Implementation of Evidence-Based Intrapartum Care and its Associated Factors Among Obstetric Care Providers Working in South Ethiopia

Abstract

Background

Despite the availability of clear guidelines, evidence from low- and middle-income countries, including Ethiopia, shows persistent gaps in implementing evidence-based intrapartum practices, contributing to high maternal and neonatal morbidity and mortality. In southern Ethiopia, including the Wolaita Zone, where resource constraints are common, the extent of adherence to these practices and factors influencing their implementation is not well understood. Therefore, this study aimed to assess the implementation level of evidence-based intrapartum care practice and its associated factors among obstetric care providers working in hospitals in Wolaita Zone in 2022.

Methods

A facility-based cross-sectional study was conducted from August 1–31, 2022, among 332 obstetric care providers in the hospitals of the Wolaita Zone. The data were collected using structured interviewer-administered questionnaires and non-participatory observation with a standard checklist supplemented with record review. Data were entered into EpiData version 4.6.0.2 and then exported to Stata Version 15 for analysis. Binary logistic regression analyses were conducted to identify factors associated with evidence-based intrapartum care among obstetric care providers. An adjusted odds ratio (AOR) with a 95% confidence interval was reported.

Results

The implementation of evidence-based intrapartum practice was 52.5% [95% CI (47.1%-57.9%)]. Work experience >5 years [AOR:1.74;95%CI (1.04,2.91)], knowledge [AOR:1.77; 95% CI (1.06,2.95)], in-service training [AOR = 1.83; 95% CI (1.05,3.17)], access to EBP guidelines [AOR:1.70; 95% CI (1.01,2.85)], and managerial support [AOR:3.1; 95% CI (1.11,8.67)] were associated with the implementation of evidence-based intrapartum care.

Conclusion

Evidence-based intrapartum care practice implementation was low in the study area. Years of work experience, knowledge, in-service training, availability of EBP guidelines, and support from managers were the factors with a significant association with evidence-based intrapartum care practice. Strengthening these enabling factors may help creating an environment that facilitates greater adherence to recommended intrapartum care practices, thereby improving maternal and newborn outcomes.

Keywords

evidence-based intrapartum care obstetric care Ethiopia

Introduction

Intrapartum care is a critical component of maternal and newborn health, directly influencing pregnancy outcomes and contributing significantly to the reduction of maternal and neonatal morbidity and mortality (Zelka et al., 2023). Despite the availability of evidence-based guidelines for intrapartum care, substantial gaps persist between recommended practices and actual clinical implementation, particularly in low-resource settings (Cortes et al., 2018; Masuda et al., 2020). Evidence suggests that the inconsistent application of evidence-based intrapartum practices, such as the use of a partograph, appropriate early labor surveillance, active management of the third stage of labor (AMTSL), and adequate pain relief, these factors may contribute to preventable maternal and neonatal complications (Miller et al., 2016).

According to the World Health Organization (WHO), in 2023, nearly 260,000 women died as a consequence of pregnancy complications, and the majority of these were in the low- and middle-income countries (LMICs) (WHO, 2025). Neonatal mortality is also disproportionately high in these settings, with complications during labor and delivery being the leading causes of early neonatal deaths (UNICEF, 2025). Ethiopia continues to have high neonatal and maternal mortality, with the 2019 Ethiopian Mini Demographic and Health Survey reporting a maternal mortality ratio of 401 per 100,000 live births and a neonatal mortality rate of 30 per 1,000 live births (EPHI & ICF., 2019).

Evidence-based intrapartum care refers to clinical practice during labor and delivery that is guided by the best available research evidence and international guidelines, for example, the WHO, the Federal Ministry of Health of Ethiopia (FMoH) (FMoH, 2022; WHO, 2018a). Recommended practices include proper use of partograph monitoring, prompt detection and intervention for complications of labor, respectful maternity care, and correct use of medical interventions. In contrast, fundal pressure during each delivery, routine episiotomy, and lithotomy position without clinical indication are considered non-evidence-based practices because they do not improve outcomes and may add to maternal and neonatal complications, including perineal trauma, postpartum hemorrhage, and fetal distress, without demonstrated benefits (WHO, 2018a). The extent to which these practices are being taught in medical and nursing schools, and the degree to which clinical providers rely on national versus international guidelines, also vary, and will affect quality of care (Dessie et al., 2020; Gudeta et al., 2024).

