Level of institutional delivery service utilization and associated factors among women who gave birth in the past 12 months, Ga’an libah district, Marodijeh region, Somaliland: a community-based cross-sectional study

Abstract

Background

Institutional delivery has been considered one of the important strategies to improve maternal and child health and significantly reduce birth-related complications. However, it is still low in developing countries though there are some improvements. even among the community who has access to the health institutions weather health center and hospital including Somaliland. Hence, the aim of this study was to assess the level of institutional delivery service utilization and associated factors among women who gave birth in the last 12 months in Ga’an libah district, Marodijeh region, Somaliland.

Methods

The community-based cross-sectional study was conducted among women who gave birth in the last 12 months from September to December 2022. A simple random sampling technique was employed to select study participants from a total of sample population. Data was collected using semi-structural administered questionnaire through interviewing women. Data was collected with online mobile data collection (Kobo collect). SPSS version 25.0 was used for data management, entering and analysis. Bivariate and multivariable logistic regression models were fitted to determine the presence of a statistically significant association between independent variables and the outcome variable with p-value < 0.05.

Result

Level of Institutional delivery services utilization in Ga’an libah district was 53.9% [95% Cl 48.2–59.6] gave birth at health institutions. Women who can read and write local were (AOR 2.18, 95% CI 1.08–4.56, p<0.01), Women with their husband can be capable to read and write are [(AOR = 6.95, 95% Cl 2.82–21.58, p<0.002]). Additionally, ability to cost transportation for referral [AOR 5.21, 95% Cl 2.44–11.13, p<0.001]. not good services available [AOR 0.07, 95%Cl 0.01–0.10, p<0.02]. lack of maternal health and child knowledge [AOR 0.034, 95% Cl 0.02–0.57, p<0.01]. were observed associated with level of institutional deliver services utilization.

Conclusion

The institutional delivery service utilization was relatively high compared to national demographic health services in the study area. A large proportion of women gave both at home without a skilled attendant. Therefore, this finding has important policy implications since changes in the cost of the health service and perceived quality would mean changes in client satisfaction as well as their choice, as well emphasize to expectant women can receive medical advice and ambulance for referrals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-024-11330-3.

Background

Institutional delivery is a delivery that takes place at any medical facility with a skilled delivery assistance [1]. Utilizing institutional delivery services is one of the major and proven strategies to promote maternal health and well-being and minimize maternal mortality by ensuring safe delivery and lowering issues related to and occurring during birth, Worldwide, around 81% of urban and 61% of rural women gave birth in a medical facility. Worldwide, the major causes of maternal mortality are hemorrhages (24%), infection (15%), Unsafe abortion (13%), prolonged labor (12%) and eclampsia (12%), where primary causes of maternal mortality in Africa are hemorrhage (34%), other direct causes (17%), infection (10%), hypertensive disorders (9%) and obstructed labor (4%), abortion (4%) and anemia (4%) [2].

Globally, 75% of neonatal deaths occur in the first week of life, with over 1 million babies dying within the first 24 h in 2019. Preterm birth, childbirth-related complications (birth asphyxia or lack of breathing at birth), infections, and birth abnormalities accounted for the majority of newborn deaths in 2019 [3, 4].

World Health Organization reported that the mortality rate for children under five in Sub-Saharan Africa remained the highest in the world, with 74 (68–86) deaths per 1000 live births, which is 14 times greater than the risk for children in Europe and North America [5]. Despite global progress in lowering maternal death, there is an urgent need for immediate action to accomplish the ambitious 2030 sustainable development goals (SDGs) and eventually eliminate preventable maternal mortality [6]. In 2020, According to the same research, the top causes of death for children under five continue to be infectious diseases such pneumonia, diarrhea, and malaria as well as problems related to preterm delivery, birth asphyxia, trauma, and congenital abnormalities [7].

In Sub-Saharan countries, 75% of urban and 40% of rural women gave birth in health facilities. [8]. Access to health care has four dimensions; geographic (or Physical), accessibility, availability, affordability (or financial access), and acceptability (cultural access). Geographic accessibility is concerned with the relationship between the location of health care facilities (supply factor) and the location of those who needs these services and their transportation opportunities (demand factors). Availability includes issue such as the level of supply of staff or drugs, the degree of fit between the hours of services of health care facilities (opening hours) and the times that individuals need services to be provided. Affordability is concerned with the with the degree of fit between the full costs to the individuals using the services and the individual’s ability to pay in the context of the household budget and other demands on that budget. Acceptability is concerned with the fit between provider and patient attitudes towards and expectations of each other [9, 10].

