Factors associated with institutional delivery in Ethiopia: A cross sectional study

BMC Health Services Research, Volume 20, No. 1, Year 2020

Interpretation

Background: In spite of the promotion of institutional delivery in Ethiopia, home delivery is still common primarily in hard-to-reach areas. Institutional delivery supported to achieve the goal of reducing maternal and neonatal mortality in Ethiopia. The objective of this study is to assess the determinants of institutional delivery in Ethiopia. Methods: Cross sectional survey was conducted in 11 administrative regions of Ethiopia. The Ethiopian demographic and health survey data collection took place from January 18, 2016, to June 27, 2016. The study subjects were 11,023 women (15-49 years old) who gave birth in the preceding 5 years before 2016 Ethiopian demographic health survey. This representative data was downloaded from Demographic Health Survey after getting permission. The Primary outcome variable was institutional delivery. The data was transferred and analyzed with SPSS Version 20 statistical software package. Results: Of 11,023 mothers, 2892 (26.2%) delivered at a health facility and 8131 (73.8%) at home. Women with secondary education were 4.36 times more likely to have an institutional delivery (OR: 4.36; 95% CI: 3.12-6.09). Institutional delivery was higher among women who were resided in urban areas by three fold (OR: 3.26; 95% CI: 2.19-4.35). Women who visited ANC (Antenatal care) were about two times more likely to choose institutional delivery (OR: 1.81; 95% CI: 1.58-2.07). Respondents who watch television at least once a week was two times more likely to experience institutional delivery than those who did not watch at all (0R: 1.90; 95% CI: 1.35-2.66). The wealthiest women were 2.61 times more likely to deliver in an institution compared with the women in the poorest category (OR: 2.61; 95% CI: 1.95-3.50). Conclusion: Women having higher educational level, being richest, residing in urban area, visiting antenatal care at least once, and frequent exposure to mass media were factors associated with institutional delivery. Improving access to education and health promotion about obstetrics and delivery through mass media will increase the uptake of institutional delivery. The population of Ethiopia is diverse encompassing 80 different ethnic groups. According to the 2017 estimate, the population of Ethiopia was about 107,406,158. Ethiopian population is equivalent to 1.41% of the total world population, which ranks number 12 from the world. About 20% of Ethiopian population were resided in urban areas [12, 13]. The Ethiopian demographic and health survey data collection took place from January 18, 2016, to June 27, 2016. The data collectors were health professionals recruited from different health facilities throughout the country. Women in reproductive age (15–49) who resides permanently in the selected households or stayed the night before the survey in the household, were entitled to be part of the study subjects. Cross sectional survey was conducted in 11 administrative regions of Ethiopia. The sample was stratified and selected in two stages where each region stratified into urban and rural areas. Samples of enumeration areas (EAs) selected independently in each stratum in two stages. Based on the 2007 population and housing census, in the first stage, 645 EAs of which 202 from urban areas and 443 from rural areas were selected. Household lists helped as a sampling frame for second stage selection of households for the study. Up to 300 households listed in one-enumeration areas. To reduce the task of household listing, each large enumeration areas selected for the survey was segmented. Then household listing was done only in the selected segments. In the second stage of selection, a fixed number of 28 households in each cluster selected with an equal probability of systematic selection from the newly created household listing. The sampling frame of the 2016 Ethiopian demographic health survey was from Ethiopia Population and Housing Census (PHC), conducted by the Ethiopia Central Statistical Agency in 2007 [4]. About 16,583 entitled women identified for individual interviews. Then Interview completed with 15,683 respondents resulting in the response rate of 95% [4]. To assess determinants of institutional delivery, mothers who gave baby within the preceding 5 years extracted from EDHS dataset. Therefore, 11,023 women included in this study. Since there was a non-proportional allocation of the sample to different regions and their urban and rural areas and the possible differences in response rates, a sampling weight used to ensure the actual representative of the survey results at both the national and domain levels. The sample was taken in a two-stage stratified cluster sample. Therefore, the sampling weights are based on sampling probabilities separately for each sampling stage and each cluster [4]. The outcome variable of the study is institutional delivery. Since the study wants to answer the question “what are the determinants of institutional deliveries?” women who deliver at health institutions at least once will be coded as institutional delivery (Yes = 1). The independent variables where socio demographic characteristics (maternal age, marital status place of resident, maternal educational, husband education, wealth index and watching television), pregnancy and health service related factors (Number of Births, antenatal care, told about danger sign during ANC, and health insurance). Data files transferred via internet file streaming system (IFSS) to the CSA central office during data collection. The data processing operation included secondary editing, which required resolution of computer-identified inconsistencies and coding of open-ended questions. Data editing was accomplished using CSPro software. During the duration of fieldwork, tables generated to check various data quality parameters [4] and specific feedback was given to the teams to improve performance. Bivariate logistic regression employed, with the outcome variable of intuitional delivery. First, univariable analyses performed with each of the demographic indicators and other independent variables with the outcome variable. Variables significant at p-value ≤0.2 were included in the multivariable logistic regression models. Variables that did not have a significant regression coefficient removed from the model. Variables that were not significant at the univariate analysis added back to the model and their significance assessed in the presence of other significant variables. Subsequently, the goodness of fit of our final model tested using the Hosmer-Lemeshow test. Data management procedures and statistical analysis done with SPSS software version 20.

