Title Determinants of the Quality of Childbirth Care Along the Continuum in Limited Resource Settings: A Structural Equation Modeling Analysis of Cross-sectional Data from Burkina Faso and Côte d’Ivoire

Introduction: Despite important increase in in-facility births, perinatal mortality rates have remained high and slow to decrease in many developing countries. This situation is attributed to the poor quality of childbirth care. The reason why women delivering in health facilities do not always receive standards of care are unclear. We assessed the determinants of the quality of childbirth care along the continuum of care using different approaches.Methods: A health facility-based cross-sectional study with a direct observation of health care workers’ practices while caring for mother-newborn pairs was carried out in Burkina Faso and Côte d’Ivoire. The performance of a set of Essential Best Practices (EBPs) was assessed in each birth event at admission, pre-pushing and immediate post-partum stages. A quality score, in the form of the additive sum of EBPs effectively delivered was computed for each stage. We used negative binomial regression models and a structural equation modeling analysis to respectively assess the determinants of the quality of care at each stage and the relationships between the quality delivered at the different stages.Results: a total of 532 and 627 mother-newborn pairs were included respectively in Burkina Faso and Côte d’Ivoire. In both countries, the quality of delivery care varies significantly at all stages between health districts. The quality of predelivery care was consistently higher in referral hospitals as compared to primary health care facilities (IRR = 1.02; p < 0.05 and IRR = 1.10; p < 0.05 respectively for Burkina Faso and Côte d’Ivoire). The quality at admission was poorer in nurses as compared to midwives in Burkina Faso (IRR = 0.81; p < 0.001). The quality at admission and pre-delivery stages were positively correlated with the immediate post-partum quality (β = 0.48;p < 0.001 and β = 0.29;p < 0.001 respectively).Conclusion: Quality improvement strategies must target both providers and health facilities and different inputs are needed depending on the stage in the continuum of care.