Delays in Utilization of Institutional Delivery Service and its Determinants in Yem Special Woreda, Southwest Ethiopia: Health Institution Based Cross-Sectional Study
Teklemariam Ergat Yarinbab* and Sileshi Gebremichael Balcha
Department of Public Health, Mizan-Tepi University, Ethiopia
Submission: June 05, 2018;Published: July 17, 2018
*Corresponding author: Teklemariam ErgatYarinbab, Department of Public Health, Mizan-Tepi University, Ethiopia; firstname.lastname@example.org;email@example.com
How to cite this article: Teklemariam E, SileshiGebremichaelBalcha. Delays in Utilization of Institutional Delivery Service and its Determinants in Yem Special Woreda, Southwest Ethiopia: Health Institution Based Cross-Sectional Study. Glob J Reprod Med. 2018; 5(3): 555661. DOI:10.19080/GJORM.2018.05.555661.
Background: Pregnancy and childbirth remain serious life threateningevents for women in low income countries. Reducing maternal morbidity and mortality is a global priority health problem. One of the key strategies for reducing maternal morbidity and mortality is increasing institutional delivery service utilization of pregnant women under the care of skilled birth attendants. Therefore, the aim of this study was to assess the delays in utilizing institutional delivery service and its determinants among women who gave birth at public health institutions in Yem Special Woreda, Southwest Ethiopia.
Methods: Health institution based cross-sectional study was conducted in Yem Special Woreda, Southwest Ethiopia. A simple random sampling technique supplemented with Focus Group Discussion was used. Data was collected using pre-tested structured questionnaires. SPSS version 20.0 was used for Bivariate and Multivariate Analysis.
Result: The prevalence of delays in delivery service utilization was 76.3%. The mean time delay to utilize institutional delivery service was 5(±3.08) hours. Low educational status of women (AOR=1.9, 95%CI: 1.09, 3.47), Parity (AOR=2.9, 95%CI: 1.57, 5.44) and Husbands decision (AOR=2.08, 95%CI=1.09, 3.95) were found to be significantly associated with delay to utilize institutional delivery services.
Conclusion: Low educational status of women, parity, not being ready to give birth in health facility and husband’s decision making were found to be determinants of delay to utilize institutional delivery services.
Abbreviations: AOR: Adjusted Odds Ratio; EDHS: Ethiopian Demographic Health Survey; FGD: Focus Group Discussion; FMOH: Federal Ministry of Health; MCH: Maternal and Child Health; SPSS: Statistical Package for Social Sciences; SNNPR: Southern Nations Nationalities and Peoples Region; Ethical approval and consent to participate
Keywords: Delays; delivery service utilization; Yem Special Woreda; Ethiopia; Maternal death; Data collectors; Logistic regression analysis; Pregnant women; Midwives; Life threatening; Safe birth; Geographical inaccessibility; Field supervisors; Investigators; Statistically significant; Motivation; Physical access
Institutional delivery service is one of the key and proven interventions to reduce maternal death. It ensures safe birth, reduce both actual and potential complications and maternal death and increase the survival of most mothers and newborns. But most deliveries in developing countries occur at home without skilled birth attendants. The 2014 EDHS report revealed that 83.4% deliveries took place at home whereas only 15.4% of deliveries were institutional . Maternal deaths are strongly associated with delays to utilization of institutional delivery service and inadequate medical care at the time of delivery. Several factors have been identified as barriers to early access to skilled care by women especially in developing countries; these include perceived quality of care at health facility, inadequate number of skilled personnel, geographical inaccessibility and financial constraints, decision making power, awareness on danger sign of pregnancy and benefit of utilizing institutional delivery services . Even with the best possible antenatal care, it is established that delivery could be complicated and timely utilization of institutional delivery service is essential to safe delivery care . Therefore, the aim of this study was to assess the delays in utilization of institutional delivery service and its determinants in Yem Special Woreda, Southwest Ethiopia.