There has been substantial progress made in Ethiopia in increasing institutional deliveries over the past decade towards improving access to skilled birth attendants. Institutional deliveries rose from 10% in 2011 to 48% in 2019, according to the Ethiopian Demographic and Health Survey (EPHI & ICF., 2019). Even today, there is no guarantee that higher institutional delivery rates will lead to better maternal or neonatal outcomes. Poor quality of intrapartum care is a major impediment, with studies showing preventable complications arising from inappropriate clinical practice, delayed interventions, or failure to follow evidence-based procedures (Asrese, 2020; Fisseha et al., 2019).

Evidence-based intrapartum care practice based on clinical guidelines and scientific evidence has been proven to have a substantial decrease in maternal and neonatal adverse outcomes (Semrau et al., 2020; Tolu et al., 2020). However, low-resource country evidence, including Ethiopia, indicates that obstetric providers’ adoption of evidence-based practice is not consistent. For instance, a study from India reported that unindicated labor augmentation occurs in 64.4% of cases, fundal pressure occurs in 50.8%, episiotomy occurs in 58.3%, and lithotomy position delivery occurs in 86.7% of cases (Iyengar et al., 2022). Similarly, in Ethiopia, only 36–63.7% of obstetric care providers consistently used evidence-based practices such as partograph monitoring, timely referral, and respectful maternity care (Abebe & Mmusi-Phetoe, 2023; Wodajo et al., 2023). Lack of training, inability to access up-to-date clinical guidelines, heavy workload, poor supervision, and health system restrictions have been identified as barriers to the use of evidence-based intrapartum care (Kassahun et al., 2017; Sendekie et al., 2022).

In southern Ethiopia including the Wolaita Zone, where resource constraints, workforce shortages, and variability in training opportunities are common, the extent of adherence to these practices and factors influencing their implementation is not well understood. Furthermore, obstetric care providers may encounter barriers, including a lack of up-to-date knowledge, inadequate skills, high caseloads, and institutional constraints, which impede adherence to clinical guidelines. Thus, identification of these factors will be crucial for the initiation of focused interventions to improve intrapartum care quality, maternal and neonatal outcomes, and foster achievement of national and international maternal health targets.

Review of the Literature

The WHO defines a package of evidence-based intrapartum care practices routine use of the partograph, effective fetal and maternal monitoring, AMTSL, infection prevention, and use of pain relief to optimize maternal and newborn health outcomes and promote a positive childbirth experience (WHO, 2018b). Despite clear global recommendations, the implementation of such practices is uneven worldwide, and the largest gap between recommendations and daily care is observed in LMICs (Abraham & Melendez-Torres, 2023; Wodajo et al., 2023). Systematic reviews and multi-country analyses provide evidence of high heterogeneity in the implementation of EBP and associate suboptimal implementation with higher maternal and perinatal morbidity and mortality rates in Ethiopia (Figa et al., 2024; Mihretie et al., 2023; Zeleke et al., 2025).

In Ethiopia, syntheses and cross-sectional studies within the last few years indicate that approximately half of obstetric care professionals implement recommended intrapartum practices, with pooled prevalence estimates around 54% with a high degree of heterogeneity across studies and regions (Figa et al., 2024). Some low-prevalence practices deserve special attention. Evidence from Ethiopia and similar LMIC contexts reveals infrequent use of pharmacological pain relief, inconsistent use of antiseptics where indicated, and incomplete or improper use of partographs, all compromising the quality of care. These gaps in practice are replicated across facility types and locations, suggesting system-level issues rather than individual provider decisions (Nori et al., 2023; Sendekie et al., 2022).

The literature consistently identifies three interacting domains that constrain EBP in LMIC maternity services: (1) budget and supply-chain restrictions (stockouts of drugs and antiseptics, constrained consumables), (2) institutional and governance flaws (inadequate or poorly disseminated guidelines, insufficient supervision, suboptimal infrastructure), and (3) human resource constraints (shortages of trained staff, inadequate pre-service and in-service training, high provider-to-patient ratios). These constraints reduce the potential and also the incentive of providers to follow best practice (Abraham & Melendez-Torres, 2023; Sarikhani et al., 2024).

Qualitative and realist syntheses also pointed out that socio-cultural factors (provider and patient expectations of labor pain, norms for medical intervention), and the local policy context (financing, monitoring of performance) influence whether or not low-prevalence interventions such as pain relief or antiseptic application become routine. Interventions that combine training with supply-chain backing, supervision, and local adaptation of guidelines are the most likely to increase practice uptake (Abraham & Melendez-Torres, 2023).

