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Abstract：
BACKGROUND: Ethiopia has one of the highest maternal mortality ratios in Africa. Few have examined the quality of labour and delivery (L&D) care in the country. This study evaluated the quality of routine L&D care and identified patient-level and hospital-level factors associated with the quality of care in a subset of government hospitals.
METHODS: This was a facility-based, cross-sectional study using direct non-participant observation carried out in 2016. All mothers who received routine L&D care services at government hospitals (n = 20) in one of the populous regions of Ethiopia, Southern Nations Nationalities and People\'s Region (SNNPR), were included. Mixed effects multilevel linear regression modeling was employed in two stages using hospital as a random effect, with quality of L&D care as the outcome and selected patient and hospital characteristics as independent variables. Patient characteristics included woman\'s age, number of previous births, number of skilled attendants involved in care process, and presence of any danger sign in current pregnancy. Hospital characteristics included teaching hospital status, mean number of attended births in the previous year, number of fulltime skilled attendants in the L&D ward, whether the hospital had offered refresher training on L&D care in the previous 12 months, and the extent to which the hospital met the 2014 Ethiopian Ministry of Health standards regarding to resources available for providing quality of L&D care (measured on a 0-100% scale). These standards pertain to availability of human resource by category and training status, availability of essential drugs, supplies and equipment in L&D ward, availability of laboratory services and safe blood, and availability of essential guidelines for key L&D care processes.
RESULTS: On average, the hospitals met two-thirds of the standards for L&D care quality, with substantial variation between hospitals (standard deviation 10.9 percentage points). While the highest performing hospital met 91.3% of standards, the lowest performing hospital met only 35.8% of the standards. Hospitals had the highest adherence to standards in the domain of immediate and essential newborn care practices (86.8%), followed by the domain of care during the second and third stages of labour (77.9%). Hospitals scored substantially lower in the domains of active management of third stage of labour (AMTSL) (42.2%), interpersonal communication (47.2%), and initial assessment of the woman in labour (59.6%). We found the quality of L&D care score was significantly higher for women who had a history of any danger sign (β = 5.66; p-value = 0.001) and for women who were cared for at a teaching hospital (β = 12.10; p-value = 0.005). Additionally, hospitals with lower volume and more resources available for L&D care (P-values < 0.01) had higher L&D quality scores.
CONCLUSIONS: Overall, the quality of L&D care provided to labouring mothers at government hospitals in SNNPR was limited. Lack of adherence to standards in the areas of the critical tasks of initial assessment, AMTSL, interpersonal communication during L&D, and respect for women\'s preferences are especially concerning. Without greater attention to the quality of L&D care, regardless of how accessible hospital L&D care becomes, maternal and neonatal mortality rates are unlikely to decrease substantially.
METHODS: This was a facility-based, cross-sectional study using direct non-participant observation carried out in 2016. All mothers who received routine L&D care services at government hospitals (n = 20) in one of the populous regions of Ethiopia, Southern Nations Nationalities and People\'s Region (SNNPR), were included. Mixed effects multilevel linear regression modeling was employed in two stages using hospital as a random effect, with quality of L&D care as the outcome and selected patient and hospital characteristics as independent variables. Patient characteristics included woman\'s age, number of previous births, number of skilled attendants involved in care process, and presence of any danger sign in current pregnancy. Hospital characteristics included teaching hospital status, mean number of attended births in the previous year, number of fulltime skilled attendants in the L&D ward, whether the hospital had offered refresher training on L&D care in the previous 12 months, and the extent to which the hospital met the 2014 Ethiopian Ministry of Health standards regarding to resources available for providing quality of L&D care (measured on a 0-100% scale). These standards pertain to availability of human resource by category and training status, availability of essential drugs, supplies and equipment in L&D ward, availability of laboratory services and safe blood, and availability of essential guidelines for key L&D care processes.
RESULTS: On average, the hospitals met two-thirds of the standards for L&D care quality, with substantial variation between hospitals (standard deviation 10.9 percentage points). While the highest performing hospital met 91.3% of standards, the lowest performing hospital met only 35.8% of the standards. Hospitals had the highest adherence to standards in the domain of immediate and essential newborn care practices (86.8%), followed by the domain of care during the second and third stages of labour (77.9%). Hospitals scored substantially lower in the domains of active management of third stage of labour (AMTSL) (42.2%), interpersonal communication (47.2%), and initial assessment of the woman in labour (59.6%). We found the quality of L&D care score was significantly higher for women who had a history of any danger sign (β = 5.66; p-value = 0.001) and for women who were cared for at a teaching hospital (β = 12.10; p-value = 0.005). Additionally, hospitals with lower volume and more resources available for L&D care (P-values < 0.01) had higher L&D quality scores.
CONCLUSIONS: Overall, the quality of L&D care provided to labouring mothers at government hospitals in SNNPR was limited. Lack of adherence to standards in the areas of the critical tasks of initial assessment, AMTSL, interpersonal communication during L&D, and respect for women\'s preferences are especially concerning. Without greater attention to the quality of L&D care, regardless of how accessible hospital L&D care becomes, maternal and neonatal mortality rates are unlikely to decrease substantially.