AI Digest

Study Justification:

– The study aims to assess the determinants of institutional delivery in Ethiopia.
– Institutional delivery is important for reducing maternal and neonatal mortality.
– Despite efforts to promote institutional delivery, home delivery is still common in hard-to-reach areas.
– Understanding the factors associated with institutional delivery can help inform interventions and policies to improve access and utilization of healthcare services.

Study Highlights:

– The study included 11,023 women aged 15-49 who gave birth in the preceding 5 years.
– Of these women, 26.2% delivered at a health facility and 73.8% delivered at home.
– Factors associated with higher likelihood of institutional delivery include:
– Women with secondary education were 4.36 times more likely to have an institutional delivery.
– Women residing in urban areas were three times more likely to have an institutional delivery.
– Women who visited antenatal care were about two times more likely to choose institutional delivery.
– Women who watched television at least once a week were two times more likely to have an institutional delivery.
– Wealthier women were 2.61 times more likely to deliver in an institution compared to the poorest women.

Recommendations for Lay Readers and Policy Makers:

– Improve access to education for women to increase the likelihood of institutional delivery.
– Focus on health promotion about obstetrics and delivery through mass media to increase awareness and utilization of institutional delivery services.
– Enhance antenatal care services to encourage women to choose institutional delivery.
– Address the disparities in institutional delivery between urban and rural areas.
– Consider targeted interventions for women with lower education levels and lower socioeconomic status to improve access to institutional delivery services.

Key Role Players:

– Ministry of Health: Responsible for developing and implementing policies and programs related to maternal and child health.
– Health Facilities: Provide the necessary infrastructure and services for institutional delivery.
– Community Health Workers: Play a crucial role in educating and mobilizing communities to promote institutional delivery.
– Non-Governmental Organizations: Support the implementation of interventions and programs to improve access to institutional delivery.

Cost Items for Planning Recommendations:

– Education Programs: Budget for initiatives to improve access to education for women.
– Health Promotion Campaigns: Allocate funds for mass media campaigns to raise awareness about the benefits of institutional delivery.
– Antenatal Care Services: Invest in improving the quality and availability of antenatal care services.
– Infrastructure Development: Budget for the construction and maintenance of health facilities to accommodate institutional deliveries.
– Training and Capacity Building: Allocate funds for training healthcare providers and community health workers to deliver quality maternal healthcare services.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study utilized a large sample size and representative data from the Ethiopian demographic and health survey. The study employed statistical analysis to identify factors associated with institutional delivery. However, the study design is cross-sectional, which limits the ability to establish causality. To improve the strength of the evidence, future research could consider a longitudinal design to examine the temporal relationship between the determinants and institutional delivery. Additionally, conducting qualitative research to explore the underlying reasons for the identified associations would provide a more comprehensive understanding of the factors influencing institutional delivery in Ethiopia.

