Abstract
Introduction
Childbirth in a health institution has been shown to be associated with lower rates of maternal and neonatal mortality. However, about 85% of mothers in Ethiopia deliver at home.
Objective
To assess factors associated with institutional delivery service utilization among women who gave birth within one year prior to the study in Dangila district.
Methods
A cross-sectional study was conducted from February 01–28, 2015. A total of 763 mothers were interviewed using structured questionnaire. SPSS version 20 was used for analysis. Crude and adjusted Odds ratios were computed for selected variables. A P-value less than 0.05 was considered statistical significant.
Results
Only 18.3% of mothers gave birth at health facilities. Knowledge on danger signs [AOR=2.0, 95% CI: (1.1, 3.4)], plan to give birth at health institution [AOR=5.4, 95% CI: (3.0, 9.6)], having ANC follow up during pregnancy [AOR=12.9, 95% CI: (5.0, 33.3)] and time taken to get to a nearby health institution [AOR=5.1, 95% CI: (2.9, 9.1)] were associated with institutional delivery service utilization.
Conclusion
Institutional delivery was very low. Knowledge about danger signs, having ANC visits, and time were factors associated with institutional delivery service utilization. Thus, the findings recommend repeated re-enforcement of institutional delivery service utilization through professionals. And also, the findings recommend promotion of institutional delivery service utilization through mass media.
Keywords: unskilled personnel, skilled professional, delivery
Introduction
Although there are national and global efforts to reduce maternal morbidity and mortality nevertheless a significant number of mothers die because of pregnancy and child birth related causes. Worldwide, an estimated 287,000 maternal deaths occur every year; almost all (99%) of them are from developing countries1.
In developing countries more than half of the women deliver at home, and this is common among the poor and rural dwellers2. Home deliveries are un-hygienic, attended by unskilled personnel and when intervention is required, it is usually late. In sub Saharan African, 74.7–89.9% of women in the lowest two wealth quartiles give birth at home3.
In Ethiopia, the maternal mortality ratio (MMR) is estimated to be 676 deaths per 100,000 live births. Women from rural areas and the less educated ones are less likely to give birth at health institution4. Lack of skilled attendance is considered as one of the major factors in maternal and neonatal mortality. During child birth, there are about 1.02 million intrapartum stillbirths, 904,000 intrapartum-related neonatal deaths and around 42% maternal deaths each year5. This can be reduced if all women give birth in a setting where skilled attendants can provide emergency obstetric care (EmOC) and life-saving neonatal interventions in the event of complications. Different studies identified inconsistent factors that affect institutional delivery service utilization such as individual, demographic, socioeconomic, and other characteristics of the mother, her family and the service environment4,6,7.
The type of assistance a woman receives during childbirth has great impact on health of the mother and her baby. An important component of efforts to reduce health risks to mothers and kids is increasing the proportion of babies that are delivered in health facilities8. Predictors of safe delivery service use and the reasons for under utilization of the existing health service are not adequately investigated. Therefore, this study was designed to assess the predictors of institutional delivery service utilization in Dangila district, North West Ethiopia.
Methods
Setting
The study was conducted in Dangila district, North West Ethiopia. The district has a total population of 174,963, of whom 53.3% are women. The estimated annual deliveries are about 5,073; of which only 12% of mothers delivered at health institution. In the district, there are 6 health centers and 34 health posts. In these health facilities, the service is delivered by health officers, midwives, nurses and health extension workers9. To increase institutional delivery, the Ethiopian government prepares transportation. This is done by assigning at least one ambulance per health institution. All maternal services are given free of charge to all women. Health extension workers have a list of pregnant and lactating mothers, and their address in their Kebele (smallest administrating unit).
Study design and study population
A community based cross-sectional study was conducted from February 01–28, 2015. Women who gave birth within the last one year prior to the study were included in the study.
Sample size, sampling procedure and data collection
A total sample size of 780 was calculated using single population proportion. We used a proportion of 18% institutional delivery10, 95% confidence level and 4% marginal error. The sample size was multiplied by a design effect of 2 and added 10% non-response rate.
Multi stage sampling was used. Five Kebeles were randomly selected. Women who gave birth within a year prior to this study were included using systematic random sampling. Women were interviewed at their home using pre tested and structured questionnaires. Three trained female diploma midwives collected the data. Two public health professionals were assigned as supervisor. Both data collectors and supervisors were trained on the purpose of the study, data collection technique and tool before and after pretest.
