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Magnitude and Factors Associated with Institutional Delivery Service among Women who have Antenatal Care Follow-Up at Hawassa University Referral Hospital, Ethiopia, 2016

Zelalem Tenaw*, Mekdes Mekonnen, Mina Mengistu, Tiruwork Getahun


School of Nursing and Midwifery, College of Medicine and Health Sciences, Hawassa University, Ethiopia

*Corresponding Author:
Zelalem Tenaw
School of Nursing and Midwifery
College of Medicine and health sciences
Hawassa University, Ethiopia
Tel: +251910916820
E-mail: [email protected]

Submitted date: December 03, 2016; Accepted date: January 09, 2017; Published date: January 16, 2017

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Background: Institutional delivery is the key intervention to reduce maternal mortality and morbidity. However, most of the mothers in developing country including Ethiopia are giving birth at home. This study, therefore, aimed at filling the gaps, by attempting to explore the factors which are affecting an institutional delivery service utilization in study area. The main objective of this study was to assess magnitude and factors affecting institutional delivery in women who have antenatal follow up at Hawassa referral hospital, Hawassa, south Ethiopia. Methods: A descriptive hospital based cross-sectional study was conducted among randomly selected 257 pregnant women. Interviewed a structured questionnaire including socio demographic characteristics and factors affecting institutional delivery. Data entry was done by using EPI Info 3.5.1 and exported to SPSS version 20.0 software package for analysis. Results: Among pregnant women 83.2% (n=139) at age group of 15-24 years old mothers give birth at health facilities. While 94.4% (n=17) of the mother at age group of 25-29 years old were give birth at home. Most of the pregnant mothers 76.1% (n=150) were prefer to give birth at home, because of different factors such as, privacy 102 (39.7%). Majority of the mothers 76.7% (n=197) were give their recent birth at health facilities. Most of the time institutional delivery was decided by both husband and wife 78.7 %( n=155). Conclusion: The prevalence of institutional delivery was high. This could be achieved due to high ANC utilization and health education. Therefore efforts should be made to sustain ANC utilization in the study area.


Delivery; Institutional delivery; Magnitude; Ethiopia.



Globally every day, approximately 800 women die from causes related to pregnancy and childbirth. 99% of maternal deaths occur in the developing countries. The maternal mortality ratio in developing countries is 240 versus 16/100,000 live birth in developed countries. It is avoidable if resources and services are made available like safe delivery. 61% occur in 10 countries including Ethiopia [1]. In Ethiopia maternal mortality rate is 676 maternal deaths per 100,000 women [2]. The key to reduce maternal mortality and morbidity is the health institutions since every pregnancy faces risk [3]. Maternal mortality rate in the world continues increased unacceptably. An estimated 2.9 million women give birth every year; of these approximately over 25,000 women and girls die each year and more than 500,000 suffer from serious injuries and permanent damage to their health, such as obstetric fistulas. It is estimated that 100,000 women suffer with untreated fistulas across the country and another 9,000 women develop fistulas every year which are mainly caused by obstructed labor and a lack of maternal health care [4]. Institutional delivery is the key intervention in reducing maternal mortality and morbidity. However, the utilization of institutional delivery service is low due to different factors. The factors which affect institutional delivery service are varying widely [5]. Increasing institutional delivery is an important intervention to reduce maternal and children mortality and morbidity. In Ethiopia most of the mother give birth at home. Only 16% of the mothers were give birth at health facility. From these mothers 15% of them were gave birth at public health institutions. Even the institutional delivery is low in Ethiopia, there an improvement with in the last fifteen years. The percentage of institutional delivery is triple higher from 5% in 2000 to 16% in 2014. First birth is much more likely at health institution when compared with six and more delivered (36 percent versus 8 percent). Delivery in a health facility is more common among mothers below age 35years. Mothers who had at least four antenatal care visits, highly educated, in the highest wealth quintile are gave birth at health institutions. Urban birth is six times more likely than rural birth to be delivered in a health facility (59 percent versus 10 percent) [6]. Women in Ethiopia gave birth at home, assisted by a traditional birth attendant or a relative as their first option. Only 10% of births in the past five years were delivered by a skilled provider. 61% of the women stated that a health facility which is institutional delivery was not necessary, and 30% stated that it was not customary [7]. Delivery assisted by skilled providers is the most important proven intervention in reducing maternal mortality and one of the Millennium Development Goal indicators to track national effort towards safe motherhood [2]. Since all pregnancies are at risk giving birth at health institutions is a mandatory [3]. This study, therefore, aimed at filling the gaps, by attempting to explore the factors that are assumed to be barriers to institutional delivery service utilization in study area.


