The study contexts
Ethiopia has 11 regional states and two city administrations. All the regions are not equally developed, and there is observed disparity in educational facilities, health service availability, and important infrastructure, including roads, electricity, and clean water . This study is conducted in poorly developed regions where a consortium of partners led by Amref health Africa has been implementing USAID transform health Activity over the last four years. The overall goal of the Transform HDR is to reduce morbidity and mortality among mothers and under-five children by improving the utilization of quality, high-impact MNCH/FP services in the DRSs in Ethiopia as stipulated in the Health Sector Transformation Plan (HSTP I -2016 – 2020). One of the priority focus areas was increasing access to integrated quality high, impact MNCH/FP services at the health facility through availing comprehensive obstetric care (CEmONC) service at the selected hospitals in Afar, Benishangul-Gumuz, Gambella, and Somali Regional States to help increase the number of healthy mothers who have successful birth outcomes.
Transform Health in Developing Regions activity is implemented in 60 woredas to benefit four million people by supporting more than 1,168 health facilities, including 984 health posts, 169 health centers, and 17 hospitals . The current study was conducted in 15 hospitals across the four DRS in Ethiopia, where pastoralists and agro-pastoralists predominate: Somali, Afar, Benishangul Gumuz, and Gambella. Somali and Afar regions are located in eastern Ethiopia, whereas Benishangul and Gambella regions are located in western Ethiopia.
A cross-sectional study was conducted on the availability of CEmONC services from January 1 to February 28, 2019, and lessons learned following the Transform HDR programs implemented from August 1, 2019, to December 2020 in the four DRS states were reviewed and documented.
We selected 15 out of 35 public hospitals in the four DRS purposely based on the availability Integrated Emergency Surgical Officers (IESOs) and operation rooms to assess the baseline CEMONC status. Six of the 15 hospitals were from the Somali region, four from the Afar region, three from Benishangul Gumuz, and the remaining two were from the Gambella region. Then ten hospitals that have IESOs, active operating rooms equipped with the appropriate equipment, and provide Caesarian Section (CS) service were identified for the implementation of a clinical mentorship program (CMP) (Supplementary Files 1 and 2).
Interventions: Brief descriptions of the project
The intervention consists of two interrelated activities: the CEmONC clinical mentorship program and general health facility support.
Intervention component 1. CEmONC Clinical Mentorship Program (CMP)
In consultation with the Ethiopian Society of Obstetrics and Gynaecology (ESOG), Transform HDR has been implementing the CEMONC clinical mentorship in ten hospitals eligible for the program. Five of the ten hospitals selected for clinical mentorship were from Somali, three in Afar, one in Benishangul Gumuz, and one in Gambella regions (Supplementary Files 1 and 2). The mentorship program primarily targeted IESOs at the selected health facilities. The CMP activities comprise mentor selection and orientation, sensitization workshops, mentorship inception, and onsite mentorship (Supplementary File 3). Experienced obstetricians/gynecologists with substantial maternity, training, and leadership expertise were chosen to provide this clinical mentorship program. The CMP began with sensitization workshops in each of the four DRS following mentors' orientation. This is followed by mentorship program inception and subsequent visits. Need-based on-the-job training was also done at different times to build mentees' capacity and achieve a quality CEmONC service. One-on-one case management refers to accepting, assessing, diagnosing, treating, and following up on cases by the mentee together with a mentor. The mentors were also oriented on the use of case-scenario discussions on a problem using real-life constraints for the mentee to develop a capacity to anticipate how a specific situation might play out in the real world and to avoid potentially adverse outcomes rather than attempting to solve a problem that is easier to prevent. Furthermore, during the orientation, the importance of reviewing medical records, telephone mentoring, and organizing needs-based on-the-job training was elaborated to improve documentation and the mentee's capacity to perform and build confidence. During each visit, the mentor observed mentees using preset checklist while performing CS, demonstrating procedures to mentees, giving feedback, performing hands-on practice with the mentees, and holding feedback with health facility managers in the presence of a USAID Transform HDR representative. The CMP was conducted for 6 consecutive rounds with six days onsite by 11 senior obstetrics and gynecologists with substantial mentorship and leadership experiences (Supplementary File 4).
