title: Barriers to providing quality emergency obstetric care in Addis Ababa, Ethiopia: Healthcare providers' perspectives on training, referrals and supervision, a mixed methods study.
abstract: BACKGROUND
  Increasing women's access to and use of facilities for childbirth is a critical national strategy to improve maternal health outcomes in Ethiopia; however coverage alone is not enough as the quality of emergency obstetric services affects maternal mortality and morbidity. Addis Ababa has a much higher proportion of facility-based births (82%) than the national average (11%), but timely provision of quality emergency obstetric care remains a significant challenge for reducing maternal mortality and improving maternal health. The purpose of this study was to assess barriers to the provision of emergency obstetric care in Addis Ababa from the perspective of healthcare providers by analyzing three factors: implementation of national referral guidelines, staff training, and staff supervision.
  
  
  METHODS
  A mixed methods approach was used to assess barriers to quality emergency obstetric care. Qualitative analyses included twenty-nine, semi-structured, key informant interviews with providers from an urban referral network consisting of a hospital and seven health centers. Quantitative survey data were collected from 111 providers, 80% (111/138) of those providing maternal health services in the same referral network.
  
  
  RESULTS
  Respondents identified a lack of transportation and communication infrastructure, overcrowding at the referral hospital, insufficient pre-service and in-service training, and absence of supportive supervision as key barriers to provision of quality emergency obstetric care.
  
  
  CONCLUSIONS
  Dedicated transportation and communication infrastructure, improvements in pre-service and in-service training, and supportive supervision are needed to maximize the effective use of existing human resources and infrastructure, thus increasing access to and the provision of timely, high quality emergency obstetric care in Addis Ababa, Ethiopia.
authors.affiliation: Maternal Health Task Force, Women and Health Initiative, Harvard T. H. Chan School of Public Health, Boston, USA. amaustin123@gmail.com.
authors.forename: Anne
authors.initials: A
authors.lastname: Austin
authors.affiliation: Addis Continental Institute of Public Health, Addis Ababa, Ethiopia. gulumah@yahoo.com.
authors.forename: Hanna
authors.initials: H
authors.lastname: Gulema
authors.affiliation: Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina. mbelizan@iecs.org.ar.
authors.forename: Maria
authors.initials: M
authors.lastname: Belizan
authors.affiliation: Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina. dcolaci@iecs.org.ar.
authors.forename: Daniela S
authors.initials: DS
authors.lastname: Colaci
authors.affiliation: Maternal Health Task Force, Women and Health Initiative, Harvard T. H. Chan School of Public Health, Boston, USA. tkendall@hsph.harvard.edu.
authors.forename: Tamil
authors.initials: T
authors.lastname: Kendall
authors.affiliation: Maternal Health Task Force, Women and Health Initiative, Harvard T. H. Chan School of Public Health, Boston, USA. mat851@mail.harvard.edu.
authors.forename: Mahlet
authors.initials: M
authors.lastname: Tebeka
authors.affiliation: Federal Ministry of Health, Addis Ababa, Ethiopia. agamkega@yahoo.com.
authors.forename: Mengistu
authors.initials: M
authors.lastname: Hailemariam
authors.affiliation: St Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia. dilayehu@yahoo.com.
authors.forename: Delayehu
authors.initials: D
authors.lastname: Bekele
authors.affiliation: St Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia. liatadesse@yahoo.com.
authors.forename: Lia
authors.initials: L
authors.lastname: Tadesse
authors.affiliation: Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina. yemaneberhane@gmail.com.
authors.forename: Yemane
authors.initials: Y
authors.lastname: Berhane
authors.affiliation: Maternal Health Task Force, Women and Health Initiative, Harvard T. H. Chan School of Public Health, Boston, USA. alanger@hsph.harvard.edu.
authors.forename: Ana
authors.initials: A
authors.lastname: Langer
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D004632:Emergency Medical Services / Q000458:organization & administration / Q000592:standards*; D005002:Ethiopia; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008427:Maternal Health Services / Q000458:organization & administration / Q000592:standards*; D008880:Midwifery / Q000193:education / Q000458:organization & administration / Q000592:standards*; D009773:Obstetric Nursing / Q000193:education / Q000458:organization & administration / Q000592:standards*; D009774:Obstetrics / Q000193:education / Q000458:organization & administration / Q000592:standards*; D017410:Practice Guidelines as Topic; D036301:Qualitative Research; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000592:standards*