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. 2021 Aug 9;16(8):e0254696. doi: 10.1371/journal.pone.0254696

Home delivery practice and its predictors in South Ethiopia

Dejene Hailu 1,*,#, Henok Tadele 2,#, Birkneh Tilahun Tadesse 3,#, Akalewold Alemayehu 1,#, Teshome Abuka 1,#, Fitsum Woldegebriel 3,#, Abel Gedefaw 4,#, Selamawit Mengesha 1,#, Yusuf Haji 1,#
Editor: José Antonio Ortega5
PMCID: PMC8351986  PMID: 34370742

Abstract

Background

Institutional delivery is one of the key interventions to reduce maternal death. It ensures safe birth, reduces both actual and potential complications, and decreases maternal and newborn death. However, a significant proportion of deliveries in developing countries like Ethiopia are home deliveries and are not attended by skilled birth attendants. We investigated the prevalence and determinants of home delivery in three districts in Sidama administration, Southern Ethiopia.

Methods

Between 15–29 October 2018, a cross sectional survey of 507 women who gave birth within the past 12 months was conducted using multi-stage sampling. Sociodemographic and childbirth related data were collected using structured, interviewer administered tools. Univariate and backward stepwise multivariate logistic regression models were run to assess independent predictors of home delivery.

Results

The response rate was 97.6% (495). In the past year, 22.8% (113), 95% confidence interval (CI) (19%, 27%) gave birth at home. Rural residence, adjusted odds ratio (aOR) = 13.68 (95%CI:4.29–43.68); no maternal education, aOR = 20.73(95%CI:6.56–65.54) or completed only elementary school, aOR = 7.62(95% CI: 2.58–22.51); unknown expected date of delivery, aOR = 1.81(95% CI: 1.03–3.18); being employed women (those working for wage and self-employed), aOR = 2.79 (95%CI:1.41–5.52) and not planning place of delivery, aOR = 26.27, (95%CI: 2.59–266.89) were independently associated with place of delivery.

Conclusion

The prevalence of institutional delivery in the study area has improved from the 2016 Ethiopian Demography Health Survey report of 26%. Uneducated, rural and employed women were more likely to deliver at home. Strategies should be designed to expand access to and utilization of institutional delivery services among the risky groups.

Introduction

Maternal mortality is a major public health problem in developing countries particularly, in sub–Saharan Africa (SSA) [1]. Every year, nearly half a million women and girls needlessly die from complications of pregnancy and childbirth, and 99% of these deaths occur in developing countries [1]. According to the joint World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) 2015 estimate, the global maternal mortality rate was 216/100,000 live births (LBs), while 436/100,000 LBs and 546/100,000 LBs were reported for the least developed and SSA countries, respectively [2]. Based on a recent report, Ethiopia is one of the countries with the highest maternal (412/100,000), neonatal (29/1000) and infant mortalities (48/1000 LBs) [3].

Most maternal deaths which occur in developing countries are due to complications during labor and delivery, and during the immediate postpartum period. The WHO recommends that every delivery should be attended by skilled personnel. However, a significant proportion of women do not have this access during childbirth [1, 4].

Globally, it was estimated that 22% of deliveries didn’t happen in health facilities by the year 2015. A similar report showed that the aggregate prevalence of home deliveries in Eastern and Southern Africa was about 38% [2]. In Ethiopia, community-based surveys conducted in various regions of the country reported 31% to 96% home deliveries [5–12], which is similar to that is reported in the Ethiopian Demographic Health Survey (EDHS) 2016 survey (73%) [3]. The consistently high prevalence of home deliveries in different parts of the country indicate that the large proportion of pregnant women and their babies are at risk of complications including death related to childbirth [1, 2].

Available evidence revealed that several factors such as socio-economic status, maternal education, infrastructure, place of residence, unpleasant experience with healthcare providers and access to primary health care services influence women’s choice of place of delivery [13–16]. For example, a study conducted in Nigeria and Ethiopia showed that women in rural areas were more likely to consider facility delivery as unimportant and complained about distance and inability to pay fees [17].

According to the EDHS data–covering 2011 to 2015 –the prevalence of home birth in Southern Nations Nationalities and Peoples Region (SNNPR) was 74% [3]. However, as part of an ongoing Kangaroo Mother Care (KMC) implementation project (ClinicalTrials.gov: NCT03506698) in southern Ethiopia, very few home births were reported by the health extension workers (HEWs). While this low home birth rate could signal an improving health system in the region, it could also indicate poor tracking and reporting systems of home births by HEWs. To assess the real burden of home births in the area, we conducted a population-based survey in three districts of Sidama Administration–Hawassa City Administration, Dale and Shebedino districts. The aims of the survey were to assess the prevalence of homebirth and determinants in three districts of Sidama Administration, SNNPR.