Study area and period

A cross sectional study was conducted from March 1 to May 30, 2016 among 257 randomly selected pregnant mothers. The study was conducted in Hawassa university referral hospital, south Ethiopia located 272 Km away from Addis Ababa. Hawassa University Referral Hospital offers services at general and specialty levels including Internal Medicine, Pediatrics and Child Health, Surgery, Gynecology and Obstetrics, ENT, Neurology, Urology, Psychiatry, Ophthalmology, Dermatology, Dentistry, Radiology, Pathology, Laboratory and Pharmacy services. Hawassa University Referral Hospital is the first Hospital in South Ethiopia in starting special services like screening for diabetic retinopathy with Retinal Photo camera. The hospital has also launched other special services including Oncology Unit (initially for Breast Cancer) and Intensive Care Unit (ICU). All services provided with in the hospital are with fee except for obstetric services, ART services, TB and DM treatment. The study period was from March to May, 2016 (Figure 1).

Study population

The study population was randomly selected pregnant mothers. The sample size was determined using single population proportion formula at 95% of confidence interval with assumption of prevalence of institutional delivery in Ethiopia 16% (6) with (α=0.05), 5% marginal error (d=0.05), 10% for possible non-response and the final sample size was 257 pregnant mothers.

Sampling technique

Systematic random sampling method was used to recruit pregnant women among ANC attendants. 522 pregnant women were expected to visit the ANC during the study period based on the ANC plan of the hospital and based on registration book. This number was divided for the sample size to get the sample interval (k value) which is 2. Of the first two subjects, one woman was be randomly selected by lottery method, and then every 2nd woman was selected to participate in the study until the calculated sample size achieved within two months of data collection period.


Figure 1: Educational status of mothers who have ANC follow up (N=257).


A face to face interview was conducted by using structured questionnaire. The English version of the questionnaire was translated in to local language (Amharic) for better understanding by the data collectors and respondents.

Data was supervised by midwives who were trained on the objective of the study, method of data collection and content to avoid any ambiguity raised during data collection. Data’s completeness and accuracy was checked daily by supervisors and principal investigator. The questionnaire was pre-tested on 5% pregnant mothers, who were not included in the study. Data were coded and entered to computer using Epi Info version 3.1 and exported to SPSS program version 20.0 for further analysis. The result was presented using frequency tables and percentage. Ethical approval was obtained from Hawassa University Ethical Review Board. Letter of cooperation to Hawassa university referral hospital. Written informed consent was also obtained from each study participants (Figure 2).

Operational definitions

Institutional delivery: Is any delivery service, women who gave birth in the health facilities, including health posts attended by health extension workers.

Skilled attendant: Is professionally trained health worker usually a doctor, midwife or Nurse with the essential skills to manage normal labor and delivery, recognize complication early and perform any essential interventions.

Institutional delivery service utilization: Is expressed as the proportion of women in need of safe delivery service who actually receive the care with in a given period of time in a health facility.

Trained traditional birth attendant: Who has received a short course of training (usually of three months) through the modern health care sector to upgrade the required skills.


Figure 2: Occupational status of women who have ANC follow up (N=257).

Traditional birth attendant: Is who initially had acquired the skill by delivering babies by herself or through apprenticeships to other TBAs (Figure 3).


Figure 3: Place of recent delivery for women who have ANC follow up (N=257).


