Study design, period, setting, and population
A mixed type institution-based cross-sectional study was conducted at North Achefer District, North West Ethiopia from November 7 to December 6, 2019. According to 2007 Ethiopia central statistics agency census, the Woreda is located 562 km Northwest of Addis Ababa, 102 km west of Bahir Dar [20] with estimated population of 251,873, of which 22, 9312 living in rural areas [20]. The Woreda has one hospital and seven health centers. There were a round 35 health care workers in the eight health institutions. All women delivered in health care institutions, and the skilled birth attendants of North Achefer district (7 health centers and one primary hospital) were the source population. Women delivered with spontaneous vaginal delivery in health care institutions during the data collection period, and the skilled birth attendants were the study population.
Sample size determination
The sample size was determined using single proportion formula with an assumption; 95% confidence interval (CI), marginal error (d), 5% and proportion of non-beneficial practice during childbirth in Ethiopia (P),15% [21].
n = [Z a/2]2 * p *q/d2= 1.96 * 1.96 * 0.15 * 0.85/0.05 * 0.05=196, with adding 10% for non-response rate; the final sample size was 216 for the quantitative data, and 44 subjects for qualitative data determined through data saturation.
Sampling technique and procedure
Women delivered in eight health facilities (7 health centers and 1 hospital) from November to December, 2019 were participated in the study. The number of participants from each health care facility was proportionally distributed through taking a one year average number of women who gave birth at each facility and estimating in a month, and then participants from each health institution were selected by simple random sampling technique (Fig. 1). Three focus group discussions with twenty four discussants (skilled birth attendants (health care worker who were currently working in maternity ward)), and with twenty in-depth interviews (women who had secondary and above education, and leaders of women’s health developmental army) were undertaken for the qualitative study until the point in data collection when new insights into the research questions were no longer viable. The participants for qualitative study and.
Variables
Dependent variable
Quality of intrapartum care.
Independent variables
Socio-demographic related factors
Age of the mothers,, marital status of mothers, number of children’s, and Level of education mothers.
Primary care function
Antenatal care follow-up for mothers, Strong emotional support of SBAs and Provider responds politely and respectfully, and use of partograph, skin to skin mother to baby care.
Facility level inputs
Facility type the care given, facility opening hour, availability of transportation, Cost for transportation to reach in health facility, and Distance to nearby health facility.
Operational definitions
Quality is measured using items adapted from the WHO standards similar to the national guidelines [22]
Good quality of intrapartum care: If the individual mothers’ score 75% or more of the intrapartum criteria [11].
Poor quality of intrapartum care: If the individual mothers’ score less than 75% of the intrapartum criteria [11].
Data collection tool and procedure
The service provision assessment and availability and readiness assessment tool was used. The tool comprises four parts. These are the Sociodemographic characteristics of the mothers (age, sex, educational level, number of children’s and marital status of the mother), primary care function factors (Antenatal care follow-up for mothers, Strong emotional support of SBAs and Provider responds politely and respectfully, and use of partograph, skin to skin mother to baby care), Facility level inputs factors (Facility type the care given, facility opening hour, availability of transportation, Cost for transportation to reach in health facility, and Distance to nearby health facility.), and quality of interapartum care measuring items had five subthemes with yes/no response (quality of health care service measuring items at during admission (21 items), during 1st stage labor(30 items), 2nd stage labor (6 items), 3rd stage labor (10 items), and immediately at postpartum period (23 items)) [11]. Semi-structured observation to observe the mothers and the skilled birth attendants during child birth and immediately at postpartum periods to assess the quality of care and record review form for gathering data from the mothers chart about the completeness of partograph were used to collect quantitative data respectively. In addition, the qualitative data were collected by using an unstructured interviewer guide through focused group discussion and in-depth interview. Eight Bachelor of Science (BSc) Nurses collected the data under the supervision of two Master of Science (MSc) Nurse. An interviewer and a note taker with a recording device were onsite during the interviews.
Data quality control
Data quality was assured through conducting training for data collectors about the overall process of data collection. The questionnaire was written in English, and then translated into Amharic, which was the study subjects' native language, and finally back to English, by language experts to ensure consistency and conceptual equivalence. At the same time, each completed questionnaire was cheeked for coherence, completeness, and consistency. The daily evaluation was carried out to address any issues that arose during the data collection process. Field notes and audio recordings were examined for appropriateness in terms of accurate coding and audibility for qualitative data. Furthermore, transcriptions were completed in a quiet environment.
Data processing and analysis
The overall quality care was determined through the summation of the quality of intrapartum care measuring items. After data analysis, descriptive statistics such as proportions, percentages, frequency distribution, and graphical presentation were used to describe the data. Variables with a p-value of less than and equal to 0.25 were entered into multivariable regression analysis and variables with p values < 0.05 were considered as statistically significant factors of quality of intrapartum care. For qualitative data, verbatim transcription in the Amharic language was made. The transcribed text file was translated into the English language for analysis. The translated text file was analyzed by using thematic content analysis. Finally, qualitative findings were used to supplement the quantitative result.