Nigus Bililign 1, Ibrahim Yimer 2, Addis Adera Gebru 3 *, Yonas Yimam Ayene 4, Tigabu Molla 5 and Markose Kidane Asefa 6

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1 International Journal of Pharma Sciences Vol.,. (20): Research Article Open Access ISSN: Assessment of prevalence and associated factors of institutional delivery among women who gave birth in the last two years in Goba Woreda, Oromia Regional State, Ethiopia Nigus Bililign, Ibrahim Yimer 2, Addis Adera Gebru *, Yonas Yimam Ayene 4, Tigabu Molla and Markose Kidane Asefa Woldia University, Health Science Faculty, Department of Midwifery, P.o.box-400,woldi, Ethiopia 2 Madawalabu University, faculty of medicine and Health Sciences, Department of Midwifery, Ethiopia Woldia University, Health Science Faculty, Department of Nursing, P.o.box-400, Woldia, Ethiopia 4 Woldia University, Health Science Faculty, Department of Nursing, P.o.box-400, Woldia, Ethiopia Woldia University, Business and economics Faculty, Department of Economics,P.o.box-400,woldi,Ethiopia Department of Economics, Faculty of Business and Economics, Unity University, Addis Ababa, Ethiopia. * Corresponding author: Addis Adera Gebru, addisaderagebru@gmail.com Received: 0 May 20 Accepted: 2 May 20 Online: 08 June 20 ABSTRACT Institutional delivery service utilization is essential to improve maternal and child health. United nations children s fund(unicef) estimate that yearly about,000 women die of pregnancy and child birth complications. It is also estimated that 00 children across the world die each day from pregnancy and child birth related problems and the greater proportion of those deaths occurs in developing countries. Prevalence of Institutional delivery in Ethiopia is 0%. A skill birth attendant at delivery is crucial to reduce maternal death. However, little is known about prevalence of institutional delivery and determinant factors of institutional delivery. This study showed the prevalence and associated factors of institutional delivery in Gobaworeda. Community based cross sectional study was done on mothers who gave birth in the last two years in Gobaworeda from April - June 08, 204. Mothers were selected by systematic random sampling technique. Data was collected by face to face interview. To determine the associated factors of institutional delivery, Bivariate and multivariate logistic regression analyses were done by using SPSS version.0. P-values <0.0 were considered as statistically significant. A total of mothers were interviewed. Among them,.2% of mothers had institutional delivery and 8.8% of the mothers gave birth at home. Mothers educational status, occupational status and age at first pregnancy were factors significantly associated to institutional delivery service utilization. Institutional delivery service in Gobaworeda was low in relation with the national plan for institutional delivery. But it is very high when compared to other studies conducted in different parts of Ethiopia. It is recommended that motivating mothers through formal education and awareness creation about the benefit of institutional delivery service utilization and the risk of home delivery should be given due attention by the local health workers. Keywords: prevalence, institutional delivery, women, birth in the last two years.. INTRODUCTION Maternal mortality remains major challenge to health system worldwide. According to assessment of trends in maternal mortality for 8 countries from it was estimated to be 42,900 maternal deaths worldwide. More than 0% of all maternal deaths were only from six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia and Republic democratic Congo) []. Most sub Saharan African countries are not on track for meeting the target pertaining to maternal mortality rate. Recent estimate suggests that the average annual rate of reduction in maternal mortality in sub-saharan African country is less than % [2].A study in Kathmandu, Nepal, showed 077

