Ethiopia has high maternal mortality ratio and poor access to maternal health services. Attendance of at least four antenatal care (ANC) visits and delivery by a skilled birth attendant (SBA) are important in preventing maternal deaths. Understanding the reasons behind the poor use of these services is important in designing strategies to address the problem. This study aimed to determine the coverage of at least four ANC visits and delivery by a SBA and to identify determinants of utilisation of these services in three districts in South West Shoa Zone, Ethiopia. A cross-sectional survey of 500 women aged 15–49 years with a delivery in two years prior to the survey was conducted in Wolisso, Wonchi and Goro districts in February 2013. Data were collected using an interviewer administered questionnaire. Logistic regression models were used to explore determinants of ANC attendance and SBA at delivery. Coverage of at least four ANC visits and SBA at delivery were 45.5 and 28.6 %, respectively. Most institutional deliveries (69 %) occurred at the single hospital that serves the study districts. Attendance of at least four ANC visits was positively associated with wealth status, knowledge of the recommended number of ANC visits, and attitude towards maternal health care, but was negatively associated with woman’s age. SBA at delivery was negatively associated with parity and time to the health facility, but was positively associated with urban residence, wealth, knowledge of the recommended number of ANC visits, perceived good quality of maternal health services, experience of a pregnancy/delivery related problem, involvement of the partner/family in decision making on delivery place, and birth preparedness. Raising awareness about the minimum recommended number of ANC visits, tackling geographical inaccessibility, improving the quality of care, encouraging pregnant women to have a birth and complication readiness plan and community mobilisation targeting women, husbands, and families for their involvement in maternal health care have the potential to increase use of maternal health services in this setting. Furthermore, supporting health centres to increase uptake of institutional delivery services may rapidly increase coverage of delivery by SBA and reduce inequity.

Access to adequate antenatal care (ANC) is critical in ensuring a good maternal health and in preventing maternal and neonatal morbidity and mortality. South Sudan has one of the world’s poorest health indicators due to a fragile health system and a combination of socio-cultural, economic, and political factors. This study was conducted to identify barriers to utilisation of ANC services in Rumbek North County. Using a qualitative design, data were collected through 14 focus group discussions with 169 women and 45 men and 12 key informant interviews with community leaders, staff working in health facilities, and the staff of the County Health Department. Data were analysed using inductive content analysis. The perceived barriers to ANC utilisation were categorised as follows: 1) Issues related to access to health facilities and lack of resources. These included long distance to health facilities, lack of means of transportation to the health facilities, floods and poor roads, and demand for payment for health care at some health facilities; 2) The influence of the socio-cultural context and conflict including heavy burden of domestic chores, the negative influence of husbands who were reluctant to allow their wives to attend ANC, and insecurity; 3) Perceptions about pregnancy including misperceptions about the benefits of ANC and low perceived risk of pregnancy-related complications; and 4) Perceptions about the quality of care and the efficacy of medical treatment. This study identified a myriad of factors deeply entrenched in the society, which prevent women from utilising ANC services. It also elicits broad aspects of interconnectedness among the barriers. To ensure effectiveness, strategies to improve utilisation of ANC in the study area and in similar contexts need to take into account the barriers identified by this study.

Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation’s lowest scores on key development and health indicators and presents a substantial challenge to Uganda’s stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided. A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated. There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section. To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.

Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda. Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified. The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery. A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.

South Sudan has one of the world’s poorest health indicators due to a fragile health system and a combination of socio-cultural, economic and political factors. This study was conducted to identify barriers to utilisation of institutional childbirth services in Rumbek North County. Data were collected through 14 focus group discussions with 169 women and 45 men, and 18 key informant interviews with community leaders, staff working in health facilities, traditional birth attendants, and the staff of the County Health Department. Data were analysed using inductive content analysis. The barriers to institutional childbirth were categorised under four main themes: 1) Issues related to access and lack of resources: long distance to health facilities, lack of transportation means, referral problems, flooding and poor roads, and payments in health facilities; 2) Issues related to the socio-cultural context and conflict: insecurity, influence of the husband, lack of birth preparedness, domestic chores of women, influence of culture; 3) Perceptions about pregnancy and childbirth: perceived benefit of institutional childbirth, low childbirth risk perception, and medicalisation of childbirth including birth being perceived to be natural, undesirable birth practices, privacy concerns, and fear of caesarean section; and 4) Perceptions about the quality of care: inadequate health facility infrastructure and perceived neglect during admission. Multiple factors hinder institutional childbirth in Rumbek North. Some of the factors such as insecurity and poor roads are outside the scope of the health sector and will require a multi-sectoral approach if childbirth services are to be made accessible to women. Detailed recommendations to increase utilisation of childbirth services in the county have been suggested.

Gaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries. Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care. All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level. Our findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.