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Determinants of Use of Skilled Birth Attendance among Mothers Who Gave Birth in the Past 12 months in Raya Alamata District, North East Ethiopia

Background: A large number of women are dying due to factors related to pregnancy and childbirth, especially in developing countries including Ethiopia, where maternal mortality ratio is one of the highest in the world. It is known that having a skilled birth attendant at every delivery can lead to marked reductions in maternal mortality. In Ethiopia, most births take place at home, particularly in rural areas, being not attended by a skilled birth attendant. The utilization of maternal health services is a complex phenomenon and it is influenced by several factors. 
Objectives: This study assessed factors that determine the utilization of skilled birth attendants among mothers who gave birth in the past 12 months in Raya Alamata District, Ethiopia. 
Methods: Community-based cross sectional study was conducted among mothers who gave birth in the past 12 months. A total of 600 study participants were recruited for the study. Logistic regression was performed using SPSS version 16.0 software and thematic interpretation based on main categories was done for the qualitative data. 
Results: A total of 584 mothers (189 urban and 395 rural) were included in the analysis. Only 23.5% of births were attended by Skilled Birth Attendants. Over 43% of urban women delivered with skilled assistance compared to 13.9% of rural women. In multivariate analysis urban residence, Age at interview, maternal formal education, Ante Natal Care visit during the last pregnancy, joint final decision making, knowledgeable and favorable attitude towards danger signs of pregnancy, child birth and delivery services were most significant determinants of skilled birth attendant use by mother. 
Conclusion and recommendation: Utilization of skilled delivery attendance services was still low with a high number of deliveries being attended by unqualified persons at home. Promotion of universal Ante Natal Care followup and encouragement of mothers regarding the need for Skilled Birth Attendants during childbirth is of paramount importance.


Introduction
Maternal mortality remains a major challenge to health systems of developing countries. Globally, an estimated 287,000 maternal deaths occurred in 2010, a decline of 47% from levels in 1990. Sub-Saharan Africa and Southern Asia accounted for 85% of the global burden of maternal deaths with sub-Saharan Africa alone accounting for 56% in 2010 [1]. Nearly two third of maternal deaths worldwide are due to five direct causes: Obstetric hemorrhage is the main direct cause accounting for 25% of maternal deaths, infections (15%), unsafe abortion (13%), eclampsia (12%), and obstructed labor (8%) [2].
Based on the available empirical evidence, facility based delivery at primary level, backed by access to referral-level facilities is a priority strategy for reducing maternal mortality [3]. In an effort to reduce maternal mortality, the indicators of progress are Maternal Mortality Ratio and proportion of births attended by skilled attendants [4]. The fifth MDG aims at improving maternal health and targets reducing Maternal Mortality Ratio by 75% between 1990 and 2015 -that is, it seeks to achieve an expected 5.5% annual decline in MMR from 1990 [1]. The recently released 2011 EDHS reported MMR of 676 per 100,000 which is a slight increase from the 2005 DHS which was MMR of 673 per 100,000 [5,6].
In almost all countries where health professionals attend more than 80% of deliveries, MMR is below 200 per 100,000 live births [7]. Skilled attendance during labor, delivery and the early post-partum period could reduce an estimated 16 to 33 percent of deaths due to obstructed labor, haemorrhage, sepsis and eclampsia [8]. Maternal health care utilization is highly varies as a function of women's background characteristics as reported by different studies. Of these; educational status, place of residence, socio-economic, age has been found to have the strongest association with the use of maternal skilled birth attendant [5,[9][10][11][12][13][14][15].
In addition mother's knowledge and attitude towards delivery services as well as ANC visit during last pregnancy were also other important predictor factors [14,16]. Other important determinants of utilization of delivery care services were parity, history of prolonged labor and women's decision-making power as well as distance and

Clinics in Mother and Child Health
transport [17][18][19][20]. According to the EDHS 2011, 57% of births were assisted by a relative, or some other person. 28% of births were assisted by a traditional birth attendant, while 4% of births were delivered without any type of assistance [5].
Hence, the objective of the study was assessing and understanding the factors that determine the utilization of skilled birth attendant. Assessing institutional service delivery among women across all geographical regions is crucial to enhance maternal health and improve the maternity services and thereby reduce maternal mortality given that the slow decline in the risk of maternal death in Ethiopia.