Intervention component 2. Health facility support
Health facility support includes Comprehensive interventions to strengthen and complement the clinical mentorship program. The general health facility support provided for 15 hospitals consists of the provision of essential CEmONC equipment (e.g., purchase and equipment with mini-blood bank refrigerators), emergency blood transfusion service through establishing a mini blood bank, follow-up supervision, and establishment of Neonatal Intensive Care Unit (NICU) in hospitals and capacity building through provision of need-based training (e.g., on the clinical use of blood and blood products (ACUBBP) and post-ACUBBP training and follow-up supervision for laboratory experts, nurses, and physicians working in the designated institutions), and establishes a mini blood bank (Supplementary File 4).
CEmONC service use: measured in terms of the number of births, CS, and blood transfusion
Obstetric complications: acute conditions arising from a direct cause of maternal death, such as antepartum or postpartum hemorrhage, obstructed labor, postpartum sepsis, complications of abortion, pre-eclampsia or eclampsia, ectopic pregnancy, and ruptured uterus, or indirect causes such as anemia  in the six months before USAID’s HDR intervention and 12 months following the intervention
Institutional maternal mortality: the number of maternal deaths among total deliveries in the study hospitals in the six months prior to USAID’s HDR intervention and 12 months following the intervention.
Institutional neonatal mortality: the number of neonatal deaths in the first 28 days of life among total deliveries in the selected hospitals in the previous six months before USAID’s HDR intervention and 12 months following the intervention
C/S delivery: the number of CS delivery
Obstetric referral for blood transfusion: the number of mothers referred from one health facility to the next higher or similar facilities for life-saving blood transfusion.
CEmONC services:—are a set of key obstetrics services or signal functions for pregnant women and newborns who may experience fatal complications, such as severe bleeding, infection, prolonged or obstructed labor, eclampsia, and asphyxia in the newborn. The nine CEmONC signal functions consist of parenteral administration of antibiotics, treatments for eclampsia (provision of anticonvulsants), parenteral administration of oxytocin, assisted vaginal delivery (vacuum extraction), manual removal of placenta, removal of retained products of conception (MVA), newborn care, blood transfusion, and caesarian delivery of fetus in emergencies .
Twelve experienced data collectors (six midwives and six public health professionals) participated in the baseline survey. Six senior and experienced obstetrician-gynecologists were recruited to supervise the data collection process. Both data collectors and supervisors received a three-day training on collecting data. The training aimed to build a shared understanding of the contents of the data collecting tool, how to fill out each question, interviewing techniques, case selection, and field protocols to be followed during the survey so that the quality of data collection was achieved and ensured. Data was collected through face-to-face interviews with hospital administrators and maternity & newborn care service coordinators. Maternal and neonatal care records were also reviewed. All study hospital administrators and maternity & newborn care service coordinators were interviewed. In addition, the delivery, CS procedures, maternal admission and discharge logbooks, two neonates’ charts with breathing difficulties, two preterm deliveries with birth weights less than 2000 g, and two cesarean section operation notes per hospital were selected for chart review.
The data collection tool was adopted from an Adapted Averting Maternal Death and Disability tools (AMDD) . The adapted data collection tool consists of structured questions to assess the facility’s infrastructure, CEmONC signal functions availability, Partograph Review; Caesarean Delivery recorded Review, and Newborn Complications Chart Reviews.
Data were entered into CSPro 6.1 programming and exported to SPSS version 20.1 (IBM SPSS Statistics for Windows, Armonk, NY) for further analysis. We used descriptive statistical methods to summarize the relative number of CEmONC functions and others collected during baseline and post-intervention assessments. Lessons learned from USAID transform HDR post-intervention support activities were also described.