Barriers of comprehensive emergency obstetric and newborn care provision at health center level in Addis Ababa, Ethiopia: A qualitative study

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Decentralizing Comprehensive Emergency Obstetric and Newborn Care (CEmONC) to health centers is a key strategy to reduce morbidity and mortality. However, the implementation of these services at the primary care level in Ethiopia faces significant systemic challenges that require further investigation. Methods A qualitative phenomenological study was conducted from May to July 2025 across five purposively selected public health centers in Addis Ababa, Ethiopia. In-depth interviews were held with 16 key stakeholders, including emergency surgical officers, anesthetists, scrub nurses, clinical directors, and maternal health experts. Data were collected using a semi-structured interview guide. Interviews were transcribed, translated, and analyzed using thematic content analysis. Results The analysis revealed a complex set of interconnected barriers to CEmONC provision. Major challenges included: ( 1 ) inadequate infrastructure: Health centers were not originally designed for surgical services, leading to critical shortages of space, operating rooms, and post-operative beds. ( 2 ) Human resource crises: While the introduction of Emergency Surgical Officers (ESOs) increased service uptake, high attrition rates due to an unclear career path and a lack of university recognition has threatened the program's sustainability. A critical shortage of trained surgical assistants and dedicated scrub nurses creates unsafe working conditions. ( 3 ) Supply chain failures: Frequent stock-outs of essential anesthesia drugs, blood, surgical consumables, and laboratory reagents regularly halt services, exacerbated by budget constraints and a slow procurement system. ( 4 ) Weak leadership and referral systems: Participants reported a lack of managerial support, motivation, and clear guidelines for the down-referral of patients from overcrowded hospitals. Conclusion The decentralization of CEmONC services to health centers in Addis Ababa is hampered by multifaceted challenges spanning infrastructure, human resources, supplies, and governance. Without urgent interventions to address the unsustainable workforce model, stabilize supply chains, improve infrastructure, and strengthen leadership, the significant gains in access to comprehensive emergency obstetric and surgical emergency care are at risk. Policymakers must prioritize these areas to ensure the long-term viability and quality of the critical lifesaving program. emergency obstetric and surgical care Ethiopia health centers implementation challenges primary health care Figures Figure 1 Figure 2 Background Despite significant progress in reducing maternal mortality globally, the burden remains unacceptably high, particularly in low- and middle-income countries (LMICs) ( 1 ). In 2020, an estimated 287,000 maternal deaths occurred worldwide, with 63% occurring in developing countries. Sub-Saharan Africa alone accounted for 70% (202,000) of these deaths. Ethiopia, like many countries in the region, continues to face substantial maternal health challenges. In 2o23, maternal mortality ratio is 195 deaths per 100,000 live births and a neonatal mortality rate (NMR) of 21 per 1,000 live births, and still above SDG targets ( 2 – 4 ). In 2021, the maternal near-miss rate in Ethiopia was 12.57%, with the largest magnitude (26.5%) in the Amhara region ( 3 ). Decentralizing emergency obstetric and neonatal care (EmONC) services to primary healthcare facilities, particularly health centers, have emerged as a critical approach to reducing maternal and neonatal mortality ( 5 – 6 ). Comprehensive EmONC (CEmONC) is a vital intervention designed to manage life-threatening obstetric complications, including hemorrhage, eclampsia, sepsis, and birth asphyxia ( 7 – 8 ). The World Health Organization (WHO) strongly recommends that CEmONC services be available at primary healthcare levels to ensure timely interventions ( 9 , 10 ). However, in many LMICs, including Ethiopia, the implementation of CEmONC at primary health facilities faces systemic challenges, including shortages of skilled personnel, inadequate infrastructure, and supply chain disruptions ( 11 , 12 ). A critical barrier to effective CEmONC delivery is the shortage of trained healthcare providers, particularly those with surgical expertise ( 13 – 15 ). To address this gap, several African countries, including Ethiopia, have introduced task-sharing programs that train mid-level healthcare providers to perform emergency obstetric and surgical procedures ( 16 – 19 ). These cadres have different designations across countries—such as clinical officers in Kenya, Uganda, and Malawi ( 20 ), assistant medical officers in Tanzania ( 21 ), and Integrated Emergency Surgical Officers (IESOs) in Ethiopia. IESOs are master’s-level associate clinicians trained to manage both surgical and obstetric emergencies at primary healthcare facilities. Studies indicate that the introduction of these cadres has contributed to significant reductions in maternal mortality in some settings ( 22 ). However, despite these advancements, Ethiopia’s CEmONC program at the health center level continues to encounter operational challenges. Research highlights that inadequate infrastructure, insufficient medical equipment, erratic supply of essential medicines, limited transportation, and weak communication systems hinder the provision of quality emergency obstetric and surgical care ( 11 , 12 ). Additionally, health system inefficiencies, such as poor referral linkages and inconsistent supervision, further exacerbate service delivery gaps ( 23 ).While task-sharing and decentralization have demonstrated success in other LMICs ( 6 , 24 , 25 ). In the context of Ethiopia, the initiative to decentralize CEmONC to primary health facilities health center level in particular remains relatively new and requires further evaluation. This study aims to shed light on evidence gaps by qualitatively investigating the challenges in providing CEmONC services at health centers level in Addis Ababa, Ethiopia, using the CFIR framework. Key research questions include: What systemic barriers hinder effective CEmONC service delivery at the health center level? How do healthcare providers and managers navigate these challenges in their daily practice? Methods Study Setting This study was conducted in Addis Ababa, the capital and largest city of Ethiopia. The city spans approximately 210 square kilometers and had a population of 5,384,569 according to the projection from the 2007 national census ( 26 ). Administratively, it is divided into 11 sub-cities, each comprising 10 to 12 woredas. The research was carried out in public health centers, which serve as primary healthcare units for their catchment population. According to a report from the Addis Ababa Health Bureau, the city has 11 public hospitals and 98 public health centers offering a broad range of services, including maternal and child healthcare. Among these, 18 health centers, along with 11 hospitals and 20 private facilities, provide CEmONC services to the city's residents and referrals from nearby regions ( 27 ). Study Design and Participant Selection We employed a qualitative phenomenological study design to examine challenges in delivering emergency obstetric and surgical services at health center level. From May 5 to 20, 2025, we conducted 16 in-depth interviews with stakeholders from five purposively selected health centers ( Felegemeles HC, Janmeda HC, Maychew HC, Akaki Kaliti HC, and Lemikura W2 HC), as well as two key informants from the Addis Ababa Health Bureau and the Federal Ministry of Health. Participants were selected to represent diverse operational roles and included emergency surgical officers ( 8 ), anesthetists ( 2 ), operating room nurses ( 2 ), clinical directors ( 2 ), and maternal health experts ( 2 ). Data Collection Data were collected using a semi-structured interview guide adapted from the Harvard Program in Global Surgery and Health, which explored six domains: infrastructure, supply chains, workforce, service delivery, financing, and leadership/information systems ( 28 ). Interviews were conducted in Amharic, audio-recorded with participant consent, and supplemented by field notes. The research team transcribed the recordings verbatim, translated them into English, and verified accuracy through cross-checking. Data Analysis We performed thematic content analysis using spreadsheet software. Transcripts were anonymized and coded iteratively. The resulting themes were then mapped to Consolidated Framework for Implementation Research (CFIR) domains to identify key barriers and facilitators to implementation. Ensuring Trustworthiness To ensure the rigor and trustworthiness of this qualitative study, we applied established criteria: credibility, dependability, confirmability, and transferability ( 29 ). For credibility, we employed prolonged engagement through in-depth interviews and triangulation of data sources by interviewing diverse stakeholders (ESOs, managers, nurses, anesthetists, and policy experts). Member checking was performed by sharing preliminary themes with a subset of participants to validate our interpretations. For dependability, we maintained an audit trail documenting all methodological decisions, from interview guide development to final analysis. For confirmability, we practiced reflexivity through regular team debriefings to discuss potential biases and ensure findings were grounded in the data. Finally, for transferability, we provide thick descriptions of the study context, participants, and settings to allow readers to assess the potential applicability of findings to similar contexts. The emergency surgical and obstetric care teams at the health center level were facing many challenges. The frequently mentioned codes (figure-1), themes and subthemes have been identified and the most commonly identified problems are categorized as infrastructure-related problems, human resources issues, supply challenges, leadership and managerial issues, and the referral system (Fig. 2 ) Identified challenges Infrastructure All the study site health centers were built to provide primary health care only; surgical care was not taken into consideration at the beginning. This study found that infrastructure related problems were mentioned the major challenge in all health centers. Participants claimed that following no standard for operation services at health center level, there is serious shortage of rooms, beds and operation room light. They complained that as a result of construction problems, there is poor installation of electricity and water supply. The emergency surgical and obstetric care service is being provided after minor renovations and merging different rooms. As one of the surgical officer explained that; “…. Operation service (Cesarean section) was not taken into consideration while constructing the health center from the very beginning. It was designed to provide only primary health care packages. Now we are working after we made some renovations on the first floor of the building, we have tried to merge 14 small rooms.” (Participant 6,female, medical director). As a result of the inadequacy of spaces for additional emergency surgical services and post-operation surgical beds, emergency surgeons claimed that their scope has been limited to only obstetric services. . The challenge here is that you can't expand the emergency surgical services as you want. Because we have only four beds due to room shortage. Due to this problem, our activity is limited to providing cesarean section.” (Participant 8,male,ESO) . Participant 2 also supported this claim by saying, ” We often do cesearean section. This is due to the limited space for operation room. The respondents said that after the start of emergency surgical services at the health center, there has been an increase in uptake of other services such as emergency and outpatient services, antenatal care, delivery and immunization. They believe that this is due to the increased awareness and confidence of the community towards the services provided by the health center. “ The other service indicators have been increased. For instance the number of births has increased from 12 (twelve) per month before surgical services were provided to 100 a month since the start of surgical delivery services”. (Participant7,Male,ESO). Human resource related challenges A critical challenge in decentralizing comprehensive emergency obstetric and surgical care to primary health facilities is the shortage of surgically trained specialists. To address this, Ethiopia introduced a task-sharing program, training mid-level health professionals as Emergency Surgical Officers (ESOs) to handle these emergencies. Although nationally around 1,000 ESOs have been trained and deployed and have brought remarkable changes in improving access of emergency obstetrics and surgical care, a new problem threatens the program's sustainability. A key informant from regional health bureau and Ministry of health explained… ( 1 ) “ We noticed that due to an unclear academic future pathway, there is a high attrition rate of ESOs. Universities are now resisting accepting these students for further training, citing unclear career progression.” public health expert in MOH ( 2 ) "Despite allocating specific budgets to recruit two ESOs per CEmONC facility, we continue to face a critical shortfall of these professionals due to both ongoing scarcity and a significant attrition rate."