Assessment of Availability and Quality of Emergency Obstetric and Newborn Care Service in Southwestern Oromia, Ethiopia, 2017

,


Background.
Maternal mortality is the most important health problem, particularly in sub-Saharan Africa, where more than half (>50%) of all maternal deaths worldwide occur. Emergency obstetric and newborn care is a vital sequence of essential lifesaving tasks which can avert the death of women facing obstetric-related complications [1]. Emergency obstetric and newborn care (EmONC) is categorized as basic emergency obstetric and newborn care (BEmONC) and comprehensive emergency obstetric and newborn care (CEmONC). BEmONC can prevent up to 40% of intrapartum neonatal and maternal mortality [2].
BEmONC services consist of seven signal functions: administering parenteral antibiotics, uterotonic drugs, anticonvulsants, manual removal of the placenta, removal of products of retained tissue, performing assisted vaginal delivery, and performing neonatal resuscitation. CEmONC services necessitate two additional signal functions to BEmONC services: cesarean section and blood transfusion [3].
e Ethiopian final report of EmONC assessment revealed that, in spite of the government's target of 100% treatment of obstetric complications in health facilities, the met need for EmONC in 2016 was low (18% in all facilities). Regionally, the met need for EmONC ranged from 3% in Gambella to 83% in Addis Ababa. Most regions had a met need for EmONC of 33.3% [4].
In Ethiopia, the availability and quality of EmONC are lower than the recommended levels, which contribute to the highest level of maternal mortality in the world. Ethiopia shares the challenges with many low-income countries of inadequate resources, weak infrastructure (especially roads), and a shortage of man power [5].
One of the key significant strategies encouraged to reduce maternal and neonatal mortality in low-and middle-income countries (LMIC) is the timely access to CEmONC, with the provision of BEmONC at the primary health-care level of a country's health system. To maintain the progression of monitoring this strategy, the availability of BEmONC services, the proportion of all live births taking place in health institutions, and the met need for EmONC are essential [6].
e study in the Tigray region indicated that the overall quality of BEmONC services from patients' perspective was poor. Clients scored lower quality rates on factors such as the availability of mandatory equipment, the lack of clean and functional bath and latrine facilities, the administration of analgesics during labor, and manual vacuum aspiration (MVA) [7]. e evaluation of EmONC in industrialized and developing countries was launched by the United Nation (UN) process indicators in 1997.
ese indicators include the number of hospitals providing emergency obstetric care per 500,000 people, the proportion of births and women with obstetric complications managed in hospitals, the cesarean section rate, and the case fatality rate [8].
A health center is a primary health-care setting that gives service to up to 25,000 people. Health-care providers working at a health center include midlevel health-care professionals, such as health officers, midwives, and nurses. e minimum recruitment at a health center set by the Ethiopian Standard Agency is two health officers, three midwives, and five nurses, together with specialized supporting personnel (e.g., laboratory and pharmacy technicians) [9]. e Averting Maternal Death and Disability Program (AMDD) and its UN partners continue to refine and improve the EmONC needs assessment. Today, the world increasingly recognizes that the value of needs assessments extends beyond EmONC and helps to improve many other parts of a country's health system [10].
Even though creditable progress has been made in availing the essential inputs and workforces, suboptimal quality BEmONC services remain mostly due to poor providers' competency, which should be a problem of urgent attention. One of the warning conditions for poor quality of health outcomes among women is the nonavailability and nonuse of modern health facilities by the majority of women in Ethiopia [11].
In southwestern Ethiopia, specifically the Ilu Abba Bor and Buno Bedelle zones, no study was conducted regarding the availability; quality, and utilization of EmONC services. erefore, the aim of this study was to assess the availability and quality of EmONC services using the process indicators in Ilu Abba Bor and Buno Bedelle zones' health facilities.
Results from this study may help to further improve the quality of EmONC throughout the region. If Ethiopia and other nations in sub-Saharan Africa are successful in improving the quality of EmONC, women's utilization of these facilities might increase, and maternal and neonatal mortality are expected to be further reduced.

