Utilization of skilled birth attendant at birth and associated factors among women who gave birth in the last 24 months preceding the survey in Gura Dhamole Woreda, Bale zone, southeast Ethiopia

The study was conducted Gura Dhamole woreda which is found 557 km away from Addis Ababa and 125 km East of Robe town, the Capital City of the Bale zone. Gura Dhamole is one of the pastoral woreda’s in Bale Zone and the woreda is bounded by Madda Walabu woreda in northeast, Barbare woreda and Somale regional state in East, Goro woreda in southwest and Dawe Kachan woreda in the southeast. The woreda have 2 urban and 15 rural kebeles. The total population of the woreda is estimated to be 37,918 according to 2016 population estimation based on Ethiopian national census of 2007. From this 8391 are women of childbearing age, 1316 are pregnant women. Regarding the health infrastructure, the woreda have 3 health centers and 14 health posts. Thirty skilled health professionals; 6 health officers, 9 diploma mid-wife nurses and 15 clinical nurses are working in the woreda [8].

A community based cross-sectional study was conducted to assess the magnitude of skilled birth attendant utilization and to identify associated factors that were assumed to be barriers/facilitator to skilled birth attendant utilization among mothers who gave birth in the past 24 months in Gura Dhamole Woreda, Bale Zone, Oromiya Regional State, Southeast Ethiopia. The source population was all women who gave birth in the last 24 months prior to the survey in Gura Dhamole. Those women who gave birth in the last 24 months prior to the study irrespective of the outcome of the birth and place of delivery in six randomly selected kebeles were the study population. Those women who were permanent residents (those who lived more than 6 months) of randomly selected kebeles and sampled household and who gave birth from March 25, 2015 to April 24, 2017 were included in the study. Those women who were mentally and physically sick and unable to respond to interview and women who lived for less than 6 months in study area were excluded from the study.

The sample size was determined using single population proportion formula, assuming SBA utilization of Oromiya Regional state of 19.7% [9], 95% level of confidence, 0.05 margin of error and 1.5 design effect was used since multi stage sampling technique was used and 10% was added non response rate and the final sample was 402 women who gave birth in the last 24 months.

Multistage sampling method was used to select respondents. First the study area was stratified into urban and rural kebeles. There were 15 rural and two urban kebeles in the woreda. From 2 urban and 15 rural kebeles, one urban and five rural kebeles were selected by lottery method.

House-to-house visit was carried out in selected kebeles to identify households with women who gave birth in the last 24 months prior to the survey and 904 households were identified fulfilling eligibility criteria. By allocating the sample size proportionally to each kebeles, using the list household as a sampling, systematic random sampling was used with a sampling interval of two. If the houses were closed or the mother was not present at the time of data collection, revisits were made until data collector got the women for the data collection. However, the next household was considered in case eligible women could not be accessed. When there were more than one eligible woman in the selected household, lottery method was used to select the one to be included in the study.

The dependent variable is utilization of skilled birth attendance. And independent variables were socio demographic characteristics (age and place of residence), socioeconomic factors (educational status of respondent and husband, occupation, family size, monthly income and communication media ownership), obstetric factors (age at first marriage, gravida, para, history of abortion and/ or still birth, pregnancy status, antenatal visit, counseling, place of delivery, birth preparedness, delivery attendant and duration of labor), husband’s factors (educational status and occupation), Knowledge of mothers on key danger signs of pregnancy/childbirth, infrastructure and health service related factors (availability, travel time, cost for service and ambulance service) and decision making on place of delivery. Utilization of skilled birth attendance was assessed by asking the mother if she gave the last birth at health center or hospital.

For the purpose of better understanding of readers the following terms and phrases were operationally defined for the current study.

Data was collected through face-to-face interview using pre-tested structured questionnaire developed after reviewing relevant literatures [10‐12] in English and translated to local language, Afan Oromo and back translated to English to check its consistency. The questionnaire had five parts; those were socio-demographic characteristics, obstetric history of respondents, knowledge and attitude of mothers on pregnancy and labor/childbirth, Reinforcing factors and enabling factors and maternity waiting area usage. Six data collectors who were outside of the study areas were recruited and trained on the face-to-face interview. Additionally the supervisor was trained on how to supervise the data collection process.