Abstract

The population of Ethiopia is diverse encompassing 80 different ethnic groups. According to the 2017 estimate, the population of Ethiopia was about 107,406,158. Ethiopian population is equivalent to 1.41% of the total world population, which ranks number 12 from the world. About 20% of Ethiopian population were resided in urban areas [12, 13]. The Ethiopian demographic and health survey data collection took place from January 18, 2016, to June 27, 2016. The data collectors were health professionals recruited from different health facilities throughout the country. Women in reproductive age (15–49) who resides permanently in the selected households or stayed the night before the survey in the household, were entitled to be part of the study subjects. Cross sectional survey was conducted in 11 administrative regions of Ethiopia. The sample was stratified and selected in two stages where each region stratified into urban and rural areas. Samples of enumeration areas (EAs) selected independently in each stratum in two stages. Based on the 2007 population and housing census, in the first stage, 645 EAs of which 202 from urban areas and 443 from rural areas were selected. Household lists helped as a sampling frame for second stage selection of households for the study. Up to 300 households listed in one-enumeration areas. To reduce the task of household listing, each large enumeration areas selected for the survey was segmented. Then household listing was done only in the selected segments. In the second stage of selection, a fixed number of 28 households in each cluster selected with an equal probability of systematic selection from the newly created household listing. The sampling frame of the 2016 Ethiopian demographic health survey was from Ethiopia Population and Housing Census (PHC), conducted by the Ethiopia Central Statistical Agency in 2007 [4]. About 16,583 entitled women identified for individual interviews. Then Interview completed with 15,683 respondents resulting in the response rate of 95% [4]. To assess determinants of institutional delivery, mothers who gave baby within the preceding 5 years extracted from EDHS dataset. Therefore, 11,023 women included in this study. Since there was a non-proportional allocation of the sample to different regions and their urban and rural areas and the possible differences in response rates, a sampling weight used to ensure the actual representative of the survey results at both the national and domain levels. The sample was taken in a two-stage stratified cluster sample. Therefore, the sampling weights are based on sampling probabilities separately for each sampling stage and each cluster [4]. The outcome variable of the study is institutional delivery. Since the study wants to answer the question “what are the determinants of institutional deliveries?” women who deliver at health institutions at least once will be coded as institutional delivery (Yes = 1). The independent variables where socio demographic characteristics (maternal age, marital status place of resident, maternal educational, husband education, wealth index and watching television), pregnancy and health service related factors (Number of Births, antenatal care, told about danger sign during ANC, and health insurance). Data files transferred via internet file streaming system (IFSS) to the CSA central office during data collection. The data processing operation included secondary editing, which required resolution of computer-identified inconsistencies and coding of open-ended questions. Data editing was accomplished using CSPro software. During the duration of fieldwork, tables generated to check various data quality parameters [4] and specific feedback was given to the teams to improve performance. Bivariate logistic regression employed, with the outcome variable of intuitional delivery. First, univariable analyses performed with each of the demographic indicators and other independent variables with the outcome variable. Variables significant at p-value ≤0.2 were included in the multivariable logistic regression models. Variables that did not have a significant regression coefficient removed from the model. Variables that were not significant at the univariate analysis added back to the model and their significance assessed in the presence of other significant variables. Subsequently, the goodness of fit of our final model tested using the Hosmer-Lemeshow test. Data management procedures and statistical analysis done with SPSS software version 20.

Materials

N/A

Innovations

The study titled “Factors associated with institutional delivery in Ethiopia: A cross-sectional study” investigated the determinants of institutional delivery in Ethiopia. The study found several factors associated with institutional delivery, including higher educational levels, urban residence, antenatal care visits, frequent exposure to mass media, and higher socioeconomic status.

Based on these findings, the following recommendations can be developed into innovations to improve access to maternal health in Ethiopia:

1. Improve access to education: Implement programs that focus on improving access to education for women. This can include initiatives such as scholarships, vocational training, and awareness campaigns to encourage girls’ education. By increasing educational opportunities, women are more likely to have higher educational levels, which the study found to be associated with institutional delivery.

2. Health promotion through mass media: Utilize mass media platforms, such as television and radio, to disseminate information about the benefits of institutional delivery and the importance of antenatal care. Develop targeted health promotion campaigns that reach women in both urban and rural areas. This can help raise awareness and encourage women to seek healthcare services.

3. Addressing geographical barriers: Implement innovative solutions to address geographical barriers to accessing maternal healthcare services. This can include mobile health clinics that travel to remote areas, telemedicine services that provide remote consultations, and community health worker programs that bring healthcare services closer to women in hard-to-reach areas.

