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ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Assessing the Magnitude of Institutional Delivery Service Utilization and Associated Factors among Mothers in Debre Berhan, Ethiopia

https://www.omicsonline.org/editorialboard-pregnancy-and-child-health-open-access.phpAsmamaw Limenih1, Negussie Deyesa2 and Adugnaw Berhane3*

1North Shoa Zonal Health Department, Amhara Regional Health Bureau, Ethiopia

2School of Public Health, Adis Ababa University, Ethiopia

3College of Health Sciences, Debre Berhan University, Ethiopia

*Corresponding Author:
Adugnaw Berhane
College of Health Sciences, Debre Berhan University
Addis Ababa, Ethiopia
Tel: 251911391111
E-mail: [email protected]

Received date: March 14, 2016; Accepted date: May 26, 2016; Published date: May 30, 2016

Citation: Limenih A, Deyesa N, Berhane A (2016) Assessing the Magnitude of Institutional Delivery Service Utilization and Associated Factors among Mothers in Debre Berhan, Ethiopia. J Preg Child Health 3:254. doi:10.4172/2376-127X.1000254

Copyright: © 2016 Limenih A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Introduction: Institutional delivery service utilization is essential to improve maternal and child health. However, little is known about institutional delivery service utilization in Debre Berhan, Ethiopia. This study was aimed at assessing the magnitude of institutional delivery service utilization. Methods: Community based cross sectional study was done on 424. Census was carried out in 5 urban and two rural kebeles (the smallest administrative unit) to identify mothers who gave birth in the past two year. Mothers were selected by systematic random sampling technique. Quantitative data were collected by means of a pre-tested and structured questionnaire. Bivariate and multiple logistic regression analysis were done by using SPSS version 16; P-values ≤ 0.05 were considered as statically significant. Results: The study indicated that 80.2% of the respondents delivered in health facilities with the assistance of skilled birth attendants, the rest home delivery from home delivery 63.7 % of them assisted by traditional birth attendants. Mothers in urban residence were 4.7 times more likely to utilize institutional delivery attendants than those who live in rural Conclusion: Institutional delivery service in Debre Berhan even though shows improvement from similar studies still mothers exercise home delivery especially in the rural settings. 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 especially in rural area by the local health workers.

Keywords

Institutional delivery service; Debre berhan; Ethiopia

Introduction

Maternal Mortality has been given due emphasis on the MDGs for its reduction by ¾ by the year 2015. This indicates the need to acquire reliable baseline information for monitoring progress. Several approaches have been adapted to acquire reliable data on maternal deaths [1]. The use of a skilled attendant at institution level has been cited as the single most critical intervention for improving maternal and child health to achieve Millennium Development Goal (MGD). Vast majority of deaths from obstetric complications are preventable and that every pregnancy faces risk which may not always be detected through the risk assessment approach during Antenatal Care [2]. The proportion of women who delivered with the assistance of a skilled birth attendant is one of the indicators in meeting the fifth millennium development goal. Moreover, providing skilled care at birth goes hand in hand with the MDG to reduce child mortality but still the coverage is very low, particularly neonatal mortality. Nearly 3.4 million of the 8 million infant deaths each year occur within the first week of life and are often due to a lack of or inappropriate care during pregnancy, delivery and the post-partum period [2]. In Ethiopia with maternal mortality of 676 per 100,000 live births, the majority of births delivered at home without any supervision from health professionals. Fifty percent of deliveries in urban and 4% rural and 10% cumulative in the country were assisted by health professionals. In Amhara region only 10.2% of deliveries were assisted by health professionals [1]. Particularly, in Debre Berhan majority of the population lives within 5 km of staffed health facilities, women who have delivery assistance from health professionals in the last two three years were low as reports show in the district. The Government of Ethiopia is committed to achieving Millennium Development Goal 5 (MDG5), to improve maternal health, with a target of reducing the maternal mortality ratio (MMR) by three-quarters over the period 1990 to 2015. Improving access to and strengthening facilitybased maternal and new born services is one such approach, and is also a Health Sector Development Plan (HSDP) strategic objective which focuses on maternal health and assess its implementation strategy and detail activities plan even though there is an improvement in the area the performance is differ from area to area to assess the current utilization conducting a study is very mandatory [1].