( Participant 10, Male, RHB maternal health expert). This resistance from universities creates a significant barrier to staffing newly constructed health centers with operational theaters, undermining the goal of improving the availability and accessibility of lifesaving surgical services nationwide. According to respondent’s description, there was a challenge during the start of surgical services at the health center level. Health center staff had poor perceptions towards surgical services and they thought that this initiative would add to their workload. Participant 7 described that it was difficult at the beginning to change the working environment and culture. Later on, through training, they have come to accept. “ Starting this service at the health center level is challenging. Due to the difficulty of changing working cultures, there are many challenges to overcome. Professionally, they also think that we make them too busy. We knew that the professional [midwife] who was only attending a few deliveries a month could not be happy when multiple activities started, such as inductions, augmentations, and so on. As a result of the launch of surgical services, the workload obviously increased.” (participant7,male,ESO) In terms of the challenges to human resources, the most frequently mentioned challenge in all health centers is the unavailability of trained assistances to the anesthetists and surgeons. They claimed that they are working in a stressful condition which is too risky if there is a complication following anesthesia. “There is fear; because Anesthesia is a very risky profession. Without assistance, it is difficult. Life can pass in three minutes. When you give spinal anesthesia there may be high spinal or in general anesthesia there may be failed intubation. So it’s dangerous! While we are working, we are getting tachycardia and bradycardic with the patient (participant 1,male, anesthetist). The worry of problems that can be raised due to lack of assistance from emergency surgeon’s side is also similar to the anesthetists. They reported that they were working alone day and night. Only one emergency surgeon is on duty in our health center. That is not enough because if a problem occur during the operation, it is difficult to manage it by single person. In case one of them has a problem; if they are two, the other will have a chance to finish. We have faced the same problem before. So it should be considered. (Participant 4,Male,ESO) As there is shortage of health professionals in the health centers, there is no separately assigned nurses to the OR department. The operation services are being provided just by calling nurses and assistances who are working in other services areas like outpatient department, antenatal care, and family planning. Even these nurses are not well trained or not exposed to surgical procedures. This creates a lot of challenges to the overall surgical activities in the facility. ... There is no independently assigned professional in the operating room. When there is an emergency surgical service, we are using nurses and assistances who are working in different departments. This is having a huge impact on the work (participant 2,Female, head nurse) Supply and budget related challenges Due to the fact that this is a new initiative, all health facilities reported many challenges associated with supply and budget issues. The most frequently raised supply related problems are lack of drugs especially anesthesia drugs (suxamethonium), lack of blood supply, lack of surgical consumables like surgical gloves and lack of laboratory reagents. .. There is hug shortage of supplies and medicines, anesthesia drugs in particular. This is creating challenges while doing our job. For example, last time, there was a shortage of anesthesia drug called suxamethinium at the national level; Surgery Service was discontinued for 15 days. We have also Glove deficiencies; it is very difficult to find different sizes (participant 2,female, head nurse) ……. Our biggest problem is lack of blood, especially to do previous c/s scar (participant 5, Male, Anesthetist)….. The medical directors and clinicians reported that the main reasons for all of these shortage supplies are budget constraints and procurement system as a bottleneck. The procurement system itself takes a long time. When there is a shortage of drugs, it is difficult to make immediate purchases. That's a problem for us (participant 5,Male, anesthetist) In all health centres, emergency surgical services especially cesarean section is being provided free of charge. Consequently, patient flow and utilization of other services are increasing. As an example, pregnant mothers who had follow-up at private hospitals are coming to the health center for caesarean section services for free, so this may also contribute to the frequent scarcity of supplies. All maternal health services given free of charge in the facilities, but there is serious shortage of budget to avail supplies, medications and equipments (participant 10,male, CEO) Leadership /management related challenges According to all participants, good leadership and management commitment starting from higher politicians is crucial for the smooth running of activities and the timely resolution of problems. The situation is different when it comes to health centres, participants complained about poor management system, limited attention to surgical services and limited knowledge about surgical procedures. Also, the study participants believe that rewarding or promoting employees by the management team is a very important thing in encouraging them. Nevertheless, no one was promoted, according to all participants ….. I can say there is no as such close interaction between the management team and we as surgical team. There is nothing to motivate. Sometimes I am wondering in this country if you are trained and assigned ….they don’t look you back. There must be updating training with recent information. It seems to me that we are excluded from everything. No one is considering us. (Participant 3) Referral system related challenges Participants also described challenges associated with hospitals down-referring patients due to a lack of beds. In contrast, there are no standards that support the down referring of cases from hospitals to health centers. This case raises the issue of responsibility and accountability… In addition, patients are also sent from hospitals to our health center due to lack of beds. This is challenging because beside to putting pressure on us, there is no set guideline regarding the transfer of patients from the hospital down to the health center (participant7,male,ESO) Respondents didn’t not only mention the challenges what they are facing, rather they also described the possible solution they used to sort out the problems: for instances using available resources, communicating with other hospitals support of supplies, convincing the management team for urgent procurements are some of the solution they have been using. As participants stated that the infrastructure issue was found to be beyond their scope. We are working by using the available resources. When shortage arises we just present it to management committee of the health center and is decided to be purchased by emergency. We also try to solve the problem by borrowing from others. But regarding the problems related with construction of infrastructure; it is beyond our capacity; So far no solution has been found (participant 2,Female, head nurse). Results Description of participants In this study, 16 participants were interviewed in randomly selected health centers providing comprehensive emergency obstetrics services, regional health bureau and ministry of health. Among the participants 6 were females and 10 were males. Interviews lasted between 10 minutes and 25 minutes, and the average interview time was 18 minutes. Based on the participant's professional category, 8 of them were emergency surgical officers, 2 chief executive officers, 2 anesthetists, 2 public health experts and 2 nurses working in the operation room. The overall experiences of the participants within the selected health centers ranged from 1 year to 5 years of work experience. The emergency surgical and obstetric care teams at the health center level were facing many challenges. The frequently mentioned codes (figure-1), themes and subthemes have been identified and the most commonly identified problems are categorized as infrastructure-related problems, human resources issues, supply challenges, leadership and managerial issues, and the referral system (figure 2) Identified challenges Infrastructure All the study site health centers were built to provide primary health care only; surgical care was not taken into consideration at the beginning. This study found that infrastructure related problems were mentioned the major challenge in all health centers. Participants claimed that following no standard for operation services at health center level, there is serious shortage of rooms, beds and operation room light. They complained that as a result of construction problems, there is poor installation of electricity and water supply. The emergency surgical and obstetric care service is being provided after minor renovations and merging different rooms. As one of the surgical officer explained that; “…. Operation service (Cesarean section) was not taken into consideration while constructing the health center from the very beginning. It was designed to provide only primary health care packages. Now we are working after we made some renovations on the first floor of the building, we have tried to merge 14 small rooms.” (Participant 6,female, medical director). As a result of the inadequacy of spaces for additional emergency surgical services and post-operation surgical beds, emergency surgeons claimed that their scope has been limited to only obstetric services. “. The challenge here is that you can't expand the emergency surgical services as you want. Because we have only four beds due to room shortage. Due to this problem, our activity is limited to providing cesarean section.” (Participant 8,male,ESO) . Participant 2 also supported this claim by saying, ” We often do cesearean section. This is due to the limited space for operation room.” The respondents said that after the start of emergency surgical services at the health center, there has been an increase in uptake of other services such as emergency and outpatient services, antenatal care, delivery and immunization. They believe that this is due to the increased awareness and confidence of the community towards the services provided by the health center. “ The other service indicators have been increased. For instance the number of births has increased from 12 (twelve) per month before surgical services were provided to 100 a month since the start of surgical delivery services”. (Participant7,Male,ESO). Human resource related challenges A critical challenge in decentralizing comprehensive emergency obstetric and surgical care to primary health facilities is the shortage of surgically trained specialists. To address this, Ethiopia introduced a task-sharing program, training mid-level health professionals as Emergency Surgical Officers (ESOs) to handle these emergencies. Although nationally around 1,000 ESOs have been trained and deployed and have brought remarkable changes in improving access of emergency obstetrics and surgical care, a new problem threatens the program's sustainability. A key informant from regional health bureau and Ministry of health explained… (1) “ We noticed that due to an unclear academic future pathway, there is a high attrition rate of ESOs. Universities are now resisting accepting these students for further training, citing unclear career progression.” public health expert in MOH (2) "Despite allocating specific budgets to recruit two ESOs per CEmONC facility, we continue to face a critical shortfall of these professionals due to both ongoing scarcity and a significant attrition rate."( Participant 10, Male, RHB maternal health expert). This resistance from universities creates a significant barrier to staffing newly constructed health centers with operational theaters, undermining the goal of improving the availability and accessibility of lifesaving surgical services nationwide. According to respondent’s description, there was a challenge during the start of surgical services at the health center level. Health center staff had poor perceptions towards surgical services and they thought that this initiative would add to their workload. Participant 7 described that it was difficult at the beginning to change the working environment and culture. Later on, through training, they have come to accept. “ Starting this service at the health center level is challenging. Due to the difficulty of changing working cultures, there are many challenges to overcome. Professionally, they also think that we make them too busy. We knew that the professional [midwife] who was only attending a few deliveries a month could not be happy when multiple activities started, such as inductions, augmentations, and so on. As a result of the launch of surgical services, the workload obviously increased.” (participant7,male,ESO) In terms of the challenges to human resources, the most frequently mentioned challenge in all health centers is the unavailability of trained assistances to the anesthetists and surgeons. They claimed that they are working in a stressful condition which is too risky if there is a complication following anesthesia. “There is fear; because Anesthesia is a very risky profession. Without assistance, it is difficult. Life can pass in three minutes. When you give spinal anesthesia there may be high spinal or in general anesthesia there may be failed intubation. So it’s dangerous! While we are working, we are getting tachycardia and bradycardic with the patient (participant 1,male, anesthetist). The worry of problems that can be raised due to lack of assistance from emergency surgeon’s side is also similar to the anesthetists. They reported that they were working alone day and night. Only one emergency surgeon is on duty in our health center. That is not enough because if a problem occur during the operation, it is difficult to manage it by single person. In case one of them has a problem; if they are two, the other will have a chance to finish. We have faced the same problem before. So it should be considered. (Participant 4,Male,ESO) As there