Background
Globally, maternal mortality has declined from 532,000 in 1990 to 303,000 in 2015 [
1], but the magnitude of maternal mortality remains major public health problems. Every day, about 830 women die from a preventable cause related to pregnancy and childbirth complications in the world. Almost all (99%) of maternal deaths occur in low-and-middle-income countries, 66% of which in Sub-Saharan Africa alone [
2,
3]. The 2016 Ethiopia Demographic and Health Survey (EDHS) reported that maternal mortality ratio (MMR) is estimated to be 412 deaths per 100,000 live births which was high among rural and non-institutional delivered women [
4].
Most pregnancy and childbirth complications are early preventable or treatable. Postpartum hemorrhage, sepsis, severe preeclampsia/eclampsia, obstructed labor, and unsafe abortion are accounted for 75 % of maternal deaths. Maternal mortality can be reduced through universal access to antenatal care, skilled care during childbirth, and postnatal care [
3]. Skilled birth attendants during childbirth in a hygienic environment with necessary skills and types of equipment are important to identify and treat complications, infections, and death of the mother, and child [
5].
The burden of home delivery is not only limited to a maternal health problem, but it also ends up with perinatal and neonatal morbidity and mortality [
6]. One of the key strategies for reducing maternal morbidity and mortality is increasing institutional delivery service utilization of pregnant women under the care of skilled birth attendants [
7].
Despite the continuous effort to encourage institutional delivery, many Ethiopian women still give birth at home. Improving the quality of antenatal care services is likely to contribute to rapid increases in skilled birth attendance and better health outcomes for women and children [
8]. In Ethiopia, 62% of women had ANC visits during pregnancy but only 26% of women gave birth in the health facility [
4]. Therefore, understanding the association between antenatal care utilization and institutional delivery services is of paramount importance to identify the potential role that ANC utilization plays in promoting institutional delivery. We hypothesized that ANC service utilization would be positively associated with institutional delivery among Ethiopian women.
Discussion
This study assessed the association between antenatal care follow-up and institutional delivery in Ethiopia. After adjusting age, distance from a nearby health facility, household wealth quintile, place of residence, exposure to media, birth order, educational level, and marital status, there was a significant positive association between antenatal care follow up and institutional delivery.
Compared to mothers who lived in rural areas, mothers who lived in urban areas were more likely to give birth in the health institution. This finding consistent with findings from other studies, including a recent systematic and meta-analysis in Ethiopia [
10], EDHS 2016 [
4], Further analysis of EDHS 2016 [
11], Ghana [
12] and India [
13]. In the urban areas, because of the higher accessibility of maternal health services near their home and availability of transportation, women in urban areas are more likely utilized institutional delivery. Moreover, rural women are more affected by cultural taboos concerning the place of delivery than urban areas.
Women with higher levels of education have a greater awareness of sexual and reproductive rights and greater autonomy to decide on their own [
12,
14]. This greater awareness may translate into more effective health-seeking behaviors and utilize hospital-based care. Furthermore, more educated women can communicate and understand information’s regarding institutional delivery, and identify danger signs easily. In this study, mothers who completed primary, secondary or higher education had higher odds of institutional delivery service utilization compared to mothers with lower educational attainment. This study supported by those of other studies from systematic and meta-analysis in Ethiopia [
10], developing countries [
15], Ghana [
12] Uttarakhand [
16], and India [
17].
The odds of institutional delivery service utilization were higher among mothers with a poorer, middle, and richer wealth quintile compared to the poorest mothers. The finding was in agreement with the previous studies other developing countries [
15], Ghana [
12], Uttarakhand, and India [
17]. The cost may help women to cover transportation and other expenses to bring and keep families at a health facility. Moreover, mothers who want to give birth in a private health institution needs to cover the cost of the service they need.
Finally, in this study, there was a significant association between antenatal care follow up and health facility delivery. The odds of institutional delivery service utilization higher among mothers who had ANC follow up one to three times and four or more times compared with mothers who had not ANC follow up during pregnancy. These results consistent with findings from other studies in Ethiopia [
18], Nigeria [
19], other African countries [
20] and Nepal [
21]. Antenatal care provides information for mother’s and her families on birth preparedness and complication. This can be an opportunity to promote the benefit of skilled attendance at birth and hospital-based delivery.
Strength and limitations
The main strengths of the study are the use of large national probability samples and the availability of several confounding variables for adjustment in the multivariable regression model. Additionally, data were collected using a standardized questionnaire with rigorous procedures to check for data quality. However, as a cross-sectional study, the observed association between antenatal care use and institutional delivery should not be interpreted as causal. Additionally, this finding is may prone to recall and socially desirability bias because of exposure to media, distance from the nearby health facility and history of antenatal care data was collected based on self-reporting of participants.
Conclusion
Increasing number of antenatal care use follow-ups was positively associated with institutional delivery service utilization. Thus, adherence to the recommended number of ANC follow up during pregnancy for all pregnant mothers is strongly recommended to improve the utilization of institutional delivery and prevent mothers and children from birth complications. Moreover, encouraging women through education and accessing maternal and child health services is recommended to increase institutional delivery service utilization.
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