Population and Illegibility
Criteria. All governmental hospitals & health centers expected to give EmONC services in the district were included in the study. But private clinics were excluded because they were not expected to give EmONC services at this level.

Sample Size Determination.
World Health Organization (WHO) recommends the use of all health facilities in the area if they are less than 100 in number for the evaluation of the EmONC performance [3]. erefore, all health facilities (thirty-nine health centers and three hospitals) expected to provide EmONC services were included.

Data Collection Procedure and Data Quality Control.
Data were collected by 4 data collectors using checklists and questionnaires developed from different literature. Each of the data collectors visited facilities and observed documents and records and interviewed key health officials at the facilities for clarification of any recorded data when required. Informed consent was taken from each health-care institution's key health officials by giving a detailed explanation about the objective, purpose, benefit, and importance of the study, and confidentiality of the information was maintained throughout data collection. e tool was pretested at five health facilities in the Jimma zone (1 hospital and 4 health centers). Data quality was guaranteed using a pretested, structured checklist, and training was given for the data collectors for common understandings about the study, provision of full information, and appropriate documentation. For consistency and quality assurance, the data was collected from multiple registers/records from 1 April to 30 May 2017 and also simultaneously supervised and cross-checked.

Study Variables.
e study variables used in this study are EmONC service availability, EmONC service quality, EmONC service utilization, roads, human resources, functional status of the EmONC facility, complicated obstetric cases, and maternal deaths.

Data Processing and
Analysis. Data analysis was done by using EPI-info version 7 and then exported to SPSS version 20 for analysis. After categorizing and defining variables, descriptive statistical tests were carried out for availability and quality of EmONC. Each descriptive statistic was summarized using frequency, percentage, and tables for categorical variables.
Calculations for the number of EmONC facilities per 500,000 people, population-based cesarean section rate, and direct obstetric case fatality rate (CFR) were done as follows [1]: (i) Rate of CEmONC facilities per 500,000 people-� existing CEmONC/total population × 500,000 (ii) Rate of BEmONC facilities per 500,000 people-� Existing BEmONC/total population × 500,000 (iii) Population-based cesarean section rate � number of CS performed in the last 12 months/expected deliveries in the catchment area with the same period × 100 (iv) Case fatality rate (CFR) � total number of maternal deaths from direct obstetric complications in the last 12 months preceding assessment × 100/expected deliveries in the catchment area with the same period 2.7. Operational Definitions 2.7.1. Availability of EmONC Services. ese are the BEmONC and CEmONC services providing lifesaving obstetric procedures, including surgery. e minimum acceptable levels are as follows: there should be one facility providing fully functioning CEmONC, and five facilities providing fully functioning BEmONC for every 500,000 people [3].

Quality EmONC Services.
Quality EmONC services are the degree to which the actual performance or achievement of the health service system corresponds to set standards.

Fully Functioning EmONC Facilities.
ese are the facilities that provide all the required signal functions.

Partially Functioning EmONC Facilities.
Partially functioning EmONC facilities are those that are missing one or more signal functions.
Facilities that did not meet these criteria were classified as non-EmONC facilities.
Hospitals that had performed seven or eight signal functions were classified as partially functioning CEmONC facilities. Likewise, health centers that had provided five or six signal functions were also classified as partially functioning BEmONC facilities.
Facilities that did not meet these criteria were classified as non-EmONC facilities.

General Information about the Facilities Expected to Provide EmONC in Southwestern Oromia, Ethiopia, in 2017.
A total of 42 facilities were planned for the study, and all of them, 39 BEmONC facilities (health centers) and 3 EmONC facilities (hospitals), were included. Nearly quarter (23.4%) of health facilities were more than 30 kilometers (10%) away from a nearby hospital. e majority of the health facilities 35 (83.3%) had car road access, and 7 (16.7%) were remote from having car road access (see Table 1).

