AA: Addis Ababa; ANC: Antenatal Care; APH: Ante Partum Hemorrhage; C/S: Caesarian Section; CMR: Child Mortality Rate; EDHS: Ethiopian Demographic and Health Survey; FMOH : Federal Ministry of Health; FP: Family Planning; HIV: Human Immunedeficiency Virus; HH: House Hold; IMR: Infant Mortality Rate; MMR: Maternal Mortality Ratio; NGO: Non-Governmental Organization; PHC: Primary Health Care; PPH: Post-Partum Hemorrhage; TASH: Taker Anbesa Specialized Hospital; TBAs: Traditional Birth Attendants; TTBAs: Trained Traditional Birth Attendants; WHO: World Health Organization

Institutional delivery is an act of giving birth in hospitals or in health centers or it may in a clinic by skilled birth attendants that mean by medical doctors, public health officers, midwives or Nurses. In developing countries, despite the great public health effort, many women are still assisted in delivery either by traditional birth attendants (TBA) or relative, delivered by them at home [1-4].

Globally, 287 000 mothers die from complications of pregnancy and childbirth. Sub-Saharan Africa and Southern Asia accounted for 85% of the global burden of maternal deaths [3-18]. The highest number of maternal deaths occurs during labor, delivery and the first day after delivery highlighting the critical need for good quality care during this period. Therefore, for the strategies of institutional delivery to be effective, it is essential to understand the factors that influence individual and household factors to utilize skilled birth attendance and institutions for delivery [19].

Most maternal deaths are avoidable, as the health-care solutions to prevent or manage complications are well known. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can decrease the risk of antepartum hemorrhage, post-partum hemorrhage, and transmission of HIV/ AIDS and make the difference between life and death [3].

Globally, unattended delivery by skilled health personnel are known to be associated with high maternal and prenatal morbidity and mortality such as Antepartum hemorrhage (APH), 122 pregnant women were treated for the diagnosis of APH. Prenatal born alive from those treated mothers were one hundred. The prevalence of APH is 2.3%, one of the associated factors was obstetric complication classified as placenta Previa which accounts for 78.8% and abreaction placenta contributes 21.2% [20-25]. Nearly, 3.4 million of the 8 million infant deaths each year occur within the first week of life and are often due to a lack of or inappropriate care during pregnancy, delivery and the post-partum period [7].

Many women in developing countries are at a greater disadvantage. These mothers are at increased risk from unpredictable obstetric complications, often ending in death either at home or after transfer to a health facility [26-28].

The lack of decision-making power of women within the family and inequities in the provision of essential maternal health care interventions remain a challenge in many Sub- Saharan African countries [29,30].

Maternal mortality and morbidity levels in Ethiopia are among the highest in the world, with the maternal mortality ratio of 412 per 100,000 live births.

This study is intended to assess factor associated with institutional delivery services among women in the reproductive age group who gave birth before in Woldia town. The result of this study could help as baseline data for another research.

The finding of this study also helps to provide local evidence that could help policymakers to develop strategies for the improvement of maternal and child health survives.

Further, the study provides more information on efficient and effective utilization of scare resource available for health to address issues of reducing maternal mortality and morbidity related to home delivery or attended by unskilled personnel elsewhere.

Study setting

This study was conducted at woldia town is located in the Amhara region, 521 km from Addis Ababa. According to the Ethiopian central statistical agency report, the total population of the Woldia town administration was 75,496 in 2007. Of this, 37,279 were females and 38,167 were males. Woldia town consists of three kebeles which are kebele 01, 02 and 03.

Among these kebeles, our study was conducted in kebele 03, with a total population of 15,743 and with a total household number of 1837. From the total of 1837 households, there were 3344 women. Of these 1200 of them were given birth for the last one year.

Among these, 378 women were selected randomly. The communitybased cross-sectional study design was conducted in Woldia town among reproductive age group women (15-49 years) who lived in Woldia town and who gave birth for the last one year regardless of the outcome, from April 1 to 30, 2017.

