Introduction

Obstetric emergencies are health problems that are life-threatening for both pregnant women and their newborn babies. They require prompt and focused interventions to save the lives of the mother and/or her babies [1]. Globally, about 260, 000 women died during and following pregnancy and childbirth in 2023, equivalent to over 700 maternal deaths every day, and approximately one every two minutes. Approximately 92% of all maternal deaths occurred in low- and lower-middle-income countries. Sub-Saharan Africa alone accounted for around 70% of maternal deaths (182,000), while southern Asia accounted for around 17% (43,000) [2]. According to preliminary findings from the Ethiopia Demographic and Health Survey (EDHS) of 2024–2025, the the maternal mortality ratio was 141 deaths per 100,000 live births, and the neonatal mortality rate was 25 deaths per 1000 live births [3].

Furthermore, the coverage of institutional deliveries has been significantly increasing over the past few decades. At the same time, a higher proportion of avoidable maternal and perinatal mortality and morbidity has also moved to health facilities, where poor quality care has become a challenge to the quest to end the preventable mortality and morbidity [4]. The research evidences showed that healthcare delivery is inadequate and of poor quality in low- and middle-income countries (LMICs), characterized by issues like shortage of resources, poor infrastructure, lack of political will, and insufficient management and governance, all of which undermine patient safety and health outcomes. The findings of these studies highlight that even when coverage expands, poor quality of care often prevents better outcomes, with factors like inadequate training, poor adherence to guidelines, and weak health system support contributing to deficiencies in health facility care [5,6].

Globally, more than half of women with obstetric complications do not receive emergency obstetric and newborn care (EmONC) services, with a significant disparity between low (21%), middle (32%), and high-income countries (99%). This disparity corresponds to an annual 11.4 million untreated complications and 951 million women without access to EmONC services [7]. A recent survey on service provision assessment (2021–2022) of EmONC services in Ethiopia among 905 health facilities also reported that only 442 facilities (49%) were able to provide fully functional Basic EmONC (BEmONC) services, while 250 facilities (27.6%) provided fully functional Comprehensive EmONC (CEmONC) services. The national coverage of BEmONC was estimated at 1.5–3.77 facilities per 500,000 population, and CEmONC coverage ranged from 0.83–2.1 facilities per 500,000 populations, indicating remains below the World Health Organization (WHO) recommended standard. The study also revealed significant geographic disparities in service availability, with relatively better access in regions such as Amhara, Southern Nations, Nationalities, and Peoples’ Region (SNNPR), and Addis Ababa, while many rural and remote areas had limited access to life-saving obstetric care services [8].

The available evidence reported that nearly half of maternal deaths and approximately one million newborn deaths could be prevented annually through the provision of high-quality care throughout pregnancy, childbirth, and the postnatal period. Nevertheless, in many low-income countries, women receive less than half of the recommended evidence-based maternal health interventions during routine maternity care visits, indicating substantial deficiencies in the quality of care delivered in health facilities (12, 13). The quality of care requires availing skilled birth attendants for every pregnant woman and their newborn and evidence-based care, including respectful care, creating supportive environments, use of effective clinical and non-clinical interventions, health care infrastructure capacitation, health care providers’ skills, and positive attitude building toward the provision of care [9].

Furthermore, in most sub-Suharian Africa (SSA) countries, where many health facilities lack some necessary medical equipment and essential drugs [10], the quality of EmONC services are not adequate [11]. A shortage of beds and a lack of separate rooms for different maternity services were frequently reported factors affecting the quality of EmOC [10,12]. The available healthcare providers are inadequate in number, and most of them lack essential skills due to insufficient training [13]. The behavior of healthcare providers usually affects the quality of care provided, particularly when the providers who have a negative attitude are treating the clients [14]. Some studies also reported that factors related to poor management of EmONC provision, including lack of supervision [15,16], delayed patient referral [10,17], and poor staff motivation [18], are challenging the provision of appropriate obstetric care services.

The period around childbirth is the most critical for saving the maximum number of maternal and newborn lives and preventing stillbirths. WHO sees a future in which “Every pregnant woman and newborn receives high-quality care throughout pregnancy, childbirth and the postnatal period” [14]. But, a conducted study indicated that poor quality of facility-based care for women and newborns is the major contributing factor to the increased rates of maternal and perinatal mortality and morbidity [13]. Advocating for the highest attainable quality of care for every mother and newborn is an imperative to achieve the SDGs since high maternal and neonatal mortality are attributable to poor quality of care [19].

