Quality of basic emergency obstetric and newborn care services from patients’ perspective in selected public health centers in Addis Ababa, Ethiopia 2022: A cross-sectional study

Willi Bahre; Achamyelesh Tadele; Finot Debebe

doi:10.1371/journal.pone.0320729

. 2025 Apr 3;20(4):e0320729. doi: 10.1371/journal.pone.0320729

Quality of basic emergency obstetric and newborn care services from patients’ perspective in selected public health centers in Addis Ababa, Ethiopia 2022: A cross-sectional study

Willi Bahre ^1,^*, Achamyelesh Tadele ², Finot Debebe ²

Editor: Mengstu Melkamu Asaye³

PMCID: PMC11967978 PMID: 40179041

Abstract

Background

The majority of maternal and neonatal deaths occur within the first 24 hours of birth. To minimize maternal as well as neonatal morbidity and mortality, it is important to supply quality Basic Emergency Obstetric and Newborn Care. Basic emergency obstetric and newborn care services prevent immediate obstetric problems. There have been studies in Ethiopia that have looked at the availability of EmONC services. However, from the clients’ perspective and experience, there is insufficient knowledge of quality BEmONC services.

Objective

To assess the quality of basic emergency obstetric and newborn care (BEmONC) services and associated factors from the perspective of mothers in selected public health centers in Addis Ababa, Ethiopia, 2022.

Methods

A facility-based cross-sectional study was used among mothers receiving at least one of the signal functions of BEmONC services. A total of 377 mothers were enrolled. Eleven public health centers, one from each of the 11 sub-cities, were selected by simple random sampling. Respondents were chosen by a systematic random sampling method. A structured questionnaire from Open Data Kit version 2022.1.2 was used. Finally, it was exported to SPSS version 26 for analysis. Bivariate analysis at a P-value of 0.25 and multivariable analysis at a P-value of 0.05 were applied.

Results

The overall quality of BEmONC services from the mothers’ perspective was 56.9%. Mothers who paid for services had lower odds of rating the quality as good compared to those who received services for free (AOR = 0.564; 95% CI: 0.327–0.971). Additionally, mothers aged 20 to 24 years had a lower likelihood of viewing the quality as good compared to those older than 35 years (AOR = 0.362; 95% CI: 0.157–0.837). However, mothers who were accompanied by relatives had significantly higher odds of rating the quality as good than those who were alone (AOR = 18.557; 95% CI: 3.844–89.588). Regarding monthly income, respondents with an average monthly income of less than 1,500 ETB had higher odds of rating the quality as good compared to those earning more than 6,000 ETB (AOR = 2.429; 95% CI: 1.026–5.753).

Conclusion and recommendation

The total quality of BEmONC services from the perspective of mothers was suboptimal. It was predicted by age, monthly income, presence of a companion, and payment. This study strongly recommends that more should be done to ensure that the services given are more client-centered.

Introduction

Maternal death is described as a mother’s death in pregnancy, childbirth, or the early forty-two days after birth, no matter the pregnancy’s duration or location, of any etiology linked with or exacerbated by childbirth or its treatment but not related to incidental or unintentional events [1]. During pregnancy, labor, delivery, and the postpartum period, global estimates suggest that 15% of all expected deliveries result in life-threatening complications [2].

According to the World Health Organization (WHO), 580,000 women of reproductive age die each year as a result of pregnancy problems, with Sub-Saharan Africa accounting for the majority of these deaths. With 686 deaths per 100,000 live births, the region has one of the highest maternal death rates in the world. Ethiopia is among the countries with the world’s highest maternal death rates. The maternal death rate in Ethiopia was predicted to be 412 per 100,000 live births, according to the Ethiopian demographic and health survey (EDHS 2016) [3]. Poor delivery care caused some of these deaths.

To reduce maternal and neonatal mortality, the World Health Organization (WHO) created and developed Emergency Obstetric and Newborn Care (EmONC) [4]. Emergency obstetric and newborn care is a vital sequence of life-saving tasks that can save the lives of mothers who are experiencing obstetric difficulties [5]. Basic Emergency Obstetric and Newborn Care (BEmONC) can prevent intrapartum neonatal and maternal deaths by up to 40% [6].

Basic Emergency Obstetric and Newborn Care (BEmONC) services encompass the giving of parenteral antibiotics, uterotonic medicine, anticonvulsants, manual placenta removal, removal of residual tissue products, guided vaginal birth, and neonatal resuscitation, which are the 7 signal functions.

Ethiopia has created and developed a thorough national guideline to ensure that quality institutional delivery services are provided at all levels of health facilities. Input, process, and output (satisfaction) are all clearly identified in the Donabedian model guideline as the three quality components. But only some studies have attempted to assess the quality of emergency obstetric and newborn care services in health institutions from the perspective of patients using all three components of the Donabedian model [7–9].

Client satisfaction with healthcare professionals’ services can be rated by taking into consideration clients’ perceptions of maternal and neonatal health care services [10]. There have been studies in Ethiopia that have looked at the availability of EmONC services [8,11–13]. But, from the clients’ perspective and experience, there is insufficient knowledge of quality BEmONC service [14].

As a result, the Donabedian model was used to assess the quality of basic emergency obstetric and newborn care services and factors affecting women’s ratings for quality from the patients’ perspective in the health centers of Addis Ababa in this study. This is going to aid in documenting the quality of EmONC services from the perspective of mothers, which is necessary for developing patient-centered basic emergency obstetric and newborn care (BEmONC) standards. It can be used as a baseline study and as a guide for conducting further studies.

Materials and methods

Study setting and study period

According to the 2019–2020 annual performance report, Addis Ababa has 41 hospitals (13 public and 28 NGO and private), 98 health centers, 122 health stations, 37 health posts, and 382 modern private clinics. Each of the public health centers serves an estimated 40,000 people. This study was conducted in the eleven public health centers in Addis Ababa, Ethiopia, which were selected by simple random sampling, one from each sub-city. All the selected eleven public health centers provide BEmONC services. A total of 771 mothers utilized Basic Emergency Obstetric and Newborn Care (BEmONC) services in the chosen eleven public health centers during the specific study period. This study was conducted from April 18, 2022, to May 19, 2022.

Study design

A facility-based cross-sectional study was conducted among mothers receiving basic emergency obstetric and newborn care services.

Population

All mothers in the reproductive age groups who had visited public health centers in Addis Ababa were the source population, while all mothers who gave birth in Addis Ababa’s randomly selected public health centers during the data collection period were the study population for this study.

Inclusion and exclusion criteria

Mothers were scheduled for discharge after getting at least one of the basic emergency obstetric and newborn care signal functions, as well as postnatal mothers within 42 days postpartum who attended postnatal follow-up at the same health center where they gave birth and received at least one of the seven signal functions, were included in this study. However, women who were referred to other health institutions, critically or mentally ill mothers, mothers in severe pain, and those unwilling to participate were excluded from this study.

