzie, 2014).

2.2. Providers Knowledge, skills and confidence

Women were encouraged to give birth in health facilities so as to benefit from skilled birth attendants but these also question the skills and knowledge of those attendants because in the context of limited workforce, material resources, the knowledge and skills of providers are of utmost importance; highly skilled health professional might be able to overcome resource limitation through careful monitoring, identification of emergencies, correct use of drugs and equipment and correct referrals (Bayley O, 2013).

A highly realistic low-tech simulation-based obstetric and neonatal emergency training program, a PRONTO training, with pre/post measurement of process indicators at intervention hospitals for management of obstetric hemorrhage, neonatal- resuscitation, general obstetric emergencies, pre-eclampsia/ eclampsia and shoulder dystocia at intervention hospitals in Mexico demonstrate significant improvement both in their knowledge and self-efficacy for both physician and nurse participants. Physicians’ self-efficacy was higher on pre-test measurement (2.8–12.5%) than nurse participants. The post-test self-efficacy scores of nurses were higher on most measures than those of their physician counterparts (Dilys Walker, 2014).

Obstetric and neonatal care providers in Guatemala that completed pre- and post- training assessment for the PRONTO training modules which evaluated knowledge of evidence based practice and self-efficacy in obstetric and neonatal topics show that knowledge and self-efficacy scores were improved significantly in all areas of teaching and more than 60% of goals to improve clinic functioning and emergency care were achieved. Thus, it concluded that, PRONTO training is effective in improving providers’ knowledge and self-efficacy training areas (Dilys M. Walker, 2015).

A systematic and standard participatory assessment on the quality of maternal and neonatal care in Albania, Turkmenistan, and Kazakhstan shows that quality of care was found to be substandard in all 13 areas. The lowest scores were obtained in areas of management of normal labour, delivery, obstetric complications and sick babies, infection prevention, use of guidelines and audits, monitoring and follow up. Obstetric care as a whole scored less than neonatal care. Interviewed mothers reported lack of information, insufficient support during labour and lack of companionship. Thus, they stated that approaches that involve health professionals and managers in comprehensive, action-oriented assessments of quality of care are promising and backed up by strong health care system (Giorgio Tamburlini, 2011).

A study of the knowledge and perception of local health care providers on the quality of obstetric and newborn care in three districts in Malawi shows that knowledge regarding the management of routine labour was good (80% correct responses to a given knowledge questions), but knowledge of correct monitoring during routine labour (35% correct) was not keeping up with internationally recognised good practice. 70% of participants correctly answered emergency obstetric care questions. Although, there is a significant variation depending on clinicians’ place of work, knowledge of emergency newborn care was poor across all groups’ surveyed (with 58% correct response) with high rates of potentially life threatening responses from BEmOC facilities. CEmOC staffs were slightly more knowledgeable than BEmOC staffs and reported that confidence and training level had little impact on their knowledge (Bayley O, 2013). Knowledge deficiency regarding early identification and management of post-partum infections and hypertensive complications were identified among PHC staffs in Mali (Traore M, 2014).

Twenty to thirty percent (20-30%) of intra-partum related neonatal death is only averted by facility based basic neonatal resuscitation as evident from several observational studies. Only few babies require advanced resuscitation using endotracheal intubation and drugs which may not survive without neonatal intensive care. The other report and expert opinion have revealed that a range of community health workers can perform neonatal resuscitation with an estimated effect of 20% reduction in neonatal deaths (Stephen N. Wall, 2010 ).

Women who had a recent facility delivery and had had either a home or facility birth in the past year in eight districts in Uganda and Zambia have were involved in FGDs and they identified transportation as a major barrier to accessing obstetric care for many pregnant and post-partum women in rural areas as they spent 62-68 minutes on the average travelling to the clinic for delivery. Different modes of transportation were observed in both countries; 91% of Ugandan women used motorcycle and taxis and 57% of Zambian women also did. Taxis, cars and trucks were the most commonly used forms of transportation in Zambia. Women with low income were less likely to use motorised form of transportations. It took some poor women 94 minutes to travel to health facility as against 34 min for the wealthy ones. The difference between the two groups of women was approximately 50 minutes in Uganda. The FGDs again confirmed transportation as major challenges and identified a number of factors associated with it - affordability, accessibility and adequacy issues which policy makers need to take into account when designing obstetric transport interventions (Sacks E, 2015).

A meta-analysis on how to avert intra-partum related deaths shows that there is moderate quality evidence that community mobilisation with high levels of community engagement can increase institutional births and significantly reduce perinatal and early neonatal mortality (35%) but no data are available on intra-partum specific outcomes (Anne CC Lee, 2012). Community support programmes in obstetric emergencies in Uganda included establishment of community savings, credit schemes and insurance schemes. Community involvement in obstetric emergency management is influenced by employment status and perceived quality of health care services (Simon Ogwang, 2012).

Merkuzie H.A and her colleagues have assessed trainees’ reaction and knowledge acquisition on BEmONC training in Addis Ababa in 2014. 95% of providers trained reported that the training updated their knowledge and skills as evidenced by post knowledge score of 83.5%. The midwives were more likely to achieve knowledge-based mastery than their nurses counterparts working in the labour ward (P<0.05). 32.9% reported that the available training facilities and arrangements were unsatisfactory (Alemnesh H. Mirkuzie, 2014).

A cross-sectional community based survey in Goba district, Ethiopia depicts that out of 562 recently delivered women, 31.9%, 27% and 22.1% participants knew at least three key danger signs during pregnancy, delivery and post-partum period, respectively. Women who attend ANC were 2.5 times more likely to know obstetric danger signs during pregnancy and childbirth (AOR= 2.5 and 95% CI= 1.24 – 5.25). Large proportion of pregnant women who do not have the knowledge of danger signs are more likely to delay in deciding to seek care (delay type 1) unlike those women who had ANC follow up who do have acquired the knowledge of obstetric danger signs from skilled professionals in the facility where they attend (Daniel Bogale, 2015). Using the same design, the study from Robe district, Arsi zone, oromia region, central Ethiopia have identified low instances of birth preparedness and complication readiness, poor knowledge and practices of preparation for birth and its complication in the study area; even though it was higher among educated mothers (AOR= 6.23, 95% CI= 1.5 – 25.87) (Kaso, 2014).

Of 485 mothers who participated in the study conducted in Tigray Region, Tsegedie district in Northern Ethiopia, 31-35% of respondents did not know any danger signs of pregnancy and childbirth while 58-62% of women stated at least two danger signs of pregnancy and childbirth. Vaginal bleeding was found to be the most commonly mentioned danger signs of pregnancy (Desta Hailu, 2013).

2.3. Facility Readiness for EmONC service provision

Seven private and four of the seven public health facilities providing CEmOC services surveyed in rural North West Bangladesh show 100% full readiness. On an average, 81% (ranges: 63-91%) of private facilities showed readiness for the provision of EmOC and associated high cost for C/S procedure were reported whereas, 67% (ranges: 48-91%) show readiness among surveyed public health facilities. The shortage of specialised staff, poor laboratory capacity and lack of CEmOC were listed as main barriers to EmOC provision (Shegufta S Sikder, 2015).

A survey of Emergency Obstetric Care in six developing countries (Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India) five years before the MDGs targeted maternal and newborn health between 2009 and 2011 reveals that 160 out of 378 health facilities surveyed were designed to provide Comprehensive EmOC and 218 to provide Basic EmOC. 23.1% of those facilities providing CEmOC were able to offer all the nine required signal functions of CEmOC and only 2.3% of BEmOC facilities were providing all the seven signal functions of Basic EmOC. Assisted delivery and manual vacuum aspiration are the two signal functions least likely provided (17.5%, 42.3% respectively). The total number of available facilities designed to provide EmOC to the population exceeds the required number with a ratio of 1:8 but none of the districts assessed met the minimum UN coverage rates for EmOC. The population based rates C/S <2%, still births rates ranges from 1.9- 6.8% and maternal case fatality rate for obstetric complication ranged from 2.0 - 9.3% (Charles Ameh, 2012).

Another study in Karnataka State, South India on the availability and distribution of Emergency Obstetric Care services based on the combination of self-reporting, record review and direct observation at sub-state level shows that only Comprehensive EmOC of 4.5/500,000 population and Basic EmOC of 1.4/500,000 population (overall, 5.9/500,000) met the benchmark. 90% of CEmOC and 70% of BEmOC private facilities met the requirements. 6% of public (government) facilities and 36% of private facilities were Emergency Obstetric Care facilities. They concluded that reducing maternal mortality will require greater attention by the government in addressing inequalities in the distribution of EmOC services (Prem K.Mony, 2013).

Afghanistan in 2013, a country with higher maternal mortality ratio as high as 1600/ 100,000 live births and neonatal mortality rate of 60/1000 live births was among the highest in the world. Ministry of public health of Afghanistan estimated that nearly 92% of all deliveries took place at home without skilled birth attendants (William Newbrander 2014).

2.4. Factors affecting provisions of quality EmONC services

According to Penny (2000) and Omrana (2010)“Emergency Obstetric and Newborn Care (EmONC) require a skilled birth attendant with the ability to provide parentral medications (antibiotics, oxytocics and anticonvulsants), perform procedures (manual removal of placenta, vacuum or forceps deliveries), carryout blood transfusions, caesarean sections and newborn care /resuscitation” said (Penny s, 2000, Omrana Pasha, 2010).

Many mothers and newborns that experience emergency complications are in places that lack appropriate lifesaving services (care) and do not meet up with the recommended minimum medical requirement which contextual and cultural factors pose intractable barriers to access (Thaddeus s, 1994, Omrana Pasha, 2010).

A recent study by Mc Donald and his colleagues on obstetric emergencies at the US-Mexico border crossings in EI Paso, Texas reveals that 10-17% of women who reside in the border area received late or no prenatal care during pregnancy (McDonald J A, 2015). A retrospective study shows that hospital records of 45/54 (29%) women with obstetric emergencies were missing. The absence of hospital records for patients with obstetric emergencies makes the delivery of care after discharge more difficult (mainly post-partum care) (Westgren M, 1986, McDonald J A, 2013).

The qualitative case studies of barriers in the delivery of quality Emergency Obstetric and neonatal care in post conflict Africa in Burundi and Northern Uganda identified two major barriers which are human resources related challenges and systematic and institutional failures. Some other barriers identified in both countries were shortage of qualified staffs, lack of essential installations, supplies and medications, increased workload, burnout and turnover and poor data collection and monitoring system. Unique to Uganda were demoralised personnel, lack of recognition, poor referral system, inefficient drug supply system, staff absenteeism in rural areas and poor stakeholders’ co-operations and co-ordinations. Specific to Burundi, weak curriculum, poor harmonisation and coordination of training and inefficient allocation of resources were unique barriers. While concluding, they stated that ‘context specific interventions’ (as in the case of post conflict) is the best approach in improving the quality of care as well as access to services (Primus Che Chi, 25 sep 2015).