Data processing and analysis
Data was entered and analyzed using SPSS version 20. A frequency of each variable was calculated to check for outliers and missed values. Proportion of institutional delivery was determined. Logistic regression was done to analyze the data. Crude and adjusted Odds ratios were computed for each explanatory variable to determine the strength of association and control confounders. P value < 0.2 was taken as a cut-off point to select variables for the multiple logistic regression models. We used backward elimination to avoid multi collinearity. A p-value of less than 0.05 was considered statistically significant.
Ethical consideration
The study was approved by the Ethical Review Committee of Amhara Regional Health Bureau. Letter of permission was taken from respective administration. Written consent (finger print for those who cannot read and write) was taken from every woman. Privacy and confidentiality was maintained throughout the study period by excluding personal identifiers from the data collection form.
Results
Socio-demographic Characteristics of Participants
A total of 763 mothers were interviewed which made the response rate 97.8 percent. The mean (+SD) age of respondents was 29.5 ±6.3 years. All the respondents were orthdox Christian followers by religion, from Amhara ethnic group, married and rural residents. Majority of the respondents, 586 (76.8%) and their husbands, 697 (91.3%) were farmers. The average family size was five . Four hundred seventy six (62.4%) mothers could not read and write. Whereas, 363 (47.4%) of their husbands could not read and write (Table 1).
Table 1.
Socio-demographic characteristics of respondents, Dangila district; Ethiopia, February 2015
| Variable | Frequency (n=763) | Percentage |
| Age of the mother | ||
| 15–19years | 18 | 2.3 |
| 20–24years | 106 | 13.9 |
| 25–29years | 263 | 34.5 |
| 30–34years | 218 | 28.6 |
| ±35years | 158 | 20.7 |
| Educational status of the mother | ||
| Unable to read and write | 476 | 62.4 |
| Can read and write | 147 | 19.3 |
| Primary education | 97 | 12.7 |
| Secondary education | 43 | 5.6 |
| Educational status of the husband | ||
| Unable to read and write | 272 | 35.7 |
| Can read and write | 362 | 47.4 |
| Primary education | 94 | 12.3 |
| Secondary education | 35 | 4.6 |
| Occupation of mother | ||
| House wife | 177 | 23.2 |
| Farmer | 586 | 76.8 |
| Occupation of the husband | ||
| Daily laborer | 25 | 3.3 |
| Farmer | 697 | 91.3 |
| Merchant and farmer | 41 | 5.4 |
| Family size | ||
| ≤5 | 470 | 61.6 |
| >5 | 293 | 38.4 |
Obstetric and maternal characteristics
Three hundred twenty seven (42.8%) mothers were gravida one to three and 121 (15.9%) had more than six gravidity. About half of the respondents (51.3%) were between para one and three while 115(15.1%) had more than six parities.
In this study, 472 (61.9%) mothers planned place of delivery for their last pregnancy; of which 342(72.5%) planned to give birth at a health institution. Three hundred thirty six mothers (71.2%) decided by themselves on their place of delivery (Table 2).
Table 2.
Obstetric and maternal characteristics of women, Dangila district; Ethiopia, February 2015
| Variable | Frequency (n=763) | Percentage |
| Number of pregnancy (gravidity) | ||
| 1–3 | 327 | 42.8 |
| 4–6 | 315 | 41.3 |
| >6 | 121 | 15.9 |
| Number of delivery(parity) | ||
| 1–3 | 392 | 51.4 |
| 4–6 | 256 | 33.5 |
| >6 | 115 | 15.1 |
| Number of children | ||
| 1–3 | 421 | 55.2 |
| 4–6 | 242 | 31.7 |
| >6 | 100 | 13.1 |
|
Abortion(termination of pregnancy before 28 weeks of gestation) in life time |
||
| Yes | 89 | 11.7 |
| No | 674 | 88.3 |
| Still birth in life time | ||
| Yes | 140 | 18.3 |
| No | 623 | 81.7 |
| ANC visit | ||
| Yes | 511 | 66.9 |
| No | 252 | 33.1 |
| Gestational week at first ANC visit(n=511) | ||
| First trimester | 165 | 32.3 |
| Second trimester | 291 | 56.9 |
| Third trimester | 55 | 10.8 |
| Number of ANC visit(n=511) | ||
| 1–3 | 235 | 46.0 |
| 4 | 242 | 47.4 |
| >4 | 34 | 6.6 |
| Plan place of delivery | ||
| Yes | 472 | 61.9 |
| No | 291 | 38.1 |
| Where did you plan to give birth? (n=472) | ||
| Health institution | 342 | 72.5 |
| Home | 130 | 27.5 |
| Decision maker about place of delivery (n=472) | ||
| The mother herself | 336 | 71.2 |
| Her husband | 97 | 20.5 |
| Her relatives | 39 | 8.3 |
| ANC provider (n=511) | ||
| Health extension worker | 118 | 23.1 |
| Nurse/midwife | 393 | 76.9 |
|
Discussion about place of delivery with professionals (n=511) |
||
| Yes | 400 | 78.3 |
| No | 111 | 21.7 |
| Assistant during last Delivery at home (n = 623) | ||
| Family member | 156 | 25.0 |
| Her friend | 25 | 4.0 |
| TBA (Untrained) | 367 | 58.9 |
| TBA(trained) | 76 | 12.1 |
ANC – Antenatal Care; TBA – Traditional Birth Attendant
Institutional delivery service utilization
Of the total respondents, only 140 (18.3%) gave birth at health facilities, and most of them (81.7%) delivered at home. Only 76 (12.1%) home deliveries were assisted by trained traditional birth attendant. Two third (66.9%) of mothers attended Antenatal Care (ANC), of whom 276(54%) had more than three ANC visit (Table 2).