Sample size determination

The minimum sample size was determined by using single population proportion formula by considering assumption of 95% level of confidence, 5% margin of error and taking the percentage of 10% of institutional delivery in Dangila, Awe zone [6], the final sample size was 378.

Sampling procedure

A multistage cluster sampling technique was applied; sampling was done at the kebele, “gott” and household levels. In the first stage, 1 out of 3 urban kebeles was randomly selected. In this selected kebele, there are 4 neighborhoods (locally referred to as “gotts”). Out of these 1 “gott” was randomly selected. Then, from each selected “gott” households with women in reproductive age group and had a history of birth for the last one year were selected.

Data collection tools and procedures

Data was collected through a pretested structured interview-based questionnaire. It was first prepared in English and translated to Amharic version and back to English again to maintain its consistency.

Five data collectors, who have a diploma in midwifery and two supervisors, were participated in the data collection process. The body of the questionaries’ consists of Sociodemographic related factors, obstetric and obstetric related factors, and knowledge related question on pregnancy and delivery.

Orientation was given for data collectors on objectives and the way of data collection before starting the actual data collection. Data collectors were supervised daily and all the collected data were checked daily by the supervisors.

The purpose and objectives of the study were explained accordingly to get the verbal and written consent of study participant before data collection and also appropriately explain how privacy and confidentiality will be maintained.

Data processing and analysis

The data were checked for completeness, inconsistencies, and then coded, entered using EPI data version 3.1. Then the data cleaned and analyzed using SPSS version 23. Descriptive statistics were computed to determine frequencies and summary statistics (mean, standard deviation, and percentage).

Data were presented using tables, graphs, and figures. Bivariate logistic regression analysis was done after dichotomizing the dependent variables.

After checking associations of the variables, those with p<0.2 in bivariate analysis was processed to multi-variable logistic regression analysis to control confounding factors. P-value of <0.05 was used to express the statistical significance of the variables.

Socio-demographic and economic characteristics of study participants

A total of 360 mothers interviewed in the study with a response rate of 95%. One hundred and twenty-nine (35.8%) were in an age above 35 years and 82 (22.8%) an age range of 30-34. Regarding marital status, 316 (87.8%) women were married. Among the total study participants about 235 (65.3%) were Orthodox in religion and 134 (37.2%) women's attended secondary school (Table 1).

Table 1: Socio demographic and economic characteristics of study participants at woldia town, Ethiopia, 2017.

Past obstetric history of the study participants

Among the total respondents, 303(84.2%) of them were >18 years old during their first marriage while 45(12.5%) of them were <18 years of age. Regarding the age of mother during first pregnancy 332(92.2) gets their first pregnancy >18 years. Two hundred eighty (80%) of them had information about the benefit of giving birth at a health institution, among these 180(50%) of them said that the primary source of information were health workers (Table 2).

Table 2: Obstetric related factors among reproductive age group women who gave birth at Woldia town, Ethiopia, 2017.

Delivery place, mode of delivery and decision-making power of the respondent’s

Institutional delivery among women who gave birth in Woldia town was found to be 74.7% [95%, CI=69.7%, 78.9%].

Among respondents who gave birth at the health institution, 170 (47.2%), 55 (15.3%), 9 (2.5%), and 6 (1.7%) of them were assisted by midwives, doctors, health officers and nurses respectively. Of women who experienced home delivery, 34 (9.7%) of them were assisted by their mother's. Regarding the decision on the place of delivery, 209 (58.1%) replied that the decision was made by both husband and themselves (Table 3).

Table 3: Last delivery place and decision-making power of the respondent’s in reproductive age among women who gave birth in Woldia town, northeast Ethiopia, 2017.

Factors associated with institutional delivery

The absence of ANC follow-up in the last pregnancy was a strong association with institutional delivery and the odds of having institutional delivery is 36 times lower among mother who attended ANC follow-up than mothers who didn't attend ANC follow up.