Another qualitative study on providers’ perspectives on quality improvement in emergency obstetric referrals in Assin North District, Ghana identified a range of challenges of the referral system related to the referral networks that resulted in type 2 and type 3 delays. The closest health facility to the District Hospital is 15km away. Apart from a stretch of about 100 km tarred road, all other roads were in poor conditions especially in rainy season and insecurity issues mostly at night further compounds the problem of travelling. The other includes high cost of transportation (20 USD), inadequate inter-facility referral transport equipment, lack of formalised communication systems between key stakeholders, poor hand-off management process (knowledge of the case and or accompanying documentation), clinical skill limitations, errors in the use of existing protocols for referrals (unreliable standards of care and monitoring), poor documentation and monitoring of indications for referral and health workers perceptions of patient-level barriers are some of them (Henrietta Afari, 2014). The study is in line with other studies which in similar settings identified important issues with referral processes such as transportation, communication, clinical skills and management and standards of care and monitoring (Gabrysch s, 2009).

In Malawi, a study assessing MNH quality of clinical care in 33 health facilities identified that birth attendants’ adherence to clinical standards was lowest in relation to risk monitoring process. Major gaps were observed in the performance of routine care processes addressing bleeding, infection and pre-eclampsia risks (Stephan Brenner, April 15, 2015 ).

A qualitative in-depth interview study on barriers to Emergency Obstetric Care services in perinatal deaths in rural Gambia identified that socio-cultural belief and family decision making where a mother-in-law decides when a woman in labour seeks health care. The women believe that a pelvic is flexible and has the ability to facilitate quick and safe delivery without any help. The means of transportation in villages is horse and donkey carts (bicycles); roads are poorly constructed and not accessible to taxis or other forms of transportations. In most cases, transportation is usually inconvenient and too slow to address the immediate needs of women in emergency situations. As a result, a woman with obstetric complication is referred to a second level hospital and this costs more money, energy and time. The other observed was that the hospital from which our patients recurred had a blood bank which was not adequately stocked. Jammeh A. et al concluded that improved and timely access to EmOC backed up by emergency transportation seems warranted for improved maternal and neonatal survival in poor rural settings in Gambia (Abdou Jammeh, 1 may 2011). A woman in Gambia reported that lack of blood for transfusion, shortage of essential medicines especially anti-hypertensive drugs considerably hindered timely and adequate treatment for obstetric emergencies. Such inadequacies also inflated the treatment cost by 5-18 times more than standard fees. These show inadequacy in funding for maternal health services (Mamady Cham, 2009).

Shiferaw S. et.al assessed reasons women prefer home births in Ethiopia. Some (42%) believe that institutional delivery is not necessary. Some others reported that they preferred home births because it was customary (36%); was considered cheaper (22%) and of the lack of transportation (8%) were amongst (Solomon Shiferaw, 2013).

Using mixed method approach in Addis Ababa, the lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient pre-service and in-service training and the absence of supportive supervision were identified as barriers to quality health care services (Anne Austin, 2015).

According to 2013 baseline facility survey in 10 randomly selected public health Centers in Addis Ababa, all the survey HCs had constant water supply, reliable telephones, logbooks and partographs. Almost half of the surveyed HCs had 24 hours ambulance services and consistent supply of uterotonic drugs. The ratio of midwives to 100 expected births was 10:3. Providers were reported as having insufficient knowledge in diagnosing post-partum hemorrhage (PPH), birth asphyxia and poor skills in neonatal resuscitation. Yet, poor providers’ competences have persisted, contributing to quality gaps on BEmONC in Addis Ababa (Alemnesh H Mirkuzie, 2014).

2.5. Other factors

Other factors that influence maternal, newborn and child health in addition to other causes which include poverty and inequity undermine their survival. Thus, intersectoral actions which include expanding educational opportunities, improving living and working conditions and increasing access to clean water and sanitation could dramatically improve health (WHO, 2008). Poverty is the reason for the (99%) problems and maternal and newborn deaths occurring in low and middle income countries (Lawn J E, 2005).

Gender discrimination, low level of female education and lack of empowerment prevent women from seeking health care and having the autonomy to make decision for themselves and their children’s health. The delay and lack of autonomy result in unexpected deaths or some form of disabilities (WHO, 2007).

The urban and rural divide also affects the health of mother and newborn and their access to health care. Mortality is lower in urban areas than in rural areas which have poor access to health care (Wirth ME, 2006). 2114 urban and 1226 rural childbirths occurring in Emergency Obstetric Care facilities (excluding abortion) were analysed in Zambia to see their contribution to Zambian maternal mortality ratio (368/100,000 live births in 2015). 81% of urban women gave birth in the facility while 16% were from rural location. 1.4% of the women sought major obstetric interventions. 73% of women from rural area reported unmet obstetric need but major obstetric interventions for absolute maternal indications were higher (2.1%) in urban areas than in rural areas (Ng’anjo phiri S, 2016).

Countries experiencing war/conflict also tend to have higher rate of maternal, newborn and child mortality due to instability in health care system. A recent study in ten Sub-Saharan Africa recorded high maternal and child mortality including Democratic Republic of Congo, Angola, Sierra Leone and Liberia because of recent complex emergencies in the troubled provinces (Coghlan B, 2006).

Corruption, authoritarian regimes, weak institutions and limited freedoms can also inhibit access to effective maternal and newborn care services. However, good government enhances effective health systems (WHO, 2008).

Finally, the cost of health care in many Sub-Saharan African countries is unaffordable and remains a major in accessing health services in this context too (Gilson L). “Ghana, South Africa, and Uganda have all experienced some success in user fee elimination for MNCH services” (Bryce J, 2008, Wilkinson D, 1997, Nebyonga- Orem J, 2008)

Finally, the reviewed literature showed that poor providers competence/ preparedness, poor or partial facility readiness and visibility, weak referral and communication systems, inaccessible, inadequate and inequitable distribution of EmONC facilities and transportation services with poorly constructed roads, poor funding for maternal and newborn health services, poor community/client health care seeking behaviors and limited government and intersectoral collaboration/coordination were among the major factors compromising the quality of care intended to be given to mothers and newborns in MNHC setting.

2.6. Conceptual framework

The framework for this study entails the harmonious interaction between dependent and independent variables using Donabedien framework in the concept of quality of care. Quality is a complex and difficult concept to define. However, health care system is said to be of good quality when the service is safe, efficient, effective, accessible, equitable and acceptable or patient centered. Donabedien entails an interconnected input that requires at different levels of health system to ensure the delivery of quality care and positive health outcomes as illustrated on the following diagram (Figure 1) (Donabedian, 1988).

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Figure 1 : Conceptual framework

Chapter Three

Objectives

3.1. General Objective

- To assess factors affecting the provision of Quality Emergency Obstetric and Newborn Care (QEmONC) services in Public Health facilities in Dire Dawa, Ethiopia from May to June, 2016.

3.2. Specific Objectives

1. To assess maternal and newborn health care providers’ level of preparedness in the provision of Quality EmONC services
2. To assess facility readiness for the availability of basic amenities/ essential installments, drugs and supplies for the provision of Quality Emergency Obstetric and Newborn Care services.
3. To assess other factors affecting the quality of Emergency Obstetric and Newborn Care service delivery.
4. To assess an association between selected socio-demographic characteristics of providers (such as year of working experience, level of education, EmONC training) and Quality of EmONC.

CHAPTER FOUR

METHODS AND MATERIALS

4.1. Study Area

This study was conducted in Dire Dawa which means “a place of remedy”. It is one of the two chartered cities in Ethiopia, the other being the capital, Addis Ababa. It is the second largest city in Ethiopia and 565 km away from Addis. It is located at 9036’Northern Latitude and 41052’ Eastern longitude in the Eastern part of the nation along Ethio-Djibouti border. It is 1191 meters (3907.48 ft) above sea level with an annual rainfall of 594 mm which represents lowlands and hot climatic setting.

Dire Dawa has a total area of 1,558.64 km[2] with an estimated density of 237.2 people per square kilometer with 2.9 % annual population growth rate and a total population of 395,000 in 2013. Total fertility rate (TFR) is about 3.4 child/ women. The town is an industrial center, home of different markets and population of different cultural and ethnic background. Majority of the population (68%) are urban dwellers.

In Dire Dawa, there are two public hospitals, 14 public health centers, 34 health posts, three private hospitals, more than 10 private clinics, different level government clinics and 3 NGO clinics. Dire Dawa Regional Health Bureau together with the Ethiopian Federal Ministry of Health have joined 7 health centres with the two public hospitals located in the urban part of the region with referral system network and provides them with standard operational manual of EmONC in 2012. For ease of the study, the networked health facilities were purposively selected.

4.2. Study Design and Study Period

A cross-sectional mixed method design (MMD) was employed to assess factors affecting the provision of Quality Emergency Obstetric and Newborn Care services in Dire Dawa, Ethiopia. The study period was from May- June, 2016.

4.3. Source Population and Study Population

Quantitative: Source population: All maternal and newborn health care providers in Dire Dawa, Ethiopia.

Study population: All maternal and newborn health care service providers working in EmONC unit/department in purposively selected (networked) health facilities in Dire Dawa, Ethiopia.

Qualitative: Source population: All women who received EmONC services and all health cadres in purposively selected health facilities.

Study population:

- Randomly selected women who received EmONC services on exit
- Medical Directors, Program Managers, Liaison Officers, Maternal, Neonatal and Child health Coordinators, Human Resource Officers for In-depth KIIs
- Gynecologists, midwives and nurses working in MNCH ward for FGDs

4.4. Eligibility Criteria

4.4.1. Inclusion Criteria

1. All maternal and newborn health care providers working in the EmONC department (unit) who consented to participate in the study.
2. All maternal and newborn health care providers who have a working experience in EmONC department (Unit) for six months and above as a probation period is over and fully responsible to care for patients
3. Trained maternal and newborn health care service providers working in the EmONC department (unit) who consented to participate in the study.

4.4.2. Exclusion criteria

1. All maternal and newborn health care providers who did not consent to participate in the study.
2. All maternal and newborn health care providers who were not at work during the data collection period like those in full time school schedule and those on leave.

4.5. Sample Size Determination and Sampling Methods

4.5.1. Sample size

Quantitative : Maternal and newborn health care providers working in EmONC department (unit) and available at the time of data collection were purposively included for the study. For purposive sampling, sample size is determined by data saturation not by statistical power analysis (Suen LJ, 2014). Thus, fifty two (52) maternal and newborn health care providers participated in this study.

Qualitative :

- Five FGDs and 5 Key Informant In-depth Interviews were conducted.
- 3-7 discussants were included in the FGDs in a way which favors mixing of discussants by their year of professional/working experience which includes gynecologists, midwives and nurses from the labor & EmONC rooms.
- The key informants were purposively selected from the population of maternal, neonatal and child health care providers/cadres in the referral network based on their professional responsibilities. These includes medical director, programme manager, liaison officers who are responsible for maternal referrals, maternal and child health coordinators, human resource officers and
- Clients who received services were selected at random for an exit interview.

4.5.2 Sampling methods

In 2012, the Ethiopian Federal Ministry of Health (EFMOH) and Dire Dawa Health Bureau (DDRHB) jointly established seven health centers and two public hospitals in the region with referral network and developed an operational manual for Emergency Obstetrics and Newborn Care. Thus, seven public health centers and the two public hospitals within Emergency Obstetric Referral Network were purposively selected for this study as illustrated in the following diagram (Figure 2 and Table 1).

