Utilization of institutional delivery service and associated factors among mothers in North West Ethiopian
Weldemariam et al. BMC Res Notes
Utilization of institutional delivery service and associated factors among mothers in North West Ethiopian
Solomon Weldemariam 0
Amare Kiros 1
Mengistu Welday 0
0 Department of Midwifery, College of Health Sciences, Mekelle University , Mekelle , Ethiopia
1 Department of Midwifery, College of Health Sciences , Pawe , Ethiopia
Objective: The aim of this study was to assess institutional delivery and its associated factors in Benishangul-Gumez region, North-West of Ethiopia. The data were obtained at community level in a single survey within 1 month and there is no continuation of this study or previously published part elsewhere. Results: Among the 428 eligible respondents recruited for this study, 427 of them responded completely to the interview, giving a response rate of 99.8%. Of the total (427) respondents, 51.1% women delivered the recent child at health facility in the 12 months preceding the survey. Among the common reasons for home delivery were, labour was urgent (25.8%), home birth was usual habit for them (23.9%) and distance to health center was too far. Age (AOR = 3.4, 95% CI 1.46, 7.97), husband occupation (AOR = 5.16, 95% CI 1.74, 15.31), frequency of antenatal care visit (AOR = 3.34, 95% CI 1.88, 5.94) and maternal knowledge on danger signs of pregnancy and delivery (AOR = 7.18, 95% CI 3.77, 13.66) were significantly associated factors with institutional delivery. Although, the prevalence of institutional delivery has improved when compared to previous reports, strategic modification is important to increase health facility delivery.
Institutional delivery; Associated factors; Benishangul-Gumez; Ethiopia
Globally, the total number of maternal deaths decreased
by 45% from 523,000 in 1990 to 289,000 in 2013 with an
annual rate of decline by 3.3% [
]. In sub-Saharan Africa
(SSA), a woman’s risk of dying from preventable
complications of pregnancy and childbirth is 1 in 22 [
99% (286,000) of the global maternal deaths occurred
in developing countries, SSA region alone accounting
for 62% (179,000) of these deaths [
]. Ethiopia is among
countries with highest maternal mortality ratio (MMR)
in the world with an estimated MMR of 676/100,000 live
births and it is one of among the ten countries accounted
for 58% of the global maternal deaths in 2013 [
Though skill-attendance is the most important
intervention to prevent life threatening complications [
most SSA women still give birth at home in the absence
of skilled birth attendant (SBA) . Worldwide, the major
direct causes of maternal mortality are haemorrhage,
sepsis, unsafe abortion; pregnancy induced hypertension
and obstructed labour [
]. Haemorrhage alone accounts
for one-third of all maternal deaths in Africa [
disparities are found among regions in the level of health
facility delivery ranging from nearly universal in Western
to about 50% in Southern Asia and SSA [
demographic variables, birth order, distance to health facility,
exposure to media, frequency of antenatal care (ANC),
knowledge on pregnancy and child birth danger signs,
history of prolonged labour, and decision making status
are among the major factors cited for low uptake of
institutional delivery [
Ethiopia in its’ Health Sector Development Plan IV’s
targeted to increase SBA to 62% by 2015; but the
coverage has reached 55% [
]. Literatures from Ethiopia
also reported that institutional delivery ranges from 15
to 47% [
]. So as to compensate this gap, Ethiopia
in its health sector transformation plan has set a goal to
increase SBA to 90% by 2019/20 . Factors associated
with institutional delivery appear to be context related
and vary across ranges of studies in Ethiopia [
9, 10, 17–
]. Therefore, it is a crucial point to identify contextual
factors determining institutional delivery to help policy
maker as guide for possible context based strategic
modification of programs and interventions. Moreover, the
study area is an emerging region and studies done in this
area are limited.
This study was conducted in Pawe district one of among
the districts of Benishangul-Gumez Regional state in
Ethiopia. Pawe district has 20 kebeles. Based on the
information obtained from the district health office, the
population of Pawe district was about 57,724 in 2014
of which, 13,882 were reproductive age group women
(unpublished report). Community based cross sectional
study was conducted from March 1 to March 30, 2015.
Sample size and sampling techniques
A single population proportion formula [n = (Z α/2)2
p(1 − p)/d2] was used to estimate the required sample
size. The following assumptions were made while
calculating the sample size. A 95% CI, 5% (d = 0.05) margin of
error, population proportion of mothers who gave birth
at health institution assumed to be 15.8% [
effect of 2 with an expectation of 10% of non-response
rate. Overall, 428 respondents were recruited. The
kebeles found in the district (17 rural kebeles and 3 urban
kebeles) were stratified into rural and urban strata then
lottery method was used to select five kebeles from the
rural strata and one kebele from the urban strata to
ensure representativeness. Proportional to population
size allocation technique was used to allocate the sample
size to each kebele. Census was done in each kebeles to
identify households with eligible women and
corresponding identification number was given to develop sampling
frame. Then systematic sampling technique was used to
recruit eligible respondents at every kth interval (k = 2,
Inclusion and exclusion criteria
The study population included all women who delivered
within the last 12 months preceding the survey and
residing in the selected kebeles at least for 6 months.