Factors associated with institutional delivery service utilization
In this study, the bivariable logistic regression analysis showed that knowledge about danger signs, planned to give birth at a health institution, had ANC follow up during pregnancy, number of live birth, age, educational status, occupational status, husband occupation, husband education, time taken to arrive at health institution were statistically associated with institutional delivery service utilization.
In the multivariable logistic regression analysis, having sufficient knowledge about danger signs [AOR=2.0, 95% CI: (1.1, 3.4)], Planned to give birth at health institution [AOR=5.4, 95% CI: (3.0, 9.6)], had ANC follow up during pregnancy [AOR=12.9, 95% CI: (5.0, 33.3)] and taking less than one hour to reach nearest health institution [AOR=5.1, 95% CI: (2.9, 9.1)] were positively associated with institution delivery service utilizatiin (Table 3).
Table 3.
factors associated with institutional delivery among women, Dangila district; Ethiopia, February 2015
| Factor | Institutional delivery | COR | AOR | |
| Yes | No | (95%c/I) | (95%c/I) | |
|
knowledge about danger signs during delivery |
||||
| Sufficient knowledge | 53(7.0) | 129(16.9) | 2.3(1.5,3.4) | 2.0 (1.1,3.4) |
| Insufficient knowledge | 87(11.4) | 494(64.7) | 1.00 | 1.00 |
| Plan to give birth at health institution | ||||
| Yes | ||||
| No | 108(14.1) | 234(30.7) | 5.6(3.6,8.5) | 5.4.1(3.0,9.6) |
| 32(4.2) | 389(51.0 | 1.00 | 1.00 | |
| ANC follow up | ||||
| Yes | 134(17.6) | 377(49.4) | 14.5(6.3,33.5) | 12.9(5.0,33.3) |
| No | 6(0.8) | 246(32.2) | 1.00 | 1.00 |
| Number of delivery(parity) | ||||
| 1 | 8(1.0) | 49(6.4) | 1.00 | |
| 2–4 | 109(14.3) | 418(54.9) | 1.5(0.7,3.4) | |
| >4 | 23(3.0) | 156(20.4) | 0.9(0.3,2.1) | |
| Having still birth | ||||
| Yes | 22(2.8) | 118(15.5) | 1.2(0.7,2.0) | |
| No | 118(15.5) | 505(66.2) | 1.00 | |
| Educational status | ||||
| Have no formal education | 83(10.9) | 540(70.8) | 1.00 | |
| Primary education | 28(3.7) | 69(9.0) | 2.6(1.6,4.3) | |
| Secondary education | 29(3.8) | 14(1.8) | 13.4(6.8,26.5) | |
| Occupational status | ||||
| Farmer | 79(10.4) | 507(66.4) | 3.3(2.2,4.9) | 3.2(1.8,5.4) |
| Housewife | 61(8.0) | 116(15.2) | 1.00 | 1.00 |
| Husband education | ||||
| Have no formal education | 95(12.5) | 539(70.6) | 1.00 | 1.00 |
| Primary education | 37(4.9) | 57(7.5) | 1.8(1.1,2.9) | 5.2(2.5,10.4) |
| Secondary education | 8(1.0) | 27(3.5) | 4.4(2.6,7.6) | 4.6(1.6,12.6) |
| Time taken to arrive at health institution | ||||
| <1hour | ||||
| ≥1hour | 113(14.8) | 337(44.2) | 3.5(2.2,5.5) | 5.1(2.9,9.1) |
| 27(3.5) | 286(37.5) | 1.00 | 1.00 | |
ANC — Antenatal Care; COR-Crude odds ration; AOR — adjusted odds ratio, C/I-Confidence interval
Discussion
This study aimed to assess factors associated with institutional delivery service utilization among mothers who gave birth in the last 12 months. Considering the last delivery a mother had, in this study, 18.3% of mothers gave birth at a health institution. This finding was consistent with study findings in Ethiopia10–13 and Bangladesh14.