The study was conducted in Yem Special Woreda, Southwest
Ethiopia, from Feb 03-28/2018.Yem Special Woreda is located
297 KMs southwest of Addis Ababa. It has three towns and 34
kebeles (the smallest administrative units) with an estimated
population of 99,714; of these 50,854 were male whereas 48,860
were females (Projected from 2007 National Census).There were
six Health Centres namely Fofa Health Centre, Semonam Health
Centre, Saja Health Centre, Toba Health Centre, Deri Health
Centre and Gesi Health Centre. Besides, there were 27 Health
Posts in the Woreda.
For quantitative study: The sample size was calculated using
single population proportion formula. The prevalence of first
delays in utilizing institutional delivery service 37%(P=0.37) ,
5% margin of error, 95% confidence level and 10% non response
rate were considered. Thus, the total sample size was calculated
to be 393.
For qualitative study: A total of eight Focus Group
Discussions were conducted. Of these; six FGDs were conducted
with MCH service user women whereas two FGDs were
conducted with service providers in selected two health centers.
For quantitative study: The required total sample size was
proportionally allocated to the six Health Centers based on their
previous three months delivery load. Accordingly, the allocated
sample was 94 for Fofa HC, 52 for Semonam HC, 75 for Saja HC,
62 for Toba HC, 56 for Deri HC and 54 for Gesi HC. All pregnant
women who utilize institutional delivery service in each health
center during data collection period were included in the study
until the required sample size was fulfilled.
For qualitative study: Delivery care providers such as
nurses and health officers who wereworking at the public
health centers and women who camefor MCH services during
the data collection period were purposively included in the
FGDs. Participants interviewed in the quantitative survey were
excluded from the FGD.
For quantitative study: Pre-tested structured questionnaire
was used to collect the data. The instrument was adopted from
JHPIEGO tools and indicators for maternal and neonatal health
. Seven health professionals and three supervisors including
the principal investigators were participated in the data
collection. Half a day orientation was given to the data collectors
and supervisors on the data collection tools and procedures by
the principal investigators.
For qualitative study: Semi-structured FGD topic guide was
used to facilitate the discussion. Each of eight FGDs had 6-12
participants and a total of 72 participants (i.e. 59 service users
and 13 service providers) were involved. Each FGD spend 45-60
minutes. Written notes were taken and all the discussions were
Data quality control: The questionnaires were translated
from English into the local language (Amharic) & vice versa. A
pre-test was conducted on 5% of the sample. Data collectors
were well trained. Daily supervision was conducted by the field
supervisors and investigators.Supervisors used to check all
procedures and completeness of formats randomly. Data were
checked before entry. Qualitative records were transcribed
carefully in themes and interpreted.
For quantitative study: Data was analyzed by SPSS for
windows version 20. Bivariate logistic regression model was
fitted as a primary method of analysis. Then, variables having
P-value <0.25 were entered into multivariate logistic regression
analysis using the forward LR method. Finally, P-value <0.05 in
multivariate analysis was used to declare statistically significant
For qualitative study: Written notes from all 8 FGDs were
compiled and labelled according to participants’ type. After
reviewing individual FGD transcriptions, data was organized
according to the themes and summarized manually. The result
was presented in narratives triangulated with the quantitative
results (Table 1).
Delays in utilization of institutional delivery service:
Refers to the time taken more than one hour to make decision
to seek care or more than one hour to reach health facility after
making decision or waiting for more than one hour in health
facility to receive delivery care.
Delay in making decision to seek care: Refers to the time
taken ≥1 hour to make decision to seek care was considered as
delay and less than an hour considered no delay.
Institutional delivery utilization: when a mother gave
birth at health institution and the delivery was assisted by skilled
birth attendant or trained health professional.
A total of 389 respondents involved in the study yielding
98.9% response rate.The mean age of the study participants was
26(±5). Majority of the respondents, 292(75.1%) were Yem in
ethnicity. Orthodox Christian, 204(52.4%), was the dominant
religion.About 306(78.7%) of mothers were married. Besides,
291(74.8%) of the study participants were house wife whereas
27(6.9%) were Government employees. Two hundred nineteen
(56.3%) of them cannot read and write (Table 2).
About 275(70.7%) of the study participants reported
utilization of ANC services. One hundred sixty nine (43.4%) and
142(36.5%) of study participants faced maternal complications
during previous and current pregnancies, respectively. With
regard to decisions; 151(38.8%) of women decide themselves,
151(38.8%) decide by their husbands and 87(22.4%) decide
by their family members to utilize delivery service (Table 3).