Data collection tool and procedures
A structured questionnaire was developed from
different literatures in English and translated into ‘Amharic’
language (local language). Data were collected by six
trained diploma midwives who can speak Amharic
language through face to face interview. A pretest was
conducted among 5% of the sample size in nearby district
which has similar basic socio-demographic
characteristics as the study district. The overall supervision was
carried out by the principal investigator and
supervisors. Ethical clearance was obtained from Institutional
Ethical Review Board of Mekelle University, College of
Health Sciences. A letter of permission was obtained
from Metekel zonal Health Office to Pawe district Health
Office then to the respective kebeles. Informed signed
consent was obtained from study participants and
consent for participants below 18 years old was taken from
Data were checked and entered into Epi Info version 3.3.2
software, and exported to SPSS version 20 software for
analysis. Variables with p < 0.2 at bivariate analysis were
included in multivariable logistic regression analysis.
Odds ratio along with 95% CI was computed to ascertain
association between independent and dependent
variables. p value of < 0.05 in the multivariable analysis was
considered as cut off point to determine statistical test.
Among the 428 eligible respondents recruited, 427 of
them responded completely to the interview, giving a
response rate of 99.8%. Majority, 318 (74.5%) of
respondents were rural residents. The mean age of the
respondents was 29.8 years (SD 7.4) with a range of 16–48 years
old. The majority of respondents, 381 (89.2%) were
married. About, 127 (29.7%) of respondents were had radio
or television at home (Table 1).
Reproductive characteristics of respondents
Two hundred seventy (60.9%) respondents were
experienced first birth before the age of 20. The mean age at
first pregnancy was 19.09 years old (SD 3.017). Twenty
(4.7%) respondents had history of still birth. Two
hundred thirty-eight (55.7%) respondents were Para two, 119
(27.9%) primi-para and the rest grand multipara (5 +).
Three hundred fifty-two (82.4%) of respondents had
ANC follow up.
Utilization of institutional delivery service
Of the 427 respondents, 218 (51.1%) of them gave birth
at health facility. Among women who delivered at health
facility, 107 (49.1%) deliveries were in hospital, 77 (35.3%)
in health center and 34 (15.6%) in health posts., The
common reasons for home delivery were labour was urgent
(25.8%), home birth was usual habit for them (24%),
health center was too far (19.1%), family influence to
deliver at home (14.8%), lack of transportation (9.1%) and
no problem at the time of delivery (7.2%). About 15.3% of
the home births were delivered without assistant (Fig. 1).
Factors associated with institutional delivery
Mothers with age group of less than 25 years old were
about 3.4 times (AOR = 3.4, 95% CI 1.46, 7.97, p = 0.005)
more likely to deliver in health facility than mothers
with age group 35 and above. Mothers whose husbands
occupation was governmental employee were 5.2 times
(AOR = 5.16, 95% CI 1.74, 15.31, p = 0.003) more likely
to deliver in health facility than mothers whose husbands
were farmer by occupation. Having 4 + frequency of
ANC visit in the recent pregnancy were about 3.3 times
(AOR = 3.34, 95% CI 1.88, 5.94, p = 0.001) more likely
to give birth in health facility when compared to
mothers who had less than 4 frequency of ANC visit.
Mothers who were knowledgeable on obstetrical danger
signs of pregnancy and delivery were about 7.2 times
(AOR = 7.18, 95% CI 3.77, 13.66, p = 0.001) more likely to
deliver in health facility when compared to mothers who
were not knowledgeable (Table 2).
According to this study, institutional delivery with
skilled birth attendant was 51.1%. This indicates that
nearly half of mothers were delivered at home
without the help of SBA to rescue the life in emergency
traditional birth attendants
families and relatives
community health workers
skilled birth attendants
situation. The current finding is consistent with the
findings reported from SSA, Nepal, East Delhi India,
and Ethiopia, where the proportion of mothers who
gave birth in health facility were 53, 48, 51, 47 and
48.3% respectively [
3, 11, 12, 20, 21
]. However, the
current prevalence of health facility delivery is higher
when compared to reports from districts of
Ethiopia, where the proportion of mothers who gave birth
at health facility were 15.7, 37.9 and 25% respectively
17, 22, 23
]. This discrepancy might be due to the
difference in intervention that has been taking place by
the midwives, Health extension workers and women
development army in auditing and mobilizing pregnant
mothers for maternal health service utilization to reach
all segments of the population.