Methods

Study design and period

Community based cross sectional study was conducted from March, 2014 to April, 2014.

Study area

The study was conducted in Debre Berhan district, North Shoa zone, in Amhara regional state, which is 130 km far from Addis Ababa in the way to Dessie. The Woreda has administratively divided into 9 urban and 5 sub rural kebeles. Its population is estimated to be 84,944 Out of this 48.5% are males, and 51.5% are females. Two health center, 5 health post, 1 Government hospital, 1 private hospital and 6 different level private clinics are available in the Woreda.

Sample size determination and sampling method

To measure the proportion of utilization of institutional delivery among mothers who gave birth in the last two years, sample size determination for single population was used.

• Women who gave live birth in the last two years in the district were 3398 from health extension worker registration book.

• Prevalence of delivery assistance from health professionals is 10.2% for Amhara region from DHS-2011

• Considering α 5% for the risk of rejecting null hypothesis and 96% confidence level

• Marginal error 4%

• Design effect of 2 because of sampling variation

• 10% for non-response rate

• The sample size for the study was 424 women who had given birth within the last two year prior to the survey.

Multistage sampling technique was used to select the study population. Initially the study area was divided in to two strata, urban and rural kebeles. For logistical and cost reasons five urban and three rural kebeles (the lowest structure unit in the community administration) was selected by simple random sampling technique in the sample frame.

Data collection and management

Interview using standard and structured questionnaire which was answered the variables like socio-demographic, obstetric, actual delivery and related variables and used after reviewing relevant literatures and adapted from previous similar studies. The English version was translated to local language to understand easily which Amharic. Data collectors were 6 female clinical nursing graduated students and one health officer supervisor. They conducted the interview at the women’s house of those who were eligible.

The quality of data was assured by proper designing and pre-testing of the standard questionnaires in the area that was not included in the main study with similar socio-demographic characteristics to ensure its validity. Training was given for 2 days by the principal investigator, on the general objective of the study and technique.

The coded data was entered, using Epi-info version 3.3.2 and exported to SPSS version 16 for data cleaning and analysis. After export Bi-variant and Multivariate analysis was carried out to calculate the crude odds ratio (OR) and Adjusted odds ratio for testing of the association b/n independent and dependent variables Analysis was done according to the objectives of the study.

Ethical consideration

The ethical approval and clearance was obtained from the Institute of Medicine and health science Debre Berhan University. Formal permission was also obtained from the woreda administrations and health office. Data collectors were diploma graduated female nurses and create a trusting environment by respecting the participant’s privacy. Participation in the survey was voluntary. Moreover, individual verbal consent of the study participant was obtained.

Results

Socio-demographic characteristics of the respondents

Out of 424 women were sampled 404 mothers who gave birth in the last 2 years were interviewed with 95.3% response rate. 325 (80.4%) were urban and therestruralresidents. 20 women were not included in the study due to different reasons. Most 149 (36.9%) of the respondents were in the age group 25-29 years with mean age of 28.1 ± 5.45. The majority 290 (71.8%) of the study subjects were housewives. Among the interviewed mothers 225 (55.7%) have primary education and 110 (27.2%) were with secondary education and above and the rest 69 (19.1%) were with no education. One hundred seventy six (43.6%) of the respondents had monthly income 150-499 Birr per month, while only 21 (5.2%) were responded<50 Birr per month (Table 1).

Variables Number Percent
Place of residence
Urban                                         
Rural                                                                                                                                                          
325
79
80.4
19.6
Age of mother at interview
15-19                                                                           
20-24
25-29
30-34
35+                                                                      
(Mean SD,28.1 ± 5.45)
26
117
149
66
46
6.4
29.0
36.9
16.3
11.4
Marital status
Married
Divorced/Widowed
366
38
90.6
9.4
Mother education
No education
Primary education and above
69
335
17.1
82.9
Husband education (n=366)
No education
Primary education and above
44
321
12.3
87.7
Mother occupation
House wife
Government and private
employed
Farmer
282
79
43
69.8
19.5
10.6
Husband occupation(n=366)
Farmer                                                         
Government and private work Family size(mean 4.18)
2-3
4-5
6+
Monthly income
<500 birr
500-999 birr
1000+ birr
87
279
158
185
61                     
197
89
118
23.8
76.2
33.9
39.1
45.8
15.1
48.8
22.0
29.2

Table 1: Selected socio-demographic characteristics of respondents (N=404) in Debre Berhan district, North Shewa Zone, Northern Ethiopia, June 2014.

