Institutional Delivery Services Utilization and Associated Factors among Mothers who gave
Birth in the Last One Year in Jimma Town,
Yibeltal Siraneh1* and Fisseha Wondimnew2
1Department of Health Economics, Jimma University, Ethiopia
2South Nations, Nationality and people regional state health bureau, Ethiopia
Submission: September 04, 2018; Published: October 25, 2018
*Corresponding author: Yibeltal Siraneh Belete, Department of Health Economics, Management and Policy, Faculty of Public Health, Institute of Health, Jimma University, Ethiopia, Tel: +251917017092;
Email: firstname.lastname@example.org; email@example.com
How to cite this article: Yibeltal S, Fisseha W. Institutional Delivery Services Utilization and Associated Factors among Mothers who gave Birth in the
002 Last One Year in Jimma Town, Southwest Ethiopia. J Complement Med Alt Healthcare. 2018; 8(3): 555736. DOI: 10.19080/JCMAH.2018.08.555736
Background: High maternal mortality was a continued challenge for the achievement of Sustainable Development Goal in Sub-Saharan African countries including Ethiopia. Although institutional delivery service utilization ensures safe birth and a key to reduce maternal mortality, interventions at the community and/or institutions were unsatisfactorily reduced maternal mortality. Institutional delivery service utilization is affected by the interaction of personal, socio-cultural, behavioral and institutional factors. Therefore, this study was designed to assess factors associated with institutional delivery service usage and utilization status among mothers who gave birth in the last 12 months in Jimma Town, Oromia Region.
Objective: To assess utilization of institutional delivery services and associated factors among mothers who gave birth in the last one year in Jimma town, south-west Ethiopia.
Method: A community based cross sectional study design was used from June 15- July 15in Jimma town south-west of Addis Ababa, Ethiopia. Five Keble were selected randomly by lottery method. Four hundred two mothers who gave birth in the last 12 months were included in the study using systematic random sampling. Data were collected by trained staff health extension workers via face to face interview and pretested structured questionnaire was used to collect data on different variables. The result was interpreted using tables, graphs, chart and figures of percentage. Chi square test was used to analysis association between variables and p-value of i.e. <0.05 was presumed to indicate significance of association.
Result: In this study, 74.4% of women gave birth to their current child at health institution. The chi square association showed that, educational status of the mother (χ2 = 71.5442, P <0.00001) and their husband (χ2 =95.1494 P <0.00001), age at first marriage (χ2 =27.1211, P <0.00001), age at first pregnancy (χ2 =41.7694, gravidity, P <0.00001), occupational status (χ2 = 41.6777, P <0.00001) parity (χ2 =36.9567, P<0.00001), types of pregnancy (planned/unplanned) (χ2 =22.5488, P<0.00001), and ANC visit during the last pregnancy (χ2 =4.2478, P= 0.039301) frequency of ANC visit (χ2 =2.0773, P=0.149509) were factors associated with institutional delivery service utilization.
Conclusion: In this study, institutional delivery service utilization is optimal; mothers in Jimma town were more likely to practice institutional delivery. Factors such as age at first marriage, age at first pregnancy, types of pregnancy (planned/unplanned), parity, gravidity, occupation, ANC visit during the last pregnancy, frequency of ANC visit, educational status of the mother and their husband and knowledge of the mothers on pregnancy and delivery services were significantly associated with skilled delivery service utilization
Keywords: Institutional delivery service utilization; Community based cross sectional study; Mothers gave birth in the last 12 months; Jimma town
Abbreviations: AIDS: Acquired Immune Deficiency Syndrome; ANC: Antenatal Care; DHS: Demographic and Health; HD: Home Delivery; HIV: Human Immunodeficiency Virus; ID: Institutional Delivery; MCH: Maternal Child Health; MMR: Maternal Mortality Rate; MOH: Ministry of Health; OR: Odd Ratio; PNC: Postnatal Care; SGA: Small for Gestational Age; TBA: Traditional Birth Attendant; TTBA: Trained Traditional Birth Attendant; WHO: The World Health Organization
Maternal mortality remains high in the developing world. Giving birth in a health facility is associated with lower maternal mortality than giving birth at home. An important component of
efforts to reduce health risks to mothers and children is increasing the proportion of babies that are delivered in health facilities. Giving birth in a medical institution under the care and supervision of trained health-care providers promotes child survival and
reduces the risk of maternal mortality. Many women lose their
lives in the process of giving life. Utilization of health services is
affected by a multitude of factors including not only availability,
distance, cost, and quality of services, but also by socioeconomic
factors and personal health beliefs. In an attempt to understand
the factors that determine women’s utilization of health services,
the role of need, permission, ability, and availability & reasoned
that when permission and ability interact with need, a demand for
health services is generated .
