Institutional Delivery Service Utilization and Associated Factors Among Mothers Who Gave Birth in the Last One Year in Ilu Ababor Zone, South West Ethiopia

Background: One of the top worldwide priorities is lowering maternal mortality, which is especially important in developing nations like Ethiopia. The use of institutional delivery services by mothers receiving competent birth attendant care is one of the primary ways to lower the maternal death ratio and enhance maternal health; nevertheless, the usage of this service is notably lower in Ethiopia.

Objective: To assess institutional delivery service utilization and associated factors among mothers who gave birth in the last one year prior to the study in the selected town, Ilu Abba Bora zone, south-west Ethiopia.

Method: A cross-sectional study was employed. Epi-Info version 7.2 and SPSS version 23 statistical software were used for data entry and analysis. Variables that were significantly associated at the 5% significance level (p-value ≤0.25) with the outcome variable were transferred to multivariate logistic regression for further analysis. An adjusted odds ratio with a 95% CI was used to examine the degree of association between independent and dependent variables. The level of significance at α ≤0.05 and p-value less than 0.05 was taken as the significance level for associations between independent variables and institutional delivery.

Result: Of the 304 study participants, 295 responded, for a 97% response rate. From the total study units, 161 (54.6%) were delivered at a health facility. Multivariate logistic regression revealed that women aged 30–34 years were twice as likely to utilize institutional delivery than those in other age groups (AOR [CI] = 2.56 (1.111, 5.858)). Women who had more than four antenatal care visits in a health facility were six times more likely to give birth at a health institution than their counterparts (AOR [CI] = 6 [0.002, 0.019]). Women whose antenatal care follow-up was at the hospital were twice as likely to deliver at a health institution than those women who didn’t visit any health institution during perinatal care (AOR [CI] = 2.31 [1.071, 4.98].

Conclusion: Generally, this study revealed that institutional delivery service utilization was low when compared with some findings from other literature, and factors associated with institutional delivery service utilization were age from 30-34 years, history of antenatal care with more than four visits, and antenatal follow-up at the hospital.

Globally, at least 160 million women become pregnant annually; of these, about two-thirds of births take place in health facilities. On the other hand, about 15% of them deliver at home and develop serious complications, which results in approximately 289,000 maternal deaths [3, 4, 5]. In developed countries, 97% of pregnant women receive antenatal care (ANC), and almost all (99%) births take place in health facilities, whereas in developing countries, only 52% of pregnant women had four or more ANC visits during pregnancy [4]. Each year, over 30 million women in the developing world suffer from serious obstetric complications, which include uterine prolapse, pelvic inflammatory disease, fistula, incontinence, infertility, and pain during sexual intercourse. Most of these complications result from the absence of care during delivery or the first few critical hours after delivery. Furthermore, these nations account for 99% (286,000) of the global maternal deaths, most of which result from home delivery. Hemorrhage and hypertensive disorders are the leading causes of maternal mortality in these countries, and they need advanced management in health institutions [4, 5]. In the last two decades, there has been a considerable increase in institutional delivery rates in South Asia. In Bangladesh, institutional delivery rates increased from 4 to 29% during the years between 1993 and 2011. Similarly, in India, institutional delivery rates increased from 26 to 79% in the years between 1992 and 2011, and in Nepal, from 8 to 35% in the years between 1996 and 2011. There are, however, substantial urban-rural disparities in the utilization of institutional delivery services. In Bangladesh, of the total number of women who utilized institutional delivery services in 2011, 49% were from urban areas and 23% were from rural areas. Comparative proportions were 71 versus 31% in India and 52 versus 15% in Nepal [3].

