Looking into opportunities for maternity continuum of care improvement within the primary health care system in Northwest Ethiopia: primary health care-oriented research

Abstract

Background

The maternity continuum of care (MCC) is an integral component of universal health coverage and a crucial strategy for reducing maternal and neonatal mortality. Despite its importance, MCC coverage remains low in low- and middle-income countries (LMICs), including Ethiopia, which bear the highest burden of maternal and neonatal mortality. This underscores the need for proactive interventions. In this perspective, the primary health care (PHC) approach holds significant potential for enhancing MCC. Exploring demand- and/or supply-side opportunities for improving MCC within the PHC system could help inform policy, practice, and further research. However, there is limited evidence on these aspects in Ethiopia. Therefore, this study aims to explore demand- and/or supply-side opportunities for MCC enhancement within the PHC system in northwest Ethiopia.

Methods

We conducted a qualitative study using an interpretive description approach within the PHC system in northwest Ethiopia from March 3 to November 27, 2022. Data collection included four key informant interviews, three focus group discussions with 29 participants, and 28 in-depth interviews, all selected through maximum variation sampling. Interviews were audio-recorded, transcribed verbatim, translated into English, and analyzed using reflexive thematic analysis in ATLAS.ti version 7.1.4 software.

Results

Three themes and 11 sub-themes have emerged. These include: (1) PHC structural enhancement with its categories: onsite mentorship, decentralized ambulance service platform, structural networks, and expansion of the scope of frontline PHC facilities; (2) PHC input enhancement with its categories: expansion of the maternity service workforce and technological advancements; and (3) PHC maternity service delivery enhancement with its categories: community engagement, approaches for reducing wait times, tailored maternity service provision in conflict-affected communities, flexible schedules for maternity service, and integrated midwifery model of care.

Conclusions

This study finds that there are several structural, input, and service delivery opportunities for enhancing the MCC within the PHC system in northwest Ethiopia. These opportunities indicate potential pathways to strengthen PHC resilience for MCC. Widespread utilization of these opportunities could significantly improve the existing MCC within the PHC system. We also recommend further research to assess the impact of these opportunities on MCC.

Background

The global community is not making satisfactory progress towards achieving universal health coverage (UHC) by 2030 [1, 2], which ensures access to high-quality healthcare services without financial burden [1]. The UHC is a vital strategy for the rest of the health-related targets under the Sustainable Development Goals (SDGs) [1, 2], primarily measured by the coverage of essential health services and catastrophic health spending [1]. The coverage of essential health services confines the maternity continuum of care (MCC) [3,4,5,6], which is a crucial strategy for achieving SDG 3 targets of reducing the maternal mortality ratio (MMR) to 70 per 100,000 live births and the neonatal mortality rate (NMR) to 12 per 1000 live births by 2030 [2, 7, 8]. There are two dimensions of the continuum of care in the context of maternity services: time and place [9]. The time dimension of MCC encompasses the recommended sequence of antenatal care (ANC), facility-based delivery (FBD) care, and postnatal care (PNC) across the maternity continuum [6]. From the place perspective, MCC refers to the seamless delivery of maternity services across various settings within the primary health care (PHC) system, ultimately facilitating the utilization of MCC throughout the maternity continuum [9, 10]. As a foundation for and a pathway toward achieving UHC in general, and MCC specifically, the World Health Organization (WHO) recommends reorienting health systems using a PHC approach [1, 11,12,13]. This approach is an effective, efficient, and sustainable method for delivering about 90% of essential UHC, including MCC, especially for low-and middle-income countries (LMICs), including Ethiopia [11, 12, 14, 15].

The connection between Ethiopia’s health policy, PHC, and maternity health services has a long history. Since the mid- 1970 s, Ethiopia has been committed to ensuring access to health services, including maternity healthcare, through a PHC approach [16]. Since 1993, PHC has been the cornerstone of Ethiopia’s health policy, continuing through the four-phased, 20-year Health Sector Development Plan (HSDP) initiated in 1997 [16]. Currently, Ethiopia is implementing a 20-year health sector strategy from 2016 to 2035, as evidenced by its visionary document titled “Envisioning Ethiopia’s path towards universal health coverage through strengthening primary health care by 2035” [3, 17]. This strategy was initiated with the first phase, Health Sector Transformation Plan I (HSTP-I: 2016–2020) [17, 18], and has been continued with the second phase, HSTP-II (2021–2025), aiming to provide MCC through a PHC approach [4, 11, 17, 18]. In the HSTP-II, the country has set maternal and neonatal-related ambitious targets for service coverage and mortality reduction by 2025. The service coverage targets include increasing ANC4 + from 43 to 81%, FBD from 48 to 76%, and PNC within 48 h postpartum (early PNC1+) from 34 to 76%. Whereas, the mortality reduction targets aim to decrease the MMR from 401 to 279 per 100,000 live births, and NMR from 33 to 21 per 1,000 live births [3]. To achieve these targets, Ethiopian Ministry of Health (MOH) has developed 14 strategic directions, such as enhancing the provision of equitable and quality comprehensive health services and ensuring community engagement and ownership [3]. Achieving these national priorities through the PHC approach highlights the critical role of PHC-oriented research, one of the ten operational levers of PHC identified by WHO [13], in generating evidence-based and context-specific strategies.

Despite the commitments, the coverage of MCC remains low in regions with the highest MMR and NMR, such as Sub-Saharan Africa (SSA) [19,20,21,22]. A further analysis of recent demographic health survey data from countries in SSA showed that MCC coverage was 11% in Nigeria [23], 17.9% in Sierra Leone [24], 16.14% in Tanzania [25], 33.8% in Rwanda [26], and 12.9% in Ethiopia [27]. This highlights the urgent need for stronger, evidence-based, and proactive interventions, with a particular emphasis on a PHC approach guided by PHC-oriented research [13].

Although LMICs have faced numerous challenges related to MCC [28, 29], various stakeholders within the PHC system may have responded by employing mitigation strategies. These responses likely vary across contexts and should be thoroughly explored for lessons. In this regard, certain qualitative studies in LMICs have been conducted and highlighted various factors that contribute to the uptake of maternity services [30,31,32]. These include network support, community awareness campaigns, training health providers, task-shifting, delivering services close to end-users, and recognizing providers for outstanding performance [30,31,32]. Similarly, a qualitative study conducted in northwest Ethiopia found that health promotion activities and community support played a significant role in facilitating the uptake of MCC [33]. However, existing studies have been fragmented, focusing solely on facilitators for specific components of MCC [30,31,32] or failing to explore the broader opportunities for MCC [33]. This underscores a significant gap in PHC-oriented research on opportunities to enhance MCC in LMICs and specifically in Ethiopia.