Sample size determination and sampling procedure

A single population proportion formula was used to calculate the sample size. Based on a prior study, it was found that 66.3 percent of BEmONC services were of good quality from the mothers’ perspective [7], with a 95 percent confidence level, a desired degree of precision of 5 percent, and a 10 percent contingency for the non-response rate. Finally, with n = 343 and a 10% non-response rate, the total number of mothers needed for this study was 377.

This study included eleven public health centers in Addis Ababa that were chosen using a simple random selection technique from the 11 sub-cities, one from each sub-city. All the selected eleven public health centers provided Basic Emergency Obstetric and Newborn Care (BEmONC) services. A one-month pre-assessment survey of mothers receiving the services was used to predict the flow of mothers and proportionate the size accordingly.

An average of 761 one-month postnatal mothers received BEmONC services at the eleven public health centers in the month prior to the study. The sampling interval was calculated by dividing the average one-month postnatal mother by the total sample size, and this interval was used in all health centers to select study subjects (k = 2). A systematic random sampling technique was applied to obtain 377 study subjects. The sampling interval was calculated by dividing the average one-month postnatal mothers by the total sample size, and this interval was used in all health centers to select study subjects (k = 2). The first mother was selected randomly from those postnatal mothers during the first day of the data collection period.

Data collection instruments and procedures

Five BSc and one MSc midwives were recruited to collect the data, and they were given training on basic data collection skills for two days and orientation on the Open Data Kit (ODK) application. The sample size was proportionally allocated to the randomly chosen health centers based on the predicted number of mothers attending throughout the data collection period. Then, from each of the randomly chosen public health centers, systematic random sampling was employed to pick study participants. Finally, mothers who gave birth and received at least one of the signal functions of basic emergency and newborn care services were interviewed.

Data were collected using a structured tool that was adapted from a similar study done in northern Ethiopia [7]. The English form of the questionnaire was first translated into Amharic. The questionnaire covered socio-economic data, obstetric characteristics, quality questions, and satisfaction questions. The ODK version 2022.1.2 software was used to collect the data, along with the Kobo Toolbox humanitarian response server to store the collected data. A total of 53 questions were asked.

Operational definitions

BEmONC: Services involve 7 signal functions like providing parenteral antibiotics, uterotonic drugs, anticonvulsants, manual placenta removal, removal of residual tissue, guided vaginal birth, and neonatal resuscitation [15].

CEmONC: In addition to the seven signal functions of BEmONC services, those include two signal functions: cesarean section and blood transfusion [15].

Signal functions: WHO, UNICEF, and UNFPA identified a set of interventions that can be used to manage direct obstetric complications. These interventions are crucial in (EmONC) [16].

Quality: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes in line with evidence-based professional knowledge [17].

Magnitude of quality with service: strongly agree (very satisfied)“ and “agree (satisfied)” were categorized as agree (satisfied), while “strongly disagree (very dissatisfied),” “disagree (dissatisfied),” and “neutral” were categorized as disagree (dissatisfied). Neutral replies were classified as disagreeing (dissatisfied) because they could indicate a modest method of expressing dissatisfaction. This is likely due to the fact that since the interview took place in a health facility, women might be unwilling to share their unhappiness with the care they received [13].

Level of quality score in mean and percentage

Good quality: The quality of BEmONC services from the mothers’ perspective when the mothers scored greater than or equal to the mean of 104 (70%) of all the quality questions [7]

Poor quality: When the mothers scored below the mean of 104.19 (69.9%) of all the quality questions [7].

Patient perspective (experience): patient feedback on the course of getting care or intervention, including both objective facts and a subjective view of it. The factual component is useful for comparing what people claim they experienced with what an agreed-upon pathway or quality standard says should happen [18].

Measurement of quality

Donabedian’s framework.

The Donabedian model is built on three quality components: input, process, and output/satisfaction. Input refers to the physical and institutional aspects of care settings, such as employees, facilities, and other material resources. Patients seeking care and professionals’ treatments and suggestions are examples of clinical encounters that describe the process. These two components interact to change the outcome, which encompasses changes in health status, behavior, and health literacy of the patients and populations. These three variables can be used to make inferences regarding health care quality [10]. As a result, the prior study [7] applied this model to build the questionnaire that we have taken.

Data quality assurance.

To ensure the quality of the data, the data collectors and supervisors were trained for 2 days on the basics of data collection skills and orientation to the ODK application. The questionnaire was designed on the Kobo Toolbox server carefully to allow optional and mandatory questions by skip logic to minimize missing data. The tool, which was first written in English, was translated into Amharic.

Before the actual data collection period, the questionnaire was checked for clarity, comprehensiveness, and internal consistency reliability using a Cronbach alpha (α = 0.946) on 5% of the sample. Finally, possible modifications were made to the questions. The supervisor evaluated and validated the obtained data for completeness and consistency during data collection, and data collectors were immediately notified if the survey forms were incomplete or incorrectly filled in.

Data processing and analysis.

Open Data Kit (ODK) version 2022.1.2 software was used to collect the data, along with the Kobo Toolbox server to store the collected data, and it was exported to SPSS version 26 for analysis. Before data export, it was checked for completeness, and frequency was run to rule out any missing values. Then the data was coded and revalued on SPSS, frequency distributions were run, and further cleansing and checking for missing values and errors were done.

The sample was described using descriptive statistics, and numerical data was reported as mean, standard deviation, proportion, or percent. A logistic regression model was used for both bivariate and multivariable analysis to identify determinants of the quality of BEmONC services among groups of independent variables. Independent variables with a p-value of < 0.25 that were biologically plausible and showed significant associations in the previous studies were included in the multivariable analysis to control for all possible confounders.

The Hosmer and Lemeshow statistics were used to check the goodness of fit of the model. The variance inflation factor (VIF) was used to assess multicollinearity. However, no multicollinearity was detected as the variance inflation factor was less than five. An adjusted odds ratio (AOR) with a 95% CI was estimated to assess the strength of associations, and statistical significance was declared at a p-value ≤ 0.05. Results were presented using tables, figures, and texts.

Ethical approval and consent to participate.

Ethical clearance was received from the departmental research and ethical review committee of the department of emergency medicine at Addis Ababa University. An official letter of permission from the department was submitted to the selected health centers. Informed consent was obtained from each participant before an interview. Throughout the study period, information was recorded anonymously, and confidentiality was ensured. All methods were performed in accordance with the Declaration of Helsinki.

Results

Socio-demographic/economic features

Out of 377 eligible mothers, 353 women who gave birth at the 11 public health centers found in Addis Ababa took part in the interview, which resulted in a response rate of 94%. A total of 153 (43.3%) of the women were aged between 25 and 29 years, with a mean of 28 ( ± 4.7); 339 (96%) of the women were from urban areas; 41 (11.6%) had not had any formal education; 206 (58.4%) of them were housewives; and 335 (94.9%) of them were married. The median monthly income was 4,500 ETB per month (Table 1).

Table 1. Socio- demographic/economic characteristics of participants at public health centers in Addis Ababa, Ethiopia, in 2022 (n = 353).

