Perceived quality of essential newborn care implementation among health facility deliveries in North Gondar Zone, Northwest Ethiopia: a cross-sectional study

Background Quality of essential newborn care is defined as the extent of health care services to improve the health of newborns. However, studies are scarce regarding the quality of newborn care implementation. Therefore, this study aimed to measure the magnitude and factors associated with essential newborn care implementation perceived quality among health facility deliveries in Northwest Ethiopia. Methods A facility-based cross-sectional study design was employed to collect data from 370 randomly selected deliveries in 11 health facilities from November 2018 to March 2019. Essential newborn care implementation perceived quality was assessed in two domains (delivery and process) from clients’ perspectives. A pre-tested interviewer-administered structured questionnaire was adopted from different kinds of literature and guidelines. The research data were collected by trained midwives and nurses. A binary logistic regression model was used to identify associated factors with newborn care implementation perceived quality. Odds ratio with 95% CI was computed to assess the strength and significant level of the association at p-value < 0.05. Results About 338 mothers completed the interview with a response rate of 97.1%. The mean age of the study participants was 26.4 (SD = 5.7) with a range of 12 and 45 years. Most mothers, 84.3%, have attended antenatal care. The overall implementation perceived quality of essential newborn care was found to be 66.3%. The implementation perceived quality of cord care, breast-feeding and thermal care was 75.4, 72.2 and 66.3% respectively. Newborn immunization and vitamin K administration had the lowest implementation perceived quality i.e. 22.4 and 24.3% respectively. Friendly care during delivery (AOR = 5.1, 95% CI: 2.4, 11.0), partograph use (AOR = 3.0, 95% CI: 1.1, 8.6), child immunization service readiness (AOR = 2.9, 95% CI: 1.5, 5.7), BEmEONC service readiness (AOR = 2.1, 95% CI: 1.2, 3.9) and facing no neonatal illness at all (AOR = 4.2, 95% CI: 1.6, 10.9) were significantly associated with good essential newborn care implementation qualities. Conclusions The perceived quality of essential newborn care implementation was low in the study area. This is associated with poor readiness on BEmEONC and child immunization services, unfriendly care and not using partograph during delivery. Hence, availing the BEmEONC and the child immunization service inputs, continuous training and motivation of healthcare workers for friendly care are vital for improving essential newborn care implementation perceived quality.


Background
Ensuring the quality of newborn care during delivery is crucial to improve health outcomes and reduce preventable mortality and morbidity among newborns. Although access to institutional delivery care and the presence of skilled birth attendants have increased globally, a substantial proportion of newborns experience many avoidable deaths within health facilities due to quality issues [1]. The World Health Organization (WHO) also stated that universal health coverage (UHC) and quality of care (QoC) are now recognized as the two main pillars for addressing these preventable deaths [2].
Essential Newborn Care (ENC) is a set of measures every newborn baby needs regardless of its birthplace and size. ENC is a framework that should be applied immediately after birth and continued at least for the first seven days to protect the newborn from adverse environmental problems [3][4][5]. Components of ENC and neonatal resuscitation are proven interventions for reducing neonatal mortality rate and stillbirth rate [6].
Globally, deaths among children aged 1 month to 5 years old have fallen dramatically in the recent decades. However, progress in reducing the deaths of newborn babies aged less than 1 month have been less notable because 7,000 newborns are still dying every day. This is because of the difficulty to address and prevent newborn deaths with a single drug or intervention; these require a system-wide approach that improves the quality of newborn care [7].
In Ethiopia, the rate of under-five mortality (U5MR) was decreased by 55%, i.e. from 123 to 55 per 1000 live births from the year 2005 to 2019. But, the neonatal mortality rate was decreased only from 39 to 30 per 1000 live births from 2005 to 2019. Because of this, the share of neonatal mortality in under-five mortality has been increased from 31 to 55% [8]. Most neonatal health problems are life-threatening. Therefore, they need optimal care for their survival [9].
Scientific pieces of evidence have also shown that many neonatal deaths and illnesses can be prevented through evidence-based interventions, including appropriate utilization of essential newborn care packages, which require clinically trained providers [10]. A research finding [11] also estimated that a skilled birth care package could reduce neonatal mortality by 20-30%. and motivation of healthcare workers for friendly care are vital for improving essential newborn care implementation perceived quality.

