Effective coverage of emergency obstetric and newborn care services in Wolaita Zone, Southern Ethiopia.
Authors:   , Arba Mihiretu Alemayehu 
Published: February 2024

Background: Despite the significant improvement in the availability and access of facilities in low and middle-income countries, a considerable burden of maternal and child morbidity and mortality exists, further suggesting the need for effective coverage of EmONC services. Understanding the extent to which the health system delivers quality service and the factors that predict the gap in providing the services are vital to evidence-based decisions at the local, national, and global levels. However, evidence is lacking on the effective coverage of EmONC services and factors influencing quality service provision. Objective: This study aimed to understand, explore, and describe the contexts, correlates, and levels of effective coverage of EmONC services in the Wolaita Zone, southern Ethiopia, and develop a model for effective coverage of EmONC services. Methods: After mapping the evidence for effective coverage of EmONC services in Africa, the study employed an explanatory sequential mixed-method approach. The quantitative study applied a cross148 sectional design, including 414 (facility-based survey) and 402 (house-to-house survey) study participants. The quantitative data were collected using an Open Data Kit (ODK) tablet phone software and exported to Stata version 17 for analysis. Simple and multiple linear regressions, along with p151 values, coefficients, and 95% confidence intervals, were used to declare the statistical significance and strength of the association. The qualitative study employed a case-study research design including 37 participants (selected using maximum variation sampling) to explore the barriers and enablers of EmONC services utilization. The coding and thematic analysis of the qualitative study were assisted by NVIVO version 12 software. The qualitative study assured trustworthiness by establishing credibility, transferability, conformability, and dependability. Result: The scoping review showed a paucity of evidence on the effective coverage of EmONC services in Africa. It also provided a summary of existing evidence on the crude coverage, quality of EmONC services assessed through diverse indicators, and factors linked with the quality of EmONC services. The household survey identified 72.1% crude coverage of EmONC services. The facility-based survey of EmONC services revealed that the indices of structural, process, and output quality were 74.2%, 69.4%, and 79.6%, respectively. Overall, 59.2% of women with EmONC service-need received poor quality services. Women’s education grade 1–8 (B=5.35, 95% C.I: 0.56, 10.14), and grade 9–12 viii (B=8.38, 95% C.I: 2.92, 13.85), age (B= 3.86, 95% C.I: 0.39, 7.33), length of stay at health facility (B= 3.58, 95% C.I: 2.66, 4.9), crowding in the delivery room (B= -4.14, 95% C.I: -6.14, -2.13), and health professional’s experience (B= 1.26, 95% C.I: 0.83, 1.69) were statistically significant predictors of observed EmONC service quality. Overall, the effective coverage (the crude coverage adjusted by the observed quality of care) of EmONC services in the Wolaita Zone was 50%, indicating half of the potential health gain loss in EmONC services. The qualitative study of barriers and facilitators of EmONC services utilization identified five themes that interacted at different levels. Theme one was women’s perceptions and experiences with EmONC services, including their knowledge and awareness of the availability of services, perception of the quality of care, reputation, respectful care, and care providers’ gender. Theme two was community-related factors encompassing misconceptions, traditional management of obstetric complications, the role of traditional birth attendants, and family and peer influence on EmONC services utilization. Theme three was the accessibility and availability of EmONC services, including infrastructure and delays in transportation. Theme four was healthcare financing which focused on drugs and supplies, out-of-pocket expenses, and service fee exemption. Theme five was the health facility-related factors related to the care provider, referral system, waiting time, and leadership. Conclusion: The study showed that the effective coverage of EmONC services in the Wolaita Zone (Southern Ethiopia) was low, where half of the potential health gain was lost due to barriers centered on the women, community, access and accessibility, healthcare financing, and health facility linked factors. The quality of EmONC services was sub-optimal, where women and newborns received inadequate services, and the care providers poorly adhered to the standard clinical actions. The study also underlined that the care providers’ adherence to the standard clinical actions was poor and is significantly associated with the age and education of women, length of stay in the facility, crowding of the delivery room, and health professionals’ experience. The inequitable effective coverage of EmONC services implied loose emphasis and suggested an urgent need for the health system’s intervention. Therefore, interventions directed at the identified bottlenecks can improve the utilization and quality of care, ultimately enhancing effective coverage. Furthermore, the model developed by the study can be utilized to enhance maternal and newborn health.