Characteristics	Frequency	Percent
Age category
15–19	3	0.8
20–24	68	19.3
25–29	153	43.3
30–34	79	22.4
>35	50	14.2
Residence
Urban	339	96
Rural	14	4
Educational level
No formal education	41	11.6
Primary level	140	39.7
Secondary level	104	29.5
Diploma	31	8.8
Degree and above	37	10.5
Occupation
Governmental	41	11.6
Private	84	23.8
Daily laborer	21	5.9
House wife	206	58.4
Others	1	0.3
Marital status
Single	4	1.1
Married	335	94.9
Divorced	9	2.5
Widowed	5	1.4
Husband’s education
No formal education	21	5.9
Primary level	85	24.1
Secondary level	133	37.7
Diploma	30	8.5
Degree and above	66	18.7
Husband’s occupation
Governmental	71	20.1
Private	187	53
Daily laborer	53	15
Unemployed	4	1.1
Driver	17	4.8
Other	3	0.8
Average monthly income category (ETB)
0–1500	40	11.3
1,501–3,000	100	28.3
3,001–4,500	43	12.2
4,501–6,000	66	18.7
>6,000	104	29.5

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Obstetric characteristics of participants

From the total of 353 mothers, more than half (61.5%) were multigravida; the vast majority (97.7%) of the mothers had antenatal care (ANC) visits for this current pregnancy; and 339 (96%) of the mothers became pregnant by choice for this current pregnancy. Two hundred twenty-three (63.2%) participants waited less than 15 minutes, followed by 68 (19.3%) 15 to 30 minutes, 33 (9.3%) above 1 hour, and 29 (8.2%) 30 minutes to 1 hour before receiving any service or care. Twenty (5.7%) of the women had no companion (attendant) in the waiting room, labor unit, and postnatal unit during their stay. Spontaneous vaginal delivery was the dominant mode of delivery (96.3%), followed by 13 (3.7%) assisted vaginal deliveries, but there was no report of abortion. Two-thirds (75.6%) of the women did not pay for any of the services in the health centers during their stay (Table 2).

Table 2. Obstetric characteristics of participants at public health centers in Addis Ababa, Ethiopia, 2022 (n = 353).

Characteristics	Frequency	Percent
Gravidity
Primigravida	136	38.5
Multigravida	217	61.5
ANC Visit
Yes	345	97.7
No	8	2.3
Desire of Current Pregnancy
Wanted	339	96
Unwanted	14	4
Type of Visit
Planned (Direct)	346	98
Referred	7	2
Mode of Transportation
Ambulance	49	13.9
Public transportation	228	64.6
On foot	44	12.5
Ride	23	6.4
Other	9	2.6
Waited Time to Receive service
< 15 Minutes	223	63.2
15 – 30 Minutes	68	19.3
30 Minutes – 1 Hour	29	8.2
>1 Hours	33	9.3
Presence of Companion During Stay
Yes	333	94.3
No	20	5.7
Mode of Delivery
Spontaneous Vaginal Delivery	340	96.3
Assisted Vaginal Delivery	13	3.7
Health Outcome of Mother after Delivery
Normal	312	88.4
With Complication	41	11.6
Birth Outcome of Newborn
Alive	352	99.7
Still birth	1	0.3
Health Problem of Newborn
Yes	41	11.6
No	312	88.4
Payment
Yes	86	24.4
No	267	75.6

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Quality of basic emergency obstetric and newborn care services from the perspective of mothers

Input.

From the 353 respondents, the overall quality of the input from the perspective of women, those scored greater than or equal to the mean of 15 (60%) or rated as good quality, was 174 (49.3%). The mothers expressed that the most contributing characteristic for rating the quality as good was the sanitation of the wards (70.5%), while the most contributing characteristic for rating the quality as poor was the availability of functional and clean shower and toilet rooms (38.2%) (Table 3).

Table 3. Quality of BEmONC services regarding input at public health centers in Addis Ababa, Ethiopia, 2022 (n = 353).

Characteristics	Good F (%)	Poor F (%)
Availability of necessary equipment’s	211(59.8)	142(40.2)
Adequate no of health providers	183(51.8)	170(48.2)
Sufficient bed, room, and space for laboring and delivering mothers	209(59.2)	144(40.8)
Sanitation of the wards	249(70.5)	104(29.5)
Functional and clean shower and toilet room	135(38.2)	218(61.8)

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Process.

From the 353 respondents interviewed, the overall quality regarding the process from the perspective of women, those who scored greater than or equal to the mean of 57 (70%) or rated as good quality, was 216 (61.2%). The women expressed staff support in breastfeeding their babies immediately after birth as the most important aspect in rating them as good quality (90.7%). However, asking permission before applying any examination or procedure (48.4%) was the major contributing aspect to rating them as poor quality, followed by the availability of health providers (59.8%) (Table 4).

Table 4. Quality of BEmONC services regarding processes, at public health centers found in Addis Ababa city, Ethiopia, 2022 (n = 353).

Characteristics	Good	Poor
Respect and courtesy by the health providers	237 (67.1)	116 (32.9)
The environment where you were laboring was comfortable	257 (72.8)	96 (27.2)
Active follow-up on the progress of labor	256 (72.5)	97 (27.5)
Permission before applying any examination and procedures	171 (48.4)	182 (51.6)
Progress of labor explanation by using clear and local language	221 (62.6)	132 (37.4)
Similar advice or information given by staff members	259 (73.4)	94 (26.6)
Health workers spent enough time for examination	246 (69.7)	107 (30.3)
Verbally encouraged, reassured and praised	252 (71.4)	101 (28.6)
Received enough care and help during the course of labor	228 (64.6)	125 (35.4)
Competence and confidence of health providers	230 (65.2)	123 (34.8)
Privacy well-kept in the delivery room	255 (72.2)	98 (27.8)
Received adequate care and support during delivery	226 (64)	127 (36)
Availability of health providers	211 (59.8)	142 (40.2)
Breast-feeding assistance from the staff immediately after birth	320 (90.7)	33 (9.3)
Got counseling on how to take care of baby	248 (70.3)	105 (29.7)
Your baby received enough care and support	235 (66.6)	118 (33.4)

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Outcome (satisfaction).

Out of the 353 respondents, the overall quality of the outcome from the perspective of women, those who scored greater than or equal to the mean of 31 (70%) or rated as good quality, was 192 (54.4%). Mothers expressed that the most contributing characteristic for rating them as good quality was health professionals’ respect for their privacy during their stay (73.1%), whereas the most common aspect contributing to rating the quality as poor was involving them in decision-making about themselves and their baby’s condition (43.1%), followed by the number of health workers in the labor and delivery ward (51.3%) (Table 5).

Table 5. Quality of BEmONC services regarding output at public health centers in Addis Ababa city, Ethiopia, 2022. (n = 353).