Plain language summary
Essential newborn care is a set of practices provided by healthcare workers and mothers to every newborn during delivery. Studies are scarce regarding the quality of newborn care implementation. Therefore, this study aimed to measure the magnitude and factors associated with essential newborn care implementation perceived quality among health facility deliveries in Northwest Ethiopia.
A facility-based cross-sectional study design was employed to collect data from 370 randomly selected deliveries in 11 health facilities. A pre-tested interviewer-administered structured questionnaire was adopted from different kinds of literature and guidelines. A binary logistic regression model was fitted to assess the strength and significant level of the association at p-value < 0.05.
The perceived quality of essential newborn care implementation was low in the study area. This is associated with poor readiness on BEmEONC and child immunization services, unfriendly care and not using partograph during delivery. Hence, availing the BEmEONC and child immunization service inputs, continuous training and motivation of healthcare workers for friendly care are vital for improving essential newborn care implementation perceived quality.
Keywords: Newborn care, Essential newborn care, Quality of care To combat this problem, Ethiopia emphasizes access to quality health services for all Ethiopians with full financial risk protection without any discrimination like age, economic capability, and geographic locations [12]. Though there are no comprehensive studies on the implementation quality of essential newborn care, different pocket studies in Ethiopia stated that the quality of newborn care practice was low [13][14][15]. Most of the previous studies mainly focused on a few components of essential newborn care services at the community level. To adopt a focused and evidence-based approach to improve essential newborn care quality in Northwest Ethiopia, a clear understanding of the current implementation quality in health facility deliveries and associated factors is necessary. Therefore, this study aimed to assess the magnitude and factors associated with essential newborn care implementation perceived quality by focusing on facility inputs and process quality components. The findings were important in planning intervention programs to improve the survival of neonates in the study area and other similar settings.

Study area and health facility setting
This study was conducted at health facilities in North Gondar Zone, Northwest Ethiopia. This administrative Zone is structured in eight districts, including the two town administrations. Debark town, which is the capital of the zone, is 90 and 820-kilo meters away from Gondar and Addis Ababa, respectively. According to the Central Statistical Agency (CSA), North Gondar Zone has an estimated total population of 887,869 individuals, 37 health facilities providing delivery services (2 hospitals and 35 health centers), and 1230 healthcare workers in 2016/17. More specifically, all delivery service providing public health facilities in three randomly selected districts (Dabat, Debark and Janamora) were included in the study. Sixteen public health facilities (14 health centers and 2 district hospitals) were considered for data collection [16].

Study design and period
The facility-based cross-sectional study design was employed among selected health facility deliveries in Northwest Ethiopia from November 2018 to March 2019.

Source and study population
All mothers in North Gondar Zone, who delivered in governmental health facilities, were the source populations. All mothers who delivered in randomly selected districts and health facilities were the study populations. And all mothers who delivered in the randomly selected districts and health facilities and who were randomly selected for inclusion were the study subjects.

Inclusion and exclusion criteria
All mothers who gave live birth/s (having evidence of life, such as the beating of heart, pulsation of the umbilical cord, or definitive movement) in the randomly selected health facilities during the study period, and who were randomly selected for inclusions as well as willing to participate were part of the inclusion criteria. Eligible mothers who were not willing to participate, seriously ill and or unable to respond to all the assessment questions were part of the exclusion criteria.

Measurements
Essential newborn care is a set of practices provided by healthcare workers and mothers to every newborn during delivery [9]. It was measured by using components and domains.
A component is an activity or set of activities, which are basic to newborn survival. Thirty-two question items were structured in 2 domains and 21 components. The items were prepared as YES/NO questions adopted from newborn care guidelines and different kinds of literature [4,[17][18][19][20][21][22][23][24][25]. Then, a composite variable from these questions was generated to categorize each component as having "Good/Poor implementation perceived quality". Each component was categorized as good perceived quality if it scored mean and above the mean value, and poor perceived quality if otherwise.

Optimum thermal care
Wiped off/ dried the baby within ten minute, wrapped in new or clean and dry old cloth and washing the body of the newborn by warm water after 24 h of delivery to prevent hypothermia.