Besides, 297(76.7%) subjects preferred health facility delivery
whereas the rest 92(23.7%) did not prefer the same. The
reported reasons for not preferring health facility delivery were
11(12.1%) fear, 16(17.6%) lack of money, 40(44.0%) distance
and 24(26.4%) poor treatment from professionals.
The prevalence of delay to utilization of institutional
delivery service in the study area was 76.3% and the mean (±SD)
of delay time to utilization of delivery service was 5(±3.08)
hours. About 172 (44.2%) respondents reported they faced
problems on making decisions to utilize delivery services from
health facilities. One hundred sixty-eight (43.2%) respondents
reported that they have transportation problems. The study
showed 198(50.9%) travelled on foot, 101(26%) were carried
by wooden stretcher and the rest 90(23.1%) travelled by car to
health facility.The qualitative result showed that, distance and
poor road conditions made it virtually impossible for many
pregnant women to reach the health facility. In some instances, inadequate or inappropriate transport made it difficult for
women to reach the health facility. In the rural areas, the common
means of transport is foot; in hills and mountain districts, people
carried pregnant women to the health facility on stretchers.
Pregnant women faced difficulties in reaching the health facility,
especially at night or during rainy seasons. This is supported by
the qualitative finding that a 30 years old woman from “Toba
kebele” commented: “....It is particularly difficult if the labor
begins at night. There is no transport facility and the way is dark.
In such a situation, how can we go to the health facility to utilize
delivery service..?....”.Other participants of the FGDs also further
suggested that lack of transport, long distance from facilities
and absence of delivery care centers appear to be significant
contributory factors for delay to seek delivery services. From
the FGDs we understood that, women who travelled the shortest
distance had a high chance of attending and coming early to
utilize delivery care from health centers whereas women who
were travelling long distances had little chance to seek treatment
as early as possible.
About 276 (71%) of the respondents reported that they were
happy with the service provided and the rest 113(29%) unhappy.
Lack of drug 5(4.4%) and poor treatment from professional
108(95.6%) were making them unhappy to the service provided
by the health facility. In support of this the qualitative result
showed that there were shortages of midwives and staffs high
work load in the health facilities.Due to these, the women waited
for long time to utilize delivery service after they reached
at health facility. The following two participants of the FGDs
suggest the same. A 27 years old Nurse, service provider, from
‘Gesi Health Centre’ commented: “Only one Midwife is available
in most of the health facilities in the woreda, thus when she is on
leave, in training or transferred to another health facility, women
cannot get timely delivery service from the health facility. And
also when the number of deliveries exceeded ability to provide
services and staff members became overburdened.” Besides; a
34 years old, Health officer, from the same health centre said that
“The absence of a clear division of roles among staff members
who shared responsibility for providing maternal health services
further aggravated this situation and affected worker motivation
and performance. This condition leads to delays in utilizing
delivery service.” Hence, lack of qualified health professionals
and absence of clear job divisions among workers contributes
for delay in institutional delivery services.
The multivariate logistic regression analysis revealed that
Parity or having three or more children, not being prepared
for birth, low educational status of mothers, and decisions
made by husbands were significantly associated with delay
in utilization of institutional delivery services. Accordingly,
women whose husbands make decisions were two times (AOR=
2.08, 95%CI=1.0, 3.9) more likely to delay in utilization of
institutional delivery services as compared to those who make
decisions by themselves (Table 4). In support of this finding,
a 30 years old mother from Gesi kebele said: “Many husbands
do not allow their wives to visit the health facility for seeking
delivery services because of traditional beliefs. Women cannot
ignore their husbands’ decision and cannot express their opinion
in the family”. Hence, it is clear that women who make decisions
by themselves free of their husbands influence are more likely
to use institutional delivery services on time. The study also
revealed that, women who have three or more children are 3
times (AOR= 2.9, 95%CI= 1.57, 5.44) more likely to get delay in
utilization of institutional delivery services as compared to those
who have two or less children (Table 4). A 42 year old woman
from Deri kebele commented that “………..I have four children.