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Figure 2: Schematic representation of sampling methods

Table 1 : Number of Maternal and Newborn Health Care providers in EmONC providing facilities, Dire Dawa, Ethiopia, 2016

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Source: Dire Dawa Regional Health Bureau report, 2015/16

4.6. Study Variables -

4.6.1. Independent Variables

- Socio demographic factors (age, sex, educational status, professional qualifications, year of work experience)
- EmONC training
- Providers’ knowledge, skills and confidence
- Facility readiness

4.6.2. Dependent Variables

- Quality of EmONC

4.7. Data Collection tools and approaches

4.7.1. Self-administered standard questionnaire

A self-administered standard questionnaire which was adapted to the Ethiopian context during 2008 and 2013 national EmONC survey (Alemnesh H Mirkuzie, 2014, EFMOH, 22 Aug 2011) is modified and used for this study to assess MNHC providers’ preparedness (Knowledge, skills and level of confidence) in the provision of quality EmONC services.

4.7.2. Health facility survey checklist

Health facility survey checklist was used to assess facility readiness (to gain insight to available basic amenities/facilities, human resources, referral and communication system, equipment, supplies and drugs)

4.7.3. FGD and Interview guide checklist

Semi-structured checklists were used to facilitate the FGDs and KIIs. There were interviews with medical director, program managers, MNCH coordinator, liaison officer who is responsible for maternal referral and human resource officer/ staff monitoring head for health staffing and staffing situation and senior staffs (which include gynecologists, senior nurses and midwives) in maternal, neonatal and child health ward/unit to extricate their insight to those factors affecting the provisions of quality EmONC services. The facilitator explored on some important issues that may arise during the discussions. The discussion was tape recorded and one moderator was facilitating the discussion and the note taker took the notes during the discussion.

4.7.4. Client exit interview guide checklist

Client exit interview was employed to assess the challenges clients faced in accessing EmONC care and their contentment to services provided to them.

4.8. Data Collection process and Quality Control

A pilot study was done to seven (10%) of MNCH care providers in Tikur Anbessa specialised and referral hospital in Addis Ababa with the use of questionnaires and observational schedule to identify practical or local problems that might potentially affect the research process before data collection. A code was used in the place of participant’s name and an open code system for pilot study samples to exclude them from the study. Participants were told to first sign the consent form. They were later then provided with self-administered questionnaires.

A questionnaire prepared in English language was used since all MNH care providers were trained in English. The questionnaires were filled in the presence of trained data collectors and participants were free to ask questions if need be on the questionnaire. Data collectors were four graduate nurses, volunteer expert nurse in the field and two supervisors who had experience on both qualitative and quantitative data collection were recruited to supervise the data collection process and all of them were trained for at least one day on the objective and procedure of the study.

10% of the collected data was checked by the supervisors daily for completeness and finally, the principal investigator monitored the overall quality of the data. Data was collected from May to June, 2016. Good rapport was maintained with the participants in the whole period of data collection.

An interview guide checklist was used to guide the interview with the key informants and the interview took not more than 45 minutes and the FGDs lasted for a minimum,of 60 minutes. A smart group formation technique took place based on their professional responsibilities, EmONC training and working experiences in order to get more information and their insight to the factors affecting the delivery of quality EmONC services to the clients. Qualitative data was collected using both hand written notes and audio taped materials. Data validation was done by cross-checking hand taken notes and recorded data before preparing the final transcripts. Health facility survey checklist was used during observation.

4.9. Data management and analysis

Data was cleaned, coded and entered using Epi Info 7 (7.0.9.34) and analysed using SPSS version 20 for descriptive and inferential statistics. Data received from data collectors were daily cleaned and coded by research supervisors. Data exploration was undertaken to see if there were odd codes or items that were not logical and then subsequent editing was done. As well as, double entered to check the consistency before analysis, and displayed using frequency tables, pie chart, figures and tables. Chi-square, binary and multiple logistic regressions were used to explore factors affecting the provision of quality emergency obstetric and newborn care services. Variables having p-value appeared less than and equals to 0.05 on binary logistic regression was a candidate for multiple logistic regressions and statistical significance was declared at Pvalue <0.05.

The qualitative inquiry was analysed using two major qualitative data management and analysis techniques namely framework/thematic analysis and report important findings with the associated quotations. Data was analysed using the following steps data familiariation, identifying a thematic framework, indexing, charting and interpretation. Familiarisation with data was done by listening to audio data tapes and reading the field notes. The data was classified and summarised into a thematic framework. Following this, the data was rearranged according to thematic content in a chart that enables participants and their responses to be viewed against the themes created. The next step was the interpretation of data which involved the comparison of the narratives within and between the themes. Findings were reported with the associated quotations from the extracted discussions.

4.10. Operational Definitions

Knowledge level refers to a subjective level judgment of rating one’s own familiarity/information/intelligence on a scale of 1 to 5 against a given knowledge questions/items. A participant who rates his/her own level of knowledge as ‘ none ’ to a given knowledge question(s) is considered as having no knowledge on that specific item. Where 1 stands for none, 2= poor, 3= adequate, 4= good and 5= excellent on this scale.

Skill : A provider who reported (‘yes ’) that s/he performed the given major EmONC procedure within the three months preceding the survey was considered as having skills on that procedure whereas, a provider who reported ‘ No ’ is indicated that s/he didn’t perform the procedure was considered as having no skill on that specific procedure of EmONC.

Level of confidence refers to a subjective level judgment of rating one’s own level of self-assurance/certainty to a scale of 1 to 5 in the three areas of work related to EmONC (in teamwork, during clinical performance and while assisting the clinical management in obstetric emergencies). A participant who responds ‘ none ’ to a given working area is considered as having no confidence on that specific area. On this scale 1 stands for none, 2= poor, 3= adequate, 4= good and 5= excellent.

Facility readiness refers to a cumulative availability of components required to provide the EmONC service in six domains of readiness (which are staffing, infrastructure, equipment, drugs, supplies, and referral and communication services) i.e. the cumulative sum of all the mean scores/percentages of each sub-categories divided by the total number of categories gives the overall facility readiness for provision of EmONC services

Quality Emergency Obstetric and Newborn Care: Subjective level of perception of quality of EmONC services provided by their facility in line with delivering complete EmONC service packages sought to be given at their respective facility as rated to the scale 1 to 5; where 1= none which means that the provider did not perceive any form of quality of EmONC service within that respective facility, 2= perceived poor quality, 3= perceived medium quality, 4= perceived good quality and 5= perceived provision of excellent quality EmONC service.

4.11. Ethical Considerations

The proposal was submitted to Pan African University Life and Earth Science Institute, University of Ibadan, College of Medicine Research Review Committee for approval. Following the approval by Research Review Committee, a formal letter was written to the Ethiopian Federal Ministry of Health and Dire Dawa Regional Health Bureau for study permit and letters to the hospitals and health centers on which the study was conducted. Since a cross-sectional mixed method approach in integration with observational study was conducted, non-invasive data collection method took place with individual study participants. Thus, they were not subjected to any harm as far as confidentiality is kept. Codes were used instead of participants’ names on data collection forms. The recorded data was not accessed by any third party.

4.12. Dissemination of Results

A copy of the final study report will be submitted to Pan African University Life and Earth Science Institute (PAULESI), Ethiopian Federal Ministry of Health (EFMOH), Dire Dawa Regional Health Bureau (DDRHB) and other health facilities that participated in the study. Furthermore, the findings will be presented in workshops, conferences, seminars and symposium and will be published for access to other users as well.

CHAPTER FIVE

RESULTS

5.1. QUANTITATIVE RESULTS

5.1.1. Population Characteristics

Of the total (n=52) maternal and newborn health care providers who completed the self-administered questionnaires, 23 (44.2%) were nurses, followed by 21 (40.4%) midwives and 6 (11.5%) physicians (Table 2). Participants were 30±6.29 years old and majorities (71.2%) of them were females. On average, 37 (71.2%) providers had a minimum of two years working experience and 9 (17.3%) had less than one year working experience in their respective facilities in different sections of MNCH department/Unit which include ANC Room, EPI and FP, Admission Room (maternal & neonatal), Pre-natal Ward, Labour Room, Post-natal Ward, and Operation Room (C/S).

Table 2: Socio-demographic characteristics of MNHC providers in surveyed health care facilities in Dire Dawa, Ethiopia, 2016

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5.1.2. Providers’ level of knowledge, skills and confidence

5.1.2.1. Providers’ knowledge

Out of 52 maternal and newborn care providers (MNCP), 19 (36.5%) had good knowledge of emergency preeclampsia diagnosis and 9.6% had poor knowledge of it. 50% reported that they had good knowledge of emergency preeclampsia treatment, 11.5% had poor knowledge and 40.4% reported that they had adequate knowledge of eclampsia diagnosis and its treatment. Some, 9.6% and 15.4% reported that they had poor knowledge of diagnosing and treating eclampsia respectively. Twenty (38.5%) reported that they had good knowledge of using MgSo4, excellent knowledge of diagnosing PPH where as 13.5% and 1.9% reported that they had poor and no knowledge of using MgSo4, respectively. More than 40% of providers reported that they had good knowledge of identifying birth asphyxia (distress) and its management including neonatal resuscitation (Table 3).

Table 3 : Maternal and newborn health care providers’ current level of knowledge in performing a major EmONC procedure in surveyed health care facilities in Dire Dawa, Ethiopia, 2016

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* 1= none, 2= poor, 3= Adequate, 4= Good, 5= Excellent

Use of partograph

Mothers who delivered in the preceding one month of data collection were checked and monitored by partograph (whether complete or incomplete). 35 mothers’ charts (5 from each facility) were randomly checked for all the parts/portions filled on the partographs. Patient identifier (name), date of admission and maternal blood pressure were all fully documented (100%) while cervical dilatation, uterine contractions and maternal pulse were partially documented (11.2%) including admission history and fetal heart rate (22.2%). Surprisingly, none of the randomly checked charts had a documented moulding, colour of amniotic fluid, temperature and urine examination portion of the partograph. The knowledge of correct monitoring during routine labour was 55.69% good and 44.31% poor but was not in line with internationally recognised good practice.

Level of knowledge

Knowledge level refers to a subjective level of judgment rating one’s own familiarity/information/intelligence on a scale of 1 to 5 against a given knowledge questions/items as illustrated on the table above (Table 3).

Averagely, 11.4% (7.7-15.4%) of MNHC providers reported that they had poor knowledge in performing major EmONC procedures, 28.15% (19.2-40.4%) reported that they have adequate knowledge, 39.52% (28.8-50%) good knowledge and 18.37% (5.8-38.5%) had excellent knowledge. The remaining 2.6% reported that they had no knowledge about the given EmONC major procedures (Figure 3).

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Figure 3 : A pie chart showing the current knowledge level of MNHC providers in purposively selected health care facilities in Dire Dawa, Ethiopia, 2016

5.1.2.2. Training

Of the total respondents (n=52), 32.73% of MNHC providers reported that they had received EmONC training within the past one year, 14.17% received training within the three months preceding the survey. 19.23% of the trainees (trained MNHC providers) reported from hospitals (Figure 4).