Safe cord care
The use of a clean cutting instrument to cut the umbilical cord (boiled new, used blade or scissor) plus clean thread, cord tie or cord clamp and no any substance applied on the cord stump.

Breastfeeding
Initiate breastfeeding within the first one hour after birth, giving no prelacteal and feeding the child with colostrum.

Eye care
The provision of tetracycline eye ointment to the newborn after birth and advising on how to maintain the newborn's eye healthy. Delele et al. Reprod Health (2021) 18:127

Vitamin K administration
The provision of 1 mg Vitamin K on anterior mid-lateral thigh to prevent the newborn from bleeding.

Immunization
The provision of BCG and OPV0 vaccines to the newborn immediately after birth.

Skin to skin care
Placing the infant in skin-to-skin contact on the mother's chest and cover both with clean linen and blanket.

Helping baby breath
If the baby is not breathing or gasping, then resuscitate.

Weighing
Weight the newborn within 90 min after birth.

Safety practices during delivery
The delivery assistant tried to minimize/avoid all the suffering: pains, all the possible medical errors during delivery.

Effectiveness in using guidelines and knowledge on reproductive health
The delivery assistant helped you as per the delivery service provision guideline, based on his/her scientific knowledge skill properly during delivery.

Timely service provision
The health care providers provided you delivery service without delay and bureaucracy.

Efficiency of using resources
The delivery care provider provided the service by minimizing unnecessary delivery related resource wastages.

Equitability of delivery services
The health care provider provided delivery services equitably (without any discrimination; like relation, neighboring, race, social etc.).

Acceptability or People-centered delivery service provision
The delivery service provider provided the service based on your interest by keeping the culture and norms of the society during delivery.

Accessibility of delivery services
The delivery ward of the health facility was accessible for vehicle transport, and found within short distance from your home to easily utilize the service.

Responsiveness of health care workers
The delivery care providers provided the service immediately and properly in responsive manner.

Respect for customers
The delivery care providers provided the service by respecting personal dignity and personality (without harassment).

Hygiene and sanitation practices
The delivery care providers tried to minimize the hygienic, sanitary problems and properly manage wastes during delivery.

Team-work during delivery
The health care providers in the delivery ward work in team during delivery.
A domain includes a group of components with a set of practices provided to every newborn. Two domains; delivery service and process domains were composite variables defined for this study purpose.
Delivery service domain was defined as a composite variable containing 10 components. This domain measures how the delivery service was provided as per the guidelines. Thermal care, cord care, breast-feeding, eye care, vitamin K administration, and immunization were the main components under the delivery care domain. Skin to skin care, Weighing, Helping baby breath, and Chlorhexidine gel application were the other components under delivery care domain.
The process quality domain was also defined as a composite variable containing 11 component. This domain measures how the delivery service provision process of efficient enough from mothers' perspective. The components include; safety, effectiveness, timeliness, efficiency, equitability, acceptability or peoplecentered, accessibility, responsiveness, respect, hygiene and sanitation, and team-work. Each domain perceived quality was good if it scored the mean and above the mean value of the sum of components in each domain, and poor perceived quality if otherwise.
Essential newborn care implementation perceived quality score was categorized as good if they scored the mean and above the mean value of the sum of scores in the two domains (service and process), and poor perceived quality if otherwise.

Item
It is a piece of question used to ascertain either the presence or absence of something. BEmEONC and Child immunization services were assessed by adopting WHO BEmEONC and Child immunization service domain items (Trained staff and guidelines, Equipment, Medicines and commodities).

Trained staff and guidelines
Assess the availability of trained staffs and guidelines on BEmEONC and Child immunization as per the WHO guideline.

Equipment
Assess the availability of different equipment applicable for BEmEONC and Child immunization services as per the WHO guideline.

Medicines and commodities
Assesse the availability of different medicines and commodities used for BEmEONC and Child immunization services as per the WHO guideline.
BEmEONC service readiness was measured using three domains (Trained staff and guidelines, Equipment, and Medicines and commodities) with 25 items. Facilities were categorized to have good readiness if it scored the mean and above the mean value of the sum of scores in all domains, and poor if otherwise.
Child immunization service readiness was measured using three domains (Trained staff and guidelines, Equipment, and Medicines and commodities) with 16 items. Facilities were categorized to have good readiness if it scored mean and above the mean value of the sum of scores in all domains, and poor if otherwise.
Partograph use was measured using chart review based on the time when a skilled birth attendant filled partograph during labor and childbirth. It was scored YES if the delivery assistant completed filling the partograph while the mother was laboring, NO if otherwise.