On the other hand, this finding was lower than study findings elsewhere in Ethiopia15,16 and other developing countries such as Zambia, Uganda, Tanzania and Nepal17–20. The difference might be due to the study area; the current study was done in a rural area, while the former studies included both rural and urban mothers. Beside this, discrepancies might be attributed to socio - economic difference of participants. Moreover, this might be due to the difference in access especially in terms of physical distance which is important to service utilization. This study was done among rural mothers; health insitutions are not in close proximity, even if the government arranges free transportation, the vehicle may not be available at the time they need it.
Knowledge about danger signs during delivery had statistically significant association with institutional delivery service utilization. Mothers who had sufficient knowledge about danger signs were 3 times more likely to give birth at a health institution compared with mothers who had insufficient knowledge. This finding was in agreement with study findings from Ethiopia and Kenya11,21,22. Knowledge is an important factor that affects attitude, intention and behavior. Women who have sufficient knowledge about delivery danger signs might have perceived service benefits of a health institution, like complication management by skilled health care workers in time of labor.
Mothers whose husbands had formal education were 5 times more likely to deliver at health institution than those mothers whose husbands had no formal education. This finding was consistent with study findings in South East Ethiopia, Nepal and Bangladesh16,23–25. Educated husbands might have better understanding about complications of home delivery and benefit of institutional delivery and assist their partner in deciding on place of delivery26. Other studies reported that partner support in decision making increases institutional delivery service utilization of mothers27.
Distance from the nearest health institution was significantly associated with institutional delivery service utilization. Women who travelled less than one hour walking distance to a nearby health facility were 3 times more likely to deliver at a health institution than women who spent more than 1 hour to access a health facility. Similarly, studies in low income countries such as Bahi District, Central Tanzania, Rural Zambia, Nepal, Rural Malawi and Rural India25,28–33 showed that physical distance is one of the major constraints that prevented community members from accessing and using trained attendants and institutional deliveries.
ANC service utilization was significantly associated with institutional delivery. Women who had ANC follow up were 13 times more likely to deliver at health institutions than their counterpart who had no ANC visits. This finding was consistent with study findings in Ethiopia, Nepal and Bangladesh11,16,23,25. Antenatal care visits offer a window of opportunity to get counseling services on the benefit of institutional delivery over home delivery. One component of focus ANC is counseling of the women about pregnancy, delivery and postnatal danger signs and importance of institutional delivery26.
Plan to give birth at health institution was another factor significantly associated with institutional delivery service utilization. Women who planned to give birth at a health institution were 5 times more likely to deliver at a health institution than their counter part. This study finding was in line with another study in Ethiopia34. Better birth preparedness being considered as an intervention fostering preventive behavior and influencing other socio-ecomnomic and cultural barriers, thus encouraging the use of health facilities.
Significant association was observed between institutional delivery service utilization and occupational status of the mother. In this study, farmers were 3.2 times more likely to give birth at a health facility than hosewives. This finding was not in agreement with study finding in Metekel Zone35. Currently, the government is working to increase institutional delivery service utilization by promoting maternal service utilization through professionals and mass media, and arranging transportation and free ANC delivery and postnatal service. Therefore, the discrepancy might be due to time gaps between studies. Farmers in the current study have the opportunity to get existing updated information than housewives, due to their outdoor exposure.
This study was limited to rural setting hence; results will not be generalized to the entire district. Since the study is cross-sectional, we could not establish a casual relationship of the explanatory and outcome variables.