Therefore, PHC-oriented qualitative exploratory studies are imperative to delve into contextual and complex nature of supply-demand side opportunities for MCC enhancement within the PHC system. Hence, this study aims to explore supply-and/or demand-side opportunities for MCC enhancement within the PHC system in northwest Ethiopia. The authors anticipated that the findings from this study would benefit the scientific community, healthcare practitioners, program managers, and policymakers by offering insights into supply-and/or demand-side opportunities for MCC enhancement.

Methods

Qualitative approach and research paradigm

Given that the constructivist philosophical paradigm emphasizes the role of context in the process of knowledge construction and advancement, it guides the exploration of opportunities for enhancing MCC in the context of the PHC system in northwest Ethiopia [34]. Hence, this paradigm guided us in selecting congruent approaches and methods under qualitative methodology. As such, we chose the Interpretive Description (ID) qualitative approach [35, 36]. This approach is particularly well-suited for addressing the multifaceted and nuanced challenges associated with health service research, as it balances methodological coherence with the flexibility needed to accommodate complex study dynamics. The adaptability and practical relevance of ID have contributed to its widespread adoption by researchers across various health-related fields, making it a preferred choice for investigations in diverse healthcare discipline [36, 37].

Study settings

This study was conducted within the frontline PHC system in northwest Ethiopia from March 3, 2022, to November 27, 2022. The study involved participants from four districts in the Central Gondar Zone, namely Gondar Zuria, West Dembiya, East Dembiya, and Wogera, as well as representatives from both the Central Gondar Zonal Health Department and the Amhara Regional Health Bureau. The Ethiopian healthcare system is structured into primary, secondary, and tertiary levels, with the PHC system comprising primary hospitals, health centers, and health posts [16]. Health centers, along with their affiliated health posts, constitute the frontline PHC system, where reproductive, maternal, newborn, and child health (RMNCH) is a key focus [4, 11]. Further contextual details are documented in earlier research [10].

Sampling strategies and data collection methods

The maximum variation sampling technique was employed to encompass a broad range of perspectives related to opportunities for MCC enhancement within the PHC. In this study, the concept of maximum variation sampling was mainly operationalized to encompass a diverse range of actors involved in the MCC, structured according to the socio-ecological model [10]. At the intrapersonal level, the study targeted maternity service end-users. These participants were further selected based on a variety of criteria to capture a wide range of experiences and perspectives. The criteria included age groups (< 35 vs. 35+), education levels (able to read and write vs. unable to read and write), resident (reside in the town vs. outside the town), current marital status (currently married vs. not married), parity (first-time pregnant women vs. women who got pregnant two or more times), pregnancy status (planned vs. unplanned), and completeness of the MCC (complete vs. incomplete). This detailed categorization aimed to ensure that the study included a diverse sample of women, reflecting the various experiences encountered across different demographic and personal backgrounds. At the interpersonal level, the selection of significant others was guided by the end-users themselves. Recognizing that significant others can vary, the study asked end-users to identify individuals who played important roles in their maternity care, aiming to include a wide range of interpersonal influences. For community-level actors, the study included representatives from various community roles to capture the broader social and cultural influences on maternity care. These community representatives were selected based on their roles as opinion leaders and community role models. At the healthcare organization/system/policy level, the study included frontline maternity healthcare providers and maternal and child health (MCH) program managers. These participants were chosen based on their current roles in maternity service provision and management within the PHC system.

As a result, we included a diverse range of participants, including end-service users (i.e., women who are pregnant or recently gave birth), significant others (i.e., mothers, mothers-in-law, and husbands), community representatives (i.e., women’s development army (WDA) and other opinion leaders), maternity service providers (i.e., midwives and health extension workers (HEWs)), and MCH program managers (i.e., Woreda health office managers and zonal and regional MCH coordinators).

Data were collected through three focus group discussions (FGDs) with 29 participants, four key informant interviews (KIIs), and 28 individual in-depth interviews (IDIs), involving 61 study participants. Piloted individual (Additional file 1) and FGD (Additional file 2) interview guides were used with open-ended questions and probes. The interview guide used for exploring several key areas related to opportunities for the MCC enhancement within the PHC system in northwest Ethiopia. It includes stem open-ended questions and probes that delve into various aspects. First, it explores opportunities for improvement, such as enhancing the quality of maternity services, reducing waiting times, improving healthcare system infrastructure, supporting and motivating healthcare providers, increasing the availability of services, and encouraging greater commitment from healthcare providers. It also looks at leveraging existing facilitators within the home-community-health facility ecosystem to improve MCC. Second, the guide addresses efforts to overcome challenges, focusing on actions taken by individuals or groups to address difficulties in providing or receiving MCC. Third, it identifies initiatives in the context of MCC that could be strengthened or scaled up, highlighting successful programs within the home-community-health facility/system ecosystem and suggesting specific initiatives that participants believe should receive more support. Fourth, it explores wishes for the betterment of MCC, emphasizing the desired actions from various stakeholders, including service users, significant others, the community, healthcare providers, policymakers, and program managers. Lastly, the guide gathers insights on positive experiences and efforts within the maternity services ecosystem, noting good practices and valuable contributions from stakeholders such as end-maternity service users, male partners, elderly people, peers, social networks, community representatives, community volunteers, healthcare providers, health facilities, the health system, policymakers, program managers, government bodies, and private organizations. These questions and probes collectively aim to explore the current state of MCC, identify opportunities for improvement, and enhance the overall maternity care experience within the PHC system in northwest Ethiopia.

The principal investigator worked with two research assistants to collect the data. Each IDI and FGD had been conducted at a health center or health post, depending on the convenience of the participants. However, two KIIs (i.e., those conducted with woreda health office managers) were held at the offices of the key informants, while the other two KIIs (i.e., those conducted with zonal and regional MCH coordinators) were conducted over the phone at their convenience (i.e., they selected the evening hour because they claimed to be extremely busy during the day). All invited participants agreed to participate in the study. Each discussion topic was accompanied by several probing questions. The interview durations ranged from 13 to 67 min for IDIs, 38 to 81 min for FGDs, and 22 to 63 min for KIIs. Only the participants and researchers were present during the sessions. In addition to the interviews, field notes were taken.

Regarding the consideration of saturation in this study, we defined saturation according to the focus in ID, which is on achieving a comprehensive understanding of the phenomenon under study rather than adhering to a predetermined notion of saturation [38]. Based on this approach from ID, we employed a hybrid method that integrates theoretical saturation, inductive thematic saturation, and data saturation [39]. As such, we initially considered theoretical saturation based on the maximum variation sampling technique, followed by data saturation during data collection and inductive thematic saturation during analysis, both of which were conducted concurrently. This comprehensive and pragmatic approach leverages the strengths of each method and is recommended in applied research [39, 40].