Sample size determination and sampling technique
The sample size of the study was determined by using a single population proportion formula by assuming a 95% confidence interval, 5% margin error and taking 67.6% proportion of newborn care quality from a study done in Tigray located in Ethiopia [17].
Considering a 10% non-response rate, the final largest sample size obtained was 370 mother-newborn pairs. The facility audit was done in all functional health facilities.
A systematic random sampling technique was used to select the study subjects. At the onset, three districts (Dabat, Debark and Janamora) were randomly selected from eight. A systematic random sampling technique was employed to select the mothers, who deliver a live birth/s in all health centers and hospitals in the three districts. The sample size was proportionally allocated to health centers and hospitals based on the respective health facilities annual antenatal care attendance before this study.

Data collection tool and method
An interviewer-administered structured questionnaire adapted from different kinds of literature and guidelines were employed to assess the newborn care implementation perceived quality [4,[17][18][19][20][21][22][23][24][25]. Facility audit assessment tools were used to collect data on the availability and readiness levels. Pre-test was done for data collection tools outside the study area. Information on socio-demographic, socio-economic obstetric and newborn care perceived quality-related characteristics were collected from mothers after delivery at health facilities. Data were collected by six trained first-degree midwives and nurses. The data collectors collected the information through a face to face interview of mothers in health facilities after delivery. The consistency and completeness of the data were regularly checked by supervisors (clinicians and researchers) throughout the entire data collection period.
Initially the questionnaire was prepared in English. This questionnaire was translated into the local language, Amharic, and back to English by translators who were bilingual and competent in the two languages to check the content validity.

Data processing and analysis
The data were entered and cleaned using the Epi-Info version 7.1.5.0 software. Cleaning was made by running frequencies, proportions and summary statistics. The Principal Component Analysis (PCA) was employed to generate a wealth index. The composite index for each component, domain, and overall essential newborn care perceived quality was calculated by including all the question items in the respective category. The indices in each category were labeled as "Good" if the composite score was equal to the mean and above the mean, and "Poor" if otherwise. Then, these values were converted into dummy variables by assigning the value of "1" to "Good" and "0" to "Poor". Inter-item consistencies between the variables were tested for the variables creating each component of the essential newborn care perceived quality using the Cronbach's alpha (all variables were > 0.86). The cleaned data were exported to STATA version 14 software for analysis. Univariable logistic regression analysis was performed primarily to select variables for the final model based on p-value < 0.2. Hosmer-Lemeshow tests (p < 0.05) were used to measure the goodness of fit of the models. Multivariable binary logistic regression analysis was employed to control the possible effect of confounders and finally, the variables which had significant association were identified based on AOR with 95% CI and p-value ≤ 0.05. About 16 health facilities were agreed for a facility audit, but 5 of them had no deliveries during the data collection period due to security issues. Most health facilities were health centers 14 (87.5%). Basic emergency and essential obstetric and newborn care service readiness levels were poor among 9 (56.2%) health facilities and three-fourth of them had poor child immunization readiness levels. Nearly one-third of the health facilities had only one or two midwives (Table 1).

Obstetric characteristics of mothers
Almost a quarter of mothers which numbered 66 (19.5%) had their first pregnancy before 18 years of age. Mothers who had a prior history of stillbirths and neonatal deaths accounted for 29 (8.6%) and 27 (8%) respectively. The majority of mothers, 285 (84.3%), had attended antenatal care during pregnancy. Similarly, 323 (95.6) of the pregnancies were singleton, 285 (84.3%) of mothers had SVD mode of delivery, 295 (87.3%) deliveries were assisted by midwives and 187 (55.3%) deliveries were performed by male delivery assistants ( Table 2).

Characteristics of newborns
The majority of newborns, 309 (91.4%) had a normal birth weight (2.5-4 kgs). About 94 (27.8%) neonatal illness cases were recorded. Most of the illnesses, 36 (38.3%) were observed on day 28 from birth, and 30 (31.9%) of them were recorded at birth. Fourteen neonatal illnesses ended with death and more than half, 54 (57.5%) of the ill neonates did not get healthcare (Table 3).