Although various Ethiopian studies quantify the level of EBP and identify corresponding factors, between-region variation and persistent low-priority practice prevalence (e.g., pain management, antisepsis, AMTSL) create room for regionally-specific, context-informed research of specific interest in South Ethiopia to identify modifiable barriers and inform targeted quality-improvement interventions.

Research Question

What is the level of evidence-based intrapartum practice among obstetric care providers in Wolaita Zone, South Ethiopia?

What individual and organizational factors are associated with adherence to evidence-based intrapartum practices?

Methods

Study Area and Period

This study was conducted in Wolaita Zone hospitals from 1–30 August 2022. Wolaita Zone is one of 11 zones in the Southern Nations, Nationalities, and Peoples’ Regional (SNNPR) State of Ethiopia. In the zone, there are 16 districts and seven town administrations with a total of 374 kebeles (the smallest administrative unit) (295 rural and 79 urban kebeles). Based on the zonal report, the zone had an estimated total population of 5,385,282 in 2014 E.C. According to the zonal health department report, there were 430 health facilities, including 8 hospitals, 3 nongovernmental organizations, 68 health centers, and 352 health posts. There were 8443 healthcare workers. Of these, 332 are obstetrics care providers working in hospitals in the Wolaita Zone (“Wolaita Wonal Health Department report”, 2022).

Study Design

A facility-based cross-sectional study was conducted.

Population and Sample Size Determination

All obstetric care providers who were actively delivering care to laboring mothers in the labor and delivery units of the selected public hospitals in Wolaita Zone were the source population. The study included all 332 obstetric care providers who are serving in hospitals in the Wolaita zone, whereas obstetric care providers who had less than 6 months of experience, were on annual leave or maternity leave, or were sick during the study period were excluded from the study.

Study Variables

The outcome variable is Evidence-based intrapartum care practice, whereas the independent variables were Socio-demographic variables (age, gender, income, and marital status), Organizational variables (computer and internet access, managerial motivation, interactive EBP skill-building workshops, cooperation, and regular mentoring), and Individual variable (profession, experience, qualification, training on obstetrics care, seminar, and health information is used to improve patient care, conduct clinical research, and teach students, Obstetric care provider's knowledge and attitude).

Operational Definition of Variables

Evidence-based intrapartum care practice is a problem-solving approach to providing care that integrates the best evidence from research, clinical expertise, and patient preferences (Levin et al., 2011; Sonia et al., 2017). Obstetrics care providers who scored above the median value on intrapartum-practice-related observational checklists are considered they practice EBP; otherwise, not considered to practice (Kassahun et al., 2017).

Obstetric care providers: Participants included a midwife, integrated emergency surgical officers (IESO), health officer, and medical doctors who work in the labor and delivery ward to provide care and treatment to women during childbirth and before and after delivery (Kassahun et al., 2017).

Knowledge: Knowledge of evidence-based intrapartum care was assessed using a structured questionnaire consisting of 10 items. Those who scored >5(the median value) on knowledge-related questions were considered to have good knowledge, while obstetric care providers who scored less than the median value were considered to have poor knowledge (Kassahun et al., 2017). The median was used as the cut-off point because the data for this variable were not normally distributed

Attitude: Attitude toward evidence-based intrapartum care was measured using 8 Likert-scale questions. Those who scored ≥6 (the median value) on attitude-related questions regarding evidence-based intrapartum practice were considered to have a favorable attitude, whereas those who scored less than the median value were considered to have an unfavorable attitude (Kassahun et al., 2017).

In-service training: Obstetric care providers who had received training related to intrapartum care, like Basic Emergency Obstetric and Newborn Care (BEmONC), Comprehensive Emergency Obstetric and Newborn Care (CEmONC), partograph, and newborn care.

Data Collection Tool and Procedure

Data were collected using a standardized questionnaire consisting of five sections, 48 items that were adapted from previously validated instruments used in Ethiopia and similar settings (Kassahun et al., 2017). The tool was pre-tested, and revisions were made to improve clarity and consistency. Section I: Sociodemographic variables (7 items) consist of age, sex, profession, years of service, level of education, and other sociodemographic background variables. Section II: Perceived barriers to evidence-based intrapartum practice (5 items) include individual and organizational problems, e.g., workload, availability of resources, and institutional support. Section III: Knowledge of evidence-based intrapartum practice (10 items) consisted of factual questions regarding the use of partograph, intrapartum monitoring, AMTSL, infection prevention, and pain relief. Responses were scored 1 (correct) or 0 (incorrect), with higher scores indicating greater knowledge. Section IV: Attitude towards evidence-based intrapartum practice (8 items). Assessed providers’ attitudes and acceptability of embracing evidence-based care, rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The instrument was highly reliable (Cronbach's alpha = 0.83 in this study). Section V: Evidence-based intrapartum practices (22 items). Measured actual practices were either “recommended” or “not recommended” according to WHO recommendations.