Characteristics	Good F (%)	Poor F (%)
Respected your personal culture and religion	215 (60.9)	138 (39.1)
Health care providers respect of your privacy during your stay	258 (73.1)	95 (26.9)
No of health care workers in labor and delivery ward	181 (51.3)	172 (48.7)
Health workers competency and confidence	236 (66.9)	117 (33.1)
Communication between different health care providers	246 (69.7)	107 (30.3)
Decision making involvement	152 (43.1)	201 (56.9)
Total counseling received during your health center stay	201 (56.9)	152 (43.1)
Total care and support provided during labor and delivery time	221 (62.6)	132 (37.4)
Total care and support provided for newborn baby	228 (64.6)	125 (35.4)

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The total quality of BEmONC services from the perspective of mothers

The total quality was computed by considering all three quality assessment aspects; these are input, process, and outcome. The quality was categorized based on the overall mean and its percentage. The proportion of those who scored greater than or equal to the overall mean of 104 (70%) or rated the quality as good in this study was 201 (56.9%) with a 95% confidence interval (51.6, 62.2). The availability of functional, clean shower and toilet rooms 135 (38.2%), involving them in decision-making about them and their baby’s condition 152 (43.1%), and asking permission before applying any examination and procedures 171 (48.4%) were among the most rated as poorly addressed aspects in BEmONC services from the perspective of mothers in this study.

Characteristics related to the quality of BEmONC services from the perspective of mothers

In a multivariable analysis, mothers aged between 20 and 24 years old had a lower likelihood of viewing the quality of services as good than those > 35 years old (AOR = 0.362; 95% CI: 0.157–0.837). On the other hand, respondents whose average monthly income was less than 1500 ETB had two times higher odds of viewing the quality as good than those with an average monthly income of above 6000 ETB (AOR = 2.429; 95% CI: 1.026–5.753).

The presence of a companion was also one of the most important predictors of quality services; mothers who had a companion throughout their stay had an 18-fold higher chance of rating the quality as good than those alone (AOR = 18.557; 95% CI: 3.844–89.588). With regard to payment, respondents who had paid for any services or products during their stay in the health centers had lower odds of rating the quality as good than those freely serviced (AOR = 0.564; 95% CI: 0.327–0.971) (Table 6).

Table 6. Factors associated with the quality of BEmONC services from the perspective of mothers in bivariate and multivariable analysis in public health centers of Addis Ababa, Ethiopia, 2022.

Factors	Overall Quality		COR (95% CI)	AOR (95% CI)	P-value
Factors	Good	Poor	COR (95% CI)	AOR (95% CI)	P-value
Age category
15–19	2	1	1.226(0.104,14.455)	0.53(0.042,6.642)	0.623
20–24	27	41	0.404(0.191,0.854)	0.362(0.157,0.837)	0.017 ^*
25–29	93	60	0.95(0.493,1.832)	0.826(0.39,1.75)	0.618
30–34	48	31	0.949(0.458,1.965)	0.901(0.393,2.062)	0.804
>35	31	19	1	1
Average monthly income category
0-1500 ETB	27	13	2.077(0.966,4.464)	2.429(1.026,5.753)	0.044 ^*
1501-3000 ETB	59	41	1.439(0.827,2.503)	1.487(0.81,2.728)	0.2
3001-4500 ETB	24	19	1.263(0.618,2.580)	1.388(0.646,2.983)	0.401
4501-6000 ETB	39	27	1.444(0.774,2.694)	1.352(0.682,2.68)	0.387
> 6000 ETB	52	52	1	1
Presence of companion during stay
Yes	199	134	13.336(3.051,58.55)	18.557(3.844,89.588)	0.000 ^*
No	2	18	1	1
Payment
Yes	41	45	0.609(0.374,0.993)	0.564(0.327,0.971)	0.039 ^*
No	160	107	1	1

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Discussion

The proportion of good quality from the perspective of mothers in this study was 56.9% with a 95% C.I. (51.6, 62.2), which is lower than a study conducted in Irbid, North Jordan, 64% [19]. This disparity may be attributed to variations in healthcare infrastructure, resource availability, study design, assessment methods, and sample size. Additionally, patient expectations, prior healthcare experiences, and the type of health facilities may have influenced the difference.

When compared to studies conducted in Tigray, Ethiopia, the reported quality in this study (56.9%) was lower than that in three zones in Tigray (65.62%) and Adigrat, Tigray (66.3%) [7,20]. Possible reasons for this discrepancy include differences in study population, the types of health facilities, and mothers’ expectations of care, which can be influenced by urban versus rural residence, educational status, and income level.

However, the finding in this study showed a higher quality rating than a study done in the Jabi Tehinan district of Northwest Ethiopia, where only 13% of mothers reported good quality of intrapartum care services [21]. This difference may be due to variations in healthcare infrastructure, health workforce capacity, and study setting, as Addis Ababa, being the capital city, has relatively better-equipped health centers and a higher number of skilled health professionals. Differences in study design and period may have also contributed to the observed variation.

In this study, several factors were found to be significantly associated with the quality of BEmONC services. These include maternal age, average monthly income, the presence of companions, and payment for services. This is consistent with a study conducted in Assela Hospital, Arsi, Oromia, Ethiopia, in which age, monthly income, and payment were important predictors [12].

Specifically, mothers aged between 20 and 24 years were less likely to report good quality compared to those above 35 years in this study; this implies that older mothers may have different expectations or experiences that lead to higher satisfaction. However, this finding contrasts with the Assela Hospital study, where women aged between 20 and 34 years reported higher satisfaction than those aged 35–49 years [12].

Income was another significant determinant of the quality of BEmONC from the mothers’ perspective. Mothers with an average monthly income below 1,500 ETB had twice the likelihood of rating the quality of care as good compared to those earning above 6,000 ETB. This finding is in line with a study done in Assela Hospital, Arsi, Oromia, Ethiopia [12]. The possible reasons may be due to expectations based on income level, suggesting that lower-income women may have fewer healthcare options and lower expectations, leading to relatively higher satisfaction with public health centers. Higher-income women, by contrast, may have greater access to private healthcare and have higher expectations, which, when unmet, may lead to lower ratings of public health center services.

The presence of a companion was one of the most important predictors of the quality of BEmONC service. Mothers who had a companion or attendant had 18-fold higher odds of rating quality as good compared to those who were alone. This finding is in line with studies from Brazil and Adigrat, Tigray, Ethiopia [7,22]. This may be due to emotional and psychological support provided by the companions and reduced feelings of neglect. In addition, the reason could also be due to the mother’s expectations and the way in which they perceived their care.

Additionally, payment for services was a significant predictor of the quality of BEmONC services. Respondents who had paid for the services had lower odds of reporting good quality compared to those who received free services. This finding is consistent with a study done in three hospitals in Amhara, Ethiopia, where mothers who paid less than or equal to one hundred fifty-seven ETB were more satisfied than those who paid above one hundred fifty-seven ETB [8]. This could be because of the poor socio-economic status of the women.

Strengths and limitations of the study

The strength of this study is its use of the Donabedian framework to assess quality BEmONC services from the perspective of mothers by using all three aspects of quality assessment methods: input, process, and outcome (satisfaction). This study was multi-centered, which increases the representativeness of the findings. This study used ODK version 2022.1.2 software to collect the data, along with a Kobo Toolbox humanitarian response server to store the collected data, and it minimizes error.