Perceived quality of essential newborn care implementation
This study revealed that the overall essential newborn care implementation perceived quality was 66.3% (224). The perceived quality provided during the delivery care domain was relatively worse with about 61.2% (207) poorer than the process perceived quality domain, which was 75.2% (254) (Fig. 1).

Predictors of essential newborn care implementation perceived quality
After controlling for facility, healthcare worker and newborn level characteristics; type of health facility, BEmE-ONC service readiness, child immunization service readiness, partograph use, birth weight, hypothermia, type of pregnancy, sex of the delivery assistant, friendly care during delivery, type of health facility and number of nurses in the health facility were the predictors that significantly affected the essential newborn care implementation perceived quality.
Mothers who got friendly care during delivery were five times (AOR = 5.1, 95% CI: 2.4, 11.0) more likely to have had good essential newborn care implementation perceived quality as compared to their counterparts. Healthcare workers who use partograph during delivery were three times (AOR = 3.0, 95% CI: 1.1, 8.6) more likely to have had good essential newborn care implementation perceived quality as compared to those healthcare workers who did not use partograph at all. Health facilities having good child immunization service readiness was three times (AOR = 2.9, 95% CI: 1.5, 5.7) more likely to have had good essential newborn care implementation perceived quality as compared to those facilities having poor child immunization service readiness levels. Newborns who did not face any illness after delivery were four times (AOR = 4.2, 95% CI: 1.6, 10.9) more likely to have had good essential newborn care implementation perceived quality as compared to those newborns who face hypothermia after delivery (Table 4).