Pregnancy and childbirth complications that may lead to healthcare mortality and morbidity are usually avoided by adopting skilled antenatal care (ANC), delivery care, and postnatal care [11]. Skilled delivery at a health facility or institution can significantly minimize maternal and newborn deaths due to birthing difficulties and infections because it assures full medical care and aseptic settings [12].

Ethiopia Oromia region 18.2% [13]. Increasing the proportion of births carried out at a health facility and under the supervision of health professionals is crucial for reducing health risks for women and children.

Maternal deaths involve both direct and indirect causes. Approximately 80% of maternal deaths result from causes directly related to pregnancy and childbirth [14]. In Somalia, a substantial proportion of births take place at home. And only a few skilled health providers attend deliveries. The proportion of births attended by a skilled health professional and delivered in a health facility has stayed at approximately 21% [15]. In other African countries, like Cameroon, 68.7% of women deliver in health facilities [13].

According to the 2019 Ethiopian Demographic health survey (EDHS) shown, the residence, 72% of urban births were assisted by a skilled provider, compared with 43% of births in rural areas. Similarly, 70% of urban births were delivered in a health facility, compared with 40% in rural areas. Somali Region has the lowest percentage of births delivered by a skilled provider or delivered in a health facility (26% and 23%, respectively), while Addis Ababa has the highest percentages for both indicators (96% and 95%, respectively). The percentage for both indicators increase along with the women’s education. For example, 35% of births to women with no education were assisted by a skilled provider and 33% were delivered in a health facility. Among women with more than secondary education, 93% of births were assisted by a skilled provider and 93% were delivered in a health facility [16].

Institutional delivery services in Ethiopia are extensively poor utilized. Maternal awareness of labor danger signs, frequent ANC visits, a highly educated husband, and household affluence predicted service utilization. As a result, adequate attention must be made to upgrading education, education, expanding health institutions, and providing awareness on the benefits of antenatal care monitoring and danger signs to ensure that all pregnancies are delivered at health institutions [17].

According to Somaliland Health & Demographic Survey 2020 (SLHDS), 79% of births were delivered at home, with only about one in every five births (21% in the five years prior to the study) being born in a health facility. Deliveries sponsored by private sector health institutions at 17%, similarly to SLHDS revealed that a slightly more than two third (67%) of births was delivered at home. Only one third (33%) of births in the five years preceding the survey was delivered in a health facility. In public facilities, deliveries are more common in rural settlements which is a 24% compared to the private sector-supported facilities are 9%. More than one third (39%) of deliveries occur in public facilities in urban settlements, compared to 20% in private facilities [18]. this study is aimed to assess the level of institutional delivery service utilization and associated factors among women who gave birth in the past 12 months prior to the study at Ga’an libah district, Marodijeh region, Hargeisa, Somaliland.

Methods and material

Study area and period

The study was conducted from September 30th to December 31st, 2022, in Hargeisa, Somaliland’s capital city. Somaliland is an unrecognized self-declared sovereign state that isn’t recognized internationally. Somaliland has country borders with Djibouti, Ethiopia, the Gulf of Aden and Somalia in the northwest, south and west, north and east respectively. The capital city of Somaliland is Hargeisa, with an estimated population of 1.3 million individuals. Hargeisa had encompassed eight major district under its local municipal administration. Hargeisa has a latitude and longitude of 9°0.5624” and 44°.177”, correspondingly, and is 1,334 m (4,377 feet) above sea level, in addition to this, women with reproductive age across the region were estimated 6,285 individuals were status on never married, married, widowed and divorced, conversely, the number of health institution that provides maternal health care services are six maternal health centers and one district hospital under Ga’an Libah district [15, 19].

Study design

A community-based cross-sectional study design was used with women who had given birth during the previous year.

Source of population

The population was selected from all reproductive women in the Ga’an libah district who had given birth during the previous 12 months, regardless of the outcome of their pregnancy.

Study population

Womens who live in and are available in the Ga’an libah district, specifically childbearing women who have given birth within the last 12 months, regardless of the outcome of the birth.