However, limitations include that the data was limited to deliveries in public health centers, restricting generalization to mothers’ total childbirth experiences in health facilities. This study, like other cross-sectional studies, has its own set of design limitations. Utilizing only a quantitative approach to assess quality may not be sufficient to see how mothers’ experience. The fact that the study was conducted in a health facility may have influenced the results in favor of the healthcare professionals. Additionally, potential recall and response bias, as mothers’ satisfaction may have been influenced by their most recent experience rather than an objective assessment of care quality.

Conclusion

The total quality of BEmONC services from the viewpoint of mothers was suboptimal. This research strongly recommends that more should be done to ensure that the services given are more client-centered. The mothers stated that the most contributing aspects to rating the quality as poor in this study were the inadequate availability of functional, clean shower and toilet rooms; not involving them in decision-making about them as well as their baby’s condition; and not asking permission before applying any examination and procedures.

Mothers between the ages of 20 and 24 years, as well as mothers who paid for the services, were more likely to rate the services as poor. On the other hand, mothers who had a companion or attendant during their stay and whose average monthly income was less than 1500 ETB were more likely to rate the services as good quality.

Supporting information

S1 File. English version questionnaire to Plos.

(DOCX)

pone.0320729.s001.docx^{(22.3KB, docx)}

S2 File. Quality of BeMONC SPSS.

(XLSX)

pone.0320729.s002.xlsx^{(75.6KB, xlsx)}

Abbreviations

ANC: Antenatal care
AOR: Adjusted Odds Ratio
BEmONC: Basic Emergency Obstetric and Newborn Care
CEmONC: Comprehensive Emergency Obstetric and Newborn Care
EDHS: Ethiopian Demographic and Health Survey
EmONC: Emergency Obstetric and Newborn Care
ODK: Open Data Kit
SPSS: Statistical Package for Social Sciences
UNFPA: United Nations Population Fund
UNICEF: United Nations Children’s Fund
VIF: Variance Inflation Factor
WHO: World Health Organization.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. 2025 Apr 3;20(4):e0320729. doi: 10.1371/journal.pone.0320729.r001

Author response to Decision Letter 0

26 Jan 2024

PLoS One. doi: 10.1371/journal.pone.0320729.r002

Decision Letter 0

Mengstu Melkamu Asaye

23 Jan 2025

PONE-D-24-01243Quality of Basic Emergency Obstetric and Newborn Care Services from Patients’ Perspective in Selected Public Health Centers in Addis Ababa, Ethiopia, 2022: A Cross-Sectional StudyPLOS ONE

Dear Dr. Bahre,

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Additional Editor Comments:

Reviewers 1

1) Summary of the research and your overall impression

This was a research conducted to assess the quality of Basic Emergency Obstetric and New-born Care services from patients' perspective in 11 public Health Facilities in Addis Ababa Ethiopia. The paper sought to establish the contribution of mothers' perspective on the care they received at the health facility in relation to their health outcomes. It provided evidence that factors such as patient purchasing power ,the patient being accompanied to the hospital and the mothers' age influenced their rating of the services received from the health facility. This study is relevant to the current literature because it allows policy makers to understand challenges which when addressed can increase the quality of care an overall reduce maternal and new-born mortality. Also, the study provides a unique opportunity to understand behavioural challenges that negatively impact on the experience of mothers while at the health facility such as administration of medication without informing them or not being courteous toward the mothers. Furthermore the study was well researched with current and relevant literature.

However, I feel the information on the quality of BEmONC based on the BEmONC signal functions is lacking which will be insightful, particularly in their appreciation of whether the dispensation of all signal functions from the mother's perspective aligns with what is expected as per the national guidelines. Also, in line 4 of page 6 the author states that the health facilities were selected through a simple random sampling method and does not clarify whether all eleven health facilities provided BEmONC services. Overall this was a well researched subject that has the potential to influence policies in the domain of preventing and managing obstetrical complications.

2)Major Issues

• It is not clear from the write up how many of the chosen facilities actually practiced BEmONC. I suggest the author states in the form of a table the facilities and categorize them as performing BEmONC or not, in addition the catchment populations of the facilities should be included to allow readers have an idea of the patient influx ,finally the number of patient captured per facility should be stated as this allows readers to better understand the conclusions drawn from the study.

• The author demonstrated a good mastery of the subject in the discussion section by pointing out discrepancies and using other studies to support their claims ,however the discussion was not well structured alternatively, the author should use the STROBE guideline linked here:https://www.strobe-statement.org/ to improve the structure of the discussion section.

• The authors clearly put in efforts to ensure their study was conformed to ethical considerations. However in paragraph 2 of page 9 entitled "Ethical Consideration" ,the author states in line 7 that verbal consent was obtained from participants ,however we note on table 1 the age group includes minors of 15 years ,could the author state if consent was obtained from their guardians for the purpose of this study.

• Under methods and materials of page 5, the author failed to indicate who was included or excluded from the study even though they belonged to the study population, to avoid confusion the author should boldly outline and inclusion and exclusion criteria for the study.

• In the discussion section the author aimed to demonstrate that discrepancies observed between the studies compared could be due to element such as a difference in culture , difference in national guideline.... however this approach undermines the efforts of the team by not comparing valuable information such as the difference in study design, study population, or the methodology used in both studies. In case the author wishes to attribute the differences to the culture, or the national guideline or other element as they may see fit , this should be substantiated by stating exactly what the difference is.

3) Minor Issues

• In paragraph 3 of the discussion entitled study limitation the author states element that reduce the validity of the study and failed to demonstrate the strengths of the study that that minimized the study limitations. Alternatively, the author should state the study limitations and how it was minimized.

• On page 7 line 15 ,the definition of signal function, "Consequences" should be replaced by "Complications"

• On Page 7 line 17 "is" should be removed.

Reviewer 2

Comments to the Author

Manuscript Number: PONE-D-24-01243

The manuscript titled " Quality of Basic Emergency Obstetric and Newborn Care Services from Patients’ Perspective in Selected Public Health Centers in Addis Ababa, Ethiopia, 2022: A Cross-Sectional Study " is important research that adds to present knowledge on obstetric violence. The study was generally well conducted but the authors need to address pertinent issues.

My comments are as follows:

Abstract:

Line 24: The gap in this study has not been adequately addressed, highlighting a significant oversight in the research process. Without a thorough exploration of this gap, the study may lack depth and fail to contribute meaningfully to the existing body of knowledge. So, addressing this issue will enhance the overall rigor and relevance of the research.

Next to line 27: Please ensure that the aim/objective of the study are included into the abstract section. This addition will provide clarity and context for readers.

Line 34: The final model identified several significant variables: age, income, companion, and payment. However, the results section only addressed two of these variables—companion and payment. For clarity and consistency, all significant variables should be discussed.