is shortage of health professionals in the health centers, there is no separately assigned nurses to the OR department. The operation services are being provided just by calling nurses and assistances who are working in other services areas like outpatient department, antenatal care, and family planning. Even these nurses are not well trained or not exposed to surgical procedures. This creates a lot of challenges to the overall surgical activities in the facility. ... There is no independently assigned professional in the operating room. When there is an emergency surgical service, we are using nurses and assistances who are working in different departments. This is having a huge impact on the work (participant 2,Female, head nurse) Supply and budget related challenges Due to the fact that this is a new initiative, all health facilities reported many challenges associated with supply and budget issues. The most frequently raised supply related problems are lack of drugs especially anesthesia drugs (suxamethonium), lack of blood supply, lack of surgical consumables like surgical gloves and lack of laboratory reagents. .. There is hug shortage of supplies and medicines, anesthesia drugs in particular. This is creating challenges while doing our job. For example, last time, there was a shortage of anesthesia drug called suxamethinium at the national level; Surgery Service was discontinued for 15 days. We have also Glove deficiencies; it is very difficult to find different sizes (participant 2,female, head nurse) ……. Our biggest problem is lack of blood, especially to do previous c/s scar (participant 5, Male, Anesthetist) ….. The medical directors and clinicians reported that the main reasons for all of these shortage supplies are budget constraints and procurement system as a bottleneck. The procurement system itself takes a long time. When there is a shortage of drugs, it is difficult to make immediate purchases. That's a problem for us (participant 5,Male, anesthetist) In all health centres, emergency surgical services especially cesarean section is being provided free of charge. Consequently, patient flow and utilization of other services are increasing. As an example, pregnant mothers who had follow-up at private hospitals are coming to the health center for caesarean section services for free, so this may also contribute to the frequent scarcity of supplies. All maternal health services given free of charge in the facilities, but there is serious shortage of budget to avail supplies, medications and equipments (participant 10,male, CEO) Leadership /management related challenges According to all participants, good leadership and management commitment starting from higher politicians is crucial for the smooth running of activities and the timely resolution of problems. The situation is different when it comes to health centres, participants complained about poor management system, limited attention to surgical services and limited knowledge about surgical procedures. Also, the study participants believe that rewarding or promoting employees by the management team is a very important thing in encouraging them. Nevertheless, no one was promoted, according to all participants ….. I can say there is no as such close interaction between the management team and we as surgical team. There is nothing to motivate. Sometimes I am wondering in this country if you are trained and assigned ….they don’t look you back. There must be updating training with recent information. It seems to me that we are excluded from everything. No one is considering us. (Participant 3) Referral system related challenges Participants also described challenges associated with hospitals down-referring patients due to a lack of beds. In contrast, there are no standards that support the down referring of cases from hospitals to health centers. This case raises the issue of responsibility and accountability… In addition, patients are also sent from hospitals to our health center due to lack of beds. This is challenging because beside to putting pressure on us, there is no set guideline regarding the transfer of patients from the hospital down to the health center (participant7,male,ESO) Respondents didn’t not only mention the challenges what they are facing, rather they also described the possible solution they used to sort out the problems: for instances using available resources , communicating with other hospitals support of supplies, convincing the management team for urgent procurements are some of the solution they have been using. As participants stated that the infrastructure issue was found to be beyond their scope. We are working by using the available resources. When shortage arises we just present it to management committee of the health center and is decided to be purchased by emergency. We also try to solve the problem by borrowing from others. But regarding the problems related with construction of infrastructure; it is beyond our capacity; So far no solution has been found (participant 2,Female, head nurse). Discussion This study provides a critical qualitative analysis of the challenges hindering the effective implementation of Comprehensive Emergency Obstetric and Newborn Care (CEmONC) at the health center level in Addis Ababa, Ethiopia. The findings reveal that the decentralization of these life-saving services is severely constrained by a complex, interconnected web of barriers spanning five key domains: infrastructure, human resources, supplies, leadership, and referral systems. These results resonate with and significantly expand upon the existing literature on surgical and obstetric care in low-resource settings. A primary finding was the profound unsuitability of existing health center infrastructure for comprehensive emergency obstetric care and surgical services. Facilities were originally designed for primary healthcare, and the provisions of major surgery like cesarean sections through making renovations such as merging small rooms, is fundamentally inadequate. This directly limits the scope of services, confining providers to obstetric emergencies and preventing the management of other surgical cases due to a lack of space and postoperative beds, as reported by participants. This finding starkly contrasts with the foundational standards recommended for CEmONC. The WHO’s Monitoring Emergency Obstetric Care handbook and Ethiopia’s National Surgical, Obstetric, and Anesthesia Plan (NSOAP) emphasize the need for appropriate, purpose-built facilities to ensure the safety and quality of surgical care ( 9 , 10 ). The participant mentioned that some of facilities use by renovating the existing health facilities for operation services. So this approach of retrofitting facilities violates the “Standards for Ethiopian Health Centers” (2019) which specify minimum infrastructure requirements for different service levels. From a programmatic perspective, this indicates that the initial scale-up of CEmONC prioritized speed of deployment over adherence to quality and safety standards. The policy implication is clear: future infrastructure investment must be guided by specific architectural standards for CEmONC-ready health centers, and a national assessment is needed to retrofit existing facilities to meet minimum safety requirements. Despite of the Ethiopian government strive, the health workforce findings in CEMONC providing health centers presented a critical challenge. The deployment of Emergency Surgical Officers (ESOs) has driven a remarkable increase in service utilization, with one health center reporting a jump from 12 to 100 deliveries per month. This demonstrates the profound positive impact of task-sharing programs, a strategy strongly supported by evidence from Ethiopia and other African nations as a solution to specialist shortages ( 16 – 19 , 22 ). However, this success is now threatened by a severe sustainability crisis: a high attrition rate among ESOs driven by an unclear academic and career progression pathway, compounded by institutional resistance from universities to continue their training. This crisis directly undermines a core objective of Ethiopia’s Health Sector Transformation Plan (HSTP II) and NSOAP, which aim to ensure an adequate, competent, and motivated health workforce. The lack of a defined career ladder and academic recognition contradicts global best practices for sustaining mid-level provider programs, as seen in Tanzania and Malawi where clear licensure and integration into the public service structure have been key to success ( 19 , 21 ). Programmatically, this signals an urgent need for the Federal Ministry of Health and higher education institutions to collaboratively establish a formal career pathway, including opportunities for specialization, academic advancement, and leadership roles. Without this, the significant government investment in training over 1,000 ESOs is at risk of being lost, crippling the decentralization strategy. Furthermore, the study uncovered a critical gap within the surgical team itself. The absence of dedicated, trained operating room nurses and anesthetist assistants creates a dangerous and stressful work environment, increasing the risk of adverse outcomes. This finding is consistent with studies highlighting that barriers to care include not just the number of providers, but also their training, support systems, and working conditions ( 13 , 14 ). The fear and risk described by participants operating alone underscore that task-sharing cannot mean task-isolating; a supportive team ecosystem is essential for patient and provider safety. The WHO Safe Surgery Checklist and standards for surgical teams emphasize the necessity of a multidisciplinary team for safe anesthesia and surgery. The current practice of pulling untrained nurses from other departments violates these basic safety protocols. This has direct policy implications for human resource planning: job descriptions and staffing norms for CEmONC health centers must explicitly include dedicated anesthetists, surgical assistants, and scrub nurses. A targeted in-service training program for existing nurses is an immediate programmatic necessity to mitigate the severe safety risks identified. Participants universally reported crippling shortages of essential supplies, including anesthesia drugs, blood, surgical gloves, and laboratory reagents. These shortages, attributed to budget constraints and a slow procurement system, frequently halt surgical services entirely. The policy of providing free CEmONC services, while crucial for equity and access, appears to be unsupported by a sustainable financing and supply mechanism, leading to a mismatch between demand and available resources. This represents a major implementation gap. While the government’s policy of free maternal health care is aligned with the SDGs and the NSOAP’s goal of financial protection, the findings reveal a critical failure in the operational financing and supply chain strategy. The Essential Medicines List and CEmONC supply kits exist on paper, but the procurement and distribution system is not resilient enough to maintain consistent availability. Programmatically, this calls for the development and implementation of a dedicated, ring-fenced financing and logistics mechanism for CEmONC facilities. This could involve creating a separate budget line, establishing last-mile distribution guarantees with regional medical stores, and implementing robust inventory management systems at the health center level to prevent stock-outs. The study identified a significant gap in leadership and management engagement with the surgical teams. Participants reported a lack of support, motivation, and opportunities for continued training. This inadequate managerial oversight and the absence of a system for rewarding or promoting staff contribute to low morale and likely exacerbate attrition. Effective leadership is a cornerstone of successful health systems, and its absence directly contravenes the management and governance pillars of the HSTP II. The reported lack of managerial knowledge about surgical services in some facilities suggests that facility managers have not been adequately oriented on the operational and supervisory requirements of a CEmONC unit. This finding implies a need for targeted capacity building for health center managers overseeing surgical services, incorporating modules on surgical safety, team dynamics, and supply chain management into their training. Furthermore, developing a performance-based recognition or incentive scheme for CEmONC teams could be a policy lever to improve motivation and retention, as suggested by the participants themselves. Finally, the challenges with the referral system highlight a systemic flaw. The down-referral of patients from hospitals to health centers due to hospital bed shortages, without clear guidelines or protocols, places an undue and unsafe burden on primary facilities. This practice indicates a breakdown in the intended referral hierarchy and suggests that decentralization is being used to compensate for hospital-level constraints rather than as a strategically planned tier of care. This down referral practice deviates from the structured, bidirectional referral networks envisioned in national policy ( 9 , 23 ). It creates clinical and legal ambiguity regarding patient responsibility and risks overloading health centers with complex cases beyond their capacity. The programmatic response must be the urgent development and dissemination of national guidelines for patient transfer between hospitals and CEmONC health centers. These guidelines must clearly define appropriate criteria for down-referral (e.g., stable post-operative patients), communication protocols, and shared responsibility frameworks to ensure continuity and quality of care. Conclusions The qualitative approach in this study provided insights into the challenges that the CEmONC providing teams facing during provision of surgical and obstetrical care at health center level in Ethiopia. Clinicians and medical directors have described the most challenging