Eligibility criteria

Inclusion and exclusion criteria

All childbearing women who had given birth in the previous 12 months in the district and were available during the study period in Ga’an libah district, regardless of birth outcome. A childbearing woman who had not lived in the study region for the previous six months, women with difficulty hearing, and those who refused to respond were excluded from the study.

Sample size determination & sampling procedure

The study’s sample size was calculated using a single population proportion method based on the following assumptions: (P) 21.0% of proportions of institutional delivery service utilization in the Somaliland Health and Demographic Survey [15], 95% confidence interval (CI) (1.96), and 5% margin. The ultimate sample size of study participants was 280, including a 10% non-response rate.

Regardless of the result of the birth, the sample consisted of women who gave birth within the last 12 months in the district. A woman who gave birth in the last 12 months in the district, regardless of their birth outcome were in the sample. Sample sizes were distributed proportionately to the number of households within each of the three clusters in the Ga’an libah district. As a basic random sampling technique, the sampling was initiated by choosing an element from the sample frame. The study followed this sample approach after all eligible women who gave birth during the previous 12 months were recorded as a sample frame, women were uploaded to an excel sheet, and a basic random sampling technique was used to determine the sampling unit.

If no response was received after three attempts, the women who was absent or whose home was closed at the time of data collection was counted as a non-respondent. A randomly chosen women was chosen from each randomly chosen home if there were many women living in the same family.

Study variables

Dependent variable

• Institutional delivery service utilization.

Independent variables

Predisposing factors.

• Maternal Age.

• Partner education.

• Women Perception to health providers.

Enabling factor.

• Place of residence.

• Wealthy index.

• Distance.

• Accessible.

Need Factor.

• Antenatal care visit.

• Delivery service utilization.

• Number of ANC visit.

• Type of pregnancy (Planned and Unplanned).

Data collection procedure and tools

Data were gathered using a structured questionnaire that was created by analyzing the body of current literature [20–22]. To maintain the study’s validity and reliability. To test the validity of questionnaire was pretested 5% the total of study subjects. The Sheikh Nour community was performed the pretest which shares the same demographics characteristics as the target location, served as the pretest site for this pilot study. The three main components of the independent variables were need factors, enabling factors, and predisposing factors. Similarly, to check the reliability of the study, Cronbach’s alpha was calculated using coefficient of Cronbach’s alpha with value of 0.674, were considered acceptable. The questionnaire was first written in English, then translated into Somali, the language spoken locally, and then back to English to ensure uniformity. The data was collected by five bachelor’s degree graduate nurses and the researcher were supervised all entire study operations. Those data collectors were recruited from district administration office. One full days of training were provided to the data collectors about the objectives and data collection process by the principal investigator. The data were checked for accuracy and constancy daily by the field supervisors.

Data analysis and quality assurance

Data was entered, cleaned and analyzed Statistical Package for Social Science window (SPSS IBM Version 25.0) by cross checking it’s completeness, the questionnaire was firstly prepared in English and then translated in local language, which is Somali, furthermore, data was pretested by 5% of study participant with a similar characteristics district. The descriptive statistics was used to compute frequencies and percentages for categorical data. Bivariate logistic regression was done to determine the association between dependent and independent variables. The P-value of <0.2 in the bivariate analysis was entered to generate the candidate variables then was perform multivariate logistic regression analysis to control confounders. Multivariate logistic regression analysis was done to perform the determine the relation independent variables to the outcome variable. Variables with a p-value of <0.05 was considered significant associated with the outcome, and adjusted odds ratio (aOR) with a 95% CI.

Operational definitions

Antennal care service utilization

A women were considered to have used ANC if she were got a check by a health professional (Doctor, Nurse, and Midwife) at least once during her pregnancy [23]. The variable was categorized into four categories: 1: NO ANC, 2: One ANC visit, 3: Two or three ANC visits, 4: fourth, and more ANC visits.

Maternal marital status

Current marital status of women at the time of the study [24]. It was categorized into two groups: 0-Not married and 1-Married. Classification of this variable were developed by putting the never married, widowed, divorced, and not living together as currently not married, and putting married and living together as currently married.

Institutional delivery service utilization

Institutional delivery is a delivery that takes place at any medical facility staffed by skilled delivery assistance [25]. This variable was categorized as 1. Number of women delivered at the health facility 2: number of women delivered at home.