Obstetric and actual delivery characteristics of the respondent

The mean age at first union was 22.44 years and 180 (44.6%) women were first union between the age of 20 and 24 years and 164 (40.6%) women at the age of 15-19 years, the rest 60 (14.8%) women at the age of >25 years. The mean age at first pregnancy was 22.67 years and 217 (53.7%) women were become pregnant at the age of 20-24 years, 87 (21.5%) were between the age of 25 and 29 years and the rest 100 (24.8%) at the age of >29 and below 19 years.

Majority 292 (72.3%) have gravidity of 1-2 times, the rest 112 (27.7%) have 3-4 times pregnant. Majority of respondents 299 (74%) have 1 to 2 children, 107 (26.5%) have 3-4 children. From 404 respondents 348 (86.1%) visited health facility during the last pregnancy from this the majority 332 (95.4%) visit for ANC service. Among mothers who attained ANC for their last pregnancy 225 (55.7%) were attained 4 and more times whereas, 94 (23.3%) and 23 (5.7%) were attained 2-3 and one times respectively. Among who visited health facilities for antenatal care 174 (43.1%) attend in the health centre, 126 (36.2%) attended in the hospital, the rest 42 (10.4%) attend in the health post and private facility. Regarding to place of delivery the majority 324 (80.2%) were delivery took place at health institution, the rest 80 (19.8%) were home delivery. Among those who gave birth at home 51 (63.7%) were assisted by traditional birth attendants (TBAs), the rest 29 (36.3%) were by family members including their husband. Among those who deliver in health facilities 256 (79%) were in hospital, 65 (20%) in the health centres and the rest 1%were in HP and private (Table 2). Among those mothers who visited health facilities for ANC service attended place were Health centre, Hospital, Health post and private health facility (Figure 1).

Variables Number Percent
Age at first marriage(Mean 20.44,with SD=3.48)
15-19
20-24
25-29
30+
 Age at first pregnancy (Mean 22.67, with SD=3.7)
15-19
20-24
25-29
30+
Gravidity (Number of pregnancy)
1-2times
3-4times
Parity (Number of children)
1-2
3-4
Still birth in life time     
Yes
No
164
180
53
7

77
217
87
23

292
112

299
105
18
386
40.6
44.6
13.1
1.7

19.1
53.7
21.5
5.7

72.3
27.7

74
26
4.5
95.5
Health facilities visit during last pregnancy(n=404)
Yes
No
ANC visit during last pregnancy(n=348)
Yes
No
Number ANC visit during last pregnancy (n=342)
1-3times
Four and more
Reason to visit health facility(n=348)
For ANC service
Other health related problems
Information got on pregnancy and delivery complication during ANC(n=342)
Yes
No
Last pregnancy(404)
Planned
Not planned
Place of delivery
Health institution
Home
Assistant during home delivery (n=80)
Traditional birth attendants(TBA)
Families  including husband
No one
348
56

342
8

103
211

332

331

11
373
31

324
80

51
27
2
86.1
13.9

98.3
1.7

30
70

95.4
4.6

96.7
3.3

92.3
7.7

80.2
19.8

63.7
33.7
2.6

Table 2: Selected obstetric characteristics of respondents (N=404) in Debre Berhan district, North Shewa zone, Northern Ethiopia, June 2014.

pregnancy-and-child-health-last-pregnancy

Figure 1: Place of delivery during the last pregnancy among mothers who gave birth in the last 2 years, in DebreBerhanDistrict, North Shewa Zone, June 2014.

During ANC follow up respondents got different types of information about pregnancy and delivery complications such as severe vaginal bleeding, severe headache, fast and marked weight gain, fetal movement cessation and others (Figure 2).

pregnancy-and-child-health-health-facility

Figure 2: Graph showing types of information they got during health facility visit among mothers who gave birth in the last 2 years in DebreBerhanWoreda, North Shewa Zone, June2014.

Reasons given for home delivery includes, short labour 36 (45.0%), usual practice 16 (20%), feeling of more comfortable just being at home 16 (20.0%) closer attention from relatives and family members and other reasons 12 (15.0%) (Figure 3).

pregnancy-and-child-health-home-delivery

Figure 3: Reasons for home delivery among mothers who gave birth in the last 2 years in DebreBerhan District, North Shewa Zone, June2014.