issues like poorly designed operation theater, poor electric and water supply, in adequate drug and medical equipment supplies, lack of blood supply, problems related with human resources like unavailability of trained assistance to surgeons and anesthetist. The study also revealed that problems related with poor coordination or leadership problem. These findings can be used by researchers, policymakers and civil society organizations to generate practical interventions that improve comprehensive emergency obstetric care capacity and quality in health center. Limitations This qualitative study was conducted only in health centers implementing decentralization of emergency surgical and obstetrical care in Addis Ababa Ethiopia. Due to limitation of resources it didn’t cover regional health centers providing emergency obstetrics and surgical services where more challenges could be explored. Declarations Ethics approval and consent to participate: Ethical approval was obtained from the St. Paul’s Hospital Millennium Medical College Institutional Review Board (Ref: Pm23/485). The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki . Support letters were secured from all relevant health authorities. All participants provided written informed consent after receiving a detailed explanation of the study objectives, the voluntary nature of participation, and measures to ensure confidentiality. The study adhered to established ethical guidelines for qualitative research throughout its implementation. Consent for publication : There are no circumstances in the study that violate anonymity, and identifying information has been kept confidential. There are no issues regarding its publication. Availability of data and materials: The data that support the findings of this study are available on request from the corresponding author. Competing interests: The authors declare no conflict of interest for this article. Funding: No Acknowledgements: The authors would like to thank the interview participants for generously sharing their time and insights. In addition, I extend my profound appreciation to the Addis Ababa Health Bureau and the health facility managers for their permission and unwavering support during conducting the interview. Authors' information Melese Takele Wossen * 1 , Yifru Berhan 1 , Katariina Laine 2,3 , Zewde Aderaw Alemu 1 , Bezatu Alemu 1 1 Saint Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia 2 University of Oslo, Oslo, Norway 3 Oslo University Hospital, Oslo, Norway Authors' contributions : All authors contributed to the following sections of the article and fulfilled the conditions for being an article writer. MTW contributed conceptualization, Investigation, Methodology, Data collection, Formal analysis; Project administration; Writing – original draft; Writing – review & editing. YB was involved in supervision, validation, writing, review & editing; Critical revision of the manuscript. KL contributed methodological review, Intellectual input, editing & reviewing manuscript, guidance and mentorship. ZA contributed for Methodological review, validation, reviewing and editing the manuscript. BA is a lead Supervisor; contributed during conceptualization, Methodological review and Validation; Writing and editing, critical revision of the manuscript. All authors read and approved the final manuscript. References Alkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, Fat DM, Boerma T, Temmerman M, Mathers C, Say L. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. The lancet. 2016 Jan 30;387(10017):462-74. World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division: executive summary. 2023. Mengist B, Desta M, Tura AK, Habtewold TD, Abajobir A. Maternal near miss in Ethiopia: Protective role of antenatal care and disparity in socioeconomic inequities: a systematic review and meta-analysis. Int J Africa Nurs Sci 2021;15:100332. Aminu M, Unkels R, Mdegela M, Utz B, Adaji S, Van Den Broek N. Causes of and factors associated with stillbirth in low‐and middle‐income countries: a systematic literature review. BJOG: An International Journal of Obstetrics & Gynaecology. 2014;121:141-53. Peters AW, Roa L, Rwamasirabo E, Ameh E, Ulisubisya MM, Samad L, Makasa EM, Meara JG. National surgical, obstetric, and anesthesia plans supporting the vision of universal health coverage. Global Health: Science and Practice. 2020 Mar 30;8(1):1-9. Nyamtema AS, LeBlanc JC, Mtey G, Tomblin Murphy G, Kweyamba E, Bulemela J, Shayo A, Abel Z, Kilume O, Scott H, Rigby J. Scale up and strengthening of comprehensive emergency obstetric and newborn care in Tanzania. PloS One. 2022 Jul 8;17(7):e0271282. Lindtjørn B, Mitiku D, Zidda Z, Yaya Y. Reducing maternal deaths in Ethiopia: results of an intervention Programme in Southwest Ethiopia. PLoS One. 2017;12(1):e0169304 Drum ET, Workneh RS, Tilahun R, McQueen KA. Safe surgery for all: early lessons from implementing a national government-driven surgical plan in Ethiopia. World Journal of Surgery. 2018 Nov;42(11):3812-3. Gausman J, Pingray V, Adanu R, Bandoh DA, Berrueta M, Blossom J, et al. Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data. Plos one. 2023;18(9):e0287904. World Health Organization. Monitoring emergency obstetric care: a handbook: World Health Organization; 2009. Dahab R, Sakellariou D. Barriers to accessing maternal care in low income countries in Africa: a systematic review. International journal of environmental research and public health. 2020;17(12):4292. AG, CC, AM, DL. Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa-a systematic review protocol. Systematic Reviews. 2018;7(1):1-14. Faqir M, Zainullah P, Tappis H, Mungia J, Currie S, Kim YM. Availability and distribution of human resources for provision of comprehensive emergency obstetric and newborn care in Afghanistan: a cross-sectional study. Conflict and Health. 2015;9(1):9. Morgan MC, Dyer J, Abril A, Christmas A, Mahapatra T, Das A, et al. Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study. BMC Pregnancy Childbirth. 2018;18(1):420. Gerein N, Green A, Pearson S. The implications of shortages of health professionals for maternal health in sub-Saharan Africa. Reproductive health matters. 2006;14(27):40-50. Ryan I, Shah KV, Barrero CE, Uamunovandu T, Ilbawi A, Swanson J. Task shifting and task sharing to strengthen the surgical workforce in sub-Saharan Africa: a systematic review of the existing literature. World journal of surgery. 2023;47(12):3070-80. Beard JH, Oresanya LB, Akoko L, Mwanga A, Mkony CA, Dicker RA. Surgical task-shifting in a low-resource setting: outcomes after major surgery performed by nonphysician clinicians in Tanzania. World journal of surgery. 2014;38:1398-404. Galukande M, Kaggwa S, Sekimpi P, Kakaire O, Katamba A, Munabi I, et al. Use of surgical task shifting to scale up essential surgical services: a feasibility analysis at facility level in Uganda. BMC health services research. 2013;13(1):1-7. Federspiel F, Mukhopadhyay S, Milsom PJ, Scott JW, Riesel JN, Meara JG. Global surgical, obstetric, and anesthetic task shifting: a systematic literature review. Surgery. 2018;164(3):553-8. Gajewski J, Borgstein E, Bijlmakers L, Mwapasa G, Aljohani Z, Pittalis C, et al. Evaluation of a surgical training programme for clinical officers in Malawi. Journal of British Surgery. 2019;106(2):e156-e65. Sirili N, Mselle L, Anaeli A, Massawe S. Task sharing and performance of Caesarean section by the Assistant Medical Officers in Tanzania: What have we learned? The East African Health Research Journal. 2020;4(2):149. Harrison MS, Kirub E, Liyew T, Teshome B, Jimenez-Zambrano A, Muldrow M, et al. Research Article Performance of Integrated Emergency Surgical Officers at Mizan-Tepi University Teaching Hospital, Mizan-Aman, Ethiopia: A Retrospective Cohort Study. 2021. Abebe F, Bilal SM, Lerebo W, Hailu T, Legesse T, Tsegaye R, et al. Barriers to accessing emergency obstetric care in Ethiopia: a qualitative study. BMC Health Serv Res . 2020;20(1):456. Available from: https://doi.org/10.1186/s12913-020-05618-3 Tsegaye R, Worku A, Kebede A, Misganaw B, Tessema GA. Health system barriers to quality emergency obstetric care in Ethiopia: evidence from a facility-based cross-sectional study. Int J Gynecol Obstet . 2021;155(2):123-30. Available from: https://doi.org/10.1016/j.ijgo.2021.05.012 Wilson S, Bah MM, George P, et al. Challenges and solutions to providing surgery in Sierra Leone hospitals: a qualitative analysis of surgical provider perspectives. BMJ Open 2022; 12:e052972. doi:10.1136/ bmjopen-2021-052972 Review world population. Addis Ababa population. Internet: https://worldpopulationreview.com/world-cities/addis-ababa-population : accessed 20th january2023, 1:30 Am. Addis Ababa Health Bureau report 2023,Addis Ababa, Ethiopia 2023 Albutt K, Yorlets RR, Punchak M, Kayima P, Namanya DB, Anderson GA, et al. (2018) You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda. PLoS ONE 13 (4): e0195986. https://doi.org/10.1371/journal. pone.0195986 Creswell, J. W. (1997). Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8555602","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":590815868,"identity":"c21156c5-5a3e-4f86-bccb-56fe628af274","order_by":0,"name":"Melese Takele 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level.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8555602/v1/c200895d4802aac6510fe5a2.png"},{"id":102962582,"identity":"f89f035b-6e1f-4773-95c0-868da8ef9b9f","added_by":"auto","created_at":"2026-02-19 04:09:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":144084,"visible":true,"origin":"","legend":"\u003cp\u003ethe group of themes and sub-themes identified for barriers of CEmONC service at Health center level.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8555602/v1/d9cb473fc75770a4394d4435.png"},{"id":103056484,"identity":"7e89b046-5181-4893-9ad2-124a302ab0d4","added_by":"auto","created_at":"2026-02-20 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study","fulltext":[{"header":"Background","content":"\u003cp\u003eDespite significant progress in reducing maternal mortality globally, the burden remains unacceptably high, particularly in low- and middle-income countries (LMICs) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In 2020, an estimated 287,000 maternal deaths occurred worldwide, with 63% occurring in developing countries. Sub-Saharan Africa alone accounted for 70% (202,000) of these deaths. Ethiopia, like many countries in the region, continues to face substantial maternal health challenges. In 2o23, maternal mortality ratio is 195 deaths per 100,000 live births and a neonatal mortality rate (NMR) of 21 per 1,000 live births, and still above SDG targets (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In 2021, the maternal near-miss rate in Ethiopia was 12.57%, with the largest magnitude (26.5%) in the Amhara region (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDecentralizing emergency obstetric and neonatal care (EmONC) services to primary healthcare facilities, particularly health centers, have emerged as a critical approach to reducing maternal and neonatal mortality (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Comprehensive EmONC (CEmONC) is a vital intervention designed to manage life-threatening obstetric complications, including hemorrhage, eclampsia, sepsis, and birth asphyxia (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The World Health Organization (WHO) strongly recommends that CEmONC services be available at primary healthcare levels to ensure timely interventions (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, in many LMICs, including Ethiopia, the implementation of CEmONC at primary health facilities faces systemic challenges, including shortages of skilled personnel, inadequate infrastructure, and supply chain disruptions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA critical barrier to effective CEmONC delivery is the shortage of trained healthcare providers, particularly those with surgical expertise (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). To address this gap, several African countries, including Ethiopia, have introduced task-sharing programs that train mid-level healthcare providers to perform emergency obstetric and surgical procedures (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). These cadres have different designations across countries\u0026mdash;such as clinical officers in Kenya, Uganda, and Malawi (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), assistant medical officers in Tanzania (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and Integrated Emergency Surgical Officers (IESOs) in Ethiopia. IESOs are master\u0026rsquo;s-level associate clinicians trained to manage both surgical and obstetric emergencies at primary healthcare facilities. Studies indicate that the introduction of these cadres has contributed to significant reductions in maternal mortality in some settings (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, despite these advancements, Ethiopia\u0026rsquo;s CEmONC program at the health center level continues to encounter operational challenges. Research highlights that inadequate infrastructure, insufficient medical equipment, erratic supply of essential medicines, limited transportation, and weak communication systems hinder the provision of quality emergency obstetric and surgical care (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Additionally, health system inefficiencies, such as poor referral linkages and inconsistent supervision, further exacerbate service delivery gaps (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).While task-sharing and decentralization have demonstrated success in other LMICs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e In the context of Ethiopia, the initiative to decentralize CEmONC to primary health facilities health center level in particular remains relatively new and requires further evaluation. This study aims to shed light on evidence gaps by qualitatively investigating the challenges in providing CEmONC services at health centers level in Addis Ababa, Ethiopia, using the CFIR framework. Key research questions include: What systemic barriers hinder effective CEmONC service delivery at the health center level? How do healthcare providers and managers navigate these challenges in their daily practice?