Line 42: Add your recommendation

Background

The discussion is well-presented, but addressing the gaps will strengthen it and make it more convincing.

Methods and material

Study setting and period

I recommend that you include the number of health facilities, the number of healthcare providers—particularly obstetric healthcare providers—and the number of women who utilized BEmONC services.

Population

How did you determine whether the women received at least one Basic Emergency Obstetric and Newborn Care (BEmONC) signal function service in order to include them in your study?

Line 121-123: Please provide the average number of one-month postnatal mothers to clarify the calculation of the k-th interval for selecting the study population.

Operational definition

The author should provide clear definitions for all components of the Donabedian model(input, process and output) to offer a more detailed understanding.

Results

Socio demographic features

Line 229: Since the table includes economic variables, it would be more appropriate to refer to it as sociodemographic/economic features.

Line 231: What were the reasons for the 6% of your sample size that did not participate in the study?

Table 1: You have three participants whose ages are under 18, classifying them as minors. This population typically requires support from their guardians or partners to participate in the study. Did you obtain assent from these minors before conducting the interviews? Additionally, how did you address the ethical considerations related to including children in your research activities?

Table 1: While the study thoroughly examined all variables related to women's sociodemographic, it notably overlooked the variables associated with husbands or partners. This omission is significant, as the role of a husband can greatly influence various aspects of women's health and well-being.

Table 1: ` What was the rationale behind classifying income in this manner? The classification of women's income is unclear. Could you please provide a detailed explanation of how it was operationalized?

Obstetric characteristics of participants

Line 272: I recommend creating a table to present the obstetric characteristics, as this will help readers easily grasp the overall context of maternal-related issues.

Line 2273-274: While it is acceptable to report whether the mothers had antenatal care (ANC) visits, what is crucial is the total number of contacts these women had with healthcare providers. This aspect has not been addressed in the study.

Line 274: “339 (96%) of them wanted pregnancy for this current one” …. This not clear. Please make it clary and understandable by the readers

Line 278-280: Do you think women can determine properly the amount of time they spend before receiving the services. Have you cross checked their responses with other mechanisms

Line 280: Companionship is an important intervention that enhances maternal healthcare services, and it is also a fundamental right for women to have during the utilization of maternal health services. In the study, “Twenty (5.7%) of the women had no companion (attendant) 281 during their stay “…this is too general. So, it should be specified where (service units) women utilize the companionship.

Line 285-286: The study revealed “Two-thirds (75.6%) of the 286 women did not pay for any of the services in the health centers during their stay.” This indicates that approximately 25% of women have covered their medical expenses. However, the Ethiopian government has exempted nearly all maternal healthcare services from charges for women. What accounts for this discrepancy in your findings?

Line 289- 290: in the methods section you operationalized good quality as the quality of BEmONC services from the mothers’ perspective when the mothers 161 scored greater than or equal to the mean of 104 (70%) of all the quality questions. However; in the result section good quality defined as those who scored greater than or equal to the mean of 15 (60%) or rated as good quality, was 174 291 (49.3%). This is contradicted with each other. Look at also the quality measures for process and output. Please see it carefully.

Line 377: In addition to the percentage, please include the frequency for the variables. For example, you could present it as frequency (56.9%).

Table 5: Avoid relying solely on statistical hypothesis testing, such as P values, which fail to convey important information about effect size and precision of estimates. thus, focusing on confidence interval can clearly explain the significance of the variables. Better if you delete the p-value.

Table 5: I have observed wide confidence interval in the final model. A wide confidence interval (CI) indicates a high level of uncertainty regarding the estimated parameter, suggesting that the sample does not provide a precise representation of the population. It suggests that there is insufficient evidence to make definitive conclusions about the parameter being estimated. This can occur due to smaller sample size, high variability or dispersion within the sample data and others. check it.

Discussion

Line 435- 437: the way you justify somehow it is not convincing. Please discuss how your findings relate to existing literature, highlighting both similarities and differences with previous studies.

The study compares and contrasts only a limited number of variables and lacks evidence-based justifications for the discrepancies and similarities between the studies. Therefore, the author should provide strong scientific reasoning for any inline studies and those that align with the findings.

Limitation

While it is important to acknowledge the limitations of your study, it is equally essential to discuss its strengths. Why was this aspect overlooked in your explanation?

Conclusion

Line 473 says the total quality of BEmONC services from the viewpoint of mothers was suboptimal. What was your criteria to declare as it is suboptimal? What was your comparator?

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1) Summary of the research and your overall impression

2)Major Issues

3) Minor Issues

• On page 7 line 15 ,the definition of signal function, "Consequences" should be replaced by "Complications"

• On Page 7 line 17 "is" should be removed.

Reviewer #2: Comments to the Author

Manuscript Number: PONE-D-24-01243

My comments are as follows:

Abstract:

Next to line 27: Please ensure that the aim/objective of the study are included into the abstract section. This addition will provide clarity and context for readers.

Line 42: Add your recommendation

Background

The discussion is well-presented, but addressing the gaps will strengthen it and make it more convincing.

Methods and material

Study setting and period

I recommend that you include the number of health facilities, the number of healthcare providers—particularly obstetric healthcare providers—and the number of women who utilized BEmONC services.

Population

How did you determine whether the women received at least one Basic Emergency Obstetric and Newborn Care (BEmONC) signal function service in order to include them in your study?

Line 121-123: Please provide the average number of one-month postnatal mothers to clarify the calculation of the k-th interval for selecting the study population.

Operational definition

The author should provide clear definitions for all components of the Donabedian model(input, process and output) to offer a more detailed understanding.

Results

Socio demographic features

Line 229: Since the table includes economic variables, it would be more appropriate to refer to it as sociodemographic/economic features.

Line 231: What were the reasons for the 6% of your sample size that did not participate in the study?

Obstetric characteristics of participants

Line 272: I recommend creating a table to present the obstetric characteristics, as this will help readers easily grasp the overall context of maternal-related issues.

Line 274: “339 (96%) of them wanted pregnancy for this current one” …. This not clear. Please make it clary and understandable by the readers

Line 278-280: Do you think women can determine properly the amount of time they spend before receiving the services. Have you cross checked their responses with other mechanisms

Line 377: In addition to the percentage, please include the frequency for the variables. For example, you could present it as frequency (56.9%).

Discussion

Line 435- 437: the way you justify somehow it is not convincing. Please discuss how your findings relate to existing literature, highlighting both similarities and differences with previous studies.

Limitation

While it is important to acknowledge the limitations of your study, it is equally essential to discuss its strengths. Why was this aspect overlooked in your explanation?

Conclusion

Line 473 says the total quality of BEmONC services from the viewpoint of mothers was suboptimal. What was your criteria to declare as it is suboptimal? What was your comparator?