Predisposing, enabling, reinforcing factors and client satisfaction

Regarding preference of place of delivery during their last pregnancy, 338 (83.7%) mothers were preferred to deliver in health institution and 66 (16.3%) in home. Similarly 339 (83.9%) of their husbands were preferred in health institution, the rest 16.1% were at home. Regarding to the women final decision power where to deliver the majority 183 (56.4%) decided by themselves followed by health worker and health extension worker advice acceptance 40% the rest by family members and husband decision. Regarding to the accessibility of transport during labour the majority 291 (72.0%) respondents were accessible for transport the rest 28% not accessible and for type of transport used the majority 127 (39.2) used Ambulance, 91 (28.1%) used by public and private transport the rest 32.7% used traditional including foot walk. Regarding knowledge and attitude about pregnancy and delivery complication, availability and importunacy of health institution, free ambulance service, susceptibility of mothers for complication of pregnancy and delivery were majority 92.3% and 84.7% were knowledgeable and positive attitude respectively (Figure 4 and Table 3).

pregnancy-and-child-health-delivery-preference

Figure 4: Reasons for institutional delivery preference among mothers who gave birth in the last 2 years in DebreBerhan District, North Shewa Zone, and June 2014.

Variables  Number Percent
Knowledge of the mother    
Knowledgeable 373 92.3
Not Knowledgeable  31 7.7
Attitude of the mother    
Favorable 342 84.7
Not favorable 34 8.4
Preference of the mother about delivery
place during her last pregnancy
   
Health facility 338 83.7       
Home  66 16.3    
Preference of the husband about delivery place during her last pregnancy        
Health facility 339  83.9               
Home 65  16.1    
Preference of other family members about delivery place during her last pregnancy    
Health facility                                                    329  81.4
Home 75 18.6  
Who finally decided delivery place
During your last pregnancy?
   
Myself 183 56.5
HW or HEW                                                          130 40.0
Family members and my husband 11 3.5
Accessibility of transport    
Yes 291 72.0
No 113 28
Type of transport used    
Ambulance 127 39.2
Public or private 91 28.1
Tradition including foot walk 106 32.7
Member of women development army    
Yes 227 56.2
No 177 43.8
Over all Client satisfaction on time spent, Cleanness of materials and rooms, Privacy and availability of equipment    
Satisfied  289 89.2
Dissatisfied 35 10.8

Table 3: Predisposing, enabling and reinforcing factors associated to institutional delivery in Debre Berhan district, North Shewa Zone, Northern, Ethiopia.

Factors associated with institutional delivery service utilization

The effects of different independent variables were tested for their association with Institutional delivery service utilization by logistic regression analysis. First the association of each explanatory variable with the dependent variable was checked individually using bi-variant analysis, and then variables with p-value<0.05 were entered into the multiple logistic regression analysis to control for confounding. The socio demographic variables which showed statistically significant association by bi-variant analysis were place of residence, mothers’ education status and occupation, husband´s educational status and occupation (p-value<0.05). The obstetric variables that which shows statistically significant association (p-value<0.05) were, frequency of health facility visit and antennal care service during pregnancy time, number of ANC visit and information obtained on pregnancy and delivery complication and where to deliver during ANC visit, member of women development army, accessibility of transport, knowledge and attitude of the mother. Finally multivariate logistic regression was carried out to predict institutional delivery service utilization with variables that were statistically associated during the bi-variant analysis p-value<0.05). Mothers’ residence, educational status, HF visit, Access of transport to go HF and Mothers attitude were significantly associated with the utilizations of institutional delivery service. The result showed that mothers who live in urban areas were more likely to utilize institutional delivery service than mothers from rural areas (AOR=4.708 and 95% CI=1.061-20.888).

Mothers who had primary education and above level were more likely to utilize institutional delivery service than those who have no education (AOR 10.5 and 95% CI=2.9-37.8). Mothers who have HF visit during the last pregnancy were more likely to utilize institutional delivery than mothers not visited HF (AOR=12.597 and 95% CI=2.665- 59.551). Mothers who have transport access during delivery were more likely to utilize institutional delivery than mothers who have no access of transport during delivery (AOR 35.034=95% CI= (9.289-132.128). Mothers who have negative attitude on institutional delivery utilization importunacy and delivery complications were less likely to utilize institutional delivery than positive attitude mothers on institutional delivery and its complications (AOR=0.008 and 95% CI (0.001-0.044) (Tables 4 and 5).