In most sub-Saharan African countries, the proportion of institutional births in urban areas is twice that in rural areas (76% versus 40%). Furthermore, this region has the lowest coverage (53% of skilled delivery service utilization). In Uganda, the proportion of mothers delivering at health facilities has been persistently low, and the rates are even lower in rural areas [1, 3, 4]. Most of the maternal deaths are preventable if deliveries are overseen by skilled personnel. To increase institutional delivery service, different organizations have developed strategic plans. For instance, to reduce maternal mortality, many scholars around the world participated in an international conference on population and development and planned to have at least 90% of deliveries attended by skilled health care providers by 2015. However, in developing regions, 40 million births were not attended by skilled health care personnel, of which over 32 million occurred in rural areas [4]. In Ethiopia, 34% of pregnant women received antenatal care from a skilled provider in 2014. However, only 10% of births were delivered by a skilled provider [6]. Giving birth in a medical institution under the care and supervision of trained health-care providers significantly reduces the risk of maternal mortality and improves maternal health. Despite the fact that some studies have been done to address this area of concern in order to improve institutional delivery service utilization in Ethiopia, there is still a clear research gap to address these particular problems in the Ilubabor Zone. This study aimed at to assess institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in the Ilu Abba Bora zone, south-west Ethiopia.

Study design and area

A cross sectional design was employed to undertake this study in the Ilu Abba Bora Zone in south-western Ethiopia. The capital city of this zone is Metu, which is located 600 kilometers southwest of Addis Ababa, which is the capital city of Ethiopia.

Population

All women who gave birth in the Ilu Abba Bora zone, south-west Ethiopia, were considered the source population, whereas the study population was all women who gave birth in the last 12 months in the selected Woreda.

Eligibility criteria

Women who gave birth in the last 12 months, regardless of the outcome, and lived in the study area for at least six months were included, and mothers who were severely ill and unable to communicate were excluded.

Sample size and sampling techniques

The sample size was determined by using a single population proportion formula with assumptions of institutional delivery service utilization of 10% that was taken from the 2011 Ethiopian demographic and health survey report.  The level of significance was 5% (α = 0.05), Z α/2 = 1.96, the absolute precision or margin of error was 5% (d = 0.05), and the design effect was 2. Finally, after adding 10% of the non-response rate, the total sample size was 304. From 13 woreda in Ilu Abba Bora Zone, eight woreda were selected using a simple random sampling technique. Similarly, from those selected, eight kebeles were selected using a simple random sampling technique. Then the sample size was proportionally allocated for each selected kebeles, and study participants were selected by a simple random sampling technique from each kebeles. The numbers of women who had given birth and their addresses were obtained from the selected health centers.

Variables of the Study

Dependent or outcome variable

Institutional delivery service utilization

Independent variables

Socio-cultural variables: address, age of the mothers, marital status, educational status of the mothers, religion, and ethnicity.

Obstetric Characteristics: Age at first marriage, parity, pregnancy outcome, visiting health facility, frequency of ANC visits, place of ANC visits, last pregnancy plans, Information about pregnancy and delivery complications, information on the place of delivery, and types of health facilities for delivery.

Operational definitions

Skilled birth attendant: people with midwifery skills (doctors, midwives, and nurses) who have been trained in the skills necessary to manage normal delivery, diagnose, and refer obstetric complications

Institutional delivery is a delivery that takes place in any medical facility owned by skilled delivery assistance.

Data collection tools, procedures and quality control

Data was collected with pre-tested structured questionnaires that were adapted from a study conducted in Mizan Aman town [1]. The pretest was conducted at Metu Town 01, Kebele. The questionnaire was translated from English into Afan Oromo and back to English by language experts to check for consistency. The questionnaire consists of socio-demographic characteristics of the respondents, obstetric factors, information about last delivery, and knowledge on pregnancy and delivery. Health extension workers were used to collect data. One midwife was assigned to supervise the data collection process. Both the data collectors and supervisors were given three days of intensive training before the actual work about the aim of the study, procedures and data collection techniques, the art of interviewing, ways of collecting the data, and clarification.