They are students and I am caring about their school. I am a
house wife and my husband is a farmer. We are responsible for
their school performance and economic issues. We did not have
money at hand, so I was late in my last birth while my husband
was looking for borrowing money for transportation....” Here,
from the opinion of woman above, we can deduce that having
more children affects the economy of family and in turn causes
delay in institutional delivery service utilization.
The study assessed delays in utilization of delivery services
and its determinants. The prevalence of delays in delivery service
utilization was 76.3%. This finding was higher than the finding
from a study in rural Bangladesh . This might be due to the
existence of differences in accessibility of health facilities and
delivery service utilization culture of the community. Regarding
physical access to health facility, about 69.4% were found to have
no access to health facility or live in a walking distance of greater
than one hour and the mean walking distance from their homes was two hours. This finding was slightly higher than findings
from studies in selected developing countries by Babinard .
The possible reason may be large distances between health
institutions due to the sparse pattern of the population in the
study area.Besides, this finding was consistent with findings
from the 2011 EDHS report in which 66% of mothers did not
have access to or live in a walking distance of more than one
hour from institutional delivery services in Ethiopia . This is
supported by findings from the qualitative study in that most of
the participants said they walk a long distance to reach health
facilities. Besides, the study revealed that 34.7% of the mothers
waited for more than one hour to utilize institutional delivery
service after they arrived at health facility. This finding was
higher than the findings from a study in Bahir Dar, Ethiopia .
The qualitative finding showed that long time admission
process, staffs work load and lack of supplies were the main
reasons for third delay to utilize institutional delivery service
at health facilities.Further the study showed that women whose
husbands make decisions were two times more likely to delay in
utilization of institutional delivery services as compared those
make decisions by themselves. This finding is consistent with the
findings from studies in rural Bangladesh and Bahir Dar Ethiopia
[6,9]. This also was supported by the qualitative findings in that
most of the participants of the FGDs argued that male dominance
for decision and not being prepared for delivery was the main
reasons for delays in utilizing delivery services. The participants
also added unless labour is complicated husbands would not
allow their wives to visit health facilities. Delay in utilizing
delivery service was seven times more likely among mothers who
were not being prepared for institutional delivery as compared
to those prepared mothers. This finding was consistent with
the cross-sectional study in Kenya and Ethiopia [10,11]. The
qualitative study showed that participants did not think it was
necessary to go to a health facility for normal delivery unless
they experienced a serious problem.
Women who have three or more children were three
times more likely to delay in utilization of delivery services as
compared to mothers who have two or less children. This finding
is consistent with the findings from studies in Bangladesh
and Nigeria [12,13]. The possible reason could be the fact
that women who have higher parity develop experience and
confidence regarding child birth, and hence might delay to utilize
delivery services.On top of this, the study indicated that women
with low education status were two times more likely to delay in utilization of institutional delivery services as compared to that
of literate women. This finding was consistent with the various
studies in Nigeria & Nepal [12,14]. The reason could be for
educated women might have better access to information about
the advantages of institutional delivery and pregnancy related
The prevalence of delays in delivery service utilization was
76.3%. Low educational status of women, parity, not being ready
to give birth in health facility and husband’s decision making
were found to be determinants of delay to utilize institutional
Federal Ministry of Health in collaboration with other
stakeholders should promote women education. Regional
Health Bureaus’ and Zonal Health Departments’ should strongly
advocate the utilization of institutional delivery services. Besides,
Woreda Health Offices in collaboration with local government
bodies and other stakeholders should work hard to improve the
awareness of women on institutional delivery.Ethical clearance
letter was obtained from department of Public Health, Mizan-
Tepi University. The participants were made aware about the
purpose of study, and oral consents were obtained accordingly.
The participants’ right to refuse or withdraw from the study and
confidentiality issues were considered.
First of all, our deepest gratitude and appreciation goes to
Department of Public Health; College of Health Sciences, Mizan-
Tepi University. We would also like to extend our gratitude to
Yem Special Woreda health office staffs and the health centres
staffs for their cooperation in data collection. Finally, our great
appreciation goes to the data collectors and supervisors.