To ensure data quality the questionnaire was translated into local language of study area i.e. Afan Oromo, for better understanding among data collectors and respondents. Pre-tested was done on 20 women at Funale Kosii kebele (outside of selected kebeles). Findings and experiences from the pre-test was used in modifying the questionnaire. Training was given to the data collectors and supervisors for two consecutive days before the actual data collection regarding the aim of the study, questionnaire and procedures of data collection.

The data collection process was supervised by the investigator and supervisor. The investigator and supervisor randomly revisited some of the households; checked if the eligible women were interviewed using systematic sampling technique from list of eligible women prepared during house-to-house visit. Data collectors were made to check questionnaire for completeness before leaving the participant and the supervisor and investigator reviewed each questionnaire on daily basis and checked for completeness. Those questionnaires found to be incomplete were completed by revisiting the household.

The data was coded and entered into SPSS windows version 20.0 statistical software by investigator. Then, the entered data was cleaned for errors prior to data analysis. Frequencies were used to check for missed values and outliers during analysis. Any errors identified were corrected after revision of the original data using the code numbers given to each questionnaire. The descriptive analyses such as percentages, measures of central tendency were conducted. Statistical association between dependent variable and covariates was done using logistic regression. Significance was determined using crude and adjusted odds ratios with 95% confidence intervals. To assess the association between the different factors variables of skilled birth attendant utilization with the dependant variable (Use of SBA), first relationships between each independent variable and dependent variable was investigated using a binary logistic regression model. Those independent variables that have association with use of SBA at the bivariate level at P < 0.05 were included in a multivariate logistic regression model, after controlling the possible effects of confounders and variable that had significant association were identified by calculating odds ratio with 95% confidence interval and those independent variables with P- value < 0.05 were declared statistically significant.

The proposal was approved by Madda Walabu University Goba Referral Hospital department graduate committee for ethics. An official letter was written from the Madda Walabu University Goba Referral hospital department of public health to Gura Dhamole woreda health and administrative office to seek cooperation.

During data collection respondents were informed about the objective of the study and procedure of selection as well as assured that their response will be kept confidential and their names were not registered; only code was used to identify the respondent’s response to minimize social desirability bias and assure confidentiality. Participation in the study was on voluntary basis and informed verbal consent was obtained from each study participants before actual data collection and participants were informed that they have the right to withdraw from the interview at any time without restriction of any of their benefits and this was approved by ethical review board of Madda Walabu University. In this study there are no minors aged less than 16 years participated.

In this study 268 (69.3%) of the respondents have got first marriage before the age of 18 years with mean age of first marriage 16.48 years (±2.01 SD). Three hundred twenty five (84%) of respondents have got their first pregnancy before the age of 20 years. Sixty six (17.1%) and 36 (9.1%) of the respondents had history of abortion and still birth respectively. One hundred twenty three 123 (31.8%) of women gave birth at health facilities for the last child birth. Majority of respondents, 264 (68.2%) delivered at home without assistance from skilled birth attendant (Table 2).

Seventy six (19.6%) of the respondents had experienced adverse pregnancy and child birth outcome at their last child birth. The complications mentioned were vaginal bleeding 21 (27.6%), prolonged labor 31 (40.8%), retained placenta 34 (44.7%), increased blood pressure 10 (13.2%) and others 1(1.3%).

The reasons respondents gave for institutional delivery were better service in health facility 96 (78%) and safe for the mother and child life 89 (72.4%) (Fig. 1). Among women who delivered at home, 101 (38.3%) were assisted by Traditional Birth Attendants (TBA), no one or without any assistance 72 (27.3%), mother 52 (19.7%), family 49 (18.6) and others (neighbors) 5 (1.9%) (Fig. 2).

Regarding to preference for future place of delivery 316 (81.7%) of respondents preferred to deliver at health institution, 35 (9%) at home and 36 (9.3%) had no decision. The reasons for preferring institutional delivery respondents for future were had faced poor outcome from home delivery 210 (66.5%), newborn had faced poor outcome from home delivery 124 (39.2%), it was against their intention that they delivered at home 96 (30.4%), fear of Human Immune Virus (HIV) infection 41 (13%) and other reasons such as being delivered at health institution previously, to get improved and enough service and to get skilled birth attendant service 11 (3.5%).

