STRENGTHS AND LIMITATIONS OF THE STUDY

The study covered relatively larger geographical areas as compared with previous studies.

Social desirability bias was minimised by using data collectors working outside the study areas.

The study has limitations as remembering the 6 months of health service may be biased.

The quantitative method alone cannot capture health system responsiveness fully as it requires further qualitative exploration.

Background

Health system responsiveness (HSR) is one of the fundamental objectives of healthcare1 2 which evaluates the interaction between patients and the health system for anticipating and adapting patients’ existing and future health needs for a better health outcome.3 4 It is important to meet the reasonable expectations of the patient.5 6 Evaluating patients’ rational expectations is crucial for better health outcomes.4 7 8 Patient experience and satisfaction are important indicators of responsiveness.9–12 The assessment of HSR in intrapartum care includes waiting time for consultation, respectful treatment, clear communication, decision-making regarding treatment/care, privacy of information and the choice of healthcare providers.13

In conflict-affected settings, there are interconnected microlevel and macrolevel health determinants. The microlevel health determinants impact on individual health status such as loss of human rights, violence, breaches of health neutrality, displacement and difficulty of obtaining food and supplies. The microlevel health impact is due to the macrolevel health determinants, which include conflict, poverty, economic crisis and destabilisation of the cultural and societal systems.14 15

Armed conflicts have negative effects on health service utilisation and responsiveness. The effect is due to direct exposure to violence and indirect impact on social and economic disruption, such as decreased access to good health services, foods and supplies.16 War has a strong gendered effect on health. Women are more likely to suffer lasting health effects from conflict, including difficulty of accessing family planning and obstetrics services that impact the safety of giving birth.17 Conflict destroys health infrastructure, drug factories and causes a substantial number of health workers to leave their workplaces.18 Consequently, the health facilities become inaccessible19 which, in turn, leaves millions of people in desperate need of medical assistance.20

Additionally, conflict reduces number of Antenatal care (ANC) visits,21 prenatal and delivery care22 and quality of life.23 24 Pregnant women in armed conflict situations are more likely to end up in unhealthy childbirth and death.25 In Ethiopia, more than 63 000 people lost their lives and over 2.7 million people became disabled as a result of war and conflicts by the year 2019.26 Northern Ethiopia has been experiencing armed conflicts that have had devastating effects on the health system since November 2020.27 Trauma, sexual violence, psychological and emotional suffering and service constraints were among the effects of the conflict in northern Ethiopia.28

In Ethiopia, evidence shows that HSR appears to vary between units of care, with 45.8% in delivery care,13 66% in outpatient care,29 55.3% in care for HIV/AIDS patients30 and 53.0% in care for pregnant women.31 The responsiveness of the healthcare system is associated with various factors including age, residence, satisfaction, perceived quality of care and satisfaction with care.29–31

Ensuring intrinsic values and safeguarding patient rights are vital components for achieving better health outcomes.10 32 33 A non-responsive health system can lead to poor pregnancy outcomes and lower satisfaction with prenatal care.34 Lack of autonomy in decision-making is a result of poor health system,35 and home births are a result of low trust in the services offered, which, in turn, raises maternal morbidity and mortality.36 Every year, over two million stillbirths and neonatal deaths are attributed to intrapartum complications.37 Women’s poor perception about the quality of healthcare they receive is one of the barriers to visit health facilities.38 39 Hence, for improvements in service deliveries in resource-constrained contexts, it is critical to assess customers’ perceptions of system inadequacies and responsiveness to their demands.40 41

In Ethiopia, responsiveness studies were conducted in general and specific communities, but none were conducted in conflict-affected areas or districts.13 29–31 42 One study was conducted to assess HSR for delivery care, but data was collected at the health facilities, limiting the scope and possibly introducing positive response bias.13

In this research, we aimed to answer a question: ‘What is the proportion of HSR and its associated factors for intrapartum care in conflict-affected areas?’ Moreover, this research tried to reduce biases that may have existed in previous studies by conducting the research at a community level in conflict-affected districts. The study helps to identify health system shortcomings, protect patient rights to timely care and improve responses to mothers’ expectations.40 43 The results of this study can also be beneficial for policymakers and non-governmental organisations to respond to the existing health needs of the population and to enhance the health system in conflict-affected settings.