Data processing and analysis

With the informed consent of all study participants, interviews were tape-recorded to ensure accuracy and completeness of the data. The recorded audio files were transcribed verbatim and subsequently translated into English to facilitate analysis. These transcripts, along with field notes collected during the study, were imported into ATLAS.ti version 7.1.4 software for analysis. We utilized a reflexive thematic analysis approach [41, 42] which is particularly suited to research methodologies rooted in the constructivist paradigm, such as ID [41]. This method of analysis poses six major complementary and iterative phases [37, 41], including: (1) familiarization with the data; (2) generating initial codes; (3) generating initial themes; (4) reviewing potential themes; (5) defining and naming themes; and (6) producing the report [41, 42].

To achieve familiarization, the first author read and re-read the transcripts multiple times during the initial stage. Additionally, he listened to each audio recording while comparing it to the corresponding transcript. In the second phase, he identified portions of the transcripts that are crucial to the development of the themes and sub-themes. As such, all data that contained pertinent information about the study questions were coded. Hence, we adopted a hybrid coding approach, utilizing both deductive and inductive methods to capitalize on the strengths of each [43]. The deductive component involved applying predefined categories and explicit codes informed by a comprehensive review of the literature [30,31,32]. Simultaneously, the inductive component facilitated the emergence of codes directly from the data. Therefore, predefined initial codes were developed (deductive coding) based on the interview guides prior to data collection. During iterative reading of the data, information aligning with these predefined codes was categorized accordingly. Conversely, data conveying unique messages that emerged during analysis were coded inductively. During the third phase, the first author collaborated with the fifth and last authors to merge codes with comparable meanings into related families, generating initial sub-themes and themes through iterative revisions. In the fourth phase, after receiving feedback from the fifth and last authors, the first author thoroughly examined the possible themes and sub-themes produced in the third phase. Additionally, all members of the research team were given access to the results. After considering and addressing the team’s feedback, a consensus was reached regarding the final themes and sub-themes. In the fifth phase, the first author interpreted, characterized, and described each theme and sub-theme in relation to the research questions and dataset and all research team members reviewed it. In the last phase, the first author created a final analysis report and distributed it to the research team members and all team members reviewed and approved it. Additionally, we adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [44] (Additional file 3).

Trustworthiness

To ensure the trustworthiness of our findings [45, 46], we implemented several key strategies, such as prolonged engagement, triangulation, and thick descriptions [45]. The primary author spent several months in the field to identify research assistants and study participants and build rapport and trust. This prolonged engagement could help optimize the credibility of the study [45]. We also utilized triangulation [45] by gathering data from various sources, such as end-users, community representatives, service providers, and program managers, and by employing multiple data collection methods, including IDIs, FGDs, and KIIs. This triangulation approach might enhance the credibility, dependability, and confirmability of our findings. Similarly, we provided rich description of the study’s context [10], methodology, and analytical processes, which could help improve transferability and dependability of the study [45, 46]. The use of direct participant quotes also could help illustrate key themes and add authenticity to the findings. In addition, data collectors reassured participants about the confidentiality of their responses, emphasized their autonomy, and used iterative questioning to gather rich, detailed insights, further enhancing the credibility of the study [47].

Regarding reflexivity, the first author of this study had involved throughout this qualitative research, from its conception to data collection, analysis, and reporting process. Coming from a rural family in the study area, he is familiar with the rural, semi-urban, and urban cultures, beliefs, languages, and healthcare practices and challenges in the study areas. His profession as a midwife offers a unique opportunity to combine his personal experiences with his midwifery knowledge and skills to delve into the opportunities for MCC enhancement within the PHC in the study area. He has clinical, academic, and research experience, including qualitative and PHC-oriented research in maternal and child health services. When he started this study, he assumed there would be several opportunities grounded within the home-community-health facilities ecosystem to improve MCC. This description of reflexivity further helps ensure confirmability [45, 46].

Operational definition

In this study, “opportunity” is operationally defined as the combination of external factors and the inherent strengths of the PHC system that can enhance the MCC. This includes any enablers or facilitators that support the effective delivery and utilization of MCC within the PHC system in northwest Ethiopia.

Results

Characteristics of the participants

The majority (60.7%) of the participants were unable to read or write, while 17 (27.9%) of the participants had attained at least a diploma or higher level of education. About 57 (93.4%), 48 (78.7%) and 44 (72.1%) of the participants are in marital relationship, rural residents, and females, respectively. Of the female participants, 23 (52.3%) of them were either pregnant or in the postnatal period at the time of the interview. The majority (70.5%) of the informants were farmers in occupation. Similarly, 29 (47.5%), 28 (39.3%), the remaining 8(13.1%) of the participants were under 35, 35–49, and > 49-year-old, respectively, with the median age of 35 years (Inter Quartile Range = 6). Details of the study participants’ characteristics are presented in a previous study [10].

Opportunities for MCC enhancement

Three major themes and 11 sub-themes have emerged. These include: (1) PHC structural enhancement; (2) PHC input enhancement; and (3) PHC maternity service delivery enhancement (Table 1).

Table 1 Themes and sub-themes of opportunities for maternity service improvement within the PHC system in Northwest Ethiopia, 2022

PHC structural enhancement

Sub-themes with a concept of structural arrangement or networking and hold a potential or actual contribution to MCC enhancement within the PHC system construct a theme PHC structural enhancement. Accordingly, this theme is built by four sub-themes, namely onsite mentorship platform, decentralized ambulance service platform, structural networks, and expansion of the scope of frontline PHC facilities.

Onsite mentorship platform

The previous “offsite” healthcare providers’ capacity building modality has been shifted to the newly launched “onsite” mentorship platform. This platform is cascaded according to the Ethiopian Primary Healthcare Alliance for Quality (EPHAQ) and Ethiopian Hospital Alliance for Quality (EHAQ) (i.e., EPHAQ-EHAQ) networking. As such, all health facilities are organized in a way that staff from the higher level of health facilities should provide mentorship for the respective staff from the lower level of health facilities. Hence, each hospital is responsible for building the catchment health centers in terms of healthcare providers’ skill and knowledge, best experience, evidence-based practices, and quality performance. These mentorship platforms have great potential for building capacities and exchanging experiences among service providers at various levels, improving the quality of maternity care provision, thereby contributing to MCC enhancement. “Totally all hospitals are clustered in a way that each hospital has catchment health centers based on the so called “EPHAQ-EHAQ” structure of Ethiopian alliance for quality. So, each hospital, for example University of Gondar hospital has a responsibility to make all the respective catchment clusters (health facilities) competent.” KII participant, program manager.