In this study women were considered knowledgeable on obstetric danger sign if they were mentioned at least three key danger signs. In this study only 105 (27.1%) women were knowledgeable on key danger signs of pregnancy, 130 (33.6%) and 149 (38.5%) women were knowledgeable on key danger signs during labor and child birth and post partum (after delivery) period respectively (Table 3).

Three hundred sixty seven (95.8%) of respondents perceived that the ability of delivery attendants during labor and child birth between skilled birth attendant and unskilled birth attendant are not similar (Fig. 3). Among respondents 292 (75.5%) mentioned the availability of HF that can give delivery service in their area and 161(41.6%) rate the easiness of getting institutional delivery service as fair (Table 4).

Maternity waiting homes are residential structures built in compounds of HF providing maternity care where mothers far from the institution can stay in the final weeks of their pregnancy. Two hundred eighty seven (74.2%) of respondents have heard about presence of maternity waiting home in nearby HC. Even though most of the respondents have heard about presence of maternity waiting home, only 37(9.6%) of them used it. Those respondents who utilized maternity waiting home 23(59.5%) of the respondents used during labor and child birth, both during pregnancy and child birth 10(27%), after giving birth at home and faced complication during visiting HC 3(8.1%) and others have used it during pregnancy 2(5.4%). The reasons for not using maternity waiting home were far from facility and transportation problem 109(31.1%), lack of information 92(26.3%), closed HC 85(24.3%), not suitable 46(13.1%), preferring home delivery 42(12%) and labor was urgent and sudden 9(2.6%).

In this study, place of residence, educational status of mother, travel time in hours from home to nearest health facility with SBA, decider on place of delivery, ANC visit frequency during last pregnancy, birth preparedness and complication readiness arrangement/action taken ahead of last child birth, knowledge of mothers on obstetric danger signs related to post partum and knowing about presence of maternity waiting home in nearby HC were independent factors associated with utilization of SBA at birth after adjusting the effect of other variables.

Women living in urban areas were about 5 (AOR = 4.74, 95% CI: 1.0–22.36) times more likely to be assisted by skilled birth attendant during child birth compared those residing in rural areas. Women who attended secondary and above educational level were four times more likely (AOR = 4.23, 95%CI: 1.19–14.98) than those mothers with no formal education in utilizing SBA at delivery. Women who were knowledgeable about danger signs of post partum period utilize SBA at birth 2.63 times more likely than that of those who were not knowledgeable (AOR = 2.63, 95%CI:1.19–5.81). More over those mothers who were well prepared (taken ≥2 of the BPACR arrangements/actions) ahead of the last child birth were 4.79 times more likely to deliver in HI with SBA than those mothers who were not well prepared (AOR = 4.79,95%CI:1.85–12.39). Those mothers who had ANC follow up of four and above were about 5.43 times more likely assisted by SBA during delivery as compared to those mother that follow ANC less than four visit (AOR = 5.43,95% CI:2.56–11.55). Those mothers who decide on place delivery jointly with their husbands were about three times more likely to be assisted by SBA at HF during their child birth compared to those mothers who decides only by themselves (AOR = 2.91,95% CI:1.17–7.24). Respondents who have access to a HF within less than 1 h travel were 4.24 times more likely to deliver in a HF with SBA than those mothers who travel more than 2 h (AOR =4.24, 95% CI: 1.18–15.20). In addition respondents who knew presence of maternity waiting home in nearby HC were 3.76 times more likely utilize HF with SBA during delivery compared to those who didn’t knew the availability the waiting home (AOR = 3.76,95 CI%:1.14–12.43) (Table 5).

As this study is community based study it has reflected the actual situation of the problem in the community that could not be addressed through facility based study.

The study cannot allow the establishment of cause and effect relationships as study is cross sectional. There could be recall bias, since the women were asked for events within the last 2 year prior to the survey which increases memory lapse.