MethodsStudy design and context

We carried out a cross-sectional study in three districts (Wadila, Gaynt and Meket) of Amhara region, where the districts were severely affected during the conflict in August 2020. In these districts, a great deal of infrastructure was destroyed, looted and damaged. As a matter of fact, multiple crimes were committed. For instance, approximately 1500 health facilities in Amhara and Afar regions were destroyed, looted or intentionally damaged, as reported by the Ethiopian Federal Ministry of Health.

Population and sampling

This study focused on women who gave birth in conflict-affected areas within the last 6 months. We used all of these women as our source population. The study population consisted of women who gave birth 6 months before the study began. We included all women who gave birth at the health facilities but excluded those who delivered at home, were critically ill or those who had hearing problems.

We determined the sample size using mean estimation formula. To reach significance,44 we used the value of mean score of responsiveness (153.1±16.7) from a study conducted in Hadiya zone public hospital by considering 95% CI, margin of error 1.6 and using 10% for non-response rate.31

where, n=sample size for the assessment of HSR and d=margin of error or desired precision which is equal to 1.6=which is judgmental to get adequate sample size.

By considering 10% non-response rate 420×0.1=42, the final sample size was 420+42= 462.

To select our study participants, we followed these procedures: first, we compiled a list of women who had recently delivered babies from the registration book of health extension workers (community health workers) in each district, which we used as our sampling frame. We then proportionally allocated a sample to each district affected by the conflict. Next, we randomly selected participants from each district using a simple random sampling method. Data collectors approached the selected participants in person, obtained written informed consent and conducted an interview.

Ascertainment of variables and definitions

To assess the responsiveness of the health system in intrapartum care, we used eight domains sourced from various literature and WHO multicountry studies. These domains include dignity, autonomy, confidentiality, communication, prompt attention, social support, choice and basic amenities. To measure these domains, we used a total of 30 items, broken down as follows: dignity (5 items), autonomy (3 items), confidentiality (3 items), communication (5 items), prompt attention (3 items), social support (3 items), choice (3 items) and basic amenities (5 items).45–47 The domains mentioned earlier were measured using a Likert scale that contained four response options ranging from ‘never’ to ‘always’ with a code of 1 and 4, respectively (please see online supplemental table 1). Considering the normal distribution of the data, we calculated the mean to facilitate comparisons with previous studies. Based on this, scores of 76 and above were considered ‘responsive’, while scores below 76 were deemed ‘non-responsive’.13

Data collection tool

An interviewer-administered questionnaire was used to gather data from mothers who gave birth in the past 6 months. The questionnaire for the assessment of HSR in intrapartum care was adapted from the WHO guidelines for multicountry studies, as well as other literature on similar studies conducted in Ethiopia.13 48 49 Moreover, the tool was used in another study by the same author in Ethiopia.13 In addition to the outcome variable, independent variables of perceived satisfaction,50 51 quality healthcare,30 sociodemographic, obstetric, economic, service delivery factors and system accessibility-related factors were included.13

Data quality assurance

To ensure the quality of the data, the questionnaire was first prepared in English and then translated into Amharic, the local language. The translated version was then retranslated into English to check for consistency. The questions were uploaded into the KOBO toolbox. Regarding the data collection and supervision, a team of 12 data collectors and 4 supervisors were recruited, respectively. Prior to data collection, a 2-day training was provided to the data collectors and supervisors, covering the objectives and the data collection process. Furthermore, collaborative discussions were held among the data collectors and supervisors to get feedback about data collection.

Data management and analysis

Once the data quality was secured, we checked the data for completeness. Then, we assigned a code number for ease of data entry. We used Epi-Data V.4.6 software for data entry. To ensure accuracy, consistency, missed values and variables, we ran frequency checks. We used parametric measurements such as mean, median and range. We presented the statistical results using tables, graphs and narratives.

We first checked normality by analysing the histogram. We found that the majority of observations were distributed in the middle (online supplemental figure 1). We then checked kurtosis and found it to be 3.5, which is close to 3. This indicates that we can safely proceed with normality analysis. Additionally, we checked skewness and found it to be 0.5, which is almost 0. Both kurtosis and skewness suggested that most observations concentrated in the middle rather than at the extreme ends. Although the data is not exactly normally distributed, it is nearly normally distributed, which allows us to proceed with linear regression analysis. We fitted a multiple linear regression model to identify the factors associated with HSR in intrapartum care. We used an unstandardised β coefficient with a 95% CI and a p value of less than 0.05 to declare significant factors.