Majority (67.35%) of the providers reported that they did not take any of an in-service EmONC training within the past one year preceding the survey. Large proportions (38.5%) of untrained staffs were reported from health centers (Figure 4).

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Figure 4 : Percentages of MNHC providers received EmONC training in the past one year in purposively selected health care facilities in Dire Dawa, Ethiopia, 2016

Low occurrences were reported from health centers. Only two providers (3.85%) reported that they had received training on performing C/S, uterine artery ligation, repairing ruptured uterus and performing hysterectomy where both were from hospitals. All the MNHC providers reported that these trainings were not applicable in all the surveyed health centers (Table 4).

Table 4 : Proportions of MNHC providers’ took in-service training on specific components of EmONC in surveyed health care facilities in Dire Dawa, Ethiopia, 2016

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PMTCT: Prevention of mother to child transmission MVA: Manual and Vacuum Aspiration

Note : Caesarian section (C/S) and hysterectomy are performed at hospital/tertiary level

5.1.2.3. Skills of providers

A provider who reported that s/he performed the given major EmONC procedure within the three months preceding the survey was considered as having skills on that specific procedure whereas, a provider who reported that s/he did not perform the procedure was considered as having no skill on that specific procedure of EmONC.

By taking these into consideration, all the MNCH care providers available at the time of data collection were asked whether or not they perform the given major EmONC procedures within the three months preceding the survey and 48 (92.3%) reported that they were administering IV fluids where 63.5% reported that they were performing it independently. Thirty seven (71.2%) reported that they were performing active management of third stage labour (28.8I, 3.8% DO, 38.5% with the help of SOG). About 48.1% reported that they performed vacuum aspiration for retained products (19.2%I). Thirty two (61.5%) did not perform curettage, but out of those who performed curettage (38.5%), about 4 (7.7%) did not feel comfortable with the procedure and they reported that they mostly did it by order from physicians or other senior MNCHC staff. (65.4%) administered parental uterotonics for PPH (32.7% using SOG, 30.8 I). (30.8%) reported that they were performing blood transfusions where all of them were from hospitals and none reported.

Thirty four (65.4%) providers reported that they were administering MgSo4 to treat eclamptic convulsions (36.5% using SOG and 23.1% I) where 6 (11.5%) of providers reported the use of valium as an alternative. Thirty four (65.4%) performed manual removal of placenta and 38 (73.1%) reported that they performed neonatal resuscitation (36.5% I, 32.7% by using SOG). Almost all of the providers who demonstrated the skills reported that they are comfortable with the procedure (except when performing curettages). Thirty one (59.4%) providers, on an average, reported that they had adequate skills for performing major EmONC procedures and 40.56% providers reported their lack of adequate skills (Table 5) and 67.5% of providers show poor adherence with clinical standards. (Note : I= Independently, DO= Direct Order, SOG= Standard Operation Guidelines)

Table 5 : Shows percentages of MNCH providers’ skills of performing major EmONC procedures in surveyed health care facilities in Dire Dawa, Ethiopia, 2016

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*= Reported only from hospitals AMTSL=Active Management of Third Stage Labour

5.1.2.4. Providers’ confidence

Majority (42.3%) of the respondents reported that they had good confidence in interacting with the rest of the team during obstetric emergencies while 7.7% (4) reported that they had poor confidence of acting together. Twenty (38.5%) respondents reported that their decisions were adequately respected by the other members of the team while 5 (9.6%) respondents reported that their decisions were poorly respected. Sixteen (30.8%) had adequate confidence in interacting with other units/providers during obstetric emergencies whereas 3 (5.8%) had poor confidence and the same proportion reported lacked of confidence (Table 6).

Majority (40.4%) reported that they had excellent confidence in PPH management and 5 (9.6%) had poor confidence, 21 (40.4%) reported that they had good confidence in maternal resuscitation while 6 (11.5%) had poor confidence, 19 (36.5%) reported that they had good and 16 (30.8%) that they had excellent confidence of preeclampsia management while 4 (7.7%) had poor confidence in it. Even though 23 (44.4%) of providers were had adequate confidence in birth asphyxia/ distress management, 12 (23.1%) providers reported lack of confidence in this regard (Table 6).

Seventeen (32.2%) reported that they have good confidence in assisting during clinical management of PPH, 22 (42.3%) during maternal resuscitation, 20 (38.5%) in preeclampsia management, 26 (50%) in eclampsia management and 20 (38.5%) in neonatal resuscitation; whereas 5 (9.6%) reported that they had poor confidence in assisting in clinical management of PPH, maternal resuscitation and preeclampsia while 13.7% and 15.4% lacked confidence in assisting the clinical management with eclampsia and birth asphyxia (Table 6).

Table 6 : Criteria for categories comprising providers’ level of confidence in surveyed health care facilities in Dire Dawa, Ethiopia, 2016

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N.B: 1=none, 2= poor, 3= Adequate, 4= Good, 5= Excellent PPH-Post Partum Hemorrhage

Level of confidence

Level of confidence here is a subjective judgment of self-assurance/certainty on a scale of 1 to 5 in the three areas of work related to EmONC (in teamwork during clinical performance and while assisting the clinical management with obstetric emergencies) (Table 6).

On the average, 11.1% (ranges: 5.8-23.1%) reported that they had poor confidence while 30.3% (ranges: 21.2-44.2%) had adequate confidence, 36.5% (ranges: 25-50%) had good confidence, 21.6% (ranges: 5.8-40.4%) had excellent confidence and less than 1% reported that they lack confidence in performing major emergency obstetric and newborn care procedures (mainly in three areas which are in interacting with the team during emergency, in clinically managing obstetric and newborn emergencies and in assisting the clinical management with emergency obstetrics and newborn(s) (Figure 5).

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Figure 5 : Confidence level of MNHC providers in surveyed health care facilities in Dire Dawa, Ethiopia, 2016

5.1.3. Facility readiness and EmONC availability audit

5.1.3.1. Facility readiness for EmONC provisions

Facility readiness refers to a cumulative availability of components required to provide the services that comprise tracer items for major domains which are infrastructure/amenities, basic supplies/equipment including small surgery, standard precautions, laboratory tests, medicines and commodities (2010 WHO monitoring indicators for health systems handbook).

This assessment was carried out in a room-by-room walk-through assessment fashioned in order to categorise the readiness of the different units of health facilities in providing EmONC services. Accordingly, emergency evaluation area/emergency department, labor/delivery room, laboratory department and autoclave room of the health facilities were surveyed. In the light of this, most basic infrastructural installments, medicines, basic supplies, equipment which must be available were checked using a standard health facility assessment/audit checklist developed by IPPF (International Planned Parenthood Federation) and Family Guidance Association Ethiopia for 2008 and 2013 national EmONC survey (Alemnesh H Mirkuzie, 2014, EFMOH, 22 Aug 2011).

Facility readiness for EmONC provision was thus expressed as a mean percentage in the four categories to represent the cumulative availability of components required to provide EmONC. Within each category, readiness scores were calculated as the percentages of items present and functioning on the day of the survey out of the total number of categories which gives to the mean scores/percentages i.e. the cumulative sum of all the mean scores/percentages of each category divided by the total number of categories gives the overall facility readiness for the provision of EmONC services (Table 7 and Figure 6).

5.1.3.1.1. Infrastructure

Of the surveyed nine health facilities (7 HCs and 2 Hospitals) in Dire Dawa, 88.9% had no access to continuous water supply where only one health center (11.1%) reported that they had satisfactory water supply but surprisingly, none of the facilities reported that they had 24 hours running water in their facilities. 44.4% of the facilities had generator set and electricity while 55.6% had no reliable source of electricity including emergency light or lamp in the case of emergency. All (100%) of the facilities surveyed had reliable access to partograph, delivery register/logbook and standard operating guidelines. Ambulances were available in 8 (88.9%) surveyed facilities but five facilities (55.6%) reported that the available ambulances (vehicle) were unsatisfactory and taxis (mostly Bajaj) and cars were used as alternative means of transportation in times of obstetric emergencies.

Large proportion (55.6%) had no access to reliable telephone service and 44.4% reported that they had. All the facilities had a formal fee waiver system and they were providing maternal and newborn care free of charge.

5.1.3.1.2. Essential medicines and supplies

All the facilities surveyed had reliable supply of uterotonic drugs except 2 facilities (22.2%) that reported a recent stock-out of Ergometrine, 6 (66.7%) had parentral antibiotics, 11.1% reported recent Ampicillin stockout and 33.3% pencillin G (PPF, BPP). MgSo4. The drug of choice to treat eclamptic convulsion was available in only 33.3% of the facilities and the alternative, diazepam/valium, in 55.6% of the facilities and 44.4% of the facilities reported that the available MgSo4 was not really satisfactory whereas 22.2% reported a recent stock-out. 66.7% of the surveyed facilities had reliable supply of antihypertensive drugs (Hydralazine and nifedipine) and 100% had methyldopa, the alternative. Only 2 (22.2%) had chlorine, 6 (66.7%) had surgical spirit and soap as disinfectants for decontamination in their stock. All were confirmed during observation.

5.1.3.1.3. Equipments

5.1.3.1.3.1. Emergency Evaluation Area

All of the surveyed facilities had functional V/S equipments (BP apparatus, Stethoscope and thermometer) in their emergency room including sterile gloves but two facilities (22.2%) reported that available vital sign equipments (particularly BP apparatus and thermometer) were not satisfactory. All of (100%) the facilities reported that there were available and satisfactory waiting rooms for relatives. Seven (77.8%) facilities reported that they had sufficient examination tables with privacy, sufficient sterilised delivery sets, fully functional oxygen cylinders with face masks, cylinder carrier and key in their emergency evaluation area.

5.1.3.1.3.2. Labour and delivery room

All the surveyed facilities reported that they had sufficient sterile gloves, gowns, gauzes, laceration repair pack, antiseptics, baby weighing scale, sharp disposal container boots and wall clock in their labour/ delivery room. Eight (88.9%) facilities had fully functional vital sign equipments, mucus extractor for neonates, ambu-bag for newborn, and caps and masks in their delivery/labour rooms. Seven (77.8%) facilities had sufficient sterilised delivery sets, sterilised forceps sets, delivery tables with lithotomy stirrups and 66.7% had buckets for decontaminations. Five (55.6%) had clean linen sets and light in their room. 5 (55.6%) observed facilities had no fully functional vacuum extractor, oxygen cylinder (mainly for neonates), scrub brushes and soap for washing of the hand. None of them had washing basins with elbow or knee taps.

5.1.3.1.3.3. Laboratory room

In all laboratories surveyed, there were reagents for screening syphilis, centrifuge, test tubes, registers for recording events, functional microscopes and refrigerators in their laboratories. Seven (77.8%) surveyed facilities reported that they conducted blood type test where only 33.3% did cross matching and none of the BEmONC facilities had blood in their laboratories.

5.1.3.1.3.4. Autoclave room

Majority (77.8%) of the surveyed health care facilities had autoclave machine with temperature and pressure gauges attached and table with masked areas indicating sterile and non-sterile areas in their autoclave room. Only 4 (44.4%) reported that they had reliable and safe electric connection or supply of kerosene oil/gas, 3 (33.3%) reported that the supply was not reliable and satisfactory, 2 (22.3%) facilities had none and 6 (66.7%) reported their lack of indicator paper supply.