Socio-demographic characteristics

A total 257 pregnant mothers were participated in the study. With 100% response rate. Out of the participants two third 167 (65.48%) were gave birth in the last five years at the age of 15- 24 years (Tables 1-4).

Distance between participant home and health facility

Majority of the participants have a health facility near to home, which is less than 30 minutes to reach on foot.147 (57.2%), took 1 h and more 81 (31.5%) and 2 h and more 29 (11.3%).

Decision for where to delivery

Most decisions 78.7% (n=155) to give birth at health facility was decided by both husband and wife but mothers who have the right to decide to go to health institutions were only 20.8% (n=41) the husbands were no mandate to decide where their wife gives birth except one person.


This study tried to determine magnitude of institutional delivery among pregnant who visit Hawassa university referral hospital ANC clinic. Among 257 respondents one third 76.7% of them were gave their recent birth at health facility. This finding was high from the study conducted in Jhang district in Pakistan and Sahrti Samre district in Tigray which is 34.6% and 54%, respectively [8,9]. The reason may be study period and population.

Variable Category No. Percentage
Age 15-19 168 65.4%
25-29 18 7.0%
30-34 48 18.7%
35-39 and above 23 8.9%
Marital status Married 257 100.0%
Education Illiterate 25 9.7%
1-4 grade 130 50.6%
5-8 grade 52 20.2%
9-12 grades 25 9.7%
Higher education 25 9.7%
Respondent’s occupation Merchant 52 20.2%
Housewife 180 70.0%
Governmental employer 25 9.7%
Respondent’s religion Protestant 154 59.9%
Orthodox 26 10.1%
Others 77 30.0%
Occupation of husband Farmer 129 50.2%
Daily laborer 25 9.7%
Merchant 52 20.2%
Governmental employer 51 19.8%
Husband’s education level 1-4 grade 51 19.8%
5-8 grade 77 30.0%
9-12 grades 78 30.4%
Higher education 51 19.8%
Health facility in your village Yes 257 100.0%
How far <30 min 147 57.2%
>1 h 81 31.5%
>2 h 29 11.3%

Table 1: Socio demographic characteristics of women who have ANC follow up (N=257).

  Place of delivery  
Variable Home Health facility
Number (%) Number (%)  Total # (%)
15-24 28 (16.8) 139 (83.2) 167 (65.4)
25-29 17 (94.4) 1 (5.6) 18 (7)
30-34 12 (24.5) 37 (75.5) 49 (18.7)
>35 3 (13) 20 (87.0) 23 (8.9)
Total 60 (23.3) 197 (76.7) 257 (100)
marital status
Married 60 (23.3) 197 (76.7)     257 (100)
Illiterate 24 (96) 1 (4) 25 (9.7)
1-4 grade 31 (23) 99 (76.2) 130 (50.6)
5-8 grade 5 (8) 47 (92) 52 (20.2)
9-12 grades 0 25 (100) 25 (9.7)
Higher education 0 25 (100) 25 (9.7)
Total 60 (23.3) 197 (76.7)     257 (100)
Merchant 0 52 (100) 52 (9.7)
Housewife 60 (33.3) 120 (66.7) 180 (50.6)
Governmental employer 0 25 (100) 25 (20.2)
Protestant 31 (20.1) 123 (79.9) 154 (59.9)
Orthodox 0 26 (100) 26 (10.1)
Others 29 (37.7) 48 (62.3) 77 (30)
Occupation of husband
Farmer 48 (37.2) 81 (62.8) 129 (50.2)
Daily laborer 5 (20) 20 (80.0) 25 (9.7)
Merchant 7 (13.5) 45 (86.5) 52 (20.2)
Governmental employer 0 51 (100) 51 (19.8)
Husband’s education
1 -4 grade 5 (9.8) 46 (90.2) 51 (19.8)
5-8 grade 31 (40.3) 46 (59.7) 77 (30)
9-12 grades 24 (30.8) 54 (69.2) 78 (30)
Higher education 0 51 (100) 51 (19.8)

Table 2: Socio economic factor affecting institutional delivery service (N=257).