But, to the knowledge of the researchers, little is known about the barriers and facilitators of quality emergency obstetric and newborn care services in Ethiopia, specifically in the study area. Additionally, factors affecting the quality of emergency obstetric and newborn care services are often inadequately captured in quantitative studies. A more comprehensive understanding of these factors can be achieved through conducting the qualitative research approaches. Therefore, this study aims to explore the perceptions and experiences of women and providers on barriers and facilitators of quality emergency obstetric and newborn care in public hospitals of west shoa zone, Central Ethiopia. Finally, West Shoa Zone was selected due to its large and diverse population, which is considered representative of many parts of the region in terms of demographic characteristics, health service structure, and maternal and newborn care practices.

Methods

Result

Description of the study participants

The study involved a total of sixty-five study participants, including twelve in in-depth interviews with women receiving EmONC services, thirty-eight providers in four focused group discussions, and fifteen key informant interviews with different levels of health facility managers at four public hospitals in the West Shoa Zone.

The in-depth interview was conducted among twelve purposively selected women treated for obstetric emergencies including preeclampsia/eclampsia, antepartum hemorrhage, obstructed labor, and postpartum hemorrhage cases and the socio-demographic characteristics of the included study participants were described as below (Table 1).

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. The socio-demographic characteristics of participants in in-depth interviews conducted in public hospitals of the West Shoa Zone, Central Ethiopia, 2024.

https://doi.org/10.1371/journal.pone.0350555.t001

Additionally, the focus group discussions (FDGs) were also conducted among thirty-eight obstetric care providers (including midwives, clinical nurses, neonatal nurses, and integrated emergency surgical officers (IESO) professionals) and the socio-demographic characteristics of the included study participants were described as below (Table 2).

Download:

• PNG
  larger image
• TIFF
  original image

Table 2. The socio-demographic characteristics of participants in focus group discussions conducted in public hospitals of the West Shoa Zone, Central Ethiopia, 2024.

https://doi.org/10.1371/journal.pone.0350555.t002

Furthermore, fifteen key informant interviews (KIIs) were also conducted with different levels of health facility managers (including the Maternity department head, Neonatal intensive care unit department head, Obstetric and Gynecology department head, Nurse director/Matron, Medical director and the Hospital Chief Executive Officer and the socio-demographic characteristics of study participants included in the key informant interviews were described as below (Table 3).

Download:

• PNG
  larger image
• TIFF
  original image

Table 3. The Socio-demographic characteristics of participants in key informant interviews conducted in public hospitals of the West Shoa Zone, Central Ethiopia, 2024.

https://doi.org/10.1371/journal.pone.0350555.t003

Discussion

This study explored the perceptions and experiences of women and providers on barriers and facilitators of quality emergency obstetric and newborn care services in public hospitals of the West Shoa Zone, Central Ethiopia. The study findings reported that several barriers and facilitators of quality emergency obstetric care services were identified as themes, such as factors related to health care facilities, factors related to health care providers, and factors related to the client and community as a whole.

The present study identified critical facility-related barriers to the provision of quality emergency obstetric and newborn care, particularly shortages of medications, medical equipment, and essential supplies. Additionally, health facility infrastructures such as scarcity of rooms, patient beds, operating tables, lack of water supply in the maternity ward, and poor latrine facilities were also reported as barriers to quality of emergency obstetric and newborn care services. This study finding was supported by previous studies conducted in Bangladesh [27], Ghana [28], Malawi [29], Gambia [30], and the different parts of Ethiopia [22–26,31], suggesting that such constraints are widespread and persistent across low-resource settings. The lack of these essential health facility resources can significantly hinder the quality of emergency obstetric care, potentially leading to preventable maternal and neonatal morbidity and mortality.

Another study conducted in the Philippines to identify factors influencing the provision of basic emergency obstetric care services reported four key themes as barriers to quality care: infrastructure, human resources, referral systems, and local government support. Factors and barriers to each sub-theme were inadequate infrastructures, non-functioning facilities, lack of essential equipment and supplies, poor data management, lack of transport, poor communication channels, lack of capacity-building opportunities, and lack of monitoring and suppervision [32]. This finding indicates that inadequate infrastructures, limited essential supplies, weak referral and communication systems, and gaps in provider capacity can delay timely interventions and compromise the quality of emergency obstetric and newborn care.

This study also reported that facility-related barriers such as high client caseloads, shortage of ambulance/transportation, lack of training, and absence of supportive supervision were the barriers to providing quality of EmONC services. This finding was similar to studies conducted in Addis Ababa, Ethiopia, which indicated lack of transportation, overcrowding at referral hospitals, insufficient training, and absence of supportive supervision were the barriers to provision of quality EmONC services [33,34]. These findings indicate that facility-related barriers can hinder life-saving interventions and limit healthcare professionals’ ability to appropriately manage the obstetric emergencies. Furthermore, the facility-level constraints can reduce the efficiency, safety, and responsiveness of emergency obstetric care, ultimately affecting the maternal and newborn health outcomes.