Methods

Study setting

This survey was conducted at KMC implementation sites in SNNPR, which included Hawassa City Administration, Dale and Shebedino districts. Hawassa Comprehensive Specialized Hospital, Adare General Hospital, Yirgalem General Hospital, and Leku Primary Hospital served as KMC implementation centers. Hawassa is the capital city of SNNPR/Sidama Administration and it is located 275 km South of Addis Ababa, the capital of Ethiopia. Hawassa City Administration has eight sub-cities divided in 32 kebeles (the lowest administration unit in Ethiopia). The estimated total population size of Hawassa city in 2017 was 455,658 as projected from the 2007 Ethiopian national census [18]. It is estimated that there are over 10,000 deliveries taking place in Hawassa every year. There are 3 public hospitals and 12 health centers in the city.

Shebedino district, the second study area is located 30km South of Hawassa city and has 32 Kebeles. Leku town is the capital of the district. There is one primary hospital, 9 health centers and 32 health posts in the district. An estimate of 121 deliveries is attended per month at Leku Primary Hospital.

The total population of Dale district in 2017 was 317,246 with 11,104 expected deliveries per year (18). Yirgalem town is the capital of the district and it is located 45kms south of Hawassa City. There is one general hospital, 10 health centers and 36 health posts in the district.

Study design and population

A community based cross-sectional survey was conducted during 15th- 20thOctober, 2018. Randomly selected women who gave birth in the last one year and residing at least 6 months in the area were included in the survey. Non-consenting mothers were excluded from the study.

Sample size

The sample size was calculated using Epi info 7 Statistical software for population survey. Considering 72.5% home delivery in SNNPR (EDHS 2016), 95% confidence interval (CI), margin of error of 5%, design effect of 1.5 for a cluster of 10 and 10% non-response rate, a total of 507 women were needed [3].

Sampling procedures

A multistage sampling technique was used to enroll study participants. There are 32 kebeles in Hawassa city, 35 in Dale and 32 in Shebedino districts. We selected 11 kebeles [4 kebeles from Hawassa City, representing urban households (36%); 4 from Dale and 3 from Shebedino districts, both representing rural households (64%)] using simple random sampling techniques. Households of women who gave birth during the last 12months preceding the study were identified and listed with the help of family folders available at the health posts of the selected 11 kebeles. Finally, the calculated sample size was proportionally allocated to the kebeles based on the identified number of eligible women. Women in each of the selected kebeles were randomly selected by simple random sampling technique using the list as a sampling frame.

Data collection

The questionnaires were first prepared in English and then translated to local languages: “Sidamu Afoo” for rural residents and “Amharic” for urban residents. Six data collectors who completed at least first degree in public health disciplines interviewed the participants.

Data analysis

Data analysis was done using SPSS version 25. Descriptive, bivariate, and multivariate analyses were done to assess association between sociodemographic variables and place of delivery. Odds ratios and 95% CIs were computed. A backward stepwise multivariate regression model was run using variables with P-value <0.2 in the bivariate analysis, which included place of residence, age, education and occupation of women, paternal education, distance of health center from home, family size, number of ANC follow up, knowing the due date, planned place of birth and birth order. Model fitness was checked using Hosmer and Lemeshow test of goodness of fit which yielded a p-value = 0;889. Level of significance for independent associations was set at p<0.05.

Ethics approval and consent to participate

This study was approved by Institutional Review Board (IRB) of Hawassa University. Considering non-invasive nature of data collection procedures, which is a case in most surveys conducted in Ethiopia, a verbal consent, which was approved by the IRB, was obtained from all women participated in the survey after detailed introduction of the objectives of the study and the right to withdraw from the study at any time. The information sheet and consent was read slowly and loudly by the data collector to the participants. Then, they were asked if there were any queries. After the mothers had confirmed that all is clear, they were asked one last question if they were willing to participate in the survey or not. The data collectors circled either ‘yes’ or ‘no’ based on whichever is selected and the interview was conducted only if the data collector was told to circle the response ‘yes’. This was attached to the questionnaire and documented.

Seven (1.4%) mothers were less than 18 years old, but the consent was obtained from these women since they have been married and do not live with the family. The IRB was aware of this situation and approved the verbal consent obtained from mothers less than 18 years old. Confidentiality was maintained by decoding study subjects’ identifiers and the consent form and questionnaires were kept in locked file cabinets.

Results

Socio-demographic characteristics of the respondents

We interviewed 495(97.6%) mothers who had given birth 12 months preceding the survey. The mean (±SD) age of the participants was 25.85(±4.95) years; 339(68.5%) were rural residents. Two hundred and seven (42%) respondents completed grades 5–8 while 61(12.3%) did not attended any school. Majority, 377(76.2%) of the women were housewives and 45% of them had at least five family members (Table 1).

Table 1. Socio-demographic characteristics of women with infants(0-12months) at three districts in Sidama Administration, 2018.