Despite this positive initiative, healthcare providers have expressed concerns that capacity-building efforts are not sufficiently implemented. They have complained about the low availability of staff training and continuous professional development (CPD) opportunities, which leads to decreased motivation among maternity service providers. They also emphasized that quality maternity care is unimaginable without CPD and motivational efforts. “There should be a practical continuous professional development system in place. Without implementing motivational efforts such as continuous professional development, the quality of maternity care is unimaginable.” IDI participant, maternity service provider.

Decentralized ambulance platform

Structurally, ambulance service system is reshuffled in a way that could reduce the bureaucratic process in access to ambulance services. Based on the new structure, ambulances are managed at the most proximal level to the end-users and all health centers can manage the ambulance and utilize them properly, and there are health centers which have implemented this so far. This new ambulance service platform has great potential to overcome distance barriers to FBD, thereby facilitating uptake of MCC. “We reshuffle the ambulance system so that all health centers can manage the ambulance and utilize properly, and there are health centers which have implemented this so far.” KII participant, program manager.

Midwives from health centers that have recently implemented the new ambulance platform reported significant improvements in emergency transport services. They observed that ambulances are consistently stationed at the health centers and respond promptly whenever requested. This marked a departure from previous practices, where delays in ambulance services were a common challenge due to logistical issues or limited coordination between health facilities and drivers. A notable shift in the community’s response was also observed whereby companions and family members increasingly bypassed health professionals and directly contacted ambulance drivers during emergencies. This practice highlights improved community awareness of the platform and enhanced trust in the system’s reliability. Direct communication between community members and drivers may have contributed to faster response times, particularly in urgent maternal health cases. “Previously, we did not access it as we needed. Fortunately, this time, I show a commitment from the ambulance’s driver… they [Ambulance’s drivers] are just here in the health center. Upon onset of labor, even the laboring mothers’ attendants call to Ambulance. The ambulance then goes to the village and brings them to health center.” IDI participant, maternity service provider.

However, participants from certain communities have expressed concerns that the new ambulance platform has not yet been implemented in their areas. They reported that access to ambulance services remains a critical challenge, particularly in specific districts where transportation barriers continue to hinder timely access to maternity health services. They reflected disparities in ambulance management and underscored the need for a more equitable rollout of the ambulance platform to ensure that all communities, especially those in remote or underserved areas, can benefit from timely emergency transport for MCC. “Access to ambulance service continues to be a major barrier to maternity health service. Concerns have been raised about the genuineness and honesty of ambulance drivers. This issue needs to be addressed to ensure that our community receives timely ambulance services, which can help prevent home deliveries and related complications.” FGD participant, community representative.

Structural networks

There are healthcare structures and programs that interconnect and extend from the health facility to the home in the community. Some of these include health extension programs (HEPs), pregnant women’s conference (PWC), women’s development army (WDA), and home-based PNC. The human resources required for those structures, such as HEWs and WDA leaders, are mainly from and members of the community. These networks of healthcare structures and programs within the PHC system extend deeply into the community and could play a vital role in enhancing both the provision and uptake of MCC by facilitating communication and collaboration among actors at various levels within the PHC system. These structural networks can help facilitate maternity service delivery (e.g., provision of ANC at the health post and PNC at home level) and improve awareness for MCC utilization among end-users. “We have established a structure that extends from the health facility to the home in the community…The members and leaders of women’s development army in the community are the community members and the mothers themselves. So, these platforms are another opportunity…The existence of HEWs and the health posts in the community is another important opportunity.” KII participant, program manager.

These group-based social structures, such as WDA (i.e., a one in five connections) within the PHC provide a good opportunity for undertaking a free discussion forum on pregnancy and childbirth issues among the group members and bring about many positive impacts on health literacy and self-efficacy, health-seeking behavior, peer-to-peer support, experience and knowledge sharing, and uptake of maternity services. Thus, members of the group are mobilized to attend ANC and receive maternity services. The group members freely discuss with their respective group leader friendly and freely, the group leaders can get full personal information even whether there are suspected pregnant women in the village and then report to HEWs early. As a result, those new suspected pregnant women are mobilized to initiate ANC early. In this regard, the group leaders work with a full sense of responsibility. “Now there are hopes that women now have women’s organizations, this is organized one by five, one by thirty, they meet regularly; they discuss things by themselves, in their own style, by themselves. This is the one that will make a big difference, there is no question because her neighbor is pregnant, and the leader of one-five is from the same neighbor.” KII participant, program manager.

The implementation of women’s connections has also been acknowledged by community representatives who serve as leaders of WDAs. They have expressed the importance of this connection, highlighting how it helps them share their concerns and important health information, as well as facilitate smooth communication with HEWs. “We have established a one-to-five connection system, and I serve as the leader. I personally mobilize the group to set rules and regulations that all members must follow. We periodically gather to share information and concerns. This platform helps us support one another and create health awareness. Additionally, there is a system in place for leaders to communicate with health extension workers.” FGD participant, community representative.

A monthly PWC platform which meets the pregnant women, midwives, HEWs, WDA leaders, and other stakeholders together at the health post is another opportunity for improving awareness about and utilization of MCC in the PHC. This platform originated from the community, serving as a link between the community and maternity service providers. “To create awareness about ANC, delivery, and PNC, women’s conference is a golden opportunity to do so. Previously, it was health extension workers who held women’s conference. But now, we also go down to the community for women’s conference” IDI participant, maternity service provider.

The structural networks among health centers and health posts within the home-community-health facility ecosystem is another opportunity to be considered for future efforts. As such, an average five health posts are clustered in one health center for harmonious and integrated efforts. “The clustering structure of each health center with 5–6 health posts (kebeles) by itself is another opportunity”. KII, program manager.

Expansion of the scope of frontline PHC facilities

The performance scope of frontline health facilities within the PHC system has been expanding. The universal provision of basic emergency obstetric and neonatal care (BEmONC) services at the health center level has been established. Additionally, certain health centers have expanded their scope to provide comprehensive emergency obstetric and neonatal care (CEmONC), which includes emergency caesarean delivery. This advancement in maternity services at the frontline of the PHC system represents a significant opportunity to enhance MCC provision. Scaling up these services further can address the community’s growing needs while aligning with the foundational principles of PHC. “There are initiatives from ministry of health to provide comprehensive emergency obstetric and neonatal care even at health centers level” KI participant, program manager.

