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Background The fundamental approach to improve maternal and neonatal health is increasing skilled delivery rate. Women giving birth at health institutions can prevent maternal and neonatal deaths by getting skilled birth attendance. In Ethiopia, despite a significant decrease in maternal mortality over the past decade, still a significant number of women give birth at home. Moreover, evidence from population-based longitudinal studies on skilled delivery is limited. Therefore, this study aims to investigate the magnitude, trend, and determinants of skilled delivery in Kilite-Awlaelo Health Demographic Surveillance System (KA-HDSS), Northern Ethiopia. Method Population-based longitudinal study design was conducted by extracting data for nine consecutive years (2009–2017) from KA-HDSS database. In order to measure the trends of skilled delivery, KA-HDSS data sets were analyzed (2009–2017). Bivariate and multivariate analyses were performed using STATA version 16. A multivariable binary logistic regression model was fitted to assess determinants of skilled delivery and odds ratio with 95% CI was used to assess presence of associations at a 0.05 level of significance. Results The skilled delivery rate have continuously increased among reproductive age women from 15.12% (95% CI: 13.30% – 17.09%) in 2010 to 95.85% (95% CI: 94.58% – 96.895%) in 2017. The skilled delivery rate becomes high (> = 82) in the period of 2014–2017. Education, residence, marital status, occupation and antenatal care (ANC) visits were the most important determinants for skilled delivery among reproductive age women during the period of high skilled delivery rate (2014–2017). Women urban dwellers had about 28 times (AOR = 27.66; 95% CI: 3.86–196.97) higher odds to deliver by skilled birth attendants than rural dwellers. Unmarried women who gave birth were 2.18 (AOR: 2.18; 95% CI: 1.30–3.64) times more likely to have skilled delivery service compared to those married. Likewise, women with four or more ANC visits were 3.2 times more likely to undergo skilled delivery service than those having no ANC visits (AOR: 3.16; 95% CI: 2.33–4.28). Moreover, women having at least a secondary education were 2 times more likely to have skilled delivery service compared to those women with no formal education (AOR = 2.10, 95% CI: 1.18–3.74). Conclusion Regardless of the importance of health facility delivery, a significant number of women still deliver at home attended by unskilled birth attendants. There has been a substantial increase in use of health facilities for delivery among women in the reproductive age. The factors affecting skilled delivery among reproductive age women were educational level, residence, marital status, occupation and use of ANC service. Maternal health related interventions are needed to change women’s attitudes towards skilled delivery. Moreover, ANC coverage should be increased to improve skilled delivery service.
KA-HDSS is an ongoing open cohort study, located in Northern Ethiopia and hosted by Mekelle University. The site has three climatic zones which includes lowland, midland and high land. Administratively, it was established in 9 rural and 1 urban kebelles in April 2009 (a kebelle is the smallest administrative component in the country). At the beginning of the surveillance, baseline socio-demographic characteristics of 65,848 individuals living in 14,455 households were collected through a census. At the same time, a unique surveillance identification number was given to every enumerated cohort and household to facilitate linking information during longitudinal observation. In 2016, 2 urban kebelles were added as part of the study area and the number of household increased to 21,688. In 2017, the project has made 11 updates rounds with population of 101,146 living in 21,688 households in 12 kebeles (9 rural and 3 urban). A house to house visit is done to capture information regarding individuals, pregnancy observation, pregnancy outcomes, deaths, births and migration. Events are collected as it occurs and updated every six months [19]. The source of data for this study was from KA-HDSS. The study population for this study was all women who had at least one birth in KA-HDSS from April, 2009 to December, 2017. Data regarding the skilled delivery were extracted mainly from pregnancy observation, pregnancy outcome, and relationship tables of KA-HDSS data considering the relevance of each explanatory variable on the prediction of skilled delivery rate in the population. The dependent variable in this study was skilled delivery. It was a dichotomized response as 1 if a woman gave birth by skilled birth attendants and 0 otherwise (if a woman gave birth by unskilled birth attendants). The independent variables were classified as socio-demographic variables, and pregnancy outcome and related variables. The socio-demographic variables are age, ethnicity, religion, marital status, occupation, level of education, and place of residence. The pregnancy outcome and related variables are age at pregnancy, number of ANC visits, bed net use, number of children born alive, number of children dead, number of previous pregnancy and previous pregnancy outcome. Data were cleaned and analysed in STATA version 15 statistical tool. The study population were described using frequency (percentage), mean (±standard deviation (sd)) depending on the nature of data (variables). A line graph was used to observe the trend of institutional delivery (number of skilled deliveries per 100) over time. Moreover, a cross-tabulation between each categorical independent variable and the outcome variable was done to check whether the expected cell counts were adequate or not. Besides, descriptive statistics, a rigorous statistical method was applied to identify the determinants of delivery in the study setting. Bivariate analysis was performed to assess the relationship between the dependent and independent variables. A multivariable binary logistic regression analysis was fitted to identify the adjusted effect of each determinant on the skilled delivery among the study population of the specified study setting. The assumptions of multicollinearity between two or more independent variables were checked. Goodness of fit of the model was assessed using Hosmer-Lemeshow test. Decision regarding the statistical significance effect of independent variables on skilled delivery was made based on either the 95% CIs for AOR or associated P-values. Permission to access the data was obtained from Mekelle University KA HDSS via an agreement on the data sharing policy after ethical approval was obtained from Institutional Review Board (IRB) of Mekelle University, College of Health Sciences. Consent to participate was fully waived as the study participants were not directly involved in the study (i.e. an already existing data were utilized for analysis in the current study). Moreover, the confidentiality of data was kept as there were no personal identifiers used and neither the raw data nor the extracted data were passed to a third person (i.e. it is only used for the purpose of the study).