Characteristics Frequency (%)
Age (years)
 ≤20 92(18.6)
 21–25 165(33.3)
 26–30 169(34.4)
 >30 69(14)
Level of education
 No class attended 61(12.3)
 Grade 1–4 completed 90(18.2)
 Grade 5–8 completed 207(41.8)
 Grade 9–10 completed 71(14.30
 Higher than grade 10 66(13.3)
Occupation
 Housewife 381(78.1)
 Employed 107(21.9)
Paternal education
 No class attended 43(8.70
 Grade 1–4 completed 36(7.3)
 Grade 5–8 completed 164(33)
 Grade 9–10 completed 122(24.6)
 Higher than grade 10 130(26.3)
Household’s monthly income (in Ethiopian Birr)
 Low (<1000) 170(34.3)
 Medium (1000–1999) 132(26.7)
 Higher income (≥2000) 91(18.4)
 Unknown income(unreported) 102(20.6)
Distance from house to health center
 <30 minutes’ walk 213(43)
 30–60 minutes’ walk 282(57)
Total Family members
 <5 members 274(55.4)
 ≥5members 221(44.6)
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Antenatal care follow- up and plan for place of delivery

The majority, 473(95.6%) of the women had antenatal care (ANC) follow up. Two-hundred forty-four (51.6%) women had at least 4 visits during the whole pregnancy of the index child. Three hundred sixty (64%) attended ANC in health centers. Three hundred forty-seven (70%) knew the due date of the index child. Four hundred eighty-two (97.4%) women planned their place of delivery; 309 (63.2%) preferred health centers, 102 (21%) preferred government hospitals and 62 (12.5%) preferred home delivery. The majority, 415(83.8%) of respondents wished their delivery to be attended by skilled health professionals while 80(16.2%) preferred their women relatives, or traditional birth attendants as birth attendants.

Characteristics of deliveries

The overall prevalence of home delivery was 22.8% (113), 95%CI: 19%, 27%). Home delivery rate among women from rural areas was 32% (108), 95%CI: 27.6–36%) while it was 3.2% (5) among urban residents (Table 2). One hundred twelve (72%) of urban women gave birth at government hospitals while 166(49%) of the rural women delivered at health centers. Reasons for home delivery included inconvenience of health facilities, 44(40.7%); personal preference to deliver at home, 39(36.3%); not considered important, 20(18.5%); fear of delivering on the way to the health facility, 15 (14%); and lack of transportation, (10%) (Table 2).

Table 2. Delivery characteristic of participants at KMC implementation sites, Sidama Administration, 2018.

Variables Categories Frequency (%)
Birthplace of the index child Health center 193(39)
Hospital 175(35.4)
Home 113(22.8)
Private clinic/hospital 14(2.8)
Reasons for home births (n = 113) Health facilities are inconvenient 45(40)
Personal preference 41(36.3)
Unnecessary to give birth at health facilities 20(18)
Fear of delivering on the way to the health facility 16(14)
No transportation 11(40)
Health Professionals (HPs) are not friendly 3(0.6)
Mode of delivery of the index child Normal vaginal delivery 448(90.5)
Caesarean Section 47(9.5)
Attendant of the delivery of the index child Doctors 56(11.3)
Nurses/Midwifery 203(41)
Unknown health professional 132(26.7)
Female relatives/friends 57(11.5)
Traditional Birth attendants 28(5.7)
No one (mother herself) 9(1.8)
Others 25(5.1)
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The proportion of home delivery significantly varied by districts (X2 = 63, DF = 2, value<0.001). In Shebedino district, majority of the women gave birth at home compared to Dale and Hawassa districts (Fig 1)

Fig 1. Place of delivery cross tabulated by the study districts, Sidama Administration, 2018.

Fig 1

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Factors associated with home delivery

Rural residence, being employed, lack of or limited education, knowing due date of the index child and planned place of delivery predicted the place of delivery.

Women residing in rural areas were 5.28 times more likely to deliver at home as compared to urban dwellers, aOR = 5.28(95%CI:1.25–22.16). Similarly, the odds of home birth among uneducated 8.78(95% CI: 2.33–33.01) or minimally educated women 3.81(95% CI: 1.16–12.49) was high. The odds of home birth among women who did not know the due date of their index child was two folds higher compared to those who knew it, aOR = 2.12(95%CI: 1.21–3.71). Furthermore, women whose husbands did not go to school were about 3 times more likely to deliver at home compared to their counter parts, aOR = 3.27, 95% CI: 1.20–8.88) (Table 3).

Table 3. Bivariate and multivariate analyses of factors associated with home deliveries at KMC implementation sites, Sidama Administration, 2018.

