Assessing basic Emergency Obstetric and Neonatal Care (BEmONC) service provision in community health centers: a mixed-methods study from Jember, Indonesia

BACKGROUND: Maternal and newborn mortality remains a persistent global health issue, and most of these deaths are preventable through timely provision of Emergency Obstetric and Neonatal Care (EmONC). Despite the integration of EmONC into health systems, many low and middle-income countries struggle with suboptimal quality and readiness of services. This study aimed to assess the implementation of EmONC in community health centers (Puskesmas) in Jember, Indonesia, focusing on facility readiness and availability of the seven Basic EmONC (BEmONC) signal functions and the factors influencing service provision. METHODS: A convergent mixed-methods study was conducted in 50 Puskesmas health facilities providing delivery services in Jember from January 1 to July 31, 2023. Quantitative data were collected using facility surveys adapted from the Rapid EmONC Assessment Tool. Qualitative data were gathered through semi-structured interviews with stakeholders (n = 12), patients (n = 10), and focus group discussions with midwives (n = 2). Descriptive statistics were used to summarize trends, and t-test or Mann-Whitney U test to compare between groups. Qualitative data were analyzed using inductive content analysis. RESULTS: None of the Puskesmas met standards for fully functional BEmONC facilities. Among the seven BEmONC signal functions, parenteral uterotonics were most commonly provided (88% of facilities), while assisted vaginal delivery was not provided by any facility (0%). Surveyed facilities had a median of 70% (interquartile range 63-77%) of the 160 essential EmONC equipment and medications available. Key gaps were identified in essential medicines, equipment, provider training, and monitoring systems. Qualitative findings revealed barriers at systemic and facility levels, including insufficient provider training, inconsistent resource availability, and inadequate monitoring. Facilitators included growing community trust, existing infrastructure, and political commitment to maternal health. CONCLUSION: EmONC implementation in Jember faces critical barriers undermining service readiness and delivery, with notable gaps in service provision and availability. Addressing these challenges requires a comprehensive service delivery redesign approach, focusing on centralizing and strengthening EmONC services in strategically selected facilities.