Conclusion
Institutional delivery service utilization was very low. Knowledge about danger signs, husband education, p0lan to give birth at a health institution, had ANC follow up during pregnancy, and time taken to get nearby health institution, were factors associated with institutional delivery service utilization. Thus, the findings recommended repeated re-enforcement of institutional delivery service utilization through professionals. And also the findings recommend promotion of institutional delivery service utilization through mass media.
Acknowledgements
We would like to thank the study participants for their participation. We were also grateful to express our gratitude to data collectors and supervisors for their time and full commitment.
Competing interests
The authors declare that they have no competing interests
Authors' contributions
YMD and GBG conceived and designed the study, conducted statistical analysis and result interpretation, prepared manuscript. AAN assisted with data analysis and interpretation. All authors read and approved the manuscript.
References
- 1.Worldbank, WHO, UNFPA, UNICEF, author. Trends in maternal mortality: 1990–2010. Geneva, Switzerland: 2012. [Google Scholar]
- 2.Wang W, Alva S, Wang S, Fort A. Levels and trends in the use of maternal health services in developing countries. Calverton, Maryland: 2011. DHS Comparative Reports No. 26. ICF Macro. [Google Scholar]
- 3.Dominic M, Gavin Y, Adam V, April H, Joanne Y. Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data. PLoS ONE. 2011;6(2):e17155. doi: 10.1371/journal.pone.0017155. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Central Statistical Agency [Ethiopia], ICFInternational, author. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International; 2012. [Google Scholar]
- 5.Lawn J, Lee A, Kinney M, Sibley L, Carlo W, Paul V, et al. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Internationl Journal of Gynaecology and Obstetrics. 2009;107(1):S5–S18. doi: 10.1016/j.ijgo.2009.07.016. S9. [DOI] [PubMed] [Google Scholar]
- 6.Gistane A, Maralign T, Behailu M, Worku A, Wondimagegn T. Prevalence and associated factors of home delivery in Arbaminch Zuria district, southern Ethiopia: Community based cross sectional study. Science Journal of Public Health. 2015;3(1) doi: 10.11648/j.sjph.20150301.12. [DOI] [Google Scholar]
- 7.Mehari AM. Levels and Determinants of Use of Institutional Delivery Care Services among Women of Childbearing Age in Ethiopia: Analysis of EDHS 2000 and 2005 Data. Calverton, Maryland, USA: ICF International; 2013. DHS WORKING PAPERS. [Google Scholar]
- 8.Lancet. 2010;376(9387):303. doi: 10.1016/S0140-6736(10)61165-8. Home birth—proceed with caution. [DOI] [PubMed] [Google Scholar]
- 9.Annual antenatal, delivery and postnatal service provision report. Dangila health Bureau, Dangila District; 2012. [Google Scholar]
- 10.AddisAlem F, Meaza D. Prevalence of institutional delivery and associated factors in Dodota Woreda (district), Oromia regional state, Ethiopia. Reproductive Health Journal. 2012;9(33) doi: 10.1186/742-4755-9-33. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Alemayehu T, Fekadu M, Solomon M. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of Ethiopia: A community - based cross sectional study. BMC Pregnancy and Childbirth. 2012;12(74) doi: 10.1186/1471-2393-12-74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Gedefaw A, Muluken A, Tesfaye S. Factors associated with Institutional delivery service utilization among mothers in Bahir Dar City administration, Amhara region: acommunity based cross sectional study. Reproductive Health Journal. 2014;11(22) doi: 10.1186/1742-4755-11-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Central Statistical Agency [Ethiopia], author Ethiopia Mini Demographic and Health Survey 2014. Addis Ababa, Ethiopia: 2014. [Google Scholar]
- 14.Kamal SMM. Preference for Institutional Delivery and Caesarean Sections in Bangladesh. Journal of Health and Population Nutrition. 2013;31(1):96–109. doi: 10.3329/jhpn.v31i1.14754. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Worku A, Jemal M, Gedefaw A. Institutional delivery service utilization in Woldia, Ethiopia. Science Journal of Public Health. 2013;1(1):18–23. [Google Scholar]
- 16.Daniel B, Desalegn M. Institutional delivery service utilization and associated factors among child bearing age women in Goba Woreda, Ethiopia. Journal of Gynecology and Obstetrics. 2014;2(4):63–70. [Google Scholar]