Variables Categories Place of delivery COR (95%CI) AOR (95% CI)
Home (%) Health facility (%)
Place of residence Rural 108(95.6) 231(60.5) 14.12(5.63–35.42) 13.68(4.29–43.65)
Urban 5(4.4) 151(39.5) 1.0 1.0
Age of women ≤20 years 12(10.6) 80(20.9) 1.0
21–25 years 33(29.2) 132(34.6) 1.67(0.81–3.41) *
26–30 years 46(40.7) 123(32.2) 2.49(1.24–4.99)
>30 years 22(19.5) 47(12.3) 3.12(1.42–6.88)
Maternal education No class attended 33(29.2) 28(7.3) 31.11(11.16–86.73) 20.73(6.56–65.54)
Grade 1–4 completed 32(28.3) 58(15.2) 14.56(5.4–39.27) 7.62(2,58–22.51)
Grade 5–8 completed 43(38.1) 164(42.9) 6.92(2.67–17.97) 3.18(1.11–9.06)
Grade 9–10+ completed 5(4.4) 132(34.6) 1.0 1.0
Maternal Occupation Housewife 89(80.2) 292(77.5) 1.0 1.0
Employed/ 22(19.8) 85(22.5) 0.54(0.50–1.44) 2.79(1.41–5.52)
Father’s education No class attended 25(22.1) 18(4.7) 19.19(8.79–41.91)
Grade 1–4 completed 15(13.3) 21(5.5) 9.87(4.32–22.54) *
Grade 5–8 completed 56(49.6) 108(28.3) 7.17(3.98–12.91)
Grade 9–10+ completed 17(15.0) 235(61.5) 1.0
Distance of house from health center <30 minutes’ walk 36(32) 177(46.3) 1.0
30–60 minutes’ walk 77(68) 205(53.7) 1.85(1.18–2.88) *
Total number of Family members <5 members 52(46) 222(58) 1.0
≥5members 61(54) 160(42) 1.63(1.10–2.48) *
No of Antenatal care visits (n = 474) 1 4(4.2) 6(1.6) 4.42(1.18–16.51)
2 26(27) 49(13) 3.51(1.92–6.43) *
3 34(35.4) 111(29.4) 2.03(1.19–3.46)
4+ 32(33.3) 212(56.2) 1.0
Knew the due date for the index child Yes 59(52.2) 288(75.4) 1.0 1.00
No 54(47.8) 94(24.6) 2.80(1.81–4.34) 1.81 (1.03–3.18)
Planned place of delivery for the index child Yes 101(89.4) 381(99.7) 1.0 1.0
No 12(10.6) 1(0.3) 45.26(5.82–352.25) 26.27(2.59–266.89)
Birth order of the child First order 23(20.4) 146(38.2) 1.0
2-3rd order 53(46.9) 171(44.8) 1.97(1.15–3.37) *
4th or more order 37(32.7) 65(17.0) 3.61(1.99–6.56)
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Discussion

This cross-sectional survey included mothers from urban and rural settings. The prevalence of home delivery was almost 23%. Rural residence, being employed and lower maternal education were among determinant factors for home birth.

In the current study, the proportion of women who gave birth at home was 22.8% (32% and 3.2% among women from rural and urban areas, respectively), a prevalence comparable to figures reported by a study conducted in Bench Maji Zone (21.7%), Southern Ethiopia [19] and EDHS report of 2016 (25.3%) in Ethiopia [20]. However, the prevalence in our study is lower than that reported by studies in different parts of Ethiopia [21–24]. This difference might be attributed to various factors including differences in infrastructures such as roads and transport systems, which are critical to ensure access to healthcare facilities [25].

A relatively high prevalence of home delivery was observed in Shebedino district which is likely related to socio-cultural factors that need to be further explored. Overall, access to local mass media in local languages, access to health infrastructure and leadership, promotion efforts for institutional delivery and factors related to demographic and socioeconomic characteristics could affect preference of place of delivery of women.

More than two-thirds of respondents who participated in the survey were 21–30 years old implying the high age-specific fertility rate. One in ten women did not attend any formal education indicating that most women in the study area attended some education compared to figures reported by similar surveys [16, 17]. The better educational status could have attributed to the observed remarkable decline of home delivery in the study area compared to figures reported by EDHS 2016 [3].

Our findings showed that women residing in rural areas were five times more likely to give birth at home compared to those living in urban areas. Several similar studies reported that place of residence and distance from health facilities as common predictors of home birth. This could be related to the limited access to health information and service as well as long distance from the health facilities among rural dwellers limiting the chances of institutional birth [4, 17, 22, 26, 27]. Our study calls for better strategies to reach the rural community to avert home births.

Our findings show that level of maternal education and occupation predicted place of delivery. Uneducated women are less empowered and are unable to make use of multiple sources of information related to complicated pregnancies [15]. Moreover, uneducated women are also more likely to be influenced by socio-cultural phenomena which discourage institutional delivery. This was well demonstrated by this study and consistently supported by similar surveys [15, 22, 26]. Lack of knowledge on the due date demonstrated similar effect as maternal education. Women who did not know expected date of delivery are more likely to deliver at home compared to those who know it. Mothers who forget expected date of delivery are less likely to get prepared and plan for institutional delivery.

One unique observation of the current study is that employed women were found to be more likely to deliver at home compared to housewives. Employed women are considered to be more mobile because of the nature of their work, more likely to use contraceptives and have better awareness compared to housewives. The finding of this study is contrary to this reality requiring further investigation. Lack of early plan of place of delivery and lack of preparedness for institutional delivery due to their busy daily routine are among the factors that might increase the probability that the employed mother could give birth at home.

