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

Background Despite global efforts, maternal and neonatal mortality remain critically high in low- and middle-income countries like Ethiopia. Decentralizing Comprehensive Emergency Obstetric and Newborn Care (CEmONC) to health centers is a key strategy to reduce morbidity and mortality. However, the implementation of these services at the primary care level in Ethiopia faces significant systemic challenges that require further investigation. Methods A qualitative phenomenological study was conducted from May to July 2025 across five purposively selected public health centers in Addis Ababa, Ethiopia. In-depth interviews were held with 16 key stakeholders, including emergency surgical officers, anesthetists, scrub nurses, clinical directors, and maternal health experts. Data were collected using a semi-structured interview guide. Interviews were transcribed, translated, and analyzed using thematic content analysis. Results The analysis revealed a complex set of interconnected barriers to CEmONC provision. Major challenges included: (1) inadequate infrastructure: Health centers were not originally designed for surgical services, leading to critical shortages of space, operating rooms, and post-operative beds. (2) Human resource crises: While the introduction of Emergency Surgical Officers (ESOs) increased service uptake, high attrition rates due to an unclear career path and a lack of university recognition has threatened the program's sustainability. A critical shortage of trained surgical assistants and dedicated scrub nurses creates unsafe working conditions. (3) Supply chain failures: Frequent stock-outs of essential anesthesia drugs, blood, surgical consumables, and laboratory reagents regularly halt services, exacerbated by budget constraints and a slow procurement system. (4) Weak leadership and referral systems: Participants reported a lack of managerial support, motivation, and clear guidelines for the down-referral of patients from overcrowded hospitals. Conclusion The decentralization of CEmONC services to health centers in Addis Ababa is hampered by multifaceted challenges spanning infrastructure, human resources, supplies, and governance. Without urgent interventions to address the unsustainable workforce model, stabilize supply chains, improve infrastructure, and strengthen leadership, the significant gains in access to comprehensive emergency obstetric and surgical emergency care are at risk. Policymakers must prioritize these areas to ensure the long-term viability and quality of the critical lifesaving program.