Reducing the unacceptably high maternal and perinatal morbidity and mortality rates in low-income countries requires considerable investment to increase access to, demand for, and use of skilled maternity care, alongside enhancing the quality of care delivered . In Ethiopia in 2017, 49%of 1010 reported maternal deaths occurred after women arrived at health facilities. Fourteen percent of these maternal deaths were attributed to a lack of supplies and equipment, 11% to delays in patient management at the facility, 6% to healthcare provider error and mismanagement, and 28% to referral delays from other facilities . Therefore, increasing access to, and utilization of, maternal healthcare alone is insufficient to improve maternal health outcomes . The quality of care a woman receives across ANC, intrapartum care, and PNC affects the health of the woman and her child and her likelihood of seeking care in the future [3, 4]. Measuring the quality of existing maternal healthcare and identifying its determinants are essential for planning improvements in current and future care .
While there has been a strong focus on improving access to healthcare during pregnancy, labour and delivery, and postnatal periods, there has been less emphasis on ensuring effective coverage or contact with the provision of all the recommended interventions during antenatal, intrapartum, and PNC services. This has resulted in missed opportunities to alleviate maternal and newborn morbidities and mortalities . Reaching the 2030 Sustainable Development Goals (SDGs) target of reducing the global maternal mortality ratio to less than 70/100,000 live births and the global neonatal mortality rates to less than 12/1,000 live births in Ethiopia requires a rapid improvement in maternal healthcare quality .
Maximizing the life-saving potential of ANC in low-resource settings requires a focus on quality. For many women around the globe, an ANC visit may be their first adult contact with the healthcare system. ANC, therefore, serves as a gateway to health services both during and beyond maternity care. In addition to diagnosing and managing pregnancy-related complications, ANC provides an opportunity to screen for and treat other chronic conditions and non-communicable diseases . However, in low-income settings, the mere focus on the proportion of mothers receiving four or more ANC contacts as a global benchmark indicator to track maternal health program performance than on the content and process of ANC is limiting the ability to early identify and address complications and maximize health outcomes .
Over the last two decades, women have been encouraged to give birth in health facilities to ensure access to skilled personnel and timely referral if required. However, giving birth in a health facility may not guarantee quality care . Disrespectful care has been reported in facilities that not only violate a woman's human rights but are a significant barrier to accessing future intrapartum care services [9, 10]. A negative experience in childbirth is associated with post-traumatic stress disorder, disruption to interpersonal relationships, and dysfunctional maternal-infancy bonding [11, 12].
Women and their newborns require support and careful monitoring after birth. Most maternal and infant deaths occur in the first six weeks after delivery, yet this remains a neglected area of care . Basic care for all newborns should include promoting and supporting early and exclusive breastfeeding if possible, keeping the baby warm, increasing handwashing, and providing hygienic umbilical cord and skincare. Families should be counselled to identify danger signs, understand the care that both the woman and newborn need, and where to reach services when needed. Promoting a healthy lifestyle and good nutrition, detecting and preventing diseases, supporting women who may be experiencing intimate partner violence, and ensuring access to sexual and reproductive health, including postpartum family planning, are also key to quality postnatal care .
Quality prenatal, intrapartum, and postnatal care are vital maternal healthcare services that should be delivered by skilled personnel. Quality ANC, according to the World Health Organization (WHO), includes nutritional counselling and multivitamin supplements, frequent visits (eight or above ANC contacts), blood and urine tests, preventive antibiotics, tetanus toxoid injections, and health education on pregnancy and birth danger signs [14, 15]. Respectful care, clear and compelling communication between the woman and her healthcare provider, the option of a companion during labour and delivery, delivery at a health facility, skilled personnel assistance, appropriate pain relief strategies, mobility in labour where possible, choice of birth position, use of uterotonics, delayed cord clamping (after a minute), immediate kangaroo care and breastfeeding, delayed bathing of the newborn (24 hours), and the care of mother and newborn in a health facility for at least 24 hours after delivery are all components of quality intrapartum care [15, 16]. Immediate PNC within 24 hours of birth and at least three additional PNC visits for the mother and the newborn within 42 days of birth, home visits in the first week after birth, exclusive breastfeeding, cord care, prophylactic antibiotics for the mother, and health education on maternal and newborn health danger signs are all components of quality PNC [15, 17].
Measuring the existing maternal healthcare quality and its determinants at a country level, using the nationally representative demographic and health survey (DHS) data, can identify gaps in care and provide insight into reducing maternal and newborn morbidity and mortality [18, 19]. There is currently no research that provides a comprehensive and standard view of the maternal healthcare quality across ANC, intrapartum care, and PNC services in Ethiopia to inform health service planning and improve outcomes.
One study focused on the quality of ANC and PNC in 20 sub-Saharan African countries, including Ethiopia. This research, based on a secondary analysis of DHSs data, revealed that while 51% of mothers received four or more ANC visits with at least one visit from skilled personnel, only 5% received eight ANC interventions (blood pressure measurement, urine and blood test, iron supplementation, tetanus protection, counselling on pregnancy complications, HIV testing and results, and three doses of intermittent preventive treatment of malaria in pregnancy). While 65% of births in this study were attended by skilled personnel, no data is provided concerning the interventions provided during intrapartum care. Only 3% of women received all seven PNC interventions (newborn weighed at birth, early initiation of breastfeeding, no pre-lacteal feed, BCG and polio vaccines, and PNC for mother and newborn within two days of birth) .
While no research has examined the quality of care across the three packages of maternal healthcare, two studies by Bayou et al. (2016) and Gebrekirstos et al. (2021) have assessed adequate ANC among slum residents in Addis Ababa, and Southern Ethiopia. These authors defined quality ANC as commencing ANC during the first trimester, four or more ANC contacts, weight, height and blood pressure measurements, urine and blood tests, tetanus injection, iron supplementation, and counselling on pregnancy complications. In this study, only 11% and 23% had adequate ANC in Addis Ababa and Southern Ethiopia, respectively [20, 21]. Based on the then most recent (2007–16) DHS and Multiple Indicator Cluster Surveys data in 91 low and middle-income countries, Arsenault et al. (2018) described quality ANC according to the receipt of three essential services (blood pressure measurement, urine examination, and blood testing) among women who had at least one visit with a skilled ANC provider .
Our study aimed to assess the quality of antenatal (ANC), intrapartum care, and PNC services and to identify their multifaceted determinants in Ethiopia using data from the 2019 Ethiopia Mini DHS (MDHS). We therefore comprehensively assessed the recommended interventions during ANC, intrapartum care, and PNC services a mother and/or her newborn received and the associated socio-demographic determinants at a national level in Ethiopia using the 2019 Ethiopia MDHS data.