Limitation of the study

All determinant factors couldn’t be assessed by this questionaries-based survey as additional qualitative component could help in ascertaining them. However, this survey is the first of its type for the site to reveal reasons for home births and assists policy makers and health system leadership to design ways of tackling the issues. In this study, numbers of ANC visits, distance of health facility from home, and total number of family size were not associated with home delivery mainly because of inadequate power of the test. The 95%CI for some aORs also indicate the effect of small sample size on the precision of estimated measures of reported effect size.

Conclusions and recommendations

The prevalence of home birth has significantly dropped in the study setting compared to figures reported in 2016. Parental and maternal education, mother’s occupation, and place of residence and planned place of delivery were found to be predictors of home delivery. We recommend further study using qualitative methods and interventions targeting rural and uneducated parents to further reduce home births.

Supporting information

S1 Data

(SAV)

Click here for additional data file. (180.7KB, sav)
S2 Data

(BIN)

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S1 Questionnaire

(DOC)

Click here for additional data file. (77.5KB, doc)

Acknowledgments

We thank Sidama Administration Health Department, district health offices and kebele administrations in the study area for their support. We extend our thanks to data collectors and respondents for their time and willingness to participate in the study.

Abbreviations

aOR

Adjusted odds ratio

CHW

community health worker

CI

confidence interval

EDHS

Ethiopian Demographic and Health Survey

KIT

KMC implementation team

KMC

Kangaroo Mother Care

LBs

Live births

SD

Standard deviation

SNNPR

Southern Nations Nationalities and Peoples Region

SSA

sub-Saharan Africa

UNICEF

United Nations International Children’s Fund

WHO

World Health Organization

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

This study based on the “Home Delivery Practice and its Predictors in South Ethiopia” survey was supported by Hawassa University through its KMC Projects in the form of funds awarded to HT. The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

José Antonio Ortega

15 Feb 2021

PONE-D-20-23821

Institutional delivery practice in southern Ethiopia.

PLOS ONE

Dear Dr. Kassa,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The main limitation of the current study is that it can be seen as a replication study of the numerous similar studies carried out in different regions of the country. Many of them are reported, some of the more recent ones are missing. PLOS ONE policy regarding replication studies is that if a submitted study replicates or is very similar to previous work, authors must provide a sound scientific rationale for the submitted work and clearly reference and discuss the existing literature. Submissions that replicate or are derivative of existing work will likely be rejected if authors do not provide adequate justification. The authors should streghthen the rationale for the submitted work and ensure they clearly reference the existing literature.

Regarding some of the key missing references: https://doi.org/10.1186/s12889-019-7854-2 is interesting since it works with the DHS survey mentioned in the introduction, DOI: 10.1186/s12884-017-1409-2 looks also at the relationship with seeking antenatal care..., DOI: 10.1186/s12889-020-08919-8 ... I believe there are more references missing.

Another limitation of this study is sample size and low power. This means that large differences in relative risk such as those of antenatal care, seem not be significant. I say seem, because there are problems in reporting. It is said that a screening based on p-values of 0.2 is carried out in a first stage, but those p-values are missing from table 3 (or elsewhere), they should be included.

There is also no treatment of multicolllinearity. Several of the variables are probably closely related, such as urban/rural and distance to health facility. This might explain changes of signs. Some evaluation of multicollinearity is needed. I suggest one of two strategies: the first one, you could use a backward/forward model selection procedure similar to the Debremarkos study mentioned above. Otherwise, you could report the R2 of the covariiates with respect to the rest of covariates (VIF, equal to 1/1-R2aux is better avoided since it does not provide a variance inflation factor in the context of logistic regression).

Due to the large number of categorical variables and small sample size, there could be problems of complete or quasi-complete separation. Please report on the convergence of estimates (at least in the review report) since lack of convergence is often due to problems of separation.

In addition, PLOS ONE policy is that the data is provided before publication. Please follow PLOS ONE policies including the data in the submission or providing a link to an open repository where the data can be accessed.

Look also at the additional points made by the reviewers.

Please submit your revised manuscript by Mar 29 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

José Antonio Ortega, Ph.D.

Academic Editor

PLOS ONE

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[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Comments to the Author

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: How could you see the significance of the study as many studies published in Ethiopia including DHS?. (may be as requirements for KMC project)As a report made by authors the study sampling procedure is multistage and design effect of 2 was used to calculate sample size but only three districts selected to represent the whole 36districts in Sidaama region mentioned in the title. 

How do you see generalization to the whole region?

and also why you are interested in urban and rural division in spite of the fact that statistical difference and separate factors for both was not appreciated(32 versus 3.2 Percent)

Need further discussion for maternal merchant occupation as risk factors for home delivery since women economic empowerment pave the way for institutional delivery?

the issues of wide confidence interval for prominent factors called planned place of delivery and chi square assumption which is not fulfilled(1)

The limitations didn't go with study objectives? Since the trend is not many objectives of current study?