2 Nigus Bililign et al. / Int J Pharma Sci. 20, (): that 72% of women age 20-4 had their most recent birth in health facility compared with 8% of women age. The same study revealed that about 79% of women with a first pregnancy and 70% of women with second pregnancy delivered in health facility compared with 0% of women with fourth or higher order pregnancy. Home delivery is more common among poorer than wealth women. A study in Nepal showed that a higher percentage of women with higher income level give birth in a hospital, compared with those with a lower income level [2]. Research conducted in Nigeria and southern Tanzania showed that, the proportion of women who give birth at health facilities was 47% and 4% respectively. Residence of the respondents was significantly associated with institutional delivery service utilizations. Several studies have shown that women s use of health facility delivery service is influenced by their demographic background characteristics and their socioeconomic status. A study in rural India showed that institutional delivery is much more common for first births than for subsequent births. Regarding age at delivery, another study in rural India, Punjab revealed that institutional deliveries were more common in comparatively younger age groups, 4% for women age 8- compared with 2% for women age -4 []. In Ethiopia institutional delivery service utilization at national level was very low, only 0 % of births were assisted by skilled health care provider. Moreover, sixty one percent of mothers stated that health facility delivery was not necessary and thirty percent stated that it was not customary to deliver at health facility. Previous local studies done in Ethiopia showed that there were variation in skilled birth attendance, 2.% in Munisa district, 4.% of rural mothers and 40% urban mother in Arsi, 2.0% (20.8%in urban and.8 % in rural mother) in Metekel,.% in rth Gondar, 2.% in Sekela district. Previous studies also showed that institutional delivery service utilization were associated with educational status of mothers and their husbands, income level, preferences of the attentions of their relatives, trust on traditional birth attendants, absence of health problems during pregnancy, antenatal visits during pregnancy, short duration of labor, mothers place of residence, age, perceived distance to the nearest health facility and transportation costs [,,7]. In 200, the gov t of Ethiopia has planned to reach 0% institutional delivery but it remains only 0%. As EDHS 20 has shown that maternal mortality ratio was 7 per,000 live birth for 7 year period preceding the survey is not significantly different from EDHS 200 which is 7 per,000 live birth [,8,9].Prevalence and associated factors of institutional delivery are different in different areas and communities. However studies have not been conducted in Gobaworeda. So this study will help to understand the prevalence and associated factors that affect institutional delivery in the study woreda to reduce all the possible negative effects of home delivery on the mother, child, family and other aspects of social life. Studying those factors will help in reducing barriers to institutional delivery. The main objective of this study was assessed prevalence and associated factors of institutional delivery among women who gave birth in the last two years in Goba Woreda, MATERIALS AND METHODS 2. Study area and period This study was conducted in GobaWoreda. The capital of the Woreda is Goba. Goba town is found in bale zone of Oromia regional state, which is located 444 kilometers from Addis Ababa. This Woreda has a total population of 42,829. The area is structured in to six urban and 8 rural Kebeles. There are four health centers, 24 health posts and one hospital. There are a total of 8 health extension workers in this Woreda. The study was conducted on Kebele 04 from the urban and Sinja and BurkituKebeles from the rural. The study was conducted from April - June 08, Study design Community based cross sectional study design was used to assess prevalence and associated factors of institutional delivery in GobaWoreda. 2. Population 2.. Source population All women of reproductive age group (-49) who live in GobaWoreda 2..2 Study population Women who gave birth within the last 2 years in GobaWoreda 2.4 Sample size determination Sample size was calculated from source population using single population proportion formula. n= Z 2 p (-p)/d 2 n= (.9) 2 0.2(-0.2)/ (0.0) 2 n= Adding 0% non-response rate, our total sample size was. 2. Sampling technique Multi stage sampling was used to select the study subjects. Two Kebeles from the rural and one Kebele from the urban were selected by simple random sampling (SRS). At the Kebeles level households were selected by systematic random sampling method. The sampling interval of the household in each Kebele was determined by dividing the total number of the household to the allocated sample size. When more than one eligible mother encountered in the household, lottery method was used to determine the woman to be interviewed. When no eligible woman identified in selected household the next household was visited. 078