Table 7 : Criteria for categories comprising emergency obstetric and newborn care readiness scores by facilities in Dire Dawa, Ethiopia, 2016

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N.B: Specialist positions, blood infusion and operation theatre exists only in higher facilities

The overall facility readiness

The cumulative mean scores/percentages of each category divided by the total number of categories gives the overall facility readiness score/percentage for the provision of EmONC services. Thus, this study shows that 73.9% of the health centers and 91.7% of the hospitals show full readiness for the provisions of EmONC services (Figure 6).

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Figure 6 : Facility readiness for emergency obstetric and newborn care provision among surveyed health care facilities in Dire Dawa, Ethiopia, 2016

5.1.3.2. Manpower and availability of EmONC and FP service

EmONC service availability is referred to as the capacity of health facilities to provide signal functions using the available man power.

There were about 65 full time providers working in MNCHC room in 9 surveyed health facilities with staffing level ranging from 4 to 19 in Dire Dawa, Ethiopia. Fifty (50) were working in pre-natal, delivery (labour) and postnatal rooms. The others were in FP room, EPI room, maternal and neonatal admission room. The number of nurses outweighed the number of midwives (23 Vs 21). Fifty four (54) obstetric beds and 25 delivery beds were observed. The total number of deliveries recorded within the last one month just before the study period in all the 9 surveyed facilities were averagely 431 (20-150) as shown on the figure below(Figure 7).

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Figure 7 : Number of mothers that took ANC and number of mothers who attended delivery in the month preceding the survey in surveyed health care facilities in Dire Dawa, Ethiopia, 2016

The ratio of midwives to the number of deliveries was 1:21 per month but the populations of midwives were not proportionally allocated to each of the facility. All the surveyed health facilities provided EmONC and FP services. Six (85.7%) BEmONC facilities were able to offer all the eight basic signal functions of BEmONC and 95% of the CEmONC facilities provided all the ten basic signal functions of CEmONC. Assisted delivery, forceps and vacuum delivery, are the two signal functions least likely provided (28.57% and 71.43 respectively). All the surveyed facilities reported that they provided family planning services (IUCD, injectables, implants of any type and pills (COC, POP)), but 22.3% of the facilities reported that a recent implanon and dipo-provera stock-out. About 88.9% of the BEmONC facilities and 100% of the CEmONC facilities were providing family planning services. On average, 87% of health centers and 97.5% hospitals show availability of EmONC and FP services (Table 8).

Table 8 : Shows availability of EmONC and FP services in surveyed health care facilities in Dire Dawa, Ethiopia, 2016

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5.1.4. Referral, transportation and communication services

Means of transportation a facility used to refer a mother with obstetric emergencies were assessed and 88.9% surveyed facilities reported that they used ambulances to bring in new cases and for referring obstetric emergencies. They also reported that the available (one or two) ambulance(s) in their facilities were not sufficient enough to handle all their referral services while 11.1% of facilities used any available form of transportation or gives families/relatives to find their own way/means to the referral points.

Only 55.6% of the facilities had functional public telephone services, 88.9% used their own private mobile phones for communication in case of emergencies and all of the surveyed health facilities reported that their major means of communication were limited only to referral letter/paper. Two (22.2%) facilities reported the lack of network and 7 (77.8%) reported that they had no internet connections available in their facilities.

5.1.5. Providers’ perceptions of quality EmONC

Providers’ perception of quality of EmONC provided by their facility were assessed and they were asked to rate their level of perception on the scale of 1 to 5 where 1= none which means that the provider did not perceive any form of quality of EmONC service within that facility, 2= perceived poor quality, 3= perceived medium quality, 4= perceived good quality while 5= perceived provision of excellent quality EmONC service. Of 52 providers, 22 (42.3%) providers reported that their facilities deliver a medium quality EmONC while 16 (30.8%) reported poor quality services (Figure 8).

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Figure 8 : Provider’s perceived level of EmONC quality in their respective facilities in Dire Dawa, Ethiopia, 2016

Providers who claimed to have received EmONC training are two times more likely to have adequate knowledge of birth asphyxia diagnosis and management than their untrained co-workers (COR 95%CI= 1.97[0.81-7.02]).

Untrained MNHC providers were twice less likely to have confidence in performing major EmONC procedures than their trained counterparts. They receive instructions and orders from physicians or other health professionals (Pvalue < 0.05, 95%CI= [1.32-8.23]).

Nurses attending labour were 1.5 times less likely to use partograph to monitor labour than midwives and a random checking again reveals that majority (75%) of the nurses attending labour partially documented the process of labour on partographs while 3% were still did not (Pvalue < 0.05).

Providers who had two and more years of working experience had adequate knowledge of diagnosing preeclampsia and eclampsia as compared to those who had less than two years of working experience (Pvalue < 0.05, AOR 95%CI= 2.81[1.77-22.36]). However, binary and multinomial logistic regression analysis could not show any significant association between the level of confidence and year of work experience (Pvalue > 0.05).

A binary logistic regression analysis reveals that there were no significant difference in quality EmONC perception between male and female MNHC providers in their respective facilities i.e., the perception of quality was not influenced by being male or female (Pvalue > 0.05, 95%CI = [0.14-1.66]) and no significant differences were found in the knowledge, skills or confidence demonstrated by physicians and midwives in performing maternal resuscitation (Pvalue > 0.05).

Age and sex were not found to be a significant indicator of quality EmONC. No significant difference was found among all age groups/categories in the provision of quality EmONC services (Pvalue > 0.05). There were no significant difference between midwives and nurses about the quality of EmONC services delivered in their respective units when compared to physicians working in the same MNCH units (Pvalue > 0.05) (Table 9).

Both binary and multinomial logistic regressions show that there is a significant difference between trained and untrained MNHC providers in the provision of quality EmONC. Thus, this indicates that there is a strong association between EmONC training and the quality of EmONC services (Pvalue < 0.001, COR 95%CI=0.013[0.002-0.083]), AOR 95%CI=80.0[12.1-530.2]) (Table 9)

There was no sufficient evidence to support the relationship between confidence and quality of care given (Pvalue > 0.05) but there is a strong evidence of relationship between the skill of the provider and confidence (Pvalue < 0.001, COR 95%CI= 4.67[2.06-17.33])

MNHC providers who reported that they possessed adequate knowledge on birth asphyxia diagnosis and management were about four times (3.5x) more likely to contribute to the quality of EmONC services (Pvalue <0.05, AOR 95%CI = 3.5[1.84-11.07]).

Chi-square, binary and multinomial logistic regression results showed that there is a significant association between skills of MNCP in Active Management of Third Stage Labour (AMTSL) and EmONC service quality (Pvalue <0.05, AOR 95%CI=1.69[1.07-9.33]) (Table 9).

Table 9 : Shows predictors of the quality of EmONC in purposively selected facilities in Dire Dawa, Ethiopia, 2016 (Chi-square/Fisher test, binary and multinomial logistic regression results)

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Note: Data transformation took place where a polythumous independent/ response/ variable is transformed to dichotomous categorical data. (QEmONC=Quality Emergency Obstetric and Newborn Care, AMTSL=Active management of third stage labour)

5.2. QUALITATIVE STUDY RESULTS

5.2.1. Characteristics of informants and discussants

Fifteen (15) informants (2 medical directors, 3 program managers, 4 MNCH coordinators, 3 liaison officers (persons responsible for coordinating referrals) and 3 human resource officers) and 23 providers (1 gynecologist, 1 emergency surgery graduate, 9 senior clinical nurses and 12 midwives working in MNCHC room) were approached for the discussions. 24 (63.16%) qualitative study respondents were female and their average age was 31 years (26-42years). All of the participants had a minimum of two years working experience in their respective facilities (2-14 years) and 14 (36.8%) reported that they were trained on EmONC. The medical charts/history paper of patients received EmONC services were reviewed for their cases on admission, three (3) with ante and post partum hemorrhage, 2 with PROM, 2 with Preeclampsia and Eclampsia, 1 with obstructed labour and 1 with septic abortion. A total of 9 clients who received the service (EmONC) were approached for an interview (client exit interview).

Table 10 : Theme, Categories and Codes identified and used for qualitative data analysis

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5.2.2. Factors affecting the provision of Quality Emergency Obstetric and Newborn Care

Quality care is a multi-dimensional health care construct affected by many variables/factors. Thus, this study portrays the factors identified during discussions and interviews as follows.

1. Providers related factors

As the name indicates, Emergency Obstetric and Newborn Care demands urgent understanding and help/care from the providers to save the lives of the mother and her newborn with complications. The more competent and skilled the providers, the better the quality of service they deliver/ provide, the better the outcome.

1.1. Poor provider’s competence /Shortage of qualified staffs

One of the factors that hinder the quality of care is the lack of qualified staff. A qualified staff has sufficient knowledge, skills and confidence to deliver anticipated care.

The discussants pointed out that, “A key predictors to unsafe care is lack of competent health care providers. Competent providers have a creativity to find a solution to the existed problems is high. His/ her flexibility and experience illuminates his work to its best […]…when our providers are less qualified, the quality of services are becoming much more sub-standard. Qualify her for quality care.” (Health center-FGD1, Hospital -FGD4)

“….We need more staffs. MNHC providers we have now are not enough to handle all the laid unto them. Besides, they recently hired new graduates and had no training [...] they only use and apply the knowledge they gained during their study in university. A provider who reported as having insufficient knowledge and skills at least on a single basic signal functions of EmONC is known to compromise the quality of care sought to be delivered,” said the MNCH Coordinator from one of the health centers

“….When one of the health centers in our region was upgraded to primary hospital in the last year, almost all we said trained, skilled and experienced staff were taken to this primary hospital…of course, most of them presented now are recently employed and didn’t get any training… ” the head of the health centre added.

1.2. Lack of training in BEmONC and CEmONC

Training provides better opportunities to expand the knowledge base of all employees. Employees with access to training and development programmes are at advantage over employees in other companies who are left out of training opportunities. Employees who got trained are more productive and are able to deliver quality services and contribute lot to the success of their organisations/companies. The success of one facility or organisation depends on how well the employees perform. Lack of training leads to physical distress/noncompliance and unproductivity on the part of the employees.