**********

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2025 Apr 3;20(4):e0320729. doi: 10.1371/journal.pone.0320729.r003

Author response to Decision Letter 1

9 Feb 2025

January 28, 2025

Dear Editor,

Thank you for giving us the opportunity to submit the revised draft of our manuscript entitled “Quality of Basic Emergency Obstetric and Newborn Care Services from Patients’ Perspective in Selected Public Health Centers in Addis Ababa, Ethiopia 2022: A Cross-Sectional Study” to PLOS ONE. We appreciate the time and effort that you and the reviewers have dedicated to providing your valuable feedback on our manuscript. We are grateful to you and the reviewers for the insightful comments on our paper. We have tried to revise our manuscript in accordance with the suggestions and comments provided by you and the reviewers.

Here is a point-by-point response to the comments made by the reviewers, the editor, and the editorial staff.

Sincerely,

Willi Bahre

Adigrat University, Ethiopia

E-mail: willibahre21@gmail.com

Phone number: +251-9 77755583

Part One: Point-by-point responses to editor and editorial staff

Please include the following items when submitting your revised manuscript:

� A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers.

Response: Uploaded

� A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes.

Response: A revised manuscript with track changes is submitted in accordance with the instruction.

� An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript.

Response: A revised manuscript without tracked changes is submitted in accordance with the instruction.

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: It meets PLOS ONE’s style requirements.

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar.

Response: Modified

3. We note that your Data Availability Statement is currently as follows: All relevant data are within the manuscript and its Supporting Information files.

Response: Incorporated

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly.

Response: Modified

Part Two: Point-by-point responses to reviewers

Reviewer 1

Thank you, dear reviewer, for reviewing our paper. We have answered each of your points below.

1. However, I feel the information on the quality of BEmONC based on the BEmONC signal functions is lacking which will be insightful, particularly in their appreciation of whether the dispensation of all signal functions from the mother's perspective aligns with what is expected as per the national guidelines.

Response: Dear reviewer, thank you for your valuable feedback. We fully agree with your idea. In response, we have incorporated all seven signal functions of Basic Emergency Obstetric and Newborn Care (BEmONC) services and analyzed them from the mother’s perspective to determine whether their delivery aligns with what is stipulated by the national guidelines.

Also, in line 4 of page 6 the author states that the health facilities were selected through a simple random sampling method and does not clarify whether all eleven health facilities provided BEmONC services.

Response: We agreed with this comment, dear reviewer. Yes, all the selected eleven public health centers in Addis Ababa provided Basic Emergency Obstetric and Newborn Care (BEmONC) services. Therefore, we have incorporated it in the revised manuscript.

2. Major Issues

It is not clear from the write up how many of the chosen facilities actually practiced BEmONC. I suggest the author states in the form of a table the facilities and categorize them as performing BEmONC or not, in addition the catchment populations of the facilities should be included to allow readers have an idea of the patient influx, finally the number of patients captured per facility should be stated as this allows readers to better understand the conclusions drawn from the study.

Response: Dear Reviewer, Thank you for your thoughtful comment. To clarify, all the selected eleven public health centers in Addis Ababa, Ethiopia practiced Basic Emergency Obstetric and Newborn Care (BEmONC) services. Since our study was aimed at assessing the quality of BEmONC from a mother's perspective rather than the availability of BEmONC services, it is not necessary to create a table. Specifically, we have included the catchment populations of the selected facilities to provide insight into patient influx. Additionally, we have stated the number of patients captured per facility. We have now made this explicit in the revised manuscript to ensure clarity.

The author demonstrated a good mastery of the subject in the discussion section by pointing out discrepancies and using other studies to support their claims, however the discussion was not well structured alternatively, the author should use the STROBE guideline linked here: https://www.strobe-statement.org/ to improve the structure of the discussion section.

Response: We agreed with this comment, dear reviewer. Modified using STROBE guideline in the revised manuscript.

The authors clearly put in efforts to ensure their study was conformed to ethical considerations. However, in paragraph 2 of page 9 entitled "Ethical Consideration”, the author states in line 7 that verbal consent was obtained from participants, however we note on table 1 the age group includes minors of 15 years, could the author state if consent was obtained from their guardians for the purpose of this study.

Response: Dear Reviewer, thank you for your insightful comment. We fully accept this suggestion. While there were three participants in the age category of 15–19 years, it is important to note that two of them were 18 years old, and the third was 19 years old. Therefore, verbal consent was obtained directly from the participants themselves. We appreciate your feedback and the opportunity to clarify this aspect of our study.

Under methods and materials of page 5, the author failed to indicate who was included or excluded from the study even though they belonged to the study population, to avoid confusion the author should boldly outline and inclusion and exclusion criteria for the study.

Response: We appreciate your valuable comment and fully agree with your suggestion. In response, we have explicitly defined the inclusion and exclusion criteria in the revised manuscript to ensure clarity and a better understanding. (Line 116-122)

In the discussion section the author aimed to demonstrate that discrepancies observed between the studies compared could be due to element such as a difference in culture, difference in national guideline.... however, this approach undermines the efforts of the team by not comparing valuable information such as the difference in study design, study population, or the methodology used in both studies.

Response: Dear reviewer, thank you for your valuable comment. We modified it in the revised document.

3. Minor Issues

In paragraph 3 of the discussion entitled study limitation the author states element that reduce the validity of the study and failed to demonstrate the strengths of the study that that minimized the study limitations. Alternatively, the author should state the study limitations and how it was minimized.

Response: Modified (Line 501-506)

On page 7 line 15, the definition of signal function, "Consequences" should be replaced by "Complications"

Response: Changed (Line 163)

On Page 7 line 17 "is" should be removed.

Response: Removed (Line 165)

Reviewer 2

Thank you, dear reviewer, for reviewing our paper. We have answered each of your points below.

1. Abstract

Response: Thank you in advance dear for your critical reviewing. We modified it the revised document (Line 27-29).

Next to line 27: Please ensure that the aim/objective of the study are included into the abstract section. This addition will provide clarity and context for readers.

Response: We definitely agreed with your comment dear. Modified in the revised manuscript (Line 30-32).

Line 34: The final model identified several significant variables: age, income, companion, and payment. However, the results section only addressed two of these variables companion and payment. For clarity and consistency, all significant variables should be discussed.

Response: Modified (Line 42-44 and 46-48)

Line 42: Add your recommendation

Response: Modified (Line 51 and 52)

2. Background

The discussion is well-presented, but addressing the gaps will strengthen it and make it more convincing.

Response: We accepted the comment and modified.

3. Methods and material

Study setting and period

I recommend that you include the number of health facilities, the number of healthcare providers, particularly obstetric healthcare providers and the number of women who utilized BEmONC services.

Response: Modified (Line 101-103, 105-108)

Population

How did you determine whether the women received at least one Basic Emergency Obstetric and Newborn Care (BEmONC) signal function service in order to include them in your study?

Response: We know by asking postpartum women about the interventions they received during labor and delivery.

Line 121-123: Please provide the average number of one-month postnatal mothers to clarify the calculation of the kth interval for selecting the study population.

Response: Modified (Line 134-137)

Operational definition

The author should provide clear definitions for all components of the Donabedian model (input, process and output) to offer a more detailed understanding.

