Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of Ethiopia: A community - based cross sectional study

Community-based cross-sectional study was conducted during the month of August, 2010 in Sekela District. Sekela District is one of the 138 districts of Amhara Region. It is found in West Gojjam Administrative Zone. The capital of Sekela is Gish Abay. It is located 175 km and 460 km far from Bahir Dar and Addis Ababa which are capital cities of the Amhara Region and Ethiopia, respectively. According to CSA 2007 census result, the district has a total population of 138,652; with sex ratio of 1.01:1. The number of child bearing women (15–49 years) is 28,544 [13]. The prevalence of any method of family planning methods in the district is 37%. About 90% of the population of the district are rural dwellers. In the district, there were five currently functional and three developing Health Centers. There were 119 health workers in the District with only two midwives in the district. In addition, 27 health posts were found with a total of 61 Health Extension Workers (HEWs). Since HEWs were not trained on delivery services, they were not allowed to assist delivery based on the current policy of the country [14].

Childbearing women who gave birth in the last 12 months in the District, regardless of their birth outcome, were included in the sample. The required sample size of eligible mothers for the study was determined using the formula to estimate single population proportion. The following assumptions were made while calculating the sample size. A 95% probability of obtaining the population proportion of mothers who gave birth at the health institutions within 4% margin of error and population proportion of mothers who gave birth at the health institutions assumed to be 7% taken from National Baseline Assessment for Emergency Obstetric and Newborn Care Ethiopia in 2008 [4]. Using the Statistical Package Epi_Info version 2000 and considering a design effect of 2 owing to the use of multistage cluster sampling [15, 16], the required size was 314. Expecting a 15% non response rate, the final sample size was calculated to be 371. Two stage cluster sampling technique was used to select the study units. Initially, the study area was divided into two clusters, urban and rural Kebeles^b. There were two urban and 27 rural Kebeles during the study time. One urban Kebele and four rural Kebeles were selected using lottery method. On the selected five Kebeles house-to-house visit was carried out to identify households with eligible women and 819 households were found fulfilling the eligibility criteria. Households from each kebele were selected again by systematic random sampling with a sampling interval of 2 using list prepared during the house to house visit. If the houses were closed or the mothers were not present at the time of data collection, frequent visits were made until we could communicate them throughout the data collection. The next houses were considered in place of the houses which could not be accessed for collecting mothers’ data regarding institutional delivery service utilization. If there were more than one mother within the same household lottery method was used to select the one to be included in the sample.

Data were collected on mothers’ age, marital status, place of residence, family income, educational status, occupation, educational status of the husband, occupation of the husband, age difference between the mother and the husband, institutional delivery service utilization, distance from health facility, family size, communication media possession and obstetrics variables such as age at first pregnancy, ANC visit, parity, gravidity, history of abortion and still birth, knowledge and attitude of the mother towards the ANC and delivery services in health facilities.

Structured and pre-tested questionnaire was prepared first in English and then translated into Amharic, the local language. Six Health Science College Students had conducted the face to face interviews and two nurses had supervised the data collection process. Training was given to the data collectors and supervisors before the actual data collection regarding the aim of study, and data collection tool and procedures going through the questionnaires question by question. In addition, the training also focused on the art of interviewing and clarifying questions that were unclear to the respondents. Data collectors were peer interviewed.

Collected questionnaires were checked visually for completeness, coded and entered into SPSS version 16.0 software package. Frequency run and double data entry on 10% of the questionnaires were performed to check data entry errors. Binary and multiple logistic regressions were run to assess the putative associations of various factors with institutional delivery service utilization. The results were presented in the form of tables, figures and summary statistics. The strength of association of predictor variables with institutional delivery service utilization was assessed using odds ratio with 95% confidence interval.

Ethical clearance was obtained from Institutional Review Board (IRB) of University of Gondar. Permission to conduct the study was also obtained from the Regional Health Bearuo and Sekela District Health Office. Informed consent was obtained from each study participant. Each respondent was informed about the purpose of the study that the findings of the study will inform policy makers and other concerned bodies. Any involvement in the study was after their complete verbal consent was obtained. Mothers were also informed that all data obtained from them would be kept confidential by using codes instead of any personal identifiers.

A total of 371 mothers who gave birth in the last 12 months were interviewed; of these, 296 (79.8%) were rural and 75 (20.2%) were urban residents with 100% participation rate.

The mean age of the respondents was 27.41 ± 5.88 SD. Two hundred twenty seven (61.3%) of the mothers were in the age range of 20–29 years. Regarding their marital status, majority 338 (91.1%) and 17 (4.6%) of them were married and separated, respectively. Only 41 (8.9%) of the mothers attended primary and secondary education while 304 (81.9%) of the mothers were unable to read and write.

Economically, 97 (26.1%) of the households had monthly income of between 60–408 ETB and 93 (25.1%) had 694–987 ETB monthly income based on quartile classification. One hundred four (28.0%) of the respondents had radio and 27 (7.3%) had TV, and the other 64.7% did not possess media of communication. Concerning the time they travelled on foot to reach the nearby health center, 268 (72.2%) of them said less than one hour, 72 (19.4%) said between one to two hours and 31 (8.4%) said more than two hours. Two hundred fourteen (57.7%) of mothers had family size of 2–5 and 157(42.3%) had more than five individuals within the household [Table 1].