\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eThis study was conducted in Addis Ababa, the capital and largest city of Ethiopia. The city spans approximately 210 square kilometers and had a population of 5,384,569 according to the projection from the 2007 national census (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Administratively, it is divided into 11 sub-cities, each comprising 10 to 12 woredas.\u003c/p\u003e \u003cp\u003eThe research was carried out in public health centers, which serve as primary healthcare units for their catchment population. According to a report from the Addis Ababa Health Bureau, the city has 11 public hospitals and 98 public health centers offering a broad range of services, including maternal and child healthcare. Among these, 18 health centers, along with 11 hospitals and 20 private facilities, provide CEmONC services to the city's residents and referrals from nearby regions (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design and Participant Selection\u003c/h3\u003e\n\u003cp\u003eWe employed a qualitative phenomenological study design to examine challenges in delivering emergency obstetric and surgical services at health center level. From May 5 to 20, 2025, we conducted 16 in-depth interviews with stakeholders from five purposively selected health centers ( Felegemeles HC, Janmeda HC, Maychew HC, Akaki Kaliti HC, and Lemikura W2 HC), as well as two key informants from the Addis Ababa Health Bureau and the Federal Ministry of Health. Participants were selected to represent diverse operational roles and included emergency surgical officers (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), anesthetists (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), operating room nurses (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), clinical directors (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and maternal health experts (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected using a semi-structured interview guide adapted from the Harvard Program in Global Surgery and Health, which explored six domains: infrastructure, supply chains, workforce, service delivery, financing, and leadership/information systems (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Interviews were conducted in Amharic, audio-recorded with participant consent, and supplemented by field notes. The research team transcribed the recordings verbatim, translated them into English, and verified accuracy through cross-checking.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe performed thematic content analysis using spreadsheet software. Transcripts were anonymized and coded iteratively. The resulting themes were then mapped to Consolidated Framework for Implementation Research (CFIR) domains to identify key barriers and facilitators to implementation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEnsuring Trustworthiness\u003c/h3\u003e\n\u003cp\u003eTo ensure the rigor and trustworthiness of this qualitative study, we applied established criteria: credibility, dependability, confirmability, and transferability (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). For credibility, we employed prolonged engagement through in-depth interviews and triangulation of data sources by interviewing diverse stakeholders (ESOs, managers, nurses, anesthetists, and policy experts). Member checking was performed by sharing preliminary themes with a subset of participants to validate our interpretations. For dependability, we maintained an audit trail documenting all methodological decisions, from interview guide development to final analysis. For confirmability, we practiced reflexivity through regular team debriefings to discuss potential biases and ensure findings were grounded in the data. Finally, for transferability, we provide thick descriptions of the study context, participants, and settings to allow readers to assess the potential applicability of findings to similar contexts.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003cp\u003eThe emergency surgical and obstetric care teams at the health center level were facing many challenges. The frequently mentioned codes (figure-1), themes and subthemes have been identified and the most commonly identified problems are categorized as infrastructure-related problems, human resources issues, supply challenges, leadership and managerial issues, and the referral system (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eIdentified challenges\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInfrastructure\u003c/h2\u003e \u003cp\u003eAll the study site health centers were built to provide primary health care only; surgical care was not taken into consideration at the beginning. This study found that infrastructure related problems were mentioned the major challenge in all health centers. Participants claimed that following no standard for operation services at health center level, there is serious shortage of rooms, beds and operation room light. They complained that as a result of construction problems, there is poor installation of electricity and water supply. The emergency surgical and obstetric care service is being provided after minor renovations and merging different rooms. As one of the surgical officer explained that;\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e“…. \u003cem\u003eOperation service (Cesarean section) was not taken into consideration while constructing the health center from the very beginning. It was designed to provide only primary health care packages. Now we are working after we made some renovations on the first floor of the building, we have tried to merge 14 small rooms.” (Participant 6,female, medical director).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003cp\u003eAs a result of the inadequacy of spaces for additional emergency surgical services and post-operation surgical beds, emergency surgeons claimed that their scope has been limited to only obstetric services.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e.\u003cem\u003eThe challenge here is that you can't expand the emergency surgical services as you want. Because we have only four beds due to room shortage. Due to this problem, our activity is limited to providing cesarean section.” (Participant 8,male,ESO)\u003c/em\u003e. Participant 2 also supported this claim by saying, ”\u003cem\u003eWe often do cesearean section. This is due to the limited space for operation room.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003cp\u003eThe respondents said that after the start of emergency surgical services at the health center, there has been an increase in uptake of other services such as emergency and outpatient services, antenatal care, delivery and immunization. They believe that this is due to the increased awareness and confidence of the community towards the services provided by the health center.\u003c/p\u003e \u003cp\u003e“\u003cem\u003eThe other service indicators have been increased. For instance the number of births has increased from 12 (twelve) per month before surgical services were provided to 100 a month since the start of surgical delivery services”. (Participant7,Male,ESO).\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eHuman resource related challenges\u003c/h2\u003e \u003cp\u003eA critical challenge in decentralizing comprehensive emergency obstetric and surgical care to primary health facilities is the shortage of surgically trained specialists. To address this, Ethiopia introduced a task-sharing program, training mid-level health professionals as Emergency Surgical Officers (ESOs) to handle these emergencies.\u003c/p\u003e \u003cp\u003eAlthough nationally around 1,000 ESOs have been trained and deployed and have brought remarkable changes in improving access of emergency obstetrics and surgical care, a new problem threatens the program's sustainability. A key informant from regional health bureau and Ministry of health explained…\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) “\u003cem\u003eWe noticed that due to an unclear academic future pathway, there is a high attrition rate of ESOs. Universities are now resisting accepting these students for further training, citing unclear career progression.” public health expert in MOH\u003c/em\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003cem\u003e\"Despite allocating specific budgets to recruit two ESOs per CEmONC facility, we continue to face a critical shortfall of these professionals due to both ongoing scarcity and a significant attrition rate.\"( Participant 10, Male, RHB maternal health expert).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003cp\u003eThis resistance from universities creates a significant barrier to staffing newly constructed health centers with operational theaters, undermining the goal of improving the availability and accessibility of lifesaving surgical services nationwide.\u003c/p\u003e \u003cp\u003eAccording to respondent’s description, there was a challenge during the start of surgical services at the health center level. Health center staff had poor perceptions towards surgical services and they thought that this initiative would add to their workload. Participant 7 described that it was difficult at the beginning to change the working environment and culture. Later on, through training, they have come to accept.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e“ Starting this service at the health center level is challenging. Due to the difficulty of changing working cultures, there are many challenges to overcome. Professionally, they also think that we make them too busy. We knew that the professional [midwife] who was only attending a few deliveries a month could not be happy when multiple activities started, such as inductions, augmentations, and so on. As a result of the launch of surgical services, the workload obviously increased.” (participant7,male,ESO)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003cp\u003eIn terms of the challenges to human resources, the most frequently mentioned challenge in all health centers is the unavailability of trained assistances to the anesthetists and surgeons. They claimed that they are working in a stressful condition which is too risky if there is a complication following anesthesia.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e“There is fear; because Anesthesia is a very risky profession. Without assistance, it is difficult. Life can pass in three minutes. When you give spinal anesthesia there may be high spinal or in general anesthesia there may be failed intubation. So it’s dangerous! While we are working, we are getting tachycardia and bradycardic with the patient\u003c/em\u003e (participant 1,male, anesthetist).\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003cp\u003eThe worry of problems that can be raised due to lack of assistance from emergency surgeon’s side is also similar to the anesthetists. They reported that they were working alone day and night.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eOnly one emergency surgeon is on duty in our health center. That is not enough because if a problem occur during the operation, it is difficult to manage it by single person. In case one of them has a problem; if they are two, the other will have a chance to finish. We have faced the same problem before. So it should be considered. (Participant 4,Male,ESO)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003cp\u003eAs there is shortage of health professionals in the health centers, there is no separately assigned nurses to the OR department. The operation services are being provided just by calling nurses and assistances who are working in other services areas like outpatient department, antenatal care, and family planning. Even these nurses are not well trained or not exposed to surgical procedures. This creates a lot of challenges to the overall surgical activities in the facility.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e... \u003cem\u003eThere is no independently assigned professional in the operating room. When there is an emergency surgical service, we are using nurses and assistances who are working in different departments. This is having a huge impact on the work (participant 2,Female, head nurse)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSupply and budget related challenges\u003c/h2\u003e \u003cp\u003eDue to the fact that this is a new initiative, all health facilities reported many challenges associated with supply and budget issues. The most frequently raised supply related problems are lack of drugs especially anesthesia drugs (suxamethonium), lack of blood supply, lack of surgical consumables like surgical gloves and lack of laboratory reagents.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e..\u003cem\u003eThere is hug shortage of supplies and medicines, anesthesia drugs in particular. This is creating challenges while doing our job. For example, last time, there was a shortage of anesthesia drug called suxamethinium at the national level; Surgery Service was discontinued for 15 days. We have also Glove deficiencies; it is very difficult to find different sizes (participant 2,female, head nurse)\u003c/em\u003e ……. \u003cem\u003eOur biggest problem is lack of blood, especially to do previous c/s scar (participant 5, Male, Anesthetist)…..\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003cp\u003eThe medical directors and clinicians reported that the main reasons for all of these shortage supplies are budget constraints and procurement system as a bottleneck.