3 Nigus Bililign et al. / Int J Pharma Sci. 20, (): Data collection tool and techniques The data was collected by face to face interviewing of the study subjects using structured questionnaire which was adopted from previous research on the same topic with proper author permission. 2.7 Operational definitions Institutional delivery service utilization: giving birth in hospital, health center and clinics or health posts. Home delivery: giving birth in their home of residence. Maternal mortality: 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. 2.8 Data quality control Pretest was conducted in % of the study population in one urban and two rural kebeles other than kebeles selected for study to assess the reliability of data collection instruments. The questionnaire was prepared in English and translated to Afan Oromo and Amharic for interview. The completeness of the questionnaire was checked during and after collection. 2.9 Data processing and Analysis Data was first checked manually for completeness and then coded and entered in to SPSS version.0 computer program. The data were then cleaned by visualizing, calculating frequencies and sorting. Finally, univariate analyses were done using frequency and percent. Bivariate analyses between dependent and independent variables were performed using chi square(x 2 ) and multiple logistic regression. Multivariate analysis was also done to control (adjust) possible confounding variable. Those variables showed significant association on bivariate analyses were adjusted to each other to identify independent determinants. During the analyses P-value and /or 9%confidence interval (CI) for OR (odds ratio) were used in judging the significance of the associations. So that P-value less than 0.0 or CI not containing one was taken as significant association. Results were presented in text, tables, charts and graphs. 2.0 Ethical considerations Formal letter written from MWU medicine and health Science College and permission from Gobaworeda administrative office were obtained to conduct the study. The study participants were informed about the purpose of the study and informed verbal consent was obtained from each participants before data collection. Finally confidentiality was assured and the data was kept by avoiding personal identifiers. The result of the study was disseminated to CBE office of MWU College of medicine and health science, health bureau of the study woreda. In addition to this the finding of the study provided and disseminated to local health department, the nearby health institutions and to Zonal health departmentto update information and make use of it for intervention.. RESULTS AND DISCUSSION. Socio demographic characteristics A total of mothers who gave birth in the last two years were interviewed and the response rate was %. Out of these 22 (.7%) were rural residents and most of the respondents (29.%) were in the age group of -29 years. Majority of the mothers were married (8.%). 28.4% of mothers completed their secondary education and above. Majority of respondents husbands (8.%) were completed their secondary education and above. Majority of the respondents were housewives (7.4%). Most of the mothers were Muslims (0.%) and Oromo is the predominant ethnic group (7%). 80.% of the total respondents had Radio and 9.% of the mothers spent 0 minutes to reach the nearest health facility. Majority of mothers (.%) had monthly income of 00 birr..2 Obstetric characteristics Out of the total respondents.4% of mothers had their first pregnancy in the age group of years and majority of the mothers (29%) had their last pregnancy in the age group of -29 years. 48.% of the mothers had conceive 2-4 times and 48.% of the respondents gave birth 2-4 times. Majority of the respondents (8%) had ANC visit in their last pregnancy and from these 8.% of the mothers visited ANC clinic 4 and above times. From the mothers who had ANC follow-up in their last pregnancy, 8.4% of the respondents were informed about delivery complications and 78.8% of the respondents were informed about place of delivery by health professionals at ANC clinic. 78.8% of the respondents stay in labor for less than 2 hours and 9.4% of the mothers had alive baby in their last birth.. Place of delivery Out of the total respondents, 70(92.9%) know that their nearby health facility is providing delivery service. From the total respondents only 7(8.8%) mothers gave birth at home, where as the majority of the mothers 22(.2%) gave birth at health facility. Among the mothers who gave birth at home, 24.% of mothers faced complication during their last birth. During home delivery.4% of the mothers assisted by their relatives and untrained traditional birth attendants assist 0.4% of the mothers..4 Reasons for not giving birth in health institutions Regarding reasons for preferring home deliveries; 24.% of the respondents reported that previous home delivery was normal and 0.9% of the mothers reported that health facility was too far. Labor was smooth and short, labor was at night, and near to be with relatives were also reasons for non-use of health facility reported by the respondents

4 Nigus Bililign et al. / Int J Pharma Sci. 20, (): Table. Frequency distribution of respondents place of residence, age, marital status, education and occupation in Gobaworeda, May 204 Variables Frequency Percentage Place of residence Urban Rural Age at interview >= Marital status Married Single Divorced Widowed Educational status of mothers Unable to read and write Able to read and write Primary school Secondary & above Educational status of husbands Unable to read and write Able to read and write Primary school Secondary & above Occupation House wife Merchant Government employee Student Others Table 2. Frequency distribution of respondents religion, ethnicity, distance from HF and income. Variable Frequency Percentage Religion Muslim Orthodox Protestant Others Ethnicity Oromo Amhara Tigre Others Radio Distance from health facility 0 minutes >0 minutes Income/month < birr -499 birr 00 birr

5 Nigus Bililign et al. / Int J Pharma Sci. 20, (): Table. Obstetric characteristics of respondents in Gobaworeda, May 204. Variables Frequency Percentage Age at st pregnancy < >= Age at last pregnancy Gravidity 2-4 Parity 2-4 ANC visit Frequency of ANC visit Table 4. Frequency distribution of respondents information on delivery complications and place of delivery, outcome of birth and duration of labor in Gobaworeda, May 204. Variables Frequency Percentage Informed about delivery complications I don t remember Informed about place of delivery I don t remember Duration of labor in last birth >2 hours 2-24 hours > 24 hours Outcome of baby in last birth Alive Still birth