Maternal education

The highest level of education attained [26]. This were categorized into secondary level was merged because the number of women in the highest education level was very small.

Wealth index

This variable in the data set were recorded into five groups, however, for this study, it was categorized into three groups by assigning the same value as that of the original variable [12]. it was categorized into three groups by assigning the same value as that of the original variable. The three categories were Poor, Middle and Rich.

Place of residence

Where the women in the study lived at the time of the study. This variable was categorized into two groups and coded as 1 Urban and 2 rural.

Gravidity/ parity

Number of pregnancies reaching viability and not the number of features delivered. This variable was categorized as the number of pregnancies without regarding its outcome [27]. This variable was categorized 1- One child, 2: Two children 3. Three children 4: fourth and more children.

Utilization

This means the extent to which a given group of people uses services in a specific period [28]. This variable was measured the number of women who received institutional delivery service utilization or did not receive any medical services at any health facility.

Results

Socio demographic characteristics of study respondents

A total of 280 women was interviewed for the study. The mean age of the study respondents was 30.0 ± 5.68. About 188 (67.1%) of the womens were in the age range of 29–39 years. Similarly, the majority (95.4%) of study respondents were Somalis by ethnicity, 196(70.0%) of both that are unable to read and write the local language, were only 84 (30%) can read and write, in addition, among the respondents, 233 (83.2%) were housewife and husbands also were jobless, whereas 46 (16.4%) was a merchant for small shops/business. Slightly more than half of subjects 144 (51.4%) women were households’ head. Under this study, women under the study nearly half (49.6%) of respondents gave birth to children 4–6 range. Lastly, to assess the income status of study subject’s principal component analysis (PCA) was employed to examine the wealth status by using Twelve variables related to the ownership of selected household assets, the size and the quantity of durable equipment, materials used for housing construction, home ownership, improved water, and sanitation facilities were considered. Ultimately, the generated principal component was divided into three equal quintiles which is Poor, Middle, and Rich categories. More than half 151 (53.9%) of subjects were shown middle income individuals. (See Table 1).

Table 1.

Socio-demographic characteristics of the respondents in Ga’an Libah district, Marodijeh region, Somaliland, 2022. (n = 280)

Variables(n = 280)	Categories	Frequency	Percent
Age group	18–28	64	22.9
	29–39	188	67.1
	Above − 40	28	10.0
Ethnicity	Somali	267	95.4
	Ethiopian	13	4.6
Educational Status of Women	Can read and write (Local language)	84	30.0
	Can’t read and write	196	70.0
Womens Occupation Status	Housewife	233	83.2
	self employed	46	16.4
	Marchant	1	0.4
Husband’s Occupation Status	private employee	1	0.4
	daily labor	46	16.4
	Jobless	233	83.2
Husband’s Educational Level	Can read & write	87	31.1
	can’t read and write	188	67.1
	Secondary education	5	1.8
Household Head	Husband	136	48.6
	Wife	144	51.4
Number of children born	1–3	82	29.3
	4–6	139	49.6
	7–10	59	21.1
Wealth Index	Poor	49	17.5
	Middle	151	53.9
	Rich	80	28.6

Level of institutional delivery services utilization

Overall institutional delivery services utilization among women in Ga’an libah district was 151 [(53.9% with 95% Cl 48.2–59.6)] of them gave birth/utilized at health institutions (hospitals and health facilities). (See Fig. 1).

Fig. 1.

Level of institutional delivery services utilization among Ga’an libah district, Marodijeh region, Somaliland

On the other hand, among those womens who did not visit health facilities, the reasons that did not deliver at health facilities during the last pregnancy included lack of privacy, long distance to health facilities, not good service available and sudden onset of labor. (Fig 2).

Fig. 2.

Reasons respondents are not to utilizing to deliver health institutions

Predisposing and enabling factors

About one-third of respondents 94 (33.6%) their cultural values influence to deliver the health facilities, similarly, more than half of the study subjects (53.6%) proposed to have a challenge with their location geographically not delivering health facilities, in addition, nearly half (48.6%) womens are decision makers for the place of delivery, furthermore, most respondents (84.6%) have proposed that the service at health facilities is costly. (See Table 2).

Table 2.