Reviewer #2: Very useful manuscript. Major revisions are required as the discussion is repetition of results. Discussion needs to be more of explanation for findings and comparison with other studies. Need to be rewritten.

Authors do not compare data across districts. No description of graph of district wise deliveries in the results but mentioned in the discussion but no elaboration.

Discrepancy of merchant women having more home births needs to be discussed in a detail.

Reviewer #3: 1. Title says "Institutional delivery practice in southern Ethiopia" but the aim is to assess prevalence and determinants of of home delvery. Better to change it " Home delivery practice and its predictors in South Ethiopia"

2. Discussion part: first paragraph should only summarize the main findings, the interpretation and comparisons should come in the subsquent paragrpahs.

3. In the limitation part: it is stated " “Being cross sectional, this study may not give picture on the trends of delivery” but the aim of your study is to determine prevalence of home delivery and factors associated, and you answered that, I don’t think the cross-sectional design is a limitation here.

**********

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Reviewer #1: No

Reviewer #2: Yes: Kranti Suresh Vora

Reviewer #3: No

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PLoS One. 2021 Aug 9;16(8):e0254696. doi: 10.1371/journal.pone.0254696.r002

Author response to Decision Letter 0

10 Jun 2021

Point by point response letter

Dear Reviewers and Editorial Team,

Thank you for taking your time to review our manuscript entitled ‘institutional delivery practice in Southern Ethiopia’ and for forwarding suggestions to help improve our manuscript.

Kindly find below the responses given to the comments and suggestions.

Responses to the most recent questions forwarded on April 29, 2021

Thank you for submitting your manuscript entitled "Home Delivery Practice and its Predictors in South Ethiopia" to PLOS ONE. Your manuscript files have been checked in-house but before we can proceed we need you to address the following issues:

1. Thank you for your recent responses. Thank you for clarifying the verbal consent procedure. Please update the manuscript and the online submission form to clarify how verbal consent was documented.

Response: The information sheet and consent was read slowly and loudly by the data collector to the participants. Then, they were asked if there were any queries. After the mothers had confirmed that all is clear, they were asked one last question if they were willing to participate in the survey or not. The data collectors circled either ‘yes’ or ‘no’ based on whichever is selected and the interview was conducted only if the data collector was told to circle the response ‘yes’. This was attached to the questionnaire and documented. For more details, please, refer to the section ‘Ethical approval and consent to participate’, in the manuscript on page 6)

Responses to the questions forwarded on April 1, 2021:

1. Please amend the title either on the online submission form or in your manuscript so that they are identical.

Response: based on the suggestion forwarded, the title “Institutional Delivery Practice in Southern Ethiopia” was amended as “Home Delivery Practice and its Predictors in South Ethiopia”

2) Thank you for clarifying the verbal consent procedure. Please update the manuscript and the online submission form to clarify how verbal consent was documented.

Response: Done as per the suggestion

3) Your demographic table indicates that 18.6% of your participants were under the age of 20. Please clarify whether or not your study involved minors (under the age of 18) and if so, whether or not consent was sought from the participants' parents or guardians. If the IRB specifically waived the requirement for parental/guardian consent, please include that information.

Response: Seven (1.4%) of women involved in this survey were less than 18 years old. However, since all women participated in the survey was married, they live with their husbands not with the parents and as a result, the consent was not sought from the parents which was waived by the IRB considering the early marriage practices (, 18 year of age) in Ethiopia.

3. Thank you for uploading your study's underlying data set, (home Delivery survey.sav). We noticed that this file may contain potentially identifying participant information (Patient ID's in column 1).

Response: Potential identifiers such as house number, individual ID numbers and name of the villages (kebeles) have been removed from the current data set.

The following include responses to the general and specific comments raised by the editor and reviewers which were sent in February, 2021.

1. General comments

Comment 1.1: The main limitation of the current study is that it can be seen as a replication study of the numerous similar studies carried out in different regions of the country. Many of them are reported, some of the more recent ones are missing. PLOS ONE policy regarding replication studies is that if a submitted study replicates or is very similar to previous work, authors must provide a sound scientific rationale for the submitted work and clearly reference and discuss the existing literature. Submissions that replicate or are derivative of existing work will likely be rejected if authors do not provide adequate justification. The authors should strengthen the rationale for the submitted work and ensure they clearly reference the existing literature.

Response 1.1: Our study was undertaken in an area where no similar studies had been conducted and this is not a replicated study. The other point is that when we had implemented a kangaroo mother care service in Sidama Zone preceding the current study, the local health authorities were unable to tell us the exact proportion of home delivery so that we could plan to reach low-birth weight babies born at home who could be eligible for KMC service. Hence, this finding informs the local health authorities the best estimate of home delivery in their zone.

Comment1.2: Regarding some of the key missing references: https://doi.org/10.1186/s12889-019-7854-2 is interesting since it works with the DHS survey mentioned in the introduction, DOI: 10.1186/s12884-017-1409-2 looks also at the relationship with seeking antenatal care..., DOI: 10.1186/s12889-020-08919-8 ... I believe there are more references missing.