Data Analysis

The collected data was cleaned for inconsistencies or missing values, coded, and analyzed using Epi-Info version 7.2 for data entry and SPSS version 23 statistical software for data analysis. Tables, proportion, cross-tabulation, odds-ratio, means, and frequency were used to describe the data. The model diagnostics for regression were carried out to check the assumptions. Bi-variable logistic regression analysis was used to assess the association between factors (independent) variables and outcome (dependent) variables. Furthermore, variables that were significantly associated with a 5% significant level at a p-value ≤0.25 with the outcome variable were transferred to multivariable logistic regression for further analysis. Furthermore, an adjusted odds ratio with a 95% CI was used to examine the degree of association between independent and dependent (outcome) variables. The level of significance at α ≤0.05 and p-value less than 0.05 was taken as the significance level for associations between independent variables and institutional delivery.

Socio-demographic characteristics

From the 304 study participants, 295 responded, for a 97% response rate. From the total number of participants in the study, 114 (38.6%) of the respondents were 25–29 years old, 100 (33.9%) were 20–24 years old, 67 (22.7%) were 30-34 years old, and 14 (4.7%) were within 15–19 years old. Two hundred twenty-eight (77.3%) participants were married, forty-one (13.9%) were divorced, and twenty-six were widowed (8.8%). Regarding the educational status of respondents, 83 (38%) attended primary education, 25 (8.4%) were unable to read and write, and 53 (53.3%) attended secondary school and above (Tab 1).

Table 1: Sociodemographic characteristics of respondents who gave birth in the last 12 months, 2018 (n = 295)

Obstetric Characteristics of Respondents

Of the total study participants, 141 (47.8%) were married at 15–19 years, 117 (39.7%) at 20–24 years. 35(11.9%) at 25-29 years and 2(.7%) were married at 30-34 years old. One hundred five (54%) study respondents delivered two live births, seventy-nine (79%) delivered one live birth, sixty-one (32%) respondents delivered three live births, twenty-eight (28%) delivered four, and twelve (6%) participants delivered four live births. Two hundred seventy-five (93.2%) had no history of abortion, nineteen (6.4%) had aborted once, and one (0.3%) had aborted twice. Two hundred eighty-two (95.6%) had no history of stillbirth, and thirteen (4.4%) had given stillbirth once. From the total study units, one hundred ninety-one (64.7%) had visited a health facility during their last pregnancy. One hundred seven (66.5%) participants were delivered in a health center, and fifty-one (31.7%) participants were given birth in a hospital (Table 2).

Table 2: Obstetric characteristics of respondents who gave birth in the last 12 months, 2018 (n = 295)

Factors Associated with Institutional Delivery Service Utilization

In this study, women’s educational status (secondary school (COR[CI]=3.14[0.18, 0.55]), women’s age (30-34 years (COR[CI]= 3.25[1.73, 6.14]), women’s age at marriage (25-29 years (COR[CI]=2.337[0.143,.792]), visit health facility for ANC (COR[CI]= 3.5[0.005, 0.032]), place of ANC visits (hospital (COR[CI]= 3.49[1.471, 8.289]), both hospital and health center (COR[CI]= 2.38[0.722, 7.905]) and frequency of ANC visits (more than four (COR[CI]= 1.33[0.162,.689]) were significantly associated at p-value of 0.25 with confidence interval of 95% in bi-variable logistic regression and were transported to multivariable logistic regression. Finally, multivariable logistic regression revealed that women’s age between 30-34 years (AOR [CI] = 2.55 [1.111, 5.858), having above four ANC visits in a health facility (AOR [CI] = 6 [0.002, 0.019]), and place of visit at a hospital (AOR [CI] = 2.31 [1.071, 4.98]) were significantly associated with institutional delivery at a p value of 0.05 and a 95% confidence interval (Table 3).