Predisposing and enabling factors the respondents in Ga’an Libah district Marodijeh region, Somaliland, 2022. (n = 280)

Variables(n = 280)	Categories	Frequency	Percent
Cultural value influences you to give delivery at Health facility	Yes	94	33.6
	No	186	66.4
Which of the list impedes you not to delivery for your last deliver	Geographical location	150	53.6
	lack of knowledge	66	23.6
	socio-economic related issue	64	22.9
Who was the decision maker about the place of delivery for last birth	My self	136	48.6
	Husband	112	40.0
	Grand mother	32	11.4
The location of the health facility is too far	Yes	257	91.8
	No	23	8.2
The services given by the health facility take too much time and costly.	Yes	237	84.6
	No	43	15.4

Factors associated with level of institutional delivery service utilization among women at Ga’an Libah district, Marodijeh region, Somaliland

Analysis of bivariate and multivariable logistic regressions was performed under this study, educational status of women and her husbands, antenatal care visit, the ability of cost transportation for referral, what make women not to deliver nearest heath facility, which of the list impedes you not to delivering health facility for your last delivery, these factors found to be significant associated with institutional delivery service utilization. Women who can read and write local language were 2 times more likelihood [(AOR = 2.18, with 95% CI = [1.04–4.56 p-value<0.03]) to give birth in health institutions than women those who can’t read and write.

Conversely, women with their husband can capable to read and write were 6 times [(AOR = 6.94 with 95% CI = [ 2.82–21.58 p-value < 0.003]) more likely to give birth at a health facility compared to those their husband can’t read and write, similarly, womens who capable for cost of transportation of referral were 5 times [(AOR = 5.21 with 95% CI = (2.44–11.13) p-value < 0.001] more likely to deliver at health institutions.

The respondents those who did not deliver to nearest health facility were [(AOR = 0.07, with 95% CI = [0.01–0.10] p-value < 0.021) lower likelihood to deliver and utilize at nearest health facility, with 93.0% reduction in odds. Women under the study were 97% [(AOR = 0.034(0.02–0.57) p-value < 0.019] less likely to deliver/utilize at health facilities due to lack of basic health education the impact of home delivery (See Table 3).

Table 3.

Factors associated with level of institutional delivery service utilization among women at Ga’an Libah district, Marodijeh region, Somaliland

Characteristics/Variables	Institutional Delivery Service Utilization		COR (Cl 95%)	AOR (Cl 95%)	P-Value (< 0.05)
	Yes (%)	No (%)
Women’s education
Can read and write	52(34.4)	30(20.3)	1.73 (1.02–2.94)	2.18(1.04–4.56))	0.038*
Can’t read and write	99(65.6)	99(76.7)	1r	1r	1r
Husband education
Can read and write	49(32.5)	47(36.7)	8.599 (2.382–31.037)	6.95(2.823–21.5)	0.003*
Can’t read and write	86(56.95)	78 (60.9)	2.915 (0.808–10.518)	3.28(0.550–19.58)	0.118
Primary education	16(10.59)	4(3.100)	1r	1r	1r
Antenatal care visit
Yes	126 (83.4)	23(17.8)	0.043 (0.02–0.08)	1.448 (0.65–3.18)	0.357
No	25 (16.55)	106(82.2)	1r	1r
Reason for home delivery
Lack of transportation	56(37.08)	69(53.5)	1.951 (1.209–3.14)	1.41(0.55–3.58)	0.474
Long distance to health facilities	95 (62.91)	60(46.5)	1r	1r	1r
The ability for cost transportation for referral
Yes	124(82.1)	63 (48.8)	0.208 (0.121–0.357)	5.21(2.44–11.13)	0.000*
No	27(17.88)	66 (51.2)	1r	1r	1r
Happy service at the health facility
Yes	71 (47.0)	20(15.5)	1r	1r	1r
No	80 (52.98)	109(84.5)	0.207 (0.116–0.367)	0.35(0.09–2.11)	0.255
What make women not to deliver nearest heath facility
lack of privacy	21(13.9)	7(5.4)	0.06 (0.021–0.223)	0.267	0.066
long distance to health facility	52(34.4)	68(52.7)	0.26 (0.111–0.656)	0.034	0.171
Not good service available	71(47.0)	20(15.5)	0.05 (0.02–0.15)	0.07(0.01–0.10)	0.021*
Sudden onset of labor	7(4.6)	34 (26.4)	1r	1r	1r
Previous traditional habit before the delivery
Yes, for traditional habit	22(14.6)	34(26.4)	8.28(3.58–19.15)	1.67(0.20–13.34)	0.628
No for traditional habit	70(46.4)	84 (65.1)	6.43(3.14–13.19)	2.26(0.41–12.37)	0.343
don’t know the traditional habit	59 (39.1)	11(8.5)	1r	1r	1r
Which of the list barrier you not to delivering health facility for your last delivery
Geographical location	80(52.9)	70(54.3)	0.342(0.182–0.644)	0.267(0.045–1.58)	0.146
Lack of knowledge	53(35.1)	13(10.1)	0.096(0.042–0.217)	0.034(0.02–0.57)	0.019*
Socio-economic related	18(11.9)	46(35.7)	1r	1r	1r
Healthcare workers had not have respect for those deliver (Bad attitudes of health workers)
Yes	93(61.6)	66(51.2)	0.653(0.406–1.052)	0.610(0.275–1.351)	0.223
No	58(38.4)	63(48.8)	1r	1r
Health facility staff availability
Yes	87(57.6)	68(52.7)	0.660(0.411–1.059)	0.84(0.37–1.90)	0.677
No	64(42.4)	61(47.3)	1r	1r
The quality of services given in health facilities is not good
Yes	108(71.5)	105(81.4)	1.742(0.988–3.071)	2.290(0.77–6.71)	0.100
No	43(28.5)	24(18.6)	1r	1r	1