Discussion
This study aimed to measure the magnitude and factors associated with essential newborn care implementation perceived quality among health facility deliveries in Northwest Ethiopia. Accordingly, only 66.3% of neonates received good implementation perceived quality of essential newborn care services. Despite the observed low implementation perceived quality of essential newborn care service readiness in the study area as compared to the national target, the study has observed and expressed room for improvement in contrast to the previous studies done in Ethiopia. Friendly care during delivery, partograph use, child immunization, and BEmEONC service readiness, having ≥ 2500 g birth weight, delivering in a health center, and facing no neonatal illness at all were the factors significantly associated with good essential newborn care implementation perceived quality.
The implementation perceived quality of essential newborn care services remains low in Ethiopia and Africa.
The current study revealed that the overall essential newborn care implementation perceived quality was low (only 66.3%), which was comparable with other study results in Ethiopia [13,14,20,21,26,27] and Africa [22,23]. On the other hand, it was lower than the study findings in Ethiopia [17,28,29]. This difference could be due to a lack of comprehensiveness on the measurement Proportion of good essential newborn care implementation perceived quality tool for quality. The focuses of the previous studies were more on thermal care, cord care and/or breast-feeding components. Besides, the availability of BEmEONC service inputs (trained staff and guidelines, types of equipment, medicines and commodities) is not uniform across health facilities in different nations. The standardized procedure for providing essential newborn care is not commonly practiced. Therefore, in order to improve the essential newborn care implementation perceived quality and neonatal survival, the North Gondar administrative zone health office need to adhere with the essential newborn care policy by availing all the inputs of BEmEONC and child immunization services, provision of continuous training and motivation of healthcare workers for friendly care. More specifically, the implementation perceived quality of thermal care was 66.3%, which was congruent with a study done in Wolaita Zone (65.3%) [30], higher than another study in Aksum Town (32.6%) [21], and lower than another study in Ethiopia and Bangladesh [24,31]. Cord care implementation perceived quality was 75.4%, which was higher than the study findings in Ethiopia and Nepal [21,24,32], but lower than the 2016 demographic and health survey finding and other studies in Ethiopia and other developing countries [16,30,31,33,34]. The possible explanations for the difference might be due to variations in study settings (community/facility-based) and time of interview after delivery.
Breast-feeding implementation perceived quality was found to be 77.2%, which is higher than the 2016 and the 2019 demographic and health survey and a study finding in Ethiopia and other low-income countries [8,16,21,24,25,[30][31][32][33][34][35]. Newborn immunization implementation was 24.3%, which was low as compared to other delivery domain components. This finding is lower than a similar study done in Aksum Town (44.7%) and the 2016 and the 2019 Ethiopian demographic and health survey findings [8,16,21]. The variations might be due to the inadequate number of skilled and competent service providers, and variations in workload in the health facilities.
The perceived quality of essential newborn care implementation in health centers was nearly three times more likely to be good as compared to hospitals. This finding contradicts the expected general truth. Because, compared to periphery areas (health centers), the service given at hospitals is expected to be better in terms of perceived quality due to the availability of experienced and high-level human power, resource, and supplies. High workload of service providers at hospitals as a result of the high case follows, inadequate number of skilled providers, and poor job satisfaction could be the possible reasons for the poor hospital services perceived quality [36][37][38]. Therefore, it is important to give attention to the quality of care given in hospitals.
The mean readiness level of health facilities on BEmE-ONC tracer items was 43.8%, which is lower than the national average (68%) and higher than a study finding in Kenya (23.8%) [39]. Similarly, the health facilities' readiness levels on child immunization services were 62.5, which was higher than the national average (54%) [40]. Consequently, health facilities having good BEmEONC service readiness were two times more likely to have good essential newborn care implementation perceived quality. Similarly, facilities having good child immunization service readiness were three times more likely to have good essential newborn care implementation perceived quality. This implies that the perceived implementation quality of essential newborn care service is highly dependent on the availability of inputs on trained staff, guidelines, equipment, medicines, and commodities. This study revealed that those delivery assistants who used to fill the partograph were three times more likely to have good essential newborn care implementation perceived quality than those who did not use it. This finding is consistent with other studies in Tigray, Ethiopia, and Africa [17,23,38]. This could be attributed to poor attitude, knowledge, and skills on how to fill partograph among healthcare providers.
In the current study, mothers who received friendly care during delivery were five times more likely to receive good implementation perceived quality of essential newborn care. This finding is supported by a similar study in Tigray, Zimbabwe and developing countries [17,41,42]. This implies that there are mothers who neither received quality essential newborn care nor friendly care during delivery. The reasons could be due to poor skills and competency of service providers.
Neonates who did not face any illness were four times and those who face illness other than hypothermia were three times more likely to have good essential newborn care implementation qualities as compared to those neonates who face hypothermia. This is supported by a study finding in Lebanon that found a two-third reduction of hypothermia through the provision of good implementation perceived quality of essential newborn care [43]. Similarly, neonates having > 2500 g birth weight had two times more likely to have good essential newborn care implementation qualities. This indicates that quality of care is crucial for the betterment of neonatal outcomes. Consequently, the Ethiopian government and the North Gondar administrative zone health office in particular, need to adhere with the essential newborn care policy by availing the BEmEONC and child immunization service inputs, continuous training and motivation of healthcare workers for friendly care to improve the essential newborn care implementation perceived quality and neonatal survival.
Furthermore, the WHO, the United Nations Children Fund (UNICEF) and the United Nations Population Fund (UNFPA) should strengthen their efforts on improving the quality of the essential newborn care implementation during and immediately after birth through availing all the essential newborn care inputs in health facilities, and provision of tailored trainings and motivation of healthcare workers in order to improve newborn survival.
This study was undertaken with the following limitations. First, due to resource limitations, the authors could not include health facilities from multiple administrative zones of the country to generalize the findings at regional and national levels. Second, as all essential newborn care component are essential (mandatory), it is very difficult to measure and conclude ENC implementation perceived quality using mean value. Third, the balance of the response rates of some variables were low, which might affect the model fit the data reasonably well. Lastly, due to ethical concerns, data were collected through interviews, unlike observation, by using trained midwives and nurses from the mothers' perspective.

Conclusions
This study revealed that the implementation perceived quality of newborn care was low because of poor readiness on BEmEONC and child immunization services, unfriendly care and none use of partograph. Friendly care during delivery, using partograph during delivery, BEmEONC service readiness, child immunization service readiness, delivering in a health center, having nine or less number of nurses, having a singleton pregnancy, having ≥ 2500 g birth weight, facing no neonatal illness, and having a male delivery assistant were the factors significantly associated with good essential newborn care implementation perceived quality. Hence, availing the BEmEONC and child immunization service inputs, continuous training and motivation of healthcare workers for friendly care are vital for improving essential newborn care implementation perceived quality in the study area and other similar settings.