Table 3: Bivariate and multivariate analysis of factors associated with institutional delivery service utilization, 2018 (n = 295)

The result from this study shows that institutional delivery service utilization was 54.6%. This finding is slightly lower than the findings from research conducted in Kometa Sub-Locality, Mizan-Aman Town, which revealed that the percentage of institutional delivery was 66.50%. This variation might be due to differences in population homogeneity. Similarly, this finding is significantly lower than the finding from the study done in Jimma, which was 86.4%. This might be as a result of the intervention provided regarding awareness of intuitional delivery service utilization by academic institutions and local government in Jimma Zone. Furthermore, the result from this research was lower than the result from research conducted in India, which was 63%. This variation may be associated with the development level and educational status of each country. On the other hand, this result is higher than the findings from Nepal and Tanzania, which were 41.2% and 46.7%, respectively. This might be due to the commitment and strategic plan of the Ethiopian government toward the reduction of maternal mortality [8, 9, 10, 12, 14, 33, 34]. In this study, those with an age group between 30-34 years were twice as likely to give birth in a facility than those with other age groups. This finding is consistent with the findings of a study conducted in the north Gondar zone, where institutional delivery was associated with women’s ages 30-34. Furthermore, this finding is also supported by a study conducted in the south Tigray Zone [17, 19].

Additionally, those women who had more than four ANC visits were six times more likely to give birth in a health facility than those who had not had an ANC visit. This finding is in line with the study findings from the north Gondar zone and the south Tigray zone. This might be due to similarities in maternal health provision policies since both are managed by the same ministry of health, which provides similar health packages. Similarly, this result is also supported by study findings from India and Mali. This might be due to a similar maternity model applied in developing counties [19, 23, 24]. Finally, mothers who had an ANC visit at the hospital were twice as likely to give birth in a health facility. This may be due to variations in staff knowledge at each facility.

Generally, this study revealed that institutional delivery service utilization was low when compared with some findings from other literature and factors associated with institutional delivery, age from 30-34 years, history of antenatal care more than four visits, and hospital visit for antenatal care follow-up was significantly associated with institutional delivery service utilization.

The local government of the Ilubabor zone, Mattu University, and other stakeholders should actively participate in educating mothers to create awareness about ANC utilization. Additionally, this responsible organization should encourage and facilitate ANC follow-up to be provided in hospitals, and attention should be given to mothers aged less than 30 and above 35 years.

The sample size used in this study was small, which may threaten the internal validity of this study and may be considered a limitation.

ANC: Antenatal Care

EDHS: Ethiopian Demographic and Health Survey; FDG: Focus Group Discussion

FMOH: Federal Ministry of Health; 

HEWs: Health Extension Workers

MDG: Millennium Development Goals 

MMR: Maternal Mortality Ratios

PPH: Post-Partum Hemorrhage 

SBAs: Skill Birth Attendants 

SSA: Sub-Saharan Africa

TBAs: Traditional Birth Attendants

TTBAs: Trained Traditional Birth Attendants

WHO: World Health Organization

Ethical Approval

The study was conducted following the 2013 revised Declaration of Helsinki, and ethical clearance was obtained from the ethical review committee of Mattu University. A letter of permission was obtained from the midwifery department. Participants were informed about the purpose, risks, and benefits of the study and were invited to participate. Confidentiality was kept to the utmost, all related queries were responded to, and they provided written informed consent for participation.

Availability of data and materials

The data sets used and examined in this study are obtainable from the corresponding author upon sound request.

Competing interests

The authors state that they have no competing interests. 

Acknowledgments

The authors are grateful to Mattu University for providing ethical permission to undertake this study.

Annex I. Information Sheet

Introduction

I am working as a data collector for the study being conducted in the Ilu Abba Bora zone for our kebele. I kindly request that you offer me your attention to explain the study and be selected as the study participant. The title of this study is the study on institutional delivery utilization and associated factors in the Ilu Abba Bora Zone.

Benefit: There would not be any direct payment for participating in this study. But findings from this research may be important for planners and the community to identify problems and reduce or prevent maternal mortality at large. 

Confidentiality: The information that you provide will be confidential. There is no information that will identify you. The findings of the study will be general for the study population and will not reflect anything particular about individual persons. The questionnaire will be coded to exclude showing names; no references will be made in oral or written reports that could link participants to research.

Rights: Participation in this study is fully voluntary. You have the right to declare to participate in this study or not to participate from the beginning, or to stop at any time after starting participation. However, we hope you will answer the questions, which will benefit the services you provide the nation.

Table 4: Sociodemographic characteristics of respondents

Table 5: Obstetric factors