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Background: Emergency obstetric and neonatal care (EmONC) is a high impact priority intervention highly recommended for improving maternal and neonatal health outcomes. In 2008, Ethiopia conducted a national EmONC survey that revealed implementation gaps, mainly due to resource constraints and poor competence among providers. As part of an ongoing project, this paper examined progress in the implementation of the basic EmONC (BEmONC) in Addis Ababa and compared with the 2008 survey.Methods: A facility based intervention project was conducted in 10 randomly selected public health centers (HCs) in Addis Ababa and baseline data collected on BEmONC status from January to March 2013. Retrospective routine record reviews and facility observations were done in 29 HCs in 2008 and in10 HCs in 2013. Twenty-five providers in 2008 and 24 in 2013 participated in BEmONC knowledge and skills assessment. All the data were collected using standard tools. Descriptive statistics and t-tests were used.Results: In 2013, all the surveyed HCs had continuous water supply, reliable access to telephone, logbooks & phartograph. Fifty precent of the HCs in 2013 and 34% in 2008 had access to 24 hours ambulance services. The ratio of midwives to 100 expected births were 0.26 in 2008 and 10.3 in 2013. In 2008, 67% of the HCs had a formal fee waiver system while all the surveyed HCs had it in 2013. HCs reporting a consistent supply of uterotonic drugs were 85% in 2008 and 100% in 2013. The majority of the providers who participated in both surveys reported to have insufficient knowledge in diagnosing postpartum haemorrhage (PPH) and birth asphyxia as well as poor skills in neonatal resuscitation. Comparing with the 2008 survey, no significant improvements were observed in providers’ knowledge and competence in 2013 on PPH management and essential newborn care (p > 0.05).Conclusion: There are advances in infrastructure, medical supplies and personnel for EmONC provision, yet poor providers’ competences have persisted contributing to the quality gaps on BEmONC in Addis Ababa. Considering short-term in-service trainings using novel approaches for ensuring desired competences for large number of providers in short time period is imperative.
Currently, over 70 public HCs and 4 public hospitals under the Addis Ababa City Administration, Health Bureau provide maternal and child health services to about 80% of the population while the private health facilities share is only about 20% of the care. BEmONC services are provided in the public HCs and hospitals provide comprehensive EmONC. Seven signal EmONC functions are provided at the BEmONC facilities which include parenteral antibiotic, parenteral uterotonic, parenteral anti-convalescent, assisted vaginal delivery, manual removal of placenta, removal of retained product and newborn resuscitation [8]. In addition to the seven signal functions, blood transfusion and caesarean section are provided in comprehensive EmONC facilities. There is a referral network system between HCs and hospitals for mothers and newborn babies requiring advanced interventions. Providers who are referring the mothers or newborn babies arrange ambulance services. The median distance from referring HC to the nearest hospital with surgical service was five about km in 2008 and is expected to be less as the number of HCs has doubled by 2013. All the 10 HCs surveyed in our project in 2013 were also surveyed during the 2008 national EmONC assessment. A health facility based intervention project has been implemented to improve maternal and neonatal health outcomes in Addis Ababa. The interventions include 1) intensive hands on skills training using simulation technology, 2) developing diagnostic and management protocol for pre-mature rupture of membranes (PROM) occurring at term and 3) implementing the PROM protocol. Ten public HCs were randomly selected, one from each sub-city. These were Woreda 7 HC from Addis Ketema sub-city, Saris HC from AkakiKality, Kebena HC from Arada, Bole 17 HC from Bole, Shiromeda HC from Gulele, Tekelehymanot HC from Lideta, Meshualekiya HC from Kirkos, Woreda 9 HC from KolfeKeraniyo, Woreda 9 HC from Nifas Silk Lafto and Entoto 1 HC from Yeka sub-city. Data collection methods include retrospective review of routine records, interviews with providers and facility observations. The principal investigator collected all the data between January and March 2013. Trained professionals did the data collection in 2008 from 29 HCs in Addis Ababa. Standard data collection tools, which were adapted to the Ethiopian context during the 2008 national EmONC survey was used in our survey in 2013 [5]. Four major areas were assessed: 1) identification of facility and infrastructure, using observation and interviewing a person of some authority at the facility 2) human recourses, using interview with one knowledgeable person about the staffing pattern and staffing situation 24 hours/7 days a week in the facility 3) essential drugs, equipment and supplies for the provision of EmONC using observation and interviewing a person of some authority at the facility 4) providers knowledge and competency for maternal and newborn care; 24 providers in 2013 and 25 in 2008 were interviewed to assess their knowledge in diagnosing and managing normal labour, PPH and neonatal conditions. Providers were also asked if they ever received EmONC training. In both surveys, the interviewed providers were selected on the basis of their presence on the date the HCs were visited with random selection in 2013 and those who attended the largest number of deliveries in the 2008 survey. Five questions on obstetrics and five on neonatal care were asked. For assessing knowledge, under each question a list of correct choices were given and providers were asked to give multiple answers (Table 1). Observation of actual performance when care is provided is the standard method for assessing skills. However, this method was not used in the 2008 survey. To facilitate fair comparison between the two surveys we used the same methodologies that were used in 2008. Hence, the proxy skill assessment method used in both surveys was asking providers what they would do to manage an asphyxiated baby for instance. Another method used to assess skill was asking providers what immediate newborn care they provided the last time they attended birth. In both cases interviewees were asked open-ended questions and were not prompted on specific practices. Questions used to evaluate obstetric and neonatal care knowledge and skills of providers Percentage, mean scores and fisher exact chi square tests were used for data analyses. We also used independent samples t-tests for comparing knowledge and skills mean scores between the 2008 and 2013 surveys. The project has received ethical approval from the Addis Ababa City Administration Health Bureau, Ethiopia and the Regional Ethics Committee in Western Norway. Study permits were sought from the Addis Ababa City Administration Health Bureau, the Health Bureaus’ of the respective sub-cities and from all the project health centers. Written informed consent were obtained from the study participants.
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