A non-participant observation was conducted to assess the actual implementation of evidence-based intrapartum care practices. The observation checklist was adapted from the WHO Intrapartum Care for a Positive Childbirth Experience guideline and a similar study conducted in Ethiopia. The key areas observed included: partograph use, maternal and fetal monitoring in labor, infection prevention practices, and AMTSL, pain relief administration, and respectful maternity care.

Observations of obstetric care providers, conducted by trained senior midwives not involved in care, preceded the interviews. Observation focused solely on provider practices, with women and providers giving informed consent in line with institutional ethics guidelines. Observers remained non-participatory unless patient safety was at risk. Following observations, interviews were conducted after data collectors introduced the purpose and procedure of the study, the expected duration of the interview, the potential burdens and benefits of participation, and their right to withdraw at any time. Eight experienced BSc midwives collected the data while being supervised by four other BSc midwives.

Data Quality Assurance

The questionnaire was pre-tested on 5% of the sample at Shone Primary Hospital. Before data collection, a one-day training was given to data collectors and supervisors. On-site supervision was given to solve any doubts during the data collection process by the principal investigator daily. The completeness and consistency of the collected data were cross-checked and compiled by supervisors and principal investigators daily.

Data Processing and Analysis

The data collected was cleaned, entered into EpiData version 4.6.0.2, and exported to Stata Version 15 for analysis. Descriptive statistics, such as frequencies and percentages, were presented to explain the study of relevant variables. Bivariate and multivariable binary logistic regression analyses were conducted to identify factors associated with EBP. Confounding was checked by looking at the regression coefficient change if greater than or equal to 20% and multi-collinearity was checked using the variance inflation factor, and a value of <10 was used as a cutoff point.

Variables having a p-value < .25 in the bivariable analysis were included in multivariable logistic regression to control for the possible effect of confounders. An adjusted odds ratio (AOR) was used to report the strength of the association at the 95% confidence interval. Variables having a p-value <.05 were considered statistically significant. The goodness of the final model was checked by the Hosmer-Lemeshow test, and the p-value was found to be 0.6330.

Results

Socio-Demographic Characteristics

A total of 327 obstetric care providers were included in this study, with a 98.5% response rate. Nearly three-quarters of the 240 (73.39%) participants were female, and 196 (59.94%) were married. Two hundred seventy-two (83.18%) participants were in the age range of 25–34 years, with the mean and standard deviation of their ages being 28.6 ± 4.5 years. Concerning profession, 199 (60.86%) participants were midwives, followed by 64 medical doctors (19.57%). Nearly two-thirds of participants, 204 (62.39%), were BSc holders, followed by 41 (12.54%) residents. Among the participants, 143 (43.73%) had a monthly salary of 5,000–8,000 Ethiopian birr, and 156 (47.71%) had working experience of 5 years (Table 1).

Table 1.

Sociodemographic Characteristics of Obstetric Care Providers in Hospitals of Wolaita Zone, Southern Ethiopia, 2022.

Variables	Categories	Frequency	Percent
Sex	Male	87	26.61
Sex	Female	240	73.39
Age	<25 years	30	9.17
	25–34 years	272	83.18
	>35 years	25	7.65
Marital status	Married	196	59.94
Marital status	Single	131	40.06
Profession	Medical doctors	64	19.57
	Midwives	199	60.86
	Nurse	36	11.01
	Health officer	17	5.20
	IESO	11	3.36
Educational level	Residents	41	12.54
	GP	26	7.95
	MSc	11	3.36
	BSc	204	62.39
	Diploma	45	13.76
Years of experience	< 5 years	171	52.29
Years of experience	≥5 years	156	47.71
Salary in Ethiopian birr	≤5000	54	16.51
	5001–8000	143	43.73
	>8000	130	39.76

Organizational-Related Characteristics

Among the participants, 105 (32.11%) had in-service training related to intrapartum care practices. Over two-thirds (66.36%) of the study participants had internet access at their workplace. A quarter of the respondents (24.99%) had access to computers, and more than half of the respondents used patient-related reading (70.5%) (Table 2).

Table 2.