Variables Skilled delivery service utilization        COR (95% CI) AOR(95% CI)           
yes  No
Residence        
Urban 277 48 3.93(2.28-6.77) 4.70(1.06-20.89**
Rural 47 33 1.00 1.00
Maternal education        
No education                      27 42 1.00 1.00
Primary school and above 297 38 12.1(6.7-21.9) 10.5(2.9-37.8)**
Husband education        
No education                      27 11 1.00 1.00
Primary school and above 275 47 2.4(1.1-5.1) 0.3(0.056-1.71)*
Maternal occupation        
House wife 229 53 1.00 1.00
Government and private work 73 6 0.28(0.08-1.0) 1.57(0.19-12.6)*
Farmer 22 21 0.45(0.13-1.5) 0.9(0.22-3.68)*
Husband occupation        
Farmer 49 38 1.00 1.00
Government and private work 248 31 3.26(1.47-7.2) 0.3(0.05-1.77)*
Transport accessibility        
Yes 270 21 14.01(7.89-25.01) 35.034(9.29-132.13)**
No 54 59 1.00 1.00

Table 4: Women actual place of delivery versus socio-demographic Variables associated with institutional delivery service utilization adjusted for socio-demographic Variables, among respondents in Debre Berhan District, North Shewa Zone, June 2014.

Variables   Skilled delivery service Utilization  COR(95% CI)           AOR(95%CI)           
Yes No
Health facility visit during last pregnancy        
Yes 317 31 71.58(29.88-171.47) 12.6(2.67-59.55)**
No 7 49 1.00 1.00
ANC service(n=348)        
Yes 314 28 1.00 1.65(0.12-23.6)*
No 3 5 0.54(0.12-0.24) 1.00
Number of ANC visit        
1-3 time 103 14 1.00 1.00
>=4 times 211 14 4.03(0.78-20.70) 2(0.9-14.o4)*
Information obtained on pregnancy and delivery complication during ANC visit        
Yes 303 28 1.00 (0.00-0.00)*
No 11 0 0.18(0.008-0.039) 1.00
Information obtained about place of delivery        
Yes 30 26 1.00 11(0.14-0.80)*
No 6 2 0.64(0.011-0.364) 1.00
Member of women development army        
Yes 194 33 2.13(1.29-3.49) 1.7(0.46-6.3)*
No 130 47 1.00 1.00
Knowledge of the mother        
Knowledgeable 321 45 1.00 0.56(0.04-7.9)*
Not knowledgeable 3 25 0.17(0.005-0.058) 1.00
Attitude of the mother        
Positive 321 21 1.00 1.00
Negative 3 31 0.006(0.002-0.022) 0.008(0.001-0.044)**

Table 5: Women’s actual place of delivery versus obstetric and actual delivery variables associated with institutional delivery service utilization adjusted for obstetric and actual delivery variables, among respondents in Debre Berhan district, North Shewa zone, June 2014.

Discussion

This community–based study has attempted to identify the magnitude and factors associated with Institutional delivery service utilization among mothers who gave birth in the last 2 years in Debre Berhan district town administration, North Shewa Zone. The study results showed that institutional delivery service utilization was 80.2% in the district, the rest 19.8% gave birth at home. This result almost similar with the Addis Ababa city health facility delivery utilization coverage which is 82.2% studied in the Ethiopian Health and demography survey before 2 years in 2011 [1]. In Ethiopia most of the studies before twothree years especially in the rural setting in the extent of Institutional delivery service utilization was extremely low which is 10% from DHS- 2011[3-6] 12.1% a study conducted in Sekela Woreda in West Gojam [7-12], Even this study shows increment than a study conducted in a town setup which is 48.3% in Woldiya town [11], 50% in the Urban areas of Ethiopia including Addis Ababa DHS 2011 shows [1] this finding might be, different in number of sample size, methodology difference, socio-demographic characteristics like urban to rural proportion and cultural difference in the study area and another discrepancy from the other studies may be because of the current Government initiative to reduce maternal mortality to achieve MDG5 because of reaching the end year and the other reason may be accessibility of health institution and Ambulance service at grass root level [2,4,7].