Response 1.2: Now we have included the additional references forwarded to us.

Comment 1.3: Another limitation of this study is sample size and low power. This means that large differences in relative risk such as those of antenatal care, seem not be significant. I say seem, because there are problems in reporting. It is said that a screening based on p-values of 0.2 is carried out in a first stage, but those p-values are missing from table 3 (or elsewhere), they should be included.

Response 1.3: We appreciate the comment. We have discussed this under the section ‘Limitation of the study’. A p-value<0.2 was used for crude analysis to screen independent variables for the final mode (adjusted analysis). We omitted inclusion of this p-value for two reasons. The first is that it is part of preliminary steps we have gone through in data analysis and is not part of the main findings to be discussed. The second is we wanted to reduce the number of columns in table 3 and we believe that the 95%CI reported in the crude analysis could be more informative.

Comment 1.4: There is also no treatment of multicolllinearity. Several of the variables are probably closely related, such as urban/rural and distance to health facility. This might explain changes of signs. Some evaluation of multicollinearity is needed. I suggest one of two strategies: the first one, you could use a backward/forward model selection procedure similar to the Debremarkos study mentioned above. Otherwise, you could report the R2 of the covariates with respect to the rest of covariates (VIF, equal to 1/1-R2aux is better avoided since it does not provide a variance inflation factor in the context of logistic regression).

Response 1.4: Based on the suggestion, a backward stepwise logistic regression model was run and accordingly, outputs presented in table 3 were revised.

Comment 1.5: Due to the large number of categorical variables and small sample size, there could be problems of complete or quasi-complete separation. Please report on the convergence of estimates (at least in the review report) since lack of convergence is often due to problems of separation.

In addition, PLOS ONE policy is that the data is provided before publication. Please follow PLOS ONE policies including the data in the submission or providing a link to an open repository where the data can be accessed.

Response 1.5: Thank you for raising this important point which is a likely problem in logistic regression. Remedial action such as increasing sample size to overcome such problem is not practical at this stage. However, during analysis, we have observed no sign of complete or quasi-complete separation reported by the model in the output. We have now uploaded the data.

Comment 1.6: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response1.6: Checked and corrected. Thanks!

Comment 2: In the Methods, please clarify that participants provided oral consent. Please also state in the Methods:

- Why written consent could not be obtained

- Whether the Institutional Review Board (IRB) approved use of oral consent

- How oral consent was documented

For more information, please see our guidelines for human subjects research: https://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research

Response 2: Now the consent steps are expanded in the manuscript based on the comments. Please, see the section ‘Ethical approval and consent to participate’ of the revised MS.

Comment 3: You indicated that you had ethical approval for your study. In your Methods section, please clarify a) if any minors were included in your study and if so, b) ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

Response 3: Our study didn’t involve minors. Our study subjects were mothers who gave birth in the last 12months prior to the survey. The seven (1.4%) mothers less than 18 years old who were participated in this survey were already married and do not live with the parents. Verbal consent to participate in the study was obtained from these mothers and approved by the IRB.

Comment 4: In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as: a) a description of any inclusion/exclusion criteria that were applied to participant recruitment, b) a statement as to whether your sample can be considered representative of a larger population.

Response 4: Additional points are included on exclusion criteria based on comments. Concerning representation of a large population, we calculated sample based on the national demographic health survey proportion with inclusion of design effect. Hence, our study included representative population with inclusion of rural and urban settings making generalizability and representation more acceptable.

Comment 5: We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

Response 5: Based on the comment, we have uploaded the data analyzed for this study and there is no restriction imposed by any one.

Comment 6: In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

Response 6: There is no restriction imposed on the data (uploaded).

Comment 7: We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section

Response 7: Noted and corrected. Funding was obtained from Gates Foundation through the WHO

Comment 8: PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Response 8: Noted and done

Comment 9: We note that you have included the phrase “data not shown” in your manuscript. Unfortunately, this does not meet our data sharing requirements. PLOS does not permit references to inaccessible data. We require that authors provide all relevant data within the paper, Supporting Information files, or in an acceptable, public repository. Please add a citation to support this phrase or upload the data that corresponds with these findings to a stable repository (such as Figshare or Dryad) and provide and URLs, DOIs, or accession numbers that may be used to access these data. Or, if the data are not a core part of the research being presented in your study, we ask that you remove the phrase that refers to these data.

Response 9: The sentence is removed as suggested.

Comment 10: Please amend either the abstract on the online submission form (via Edit Submission) or the abstract in the manuscript so that they are identical.

Response 10: Done as suggested

Comment 11: Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response: done as suggested

Comment 12: Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Response 12: It is corrected.

Review Comments to the Author

Reviewer #1: How could you see the significance of the study as many studies published in Ethiopia including DHS? (may be as requirements for KMC project) As a report made by authors the study sampling procedure is multistage and design effect of 2 was used to calculate sample size but only three districts selected to represent the whole 36districts in Sidaama region mentioned in the title.

