Use of institutional delivery services in the Southern Nations, Nationalities, and People's Region, Ethiopia: a cross-sectional comparative mixed methods study

Abstract

Background118 000 newborn babies in Ethiopia die each year and 500 000 pregnancy-related complications occur. Maternal mortality in Ethiopia is also very high (676 deaths per 100 000 livebirths); only 34% of mothers receive antenatal care and 10% of births took place in health facilities in 2011. We identified factors contributing to low use of institutional delivery services in the Southern Nations, Nationalities, and People's Region, Ethiopia. MethodsWe interviewed mothers who had given birth within the past year and organised six focus group discussions. We selected participants by multistage sampling proportional to the number of expected pregnancies in the 19 administrative zones in the region. We did univariate, bivariate, and multivariate analyses to assess 24 potential predictors of non-institutional delivery. We analysed focus group discussions with NVivo (version 10). FindingsWe interviewed 502 women from urban areas, 164 from rural pastoral areas, and 2231 from rural agrarian areas. 876 of 2897 (30·2%) births occurred in health institutions—412 of 502 (82·1%) births in urban areas, seven of 164 (4·3%) in rural pastoral areas, and 457 of 2231 (20·5%) in rural agrarian areas. Factors associated with non-institutional delivery include mother's education status (none vs grade 9 or higher: adjusted odds ratio [AOR] 3·91, 95% CI 2·76–5·56), mother's partner's educational status (primary vs none: AOR 0·65, 95% CI 0·49–0·86), occupation (merchant vs farmer: AOR 0·56, 95% CI 0·36–0·87), household financial decision-maker (male partner vs mother: AOR 2·12, 95% CI 1·52–2·95), monthly income (<700 birr vs ≥700 birr: AOR 1·77, 95% CI 1·43–2·18), use of antenatal clinic services (no use vs use: AOR 5·63, 95% CI 3·76–8·43), and knowledge of danger signs during delivery (don't know vs do know: AOR 2·16, 95% CI 1·83–2·55). Mothers with no education and who were aged younger than 18 years at their first marriage were more likely to give birth outside of a health institution compared with mothers who were educated to grade 9 or higher (AOR 3·91, 95% CI 2·76–5·56) and mothers who were aged 18 years and older at their first marriage (crude odds ratio 1·69, 95% CI 1·43–1·99). Mothers who planned their last pregnancy were less likely to give birth outside of a health institution compared with mothers who did not plan (AOR 0·48, 95% CI 0·37–0·63). InterpretationInstitutional delivery is still uncommon in the Southern Nations, Nationalities, and People's Region despite several interventions. Innovative approaches are needed to attract women to health facilities. FundingSave the Children International.