Methodology Study area and design
The study area was Raya Alamata District which is found 600 km away from Addis Ababa. The District had four urban kebeles and 15 rural tabias. Its population was estimated to be 141,695 based on census 2007. Regarding the health infrastructure, the district had one district hospital, six health centers and 13 health posts [21]. Community based cross-sectional study design was employed to assess the determinants of utilization of skilled birth attendant.

Source and study population
All women in the reproductive age group (15-49 years) in Alamata District constituted the source population. Women who had given birth in the last 12 months, irrespective of the outcome of the birth were included for the study.

Sample size and sampling procedures
Sample size was determined using a formula for two population proportions by taking the level of significance to be 5% and the power 80%.
To determine the sample size, the following assumptions were considered.
Place of residence was considered as predictor factor for use of skilled birth attendant. Women were categorized into Urban and Rural [15]. P 1 =Proportion of urban resident women who delivered by skilled birth attendant=22.4% P 2 =Proportion of rural resident women who delivered by skilled birth attendant=10.7% r=ratio of n 1 to n 2 considered to be 1:2 and Confidence level=95% Based on the above assumptions design effect of 1.5 and 5% nonresponse rate, 600 women who gave delivery in the past 12 months were requited. Using proportional allocation to the Rural and Urban; 400 samples were from rural kebeles and 200 samples from urban residents.

Sampling procedures
Multi-stage stratified sampling method with probability proportionate-to-size was employed. First, the District was stratified into four urban kebeles and 15 rural Tabias; two from urban kebeles and four from the rural tabias were chosen by lottery method. The final sampling units were households with at least one birth in the 12 months preceding the survey. Out of the four sampled rural Tabias, a total of 400 samples were selected; of those, 103 from Tao, 108 from Selenwuha, 57 from Kulugeze Lemlem and 132 from Timuga. From the two sampled urban kebeles, a total of 200 women; 94 for kebele 02 and 106 for kebele 04 were allocated. Finally, Systematic sampling method was applied to select study participants ( Figure 1). Independent variables include socioeconomic and demographic factors such as age, education, occupation, income, obstetric factors such as parity, history of stillbirth, ANC follow up and knowledge and attitude on key danger signs of pregnancy, labor/childbirth and delivery services. The dependent variable was use of Skilled Birth Attendant.

Data collection procedures
Data were collected through face-to-face interview using pre-tested structured questionnaire developed in English after reviewing relevant literatures. The questionnaire was translated into the local language, and to check for its consistency, back translated into English. Five data collectors were used to conduct the face-to-face interview and data collection process was supervised by one health officer and the Principal Investigator. Training was given to the data collectors and supervisors before the actual data collection regarding the aim of the study, data collection tool and procedures going through the questionnaires question by question.

Data quality management
The data collection tool was pre-tested on 15 similar women in the study area from randomly selected kebeles and tabias which were not included in the study before the initiation of the main study. Findings and experiences from the pre-test were utilized in modifying the data collection tool. Supervision was conducted by the Principal Investigator and Supervisor. Each questionnaire was given a unique code and was entered using Epi-info version 3.5.1. Then, the entered data were cleaned for errors prior to data analysis. Frequencies were used to check for missed values and outliers during analysis. Any errors identified were corrected after revision of the original data using the code numbers given to the questionnaires.

Data analysis procedures
Data were cleaned for inconsistencies and missing values and analyzed using SPSS version 16.0 statistical software. Frequencies and Proportions were computed for description of the study population. Significance was determined using crude and adjusted odds ratios with 95% confidence intervals. First bivariate relationships between each independent variable and outcome were investigated using binary logistic regression model. Those independent variables found to be significant with p-value less than 0.05 at the bivariate level were included in a multivariate logistic regression model for each dependent variable to control for potential confounding variables. The results were presented in the form of tables, figures and summary statistics.

Operational definitions
Skilled attendant: is a professionally trained health worker having the essential midwifery skills to manage normal labour and delivery, recognize complications early and perform any essential interventions including early referral.
Reinforcing factors: are influences of people that encourage or discourage behavioral change.
Formal education: consists of primary, secondary and above educational attainment of respondents.
Non-formal education: consists of unable to read and write, read and write only educational attainment of respondents Knowledgeable: women were considered knowledgeable if they were aware of danger signs related to pregnancy and childbirth and advantages of delivery service, and use SBA if they scored above median of knowledge questions, and not knowledgeable if otherwise.
Favourable attitude: women were considered as having favorable attitude towards danger signs related to pregnancy and childbirth and advantages of delivery service, and use SBA if they scored above the median on attitude questions, and unfavourable if otherwise.