6 Nigus Bililign et al. / Int J Pharma Sci. 20, (): Table. Place of deliveries in Gobaworeda, May 204 Variables Frequency Percentage Do you know that the nearby health facility is providing delivery service? I don t remember Place of delivery in last delivery Health facility Home Had complication during last birth among home deliveries Assistant during home delivery in last birth attendant TTBAs Untrained TBAs Relatives P r e v a l e n c e Reasons for not giving birth in health institution Figure : Reasons for not giving birth at health institutions reported by respondents in Gobaworeda, May 204. Figure 2: Types of complications faced during home delivery reported by mothers who gave birth at home in GobaWoreda, May

7 Nigus Bililign et al. / Int J Pharma Sci. 20, (): Types of complications Among the mothers who gave birth at home, obstetric complications were reported. Majority of the mothers (.8%) reported excessive bleeding followed by loss of consciousness (8.2%) and prolonged labor (7.%).. Factors associated with institutional delivery service utilization Bivariate analysis was carried out to examine factors associated with institutional delivery service. The socio demographic variables which showed statistically significant association were mothers educational status and occupational status (p-value 0.0). The obstetric variable that showed statistically significant association (p-value 0.0) was age at first pregnancy. Finally, multiple logistic regressions were carried out to predict institutional delivery service utilization with variables that were statistically significant during bivariate analysis (p-value 0.0).The result showed that mothers who had secondary and above educational level were more likely to utilize institutional delivery service than those who cannot read and write (AOR=. & 9% CI=2.2-.7). Regarding respondents occupational status, government employees were about seven times more likely to had institutional delivery than housewives. Age at first pregnancy was also another variable which showed significant association with institutional delivery service utilization. Women in the age group of years were about seven times more likely to give birth at health facility than those whose age was less than years. Table. Association of socio demographic factors of respondents with preference to health institution delivery. Variables Institutional delivery COR(crude odd ratio) 9% CI AOR(adjusted odd ratio) 9% CI Place of residence urban rural ( ) 0.29 ( ) Age at interview Respondents education Illiterate Read and write Primary education Secondary and above Husbands education Illiterate Read and write Primary education Secondary and above Respondents occupation Housewife Gov t employee Merchant Student Others Radio ( ) 0.8( ) 0.8(0.09-.) 0.2( ) 8.(2.8-.7) 7.78(.7-.) 8.( ).48(.-2.8).87(.-9.8).(7.-79) 2.0(0.00).7(2.-.) 2.(0.7-7.).4(0.7-.8) 0.( ) (.0-.9) 0.7 ( ) ( ) 0.0 ( ).94( ).47( ).(2.2-.7E)* 0.444( ) 0.2( ) 0.9( ).982E7(0.00)* 2.0( ) 2.00( ) 0.97( ) 0(0.-.00) Distance from HF 0 minutes >0 minutes (0.0-0.) 0.42( ) Monthly income < birr -499 birr 00 birr ( ) 2.0( ) 2.( ).47( ) 08

8 Nigus Bililign et al. / Int J Pharma Sci. 20, (): Table 7. Association of obstetric factors of respondents with preference to health institution delivery in Gobaworeda, May 204 Variables Institutional delivery COR(crude odd ratio)(9% AOR(adjusted odd ratio)(9% CI) CI) Age at st pregnancy < >= (0.7-.) 7.4E(0.00)* 0.00(0.00) Gravidity Parity Use of ANC Frequency of ANC visit 2-4 Informed about place of delivery during last pregnancy I don t remember (0.-.22) 0.07( ) 0.(0.-.) 0.08( ) 0.08( ) 2.( ) 0(.0-2.) 0.4( ) 0.7(0.8-.2) 0.98( ) 2.4( ).790( ) 2.8( ).7(0.-4.8) 0.70( ) 0.0( ) Knowledge of mothers about institutional delivery service I don t remember ( ) 0.4( ).04 ( ) 0.44 ( ) This community based study has attempted to show prevalence of institutional delivery and factors associated with use of health facility in Gobaworeda, Oromia regional state. The results of this study revealed that the proportion of women who delivered at health facilities was.2% in the woreda and that, 8.8% of the mothers gave birth at home. This finding was high when compared to study conducted in MunisaWoreda which was only 2.% [2]. The difference could be explained by the fact that mothers in this study area had better awareness on health facility delivery and better antenatal care service utilization. The vast Majority of mothers gave birth at health facilities but 8.8% of the mothers preferred home delivery. The most common reasons for home delivery were previous home delivery was normal, health facility was too far, labor was smooth and short and time of labor was at night. According to the 20 EDHS report, the main reasons for home delivery were health facility delivery was not necessary (%), health facility delivery was not customary (0%) and health facility was too far (4%). The main reasons for home delivery in Oromia regional state were health facility was not necessary (.%), health facility was too far (8.2%) and not customary (28.9) according to the national demographic health survey of 20 [, 0,4].This study showed that mothers who delivered at home had faced birth complications. Mothers who delivered at home reported complications such as excessive vaginal bleeding, loss of consciousness prolonged labor and retained placenta. This finding is similar with the result reported from rth Gondar, which revealed that mothers who gave birth at home had excessive vaginal bleeding, prolonged labor and retained placenta respectively [2,,9, 7]. Respondents educational status, occupation and age at first pregnancy were factors found to be significantly associated with institutional delivery service utilization. However, variables like place of residence, age, husband education, income, gravidity, parity and ANC visit had no significant association with institutional delivery service utilization. Respondents educational status showed statistically significant association with institutional delivery service utilization. Mothers who had educational level of secondary and above were more likely to utilize 084