The study also identified barriers related to health care providers, including knowledge and skills gaps of HCPs, less motivation and commitment of health care providers, poor respectful maternity care, shortage of HCPs, lack of updated training on EmONC services, and high turnover of skilled HCPs. These barriers can lead to reduced adherence to the standards of care, delayed or inappropriate management of obstetric emergencies, and increased risk of preventable maternal and neonatal mortality and morbidity. This finding is consistent with a study conducted in the Tigray region, which reported that poor quality of care during childbirth and postpartum was associated with gaps in providers’ skills and knowledge, inadequate motivation schemes, and suboptimal caring behaviors among providers [26].

The study reported that a gap of awareness about obstetric emergency cases and delays of emergency obstetric care services were barriers related to the client and community for receiving quality emergency obstetric and newborn care services. Similar findings were reported in Malawi that indicated the client-related factors contributing to poor quality of care included delays in seeking care and a lack of awareness regarding the signs of obstetric emergencies [29].

Another study conducted in the Wolaita Zone of Southern Ethiopia also revealed that service users’ perceptions and experiences (knowledge, perceived quality, reputation, respectful care, and gender) and community-related factors (misconceptions, traditional practices, and family and peer influence) were barriers to emergency obstetric and newborn care services [22]. The findings highlight that low community awareness of obstetric danger signs and delays in seeking care can hinder timely access to emergency obstetric and newborn care and increase the risk of preventable maternal and neonatal morbidity and mortality.

This study identified the main health facility-related facilitators of quality emergency obstetric and newborn care services as including the availability of free maternity care, a multidisciplinary team within the facility, availability of liaison office for client referrals, established blood banks and NICU services, availability of ambulances and community pharmacies at public health care facilities, and continuous 24-hour obstetric care services. These factors collectively enhance the readiness and capacity of health facilities to respond effectively to obstetric emergencies and improve the maternal and neonatal outcomes. This finding was supported by previous studies conducted in Ethiopia [22,23], which highlighted that the combination of well-resourced facilities, competent healthcare providers, and effective health system organization are the key facilitators of quality EmONC services in sub-Saharan Africa.

The healthcare provider–related facilitators of quality emergency obstetric and newborn care services were providers’ commitment and teamwork, respectful maternity care, and effective communication among healthcare providers. This finding is consistent with the WHO quality of care framework, which emphasizes respectful care and effective communication as essential components of high-quality maternal and newborn services [35]. It is also supported by a study on facility readiness and the experiences of women and health care providers in receiving and delivering obstetric care at comprehensive health posts in Ethiopia found that women reported positive experiences, particularly highlighting compassionate care and improved access due to the proximity of health care providers as the main factors facilitating quality emergency obstetric and newborn care services [25]. Providers’ commitment, respectful maternity care, and effective communication are clinically important because they ensure timely, safe, and patient-centered emergency obstetric and newborn care.

The study reported that community willingness to get obstetric care from health care providers, community awareness on pregnancy danger signs, and community support for mothers’ transportation during emergency cases were the main facilitators of community related factors for taking quality emergency obstetric and newborn care services. These findings are consistent with another Ethiopian study indicating that improved awareness and behavioral shifts at the individual and community levels are key facilitators of maternal and newborn health service utilization [23]. This implies that community-level factors play a critical role in determining whether women receive high-quality emergency obstetric and newborn care. Therefore, improving clinical outcomes is not only dependent on facility readiness, but also on how well the community recognizes and responds to obstetric emergencies.

Conclusion and recommendations

The study identified several barriers to the quality of EmONC services: shortage of medications, medical equipment, and medical supplies; laboratory investigations; facility infrastructures; delay in obstetric care; poor patient referral system; shortage of human resources; lack of capacity-building training; knowledge and skill gap of health care providers; and insufficient mentoring and supervision activities for obstetric care services. The identified facilitators were availability of free maternity services, availability of ambulances and multidisciplinary team of health care providers’, establishment of blood banks and NICU services, providers’ commitment and teamwork, and availability of ambulances and community pharmacies at public health facility. Therefore, the health facilities need to work harder to secure the resources required to improve the quality of care provided for all obstetric mothers. Additionally, the regional health bureau must ensure that all healthcare facilities are adequately equipped with necessary resources including medications, medical supplies, infrastructure, and human resources by actively involving all stakeholders in the health sector. Furthermore, addressing the identified barriers and strengthening the facilitators of quality services are very essential for enhancing the quality of EmONC services.

Supporting information

Acknowledgments

We acknowledge Wallaga University, Ambo University, study participants, data collectors and facility managers at the study conducted.