Two hundred ninety seven (80.1%) of the mothers became pregnant before the age of 20 years. The minimum and maximum ages at first pregnancy were 15 and 27 years with mean 18.2 years and ± 2.71 SD. One hundred eighty nine (50.9%) of the mothers were gravida two to four and 113 (30.5%) of them were gravida five and above, more than half of the respondents (52.8%) were between para two and four while 28.6% were parity five and above.

Before the last pregnancy, 167 (44.0%) of the respondents had ever visited health facilities during pregnancy and 248 (66.8%) of them visited health facilities for ANC purposes during their last pregnancy. Among the mothers who attended ANC, 165 (66.5%) of them visited health facilities two to three times [Table 2].

Of the total respondents, only 45 (12.1%) of them gave birth at health facilities and majority of them (87.9%) delivered at home claiming that home was best place for giving birth [Figure 1]. Out of those mothers who delivered at home, 274 (80.0%) were assisted by family members [Table 2].

Among those mothers who visited health facilities, the reasons for visiting health facilities during the last pregnancy included ANC services, delivery, problems related to pregnancy and problems not related to pregnancy [Figure 2].

Many different reasons were forwarded for home delivery. Two hundred twenty six (60.9%) of the mothers said having closer attention from family members, 214 (57.7%) said delivering at home is my usual experience, 124(33.4%) said labour was short/urgent, 80 (21.6%) said they did not have any problem to go to health facilities, and 52 (14.0%) said influence from family members and others [Figure 3]. Two hundred ten (56.6%) of the mothers scored more than the mean score on knowledge questions which were asked to assess mothers’ knowledge regarding ANC and delivery services at the time of the study. Similarly, 245 (66.0%) of the mothers scored more than the mean score on attitude questions regarding ANC and delivery services while the rest (126, 34.0%) scored less than the mean score [Table 3].

Regarding preference of the mothers about delivery place during their last pregnancy, 288 (77.6%) preferred to deliver at home, 70 (18.9%) preferred to give birth in health facilities with the assistance of skilled professionals, and 3.5% of the mothers preferred to deliver in their mother’s home. Similarly, 80.6% of their husbands preferred their wife to deliver at their own home, and the rest (19.4%) preferred their wife to deliver in health facilities.

As to the preference of the mothers about delivery attendant, 275 (73.1%) preferred to be attended by family members and 20.7% preferred to be attended by skilled birth attendants during their last pregnancies and 278 (78.3%) of their husbands preferred their wives to be assisted by family members while 18.9% of them preferred them to be assisted by skilled attendants. In line with this, majority (87.1%) of the family members and 88.7% of the community preferred mothers to deliver at home during their last pregnancy [Table 4].

On bivariate analysis, age of the mother, occupational status of the mother, educational status of the mother, distance from the nearby health center, residence, media of communication, monthly income, number of ANC visits at last pregnancy, gravidity, parity, knowledge and attitude of the mother, ANC visit during last pregnancy, husband’s educational status, husband’s occupational status and obtaining information about delivery place during ANC visit were the factors found to be significantly associated with institutional delivery service utilization [Table 5].

In the multivariable logistic regression analysis only residence of the mother, age at interview, educational status of the mother, ANC visit during last pregnancy and knowledge of the mother were found to be significantly associated with the institutional delivery service utilization [Table 6].

Mothers who were urban residents were about 5 times (AOR = 4.6, 95% CI = [1.91, 10.9]) more likely to give birth in health facilities than rural mothers. Mothers with age group of 15–24 years were 4 times more likely to deliver in health institutions than mothers with age group 35 and above (AOR = 4.4, 95% CI = [1.15,16.8]). Mothers with educational level of secondary and above were about 12 times more likely to give birth in health facilities than those with primary education and below (AOR = 11.98, 95% CI = [3.46, 41.4]). ANC visit during last pregnancy was also found to be a strong predictor of institutional delivery service utilization. Mothers who had ANC visit during pregnancy were 4 times more likely to deliver in health facilities than those who did not have ANC visit during last pregnancy (AOR = 4.26, 95% CI = [1.1, 16.4]). Mothers who were knowledgeable on ANC and delivery services were about 3 times more likely to deliver in health institutions than mothers who were not knowledgeable (AOR = 2.97, 95% CI = [1.1, 8.6]).

Health improvement strategies with a focus on increasing mothers’ knowledge and awareness about the services given, the benefits of these services, and complications related to pregnancy and delivery, should be designed and implemented. Skilled attendants at Health Post level should be trained and assigned to provide home delivery. As a short term solution, training all Health Extension Workers so that they could have some midwifery skills is highly recommended. Information, education, communication, and empowering mothers is essential, and could help them in decision making regarding their own health, being committed to use the services and able to persuade their partner and family members if they encountered opposition. Information on the complications of pregnancy and delivery and on the importance of using either the institutional delivery service, or skilled midwifery assistance in the home, at every childbirth should be given to every mother who came to health facility in general and at ANC visits in particular.”

The main strength of this study is that, being community based, it could reflect the actual experience of the mothers during the study period. However, the cross sectional nature of the study means that it cannot establish causal associations.