- 17.Mwewa D, Michelo C. Factors associated with home deliveries in a low income rural setting-observations from Nchelenge district, Zambia. Medical Journal of Zambia. 2010;37(4):235–238. [Google Scholar]
- 18.Jerome K, Per-Olof O, Eleanor T, Odberg P. Influence of Birth Preparedness, Decision-Making on Location of Birth and Assistance by Skilled Birth Attendants among Women in South-Western Uganda. PLoS ONE. 2012;7(4):e35747. doi: 10.1371/journal.pone.0035747. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Rose N, Japhet Z, Melkzedeck T, Siriel N, Albrecht J, Declare M, et al. Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy and Childbirth. 2007;7(29) doi: 10.1186/471-2393-7-29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Damaru PP. Pattern of Institutional delivery in Dadeldhura district of Nepal: A cross-sectional study. Journal of the Scientific Society. 2014;41(2):94–100. [Google Scholar]
- 21.Fantu A, Yemane B, Belaineh G. Factors associated with home delivery in Bahirdar, Ethiopia: A case control study. BMC Research Notes. 2012;5(653) doi: 10.1186/1756-0500-5-653. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Carol W, Moses M, Evans M, Gabriel M, Zipporah N. Delivery Practices and Associated Factors among Mothers Seeking Child Welfare Services in Selected Health Facilities inNyandarua South District, Kenya. BMC Public Health. 2011;11(360) doi: 10.1186/1471-2458-11-360. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Nazrul I, Mohammad TI, Yukie Y. Practices and determinants of delivery by skilled birth attendants in Bangladesh. Reproductive Health. 2014;11(86) doi: 10.1186/1742-4755-11-86. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Abdella A, Abebaw G, Zelalem B. Institutional delivery service utilization in Munisa Woreda, South East Ethiopia: a community based cross-sectional study. BMC Pregnancy and Childbirth. 2012;12(105) doi: 10.1186/1471-2393-12-105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Damaru PPM. Factors Influencing Delivery Service Utilization in Rural Areas of Dadeldhura District of Nepal. PARIPEX. Indian Journal of Reesearch. 2014;3(7) ISSN - 2250-1991. [Google Scholar]
- 26.Kihulya M, Elia MJ. Prevalence and predictors of institutional delivery among pregnant mothers in Biharamulo district, Tanzania: a cross-sectional study. Pan African Medical Journal. 2015;21(51) doi: 10.11604/pamj.2015.21.51.6347. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Eshetu E, Tadele Nigusse. Determinants of Skilled Institutional Delivery Service Utilization among Women Who Gave Birth in the Last 12 Months in Bako District, Oromia, Ethiopia, 2012/13 (Case-Control Study Design) Journal of Gynecology and Obstetrics. 2015;3(2):36–42. [Google Scholar]
- 28.Lwelamira J, Safari J. Choice of Place for Childbirth: Prevalence and Determinants of Health Facility Delivery Among Women in Bahi District, Central Tanzania. Asian Journal of Medical Sciences. 2012;4(3):105–112. [Google Scholar]
- 29.Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Social Science Medicine. 1994;38(8):1091–1110. doi: 10.1016/0277-9536(94)90226-7. [DOI] [PubMed] [Google Scholar]
- 30.Sabine G, Simon C, Jonathan C, Oona M. The Influence of Distance and Level of Care on Delivery Place in Rural Zambia: A Study of Linked National Data in a Geographic Information System. PLoS Med. 2011;8(1):e1000394. doi: 10.1371/journal.pmed. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Line S, Johanne S, Jane C. Factors Influencing Women's Choice of Place of Delivery in Rural Malawi- an explorative study. REview. African Sante Reprod. 2006;10(3):66–75. [PubMed] [Google Scholar]
- 32.Amy JK, John C, Andy S, Carine R. IRnesesatrciht aurtticileonal delivery in rural India: the relative importance of accessibility and economic status. BMC Pregnancy and Childbirth. 2010;10(30) doi: 10.1186/471-2393-10-30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Santosh K, Emily AD, Christopher JLM. Does distance matter for institutional delivery in rural India? Applied Economics. 2014;46(33):4091–4103. doi: 10.1080/00036846.2014.950836. [DOI] [Google Scholar]
- 34.FeyissaTesfaye R, Gebi AG. Determinants of Institutional Delivery among Childbearing Age Women in Western Ethiopia, 2013:Unmatched Case Control Study. PLoS ONE. 2014;9(5):e97194. doi: 10.1371/journal.pone.0097194. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Gurmesa T, Abebe Gm. Safe Delivery Service Utilization in Metekel Zone NorthWest Ethiopia. Ehtiopian Journal of Health Science. 2008;17(4):213–222. [Google Scholar]