PHC input enhancement

The theme PHC input enhancement encompasses sub-themes that focus on input-related opportunities to improve MCC within the PHC system. These sub-themes include expansion of the maternity service workforce and technological advancements.

Expansion of the maternity service workforce

The number of maternity service providers, such as obstetricians and midwives, is steadily increasing. In the past, the availability of midwives in the market was insufficient to assign them to every health facility for midwife-led maternity care. However, their numbers have now grown, ensuring availability whenever needed. Similarly, the increase in the number of physicians, including obstetricians, and their improved market availability present significant opportunities to enhance efforts in improving maternity services and outcomes within the PHC system. This growing workforce has the potential to reduce waiting times for maternity services, enhance the quality of care, and attract more end-users, thereby contributing to the overall enhancement of MCC provision and utilization. “The increment of number of midwives is also another good opportunity as their number was too few to address the midwife-led maternity care…Similarly, the numbers of gynecologists are increasing, and this is also another opportunity.” KII participant, program manager.

Technological advancement

Maternity service providers and program managers emphasized the transformative potential of technology in improving maternal outcomes, addressing social determinants of health, enhancing communication between healthcare facilities and patients, and ensuring high-quality care. They highlighted the recent introduction of electronic client registration systems in the chart rooms for PHC settings. These systems have already begun contributing to MCC enhancement by facilitating provider-client communication, supporting decision-making, integrating electronic medical records, and improving care coordination across service locations. This has enhanced continuity of care, reduced care fragmentation, and increased MCC provision and utilization across PHC settings. “Now we launched smart care in the chart room since September this year. For example, I recall a woman whom I have evaluated last time. So, if she comes up with a new chart, I will not accept the new chart. Instead, I go to the chart room and request the previous chart in which I documented her medical conditions during her previous contacts. This time, the problem in the chart room somehow gets improved.” IDI, participant, maternity service provider.

The initiative, however, is not widely implemented across all PHC settings, and end-users in some PHC settings have reported challenges in accessing their medical records in the chart room. They also complained about experiencing unfair bureaucratic processes when trying to retrieve their charts. “I have endured many bureaucratic processes here in the chart room, and many other women are facing similar struggles. They force us to go back and forth unnecessarily, causing frustration and hardship.” IDI participant, end-user.

PHC maternity service delivery enhancement

Maternity service delivery approaches, models, platforms, or initiatives with a potential or actual contribution to MCC enhancement within the PHC system are categorized under this theme. As such, five sub-themes, including community engagement in maternity services, approaches for reducing waiting times, tailored maternity service provisions in conflict-affected communities, flexible schedules for maternity services, and integrated midwifery model of care within the PHC system build this theme.

Community engagement in maternity services

In some Kebeles (i.e., the smallest administrative unit), TBAs, Kebele leaders, and ambulance drivers have demonstrated outstanding performance and had a positive impact on community-level referral services and maternity service uptake. In certain cases, TBAs take on multiple critical roles, such as community mobilization, awareness-building, and linking the community to health facilities, ultimately contributes to MCC utilization. “She previously had attended births at home. This time, she is doing a wonderful job in contributing to the maternal health service uptakes through creation of linkage and referral to health facilities. She usually directly calls to ambulance and refer women when necessary. She has a strong bonding with all stakeholders.” IDI participant, maternity service provider.

The dedication of kebele leaders to maternity services is a notable example of community volunteers’ involvement in this critical area. In one model kebele, the leader demonstrated exceptional commitment by showing zero tolerance for pregnancy-related issues and addressing them promptly. A study participant described how the kebele leader worked tirelessly to improve ambulance accessibility, eliminate delays in reaching health facilities, and ensure timely and high-quality emergency obstetric care. “If there are laboring mothers throughout 30 days, the Ambulance will come timely throughout 30 days. This good system is attributed to Kebele leader’s strong commitment for maternity health service. He has zero tolerance for problems related to maternity health condition.” IDI participant, maternity service provider.

Participants from the significant others’ categories also witnessed that community awareness about maternity services is increasing, driven by community demand creation led by influential community members. “Nowadays, traditional birth attendants encourage mothers to attend maternity service. They urge mothers to go to health facilities…they encourage and facilitate referral to health facility.” IDI participant, significant other.

The engagement and commitment of community volunteers in mobilizing the community and raising awareness about maternity services have been further affirmed by the leaders of WDAs, who participated in the FGD as community representatives. They explained that they dedicate their time to the community, driven by a strong sense of ownership and responsibility. “I achieve things by plan in a way that both my tasks for my home and my task for my community are balanced as I feel responsibility. My reward is my satisfaction, my reward is preventing maternal death, and my reward is improving the health of my community. By doing so, the traditional beliefs, which were the underline reason for our losses of mothers, are getting rid of this time. We will keep the momentum for free in the expense of our time and energy.” FGD participant, community representative.

Approaches for reducing waiting times

A significant barrier to efficient maternity care in many health centers is long waiting times, particularly for laboratory services. This issue often delays diagnostic procedures that are essential for identifying complications during pregnancy, childbirth, and postpartum. A notable solution has emerged in one health center, where a separate laboratory room dedicated exclusively to maternity services has been established. This initiative has proven effective in minimizing waiting times, and it serves as a model that can be scaled up to other health centers to enhance overall maternal care. The establishment of a separate laboratory for maternity services addresses the specific needs of pregnant women and mothers, who require quick and accurate diagnostic results to manage their care effectively. With faster results, healthcare providers can diagnose potential complications earlier, allowing for timely interventions that could improve MCC. “Just to reduce mothers’ queue at the laboratory, we have assigned one laboratory professional to serve only mothers.” KII participant, program manager.

Another approach for reducing long waiting times is that of a manual ‘Kaizen’ whereby midwives sort mothers’ medical records by their respective Kebeles of residence. This simple approach enables midwives to quickly retrieve mothers’ charts based on the client’s residence, reducing the time spent searching for records and improving delivery service. By implementing this sorting system, midwives can enhance workflow efficiency, ensuring that mothers receive timely care without unnecessary delays. This approach not only improves organizational efficiency but also reduces frustration among both patients and healthcare providers. Mothers, who often face multiple barriers to accessing quality maternal health services, benefit from a streamlined process that allows for quicker consultations, faster diagnosis, and timely interventions when necessary. Furthermore, this approach can serve as a model for broader health system improvements, inspiring further innovations in patient record management and service optimization. “Now we tried to manage this issue by ourselves, we midwives go to chart room to bring mothers’ chart whenever there is crowded case-flow at chart room. The good thing now is we identify mothers with reference to their Kebeles’ of residency. We sorted mothers’ charts out according to their kebeles…So, now the issues at chart room are being corrected in that way.” IDI participant, maternity service provider.