Two human resource officers and MNCH coordinators who were interviewed from one of the health centres shared the same point and said : “Three midwives and one nurse who trained on BEmONC were taken to hospital and new staffs were recruited instead….they are not even experienced”

“I have been working for two years in this facility but still I didn’t get any training regarding to EmONC services but I am working in the labour ward….” (Female, Health Center, BSc Nurse)

“I have been working in this hospital for 3 years and half… I took some BEmONC training three years when I was in health centre….I like if refreshment training is given for me and my colleagues too” (Female, Health Center, BSc Midwife)

1.3. Improper client handling

Patients’ satisfaction is commonly measured and many be considered as an indicator of medical care quality. Thus, it is very important to recognise interpersonal aspects of high quality care. A 28 year old woman who had ante partum hemorrhage narrated her ordeal thus:

“We were two then but I was screaming….a man wearing a white gown came to my side, he is a nurse midwife and told me to keep silent. I was in trouble and no one gave me any treatment even painkiller. I start calling again and again for help, the same man came … and he was becoming rude and even shouted at me and said, “ you can go if you can’t wait for me” […] , I know that he deprived me of my rights. I have the right to dignity, safety and access to care isn’t that so? … Why am I going to be insulted when I even need more help and hospitality from him at this time than any other time…”

1.4. Poor adherence to Clinical standards/SOG

Adherence to clinical guidelines limits the variation in the delivery of service among providers. Some of these variations stem from inappropriate care which leads to overuse or underuse of services a patient intends to enjoy. Clinical guidelines are tools used for consistent and efficient care, It closes the gap between what the clinicians do and what scientific evidence supports that pays the right amount to quality.

“… Lots of training books and clinical guidelines fill our cupboard. Once trained, no one is interested to use it again. Things that we can even do ourselves by seeing guidelines we call gynecologists or awaited the patient for consultation…” said midwife from labour ward.

1.5. Poor documentations and monitoring

Documentation is a very important vehicle for conveying essential clinical information about patients’ diagnosis, treatment and outcomes. It ensures continuity of care as it serves as a communication tool among health care providers.

“…I…for example, a woman came last year and gave birth by C/S in this hospital. This is her second time she came. When I tried to ask her for her previous history, she told me that she as she gave birth by operation. I want to confirm what she said and when I opened her medical/history chart, nothing was written …” said the Gynecologist .

2. Facility/Infrastructure related factors

One of the major predictors of quality is the availability of a well-equipped facility. Quality of care is considered as patients’/users basic human right (ICPD, 1994). High quality service ensures that clients receive the care they deserve. When the facility lacks basic facilities/services, equipments, drugs and supplies, the quality of the service becomes poor and patients are dissatisfied.

2.1. Service inaccessibility and overcrowded at referral hospital

Improved and timely access to Emergency Obstetric and Newborn Care (EmONC) are needed for improved maternal and neonatal survivals. Lack of emergency services make pregnant women suffer from unexpected birth complication which can result to death. This contributes to the loss of thousand of mothers and their babies. Thus, timely and reasonable EmONC services where skills and resources are available to mothers and their babies can avert all the sufferings. Any hindrance to the services components will considerably hamper the quality of service to be delivered.

A 32 year old eclampsia patient said thus:

“…where we are now is approximately 60km away from our home. Transportation service is very challenging. We came here because we have no facility nearby to go to, but thanks to HEW visited me in my house that time when I was in critical condition and moaning that my body became austerely swollen. She advised me to see doctors for treatment as soon as possible …I told my husband to take me to the hospital. But I know we do not have enough money to go anywhere….my husband spent 2 days getting money from friends and relatives….my problems got worse and I don’t know how did I got here…. Do you see them? We all have the same problem but they are still waiting...”

2.2. Lack of Essential installations, supplies and drugs

All the informants and discussants unanimously reported that they lacked 24 hours running water (particularly, in the labour room), unreliable power/electric supply, stock-out of essential emergency drugs (mainly magnesium sulphate and hydralazine) and blood for infusions.

“There is a time we had no water to clean the used equipments and the delivery bed we used, and there was no electricity/functional generator set and a pregnant mother developing PPH after home delivery came …then we referred her to the referral hospital and we heard she died before getting there because she lacked emergency obstetric care…” (Health center, FGD4, KII 3, 4)

“We buy water from water panther car and we provide them with petroleum. This petroleum is the one that government gave us for fueling the ambulance, generator and other vehicles we have. But, water is more expensive in our facility than petroleum…” said head of the health center.

2.3. Lack of strong referral network, transportations and Communication services

All the informants and interviewees unanimously reported that ambulances are available but were not sufficient to handle all the referral services. Poor or no mobile network and internet services affect communication among facilities to its worst ground.

3. Facility management/leadership related factors

Where good management/leadership is in place, services are provided timely, efficiently and effectively. These are the major dimensions of quality.

3.1. Quality and quantity of workforce recruited

A human resource officer interviewed pointed out that, “…some of the staffs are directly assigned to our facility by government (MOH) once they were graduated from public college/university whether they have acquired necessary knowledge or skills. They start doing in the unit or ward assigned to them by their coordinator based on their professional qualification….” Now we have three midwives in our facility. They are doing in shift. Two for day shift while only one for the night duty…but still they are unable to handle it” (Health center, male, HRO)

3.2. Weak procurement and maintenance services

All the interviewees and discussants commented that emergency materials (equipment, drugs and supplies) were out of stock and were not purchased timely. There is no culture of maintaining some equipment that can be easily maintained (like oxygen cylinder, refrigerator, beds, water line or pipes, container, generators, etc…). If they valued the life they would have to value the equipments too. Purchasing somehow takes time thus; they have to think of maintaining what they had at hand. They also included that stock should be audited regularly and given right feedback very soon.

3.3. Lack of mentoring and coaching/supervisions

“Program officers, most of the time, only collect reports from area offices, assemble it and keep all with them. But, what we need mentoring and supervising from them. Because, science is very dynamic and what we know yesterday may become wrong today. Knowledge is updated by mentoring when some experienced body is stand near/in front of you and advising, showing and teaching you. That is what actually it should be but when we are simply using our old concepts we may make mistakes. Some mistakes are irrevocable...” said discussants unanimously (FGD1, 3, 4)

3.4. Task-shifting

Task shifting is a process of delegation whereby tasks are moved from specialised health workers to less specialised ones either through training/education. It is a reasonable way of distributing tasks among available workforce. It is a viable solution for health facilities with the shortage of specialised staffs.

“….I think task shifting is the best option we have to choose related to the current situation we have in our region and at national level as a whole because maternal and neonatal mortality are still remaining plausibly high. One and the major reason is due to lack of effective and timely EmONC service from skilled health professionals. Since we have shortages of qualified staffs; task-shifting seems appropriate as of me” said medical director.” (Hospital, I4)

3.5. Weak partnerships and Intersectoral collaborations

Health of the population is determined not only by the activities of the health sector alone but also by other sectors such as finance, education, agriculture, environment, housing and transport. Health is a cumulative sum individual part. A defect in single component within the chain affects the sum of total health. Thus, it is advisable for health sector to work in collaboration with other sectors to raise awareness and health of its beneficiaries.

“Partnerships and intersectoral collaboration is among the weakest of our strategic inputs that impede the success of primary health care”, said an interviewed programme manager from hospital.

4. Client/ Community related factors

If there is no utilisation there is no provision. If there is no provision, quality cannot be talked about.

4.1. Attitude and socio-cultural beliefs

Socio-cultural factors greatly influence women’s tendency to seek health care during pregnancy and childbirth. In rural areas of the region most of the women live with her husbands’ family members and home delivery is very common. Mothers-in-law determine when the women visit health facilities.

A 27 years old woman who came with obstructed labour and gave birth with C/S reported thus: “ ... my mother-in-law told me that all pregnancy have pain but all pain can’t take you to health care facilities when it can be managed with simple herbs…finally I came here after developing more complication but thanks to Allah ….”

“There is a culture… when she (referring to a pregnant mother) shouts or complaining too much; it is taken by her husband’s family as she hate their son’s baby and thus, she should bear all the pain and stay calm to be with her husband again.” (FGD 2, 3)

4.2. Illiteracy/ Educational status and lack of awareness

Most studies reveal that as the educational level of the communities is lower, the behaviour to seek health care becomes diminutive. Lack of awareness on advantages of skilled attendance during pregnancy, labour and child birth increases home delivery.

“Educational background of our community affects our service delivery. A place where service utilisation is good, service delivery is well. But, the place where service utilisation is poor, a service is given incomplete or impartial, and this in turn put the quality of the service under great question mark. I can confidently say that the problem in the community is greater than the problem in our facility…,” said head of the health center .

CHAPTER SIX

DISCUSSION

This study uncovers substantial factors that brought quality gap in EmONC service delivery points. Most of the identified barriers were relatively similar in low and middle income settings basically related to inaccessible, inadequate and inequitable distribution of EmONC facilities, poor providers competence, poor community/client health care seeking behaviors and limited government and intersectoral collaboration/coordination associated with poor funding for maternal and newborn health services were among the major factors.

Women who were encouraged to give birth in health facilities benefit from the skills of birth attendants, but these also calls in to questions the skills and knowledge of those attendants because in the context of limited workforce, material resources, the knowledge and skills of providers are of utmost importance. Highly skilled health professional might be able to overcome resource limitation through careful monitoring, identification of emergencies, right/correct use of drugs and equipments, and correct referrals (Bayley O, 2013).

Even though there is a significant variation based on a clinicians’ place of work, majority of the study participants in this study reported that they had good knowledge of birth asphyxia identification and management and preeclampsia/ eclampsia treatment (including use of MgSo4) which were the two areas where poor knowledge was reported. Though knowledge of correct monitoring during routine labour was good, 44.31% was poor and were not keeping with internationally recognised good practices with high rate of potentially life threatening responses from BEmONC facilities. CEmONC staff was slightly more knowledgeable than BEmONC staff and had more impact on their level of knowledge.

“Emergency Obstetric and Newborn Care (EmONC) requires a skilled birth attendant with the ability to provide parentral medications (Antibiotics, oxytocics and anticonvulsants) to perform procedures (manual removal of placenta, vacuum or forceps deliveries), carryout blood transfusions, caesarean sections and newborn care /resuscitation” (Penny s, 2000, Omrana Pasha, 2010).

FGDs with senior providers also pointed out that lack of competent health care providers is a key predictor to unsafe care and an interview with the human resource officers also reveals that recruiting new graduates with different knowledge level, skills and background (as in experience) may positively or negatively affect the quality of care which has been identified in different literature as determinants of third delay of emergency obstetric care which accounts to the quality of services available within the facilities through facility readiness (in terms of providers and infrastructural capacity including basic infrastructures/amenities, drugs and supplies). The study from Malawi shows that poor providers’ competences were among the major barriers to the quality of EmONC. The finding from Malawi is more or less similar with this study where it found out that provider’s knowledge regarding the management of routine labour was 80% good and 35% was not keeping up with internationally recognised good practice. Knowledge of emergency newborn care was poor across all the groups surveyed (with 58% correct response) where majority of the responses from BEmOC facilities reported that their confidence and training level had little impact on their knowledge (Bayley O, 2013) and knowledge deficient regarding early identification. The management of post-partum infection and hypertensive complication were identified among PHC staff in Mali as well (Traore M, 2014).

Thirty-five (67.35%) providers out of 52 reported that they did not take any of an in-service EmONC training within the past one year where large proportions (57.2%) of untrained staff were reported from health centers, BEmONC facilities. Interviewed participants reported that the lapse in BEmONC and CEmONC refreshment training. Untrained MNHC providers were twice less likely to express confidence in performing major EmONC procedures than their trained counterparts. Those who received EmONC training are two times more likely to have adequate knowledge on birth asphyxia diagnosis and management than their untrained co-workers. A highly realistic low-tech simulation-based obstetric and neonatal emergency training program (PRONTO training) with pre/post measurement was given on the management of obstetric hemorrhage, neonatal resuscitation, general obstetric emergencies, pre-eclampsia/ eclampsia and shoulder dystocia at intervention hospitals in Mexico. They also demonstrate significant improvement in knowledge and self-efficacy for both physicians and nurse participants (Dilys Walker, 2014).

