Background
Approximately 830 women die daily from pregnancy related causes globally [
1]. More than half of these deaths occur in sub-Saharan Africa [
2]. Majority of these deaths are due to direct obstetric complications [
2,
3] that can be prevented through early detection and intervention by a skilled healthcare provider [
1,
4]. Sadly, a significant proportion of women in low- and middle-income countries still give birth at home unattended to by a skilled health worker [
5].
The World Health Organization (WHO) recommends health facility-based childbirth as a key strategy to reduce both maternal and infant mortality, and yet less than half (48%) of childbirths in sub-Saharan Africa occur in a health facility [
6]. The remaining half of childbirths occur outside health facilities at home, on the way to the health facility, or at traditional birth attendants’ places that are often unsafe and unhygienic [
7]. This low utilization of health facilities during childbirth is likely a reflection of poor affordability and accessibility of health care services [
6]. In most low and middle-income countries, home childbirths are conducted by traditional birth attendants (TBAs) because they are cheaper and more readily available for childbirth. However, TBAs are not skilled providers, and are usually under-equipped and lack the appropriate technologies to handle critical birth-related complications, unlike in most health facility childbirths [
7].
Over the last two decades, Uganda has achieved a steady reduction in the maternal mortality ratio, currently standing at 336 deaths per 100,000 live births, with substantial variation across regions [
8]. However, the current maternal mortality ratio is still high as compared to the Sustainable Development Goals’ target of 70 deaths per 100,000 live births by 2030 [
9]. In a low-income country like Uganda, the chances of a safe childbirth are higher when the birth occurs in a health facility than at home or any place outside the health facility [
10]. Safe childbirth comprises supportive care, clean delivery practices, timely recognition and management of maternal and neonatal complications [
10].
Recent evidence on the determinants of health facility childbirths in Uganda using a nationally representative sample is lacking. Relevant Ugandan studies are either old or have focused on sub-national scope such as districts or regions [
11‐
14]. Mbonye et al. focused on institutional predictors of health facility delivery using data from 2010 national health facility survey [
15]. Rutaremwa et al. reported factors associated with a composite outcome - desirable maternal health care package which combined antenatal care (ANC), skilled birth attendance, post-natal care and health facility utilization during childbirth using the 2011 Uganda Demographic and Health Survey (UDHS). Rutaremwa et al. did not assess the predictors of health facility childbirth on its own [
16]. Another study by Micah et al. analyzed the 2009–2011 Uganda National Panel Survey data and reported community factors, albeit from a smaller sample size of 3310 [
1]. Understanding the determinants of health facility childbirth in Uganda is crucial for prioritizing and stratifying proven interventions that increase utilization of quality maternal health services. Our study aimed to establish the factors associated with utilization of health facilities during childbirth in Uganda.
Discussion
This study examined the factors associated with health facility delivery among Ugandan women. We found that almost 80% of the women gave birth in a health facility. This proportion is higher than national studies that have used similar DHS survey data in Kenya [
5], Indonesia [
25], Ghana [
26] and in other regional studies done in South Sudan, Kenya and Ethiopia [
2,
27,
28]. Studies that showed a lower proportion of health facility utilization during childbirth compared to our study were done earlier than our study (2011–2014) except Tongun et al. in South Sudan [
2]. The earlier studies reported lower proportions likely because health facility utilization during childbirth has been shown to increase with time. Furthermore, the differences in the health facilities’ access, health system capacity and economic development among these countries could also explain the observed differences. The significantly low proportion of health facility utilization during childbirth (25%, lowest in the region) shown by Tongun et al. in South Sudan could be attributed to the fact that the study was done when the country was experiencing insecurity due to the civil unrest, which negatively affected health facility access and led to destruction of infrastructure [
2]. South Sudan received independence from Sudan nine (9) years ago and it is still grappling with a weak health infrastructure and system.