How do you see generalization to the whole region? and also why you are interested in urban and rural division in spite of the fact that statistical difference and separate factors for both was not appreciated(32 versus 3.2 Percent)

Need further discussion for maternal merchant occupation as risk factors for home delivery since women economic empowerment pave the way for institutional delivery? The issues of wide confidence interval for prominent factors called planned place of delivery and chi square assumption which is not fulfilled(1)The limitations didn't go with study objectives? Since the trend is not many objectives of current study?

Response to comments of Reviewer 1

- Representation to the wider Sidama Region from this survey: We have calculated sample size based on the DHS figure reported in 2016. The sampling was done from the districts where the KMC implementation research was undertaken. As we have included rural and urban settings quite similar to other districts, we feel the generalizability to the whole Sidama region is acceptable.

- Concerning the urban and rural setting interesting despite absence of statistical difference: We used urban and rural settings during sample size calculation for allocation of sample to each. There is statistical difference between urban and rural settings as to home delivery, mothers residing in the rural area have five times higher odd of home birth (Table 3).

- Merchant occupation and home delivery: As we described it in the discussion part, it is contrary to the expectation. We have highlighted that it could be related to their busy daily routine and missing scheduled ANC appointments to plan the delivery ahead.

Reviewer #2: Very useful manuscript. Major revisions are required as the discussion is repetition of results. Discussion needs to be more of explanation for findings and comparison with other studies. Need to be rewritten.

Response: Corrected.

Authors do not compare data across districts. No description of graph of district wise deliveries in the results but mentioned in the discussion but no elaboration.

Response: It was shown in figure 1 under the section ‘characteristics of deliveries’. This point was discussed in the second paragraph of the discussion.

Discrepancy of merchant women having more home births needs to be discussed in a detail.

Response: We have added few points on the discussion part. It is subject to further study.

Reviewer #3:

1. Title says "Institutional delivery practice in southern Ethiopia" but the aim is to assess prevalence and determinants of home delivery. Better to change it " Home delivery practice and its predictors in South Ethiopia"

Response 1: Comment is accepted and corrected

2. Discussion part: first paragraph should only summarize the main findings; the interpretation and comparisons should come in the subsequent paragraphs.

Response 2: Comment accepted and corrected.

3. In the limitation part: it is stated " “Being cross sectional, this study may not give picture on the trends of delivery” but the aim of your study is to determine prevalence of home delivery and factors associated, and you answered that, I don’t think the cross-sectional design is a limitation here.

Response 3: Comment is accepted and correction is made.

I thank all the reviewers and the editorial board members for their important comments and questions provided

Sincerely yours,

On behalf of the authors,

Dejene Hailu Kassa (PhD)

Attachment

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Decision Letter 1

José Antonio Ortega

2 Jul 2021

Home Delivery Practice and its Predictors in South Ethiopia

PONE-D-20-23821R1

Dear Dr. Kassa,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

José Antonio Ortega, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

There are some editing suggestions by reviewer 3 that should be incorporated.

Also I have noticed that in the main text you refer to merchant women when the category includes all employed women (including self-employed). I would suggest changing merchant to employed women throughout, making sure the first time to mention that employed women include those working for wage and self-employed.

Regarding the backwards-selection GLM regression, it is important to specify in the methods section the procedure employed (alpha level chosen for removing, or AIC maximization, ...).. Also note that PLOS ONE criteria for statistical reporting ask you to Include the full results of any regression analysis performed as a supplementary file. Include all estimated regression coefficients, their standard error, p-values, and confidence intervals, as well as the measures of goodness of fit. I'd suggest including the first full model estimated and the final model selected by the backward selection algorithm.

Reviewers' comments:

Reviewer's Responses to Questions

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Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: (No Response)

Reviewer #3: 1. Title is corrected as suggested in the previous review report; which is good.

2. There are few editorial correction which need to be corrected to show some of them

-Introduction last paragraph, last sentence, better be corrected to read " to assess the prevalence of homebirth and determinants, omit "rate"

-Results: sociodemograph characterstics: last sentence "377 (76.2%) of the women were housewives and 45% of had at least'' either remove "of" or add "them" after it.

- Under the heading Antenatal care follow up and plan for place of deliverey: first paragraph , last sentence "preferred their women,relatives" I think you need to omit the coma betwen women and relative.

- Conclusion and recommendation: don't you think it is important to recommend further study using qualitative methods, as it allows to get depth information about the issue. There are recent quaitative studies from Ethiopia on similar topics.

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Reviewer #2: Yes: Kranti Suresh Vora

Reviewer #3: No

Acceptance letter

José Antonio Ortega

30 Jul 2021

PONE-D-20-23821R1

Home Delivery Practice and its Predictors in South Ethiopia

Dear Dr. Hailu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. José Antonio Ortega

Academic Editor

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Associated Data

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    Supplementary Materials

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    S2 Data

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    S1 Questionnaire

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    Attachment

    Submitted filename: Point by point response.docx

    Click here for additional data file. (16.6KB, docx)

    Data Availability Statement

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