Effective coverage of skilled birth attendance in Ethiopia: a population-based cross-sectional study

Skilled birth attendance is among the crucial maternal health interventions for maternal and neonatal mortality reduction. The availability of core components of services at healthcare facilities and the quality-of-service provision are essential for the effective utilization of skilled birth attendance. Effective coverage measures the availability of essential components at health facilities and the quality of care delivered. This study aimed to measure effective coverage of skilled birth attendance in Ethiopia.

We applied the cascade approach to measure effective coverage, focusing on four steps up to quality-adjusted coverage as a proxy for effective coverage of skilled birth attendance. To assess the structural quality of facilities, we used the PMA service delivery assessment data in 2019. Effective coverage was defined as the product of skilled birth attendance, facility readiness score, intervention coverage (proportion who received uterotonic injection), and a process quality score.

The crude coverage for skilled delivery attendance was 54% (95%CI; 52, 56). The average level of facility readiness to provide skilled delivery service was 72%, ranging from 17% for private and non-governmental facilities to 88% for hospitals. The uterotonic injection coverage was 42% and the mean process quality for skilled delivery service was 46%. Based on the effective coverage cascade, the input-adjusted coverage was 38%, and the intervention-adjusted coverage was 16%, and the quality-adjusted coverage was 7%. Low level of facility readiness and low quality of service explain the low effective coverage of skilled delivery attendance. Apart from the overall low level of readiness, there was variability between different levels of facilities. Though the skilled delivery attendance coverage is improving, the low level of readiness, intervention provision, and poor process quality resulted in low effective coverage. The minimum level of readiness needs to be ensured at all levels of facilities to provide skilled delivery services. The minimum level of service readiness and quality of care need to be ensured at all facilities to provide skilled birth attendance.