Another solution for reducing waiting times adopted by midwives at a health center involves placing mothers’ charts directly in the maternity room instead of the central chart room. This simple adjustment has reduced waiting times for charting services, ensuring that mothers receive timely care. By keeping patient records readily accessible in the maternity room, midwives can retrieve and update charts quickly, eliminating the need for mothers to wait in long queues at the chart room. This practice enhances workflow efficiency, allowing healthcare providers to focus more on direct patient care rather than administrative delays. Furthermore, reducing wait times fosters greater patient satisfaction, encouraging more women to seek and continue using essential maternity services, including antenatal, delivery, and postnatal care. “We started placing maternal charts at the maternity room.” IDI participant, maternity service provider.

Tailored maternity service provisions in conflict-affected districts

In certain kebeles, PWC serves both as a platform for addressing various local issues and as an alternative for delivering basic maternity care, particularly in conflict-affected areas. In these kebeles, midwives and other stakeholders organize PWC twice a month to increase their engagement with women and provide essential maternity services, as these sessions may be their only opportunity for care. Furthermore, they collaborate with stakeholders to ensure the availability of ambulance services for emergency obstetric care. These tailored maternity service platforms in conflict-affected districts play a crucial role in ensuring resilient MCC provision. “We have started to hold women’s conference twice a month by considering social crisis due to blooding so that a mother in a difficulty social crisis can get the opportunity to receive maternity services at women’s conference which is held at the Kebele level… On top of that, if the mother experiences severe complication, we communicate with Ambulance’s driver and bring her to health facilities for emergency obstetric care.” IDI participant, maternity service provider.

This mobile, tailored maternity service provision in conflict-affected districts was also highly appreciated by community representatives who participated in the FGD. They acknowledged the dedication of healthcare providers in reaching and serving the community, ensuring the delivery of maternity services within villages. “I truly appreciate the efforts made by the healthcare providers… Healthcare providers are actively engaging with the community and reaching out to people where they live” FGD participant, community representative.

Flexible schedule for maternity services

In some kebeles, women prefer to seek PWC and other maternity services on shopping days or holidays, aligning their healthcare visits with routine social and economic activities. This pattern reflects the broader reality that maternal health-seeking behavior is often influenced by cultural norms, convenience, and economic obligations. Recognizing this preference, midwives have adapted their service schedules to accommodate client-convenient days, ensuring that women can access essential maternity care without disrupting their daily responsibilities. “But women come for women’s conference just only on holidays as you heard while we talk about this issue earlier…The second one is mothers come to health facilities on Marketing days… So, we adjust their appointment by taking these days into account and book our Calendar accordingly.” IDI participant, maternity service provider.

Integrated midwifery model of care

Certain districts have adopted an integrated midwifery model of care (MMC) that holistically addresses women’s social, emotional, cultural, spiritual, psychological, and physical experiences throughout maternity care. This model prioritizes professional autonomy, continuity of care, women-centered care, and collaborative practices, fostering a supportive and responsive healthcare environment for perinatal women. This model enhanced community trust in midwives, reinforcing their role as primary caregivers in maternal health. The integrated MMC has also benefited from exceptional community involvement and strong government commitment, ensuring that maternal care services are both accessible and responsive to local needs. This integrated approach has led to significant improvements in the provision and utilization of MCC services. “…We midwives served the community with a full dedication and love, and we gained a magnificent satisfaction. Our interaction with clients was… truly humanistic and joyful. We midwives always bother about clients’ safety and comfort. We dealt with the better plans and solutions for existing challenges…The commitment of the district’s health office was extraordinary. The woreda health office gave priority just for maternity issues. The community shared local food products with us…” IDI participant, maternity service provider.

Community representatives participating in the FGD also testified that the approach of midwives in treating laboring women and their attendants is genuinely humanistic. They appreciated the respectful treatment provided to clients, from the warm welcome to the thoughtful farewell. “Once upon the time while I was at the health center as I brought a laboring mother there, the Ambulance brought a laboring woman to the health center. Upon arrival, a midwife welcomed and attended to her condition, and she delivered soon. After that, he instructed me to call him in case of any problem. Then, she started bleeding a lot and I called him accordingly. Then he come and managed the bleeding quickly and I really appreciated him.” FGD participant, community representatives.

Sub-themes’ classification under supply-demand continuum

We further classified the sub-themes as supply-side opportunities, demand-side opportunities, and cross-cutting (i.e., both supply- and demand-side) opportunities (Table 2).

Table 2 Summary of supply-and/or demand-side opportunities of MCC within the within the PHC system in Northwest Ethiopia, 2022

Mapping themes and sub-themes onto the PHC monitoring conceptual framework

After finalizing all analyses, we mapped the themes and sub-themes onto the PHC monitoring conceptual framework [48]. This mapping process was designed to enhance conceptualization and establish clear connections with the existing framework. By aligning our findings with the PHC monitoring framework, we aimed to improve coherence and provide a structured approach for future implementation and monitoring (Fig. 1).

Fig. 1

Conceptual framework adapted from the PHC monitoring conceptual framework [48]

Discussion

Given that MCC is a critical strategy for reducing MMR and NMR [7, 19, 20] and remains low in many LMICs [49], which bear the largest burden [50], it is imperative to explore opportunities for enhancing MCC within the PHC system. Hence, this study explored and identified supply-and/or demand-side opportunities for enhancing MCC within the PHC system. These include a novel onsite mentorship platform, an innovative decentralized ambulance service platform, structural networks, and expansion of the scope of frontline PHC facilities (structural enhancement). Additionally, the study highlights the augmentation of the number of maternity service providers and technological advancements (input enhancement), community engagement in maternity services, approaches for reducing wait times, tailored maternity service provisions in conflict-affected districts, flexible schedule for improved maternity services, and an integrated midwifery model of care (service delivery enhancement). The findings can be utilized by audiences in the maternity health service, including policymakers, healthcare practitioners, and researchers, to improve MCC and facilitate progress towards UHC and meet the health-related SDG 3 [1, 2].

In many LMICs, including Ethiopia, socio-cultural factors have prominent roles in influencing MCC utilization [51,52,53,54,55]. As such, many women prefer to receive services in environments where their cultural practices are respected and where they can be supported by community members and relatives, often at a lower cost [32, 51,52,53,54,55], highlighting the need for culturally sensitive maternity services [51,52,53,54,55]. Our study findings demonstrated that there are several culturally appropriate and community participatory approaches and initiatives with great potential for addressing the growing demand for socio-culturally sensitive and community participatory maternity services [56,57,58]. While delving into the implications of the findings, it is evident that the initiatives within the PHC system in northwest Ethiopia—such as the novel ambulance service platform, structural networks within the home-community-health facility ecosystem, community engagement in maternity services, tailored maternity service platforms in conflict-affected communities, flexible maternity service schedules, and an integrated midwifery model of care—are all socio-culturally sensitive and community participatory. These findings hold substantial potential to inspire further research and advance the broader implementation of MCC enhancement.