Obstetric care from a trained provider during delivery is
recognized as critical for the reduction of maternal and neonatal
mortality. Births delivered at home are usually more likely to be
delivered without assistance from a health professional, whereas
births delivered at a health facility are more likely to be delivered
by a trained health professional. Delivery assisted by skilled
providers is the most important proven intervention in reducing
maternal mortality and one of the MDG indicators to track national
effort towards safe mother hood. In spite of this, 16 percent of
births were assisted by a skilled provider: 5 percent by a doctor
and 11 percent by a nurse or midwife. About 2 percent of births
were assisted by a HEW, and 51 percent of births were assisted by
a relative, or some other person. Twenty-seven percent of births
were assisted by a traditional birth attendant, while 5 percent of
births were unattended. Skilled assistance at delivery increased
from 6 to 16 percent in the last fifteen years. The majority of births
are attended by a relative or some other person (51 percent). Five
percent of all births are delivered without any type of assistance
at all .
Not surprisingly, skilled providers attended an overwhelming
majority of births delivered in a health facility compared with
births delivered elsewhere. Urban births were more than six
times as likely to be attended by skilled providers as rural
births. Regional differences in delivery assistance are large. The
proportion of births assisted by a skilled provider ranged from 10
percent in Afar to 86 percent in Addis Ababa. Skilled attendance at
delivery increases with mother’s education and household wealth.
As expected, mother’s education has a positive relationship with
delivery care. Births to women with primary education are almost
four times (9 percent) more likely and births to women with
secondary or higher education are 25 times (58 percent) more
likely to receive delivery assistance from a health professional than
births to women with no education (2%). Similarly, assistance by
a trained health professional varies by economic status of women
, Hence, assessing institutional delivery service utilization and
associated factors is very important to inform service providers
and service users.
a) To assess utilization of Institutional delivery services
and associated factors among mothers who gave birth in the last
one year prior to the study from June 15- July 15inJimma town,
Oromia region, Southwest Ethiopia.
Community based cross sectional study was conducted in
Jimma town from June 15-July 15, 2016 on women who gave birth
12 months before the study period. Jimma town is located 350km
south west of Addis Ababa which is the capital city of Ethiopia.
Administratively, the town is structured into 17 Keble (4 rural &
13 urban). According to 2015 census the projected population of
the town by 2015/16 was estimated to be 182,818 with 91,848
male and 90,970 which is approximately about 1 to 1 male to
female ratio where total number of women who gave birth in the
last one year was 7170.
The study design: A community-based cross-sectional study
design was used.
Source population: Source populations of the study were all
mothers who gave birth in Jimma town in the last 12month.
Study population: All mothers who gave birth in the last 12
months were sampled and included in the study.
Inclusion criteria: Women who gave birth in the last 12
months regardless of the outcome and who lived in the study area
for at least six months.
Exclusion Criteria: Mothers who are severely ill and unable
to hear will be excluded in the interview.
Mothers who gave birth in the last 12 months in the Town,
regardless of their birth outcome, were included in the sample.
Five urban Keble were selected using simple random method
(lottery method). Households from each Keble were selected again
by systematic random sampling with a sampling interval of 7. The
allocated sample size was obtained using proportional allocation
to the size of households found in each Keble. The sampling
was started by selecting an element from the list at random
and then every 7th household where,7, the sampling interval for
interviewing. For those closed houses or the mothers were not
present at the time of data collection, after maximum of 3 repeated
visits were made I was taking as non- respondent. If there were
more than one mother within the same household lottery method
was used to select the one to be included in the sample.
Dependent variables: institutional Delivery service utilization
Independent-variables: age, marital status, religious, ethnicity,
educational status, economic status (income), occupation, age at
first birth, age at first marriage, age at first pregnancy, preference
of husband to place of delivery, preference of other family members
to place of delivery, past birth outcomes, ANC follows up, decision
to seek care, gaining adequate health care.
Data were collected using structured, pre-tested interviewer
administered questionnaire. A structured questionnaire developed
in English in such a way that it includes all the relevant variables
to meet the objective of the study after a review of literature.
Socio-demographic, obstetric and maternal data were collected.