Ethical consideration
The proposal was approved by the Addis Ababa University, School of Public Health, and the College of Health Science Institutional Ethical Review Board. An official letter was written from the School of Public Health to Tigray Regional Health Bureau and Alamata Woreda Health and Administrative Offices to seek the essential cooperation. During data collection, individual informed verbal consent was obtained and each respondent was informed about the objective of the study, procedures of selection and assurance of confidentiality.

Socio-demographic characteristics of the respondents
The majority of the respondents were in the age range of 25

Past obstetric characteristics of the respondents
Regarding age at first marriage 354 (60.7%) of the study subjects were married before the age of eighteen. Four hundred thirty (73.6%) respondents were first pregnant before the age of 20 years. The mean parity of participants was 3.4. In this study, 536 (91.8%) women reported that their last pregnancy was planned and 520 (89.1) of respondents said that there was preparation for the last delivery. Out of the total respondents, 51 (9%) had history of abortion and stillbirth 40 (7.1%). Regarding the prenatal service utilization of the respondents, 338 (57.9%) had attended ANC service. Among those women who attended ANC the majority, 149 (44.1%) respondents had ANC visits of four and above (  Seventy five of the respondents experienced at least one adverse pregnancy and child birth outcome previously ( Table 2). Among the problems mentioned were bleeding 35 (46.7%), prolonged labor 26 (34.7%), retained placenta 21 (28%) and others 7 (9.3%). Out of the total study subjects 69 (17.5%) rural and 19 (10.1%) urban had visited health facility for postnatal natal care (Table 2). Reasons for PNC visit were bleeding 25 (28.4%), retained placenta 22 (25%), puerperal sepsis 11 (12.5%), breast problems 11 (12.5%) and others including immunization and family planning 25 (28.4%).

Institutional delivery service utilization
Regarding institutional delivery service utilization, 137 (23.5%) of the women gave their last birth at health institutions being attended by skilled birth attendant [Urban 82 (43.4%), 55 (13.9%) of the rural]. The majority of rural study subjects 340 (86.1%) delivered at home without assistance from skilled birth attendant compared.
The majority of the respondents gave reasons for institutional delivery, 110 (80.3%) safe for the mother and child, 83 (60.6%) better outcomes from institutional delivery. The respondents also reported that delivery at health institution lowers maternal exhaustion, facilitate the progress of labor by giving medication and avoid excessive bleeding which all are classified under others 8 (5.8%) (Figure 2).
Among the mothers who delivered at home, 396 (88.6%) were assisted by family members and mothers, untrained TBAs 91 (20.4%) and no one or without any assistance 18 (3.1%). Mothers gave a variety of reasons for delivering at home. Of these, having closer attention from family members and relatives 327 (73.2%), feel more comfortable 269 (60.2%), urgent and smooth labor 256 (57.3%), delivering at home is my usual experience 118 (26.4%), were among fthe commonest (Figure 3).

Knowledge and attitude about pregnancy, labor and delivery service
One hundred eight (57.1%) of urban and 193 (48.9%) of rural mothers scored more than the mean score on knowledge questions of danger signs related to pregnancy, labor and child birth, and also on advantages of delivery service. On the other hand, their attitudes towards danger signs of pregnancy, child birth and safe delivery service utilization, 154 (81.5%) urban and 282 (62.8%) rural study subjects showed favorable attitudes towards pregnancy, child birth and safe delivery service utilization (Table 3).

Variable
Rural (  Mothers who live in urban were 2.2 times more likely to be assisted by skilled birth attendant during delivery (AOR=2.2, 95% CI; 1.2-4.1). Mothers in 15-24 years age group during the interview were 3.7 times (AOR=3.7, 95% CI: 1.3-7.4) more likely to be assisted by skilled birth attendant than mothers more than 35 and above. Mothers with formal education (AOR=5.3, 95% CI=2.9-9.8) had a 5.3 times higher to be attended by skilled birth assistants than those who had no formal education (Table 4).

Variables
Skilled birth attendant COR (95%CI) AOR 95% CI  Mothers who had ANC visit were 3.4 times more likely to be assisted by skilled birth attendants than women who did not have ANC visit in the district (AOR=3.4, 95% CI=1. 8-6.5). In addition, mothers who were knowledgeable and having favorable attitude were 4.7 (AOR=4.7 95% CI: 2.1-10.5) and 3.3 (AOR=3.3, 95% CI: 1.2-8.9) respectively times more likely to be attended by skilled birth attendants in rural areas (Table 4).