Note: 1^r stand for reference category

Discussion

The current study showed that the proportion of institutional delivery was (53.9% with 95% Cl 48.2–59.6) in the study area. However less than a half of women gave birth at home ((46.1% with 95% Cl 40.4–51.8)). A similar study conducted in the central Gondar zone revealed 58.17% were proportional to women who gave birth in health facilities. However, the prevalence of institutional delivery rate was 58.17% study conducted in northwest of Ethiopia which is higher utilization than this study [29]. The other similar study findings are approximately in line with a study done in the Pawi district of Ethiopia, Kenya, and Sub-Saharan Africa where the proportion of women who gave birth in the health facilities was 60.5%, 61%, and 57% respectively [30–32]. Conversely, the findings of the current study are lower than studies conducted in the following districts, Mana districts, Bench Maji, and Debre Behan in Ethiopia in which the institutional delivery was 86.4%, 78.3%, and 80.2% respectively [17, 30, 33]. This difference could be due to differences in socio-cultural factors, awareness and Knowledge of facility birth, health education, and accessibility of health facilities in relation to socio-demographic characteristics [34]. This current study’s findings were higher than the Somaliland demographic health survey (SDHS) which was 33.0% of women gave birth at health institutions [15]. The reason for these differences might be due to the sample size differences because it smaller than Demographic health survey Somaliland, the current study interviewed 280 women with at least one delivery during the past 12 months and then Andersen’s behavioral model of health service utilization was applied for analysis. In the current study the women’s education, the Husband’s education, the women/Family’s lack of basic health education about health facility services, the women’s ability for transportation costs, and Poor medical service in the residence were found to be significant predictors of not choosing to deliver health facilities [15].

In other similar studies conducted in Ethiopia found that the husband’s educational status was the other factor significantly associated with institutional delivery service utilization, Women whose husbands had at least a primary school education were nearly 4 times more likelihood to utilize institutional delivery services [35], in contrast, the current study strongly agreed with the findings of other studies conducted in Ethiopia which found that women’ husband education is associated with institutional delivery services utilization. Additionally, this finding was comparable to the results of other studies where women’s husbands who were jobless are more likelihood to deliver at home [17, 36, 37].

The current study found the influence of traveling (distance in kilometer (KM) spent to reach nearby health institutions was another important factor that was identified. Women who had to walk less than 5 km to the nearest health facility were 10 times more likely to deliver health facilities, than women who could travel more than 5 km (KM). Similarly, women that live at less than 5 km away from a health facility were 9.2 more likely to utilize delivery care from health institutions than those women who live at a distance greater than 5 km away from a health facility in Ethiopia [38, 39].

barriers of the health service delivery system in Uganda including policy matters, medical staff, transport, distance and referral mechanism, drugs and medical facilities, costs and financing of services, corruption and bribery, culture and attitudes. Additionally, some common barriers women observed in Ethiopia include financial constraints, cultural beliefs, lack of basic health education about the importance of institutional delivery, and logistical challenges such as distance to health facilities and inadequate transportation. In rural areas, these barriers are more pronounced, leading to lower utilization rates compared to urban areas [37, 40].