Home delivery was considered when a mother reported birth at
home (other than health institution) to her recent delivery. Data
were collected through face to face interview. Data collectors and
supervisors were trained for three days on the objectives of the
Data were analyzed and tallied manually by using pen, pencil,
paper, calculator and computer. Associations between dependent
and independent variables were assessed using chi square at pvalue
less than 0.05 was considered as statistically significant.
Three staff health extension workers had conducted the face
to face interviews and the main investigate & one nurse had
supervised the data collection process. Training was given to the
data collectors and supervisors for three days before the actual
data collection regarding the aim of study, and data collection
tool and procedures going through the questionnaires question
by question. In addition, the training also focused on the art of
interviewing and clarifying questions that were unclear to the
respondents. To ensure data quality, proper designing, translation
to the local language (during data collection) and pre-testing
of the research tool were done. The filled data was checked for
completeness on daily basis and feedback was given to data
collectors on the next morning.
Letter of ethical approval was received from Institutional
Review Board (IRB) of Jimma University and that was
communicated to the town Health Office and Keble. Permission
and verbal consent were obtained from each respondent during
interview and confidentiality was assured before conducting data
collection. All information that was obtained from the individuals
was kept confidential. The respondent right was guaranteeing to
stop or refuse participation at any time.
Preference of place of delivery: The choice of mothers
where to give birth (home vs. institutional).
Utilization: Means the extent to which a given group of people
uses particular service in a specified period of time.
Maternal death: Is the death of a woman while pregnant or
within 42 days of termination of pregnancy, irrespective of the
duration and site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management but not from
accidental or incidental causes.
Skilled attendants: Refer to people with midwifery skills
(midwives, doctors and nurses with additional midwifery
education) who have been trained to proficiency in the skills
necessary to manage normal deliveries and diagnose, manage or
refer obstetric complications’ (WHO).
Gravidity: Total number of pregnancies.
Grand multi-parity: A mother who has 5 or more viable
Elderly primi-gravida: Any women who experiences her first
pregnancy after the age of 35 years
Teenage pregnancy: is pregnancy in human females under
the age of 20.
Decision to seek care: Mothers tendency towards getting
health care service.
Gaining adequate health care: is the maintenance or
improvement of health via the diagnosis, treatment, and
prevention of disease, illness, injury, and other physical and
mental impairments in all women.
In this study, a total of 402 mothers who gave birth 12 months
prior to study were proposed to be included. Of the total proposed
women, 375 mothers were included in the analysis which made
the response rate 93.3% among which 126 (31.35%) were in the
age group of 25- 29yrs followed by 95(28.6%) in the age group of
20-24. Majority, (91.47%), were currently married with10(2.6%^)
were never married. 45.06% were oromia in their ethnicity
and majority 34.13% were orthodox Christians and a higher
proportion 266 (71.2%) of the respondents attended primary
education and above followed by 16.27% were able to read and
write while 48(12.8%) were unable to read and write. Regarding
occupational status most of the respondents 140 (36.5%) were
engaged in private business and 93(25.6%) were merchant
followed by 87(24.2%) were governmental employee. The rest
13.6 % of the respondents were house wife, daily laborer and other
field of work. Most of husband’s occupation was governmental
employ and private. Around 79% of the respondents had family
size of below 4. Regarding to their economic status majority of the
respondents 270 (72%) were having >500-birr monthly income
even though around 7% of the respondents were having less than
250-birr monthly income. (See Table 1 below).