On the contrary, the current report is lower when
compared to reports from districts of Ethiopia, where 97, 61.6
and 62.2% of mothers gave birth in health facility
]. This could be due to the fact that majority
of respondents in this study were rural residents, where
as participants of the above studies were urban residents.
Hence, they could have better decision making autonomy
and better access to information than rural residents.
Respondents in the age group of less than 25 years old
were about 3.3 times more likely to give birth in health
facility when compared to mothers in the age of 35 and
above. This finding is consistent with the reports from
districts of Ethiopia, where respondents within the age
group of 15–24 years were about 4 times more likely to
give birth in health facility as compared to age group
of 35 and above respectively [
18, 22, 27
]. This might be
due to the fact that younger mothers are more likely to
be educated and they may have a better opportunity
to access information as compared to older mothers.
Respondents whose husbands occupation were
governmental employee were about 5.2 times more likely to give
birth at health facility as compared to mothers whose
husbands were farmers by occupation. This finding is in
line with the findings from Bangladesh and Ethiopia [
]. This might be people working in government
organizations usually educated and might have better
opportunity to access information and use health services when
compared to farmers. Respondents who had 4 +
frequency of ANC visit were about 3.3 times more likely to
give birth in health facility when compared to mothers
with less than four visit. This finding is consistent with
many reports from parts of Ethiopia [
]. This might
be ANC can provide an opportunity for health workers
to promote health facility delivery and to counsel birth
preparedness and complication readiness. Moreover,
mothers who present for ANC follow up have already
demonstrated readiness to use available services.
Maternal knowledge on danger signs of obstetrics in pregnancy
and delivery was about 7.2 times more likely to give birth
in health facility as compared to their counterparts. The
current finding is consistent with the reports from
Ethiopia (Metekel and Sodo) [
]. This might be due to that
respondents who had knowledge on danger signs could
have a greater fear of complications, lead them to seek
skilled attendance during birth.
Conclusion and recommendation
Although, the prevalence of institutional delivery is high
when compared to previous reports from districts of
Ethiopia, still institutional delivery is low in the study
area. This finding is a clue to modify strategies and
programs to close the gaps and improve health service
utilization. The interventions that have been taking place by
ministry of health to increase health service utilization
should be strengthening. Moreover, midwives should
strengthen the counseling session regarding pregnancy
and delivery danger signs. Midwives should give
emphasis in counseling mothers with age group of 25 and
above that all pregnancy is at risk of complication and
the importance of health facility delivery. Government
should give emphasis on strategies that create awareness
on farmers to involve in every maternal health care
service given for their wives.
This study was conducted in one district of
BenishangulGumez region therefore the findings might not be
generalizable to the entire region. The cross-sectional nature of
the study does not allow for causality inferences. Despite
of these limitations, being a community based study and
its sample size adequacy might be taken as strength.
Additional file 1. This SPSS template contains that data that support the
findings of this study.
Additional file 2. It is an English version questionnaire used to measure
this findings and it was developed from different literatures and adjusted
contextually by consulting seniors.
ANC: antenatal care; DHS: Demographic and Health Survey; EDHS: Ethiopian
Demographic and Health Survey; MMR: maternal mortality ratio; SBAs: skill
birth attendants; SSA: sub Saharan Africa; TBAs: traditional birth attendants.
AK, SW and MW designed the study. AK prepared the proposal, obtained the
data, analyzed and interpreted the data and obtained funding. MW and SW
reviewed and commented the entire of the paper from inception to end and
involved in the analysis. SW prepared the first draft of this manuscript. All
authors read and approved the final manuscript.
We would like to forward our gratitude to Mekelle University, College of Health
Sciences for its support. We would like also to acknowledge Department of
Midwifery for its contribution in monitoring this study. Moreover, we thank
also the participants of this study, Pawe district health office and
BenishangulGumez College of Health Sciences for their support and collaboration.
The authors declare that they have no competing interests.
Availability of data and materials
All data have been included in the manuscript and it is also the data which
supports this findings and questionnaire submitted as Additional files 1 and 2.
Consent for publication
Ethics approval and consent to participate
Ethical clearance was obtained from Institutional Ethical Review Board (IERB)
of Mekelle University, College of Health Sciences, Ethiopia. A letter of
permission was obtained from Metekel zonal Health Office to Pawe district Health
Office then to the respective kebeles. Informed signed consent was obtained
from study participants after explaining the objective of the study and signed
consent for participants below 18 years old was also taken from their fathers/
This work has been funded by Mekelle University as for M.Sc. thesis fulfillment
and department of midwifery was involved in the project through
monitoring and evaluation of the work. But this organization did not involve in
designing, analysis, critical review of its intellectual content, and preparation
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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