Organizational and Individual-Related Characteristics of Obstetric Care Providers in Hospitals of Wolaita Zone, Southern Ethiopia, 2022.

Variables	Categories	Frequency	Percent
Training	Yes	105	32.11
Training	No	222	67.89
Level of Knowledge	Good	186	56.88
Level of Knowledge	Poor	141	43.12
Level of Attitude	Good	205	62.69
Level of Attitude	Poor	122	37.31
Computer access	Yes	85	25.99
Computer access	No	242	74.01
Internet access	Yes	217	66.36
Internet access	No	110	33.64
Availability of guidelines	Yes	137	41.90
Availability of guidelines	No	190	58.10
Access to health information	Scientific journals	49	14.98
	Textbook	182	55.66
	Colleagues	47	14.37
	Conferences	49	14.98
Encouraging to utilization of EBP	Managerial support	33	10.09
	Scientific meetings	48	14.68
	Skill-building workshops	87	26.61
	Mentorship	60	18.4
	Conduct research	28	8.56
	Condition of mothers	215	65.75
	Cooperation	136	41.59

Individual-Related Characteristics

Among the total respondents, 186 (56.88%) and 205 (62.69%) had good knowledge and a positive attitude toward evidence-based intrapartum practice, respectively. More than half of them, 182 (55.66%), were using textbooks either in addition to or without the Internet. The conditions of mothers was the most common motivation for following EBP, with a 215 (65.75%) response rate, followed by cooperation among staff members at 136 (41.59%) (Table 2).

Implementation of Evidence-Based Intrapartum Practice

Obstetric care providers were observed for their implementation of various recommended and non-recommended practices during intrapartum care. The overall implementation of evidence-based intrapartum practice was 52.5% [95% CI (47.1%–57.9%)]. Participants with good intrapartum practices included providing a pre-warmed neonatal corner for neonatal care (89%), appropriate AMTSL (85.3%), providing oral fluid and food (80.1%), and effectively communicating using straightforward and culturally acceptable techniques (66.4%).

Contrarily, the non-participatory observation revealed that the non-recommended practices that were most frequently observed during intrapartum care were immediate umbilical lead clamping less than one minute (83.79%), fundal pressure (44.65%), routine rupture of amniotic fluid (53.82%), and routine IV ﬂuid infusion (60.1%) (Table 3).

Table 3.

Observed, Recommended, and Non-Recommended Practices of Intrapartum Care Among Obstetric Care Providers in Wolaita Zone Public Hospitals, South Ethiopia, 2022.

Recommended Practice	Frequency (%)	Non-Recommended Practice	Frequency (%)
Effective communication	217 (66.4)	Routine rupture of amniotic ﬂuid	176(53.8)
Freedom of movement during the latent 1st stage of labor	195 (59.6)	Cleaning of the vulva and perineum with antiseptics	20(6.1)
FHR monitoring within 15 min during the 2nd stage of labor	113(34.6)	Routine IV ﬂuid infusion	199(60.1)
Episiotomy is done using local anesthesia	193 (59)	Perineal shaving	12(3.7)
Vaginal examination every 4 h	83 (25.4)	Fundal pressure	146(44.6)
Opioid analgesia for pain relief	14 (4.3)	Routine uterine exploration	226 (69.1)
Provide oral ﬂuid and food	262(80.1)	Immediate umbilical cord clamping	274(83.8)
Use relaxation techniques for pain management	56(17.1)	Routine nasal or oral suction of newborns	165(50.5)
Follow the progress of labor by using a partograph	121 (37)
FHR was monitored within 30 min during the active 1^st stages of labor	185 (56.6)
Pre-warmed neonatal corner for neonatal care	291(88.9)
Skin-to-skin contact of the newborn	161 (49.2)
AMSTL using appropriately	279 (85.3)

Factors Associated With Implementation of Evidence-Based Intra-Partum Practice

In bivariable logistic regression analysis, obstetric care providers’ sex, age, profession, work EBP guidelines, experience, access to a computer, training, knowledge, and attitude toward evidence-based practice were candidates for multivariable analysis. However, in the multivariable logistic regression model, knowledge, training, availability of EBP guidelines, managerial support, and working experience remained significantly associated with the evidence-based intrapartum practice.