Moreover, the mother who had good knowledge was 95.4% more likely to deliver at health institution than mother with poor knowledge.

Unwanted type of pregnancy was found to be a predictor of institutional delivery services utilization, those mothers who had unwanted pregnancywere78.9% less likely to give birth at the health facility than women who had wanted pregnancy (Table 4).

Table 4: Factors associated with institutional delivery at Woldia town, Ethiopia, 2017.

The prevalence of institutional delivery service utilization in woldia town among woman in a reproductive age that gave birth before was found to be 74.7% (95% CI 69.7%-78.9%). The prevalence of this study is higher than previously study done in Goba wereda Oromia 61.2% [20], Lume wereda east showa 37% [21], Woliyta Dawro 38% [18], Semere sahreti Tigray 4% [19], Dubti district Afar 7.4%[12], Sidama 4.9% [31], Welyta sodo 62.2% [32], Dangla district 18.3% [6]. The possible difference might be due to the participant of this study was an urban mother and the time gap where several measures were taken by the government to improve institutional delivery.

The prevalence of the study appears to be a low comparing study done in Debre-birhan 80.2% [7], and in Adigrat 85% [22] this discrepancy may be due to different socioeconomic characteristics of study participant and the towns are near to capital cities thus have access of information and chance of acquiring knowledge. But the result of our study is in line with the study done in Bahr Dar 78.8% [11].

In the study area despite that ANC coverage was higher at 79.2%, all mothers who had ANC visit did not give birth at the health facility (74.7%). This might be due to the reason that during ANC, mothers did not get enough information about the risk of home delivery. On the other hand, mothers can come for ANC by themselves, but they could not come when they are in labor because they need the help of others. A similar study conducted in Adigrat showed that there is a high prevalence of ANC 88.1% while institutional delivery is 85%.

Having ANC is a significant association between institutional delivery utilization and those women had ANC follow-up were more likely to had institutional delivery. This is in accordance with studies done in Debre birehan [7], Welayta Dawro [18], Bahr Dar [11], Dangla [6], Adigrat [22], and Butajira [30-33]. This might be due to mother who attend antenatal care have a chance of getting information on place of delivery and complication of pregnancy and delivery.

Women whose knowledge was poor 95.4% less likely to give birth at the health facility than mother with good knowledge [AOR=0.046, 95%CI (0.013-0.158)]. Another previous study conducted in another part of Ethiopia at Welayta Dawro [18] founds knowledge of woman to be determinant for institutional delivery utilization.

Nature of pregnancy found to have significant association, mother whose index child was unwanted pregnancy were 78.9% less likely to deliver at health facility than counterpart this shows that mother whose pregnancy was unwanted may have less confidence to deliver at health facility, may not get support from their partner and are less interested in their pregnancy. This study is in line with other study conducted in Welayta Dawro [18].

This study revealed that the utilization of institutional delivery services was higher as compared to the national figure which is 26% in 2016 according to EDHS.

The most important identified factor influencing utilization of institutional delivery was: absence of antenatal care service, being unwanted pregnancy) and poor knowledge of a woman. This study shares the limitations of cross-sectional studies and hence may not be possible to establish a temporal relationship between institutional delivery and explanatory variables.

Ethical clearance was obtained from the ethical review committee of Woldia University Faculty of health science. Permission letter was obtained both from Woldia zonal health department. Anonymity was maintained by using identity numbers instead of patient names. Besides, all the data abstracted was kept confidential and not used for any other purposes than the stated research objective.

Not Applicable

All relevant data are within the manuscript.

No funding

The authors have declared that no competing interests exist.

EA, GG, AA, and RN wrote the proposal, participated in data collection, analyzed the data and drafted the paper. GG and BM approved the proposal with some revisions, participated in data collection, analysis, and manuscript writing. All authors read and approved the final manuscript.

We would like to thank all the study participants and data collectors. The authors also acknowledge all contributors to the study at all stages of proposal development, data collection, and data analysis.