The same experience from Guatemala also reveals a significant improvement in the knowledge and self-efficacy scores of obstetric and neonatal care providers post PRONTO training. More than 60% of the goals set to improve clinic functioning and emergency care were achieved (Dilys M. Walker, 2015). Trainees’ reaction and knowledge acquisition to BEmONC training in Addis Ababa, Ethiopia have also identified an improved provider’s knowledge and skills as evidenced by post knowledge score of 83.5% (Alemnesh H. Mirkuzie, 2014).

All the literature identified here are more or less supportive of training as a better means whereby providers get the opportunity to expand their knowledge base. Employees who got trained are more satisfied and are able to deliver quality services that contribute a lot to the success of their organisation/company. The success of a facility or organisation depends on how well their employees perform. Lack of training leads to employees’ turnover, physical distress/noncompliance and unproductivity. Thus, this highly indicates that health care directors and programme managers sought to maximise the trained staff either through TOT (Training of Trainee) or through creating opportunities for every staff to get trained and further help through establishing training infrastructure within the facilities that enable the trained providers to share their knowledge and experiences with the other members of staff. It is also important to work in collaboration with other external organisations/NGO’s to maximise the opportunities and get all the dedicated staffs trained and further corroborate the mentoring and supervision from programme officers which leads to better outcome.

The qualitative case studies on barriers in the delivery of quality Emergency Obstetric and neonatal care in Burundi and Northern Uganda also identified human resources related challenges and systematic and institutional failures as the two major barriers to quality of EmONC (Primus Che Chi, 25 sep 2015). A common barrier identified in both countries where is the shortage of qualified staff, lack of essential installations, supplies and medications, increased workload, burnout and turnover; and poor data collection and monitoring system which are more or less similar to the findings of this study.

Seven BEmONC facilities and two CEmONC facilities were surveyed for their readiness in Dire Dawa. On an average, 73.9% of BEmONC facilities and 91.7% of CEmONC facilities show full readiness for the provision of EmONC services. Their recent stock of emergency drugs (MgSo4 and hydralazine), lack of reliable electric and water supply, shortage of trained and specialised staff were reported as a main barrier to the quality of EmONC. Similarly, the study from rural North West Bangladesh found that associated high cost for C/S procedure, shortage of specialised staff, basic infrastructures, drugs and supplies mostly in rural public sub-district were listed as main barriers to EmOC provision (Shegufta S Sikder, 2015).

The study also goes with the study done in Assin Northern district of Ghana (Henrietta Afari, 2014) and Malawi (Stephan Brenner, April 15, 2015 ) where inadequate inter-facility referral transport equipment, lack of formalised communication system between key stakeholders, poor hand-off management process (knowledge of the case and or accompanying documentation), clinical skill limitations, errors in the use of existing protocols for referrals (unreliable standards of care and monitoring), poor documentation and monitoring of indications for referral and health workers’ perception of patients were identified as a barriers to provision of Quality Emergency Obstetric and Newborn Care services. Thus, these findings also inform that ‘context specific interventions’ is the best approach in improving the quality of care as well as access to services.

This study also shows that very few (28.6%) of the facilities providing BEmONC were able to offer all the eight signal functions of basic EmONC whereas, only half (50%) of the CEmONC facilities were providing all the ten/eleven signal functions of CEmONC. Forceps and vacuum delivery are the two signal functions least likely provided (28.57%, 71.43% respectively). A cross-sectional survey on status of Emergency Obstetric Care in six developing countries (In Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India) five years before the MDG targets for maternal and newborn health between 2009 and 2011 also reveals that 160 facilities out of the 378 health facilities surveyed were designed to provide Comprehensive EmOC and the remaining 218 provide Basic EmOC. 23.1% of the facilities providing CEmOC were able to offer all the nine required signal functions of CEmOC whereas only 2.3% of BEmOC facilities were providing all the seven signal functions of Basic EmOC. Assisted delivery and manual vacuum aspiration are the two signal functions least likely provided (17.5%, 42.3% respectively).

Another study in Karnataka State, South India on the availability and distribution of Emergency Obstetric Care services based on the combination of self-reporting, record review and direct observation at sub-state level (Prem K.Mony, 2013) showed unequal distribution of EmONC facilities across the region similar to the main challenges reported from this study. Thus, this implies that reducing maternal and neonatal mortality will require greater attention by the government to equip all the EmONC facilities with basic EmONC infrastructural installments such as reliable power and water supply, equipments and drugs, etc and to work well in addressing the inequalities in the distribution of EmONC services to make the service more accessible by the users. Physical inaccessibility of the service contributes more to the second delay of Emergency obstetric and newborn care delay in reaching the facility.

In Zambia (Sacks E, 2015) and Gambia (Abdou Jammeh, 1 may 2011), taxis/Bajaj were the most commonly used forms of transportation. In this study, setting and women with low income and from remote areas were less likely to use motorised forms of transportation. The common modes of transportation in villages were horse and donkey carts (bicycles) on bad roads which are far from good roads that are accessible to taxis. These modes of transportation were usually inconvenient and too slow to address the immediate needs of women in emergency situations. Besides, a number of factors associated with it which are affordability, accessibility and adequacy which policy makers need to take into consideration when designing obstetric transport interventions to avert the death of mothers and newborns before accessing care.

This study also identified socio-cultural factors and community’s level of education/awareness as the two major factors affecting health care seeking behaviour of the community. Majority of mothers and newborns experiencing emergency complications are in areas that lack appropriate lifesaving services (care) and the recommended minimum medical requirement. A qualitative in-depth interview on barriers to Emergency Obstetric Care services in perinatal deaths from rural Gambia also identified socio-cultural belief and family decision making as the two major barriers to access EmONC care. This contributes a lot to the first tier delay of emergency obstetric and newborn care. Illiteracy/ low community educational status, low community awareness and client/communities behaviour to seek health care largely complicate the situation for accessing care. Thus, all stake holders including the government and NGOs will help to greatly avert the difficulties in this regard.

As discussed above, equipments and infrastructural improvements alone cannot bring good quality services. Quality by its nature is dynamic and is culturally biased which seeks multiple interventions and multidisciplinary approach.

STRENGTH AND LIMITATION OF THE STUDY

STRENGTHS OF THE STUDY

- It is the first of its kind to be conducted in Dire Dawa, Ethiopia.
- It withstands a lots of challenges (such as: going long distances on foot to get data from facilities that are not accessible with cars, pleading and disregarding the difficulties in contacting all organisational hierarchy).
- It adopts mixed method design, using strength of both design minimizes subjectivity and biases
- Since standard questionnaire was used, it maximises validity.
- The response rate was 100%, which also maximises the representativeness of the sample for the source population.

WEAKNESSES / LIMITATIONS OF THE STUDY

- The presence of few participants (MNCP). This may threaten the external validity of the findings hence; another wide scale study (research) on this title is required with large sample size.
- Optimism bias/exaggeration bias: a cognitive bias that causes a person to believe in having an optimal/good knowledge of many events which seem related but are completely different. It is overrating his/her own perception, knowledge, skills and confidence level.

Chapter SEVEN

Conclusion AND RECOMMENDATIONS

7.1. CONCLUSION

This study found out that lack of trained and specialised providers, poor or partial facility readiness and visibility, weak referral and communication systems, inadequate and inequitable distribution of EmONC facilities and transportation services with poorly constructed roads, poor community/ clients health care seeking behaviors and low educational level of the community, poor funding for maternal and newborn health services and limited government and intersectoral collaboration/coordination were among the major factors compromising the quality of care intended to be given to mothers and newborns in the surveyed MNHC settings in Dire Dawa, Ethiopia.

IMPLICATION OF THE STUDY

The study inferred that the lack of qualified health care professionals and basic amenities (including essential drugs and supplies) within the facilities greatly affect the timely provisions of quality EmONC services. MNHC providers ought to investment in training/education and research. The study also implies that there is a lot of undone work for all stakeholders including the government and NGOs working towards improving the health of maternal and newborn to work in collaboration with different sectors (interdisciplinary approaches) other than health sectors alone to provide solutions in a way that services has to be provided timely in a safe, efficient, effective and acceptable way.

7.2. RECOMMENDATIONS

- Dire Dawa Regional Health Bureau should establish a strong EmONC service monitoring and evaluation team backed up by strong audit and feedback system, encourage/initiate programme officers to mentor and supervise (coach) the work of MNHC providers and encourage them to follow strict, acceptable and evidence based guidelines and provide them with guidebook to establish training infrastructure in order to provide pre- and in-service training and or education.
- Facilities on which the study was conducted should make an MNHC environment to enable providers to fully demonstrate their knowledge/skills by ensuring the availability of basic amenities like reliable source of power/electricity and water supply, delivery beds, hand washing sinks, soap and disinfectants for cleaning and disinfecting equipments within MNCH departments/units, drug revolving fund and other alternative means of income in purchasing stoke-out emergency equipments, drugs and supplies as gap filling and maintaining continuity of care until it is fully purchased and funded by the government/donors.
- Administrative

- Ethiopian Federal Ministry of Health (EFMOH) should use centrally processed monitoring and evaluation channeling system to provide timely feedback and supply of basic commodities of emergency obstetric and newborn care including standard of operation guidelines. Expanding and strengthening maternal waiting homes (MWHs) that help pregnant mothers to easily access care and double the number of EmONC facilities and qualified health care providers.
- Decision makers and program managers should use task shifting as a reasonable way of distributing tasks among available workforce that helps every provider to interact in obstetric emergencies which is a viable solution for health facilities with shortage of specialised staffs. Making EmONC more accessible and affordable in ways the community can easily utilise and integrating EmONC curriculum to the education of nurses, midwives and doctors is recommended.
- Head of health centers and medical directors should motivate opinion leaders among the providers in the units which promote cohesive and warmed interaction within the MNCPs that ease the way to put guidelines for quality EmONC practice within themselves. Besides, learning resources such as articles, journals and electronic resources such as computers and internet should be made accessible in the units for staff members.
- Human resource officers should consider competence while recruiting.

- Researchers should conduct large scale study on similar title. Further studies on factors affecting the provision of quality emergency obstetric and newborn care services are recommended.

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APPENDIX-II: INFORMED CONSENT SHEET AND QUESTIONNAIRE

1. INFORMATION SHEET AND INFORMED CONSENT

“IMPROVING QUALITY OF EMERGENCY OBSTETRIC AND NEWBORN CARE”

IRB research approval number: UI/EC/15/0400

The approval elapsed on: 13 MAY 2016

The title of the project is: “Assessment of factors affecting provisions of Quality Emergency Obstetric and Newborn Care services in Dire Dawa, Ethiopia.”

Good Morning/Afternoon. My name is (Name). I am collecting this data for the study conducted by WAMI, Girma Alemu a master’s student in Reproductive Health at Pan African University Life and Earth science Institute, University of Ibadan, College of Medicine, Ibadan, Nigeria.