Socioeconomic status plays a critical role in the likelihood of using institutional delivery services. Higher household wealth and better educational levels are strongly associated with increased use of these services. This trend is consistent across various countries, including Ethiopia and India [41].

The current study also showed that 48.6% of women’s decision power about the place of delivery was the influencing factor for the institutional delivery of women. Furthermore, the majority of respondents (84.6%) have proposed that the services provided by the nearest health facilities were much higher cost than the other health facilities in downtown, Hargeisa. A similar result was observed in a study in Hadya zoone, Holeta town, and Awash Fentale [35, 42, 43]. In most situations, relatives and neighbors who are the main decision maker in the community can be one of the reasons why laboring women stay at home during delivery [40].

There is a strong positive correlation between antenatal care (ANC) follow-up and institutional delivery service utilization. Women who attend more ANC visits are significantly more likely to give birth in health facilities. This underscores the importance of comprehensive prenatal care in improving maternal health outcomes, but this study did not observe any relation between ANC and institutional delivery services utilizations [40].

On the contrary, women with their husband can capable to read and write were 6 times [(AOR = 6.94 with 95% CI = [ 2.82–21.58 p-value<0.003]) more likely to give birth at a health facility linked to those their husband can’t read and write, similarly, women who capable for cost of transportation of referral were 5 times [(AOR = 5.21 with 95% CI = (2.44–11.13) p-value<0.001] more likely to deliver at health institutions. This factor emphasized the understanding and reading the local language perhaps probably promote the institutional delivery, on the other hand knowledge have pivotal role for health facilities delivery.

This study also found that 93.0% of women in the stud area were less likelihood to deliver to the nearest health facility, due to poor medical services. The result is inconsistent with studies conducted in the Metekele zone and Arsi zone in west Ethiopia respectively. This might be due to the institutional delivery service utilization being affected most importantly by the satisfaction of women with the medical service given by the nearest health facility and its quality [40, 43, 44].

For low- and middle-income countries (LMIC) were recommended to increase institutional delivery rates, targeted interventions addressing the specific barriers faced by disadvantaged groups are essential. Strategies could include improving access to affordable healthcare, enhancing public awareness about the benefits of institutional deliveries, and ensuring better coverage of antenatal care services, this study is different recommendation which are to improve the situation health education should be given to women and the community to equip them with knowledge on the importance of skilled attendants during childbirth, furthermore, To ameliorate the situation, women and the community should receive health education to enlighten them on the significance of having skilled attendants during labor. The community’s use of obstetric series will be greatly increased, leading to a decrease in maternal deaths, if universal education is made mandatory, at least up to the community education level, women’s economic status is improved, and women are specifically targeted with reproductive health information. To sustain high levels of facility delivery service consumption, more extensive and tailored interventions and strategies are required. All healthcare institutions offering delivery services should have access to qualified healthcare professionals, and they should treat expectant mothers with the utmost courtesy rather than dehumanizing them. Additionally, vital delivery equipment has to be accessible in rural health institutions, preferably for free, or at a price that is affordable for everyone.

Conclusion

The institutional delivery service utilization was relatively high (53.9%) compared to Somaliland Demographic Health Survey in the study area which is 33.0%. A large proportion (46.1%) of women gave birth at home without a skilled birth attendant. This study identified that women’ educational status, Husband’s education, the ability for transportation costs for referral, poor service delivery, and Lack of basic health education were significantly associated with the outcome. This is a small, but relevant step towards a healthy population who can take care of their children and their family and contribute to the development of their community and country at large. As a result, the challenges of closing the gap of health care, by improving women’s educational levels, expanding the number of health care institutions, and raising awareness of visiting and giving birth in health care facilities must all be tackled.