Functional Status of the Facility for BEmONC and CEmONC in Southwestern Oromia, Ethiopia, in 2017.
e facility needed to have provided seven signal functions during the three months before the survey, to be said to give quality BEmONC services. To provide quality care for the CEmONC designation, a facility needed to have performed all nine signal functions.
As a result, the majority of facilities in this study, 23 (58.98%), were providing all of the signal functions of BEmONC services (fully functioning), and only 6 (15.38%) of BEmONC facilities were partially functioning, but nearly one-fourth, 10 (25.64%), were providing less than expected signal functions, which can be said to be nonfunctional (see Table 2). Administration of uterotonics was performed 100% in health centers, manual removal of the placenta was performed 84.6%, removal of retained products of tissue was performed 89.7%, and assisted vaginal delivery was performed 92.3%. Among hospitals, two of them (66.7%) were not performing blood transfusions, and one (33%) was not performing cesarean section, while administration of parenteral antibiotics, administration of uterotonics, administration of parenteral anticonvulsants, manual removal of the placenta, removal of the retained products of tissue, assisted vaginal delivery, and performing newborn resuscitation with bag and mask were the most performed signal functions among the assessed hospitals in the zones (see Tables 3 and 4).

Quality of EmONC Facilities at Perform Signal Functions At Least Once during the Last 3 Months in
Southwestern Oromia, Ethiopia, in 2017. Good quality maternal health services are those which are readily reachable; safe, effective, acceptable to potential users and are staffed by technically competent people; provide prompt Advances in Public Health comprehensive care; and provide continuity of care. Quality of EmONC service is determined by the proportion of the maternal death within the EmONC facility at a specified period admitted with direct obstetric complications at the same period. is is termed as the direct obstetric case fatality rate (CFR). e maximum acceptable level is less than 1% [1].
e study also revealed that the maternal death occurred due to obstetric hemorrhage (postpartum hemorrhage) and hypertensive disorders (preeclampsia and eclampsia). Only one-third, 13 (33.3%), health centers used partograph to monitor labor progress (Table 5).

Utilization of EmONC Facilities at Perform Signal Functions At Least Once during the Last 3 Months in Ilu Abba
Bor District, Southwestern Oromia, Ethiopia, in 2017. e proportion of expected births that occurred in the assessed health facilities was 61% of all births in the study area. According to UN recommendation, the expected population need for EmONC is based on the assumption that 15% of expected deliveries will end up with complications.
In this study, out of total deliveries in the facility, 4.22% ended up with complications. Cesarean section performed was 251 (7.6%) in two CEmONC facilities, and the population-based cesarean section rate (PBCSR) was 4.6%. e case fatality rate (CFR) recorded in the past 3 months prior to assessment was 0.073% which was less than the acceptable level. Ninety-five mothers were referred to higher facilities (see Table 6).

Staff Profile of Health Facilities Working in the Delivery Room and Conducting Deliveries in Ilu Abba Bor and Buno Bedelle District, Southwestern Oromia, Ethiopia, in 2017.
e minimum staffing level at a health center set by the Ethiopian Standard Agency (ESA) is two health officers, three midwives, and five nurses [9,10].
is study identified that 165 different staffs were working in the delivery room of health facilities of the district during the study period. e majority of staffs providing EmONC service were midwives, 104 (75 in the health centers and 29 in the hospitals). According to the ESA recommendation, the number of health staffs was not adequate to give EmONC services.
For example, the ESA recommends three midwives required for each 39 health center which mean 117 midwives for 39 health centers required. But, only 75 midwives were giving BEmONC services in the health centers during the study period (Table 7).