One hundred seventy-three (46.13%) of mothers had got
marriage at their early age <20 years while one hundred six
(28.27%) of the mothers reported as they were less than 20
years old during their first pregnancy. Two hundred twentyseven
(60.53%) of the mothers were para three and below while
two hundred fifteen (57.33%) mothers were gravid three and
below and one hundred forty-eight mothers was gave birth more
than three. Three hundred forty-five (82%) of the respondents
had ever visited health facilities during pregnancy and 304
(81.07%) of them visited health facilities for ANC purposes
during their last pregnancy. Among the mothers who attended
ANC, majority, 190(63%), made more than 2 ANC visits during
their last pregnancy. One hundred sixty-five (54.28%) of mothers
attended at hospitals and one hundred twelve (36.8%) were at
health center. Out of 304 mothers who attended ANC 282(92.76)
of mothers were getting information regarding the possible
pregnancy and delivery related complications during their ANC
follow up like, severe vaginal bleeding, severe headache, epigastric
pain, blurring of vision, passage of liquor, prolonged labor, cord
prolapse, fast and marked weight gain, fetal movement cessation,
uterine rupture, and so on. The rest 22(7.24%) of mothers who attended ANC were not getting such kind of awareness regarding
the possible pregnancy and delivery related complications. Two
hundred twenty-one (cumulative frequency) (95.7%) preference
of those who attend ANC at health facility was due to their
closeness to their residence and competent workers. About ten
percent, 40 (10.67%) of respondents were encountered abortion
one to two times. Of the total reported pregnancies, 15.2% were
unplanned. In this study, the prevalence of institutional and
home delivery was 74.4% and 25.6% respectively. When mothers
asked for their reasons why give birth at health institution they
told that because they want to get better service, better outcome
for their self and their new born, closeness to their living house
and they also told that they were informed to have birth at the
health institution.4.3% of mothers gave birth at health institution
because of they had a bad experience from past home delivery. And
the reasons not to give birth at the health institution were 31.3%
close attention from their family and relatives, 16% previous bad
experience from health facility, 16.5 % feeling more comfort while
at home and the like. Regarding to husbands and other family
members preference towards the place of delivery 275 (73.33%)
of husbands and 237 (63.2%) of other family members prefer to
give birth to the health facility (Table 2). This study revealed that
the prevalence of institutional delivery service utilization was
74.4% (Figure 1).
Out of 375 mothers who gave birth in the last 12 months prior
to the study 318 (85%) of them responded that their pregnancy
was planned while the rest 57 (15%) of the mother’s pregnancy
was unplanned from which majority was ending up with medical
abortion (Figure 2).
Among those mothers who visited health facilities, the reasons
for visiting health facilities during the last pregnancy included
ANC services (88.2), delivery, problems related to pregnancy and
problems not related to pregnancy (Figure 3 & 4).
Many different reasons were forwarded for home delivery.
Thirty one (32.2%) of the mothers said having closer attention
from family members, 16 (16.66%) said just it was comfortable
delivering at home is 4 (4.37%) said it was my usual experience,
10(10.42%) said lab4r was short/urgent, 9(9.37%) said
unwelcoming approach of the health professional, 16 (16.66) they
said previous bad experience from the health institution (Figure
Majority (70%) of mothers are the final decision makers
regarding place of delivery followed by their husband (20%) and
their relatives/partners (10%).
In this study, among the socio-demographic variables, age
of the mother at interview, occupational status of the mother
and their husband and educational status of mothers and their
husband were statistically associated with institutional delivery
service use. In contrast, marital status, religion and ethnicity had
no association with institutional delivery service utilization (Table
In this study obstetric and maternal variable; age at first
marriage, number of pregnancies, type of pregnancy (planned Vs
unplanned), attending ANC visit in their last pregnancy, number
of ANC visit and number of live births showed statistically
significant association with institutional delivery service use,
while pregnancy loss (abortion) has no association with that of
institutional delivery service utilizations (Table 4).
This community - based study attempted to identify the
magnitude of institutional delivery service utilization and
associated factors among mothers who gave birth in the last 12
months prior to the study in Jimma Town. Despite the relative
accessibility of health institutions in urban areas, a significant
number of urban resident women still delivered at home. The
study results showed that home delivery in the Town was 25.6%
and the majority of mothers (74.4%) gave birth at the health
institution which made the result unsatisfactory. It means overall
delivery assisted by skilled birth attendants was 74.4%. This
study finding was higher than National and Oromia region mini
EDHS result of 2014  which was 16% and 13.1% respectively
but it is lower than Addis Ababa (86.1%); the reason for these big
difference might be due the fact that in urban areas the proportion
of mothers with education is higher, accessibility of the services
with minimal distance and transport, and mothers could have
better decision making autonomy, good knowledge of pregnancy
and delivery complications, and better access to information than
rural mothers .
The finding was much lower when we compare with the
findings of community based cross sectional study on mothers
who gave birth 12 months prior to the study done in Bihar Dar city
administration (urban mother accounts only 83.4%) in 2014, was
78.8% but it was in consistent with cross sectional follow up study
done at Debra Marcos town in 2015, which was74.3% [5,6]. But
from the mini EDHS result of 2014  the finding was much better
than others like Amhara region, Tigray region and Dire Dawa town
in which delivery service utilization rate was 11.7%, 26.2% and
59.2% respectively. This large difference could be due study done
in Amhara Region and Tigray region included both urban and rural
in which the negative influence of husbands and family members
could be lower than Rural Keble, and Urban mothers might be able
to decide on their own health [4-9].