Obstetric care providers who had good knowledge about intrapartum care were 1.77 times [AOR: 1.77; 95% CI (1.06, 2.95)] more likely to have good evidence-based intrapartum practice as compared to their counterparts. Likewise, obstetric care providers who had access to national or international EBP guidelines in their workspace were 1.70 times [AOR: 1.70; 95% CI (1.01, 2.85)] more likely to give intrapartum care based on the available evidence than those who did not have access to EBP guidelines. Obstetric care providers who had managerial support were three times [AOR: 3.1; 95% CI (1.11, 8.67)] more likely to have good evidence-based intrapartum practice as compared to their counterparts.

Obstetric care providers who had working experiences of 5 years were 1.74 times more likely [AOR: 1.71; 95% CI (1.04, 2.91)] to provide evidence-based intrapartum practice than those who had working experience of 5 years. Furthermore, those respondents who had in-service training related to intrapartum practice were 1.83 times [AOR = 1.83; 95% CI (1.05, 3.17)] more likely to have good evidence-based intrapartum practice compared with their counterparts (Table 4).

Table 4.

Binary Logistic Regression Analysis to Identify Factors Associated With Implementation of Evidence-Based Intrapartum Practice Among Obstetric Care Providers in Wolaita Zone, Southern Ethiopia, 2022.

Variables	Categories	Evidence-Based Intra		COR (95%CI)	AOR (95%CI)
		Partum Practice
		Yes	No
Sex	Male	56(64.37)	31(35.63)	1.93 (1.16, 3.20)	1.72(0.97, 3.07)
Sex	Female	116(48.33)	124 (51.67)	1
Age	<25	18(60.00)	12(33.33)	1.45 (.67, 3.13)	1.86(0.77, 4.48)
	>35	16(64.0)	9(40.0)	1.72 (0.73, 4.04)	0.79(0.28, 2.19)
	25–34	138(50.74)	134(49.26)	1	1
Profession	Midwife	105(52.76)	94(47.24)	1	1
	Medical doctor	27(42.19)	37(57.81)	0. 65(0.36, 1.15)	0.64(0.32, 1.28)
	Nurse	20(55.56)	16(44.44)	1.11(0.54, 2.18)	1.16(0.51, 2.64)
	Health officer	11(64.71)	6(35.29)	1.64(0.58, 4.61)	1.81(0.57, 5.71)
	IESO	9(81.82)	2(18.18)	4.0(0.84, 19.1)	1.75(0.30, 10.0)
Attitude	Favorable	102(49.76)	103(50.24)	0.73(0.46,1.15)
Attitude	Unfavorable	70(57.38)	52(42.62)	1
Knowledge level	Good	111(59.68)	75(40.32)	1.94(1.24, 3.02)	1.77(1.06, 2.95) *
Knowledge level	Poor	61(43.26)	80(56.74)	1	1
Training	Yes	71(67.62)	34(32.38)	2.50 (1.53, 4.07)	1.83(1.06, 3.17) *
Training	No	101(45.50)	121 (54.50)	1	1
Computer access	Yes	54(63.53)	31(36.47)	1.83 (1.10, 3.04)	1.49(0.83, 2.67)
Computer access	No	118(48.76	124(52.24)	1	1
Experience	<5 years	74(43.27)	97(56.73)	1	1
Experience	≥5 years	98(62.82)	58(37.18)	2.21(1.42, 3.45)	1.74(1.04, 2.91) *
EBP guidelines	Yes	92(67.15)	45(32.85)	2.52(1.60, 3.97)	1.70(1.01,2.85) *
EBP guidelines	No	80(42.11)	110(57.89)	1	1
Managerial support	Yes	27(81.82)	6(18.18)	4.62(1.85, 11.5)	3.1(1.11,8.67) *
Managerial support	No	145(49.32)	149(50.68)	1	1
Mentorship	Yes	41(68.33)	19(31.67)	2.24(1.23, 4.05)	1.74(0.88,3.43)
Mentorship	No	131(49.06)	136(50.94)	1	1

*Significant at a p-value < .05 level.

Discussion

This study revealed that the overall implementation of evidence-based intrapartum practice was 52.5%. Work experience in years, knowledge, in-service training, managerial support, and access to EBP guidelines determine the practice of evidence-based intrapartum care. The finding of this study was comparable with studies conducted in the Arbaminch district (54.06%) (Dewana, 2017) and public Hospitals of South Wollo Zone, North-Central Ethiopia (54.7%) (Sendekie et al., 2022); however, it was found to be higher than a study done in five referral hospitals in Northwest Ethiopia (38.3%) (Kassahun et al., 2017). This might be due to differences in the study period and setting, and the current increased efforts of the government to promote evidence-based practices and better access to evidence-based information.