Statement on involvement of patients and the public

Mothers in our study did not participate in the design or execution of the study, nor have they been involved with the design of the protocol, data collection methods or dissemination of results.

ResultsSociodemographic characteristics of the study participants

The median age of the study participants was 28 years, with an IQR of 11. The majority (31.26%) of them had attended primary education. More than two in five participants (45.11%) reported that they make joint decisions regarding the use of health services (table 1).

Table 1

Sociodemographic characteristics of the study participants (n=419)

Obstetric characteristics of the study participants

Of the study participants, 367 (87.59%) had a history of ANC visits during their pregnancy. Nearly three-fourths (74.51%) of the mothers were multipara (table 2).

Table 2

Obstetric characteristics of mothers who recently gave birth (n=419)

HSR and service accessibility-related characteristics

Out of all the participants in the study, 55.85% reported that doctors, nurses or other healthcare providers usually treat them with respect. Additionally, around 45% of the mothers stated that they were never asked for their permission before tests or treatments were conducted (table 3).

Table 3

Some selected health system responsiveness question results

The study revealed that the overall HSR Score was 45.11% (95% CI: 40.38 to 49.92). The autonomy domain had the lowest score, while the confidentiality domain had the highest (online supplemental figure 2).

Out of all the participants in the study, 61.1% received intrapartum services at the health centre. The average duration of their stay in the health facility before delivery was 5.18±7.12 hours. The majority of the mothers (55.13%) were attended by male healthcare providers (table 4).

Table 4

Health service accessibility-related characteristics (n=419)

Factors associated with HSR in intrapartum care

The final multiple regression model revealed that 71.5% (adjusted R2=0.715) of the variation in HSR for intrapartum care was accounted for the factors included in the analysis. After performing a simple linear regression analysis, it was found out that fifteen variables were eligible (p value≤0.2) for multiple linear regression.

Mothers living in urban areas received 4.28 times better HSR during their intrapartum care compared with mothers living in rural areas (95% CI; 2.06 to 6.50). Government employees were found to have five times higher HSR in intrapartum care than non-government employees (95% CI: 0.51 to 9.48). Hospital delivery was associated with a decrease in HSR by a factor of −3.62 (95% CI; −5.60 to –1.63) while hospital stay before delivery increased HSR by 0.22 (95% CI; 0.09 to 0.35). The perceived satisfaction of healthcare services and quality showed an increase in HSR by 0.69 (95% CI; 0.08 to 1.30) and 0.96 (95% CI; 0.72 to 1.19), respectively. In contrast, joint decision-making decreased HSR by a factor of −2.46 (95% CI: −4.81 to –0.10) (table 5).

Table 5

Factors associated with intrapartum care responsiveness (n=419)

Discussion

According to our findings, less than three out of seven mothers who recently gave birth received responsive care during the intrapartum period. Furthermore, confidentiality was maintained for only 68.2% of women, autonomy for 35.5%, prompt attention for 52%, dignity for 60%, communication for 59.2%, choice for 49.4%, basic amenities for 56% and social support for 62.5% during intrapartum care. It has been observed that a considerable number of women do not receive appropriate care during childbirth at healthcare facilities. This situation can be attributed to the conflict and its effects on healthcare services. The research finding is consistent with a study conducted in Dessie city administration, where 45.8% of the mothers rated the health system as responsive.13 However, higher findings were reported in Ethiopia in Asagirt district 66.2%,29 Shewa Robit town 55.3%30 and Hadiya zone 53%31 as compared with our findings. The lower responsiveness observed in this study might be due to the impact of conflict.43 52 It is evident that conflict negatively impacts all aspects of society, including infrastructure and healthcare delivery for women.42 53

Mothers’ socioeconomic conditions were found to be associated with their perception of the responsiveness of care. Urban resident mothers rated the HSR higher than those residing in rural areas. However, the study conducted in Hadiya zone, Ethiopia indicated that urban resident mothers reported the HSR as poor.31 The higher HSR rating in this study could be attributed to the fact that urban mothers had better access to delivery care during the war compared with rural mothers. Meanwhile, rural dwelling mothers may have been unable to leave their homes due to the fear of war and the long distance to reach health facilities.54