Recommendations

Health education to the community on the importance of conducting their deliveries in health facilities where skilled personnel will attend them should be intensified and made more effective. This was even proposed by most of the participants during the study survey; sensitization will awaken the low knowledge of safe womanhood practices and strengthen the community’s health education awareness in general. According to this study the major inhibiting factor was a lack of basic health education on the importance of institutional delivery and maternal risks associated with home delivery among women of bearing age. To improve the situation health education should be given to women and the community to equip them with knowledge on the importance of skilled attendants during childbirth. Provision of compulsory universal education at least to the community education level, improvement of the economic status of women, and targeting them with reproductive health information will significantly improve the utilization of obstetric series with a resultant reduction in maternal deaths in this community. More comprehensive and customized interventions/strategies are needed to maintain and sustained high levels of utilization of facility delivery services. Qualified health workers should be made available in all health facilities proving delivery services and that health workers should not humiliate clients but instead should exercise maximum politeness in handling pregnant women. Also, essential delivery equipment should be made available in rural health facilities and be made free if possible or affordable to all. The study further recommends more research on identified specific issues related to the choice of place of delivery among women of different age cohorts and geographical settings and finding out possible interventions to overcome such issues.

The authors suggest that the Ministry of Health establish a support group where expectant women can receive medical advice and ambulance for referrals to nearest health hospitals or specialist.

Limitation of the study

The limitations of this study include respective views. Firstly, the cross-sectional nature of the study design impedes the ability to establish a temporal relationship between trigger and outcome. Consequently, causal interpretations and the direction of causation cannot be definitively determined. Furthermore, the study is vulnerable to probable recall bias among participants, particularly when answering questions related to events such as the actual date of delivery history. The accuracy of reported information may be influenced by memory limitations or variations in individual recall.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

ANC

Antenatal care

ANM

Auxiliary nurse midwife

CBE

Community-based education

CB-NCP

Community-based newborn care program

DPHO

District public health office

DTTP

Developmental team training program

EDD

Expected date of delivery

MMR

Maternal mortality ratio

MoH

Ministry of heath

MoNP

Ministry of national planning

NGO

non-governmental organization

PHCC

Primary health care center

PHC-ORC

Primary health care – outreach clinic

SBA

Skilled birth attendant

SDG

Sustainable development goal

SLDHS

Somaliland Demographic and Health survey

TBA

Traditional birth attendant

UNICEF

United nation child’s fund

WHO

World Health organization

Author contributions

Mustakim Mohamed, Muluneh Getachew and Fikru Tafese designed the study, Mustakim Mohamed, Barkhad Abdeeq, Hassan Jama and Ahmed Mohamed participated in the data collection, performed preliminary analysis and interpretation of data, drafted the first paper prepared them to manuscript. Muluneh and Fikru Tafese assisted in the design, approved the proposal with some revisions, participated in data analysis, and revised subsequent drafts of the paper. All authors read and approved the final manuscript.

Funding

This study did not receive any funding.

Data availability

data is avaiable for corresponding author ‘s on reasonable request.

Declarations

Ethics approval and consent to participate

was received from the ethics committee or IRB Jimma University Department of health policy and Management with reference number of IHIRB/591/2022. also, Permission letter was obtained from local administration. Before the data collection, the participants were informed about the purpose of the study, their right to refuse participation and discontinue the interview. Written and Verbal consent were obtained from each participant before to interview to confirm willingness for participation. The participants were informed on the information obtained was kept confidential throughout the process of this study. Similarly, any identification information including the name of the participants were not written on the questionnaire due to confidential kept purpose. The informed consent was verbally explained bit by bit to the illiterate participants and requested permission to proceed, if they weren’t happy, had given a rejection option. All illiterate participants gave verbal informed consent. All study subjects, both literate and illiterate, provided informed consent. The illiterate respondents were informed verbally, and their legal guardians signed on their behalf, while the literate respondents signed their consent. This study was conducted ethically according to the IRB-provided criteria since Mohamoud Askar, a member of the IRB Committee, was designated as an ethical compliance checker during the study period and presented all necessary documentation with supporting data. To maintain confidentiality, no identification information, including the names of the participants, was recorded on the questionnaire. Respecting the principles of ethics, the study followed the principles outlined in the Declaration of Helsinki, underscoring our commitment to ethical practices in human research. In addressing the local context, permission was obtained from relevant Somaliland authorities to conduct this study. This underscores our commitment to respecting the autonomy and rights of individuals involved in the study while aligning with ethical committee-approved procedures. The study didn’t involve experimental and human sample study, likewise the study participants were given a consent/permission both verbal and written form for study respondents. The Authors had declared the study are followed the principle of Helsinki declarations and no human sample were involved.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no potential competing of interests.