Age, level of education, region, wealth index, residence, ANC attendance, religion, tribe, exposure to mass media and problems with distance to health facility were significantly associated with health facility delivery utilization. Younger women had higher odds of utilizing a health facility for childbirth compared to their older counterparts. Older women tend to have more traditional cohorts hence can easily resist modern health care services [
29,
30], and some tend to have a sense of having gained enough experience when it comes to childbirth, hence have less fear for negative pregnancy outcomes associated with delivery outside a health facility [
31,
32]. Age as a predictor of health facility utilization during childbirth has also been evidenced by other studies [
5,
29,
32‐
34]. Women with secondary and post-secondary education had higher odds of giving birth from a health facility compared to women with no education. Women with higher levels of education have been shown to be more receptive to new health related information, have better maternal health literacy and increased awareness of available health resources. They also seem to have better decision-making abilities, more financial resources and access to health insurance. Taken together, these factors have been shown to increase health facility-based deliveries [
2,
27,
29,
35]. With improved maternal health literacy, women become more informed about maternal health care issues which enables them to make positive health care decisions [
26]. Maternal education as a predictor of health facility utilization during childbirth has also been evidenced by other studies [
2,
26‐
28,
36]. Therefore, the government of Uganda needs to intensify girl-child education to at least secondary level and also improve or start maternal health programs targeting the less educated women.
The odds of women from the northern region utilizing health facilities during childbirth were three times those in the central region. This is a surprising finding because the central region is more advanced with a high concentration of health facilities and health care workers. However, our finding is similar to that of Rutaremwa et al. who analyzed the utilization of maternal health services with the 2011 UDHS data [
16]. Rutaremwa et al. using Kampala (the capital) as the reference showed that even if the other four regions were less likely to utilize maternal health services compared to Kampala, northern region had the highest likelihood of utilizing the desirable maternal health services package compared to the central, western and eastern regions [
16]. The differences in health facilities’ accessibility, sociocultural context and economic development could have contributed to the observed regional differences in utilization of health facility at birth [
16]. Following the civil war, the northern region has had many interventions and humanitarian aid mainly targeting maternal health services improvement [
37]. The other possible explanation could be that many people were residing in internally displaced peoples’ camps and these usually have health facilities provided freely near the camps [
37]. However, further research is needed to explore the increased utilization of health facilities at birth in northern Uganda. Region as a predictor of health facility delivery has been reported in studies done in similar contexts [
5,
16,
32].
Women belonging to higher wealth quintiles had higher odds of giving birth from a health facility compared to those in the poorest wealth quintile. Given that Uganda has free health care services [
18], our results suggest that, apart from the cost of health services, other economic factors influence the choice of place of delivery. This is consistent with findings from other studies, which have reported economic factors such as transportation costs, and miscellaneous fees paid for healthcare to influence the women’s decision regarding the place of childbirth [
26,
38]. Hence, there is a need for gaining a deeper understanding of how financial status influences women’s decision regarding choice of place of childbirth. Women belonging to the lower wealth quintiles are more likely to have difficulties in meeting transport and indirect costs related to childbirth in government facilities which prevents them from utilizing health facilities for childbirth [
2], and this is further worsened by the high costs of private health facilities [
9]. Wealth index has also been shown to be a predictor of health facility deliveries in previous studies done in Kenya, Ghana and South Sudan [
2,
5,
26,
27].
Urban women had higher odds of giving birth from a health facility compared to rural women. Urban areas usually have more and better health facilities than rural areas hence better access to healthcare [
25,
26,
39]. This proximity to health facilities in urban areas ensures better quality of maternal health services through quick referrals and easier use of multidisciplinary teams [
26]. In addition, women in urban areas are usually more financially stable, and have more access to media promoting good maternal health [
26,
39]. Place of residence has been shown in other studies done in Indonesia, Ethiopia, Nigeria, Kenya and Ghana to influence choice of place of childbirth [
5,
16,
25,
26,
39,
40]. With evidence of the association between residence and place of childbirth presented in the current, the government efforts should prioritize improving rural health services in Uganda.
Women who had attended antenatal care had higher odds of utilizing health facilities for childbirth compared to those who had not attended antenatal care. Visiting of health facilities for antenatal care ensures that women get health education sessions regarding the benefits of institutional delivery and creates rapport between the health workers and the pregnant women [
27,
41]. The health education and counselling sessions during antenatal care visits also ensures that women make birth preparedness and complication readiness plans which contributes to increased health facility utilization during childbirth [
36]. Antenatal care attendance has also been shown to be a predictor of health facility utilization during childbirth in studies done in similar contexts [
11,
27,
28,
36].