Discussion
is study has shown that among assessed facilities, the majority of them had availability of BEmONC as recommended by the UN. While CEmONC facilities were inadequate, the population-based cesarean section rate (PBCSR) was less than the recommended, and staffs for each health facility were inadequate. Maternal death occurred due to obstetric hemorrhage (postpartum hemorrhage) and hypertensive disorders (preeclampsia and eclampsia). According to the Ethiopian Standard Agency (ESA) recommendation, the number of health staffs was not adequate to give EmONC services.
Even though the overall coverage of fully functioning BEmONC facilities was >5 per 500,000 people, nearly onefourth (25.64%) provided less than expected signal functions which can be said to be nonfunctional BEmONC facilities. e ratio of CEmONC facilities per 500,000 people was only 0.24.
is is partly comparable with the study conducted in Ethiopia, Tanzania, and Cameroon which found that the availability of EmONC is below recommended levels. e study conducted in Tanzania reported that a total population of 214,454 required 1 CEmONC facility and 2 BEmONC facilities. In terms of the number of health facilities, the district has an excess number of CEmONC and BEmONC facilities, but in terms of functionality, the BEmONC Hurumu Haro yajo       [5,12,13]. However, the findings of the studies conducted in the Dire Dawa town, Ethiopia, and Ibadan-Ibarapa zone, Nigeria, were in line with this study which revealed the BEmONC facility ratio met the minimum standard, and the CEmONC facility is not adequate to the size of the population [1,14].

Advances in Public Health
Regarding utilization of EmONC, the study showed that the proportion of expected births that occurred in the assessed health facilities was 61% which was higher than the recommended level by the UN. Out of total deliveries in the facility, 7% ended up with complications. In CEmONC facilities of the study area, the population-based C/S rate was 4.6% that was less than the recommended level.
is is also in agreement with the study conducted in Lusaka District, Zambia, which indicated that the observed proportion of expected births taking place in the facilities was 65.3% and cesarean section (C/S) was 7% which have met the UN recommended levels. Public and private health facilities performed 4% elective and emergency cesarean sections that was below the recommended level [15].
Another result of this study revealed that the quality of EmONC facilities in all health-care setting was poor. e quality of services provided by health facilities is measured by calculating the case fatality rate. ere were 230 mothers with direct obstetric complications recorded in the study facilities due to different causes.
Another finding of this study also indicated that maternal death occurred due to obstetric hemorrhage (postpartum hemorrhage) and hypertensive disorders (preeclampsia and eclampsia). e maternal death rate recorded in the past 3 months prior to assessment was 0.12%.
is is in line with a study conducted in Addigrat town, Tigrai, which revealed that the overall quality of BEmONC services from patients' perspective was poor. Clients noted lower quality services during receiving BEmONC [7].
Trained and competent health-care providers are required for the provision of quality services. But, in this study, there was no fair distribution of health-care providers in which many of the providers were being at the hospital that most of them are in urban, and health centers in rural mostly have the lower and least trained personnel. is corresponds with the study conducted in Tanzania which showed that the human resource challenge has been reported by the lower facilities which are mostly in rural tend to have the least trained personnel compared to hospitals which are mostly in urban areas [16].

Conclusion
is study has shown that the BEmONC facility ratio met the minimum standard for the population size while the CEmONC facility ratio was not adequate. e case fatality rate was lower than acceptable by the UN standard. In CEmONC facilities of the study area, the population-based C/S rate was lower than the recommended, 4.6%. Obstetric hemorrhage (antepartum and postpartum hemorrhage) and hypertensive disorders (preeclampsia and eclampsia) were the leading cause of maternal death and the most frequent obstetric complications in district health facilities.

Recommendation.
Hospitals should improve to give CEmONC services, and health centers had to be upgraded to fully functioning BEmONC facilities. Quality improvement of EmONC services need to be offered through enabling facilities for accessible utilization of EmONC facilities, increasing supplies for health facilities, improving providers' skills in EmNOC through BEmONC and CEmONC training because many obstetric complications such as hypertensive disorders and obstetric hemorrhage cause maternal death. Further research is needed to identify factors that could be barriers to the performance of signal functions and ultimately the functionality, quality, and coverage of EmONC services in the study area. Data Availability e data used or analyzed throughout the current study will be obtained upon request from the corresponding author.

Ethical Approval
Ethical approval for the study was given by the Ethio-Canada MCH project and Mettu University Research Ethical Review Committee, and permission for the study was taken from the relevant institutions. Consent e data were collected after fully informed written consent was taken, and the confidentiality of the information was maintained throughout data collection.

Conflicts of Interest
ere are no conflicts of interest.
Advances in Public Health 7