Home delivery among antenatal care booked women in their last pregnancy and associated factors: community-based cross sectional study in Debremarkos town, North West Ethiopia, January 2016

Antenatal care is complex of interventions that a pregnant woman receives from related health care services to prevent, identify and treat complications and as well help a lady approach pregnancy and birth as positive experiences [1]. Antenatal care, skilled personnel attended delivery and postnatal care services have a crucial role in the reduction of both maternal and perinatal mortality, also they were indicators of progress toward achievement of fifth MDGs and currently also included under third SDGs. Levels of antenatal care have increased in many parts of the world, though only 46% of low-income countries benefited from attended delivery. Skilled attendant at delivery is advocated as a single most important factor to prevent maternal mortality [2, 3].

Every day over 800 maternal deaths occur worldwide, and 99% of this death is occurring in developing countries secondary to preventable causes, making maternal mortality the health statistic with the largest inequality between developed and developing countries [4]. These high maternal mortalities occur due to various direct and indirect causes, which indicate poor-quality maternal health care [5‐7]. Since the launch of the motherhood initiatives, maternal mortality was taken as social injustice and health disadvantages. This consensus raised the attention and commitment of providing accessible and high-quality maternity care, even though the problem still needs more attention [8].

Although safe motherhood service has been on implementation for about three decades, overall global maternal mortality ratio was decreased from 422 in 1980 to 251 in 2008 and to 210 per 100,000 live birth in 2013 [9, 10], yet average annual reduction in Africa (1.6%) and sub-Saharan African (SSA) (1.7%) region was slowest of all other regions [11, 12]. In SSA, the burden of low-skilled birth attendant has been significant. In this region, 70% of births from poorest women occur at home and among this 56% of them were unattended [13].

Ethiopia is also among countries from which high maternal mortality has been occurring. Joint report of the maternal mortality estimates from WHO and UNICEF identified a reduction of maternal mortality to 420 per 100,000 live birth with a very wide confidence interval from 240 to 720. Antenatal care coverage at least one time and at least four times remain low even though there were encouraging improvement from 27 and 10% in 2000 to 42 and 19.1% in 2011 consecutively. The 2014 report of Central Statistical Agency revealed as Antenatal Care coverage reached 57.2% (at least one time) and 31.6% (at least four times), while the proportion of births attended by skilled health personnel improving slowly from 10% in 2011 and 14.5 in 2014 [5, 14, 15].

This discrepancy between ANC coverage and the skilled attendant at birth clearly indicates whatever women get ANC services, enormously they prefer or forced to choice home or unattended delivery. Comparative descriptive analysis demonstrated high gap between the proportion of antenatal care utilization and institutional delivery by the same individuals, which ranges 27–95% verses 4–45% [3].

The burden of home delivery, mainly that of unattended delivery is not only limited to a maternal health problem, rather it also ends up with perinatal and neonatal morbidity and mortality. Perinatal mortality found to be 21% higher in home delivery as compared to institutional delivery in SSA [16]. The opposite is true in developed country, there was no significant difference between home delivery and hospital delivery regarding perinatal or neonatal mortality, where midwives provide both hospital and home care [17].

Various reviews from a different part of the world reported factors affecting utilization of ANC service and place of delivery [18], but there was no adequate literature which answers about the reason that ANC booked women prefer home delivery or forced to do so in the study area as well in the country. This study was aimed to determine the proportion of home delivery and tried to explore factors determining home delivery among antenatal care booked women.

A total of 502 women who had booked for antenatal care visit for their last pregnancy and gave birth within 1 year prior to the survey were interviewed which makes response rate of 96.9%, while the remaining 16 selected samples were not present at home during data collection and considered as none respondents after three continuative re-visit.

This study was aimed to assess the proportion of home delivery and associated factors among ANC booked and gave birth in the last 12 months preceding survey. It is reasonable to assess proportion and associated factors of home delivery among ANC utilized individuals in an urban community where having more infrastructures in healthcare facilities than rural areas, and thus, usage of institutional delivery is expected to be high.

The result of this study revealed that 127 (25.3%, with 95% CI [21.6, 28.7]) of total respondents were given delivery at home. The proportion of home delivery in this study is lower than 2011 EDHS (76.25% National and 89.3% of Amhara region) and study done in Fogera district of Northwest Ethiopia which was 68.4% of total participants. This large difference could be due to the difference in residency, as most of the participant in those studies were residents from rural [21, 22].

The magnitude of home delivery in this study is also lower than the result of a study done 4 years back in the same setting on the preference of place of delivery in which 37.7% of them delivered at home. It is also lower than studies done in other parts of Ethiopia [22‐30] which could be because of time and study subjects’ difference as these studies included individuals who did not have antenatal care follow up which is one of the most known predictors of home delivery. A lot of contributions had been made to change the awareness of women’s and communities’ on the utilization of institutional delivery which might result in this decreased home delivery than these mentioned studies. It might be due to the fact that most of the respondents and majority (86.2%) of their family believed in the necessity of institutional delivery in this study.

It is also lower than studies done in other developing countries like Kenya [31], Tanzania [32], Ghana [33], Nigeria [34], Nepal [35], this might be due to presence of a difference in the health service delivery system, socio-cultural difference, economic or study setting difference.