Women that belonged to other ethnic groups (Itesot, Langi, Banyankole, Bakiga, Bagisu and others) were had lower odds of utilizing health facilities for childbirth compared to Baganda. In addition, contrary to studies done in Nigeria, Ghana, Guinea and Bangladesh [
42‐
45] that showed Muslim women to have lower odds of utilizing health facilities for childbirth compared to Christian women, our study showed Muslims to have higher odds of using health facilities for childbirth. Religious and ethnic cultural values and norms have been shown to influence choice of the place of childbirth [
16,
42,
44‐
48]. Plausible explanations include differences in levels of literacy, empowerment, and autonomy among the different ethnic groups and differences in religious teachings and related preferences, and choices regarding the use of modern versus traditional medicine [
44,
45]. Rutaremwa et al. showed that some cultural norms make women to adhere to very traditional childbirth practices and believe that pregnancy is a test of endurance [
16]. Thus, in some Ugandan tribes, women are considered to be strong and independent if they can handle the childbirth process by themselves which discourages women from seeking professional maternity care and opt for childbirth outside health facilities [
16,
44,
46]. However, there is need for further exploration of the impact of ethnicity and religion on the place of childbirth in Uganda. Maternal health policy makers should consider systematic and deliberate involvement of tribal and religious leaders when formulating strategies to improve inclusive maternal health care.
Women who were exposed to mass media (radio and newspapers) had higher odds of having childbirth at a health facility compared to those who were not exposed. This finding is consistent with studies conducted in Bangladesh, Guinea and Eritrea [
42,
43,
49]. Mass media can promote healthy behavioral changes by frequently broadcasting programs and public service announcements that describe the benefits of health facility childbirths and other maternal healthcare services [
50]. This enables positive changes in women’s attitudes, social norms and behavior that may lead to increased utilization of health facilities for childbirths [
43]. Mass media also offer health information services such as announcements of locations and working hours of health facilities with free maternal healthcare services which encourage women and their partners to take practical action towards healthy behavioral changes [
50,
51]. The role of mass media in women’s choice of place of delivery calls for enhancement in easier and cheaper access to media.
The study results also indicated that women who had no big problems regarding the distance to the nearby health facility had higher odds of having a health facility-based childbirth compared to women who had big problems accessing health facilities. Distance to health facilities has been found to be an important determinant of place of delivery in other similar contexts [
1,
27,
49]. Since over 75% of the women in Uganda live in rural areas, proximity to a health facility is likely to affect use of the available services. Distance has a direct impact on the choice of the place of childbirth due to transportation challenges in terms of availability and affordability [
49]. Hence women who are unable to afford these costs will end up having home childbirths. Thus, concerned stakeholders need to explore sustainable solutions to health facility access barriers such as maternity waiting homes and construction of more maternal health facilities.
Strengths
Standardized procedures are a requirement of DHS surveys in data collection and validated questionnaires are used which ensures the internal and external validity of the results.
Secondly, we used the most recent nationally representative sample and weighed the data for analysis and therefore our results are generalizable to all Ugandan women aged 15 to 49 years.
Limitations
Most data on the predictors were based on self-reports and could not be verified through records given this was cross sectional study. This carries a risk of social desirability bias. Additionally, the data could be affected by recall and interviewer biases. However, we do not anticipate these biases to affect the observed estimates because our study was based on secondary data collected through the robust validated DHS surveys. Data on explanatory variables such as wealth, residence reflected the women’s conditions at the time of the survey and not at the time of childbirth and hence women may have moved from one category of classification into another. Whereas the possibility of the study participants crossing from one category to another exists, it does not affect the overall interpretation and implications of our findings, especially as there is an equal chance of backward movement as well.
Conclusion
Our study has revealed that health facility utilization during childbirth is higher relative to other countries in the East African region and it is associated with age, level of education, wealth index, residence, region, ANC utilisation, exposure to mass media, distance to health facilities, religion and ethnicity. The identified predictors act on both the supply and demand side for health care services, and thus emphasizes the significance of the social determinants of health as well as the need for programs/ interventions that focus beyond improving physical access. Rural areas should be targeted to address the barriers to health facility delivery. Implementation of proven interventions to improve utilization of health facility delivery should be tailored according to geographical regions and education level.
Given that Uganda has free health care services, the study showed that poorer women are less likely to utilize health facility delivery. Studies to evaluate different economic interventions targeting the poorer women are warranted. Taken together, it is recommended that in order to increase health facility deliveries in Uganda, maternal health programs should be promoted to target the poor, less educated and older women especially those residing in rural areas with limited exposure to mass media.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.