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe procurement system itself takes a long time. When there is a shortage of drugs, it is difficult to make immediate purchases. That's a problem for us (participant 5,Male, anesthetist)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003cp\u003eIn all health centres, emergency surgical services especially cesarean section is being provided free of charge. Consequently, patient flow and utilization of other services are increasing. As an example, pregnant mothers who had follow-up at private hospitals are coming to the health center for caesarean section services for free, so this may also contribute to the frequent scarcity of supplies.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eAll maternal health services given free of charge in the facilities, but there is serious shortage of budget to avail supplies, medications and equipments (participant 10,male, CEO)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLeadership /management related challenges\u003c/h2\u003e \u003cp\u003eAccording to all participants, good leadership and management commitment starting from higher politicians is crucial for the smooth running of activities and the timely resolution of problems. The situation is different when it comes to health centres, participants complained about poor management system, limited attention to surgical services and limited knowledge about surgical procedures. Also, the study participants believe that rewarding or promoting employees by the management team is a very important thing in encouraging them. Nevertheless, no one was promoted, according to all participants ….. \u003cem\u003eI can say there is no as such close interaction between the management team and we as surgical team. There is nothing to motivate. Sometimes I am wondering in this country if you are trained and assigned ….they don’t look you back. There must be updating training with recent information. It seems to me that we are excluded from everything. No one is considering us. (Participant 3)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eReferral system related challenges\u003c/h2\u003e \u003cp\u003eParticipants also described challenges associated with hospitals down-referring patients due to a lack of beds. In contrast, there are no standards that support the down referring of cases from hospitals to health centers. This case raises the issue of responsibility and accountability…\u003cem\u003eIn addition, patients are also sent from hospitals to our health center due to lack of beds. This is challenging because beside to putting pressure on us, there is no set guideline regarding the transfer of patients from the hospital down to the health center (participant7,male,ESO)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eRespondents didn’t not only mention the challenges what they are facing, rather they also described the possible solution they used to sort out the problems: for instances using available resources, communicating with other hospitals support of supplies, convincing the management team for urgent procurements are some of the solution they have been using. As participants stated that the infrastructure issue was found to be beyond their scope.\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe are working by using the available resources. When shortage arises we just present it to management committee of the health center and is decided to be purchased by emergency. We also try to solve the problem by borrowing from others. But regarding the problems related with construction of infrastructure; it is beyond our capacity; So far no solution has been found\u003c/em\u003e (participant 2,Female, head nurse).\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDescription of participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, 16 participants were interviewed in randomly selected health centers providing comprehensive emergency obstetrics services, regional health bureau and ministry of health. Among the participants 6 were females and 10 were males. Interviews lasted between 10 minutes and 25 minutes, and the average interview time was 18 minutes. Based on the participant\u0026apos;s professional category, 8 of them were emergency surgical officers, 2 chief executive officers, 2 anesthetists, 2 public health experts and 2 nurses working in the operation room. The overall experiences of the participants within the selected health centers ranged from 1 year to 5 years of work experience.\u003c/p\u003e\n\u003cp\u003eThe emergency surgical and obstetric care teams at the health center level were facing many challenges. The frequently mentioned codes (figure-1), themes and subthemes have been identified and the most commonly identified problems are categorized as infrastructure-related problems, human resources issues, supply challenges, leadership and managerial issues, and the referral system (figure 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentified challenges\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfrastructure \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the study site health centers were built to provide primary health care only; surgical care was not taken into consideration at the beginning. This study found that infrastructure related problems were mentioned the major challenge in all health centers. Participants claimed that following no standard for operation services at health center level, there is serious shortage of rooms, beds and operation room light. They complained that as a result of construction problems, there is poor installation of electricity and water supply. \u0026nbsp; The emergency surgical and obstetric care service is being provided after minor renovations and merging different rooms. As one of the surgical officer explained that;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;. \u003cem\u003eOperation service (Cesarean section) was not taken into consideration while constructing the health center from the very beginning. It was designed to provide only primary health care packages. Now we are working after we made some renovations on the first floor of the building, we have tried to merge 14 small rooms.\u0026rdquo; (Participant 6,female, medical director).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs a result of the inadequacy of spaces for additional emergency surgical services and post-operation surgical beds, emergency surgeons claimed that their scope has been limited to only obstetric services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;.\u003c/em\u003e\u003cem\u003eThe challenge here is that you can\u0026apos;t expand the emergency surgical services as you want. Because we have only four beds due to room shortage. Due to this problem, our activity is limited to providing cesarean section.\u0026rdquo; (Participant 8,male,ESO)\u003c/em\u003e. Participant 2 also supported this claim by saying, \u0026rdquo;\u003cem\u003eWe often do cesearean section. This is due to the limited space for operation room.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe respondents said that after the start of emergency surgical services at the health center, there has been an increase in uptake of other services such as emergency and outpatient services, antenatal care, delivery and immunization. They believe that this is due to the increased awareness and confidence of the community towards the services provided by the health center.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eThe other service indicators have been increased. For instance the number of births has increased from 12 (twelve) per month before surgical services were provided to 100 a month since the start of surgical delivery services\u0026rdquo;. (Participant7,Male,ESO).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman resource related challenges\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA critical challenge in decentralizing comprehensive emergency obstetric and surgical care to primary health facilities is the shortage of surgically trained specialists. To address this, Ethiopia introduced a task-sharing program, training mid-level health professionals as Emergency Surgical Officers (ESOs) to handle these emergencies.\u003c/p\u003e\n\u003cp\u003eAlthough nationally around 1,000 ESOs have been trained and deployed and have brought remarkable changes in improving access of emergency obstetrics and surgical care, a new problem threatens the program\u0026apos;s sustainability. A key informant from regional health bureau and Ministry of health explained\u0026hellip; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(1) \u0026ldquo;\u003cem\u003eWe noticed that due to an unclear academic future pathway, there is a high attrition rate of ESOs. Universities are now resisting accepting these students for further training, citing unclear career progression.\u0026rdquo; public health expert in MOH\u003c/em\u003e(2)\u003cem\u003e\u0026quot;Despite allocating specific budgets to recruit two ESOs per CEmONC facility, we continue to face a critical shortfall of these professionals due to both ongoing scarcity and a significant attrition rate.\u0026quot;( Participant 10, Male, RHB maternal health expert).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis resistance from universities creates a significant barrier to staffing newly constructed health centers with operational theaters, undermining the goal of improving the availability and accessibility of lifesaving surgical services nationwide.\u003c/p\u003e\n\u003cp\u003eAccording to respondent\u0026rsquo;s description, there was a challenge during the start of surgical services at the health center level. Health center staff had poor perceptions towards surgical services and they thought that this initiative would add to their workload. Participant 7 described that it was difficult at the beginning to change the working environment and culture. Later on, through training, they have come to accept.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003eStarting this service at the health center level is challenging. Due to the difficulty of changing working cultures, there are many challenges to overcome. Professionally, they also think that we make them too busy. We knew that the professional [midwife] who was only attending a few deliveries a month could not be happy when multiple activities started, such as inductions, augmentations, and so on. As a result of the launch of surgical services, the workload obviously increased.\u0026rdquo; (participant7,male,ESO)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn terms of the challenges to human resources, the most frequently mentioned challenge in all health centers is the unavailability of trained assistances to the anesthetists and surgeons. They claimed that they are working in a stressful condition which is too risky if there is a complication following anesthesia.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is fear; because Anesthesia is a very risky profession. Without assistance, it is difficult. Life can pass in three minutes. When you give spinal anesthesia there may be high spinal or in general anesthesia there may be failed intubation. So it\u0026rsquo;s dangerous! While we are working, we are getting tachycardia and bradycardic with the patient\u0026nbsp;\u003c/em\u003e(participant 1,male, anesthetist).\u003c/p\u003e\n\u003cp\u003eThe worry of problems that can be raised due to lack of assistance from emergency surgeon\u0026rsquo;s side is also similar to the anesthetists. They reported that they were working alone day and night.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOnly one emergency surgeon is on duty in our health center. That is not enough because if a problem occur during the operation, it is difficult to manage it by single person. \u0026nbsp; In case one of them has a problem; if they are two, the other will have a chance to finish. We have faced the same problem before. So it should be considered. (Participant 4,Male,ESO)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs there is shortage of health professionals in the health centers, there is no separately assigned nurses to the OR department. The operation services are being provided just by calling nurses and assistances who are working in other services areas like outpatient department, antenatal care, and family planning. Even these nurses are not well trained or not exposed to surgical procedures. This creates a lot of challenges to the overall surgical activities in the facility.\u003c/p\u003e\n\u003cp\u003e... \u003cem\u003eThere is no independently assigned professional in the operating room. When there is an emergency surgical service, we are using nurses and assistances who are working in different departments. This is having a huge impact on the work (participant 2,Female, head nurse)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSupply and budget related challenges\u003c/p\u003e\n\u003cp\u003eDue to the fact that this is a new initiative, all health facilities reported many challenges associated with supply and budget issues. The most frequently raised supply related problems are lack of drugs especially anesthesia drugs (suxamethonium), lack of blood supply, lack of surgical consumables like surgical gloves and lack of laboratory reagents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e..\u003cem\u003eThere is hug shortage of supplies and medicines, anesthesia drugs in particular. This is creating challenges while doing our job. For example, last time, there was a shortage of anesthesia drug called suxamethinium at the national level; Surgery Service was discontinued for 15 days. We have also Glove deficiencies; it is very difficult to find different sizes (participant 2,female, head nurse)\u003c/em\u003e \u0026hellip;\u0026hellip;. \u003cem\u003eOur biggest problem is lack of blood, especially to do previous c/s scar\u0026nbsp;\u003c/em\u003e\u003cem\u003e(participant 5, Male, Anesthetist)\u003c/em\u003e\u003cem\u003e\u0026hellip;..\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe medical directors and clinicians reported that the main reasons for all of these shortage supplies are budget constraints and procurement system as a bottleneck.