Proportion of women attending antenatal clinic and
delivery in health facility: Antenatal care (ANC) services provide
opportunities for health workers to promote a specific place
of deliver or give women information on the status of their
pregnancy, which in turn informs their decisions on where to
deliver. Risk assessment during ANC may explicitly recommend
a place of delivery, for instance to deliver in a hospital for a twin
pregnancy under normal circumstances [10-12].
WHO recommends that pregnant mother without any
complications have at least four antenatal care clinics to provide
sufficient information for the mother and the developing embryo
In this study, 304(81%) had attended antenatal clinic (ANC).
this is slightly higher than that of national estimate of 54%
(EDHS -2014) (3, 18) and slightly lower than findings of studies
conducted in Debra Marcos town (88.5%). This study also found
that Concerning to number of ANC visit, Out of 304 women
attended antenatal clinic, most of them 190 (62.5%) attended
more than three visits and 114 (37.5%) attended three and above
visits. In this study, age at first marriage and early ANC visits were
also factors associated with institutional delivery service use.
Similarly, planned pregnancy, parity of below three children and
gravidity of less than three were important factor associated with
institutional delivery service use in this study .
There is also an association between mother’s education and
place of delivery. The proportion of births delivered in a health
facility is only 39% percent among uneducated mothers, and 50%
percent among mothers who able to read and write compared
with 86% percent among mothers with primary and higher
The prevalence of unplanned pregnancy from the study
subjects were 15% which is slightly lower than a study conducted
at Bahir Dar city administration in 2014 which was 19%. The
gap might be due to there is a two year different between the
two research studied and women became aware and have a good
attitude towards the modern contraceptive method and most of
the mothers might use the service .
From the total 375 about 40 (10.67%) of respondents were
encountered abortion one to two times. And majority of them are
from unplanned pregnancy because most of mothers who face
such kind of challenge they want to abort and the pregnancy ends
up with abortion .
From the different reasons forwarded from respondent
mothers for the preference home delivery majority thirty one
(32.2%) of the mothers said having closer attention from family
members, 16 (16.66%) said just it was comfortable delivering at
home is 4 (4.37%) said it was my usual experience, 10(10.42%)
said lab4r was short/urgent, 9(9.37%) said unwelcoming
approach of the health professional, 16 (16.66) they said previous
bad experience from the health institution [17,18].
This study also shows that most mothers preferred to give
birth to the health institution because of they want to get a better
service from the health institution, to get better outcome for their
self and to the newborn, some of them were informed when and
where to give birth .
In this study, institutional delivery service utilization is optimal.
Institutional delivery service use among women in Jimma Town
was higher compared with the national and regional estimates,
higher proportion of women from the selected Keble’s of the
Town gave birth at home. Closer attention and care from family
members and relatives, delivering at home is usual experience,
having much freedom at home during delivery, influence from the husband and other family members, disliking the services
provided at the health facilities, bad experience from previous
health facility delivery, labor was unexpected/short and absence
of problem were the main reasons given by mothers not attending
health care delivery. Factors such as age at first marriage, age at
first pregnancy, types of pregnancy (planned/unplanned),parity,
gravidity, occupation, ANC visit during the last pregnancy,
frequency of ANC visit, educational status of the mother and their
husband and knowledge of the mothers on pregnancy and delivery
services were significantly associated with skilled delivery service
We would like to express our deepest gratitude and
appreciation to JUIH, and health professionals working at each
health facilities. We also aknowledge Jimma University -Institute
of health-IRB for securing ethical letter and for the fund provided.
Ethical clearance and an approval letter obtained from Jimma
University institute of health- institutional reviewing board, then
support letter obtained from JU to the study area. Confidentiality
was maintained by using anonymous codes or number.
All parties involved agreed to publish on international peer
reviewed journal. During data collection, all concerned body
informed and agreed on the major objective of the study which is
for accademic purpose including publication.
All authors declare that they have no any financial and nonfinancial
competing interests. None of the authors of this paper
has a financial or personal relationship with other people or
organizations that could inappropriately influence or bias the
content of the paper.
Yibeltal Siraneh B had made substantial contributions to
conception, design, analysis and interpretation of data including
manuscript preparation. Fisseha W worked a lot in acquisition of
data and reviewed the manuscript for the intellectual content. All
authors read and approved the final manuscript.