It is consistent with a study done in Bahir Dar city administration and another African country like Nigeria and Senegal. This might be because the majority of the respondents were from urban and ANC booked [36‐38].

In another study from Nepal [39] proportion of home delivery (15%) was lower than this study, which might be because of difference in study design. The study from Nepal had a nature of follow-up in which participants were asked about their preference of place of delivery, which could have imposed them to had more institutional delivery than home.

Educational status of the responding women and husband was reported as a determinant factor to home delivery from the vast majority of studies done both in our country and abroad [21‐30, 34, 40, 41]. The result of this study also supports those findings as being uneducated was significantly associated with home delivery. Mothers who did not have any formal education were seven times (AOR = 7.56, 95% CI: [3.28, 17.44]), more likely to deliver at home than those educated to secondary and above educational levels. Education is a major key strategy to enhance health care service utilization. However, if there is no universal access to education it would be the big gap between educated and not in understanding the difficulties of laboring and childbirth as well complications related to unattended delivery. Being educated increase the awareness of preventive health care services and the receptive ability for new information. Education could also enhance women autonomy which enables them to discuss and determine on the place of delivery. Due to these facts, women who did not attend any formal education ended up with home delivery than their counterparts.

Media exposure was also another determinant of home delivery with four times (AOR = 4.46, 95% CI: [2.09, 9.49]) likelihood of delivering at home among not exposed group than exposed ones. This is in line with the studies done in Gondar and Holeta. This could be due to the fact that individuals whom having media exposure had the ability to attend the awareness information on the importance of institutional delivery. Media also have the ability to change attitudes women and communities used to have on home delivery, as a result individual who not exposed to any source of media might be continued having home delivery more likely than those who exposed [23, 40].

Distance to the nearest health facility is also found to be associated with home delivery which was also reported from Jimma [42]. Individuals who lack geographic access to a health facility within a 30 min distance from women’s home were three times (AOR = 3.41, 95% CI: [1.42, 8.20]) more likely to have home delivery than their counterparts. Presumably the shorter the distance to the health facility the easier it is for a woman to get there, even if she has to walk. Pregnant mother’s effort to travel on foot even when alternative traveling means is absent could be higher when the distance to a nearby health facility is shorter. Walking more kilometers is difficult in labor and it worse if the labor starts at night and very urging as most of the respondents gave it as a reason for home delivery.

Individuals who unplanned their last pregnancy had three (AOR = 3.47, 95% CI [1.82, 6.61]) times likelihood of delivering at home than those who had planned their last pregnancy. Planning to have child needs mental, psychological and financial readiness. If one planned to have a child it means that this person fitted with these necessities. Again planned pregnancy indicates the presence of support person either the husband or partner. So as the pregnancy was planned and supported the probability of seeking institutional delivery increases. As a result, the likelihood of having home delivery could increase as one had unplanned pregnancy.

Institutions, where ANC was attended, was also found to be one of the predictors of home delivery. Having ANC attendance at health post were five times (AOR = 5.45, 95 CI: [1.21, 24.49]) more likely to deliver at home than whom attended at the hospital. Similarly, women who attended ANC at health center were three times (AOR = 2.74, 95% CI [1.29, 5.82]) more likely to deliver at home than those who attended ANC at the hospital. Most of the health care providers in health center are midlevel educated and lack vast of experience, which might have helped them in counseling during antenatal care on the place of delivery. Though more investigations are needed, lack of experience, the absence of specialized health personnel in health post and health center and quality of ANC might be related to increased odds of home delivery.

Perceived lack of privacy during ANC increases the odds of home delivery four times than (AOR = 3.69, 95% CI: [1.25, 10.91]) who believed that they had been possessed privacy while ANC. It is in line with a report from Fogera district [20]. This might be because individuals who perceived a lack of privacy during ANC expect the same while they revisit health facility for childbirth. This could be also due to the fact that most of the respondents who perceived lack of privacy reported that they fear to expose their reproductive organs during delivery.

Similarly, as reported from other studies [20, 33, 39‐41], increments in a number of ANC visit will result in less likelihood of delivering at home. Individuals who did not complete recommended four visits were five times (AOR = 5.04, 95% CI (2.30, 11.04]) more likely to deliver at home when compared to those who had four and more ANC visits. This might be because number of the visit will increase the chance of having more awareness on the importance of institutional delivery. It also creates good opportunity on increasing counseling mothers got from health professionals which have great ability in minimizing home delivery. In addition, mostly practiced timing of advice on birth preparedness, especially on the place of delivery is in later gestational age and with increased number of visit.

The proportion of home delivery in this study among women who were booked for antenatal care and gave childbirth within 1 year prior to survey time was found to be low. Un-attending formal education, presence of health facility within 30 min distance on foot, none exposed to media, unplanned pregnancy, attending antenatal care at health post and health center, perceived lack of privacy during antenatal care and antenatal care visits less than four times were factors found to be associated with home delivery significantly.

All concerned stakeholders need to take actions to alleviate the presenting problem by increasing educational opportunity for all women, enhancing geographic access to a health facility, awareness creation on the importance of media and utilization of family planning services in order to decrease home delivery for antenatal care booked women. The quality of antenatal care at health post and health centers has to be measured as individuals who received antenatal care at these facility tends to have more home delivery. In addition, there have to be strategies in which a number of antenatal care visit could be raised.