The result of the present study describe that place of residence had significant association with institutional delivery service utilization. The rural mothers were less likely to give birth at health facility compared to urban mothers. This finding was consistent with other research findings reported in Ethiopia, findings of Ethiopia demographic and health surveys of year 2011 [1], Gondar [10] and Woldiya [11]. The reason might be that urban mothers tend to have better access to health facilities and other promotional services than rural mothers [3,9,10].

Mothers who had educational level of primary and above were ten times (10.5 (2.9-37.8) more likely to utilize institutional delivery service than mothers who cannot read and write. This finding is consistent with that of some previous studies showed that educational status of mothers to be the most significant associated factors for utilization of institutional delivery service [11]. Any visit of health facility during the last pregnancy were other significant factor for institutional delivery service utilization 13 times more likely than who does not visit (AOR=12.6 and 95% CI: 22.6-731.03) and the reason for visit were 95% for ANC service, this could be explained by; those who visit health facility may have the chance to get information on the importance utilization of skilled delivery attendant which can help them to make informed decision on the delivery plan [9]. The coverage of institutional delivery is lower than other maternal health care services like ANC due to this home delivery is not reach zero coverage. The most common reasons for home delivery were smooth and short labor (45%), usual practice (20%), home is more comfortable (20%) and close follow up from family (15%). Similar study from Woldiya revealed that the main reasons for mothers to prefer home delivery was short labor (42%) [11]. Similar study in Sekela identified that the main reasons for home delivery were smooth and short labor 42% [12].

Mothers who have accessibility of transport like Ambulance and public transport or private service access (e.g. Bajaj and Cart) during labor were significant association for institutional delivery (AOR=35.0, 95% CI (9.29-132.13) more likely than inaccessible areas for transport. Another associated factors in this study which is highly significant to institutional delivery was attitude of the mother on importunacy of institutional delivery and preference of place of delivery and susceptibility of the mother for risk of delivery complication (AOR=0.008 and 95% CI: (0.001-0.044). This finding is in line with study conducted on factors determine delivery practice of pregnant women in Jima town [13].

Conclusion and Recommendation

Conclusion

1. Even though Institutional delivery service utilization in the study area was shows improvement from similar studies still mothers exercise home delivery especially the rural mothers were less likely to use institutional delivery during their child birth than urban counterpart which shows unequally distributed. Distribution varied among the different sociodemographic and obstetric factors.

2. Rural mothers were less likely to use skilled attendants during their child birth in health facilities than urban counterpart.

3. Maternal education, Health facility visit during last pregnancy, accessibility of transport during delivery and attitude of mothers towards institutional birth attendant utilization were other determinants that influence the use of institutional delivery utilization which needs infancies to save mothers maternal related death.

Recommendations

Based on the finding of the study the following recommendations were forwarded to all concerned bodies:

1. Appropriate package of delivery service to vulnerable group’s rural, uneducated women and, transport inaccessible area especially for Ambulance easily entrance to the village should be prepared by the government especially the MOH structure such as Woreda health office, Zonal health Department, etc. and the woreda administration due emphasis with collaboration to other sectors like education, rural road construction, transport sector and other partners to minimize the disastrous consequences of pregnancy and child birth.

2. Improving the quality of antenatal care services during health facility visit when mothers are pregnant should be given great attention specifically focusing on giving appropriate advice on delivering with assistance from a health professional and consciences on delivering in health facilities since delivery outcome is unpredictable according to MDG5.

Limitation of the study:

• This cross sectional study by its nature and design cannot establish cause and effect relationship. Some of the data like antenatal visit, HF visit, preference of delivery place, being informed about place of delivery, transport accessibility, and types of complication they faced during home delivery were based on mothers’ response.

• It is not supplemented with focused group discussion. FGD is allowed them to freely describe their experience and perception without being influenced by the line of questioning.

Acknowledgement

We would like to thank Debre Berhan University and Victory College. I would like to appreciate and gave special thanks for north Shewa zonal health department head Mr. Atsiku Hsilasie for financial & stationery support on behalf of Zonal health Department. We are also grateful for the cooperation of data collectors and all study participants.

References

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