The overall goal of this project is to decrease maternal morbidity and mortality through the use of innovative and scalable quality EmONC services. The main purpose of this study is to find out those factors affecting provisions of Quality EmONC services in this facility when handling obstetric emergencies. The information obtained from the study is intended to be used to improve the quality of the service provided to mothers and newborn in critical condition during pregnancy, delivery and post-partum period. Having this in mind your department/facility is one of those selected for this study.

This information will only be used for the purposes of this study; it will be kept confidential and it will only be made available to the principal investigator. Further, your name and that of your institution will not be specifically mentioned or referred to in the report that we will produce at the end of the analysis.

Autonomy

Your participation in this study is voluntary. You may refuse to answer any question, and you may choose to stop the interview at any time. If you agree to participate in this study, you will be asked to answer a questionnaire. The questionnaire will be administered to all maternity nurses serve pregnant women and newborn in hospitals or health centers.

Confidentiality

The information that you are going to provide us will be kept strictly confidential. It will not be transferred to any other third parties including your colleagues and boss. The data collection form will contain the name of your institution (Hospital/primary care health facility) but will not contain your name or any other information that could directly identify you. Your honest feedback will help us evaluate the effectiveness of our proposal. The questionnaire will ask you to do the following: describe your role as a health professional performing obstetric and newborn care and how confident you are in performing certain procedures at your institution. You will also be asked to provide some personal information such as sex, age, year of graduation and profession.

Benefit

The benefit of this study includes that, what we learn from this study may benefit women and newborn, who in the future will receive obstetric and newborn care. Besides you will not be paid if you participate in this study or you will not have to pay if you decide to participate. This survey will take us about 20-30 minutes to finish.

Risks/harm

There is no any harm happened to you as a result of joining this study and no risks to your organization or institution in any way.

Participant’s Statement

The reason as to why this study is conducted has been explained to me and I have agreed to take part. I have been given a chance to ask any questions I may have and my questions have been answered to my satisfaction. I understand that the information collected through my participation will be kept confidential /private. I understand that I may withdraw from this study at any time. My withdrawal from this study or my refusal to participate will in no way affect my working conditions at this centre or at any other centers. I agree to participate in this study voluntarily.

Abbildung in dieser Leseprobe nicht enthalten

2. QUESTIONNAIRE

Abbildung in dieser Leseprobe nicht enthalten

308 . Rate your perceived level of quality of EmONC services delivered by your facility to the scale of 1 to 5 where one (1= none) stands for didn’t perceive any form of quality services, two (2) for perceived poor quality services, three (3) for perceived medium quality services, four (4) for perceived good quality services and five (5) for perceived excellent quality services. Tick (X) in the box given below.

Abbildung in dieser Leseprobe nicht enthalten

Appendix-III: Interview guide Checklists

“IMPROVING QUALITY OF EMERGENCY OBSTETRIC AND NEWBORN CARE”

Approved date: 13 MAY 2016

Dear Respondent,

I _______________________________extend my greeting to you. I am from Pan African University Life and Earth Science Institute, University of Ibadan, College of Medicine, Post graduate program and I am here to collect health related data for the purpose of generating information for the project aiming at assessment of factors affecting provisions of Quality Emergency Obstetric and Newborn Care services, whether Quality Emergency and Newborn Care services is a wishful dream or achievable with regard to improving Maternal and Newborn health and reducing loss of thousand lives of mothers and neonates due to easily preventable medical conditions. Thus, the purpose of this study is to gather valuable and accurate information concerning the realities on ground and links them to programmes, the health system and policy setting to take appropriate and timely actions.

The study is entirely academic; thus, your responses will be kept confidential. Not to miss your valuable responses, the interview that will last a maximum of an hour will be recorded to guide analysis. Your cooperation will be highly appreciated.

Key Informant Interview Guide

Responsibility of respondent_____________________________________________________

1. How do you see the status of maternal health service in your catchment area (Health center/ Hospital)?

Probe: Access and utilization of antenatal care, safe and clean delivery services, EmONC and post-partum care

2. Where do women in your area prefer to deliver? Why?

3. How do you perceive the quality of maternal and newborn health services rendered in your facility?

Probe one by one: quality of antenatal care, delivery service, post-partum care, family planning, Cesarean section and post natal care.

4. What do you think are the barriers to provisions of Quality EmONC services in your facility?

Probe: Financial, staffing (skill, behavior, commitment), logistics (any stoke out): equipment, emergency drugs, supplies, infrastructure (electricity, water…), technical assistance, supervision, transport (ambulance), Service fee, user unable to afford, attendant at community

5. Do you have any information on national or regional policies/guidelines on maternal and newborn care(particularly regarding EmONC)?

Probe: policy documents, implementation guidelines, etc which primarily focus on maternal and newborn care

6. How do you coordinate with other sectors/ facilities?
7. What would you recommend to make EmONC best of its Quality?
8. Are there any questions you need to ask or share?

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Human Resource Officer

1. Do you think human resource for healths do affect quality of care in one or other way? For example in what way and how?
2. Do you think human resources for health recruited are in their right Qualifications? How do you express them? (probing: In the right number, Skills, Level of Education…etc)
3. How many human resources for health did you recruit this year? How many of them still working? ________ How many of them left? _______ . What do you think the reason for their leave? What measures have to took to fill recommended number of health personnel your facility (Hospital or HC) do actually and potentially require/ need? What are your main criteria’s when recruiting them? (Mostly in terms of their qualifications)
4. You as HRO, Is there any Challenge you faced with regard to Human resource for health? How did you overcome it?
5. Anything you want to ask? Finally, anything you want to share with us (thinking that it is directive and priority to be done on it by implementers’)

CLIENTS ON EXIT INTERVIEW GUIDE

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1. Are you in position to seek care whenever required?
2. Please explain where you seek care during pregnancy, during and after delivery
3. What are the reasons for seeking care in the places you have explained (please elaborate)?Please share your experience in the places you selected to access health care before, during and after delivery
4. Do you/Have you gone for any ANC visits, how many visits? Do you know danger signs during pregnancy?
5. What are the challenges you faced in accessing care (before, during and after delivery) particularly in case of Emergency?
6. After delivery will you seek care/did you seek care (please explain why you will seek care)
7. Are you satisfied to the care provided? How do you rate?
8. What would you recommend to make pregnancy safer?
9. Are there any other questions you would like to raise?

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Thank you for your time and cooperation!

THANK YOU SO MUCH!

APPENDIX IV: FGD GUIDE CHECKLIST

“IMPROVING QUALITY OF EMERGENCY OBSTETRIC AND NEWBORN CARE”

Approved date: 13 MAY 2016

Dear discussants,

I, _______________________________extend my greeting to you. I am from Pan African University Life and Earth Science Institute, University of Ibadan, College of Medicine, Post graduate program and I am here to collect health related data for the purpose of generating information for the project aiming at assessment of factors affecting provisions of Quality Emergency Obstetric and Newborn Care services, whether Quality Emergency and Newborn Care services is a wishful dream or achievable with regard to improving Maternal and Newborn health and reducing loss of thousand lives of mothers and neonates due to easily preventable medical conditions. Thus, the purpose of this study is to gather valuable and accurate information concerning the realities on ground and links them to programmes, the health system and policy setting to take appropriate and timely actions.

The study is entirely academic; thus, your responses will be kept confidential. Not to miss your valuable responses, the discussions that will last a maximum of an hour will be recorded to guide analysis. Your cooperation will be highly appreciated.

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FGD Guide

1. How do you see the status of maternal health service in your facility (Health center/ Hospital)?

Probe: Access and utilization of antenatal care, safe and clean delivery services, EmONC and post-partum care

2. Why do women in your area prefer to deliver at home?What needs to be done to attract more women to health facility for their delivery? Probe: explore on the possible causes
3. How do you perceive the quality of Maternal and Newborn health services rendered in your facility?

Probe one by one: quality of antenatal care, delivery service, post-partum care, family planning, Cesarean section and post natal care.

4. What are the factors that affect delivery of Quality maternal and newborn health care service at your facilities (particularly QEmONC services)? Probe: Staffing (skill, behavior, commitment), equipment, supplies, infrastructure (electricity, water…), quality of care, technical assistance, supervision, transport (ambulance), service fee, user unable to afford, attendant at community….explain if others.
5. How do you respond to emergencies? (EmONC)
6. Do you have any information on national or regional policies/guidelines on maternal and newborn care (particularly with regard to EmONC)?
Probe: policy documents, implementation guidelines, Rx protocols & standard operational guideline, etc …which primarily focus on maternal and newborn care
7. How do you coordinate with other sectors/ facilities? Probe: in terms of referral and communication systems, and some associated challenges you ever experienced.
8. What would you recommend to make EmONC best of its Quality?
9. Are there any questions you need to ask or share?

Place of the FGD: _____________________________________

Facility: _____________________________________________

Number of discussants: ________________________________

Date ________________________________________________

Time: ________________ _______________________________

Duration of FGD: _____________________________________

APPENDIX V: HEALTH FACILITY SURVEY CHECKLIST

“IMPROVING QUALITY OF EMERGENCY OBSTETRIC AND NEWBORN CARE”

Approved date: 13 MAY 2016

FACILITY ASSESSMENT CHECKLIST, 2016

Dear Head of Hospital/Health Center, I _______________________________extend my greeting to you. I am From Pan African University Life and Earth Science Institute, University of Ibadan, College of Medicine, Post graduate program and I am here to collect Health related data for the purpose of generating baseline information for the project aiming at assessing factors affecting provisions of Quality Emergency Obstetric and Newborn Care in this region. I am requesting your permission to get access to units of your health center so that I can assess your facility’s Readiness in Provision of Quality EmONC services.

This Information will help the policy makers, program implementers and other stakeholders to get baseline information on the status of Quality EmONC and on key areas and gaps seeks t interventions. I assure you that the information sought from this Hospital/ Health Center will only be used for the purpose of this study and kept confidential not to be simply accessed by other third person except the program Implementers.

Your willingness to allow us audits your Hospital/Health Center is very much appreciated. I also assure you that the Interview process will not bring any harm to you and your facility.

The purposes of the survey and confidentiality procedures have been explained to me and on my own consent; I Agree Disagree to allow him/ them for facility audit/ survey as outlined in the following page with respective departments. (Mark the check-box with X)

Organization’s Stamp is required!

Name &Signature______________________________ Date __________________

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I. HUMAN RESOURCES PROFILE

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II. INFRASTRUCTURAL READINESS

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III. EQUIPMENT, DRUGS AND SUPPLIES

For each item mark whether the item is available and whether it is satisfactory condition at the facility. Please use the comments box to provide additional information. Please mark “√” for appropriate response.

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IV. AVAILABILITY OF EmONC and SRH SERVICES

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V. USE OF PARTOGRAPH TO MONITOR LABOR (charts of mothers who delivered in the past one month)

Total number of delivered mothers who didn’t monitored by Partograph __________________

Total number of delivered mothers monitored by Partograph (complete or incomplete) ____________

If Partograph each was used: check for completeness by the following checklist (to be duplicated for each case)

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VI. REFERRAL, TRANSPORTATION AND COMMUNICATION SURVEY CHECKLIST

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