9 Nigus Bililign et al. / Int J Pharma Sci. 20, (): institutional delivery service than mothers who cannot read and write (AOR=. & 9% CI=2.2-.7). This finding was consistent with findings of research conducted in Nigeria, Tanzania which showed that, educational status of mothers to be the most significant associated factor for utilization of institutional delivery service [,,7, 8]. There are a number of reasons why educational status of mothers has significant positive relationship with utilization of institutional delivery service. Education may enhance females autonomy; thus increasing mothers ability to make decisions regarding their utilization of health facility delivery service. Education also increases the knowledge of delivery care, thus increasing the demand for institutional delivery service. Husband education level was also one of the factors that predict health institutional delivery in the present study. Women whose husbands had secondary and post-secondary education were more likely to give birth at health facility than those women whose husbands were unable to read and write. However, husbands educations do not show statistically significant association for institutional delivery service utilization. This finding was in line with a study conducted in Enugu, rtheastern Nigeria. Women whose husbands had secondary and post-secondary educations were about 2.8 times more likely to deliver in health facilities as compared to women whose husband were unable to read and write [7,8,20]. The possible explanation for this might be that educated husbands might be close towards modern medicine and aware of the benefit of giving birth at health facilities. Mothers occupational status was another socio demographic factor found to be significantly affecting the use of health facility delivery. Government employees were seven times more likely to utilize institutional delivery than housewives. This finding is also similar with a study conducted in MunisaWoreda, Southeast Ethiopia [4, 2]. This might be due to the fact that employed women have a better chance in decision making and also they have better opportunity for information about the importance of health facility delivery in their work place than mothers who are not employed. Age at first pregnancy was found to be a factor found to be significantly affecting the use of institutional delivery service. Women in the age group of 20-4 years were seven times more likely to give birth at health facilities than those whose age was less than. Findings of a study conducted in MunisaWoreda, Southeast Ethiopia revealed that women in the age group of 20-4 were four times more likely to give birth at health facilities compared to women aged less than 20 years [2]. This reason can be explained by women in this age group may be more aware and had information about the importance of institutional delivery. Furthermore, most of the time younger women become pregnant after marriage and the lack support during labor to go to health facility. 4. CONCLUSION This study revealed that the proportion of women who gave birth at health facilities in the woreda was relatively low (.2%) in relation to the national plan for institutional delivery. The rest 8.2% of the mothers gave birth at home. The most common reasons for home delivery were previous home delivery was normal, health facility was too far, labor was smooth and short and time of labor was at night. This study showed that mothers who delivered at home had faced birth complications. Mothers who delivered at home reported complications such as excessive vaginal bleeding (.8%), loss of consciousness (8.2%) prolonged labor (7.%) and retained placenta (4.9%). Mothers educational status, occupational status and age at first pregnancy were factors significantly associated with institutional delivery service utilization.. ACKNOWLEDGEMENTS We are thankful to all our department technical staffs for their excellent technical support. We are grateful to all the participants for their cooperation and Madawalabu Universityfor financial support Author s Contributions NBY, have made substantial contributions to beginning and design, collection of data, analysis and interpretation of data and in drafting the manuscripts and correcting the comment given by the advisors. IY, involved in revising the research paper and the manuscript critically for important intellectual context and approval of the final version to be published and participated in its design and coordination. He participated in the approval and funding process, participated in the design of the study participated in its design and coordination. AAG, had greater contribution in reviewing the manuscript English and topography. And helped to draft the manuscript. YYA had greater contribution in reviewing the manuscript English and topography. 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