摘要：
背景：埃塞俄比亚是非洲孕产妇死亡率最高的国家之一。很少有人检查该国的劳动力和分娩（L＆D）护理质量。这项研究评估了常规L＆D护理的质量，并确定了部分政府医院中与护理质量相关的患者级和医院级因素。
方法：这是一个基于设施的，2016年进行的使用直接非参与者观察的横断面研究。所有在埃塞俄比亚人口稠密地区之一的政府医院接受常规L＆D护理服务的母亲（n=20），南方国家民族和人民地区（SNNPR），包括在内。以医院为随机效应，分两个阶段采用混合效应多级线性回归模型，以L&D护理质量为结果，选择患者和医院特征为自变量。患者特征包括女性年龄,先前出生的数量，参与护理过程的熟练服务员数量，以及当前怀孕中存在任何危险迹象。医院特点包括教学医院地位，上一年的平均接生人数，L&D病房的全职熟练服务员人数，在过去的12个月里，医院是否提供了关于L&D护理的进修培训，以及医院在多大程度上符合2014年埃塞俄比亚卫生部关于提供优质L&D护理的可用资源标准(以0-100%的规模衡量)。这些标准涉及按类别和培训状态划分的人力资源可用性，基本药物的可用性，L&D病房的用品和设备，实验室服务和安全血液的可用性，以及关键L&D护理流程的基本指南的可用性。
结果：平均而言，医院达到了三分之二的L&D护理质量标准，医院之间有很大差异(标准差10.9个百分点)。虽然表现最好的医院达到了91.3%的标准，表现最差的医院仅达到标准的35.8％。医院在即时和基本新生儿护理实践领域遵守标准最高（86.8％），其次是第二和第三分娩阶段的护理领域(77.9%)。医院在第三产程积极管理（AMTSL）领域的得分大大降低（42.2％），人际交往(47.2%)，和对分娩妇女的初步评估(59.6%)。我们发现，对于有任何危险体征史的女性（β=5.66；p值=0.001）和在教学医院接受护理的女性（β=12.10；p值=0.005），L＆D护理质量评分明显更高。此外,容量较低且可用于L&D护理的资源较多(P值<0.01)的医院L&D质量评分较高.
结论：总体而言，SNNPR政府医院为劳动母亲提供的L&D护理质量有限。在初步评估的关键任务领域缺乏对标准的遵守，AMTSL,L&D期间的人际沟通，对女性偏好的尊重尤其令人担忧。如果不更多地关注L&D护理的质量，无论医院L&D护理变得多么容易获得，孕产妇和新生儿死亡率不太可能大幅下降.
方法：这是一个基于设施的，2016年进行的使用直接非参与者观察的横断面研究。所有在埃塞俄比亚人口稠密地区之一的政府医院接受常规L＆D护理服务的母亲（n=20），南方国家民族和人民地区（SNNPR），包括在内。以医院为随机效应，分两个阶段采用混合效应多级线性回归模型，以L&D护理质量为结果，选择患者和医院特征为自变量。患者特征包括女性年龄,先前出生的数量，参与护理过程的熟练服务员数量，以及当前怀孕中存在任何危险迹象。医院特点包括教学医院地位，上一年的平均接生人数，L&D病房的全职熟练服务员人数，在过去的12个月里，医院是否提供了关于L&D护理的进修培训，以及医院在多大程度上符合2014年埃塞俄比亚卫生部关于提供优质L&D护理的可用资源标准(以0-100%的规模衡量)。这些标准涉及按类别和培训状态划分的人力资源可用性，基本药物的可用性，L&D病房的用品和设备，实验室服务和安全血液的可用性，以及关键L&D护理流程的基本指南的可用性。
结果：平均而言，医院达到了三分之二的L&D护理质量标准，医院之间有很大差异(标准差10.9个百分点)。虽然表现最好的医院达到了91.3%的标准，表现最差的医院仅达到标准的35.8％。医院在即时和基本新生儿护理实践领域遵守标准最高（86.8％），其次是第二和第三分娩阶段的护理领域(77.9%)。医院在第三产程积极管理（AMTSL）领域的得分大大降低（42.2％），人际交往(47.2%)，和对分娩妇女的初步评估(59.6%)。我们发现，对于有任何危险体征史的女性（β=5.66；p值=0.001）和在教学医院接受护理的女性（β=12.10；p值=0.005），L＆D护理质量评分明显更高。此外,容量较低且可用于L&D护理的资源较多(P值<0.01)的医院L&D质量评分较高.
结论：总体而言，SNNPR政府医院为劳动母亲提供的L&D护理质量有限。在初步评估的关键任务领域缺乏对标准的遵守，AMTSL,L&D期间的人际沟通，对女性偏好的尊重尤其令人担忧。如果不更多地关注L&D护理的质量，无论医院L&D护理变得多么容易获得，孕产妇和新生儿死亡率不太可能大幅下降.