4. Strengthen antenatal care services: Focus on strengthening antenatal care services by ensuring their availability, accessibility, and quality. This can be achieved through training healthcare providers, improving infrastructure, and providing necessary resources for antenatal care clinics. By enhancing antenatal care services, more women will have the opportunity to receive information and support for institutional delivery.

5. Address socioeconomic disparities: Develop innovative approaches to address socioeconomic disparities in accessing maternal healthcare services. This can include providing financial assistance or implementing health insurance schemes specifically targeting disadvantaged women. By addressing socioeconomic barriers, more women will have the means to choose institutional delivery.

By implementing these recommendations, it is possible to improve access to maternal health services and increase the uptake of institutional delivery, ultimately reducing maternal and neonatal mortality rates in Ethiopia.

AI Innovations Description

Based on the study titled “Factors associated with institutional delivery in Ethiopia: A cross-sectional study,” the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve access to education: The study found that women with higher educational levels were more likely to have an institutional delivery. Therefore, implementing programs that focus on improving access to education for women can help increase the uptake of institutional delivery.

2. Health promotion through mass media: The study also found that women who had frequent exposure to mass media, such as television, were more likely to choose institutional delivery. Utilizing mass media platforms to disseminate information about the benefits of institutional delivery and the importance of antenatal care can help raise awareness and encourage women to seek healthcare services.

3. Addressing geographical barriers: The study highlighted that home delivery is still common in hard-to-reach areas. To improve access to institutional delivery, innovative solutions such as mobile health clinics or telemedicine can be implemented to reach women in remote areas and provide them with the necessary maternal healthcare services.

4. Strengthen antenatal care services: The study found that women who visited antenatal care were more likely to choose institutional delivery. Therefore, it is crucial to strengthen antenatal care services by ensuring their availability, accessibility, and quality. This can be achieved through training healthcare providers, improving infrastructure, and providing necessary resources.

5. Address socioeconomic disparities: The study identified that wealthier women were more likely to deliver in an institution compared to those in the poorest category. To address this disparity, innovative approaches such as providing financial assistance or implementing health insurance schemes specifically targeting disadvantaged women can be explored.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Improve access to education: To assess the impact of improving access to education on institutional delivery, a pilot program can be implemented in a selected region or community in Ethiopia. The program should focus on providing educational opportunities for women, including scholarships, vocational training, and adult education programs. Data can be collected before and after the implementation of the program to compare the rates of institutional delivery among women with different educational levels. This can be done through surveys or interviews with women who have given birth in the past 5 years.

2. Health promotion through mass media: A media campaign can be launched to promote the benefits of institutional delivery and the importance of antenatal care. The campaign should utilize various mass media platforms such as television, radio, and social media. Data can be collected through surveys or interviews to assess the impact of the campaign on women’s knowledge and attitudes towards institutional delivery. The number of women choosing institutional delivery before and after the campaign can also be compared.

3. Addressing geographical barriers: To address geographical barriers, a mobile health clinic or telemedicine program can be implemented in hard-to-reach areas. The program should provide maternal healthcare services, including antenatal care and institutional delivery, to women in remote areas. Data can be collected through surveys or interviews to assess the impact of the program on the rates of institutional delivery in these areas. The number of women choosing institutional delivery before and after the implementation of the program can be compared.

4. Strengthen antenatal care services: To strengthen antenatal care services, improvements can be made in healthcare provider training, infrastructure, and resource allocation. A selected region or community can be chosen for the implementation of these improvements. Data can be collected through surveys or interviews to assess the impact of the strengthened antenatal care services on the rates of institutional delivery. The number of women choosing institutional delivery before and after the improvements can be compared.

5. Address socioeconomic disparities: To address socioeconomic disparities, financial assistance programs or health insurance schemes can be implemented specifically targeting disadvantaged women. A selected region or community can be chosen for the implementation of these programs. Data can be collected through surveys or interviews to assess the impact of the programs on the rates of institutional delivery among disadvantaged women. The number of women choosing institutional delivery before and after the implementation of the programs can be compared.

By collecting data before and after the implementation of these recommendations, the impact on access to maternal health services, specifically institutional delivery, can be assessed. The data can be analyzed using statistical software such as SPSS to determine the effectiveness of each recommendation in improving access to maternal health in Ethiopia.

Author

Dima Health

Statistics:

Citations: 13

Identifiers:

DOI: 10.1186/s12913-020-05096-7

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female