Residence
Regarding final decision making about place of delivery; mothers who decided jointly were 3.2 times more higher of utilizing of skilled birth attendants during delivery when compared to self-decision making in the district (AOR=3.2, 95% CI: 1.7-6.0) ( Table 4).

Discussion
The results of the study revealed that the proportion of women who delivered with assistance of skilled birth attendant was 23.5% in the District. This result is in line with that of a study done Ephratanagidim District, North Shoa zone which was 21.4% [22]. However, it was higher than Tigray Region EDHS result of 2011 which were 11.6% [5]. This might be improvements in accessing and utilizing of the service and community mobilization through developmental army. On the other hand, it was lower than those studies conducted in central Tanzania and India where the proportion of women who gave birth at health facilities was 54% and 49.8%, respectively [23,24]. The difference could be explained by the fact that women in those countries had better economic status, educational status and ANC service.
There was a statistically significant association between place of residence and use of skilled birth attendant. The result revealed that urban women were more likely to give birth assisted by skilled birth attendants at delivery. This finding was in agreement with previous studies conducted in other areas of the country [14][15][16] and elsewhere [12,25]. This might be due to the fact that urban women tend to have advantage from increased knowledge and access to delivery service.
Health promotion mass media programs are urban-focused compared to the rural counterparts. On the other hand their rural counterparts are mostly influenced by traditional practices [17].
Younger women were more likely to give birth assisted by skilled birth attendants than those with age of 35 years and above. This finding is in agreement with studies done in other areas of the country [17,26]. When younger women are just starting child bearing, they are told to be in a high risk group and so they tend to fear home deliveries. On the contrary, older women consider that giving birth at home is not risky as they had experienced previously. It is also higher proportion of younger women had formal education which in turn had different perspectives on delivery care when compared to the elder.
Among social factors women's education was statistically and positively related to the use of skilled birth attendants during delivery. Again, the finding was consistent with other studies done in other areas of the country [15,16,26] and elsewhere [9,23]. This may be due to the fact that educated women are more likely to make wise decisions about their own health and seek proper health care than their counterparts.
The study also revealed a significant association between ANC visit during last pregnancy of the women and the use of skilled assistance during delivery. Women who had ANC visit were 3.4 times higher odds of delivering with assistance by health professionals than mothers who didn't visit ANC. The result was in line with other studies done [9,13]. It is fact that women having ANC visit are provided with health education and information regarding the benefits of having a skilled birth attendant during childbirth.
Women who had knowledge regarding pregnancy and delivery risk factors were more likely to give birth assisted by skilled birth attendant during delivery. Similar findings were reported in other parts of the county and Sub-Saharan African countries [14,27]. Women's positive attitude towards danger signs related to pregnancy and childbirth was also important predictor for the utilization of skilled birth assistant. This finding was in agreement with a study done in Arsi zone, South East Ethiopia [16]. This might mean that better informed individual is better placed to make reasonable decisions.
The patterns of decision making power within the household were perceived as key determinants of place of delivery. The study showed that joint decision making had significant association with use of skilled birth attendant during delivery. The finding is in agreement with study done in Uganda [28]. More than two third were assisted by family members and mothers, followed by untrained traditional birth attendant. This finding was consistent with Tigray Region EDHS 2011 and studies done in other parts of the country [5,14]. This might be due to the trust on the family or the relatives in giving support, close attention and fulfilling different cultural and religious ceremonies.
Concerning reasons for home delivery preference the finding revealed that having closer attention from family members, feel more comfortable, delivering at home being the women's experience, and distance and poor road were the commonest reasons. This finding is in agreement with studies done in North Gonder, Arsi Zone and South East Ethiopia [10,15,16]. This implies significant proportions of women may seek help from skilled birth attendants after encountering obstetric complications and when other traditional interventions fail.
In conclusion, utilization of skilled delivery attendance services was low with a high number of deliveries being attended by unqualified persons at home. Women's education, place of residence, having ANC visit, age at interview, final decision maker and knowledge and attitude towards pregnancy, child birth and delivery services were found to be determinants of skilled birth attendance. Promote universal ANC follow-up and encourage mothers to utilize skilled birth attendants during pregnancy and childbirth. Increase the number of ambulance or vehicle for referral of the women with obstetric complication to the nearest possible health facilities with Comprehensive Emergency Obstetrics Cares. Design different means of behavioral change communication to improve the demand. Moreover, to explore further factors related with the use of skilled assistance at delivery qualitative studies need to be conducted.