Response: We agreed with your comment and we have added additional operational definitions that we have used. (Line 184-188)

4. Results

Socio demographic features

Line 229: Since the table includes economic variables, it would be more appropriate to refer to it as sociodemographic/economic features.

Response: Incorporated in the revised manuscript. (Line 236)

Line 231: What were the reasons for the 6% of your sample size that did not participate in the study?

Response: 24 (6%) of the participants were not volunteer to participate (they refused to take part in the interview). So, this was compensated by non-response rate. Since we have considered 10% non-response rate during sample size calculation.

Response: Dear reviewer, thank you in advance for your critical reviewing. We fully accept this suggestion. While there were three participants in the age category of 15–19 years, it is important to note that two of them were 18 years old, and the third was 19 years old. Therefore, since we have no minors in our study verbal consent was obtained directly from the participants themselves.

Response: We appreciate your concern dear. However, we are incorporated important husband related variables such as husband’s education, husband’s occupation in table one and presence of companion or attendant in the obstetric characteristics of participants part.

Table 1: What was the rationale behind classifying income in this manner? The classification of women's income is unclear. Could you please provide a detailed explanation of how it was operationalized?

Response: Dear Reviewer, Thank you for your comment. We have taken this category of women’s income from a study conducted in Adigrat, Tigray, Ethiopia, which focused on a similar topic. We believe this source is relevant and aligns with the context of our data.

Obstetric characteristics of participants

Line 272: I recommend creating a table to present the obstetric characteristics, as this will help readers easily grasp the overall context of maternal-related issues.

Response: Modified it in the revised document. (Line 295)

Line 273-274: While it is acceptable to report whether the mothers had antenatal care (ANC) visits, what is crucial is the total number of contacts these women had with healthcare providers. This aspect has not been addressed in the study.

Response: We definitely agreed with your comment dear. Our intention was to assess the quality of BEmONC services and associated factors from the perspective of mothers in selected public health centers in Addis Ababa, Ethiopia. So, we think it is a sufficient indicator to report the presence of ANC follow-up rather than the number of ANC visits.

Line 274: “339 (96%) of them wanted pregnancy for this current one” …. This not clear. Please make it clary and understandable by the readers.

Response: Clarified in the revised manuscript. (Line 275 and 276)

Line 278-280: Do you think women can determine properly the amount of time they spend before receiving the services. Have you cross checked their responses with other mechanisms.

Response: We definitely agreed with your comment dear. Yes, we have cross checked it with their medical records.

Line 280: Companionship is an important intervention that enhances maternal healthcare services, and it is also a fundamental right for women to have during the utilization of maternal health services. In the study, “Twenty (5.7%) of the women had no companion (attendant) during their stay “…this is too general. So, it should be specified where (service units) women utilize the companionship.

Response: Dear reviewer, we accepted this comment. Modified (Line 279 and 280)

Line 285-286: The study revealed “Two-thirds (75.6%) of the women did not pay for any of the services in the health centers during their stay.” This indicates that approximately 25% of women have covered their medical expenses. However, the Ethiopian government has exempted nearly all maternal healthcare services from charges for women. What accounts for this discrepancy in your findings?

Response: Dear reviewer, thank you for your valuable feedback. Even though, the Ethiopian government has exempted nearly all maternal healthcare services are free from charges; in our study 24.4% of the women reported that they went to nearby private clinics for different laboratory checkups and ultrasound due to unavailability of the services in the health centers during their stay.

Line 289- 290: In the methods section you operationalized good quality as the quality of BEmONC services from the mothers’ perspective when the mothers scored greater than or equal to the mean of 104 (70%) of all the quality questions. However; in the result section good quality defined as those who scored greater than or equal to the mean of 15 (60%) or rated as good quality, was 174 291 (49.3%). This is contradicted with each other. Look at also the quality measures for process and output. Please see it carefully.

Response: Dear reviewer, we accepted this comment. The total good quality from the mothers’ perspective regarding input was, these scored ≥ to the mean of 15 (60), which was 174 (49.3%). The total of good quality from the perspective of women regarding process was, these scored ≥ to the mean of 57 (70%), which was 216 (61.2%). The total of good quality regarding output / satisf

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PLoS One. doi: 10.1371/journal.pone.0320729.r004

Decision Letter 1

Mengstu Melkamu Asaye

25 Feb 2025

Quality of Basic Emergency Obstetric and Newborn Care Services from Patients’ Perspective in Selected Public Health Centers in Addis Ababa, Ethiopia, 2022: A Cross-Sectional Study

PONE-D-24-01243R1

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PLoS One. doi: 10.1371/journal.pone.0320729.r005

Acceptance letter

Mengstu Melkamu Asaye

PONE-D-24-01243R1

PLOS ONE

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S2 File. Quality of BeMONC SPSS.

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pone.0320729.s002.xlsx^{(75.6KB, xlsx)}

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Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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PERMALINK

Quality of basic emergency obstetric and newborn care services from patients’ perspective in selected public health centers in Addis Ababa, Ethiopia 2022: A cross-sectional study

Willi Bahre

Achamyelesh Tadele

Finot Debebe

Roles

Abstract

Background

Objective

Methods

Results

Conclusion and recommendation

Introduction

Materials and methods

Study setting and study period

Study design

Population

Inclusion and exclusion criteria

Sample size determination and sampling procedure

Data collection instruments and procedures

Operational definitions

Level of quality score in mean and percentage

Measurement of quality

Donabedian’s framework.

Data quality assurance.

Data processing and analysis.

Ethical approval and consent to participate.

Results

Socio-demographic/economic features

Table 1. Socio- demographic/economic characteristics of participants at public health centers in Addis Ababa, Ethiopia, in 2022 (n = 353).

Obstetric characteristics of participants

Table 2. Obstetric characteristics of participants at public health centers in Addis Ababa, Ethiopia, 2022 (n = 353).

Quality of basic emergency obstetric and newborn care services from the perspective of mothers

Input.

Table 3. Quality of BEmONC services regarding input at public health centers in Addis Ababa, Ethiopia, 2022 (n = 353).

Process.

Table 4. Quality of BEmONC services regarding processes, at public health centers found in Addis Ababa city, Ethiopia, 2022 (n = 353).

Outcome (satisfaction).

Table 5. Quality of BEmONC services regarding output at public health centers in Addis Ababa city, Ethiopia, 2022. (n = 353).

The total quality of BEmONC services from the perspective of mothers

Characteristics related to the quality of BEmONC services from the perspective of mothers

Table 6. Factors associated with the quality of BEmONC services from the perspective of mothers in bivariate and multivariable analysis in public health centers of Addis Ababa, Ethiopia, 2022.

Discussion

Strengths and limitations of the study

Conclusion

Supporting information

Abbreviations

Data Availability

Funding Statement

References

Author response to Decision Letter 0

Decision Letter 0

Mengstu Melkamu Asaye

Roles

Author response to Decision Letter 1

Decision Letter 1

Mengstu Melkamu Asaye

Roles

Acceptance letter

Mengstu Melkamu Asaye

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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