The level of EBP revealed by the current study is lower than the study done in California, 74.4% (Shaw-Battista et al., 2011), Arab tertiary hospitals discovered in Egypt, 60%, 82% in Lebanon, and Syria, 73% (Kabakian-Khasholian et al., 2018). This variation may be caused by differences in access to essential supplies, inadequate staffing, and overloads of patients might hinder the consistent application of recommended practices. Variation in pre-service and in-service training might also be an influencing factor, as some providers might not possess up-to-date knowledge or practical skills to undertake interventions like the application of a partograph, AMTSL, or administration of pain relief. Socio-cultural factors, including patient expectations and neighborhood beliefs regarding work and giving birth, may also affect providers’ behavior. Additionally, variations in healthcare facilities and organizational support, like supervision, monitoring, and access to evidence-based protocols, will most certainly affect the quality and consistency of care. Generally, all these suggest the potential that the structural, educational, and cultural barriers are all contributing factors to this suboptimal level of adherence to evidence-based intrapartum practice observed in this study.

In this study, some of these evidence-based intrapartum interventions were practiced infrequently, including pain relief and antiseptic application. The low implementation of these practices may reflect a combination of training, resource, and socio-cultural challenges. Low availability of analgesics, antiseptics, and other commodities in low-resource settings has a direct impact on making it challenging for the providers to adopt these interventions. Additionally, socio-cultural expectations and norms regarding labor pain can also influence both patients’ demand for analgesia and providers’ willingness to administer it (Wakjira et al., 2025). The same has been observed elsewhere in low-resourced settings (Mukamurigo et al., 2019; Weerasingha et al., 2024), highlighting the need for targeted interventions to enhance implementation of these underutilized practices.

Obstetric care providers who had good knowledge about intrapartum care were more likely to have better evidence-based intrapartum practice as compared to their counterparts. This finding was supported by reports from other similar studies (Kassahun et al., 2017; Sendekie et al., 2022). This implies that knowledge is one of the prerequisites for providing quality services, making professionals more competent to practice according to recommended standards. At the same time, this knowledgeable professional may have updated training and more experience, allowing them to perform according to recommended standards.

Obstetric care providers who had working experience of ≥5 years were more likely to provide evidence-based intrapartum practice than those who had working experience of <5 years. This finding is in line with findings reported by Gonder and Wollo (Kassahun et al., 2017; Sendekie et al., 2022). Professionals with more experience are likely to have received more up-to-date training, participated in workshops, accumulated knowledge from exposure to diverse case scenarios, and benefited from the presence of role models in the work environment.

The respondents who received in-service training related to intrapartum practice were more likely to have good evidence-based intrapartum practice compared with their counterparts. This finding is in agreement with a study from Gonder (Kassahun et al., 2017). Up-to-date service training can fill gaps in professional practice and motivate workers to provide quality services in line with recommendations. Obstetric care providers who have received job training may be more motivated to adhere to evidence-based practices due to the insights gained from the training.

This study also showed that obstetric care providers who had access to EBP guidelines in their workspace were more likely to perform intrapartum care based on the available evidence than those who did not have access to EBP guidelines. The finding is also supported by other related studies (Degu et al., 2022), which investigated that the availability of human information sources of printed information in the work environment was associated with the utilization of evidence-based practices. The availability of up-to-date guidelines in the workplace can serve as an enabling factor for evidence-based practice by providing knowledge of recommended practices and may also reflect a supportive work environment. Moreover, in this study, obstetric care providers who had managerial support were three times more likely to have good evidence-based intrapartum practice.

In conclusion, the implementation of evidence-based intrapartum practices was suboptimal in Wolaita zone hospitals. The suboptimal compliance can reflect systemic challenges common in LMICs, including limited resources, insufficiencies in trained human resources, high patient-provider ratios, and inadequate infrastructure (Chauke, 2025; Sarikhani et al., 2024). Institutional problems such as limited access to updated guidelines, poor supervision, and gaps in pre-service or in-service training undoubtedly contribute even more to the hindrance of routine application of recommended practices (Ajegbile, 2023). Financial and socio-cultural determinants may also influence provider behavior, particularly for low-prevalence practices such as pain relief or antiseptic use, which were rarely practiced (Zakar & Iqbal, 2024). Collectively, these determinants of structure, education, and context are what lie behind lower rates of use of evidence-based intrapartum care in this setting and highlight the need for targeted interventions to improve maternal and newborn care.