This study demonstrated that a novel onsite mentorship platform has been launched through the EPHAQ-EHAQ [59] networks on a small scale within the PHC system in northwest Ethiopia, compatible with the Ethiopian three-tier healthcare structure (3). In this platform, the top-level health facility is responsible for supporting the respective lower-level health facilities. This initiative presents an opportunity for MCC improvement within the PHC system, as it builds the capacity of frontline maternity providers and aligns with PHC approaches. As a result, a greater range of disease prevention and health promotion services, including universal maternity health services, can be delivered at the PHC level, bringing care closer to the community [1, 12]. These structural networks present an excellent opportunity to strengthen the referral system for maternity services, enabling bidirectional referrals across the spectrum of care [12], This facilitates the seamless delivery of maternity services across various PHC settings, including homes, communities, and health facilities.

Delays in obstetric emergency care in LMICs significantly impact maternal and perinatal mortality [60, 61], necessitating a well-coordinated, prepared health system, with emergency ambulance service playing a crucial role [62, 63]. To prevent delays in reaching health facilities for obstetric care, several LMICs implemented free ambulance service [62, 63,64,65,66]. Previous studies identified that although pregnant women were more likely to use ambulance services during obstetric emergencies, modifiable factors such as poor communication and delayed responses from dispatchers hindered the effective utilization of these services [63, 64]. These findings suggest the need for a novel ambulance system that facilitates timely access and prevent bureaucratic communication processes in ambulance management. Unlike previous studies in Ethiopia, such as Tiruneh et al. [33], the current study identified a decentralized ambulance system as a novel structural intervention. This system enables health centers to manage ambulance cars closer to end-users, thereby reducing bureaucratic barriers and ensuring more efficient utilization. However, its implementation is limited to certain health centers (clusters), as evidenced by contradictory feedback from participants across those facilities. Participants residing in clusters where the new platform was implemented appreciated its positive contribution, while those in non-implementing clusters complained about delays in accessing ambulance services. These contradictory findings imply the necessity of large-scale implementation of the decentralized novel ambulance system in all clusters.

Unlike previous qualitative studies in Ethiopia [33, 67], this study identified structural networks as an important scalable opportunity for improving MCC within the PHC system. Facilitated by community-based programs, such as HEP, PWC, and WDA, these structural networks have been operated within the home-community-health facility ecosystem. These care networks align closely with the WHO’s “network of care for maternal and newborn health,” which is recommended for implementation in LMICs while considering contextual variations [68]. This alignment highlights a strategic opportunity to enhance MCC and accelerate progress toward both national and international maternity service targets [2, 3]. The finding is further supported by a recent study by Tiruneh GT et al. in Ethiopia [69], reinforcing the need for contextual and implementation research to optimize the integration of network of care into Ethiopia’s PHC framework. Furthermore, since these structural networks primarily operate through group-based approaches, they present additional opportunities for expanding group-based maternity services. This suggests the feasibility of future interventions, such as group antenatal care (G-ANC), which aligns with the 2016 WHO recommendations for ensuring a positive pregnancy experience [58]. In addition, these structural networks are inherently community-engaging, offering a valuable platform for community participation in enhancing MCC within the PHC system. This finding is consistent with previous evidence, which indicates that community volunteers and structures play a crucial role in strengthening PHC by carrying out various healthcare service tasks [70, 71].

The monthly PWC, involving stakeholders like pregnant and postnatal women, members of WDAs, midwives, HEWs, and HEP focal persons, provides an excellent opportunity to influence various maternity service-related agendas. Our findings show successful responses to MCC challenges in conflict-affected districts, enabling tailored maternity service provision through PWC, focusing on community-based services according to PHC principles [3, 12]. The study aligns with the three PHC approaches: integrated health services, empowered people and communities, and multi-sectoral policy and actions [3, 12]. The PWC provides critical opportunities for recommended health system interventions like midwife-led continuum of care [58], group antenatal care [58], male involvement in maternity services [72], social accountability [73], and community-based interventions to improve communication and support [58]. To maximize the impact of community-based maternity health care provision, stakeholders should invest in strengthening and expanding PWC platforms, particularly in hard-to-reach areas where access to facility-based maternal healthcare remains limited. Strengthening these platforms can enhance peer support, health literacy, and early maternal health-seeking behaviors, ultimately improving MCC within Ethiopia’s PHC system. In addition, we also propose further PHC-oriented implementation research on various 2016 WHO’s context-specific health system interventions, such as group ANC and facilitated participatory learning and action cycles with women’s groups [58] through integration with PWC.

The study also revealed the success story of the integrated MMC and its contributions to MCC enhancement within the PHC system in northwest Ethiopia. The MMC, a maternity service delivery model based on compassion, respect for human dignity, and the advancement of human rights [74], creates woman-centered care that considers the socio-cultural needs of women and the community [74, 75]. As such, this model has the potential to address the growing demand for culturally sensitive maternity services [51,52,53,54,55]. This finding showed that an integrated MMC signified professional autonomy, continuity of care, women-centered care, collaborative care, and evidence-based practice. These features of the MMC align with the ones described in the existing literature [75]. This finding aligns with the latest WHO recommendations to adopt MMC globally, particularly in LMICs [76]. From a philosophical standpoint, the latest WHO’s ANC [58], intrapartum [57], and PNC [56] guidelines, as well as the Ethiopian national ANC guideline [77], align with the philosophy of MMC. Evidences exhibit this model improved maternal and perinatal outcomes, and was favored by end-service users [78, 79]. Existing evidence predicted that the MMC is also expected to prevent 65% of stillbirths, 67% of maternal deaths, and 64% of neonatal deaths by 2035, saving 4.3 million lives annually [80]. The results of our study build on earlier findings that the MMC may have a practical impact on maternal and perinatal health services and outcomes. They also imply that the initiatives of the MMC within Ethiopia’s PHC will be beneficial in reaching the country’s ambitious HSTP-II national targets [3] as well as the global SDG 3 targets [2, 8]. Unfortunately, a lack of leadership and governance, poor sectoral coordination, and a lack of funding for health system inputs have restricted Ethiopia’s ability to reap the wide potential benefits of the MMC [3]. Therefore, maternity health care program stakeholders need to work collaboratively to implement integrated MMC, while researchers are invited to explore strategies, identify barriers, and assess potential impacts of MMC implementation.