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe procurement system itself takes a long time. When there is a shortage of drugs, it is difficult to make immediate purchases. That\u0026apos;s a problem for us (participant 5,Male, anesthetist)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn all health centres, emergency surgical services especially cesarean section is being provided free of charge. Consequently, patient flow and utilization of other services are increasing. As an example, pregnant mothers who had follow-up at private hospitals are coming to the health center for caesarean section services for free, so this may also contribute to the frequent scarcity of supplies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll maternal health services given free of charge in the facilities, but there is serious shortage of budget to avail supplies, medications and equipments (participant 10,male, CEO)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLeadership /management related challenges\u003c/p\u003e\n\u003cp\u003eAccording to all participants, good leadership and management commitment starting from higher politicians is crucial for the smooth running of activities and the timely resolution of problems. The situation is different when it comes to health centres, participants complained about poor management system, limited attention to surgical services and limited knowledge about surgical procedures.\u0026nbsp;Also, the study participants believe that rewarding or promoting employees by the management team is a very important thing in encouraging them. Nevertheless, no one was promoted, according to all participants \u0026hellip;.. \u003cem\u003eI can say there is no as such close interaction between the management team and we as surgical team. There is nothing to motivate. Sometimes I am wondering in this country if you are trained and assigned \u0026hellip;.they don\u0026rsquo;t look you back. There must be updating training with recent information. It seems to me that we are excluded from everything. No one is considering us. (Participant 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferral system related challenges\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also described challenges associated with hospitals down-referring patients due to a lack of beds. In contrast, there are no standards that support the down referring of cases from hospitals to health centers. This case raises the issue of responsibility and accountability\u0026hellip;\u003cem\u003eIn addition, patients are also sent from hospitals to our health center due to lack of beds. This is challenging because beside to putting pressure on us, there is no set guideline regarding the transfer of patients from the hospital down to the health center (participant7,male,ESO)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRespondents didn\u0026rsquo;t not only mention the challenges what they are facing, rather they also described the possible solution they used to sort out the problems: for instances using available resources , communicating with other hospitals support of supplies, convincing the management team for urgent procurements are some of the solution they have been using. As participants stated that the infrastructure issue was found to be beyond their scope.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe are working by using the available resources. When shortage arises we just present it to management committee of the health center and is decided to be purchased by emergency. We also try to solve the problem by borrowing from others. But regarding the problems related with construction of infrastructure; it is beyond our capacity; So far no solution has been found\u003c/em\u003e (participant 2,Female, head nurse).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a critical qualitative analysis of the challenges hindering the effective implementation of Comprehensive Emergency Obstetric and Newborn Care (CEmONC) at the health center level in Addis Ababa, Ethiopia. The findings reveal that the decentralization of these life-saving services is severely constrained by a complex, interconnected web of barriers spanning five key domains: infrastructure, human resources, supplies, leadership, and referral systems. These results resonate with and significantly expand upon the existing literature on surgical and obstetric care in low-resource settings.\u003c/p\u003e \u003cp\u003eA primary finding was the profound unsuitability of existing health center infrastructure for comprehensive emergency obstetric care and surgical services. Facilities were originally designed for primary healthcare, and the provisions of major surgery like cesarean sections through making renovations such as merging small rooms, is fundamentally inadequate. This directly limits the scope of services, confining providers to obstetric emergencies and preventing the management of other surgical cases due to a lack of space and postoperative beds, as reported by participants. This finding starkly contrasts with the foundational standards recommended for CEmONC. The WHO\u0026rsquo;s Monitoring Emergency Obstetric Care handbook and Ethiopia\u0026rsquo;s National Surgical, Obstetric, and Anesthesia Plan (NSOAP) emphasize the need for appropriate, purpose-built facilities to ensure the safety and quality of surgical care (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The participant mentioned that some of facilities use by renovating the existing health facilities for operation services. So this approach of retrofitting facilities violates the \u0026ldquo;Standards for Ethiopian Health Centers\u0026rdquo; (2019) which specify minimum infrastructure requirements for different service levels. From a programmatic perspective, this indicates that the initial scale-up of CEmONC prioritized speed of deployment over adherence to quality and safety standards. The policy implication is clear: future infrastructure investment must be guided by specific architectural standards for CEmONC-ready health centers, and a national assessment is needed to retrofit existing facilities to meet minimum safety requirements.\u003c/p\u003e \u003cp\u003eDespite of the Ethiopian government strive, the health workforce findings in CEMONC providing health centers presented a critical challenge. The deployment of Emergency Surgical Officers (ESOs) has driven a remarkable increase in service utilization, with one health center reporting a jump from 12 to 100 deliveries per month. This demonstrates the profound positive impact of task-sharing programs, a strategy strongly supported by evidence from Ethiopia and other African nations as a solution to specialist shortages (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). However, this success is now threatened by a severe sustainability crisis: a high attrition rate among ESOs driven by an unclear academic and career progression pathway, compounded by institutional resistance from universities to continue their training. This crisis directly undermines a core objective of Ethiopia\u0026rsquo;s Health Sector Transformation Plan (HSTP II) and NSOAP, which aim to ensure an adequate, competent, and motivated health workforce. The lack of a defined career ladder and academic recognition contradicts global best practices for sustaining mid-level provider programs, as seen in Tanzania and Malawi where clear licensure and integration into the public service structure have been key to success (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Programmatically, this signals an urgent need for the Federal Ministry of Health and higher education institutions to collaboratively establish a formal career pathway, including opportunities for specialization, academic advancement, and leadership roles. Without this, the significant government investment in training over 1,000 ESOs is at risk of being lost, crippling the decentralization strategy.\u003c/p\u003e \u003cp\u003eFurthermore, the study uncovered a critical gap within the surgical team itself. The absence of dedicated, trained operating room nurses and anesthetist assistants creates a dangerous and stressful work environment, increasing the risk of adverse outcomes. This finding is consistent with studies highlighting that barriers to care include not just the number of providers, but also their training, support systems, and working conditions (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The fear and risk described by participants operating alone underscore that task-sharing cannot mean task-isolating; a supportive team ecosystem is essential for patient and provider safety. The WHO Safe Surgery Checklist and standards for surgical teams emphasize the necessity of a multidisciplinary team for safe anesthesia and surgery. The current practice of pulling untrained nurses from other departments violates these basic safety protocols. This has direct policy implications for human resource planning: job descriptions and staffing norms for CEmONC health centers must explicitly include dedicated anesthetists, surgical assistants, and scrub nurses. A targeted in-service training program for existing nurses is an immediate programmatic necessity to mitigate the severe safety risks identified.\u003c/p\u003e \u003cp\u003eParticipants universally reported crippling shortages of essential supplies, including anesthesia drugs, blood, surgical gloves, and laboratory reagents. These shortages, attributed to budget constraints and a slow procurement system, frequently halt surgical services entirely. The policy of providing free CEmONC services, while crucial for equity and access, appears to be unsupported by a sustainable financing and supply mechanism, leading to a mismatch between demand and available resources. This represents a major implementation gap. While the government\u0026rsquo;s policy of free maternal health care is aligned with the SDGs and the NSOAP\u0026rsquo;s goal of financial protection, the findings reveal a critical failure in the operational financing and supply chain strategy. The Essential Medicines List and CEmONC supply kits exist on paper, but the procurement and distribution system is not resilient enough to maintain consistent availability. Programmatically, this calls for the development and implementation of a dedicated, ring-fenced financing and logistics mechanism for CEmONC facilities. This could involve creating a separate budget line, establishing last-mile distribution guarantees with regional medical stores, and implementing robust inventory management systems at the health center level to prevent stock-outs.\u003c/p\u003e \u003cp\u003eThe study identified a significant gap in leadership and management engagement with the surgical teams. Participants reported a lack of support, motivation, and opportunities for continued training. This inadequate managerial oversight and the absence of a system for rewarding or promoting staff contribute to low morale and likely exacerbate attrition. Effective leadership is a cornerstone of successful health systems, and its absence directly contravenes the management and governance pillars of the HSTP II. The reported lack of managerial knowledge about surgical services in some facilities suggests that facility managers have not been adequately oriented on the operational and supervisory requirements of a CEmONC unit. This finding implies a need for targeted capacity building for health center managers overseeing surgical services, incorporating modules on surgical safety, team dynamics, and supply chain management into their training. Furthermore, developing a performance-based recognition or incentive scheme for CEmONC teams could be a policy lever to improve motivation and retention, as suggested by the participants themselves.\u003c/p\u003e \u003cp\u003eFinally, the challenges with the referral system highlight a systemic flaw. The down-referral of patients from hospitals to health centers due to hospital bed shortages, without clear guidelines or protocols, places an undue and unsafe burden on primary facilities. This practice indicates a breakdown in the intended referral hierarchy and suggests that decentralization is being used to compensate for hospital-level constraints rather than as a strategically planned tier of care. This down referral practice deviates from the structured, bidirectional referral networks envisioned in national policy (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). It creates clinical and legal ambiguity regarding patient responsibility and risks overloading health centers with complex cases beyond their capacity. The programmatic response must be the urgent development and dissemination of national guidelines for patient transfer between hospitals and CEmONC health centers. These guidelines must clearly define appropriate criteria for down-referral (e.g., stable post-operative patients), communication protocols, and shared responsibility frameworks to ensure continuity and quality of care.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e The qualitative approach in this study provided insights into the challenges that the CEmONC providing teams facing during provision of surgical and obstetrical care at health center level in Ethiopia. Clinicians and medical directors have described the most challenging issues like poorly designed operation theater, poor electric and water supply, in adequate drug and medical equipment supplies, lack of blood supply, problems related with human resources like unavailability of trained assistance to surgeons and anesthetist. The study also revealed that problems related with poor coordination or leadership problem. These findings can be used by researchers, policymakers and civil society organizations to generate practical interventions that improve comprehensive emergency obstetric care capacity and quality in health center.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003e This qualitative study was conducted only in health centers implementing decentralization of emergency surgical and obstetrical care in Addis Ababa Ethiopia. Due to limitation of resources it didn\u0026rsquo;t cover regional health centers providing emergency obstetrics and surgical services where more challenges could be explored.