Strengths and Limitations

This study has some strengths and limitations that need to be considered. The use of both interviewer-administered questionnaires and non-participatory observations enhanced the validity of the findings by capturing practices reported and practice in action, and the use of multiple cadres of intrapartum care providers allowed examination of factors influencing evidence-based intrapartum practice across professional groups. However, cross-sectional design precludes causal inference, and restriction to hospitals in a single zone reduces generalizability to other than hospital settings, such as health centers and health posts that cover much of maternity care in Ethiopia. Additionally, the Hawthorne effect, while observed, and social desirability bias in self-report may have overestimated reporting of compliance with recommended practices.

Implications for Nursing Practice

The findings of this study have important implications for improving intrapartum care. While these findings apply to all obstetric care providers, they may be particularly relevant for nurses and midwives who provide routine intrapartum care and interact closely with patients. Implications for EBP drawn from the conclusions are:

Capacity Building: In-service training and mentoring to enhance nurses’ and midwives’ knowledge and competency in using recommended intrapartum practices should have a high priority.

Guideline Integration: National and international evidence-based guidelines should be made easily accessible. Nurses need to be enabled to use the guidelines in real-time for decision-making during intrapartum care.

Supportive Environment: Managerial support and organizational reinforcement are critical in creating an enabling environment wherein nurses practice according to evidence-based standards.

Practice Autonomy: Nurses and midwives need to be empowered to provide non-invasive, supportive intrapartum care (e.g., respectful care, freedom of movement during labor, effective communication) with minimal unnecessary medical interventions.

Quality Improvement: Nursing managers can include intrapartum EBP monitoring in routine quality audits to verify compliance and identify gaps for focused interventions.

Patient-Centered Care: Training and supportive supervision must facilitate the integration of women's preferences and rights during childbirth as per international standards of respectful and evidence-based maternity care

Conclusion

This study showed that in the hospitals of the Wolaita Zone, implementation of evidence-based intrapartum care was low. The implementation of evidence-based intrapartum care is determined by factors such as years of work experience, knowledge, in-service training, access to EBP guidelines, and managerial support. Therefore, obstetric care providers should be compliant with the recommended intrapartum care, and creating an enabling environment might enhance intrapartum care.

Supplemental Material

sj-docx-1-son-10.1177_23779608251393755 - Supplemental material for Implementation of Evidence-Based Intrapartum Care and its Associated Factors Among Obstetric Care Providers Working in South Ethiopia

Supplemental material, sj-docx-1-son-10.1177_23779608251393755 for Implementation of Evidence-Based Intrapartum Care and its Associated Factors Among Obstetric Care Providers Working in South Ethiopia by Senait Girma, Desalegn Dawit Assele, Abera Gezume Ganta and Ermias Wabeto in SAGE Open Nursing

Supplemental Material

sj-docx-2-son-10.1177_23779608251393755 - Supplemental material for Implementation of Evidence-Based Intrapartum Care and its Associated Factors Among Obstetric Care Providers Working in South Ethiopia

Supplemental material, sj-docx-2-son-10.1177_23779608251393755 for Implementation of Evidence-Based Intrapartum Care and its Associated Factors Among Obstetric Care Providers Working in South Ethiopia by Senait Girma, Desalegn Dawit Assele, Abera Gezume Ganta and Ermias Wabeto in SAGE Open Nursing

Footnotes

Abbreviations

Acknowledgment

We would like to say thanks to Wolaita Sodo University College of Health Sciences and Medicine for facilitating this study. Our special thanks go to the data collectors for their kind and excellent cooperation during data collection.

ORCID iDs

Desalegn Dawit Assele

Abera Gezume Ganta

Ermias Wabeto

Ethical Consideration

Ethical clearance was obtained from the ethical review committee of the College of Health Sciences of Wolaita Sodo University (Ref.NoCRCSD 132/02/14). A formal letter including the study objectives was submitted to the Zonal Health Department based on the approval and permission obtained from the Zonal Health Department, the Woreda Health Office, and the respective hospitals where the study was conducted. Women receiving care were informed that an observer would be present to watch provider practices, and verbal consent was obtained before observation began. Providers also gave written informed consent to be observed during routine care. To minimize possible bias, observers did not engage in the provision of care unless patient safety was at risk. Information about specific personal identifiers, like names, was not collected, and the personal information was kept confidential throughout the study process.

Author Contributions

SS contributed to the conception, design, and supervision of data collection, analysis, and interpretation. DDA contributed to the design, analysis, and interpretation, and AG and EW conducted the analysis, interpreted the findings, and wrote the manuscript. All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

Supplemental Material

Supplemental material for this article is available online.

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