Limitations

This study poses certain limitations. Readers need to be aware that this study exclusively explored and reported opportunities for MCC enhancement although there were also several challenges of MCC within the PHC system in northwest Ethiopia [10]. This is because the challenges of the MCC have been analyzed and prepared in a separate article [10] due to the volume of information. Furthermore, the term ‘opportunity’ in this study refers to both current and potential positive prospects that could contribute to the improvement of MCC within the PHC system through piloting, scaling up, or further research. In addition, the relevance of the findings may have been affected by contextual factors. The data collection took place during a period of internal conflict, which likely disrupted healthcare services and influenced the maternity care experiences of the participants.

Practical implications and recommendations

We prioritized the top three opportunities identified from this study based on our judgement taking their potential feasibility and impact on national and international targets into account. These include MMC, structural networks, and the novel decentralized ambulance platform.

As the number of midwifery graduates in Ethiopia continues to increase, and MMC shows a global positive impact throughout the maternity continuum, the full-scale implementation of MMC within the PHC system in Ethiopia could accelerate progress towards HSTP and SDG 3 targets. Thus, we put the following actionable recommendations: (1) Deploy adequate midwives in all PHC settings: (2) Strengthen midwives’ CPD and mentorship: (2.1) Implement structured CPD programs to enhance midwives’ clinical competencies, (2.2) Establish regular onsite mentorship systems to provide hands-on guidance and professional support, and (2.3) Develop digital learning platforms for remote capacity building; 3) Integrate MMC into national PHC policies & guidelines: (3.1) Institutionalize MMC within PHC service delivery models and (3.2) Align midwifery workforce policies with Ethiopia’s HSTP; and 4) Support MMC scale-up through PHC-oriented implementation research: (4.1) Conduct implementation research to assess the feasibility and impact of MMC and (4.2) Evaluate barriers and facilitators for MMC integration within different PHC settings.

The second priority for recommendation is structural networks. Structural networks play a critical role in strengthening MCC by facilitating group-based maternity service delivery, improving onsite mentorship, and enhancing community engagement. Given their potential to accelerate progress toward SDG 3 targets, prioritizing the co-design and implementation of these networks within Ethiopia’s PHC system is imperative. As such, we put the following recommendations: 1) Co-design and implement structural networks within PHC: (1.1) Adopt a participatory approach to co-design tailored structural networks, ensuring alignment with local community needs before large-scale implementation, (1.2) Integrate group-based maternity care models to improve peer support and service accessibility, and (1.3) Strengthen community engagement mechanisms to foster trust and collaboration among stakeholders at all PHC levels; 2) Establish a national guideline for structural networks of care: (2.1) Contextualize and mandate a national framework to guide the design, implementation, and governance of structural networks within PHC setting and (2.2) Integrate multi-sectoral collaboration to link health, social, and community-based services; 3) Support scale-up through PHC-oriented implementation research: (3.1) Conduct implementation research to evaluate the feasibility and impact of structural networks, (3.2) Identify barriers and facilitators in different community contexts to inform scalable and adaptable models, and (3.3) Conduct implementation research on group-based maternity service (e.g., group antenatal and/or postnatal care) using existing structural networks.

Considering that delays in reaching health facilities during obstetric emergencies account for over one-third of maternal deaths in Ethiopia [81], the novel decentralized ambulance platform presents a promising structural solution for improving MCC and reducing perinatal deaths. This intervention has great potential to significantly impact SDG 3 targets, such as target 3.1 [82], 3.2 [83], 3.7 [84], and 3.8 [85]. Thus, we recommend actionable steps to inform policy, practice, and research for expanding decentralized ambulance services in all PHC settings with a robust monitoring and evaluation system: (1) Establish a policy framework that mandates decentralized ambulance services as a core component of the PHC system; (2) Deploy ambulances to all PHC facilities, prioritizing remote and high-mortality regions; (3) Strengthen linkages between ambulances, health posts, health centers, and referral hospitals through standardized protocols; (4) Implement shift-based staffing and standby mechanisms to guarantee continuous ambulance operations; (5) Conduct implementation research on the impact of decentralized ambulance services on MCC and maternal and neonatal outcomes; and (6) Investigate the use of digital technologies to improve ambulance response times.

Given that the PHC approach is the most efficient, effective, and affordable strategy for essential health services, the identified opportunities within the PHC system in northwest Ethiopia—even amid internal conflict and resource constraints—offer a sustainable pathway for improving MCC. These opportunities can be effectively utilized and implemented within the PHC framework through: (1) Strong stakeholder engagement, ensuring multi-sectoral collaboration and policy alignment, (2) Community-driven implementation, leveraging existing structures like PWCs, HEWs, and WDA to enhance maternal health service uptake, and (3) Minimal resource allocation, as many interventions can be integrated into existing PHC services with limited additional costs. By maximizing these PHC-based opportunities, Ethiopia can strengthen MCC, improve maternal and newborn health outcomes, and build a more resilient PHC system, even in challenging contexts.

Conclusion

This study identifies a range of supply-and/or demand-side opportunities that may enhance MCC within the PHC system in northwest Ethiopia. Key findings highlight innovative initiatives such as the novel onsite mentorship platform and the decentralized ambulance service platform, both of which aim to address logistical and resource-related challenges. Additionally, structural improvements, such as strengthened networks within the home-community-health facility ecosystem, alongside advancements in the scope of practice for frontline PHC workers, offer promising solutions to enhance service delivery. From the input perspective, the study underscores critical input enhancements, including the expansion of maternity service providers and the integration of technological advancements, which may help improve service accessibility and efficiency. These efforts are complemented by the engagement of community volunteers, who play a pivotal role in improving outreach and support for MCC. Furthermore, tailored maternity services in conflict-affected districts and flexible scheduling options are vital in responding to the unique challenges faced by marginalized populations. From a service delivery perspective, the study emphasizes the need for strategies to reduce wait times, an issue that is often a barrier to timely care, and the promotion of an integrated midwifery care model, which has the potential to streamline maternity services and improve maternal health outcomes. By addressing both the structural, input, and service delivery aspects of maternity care, this study provides a holistic view of the interventions required to optimize MCC.

The findings of this study may serve as a valuable resource for a wide range of stakeholders, including policymakers, healthcare practitioners, and researchers, offering actionable insights that may be applied to improve MCC and advance progress toward UHC. By strengthening the PHC system through these targeted initiatives, Ethiopia and LMICs may make meaningful strides toward MCC enhancement, thereby reducing maternal and neonatal morbidity and mortality, ultimately creating more equitable and effective health systems.