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eEthical approval was obtained from the St. Paul’s Hospital Millennium Medical College Institutional Review Board (Ref: Pm23/485). The study was conducted in accordance with the ethical principles outlined in the \u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e. Support letters were secured from all relevant health authorities. All participants provided written informed consent after receiving a detailed explanation of the study objectives, the voluntary nature of participation, and measures to ensure confidentiality. The study adhered to established ethical guidelines for qualitative research throughout its implementation.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u0026nbsp;There are no circumstances in the study that violate anonymity, and identifying information has been kept confidential. There are no issues regarding its publication.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The data that support the findings of this study are available on request from the corresponding author.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare no conflict of interest for this article.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors would like to thank the interview participants for generously sharing their time and insights. In addition, I extend my profound appreciation to the Addis Ababa Health Bureau and the health facility managers for their permission and unwavering support during conducting the interview.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors' information\u0026nbsp;\u003c/strong\u003eMelese Takele Wossen *\u003csup\u003e1\u003c/sup\u003e, Yifru Berhan\u003csup\u003e1\u003c/sup\u003e, Katariina Laine \u003csup\u003e2,3\u003c/sup\u003e, Zewde Aderaw Alemu\u003csup\u003e1\u003c/sup\u003e, Bezatu Alemu \u003csup\u003e1\u003c/sup\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eSaint Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eUniversity of Oslo, Oslo, Norway\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u003c/sup\u003eOslo University Hospital, Oslo, Norway\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e: All authors contributed to the following sections of the article and fulfilled the conditions for being an article writer. MTW contributed conceptualization, Investigation, Methodology, Data collection, Formal analysis; Project administration; Writing – original draft; Writing – review \u0026amp;amp; editing. YB was involved in supervision, validation, writing, review \u0026amp; editing; Critical revision of the manuscript. KL contributed methodological review, Intellectual input, editing \u0026amp; reviewing manuscript, guidance and mentorship. ZA contributed for Methodological review, validation, reviewing and editing the manuscript. BA is a lead Supervisor; contributed during conceptualization, Methodological review and Validation; Writing and editing, critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlkema L, Chou D, Hogan D, Zhang S, Moller AB, Gemmill A, Fat DM, Boerma T, Temmerman M, Mathers C, Say L. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. The lancet. 2016 Jan 30;387(10017):462-74.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division: executive summary. 2023.\u003c/li\u003e\n\u003cli\u003eMengist B, Desta M, Tura AK, Habtewold TD, Abajobir A. Maternal near miss in Ethiopia: Protective role of antenatal care and disparity in socioeconomic inequities: a systematic review and meta-analysis. Int J Africa Nurs Sci 2021;15:100332.\u003c/li\u003e\n\u003cli\u003eAminu M, Unkels R, Mdegela M, Utz B, Adaji S, Van Den Broek N. Causes of and factors associated with stillbirth in low‐and middle‐income countries: a systematic literature review. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology. 2014;121:141-53.\u003c/li\u003e\n\u003cli\u003ePeters AW, Roa L, Rwamasirabo E, Ameh E, Ulisubisya MM, Samad L, Makasa EM, Meara JG. National surgical, obstetric, and anesthesia plans supporting the vision of universal health coverage. Global Health: Science and Practice. 2020 Mar 30;8(1):1-9.\u003c/li\u003e\n\u003cli\u003eNyamtema AS, LeBlanc JC, Mtey G, Tomblin Murphy G, Kweyamba E, Bulemela J, Shayo A, Abel Z, Kilume O, Scott H, Rigby J. Scale up and strengthening of comprehensive emergency obstetric and newborn care in Tanzania. PloS One. 2022 Jul 8;17(7):e0271282.\u003c/li\u003e\n\u003cli\u003eLindtj\u0026oslash;rn B, Mitiku D, Zidda Z, Yaya Y. Reducing maternal deaths in Ethiopia: results of an intervention Programme in Southwest Ethiopia. PLoS One. 2017;12(1):e0169304 \u003c/li\u003e\n\u003cli\u003eDrum ET, Workneh RS, Tilahun R, McQueen KA. Safe surgery for all: early lessons from implementing a national government-driven surgical plan in Ethiopia. World Journal of Surgery. 2018 Nov;42(11):3812-3.\u003c/li\u003e\n\u003cli\u003eGausman J, Pingray V, Adanu R, Bandoh DA, Berrueta M, Blossom J, et al. Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data. Plos one. 2023;18(9):e0287904.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Monitoring emergency obstetric care: a handbook: World Health Organization; 2009.\u003c/li\u003e\n\u003cli\u003eDahab R, Sakellariou D. Barriers to accessing maternal care in low income countries in Africa: a systematic review. International journal of environmental research and public health. 2020;17(12):4292.\u003c/li\u003e\n\u003cli\u003eAG, CC, AM, DL. Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa-a systematic review protocol. Systematic Reviews. 2018;7(1):1-14.\u003c/li\u003e\n\u003cli\u003eFaqir M, Zainullah P, Tappis H, Mungia J, Currie S, Kim YM. Availability and distribution of human resources for provision of comprehensive emergency obstetric and newborn care in Afghanistan: a cross-sectional study. Conflict and Health. 2015;9(1):9.\u003c/li\u003e\n\u003cli\u003eMorgan MC, Dyer J, Abril A, Christmas A, Mahapatra T, Das A, et al. Barriers and facilitators to the provision of optimal obstetric and neonatal emergency care and to the implementation of simulation-enhanced mentorship in primary care facilities in Bihar, India: a qualitative study. BMC Pregnancy Childbirth. 2018;18(1):420.\u003c/li\u003e\n\u003cli\u003eGerein N, Green A, Pearson S. The implications of shortages of health professionals for maternal health in sub-Saharan Africa. Reproductive health matters. 2006;14(27):40-50.\u003c/li\u003e\n\u003cli\u003eRyan I, Shah KV, Barrero CE, Uamunovandu T, Ilbawi A, Swanson J. Task shifting and task sharing to strengthen the surgical workforce in sub-Saharan Africa: a systematic review of the existing literature. World journal of surgery. 2023;47(12):3070-80.\u003c/li\u003e\n\u003cli\u003eBeard JH, Oresanya LB, Akoko L, Mwanga A, Mkony CA, Dicker RA. Surgical task-shifting in a low-resource setting: outcomes after major surgery performed by nonphysician clinicians in Tanzania. World journal of surgery. 2014;38:1398-404.\u003c/li\u003e\n\u003cli\u003eGalukande M, Kaggwa S, Sekimpi P, Kakaire O, Katamba A, Munabi I, et al. Use of surgical task shifting to scale up essential surgical services: a feasibility analysis at facility level in Uganda. BMC health services research. 2013;13(1):1-7.\u003c/li\u003e\n\u003cli\u003eFederspiel F, Mukhopadhyay S, Milsom PJ, Scott JW, Riesel JN, Meara JG. Global surgical, obstetric, and anesthetic task shifting: a systematic literature review. Surgery. 2018;164(3):553-8.\u003c/li\u003e\n\u003cli\u003eGajewski J, Borgstein E, Bijlmakers L, Mwapasa G, Aljohani Z, Pittalis C, et al. Evaluation of a surgical training programme for clinical officers in Malawi. Journal of British Surgery. 2019;106(2):e156-e65.\u003c/li\u003e\n\u003cli\u003eSirili N, Mselle L, Anaeli A, Massawe S. Task sharing and performance of Caesarean section by the Assistant Medical Officers in Tanzania: What have we learned? The East African Health Research Journal. 2020;4(2):149.\u003c/li\u003e\n\u003cli\u003eHarrison MS, Kirub E, Liyew T, Teshome B, Jimenez-Zambrano A, Muldrow M, et al. Research Article Performance of Integrated Emergency Surgical Officers at Mizan-Tepi University Teaching Hospital, Mizan-Aman, Ethiopia: A Retrospective Cohort Study. 2021.\u003c/li\u003e\n\u003cli\u003eAbebe F, Bilal SM, Lerebo W, Hailu T, Legesse T, Tsegaye R, et al. Barriers to accessing emergency obstetric care in Ethiopia: a qualitative study. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2020;20(1):456. Available from: https://doi.org/10.1186/s12913-020-05618-3 \u003c/li\u003e\n\u003cli\u003eTsegaye R, Worku A, Kebede A, Misganaw B, Tessema GA. Health system barriers to quality emergency obstetric care in Ethiopia: evidence from a facility-based cross-sectional study. \u003cem\u003eInt J Gynecol Obstet\u003c/em\u003e. 2021;155(2):123-30. Available from: https://doi.org/10.1016/j.ijgo.2021.05.012 \u003c/li\u003e\n\u003cli\u003eWilson S, Bah MM, George P, et al. Challenges and solutions to providing surgery in Sierra Leone hospitals: a qualitative analysis of surgical provider perspectives. BMJ Open 2022; 12:e052972. doi:10.1136/ bmjopen-2021-052972 \u003c/li\u003e\n\u003cli\u003eReview world population. Addis Ababa population. Internet: https://worldpopulationreview.com/world-cities/addis-ababa-population : accessed 20th january2023, 1:30 Am.\u003c/li\u003e\n\u003cli\u003eAddis Ababa Health Bureau report 2023,Addis Ababa, Ethiopia 2023\u003c/li\u003e\n\u003cli\u003eAlbutt K, Yorlets RR, Punchak M, Kayima P, Namanya DB, Anderson GA, et al. (2018) You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda. PLoS ONE 13 (4): e0195986. https://doi.org/10.1371/journal. pone.0195986 \u003c/li\u003e\n\u003cli\u003eCreswell, J. W. (1997). Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"emergency obstetric and surgical care, Ethiopia, health centers, implementation challenges, primary health care","lastPublishedDoi":"10.21203/rs.3.rs-8555602/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8555602/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite global efforts, maternal and neonatal mortality remain critically high in low- and middle-income countries like Ethiopia. Decentralizing Comprehensive Emergency Obstetric and Newborn Care (CEmONC) to health centers is a key strategy to reduce morbidity and mortality. However, the implementation of these services at the primary care level in Ethiopia faces significant systemic challenges that require further investigation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative phenomenological study was conducted from May to July 2025 across five purposively selected public health centers in Addis Ababa, Ethiopia. In-depth interviews were held with 16 key stakeholders, including emergency surgical officers, anesthetists, scrub nurses, clinical directors, and maternal health experts. Data were collected using a semi-structured interview guide. Interviews were transcribed, translated, and analyzed using thematic content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis revealed a complex set of interconnected barriers to CEmONC provision. Major challenges included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) inadequate infrastructure: Health centers were not originally designed for surgical services, leading to critical shortages of space, operating rooms, and post-operative beds. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Human resource crises: While the introduction of Emergency Surgical Officers (ESOs) increased service uptake, high attrition rates due to an unclear career path and a lack of university recognition has threatened the program's sustainability. A critical shortage of trained surgical assistants and dedicated scrub nurses creates unsafe working conditions. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Supply chain failures: Frequent stock-outs of essential anesthesia drugs, blood, surgical consumables, and laboratory reagents regularly halt services, exacerbated by budget constraints and a slow procurement system. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Weak leadership and referral systems: Participants reported a lack of managerial support, motivation, and clear guidelines for the down-referral of patients from overcrowded hospitals.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe decentralization of CEmONC services to health centers in Addis Ababa is hampered by multifaceted challenges spanning infrastructure, human resources, supplies, and governance. Without urgent interventions to address the unsustainable workforce model, stabilize supply chains, improve infrastructure, and strengthen leadership, the significant gains in access to comprehensive emergency obstetric and surgical emergency care are at risk. Policymakers must prioritize these areas to ensure the long-term viability and quality of the critical lifesaving program.\u003c/p\u003e","manuscriptTitle":"Barriers of comprehensive emergency obstetric and newborn care provision at health center level in Addis Ababa, Ethiopia: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 10:33:58","doi":"10.21203/rs.3.rs-8555602/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-23T10:11:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5755685618607844450213601481503119087","date":"2026-02-18T05:53:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-11T09:16:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-10T04:49:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-22T17:14:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-20T18:31:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-20T18:26:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d41abae-caea-4bc4-8078-fed63291e5ae","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T10:33:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 10:33:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8555602","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8555602","identity":"rs-8555602","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}