Mothers employed by the government had a higher HSR than other employees, potentially due to the increased access to healthcare services.55 Mothers who worked for government may be better to afford medical treatment than non-working mothers.56 Mothers who gave birth at hospitals gave lower ratings to the health system’s responsiveness compared with those who gave birth at health centres. This may be due to the higher expectations held by mothers who delivered at hospitals as compared with those who visited health centres.57 Hospitals are often busier than health centres, which may lead to longer wait times and lower quality care. Therefore, hospitals should assess their services and make changes based on their findings to improve patient outcomes.58

According to the findings of this study, mothers who were admitted to a health facility before delivery reported higher levels of responsiveness of the health system. This could be because staying within health centres and hospitals is a feasible strategy for ensuring safety and receiving at least the minimum required maternal healthcare services. As a result, these mothers rated the health facility as highly responsive.54 Mothers who stayed at the health facility during the conflict felt safer and found it to be an escape from the conflict.59 To improve the health facility’s responsiveness during conflict, it is important to provide screening and follow-up care for pregnant women, particularly in cases of pregnancy-related maternal morbidity.

Recognising the tendency toward bidirectional determinism between HSR and satisfaction,60 our study revealed that an increase in maternal satisfaction led to a corresponding increase in HSR. This finding is consistent with studies conducted in Ethiopia.29–31 Maintaining patient happiness and satisfaction while using healthcare services results in higher evaluations of the healthcare system.61 This suggests that it may be important to increase positive interactions between healthcare professionals and patients, as well as meet patients’ legitimate expectations.62

Perceived quality of care is directly related to the evaluation of HSR.63 64 The study showed that higher perceived quality of healthcare is associated with increased responsiveness of the health system. In congruent with this, other study findings in Ethiopia revealed that HSR was positively correlated with perceived quality of care.29 30 Therefore, improving the quality of healthcare services requires regular enhancement of services, staff training, completion of necessary maternal services and an effective management system.

In Africa, women’s decision-making autonomy regarding healthcare is crucial for maternal health.65 66 According to the study, mothers who made joint decisions with their husbands regarding maternal healthcare utilisation reported lower rates than mothers who made these decisions alone.30 The finding is similar with a study conducted in sub-Saharan Africa,65 where decision-making autonomy for healthcare service increases the utilisation of health services.

Strengths and limitations

The study was conducted within a sizeable geographical region. To decrease social desirability bias, data was collected by personnel who were not working within the study area. The research evaluated the non-medical features of health facilities in areas affected by conflict. Several significant ethical recommendations, such as providing adequate care to pregnant women during times of conflict were proposed, even though they may be difficult to implement.

It is also important to note that the study has some limitations that need to be considered. First, there may be a recall bias due to the 6 months memory time-lapse. Second, the absence of a qualitative aspect means that HSR cannot be fully captured using quantitative methods alone. This is because there are numerous aspects of responsiveness that require qualitative exploration. The measure of HSR tool has not undergone any kind of formal validation process. Additionally, while the conflict may explain much of the unresponsiveness, it was not explicitly inquired in the questionnaire. Some unresponsiveness may have existed prior to the conflict, as it is present in all the health systems worldwide. Therefore, to gain a comprehensive understanding of HSR in maternal and child health services provision, future studies should prioritise the use of qualitative methods or a mixed-methods approach from the healthcare providers’ perspective.

Conclusion

This study showed that more than half of the mothers who gave birth rated the health facilities where they received care as unresponsive. The finding is lower than the results of previous studies conducted in Ethiopia. To improve the situation, we recommend that the national government and non-governmental partners carefully design the fundamental components of the health system in conflict-affected areas. Regardless of where they have started, governments and agencies are advised to avoid wars and to conduct them in a way that does not result in massive destruction of civil infrastructure, in particular healthcare infrastructure. Special attention should also be given to the autonomy and choice domain, as well as strengthening positive patient–physician interactions. Empowering mothers who live especially in rural areas to make healthcare decisions independently is also crucial.

Data availability statement

Data are available on reasonable request.

Ethics statementsPatient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants. For this study, ethical clearance was obtained from the University of Gondar Institutional Review Board, Vice President for Research and Technology Transfer Office (Reference IRB: VP/RTT/05/832/2023). We also received support letter from each district health office. Besides, informed written consent was obtained from each study participant. All the methods of this study were conducted according to the Helsinki declaration ethical principles. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

Our thanks are forwarded to the study participants for their relevant information and time. We also would like to acknowledge the Korean Foundation for International Healthcare (KOFIH) for their financial support to data collection and fulfilling medical equipment to the conflict-affected areas.