The finding from this study revealed that about 61.9% were received the antenatal care. Which is almost similar to the study conducted by EDHS report 2014.But higher than the study conducted in five densely populated zone of southern region revealed that 26.1%, in Oromia, Ethiopia About 32.7%, In SNNPR, Ethiopia About 39%, of the women received ANC for their last pregnancy [10]. The possible reason for this finding may be study population difference and sample size.

In this study the magnitude of institutional delivery is 76.7%. This finding is better than the studies conducted in Oromia, Ethiopia 13.3%, in SNNPR, Ethiopia 14.9% and 41% by EDHS report of 2014 [11]. The possible reason for this finding may be study population difference and sample size.

In this study different factors were affect the choice of place of birth of the mothers during their last pregnancy. These factors are number of gravid, 76.1% of gravida I and 0.5% of gravida III and above mothers gave birth at health institutions. Dissemination of information during ANC visits on importance of institutional delivery and birth preparedness/complication (all mothers gate three sessions during ANC gave birth at health institutions). Educational statuses 75.11% of the mother who follow ANC were literate, which is different from the study conducted in Pakistan, Tigray, Ethiopia and Mizan Ethiopia?

This study showed that mothers who were visited ANC four and above gave birth at home. These finding is different from the study conducted in Indonesia and Kenya ANC4+ visits showed increased association with institutional delivery [12]. The difference may be majority of the participants were primigravida and the primigravida mothers want to give birth at their mother’s home after they finished the ANC follow up, because of religion and culture.

  Place of delivery  
Variable Home Health facility
Number (%) Number (%)  Total # (%)
Total pregnancies
One-four 31 (51.7) 176 (89.3) 207 (80.5)
Five-six 29 (48.3) 21 (10.7) 50 (19.5)
Number of pregnancies in the last 2 years
One 60 (23.3) 197 (76.7)  257 (100)
Number of under five children
One 31 (51.7) 150 (76.1) 181 (70.4)
Two 5 (8.3) 46 (23.4) 51 (19.8)
Three 24 (40) 1 (0.5) 25 (9.7)
ANC for your recent pregnancy
Yes 7 (11.7) 122 (61.9) 129 (50.2)
No 53 (88.3) 75 (38.1) 128 (49.8)
Gestational age for Yes for ANC
1st Trimester 7 (11.7) 78 (39.6) 78 (33.4)
2nd Trimester 0 (0) 44 (22.3) 51 (17.8)
No 53 (88.3) 75 (38.1) 128 (49.8)
How many times visit ANC clinic
Two 7 (11.7) 44 (22.3) 51 (19.8)
Three 0 (0) 78 (39.6) 78 (30.4)
Why ANC visit
I was sick 0 (0) 25 (12.7) 25 (9.7)
Good service 0 (0) 26 (13.2) 26 (10.1)
To know my health status 7 (11.7) 71 (36) 78 (30.4)
Did you receive any advice where to deliver
Yes 7 (11.7) 122 (61.9) 129 (50.2)
No 53 (88.3) 75 (38.1) 128 (49.8)
If No for ANC why?
Work load 0 (0) 52 (26.4) 52 (20.2)
feel sham 24 (40) 1 (0.5) 25 (9.7)
Don, t knows importance 29 (48.3) 22 (11.2) 51 (19.8)
Do you know any danger signs of pregnancy
Vaginal bleeding 5 (8.3) 175 (88.8) 180 (70)
Reduced/absence of fetal movement 55 (91.7) 22 (11.2) 77 (30)

Table 3: Obstetric history that can affecting institutional delivery service (N=257).

There are different reasons for women to not follow antenatal care. The common reasons were due to long waiting time to get service at health facility, husband disapprovals, being busy and perceived good health. These reasons are consistent with the finding of other studies in Ethiopia [1].

Mothers who gave birth at home have different reasons 46% of them think giving birth at health facility has no necessity, 33% of mothers said the service at health facility is not customary, 21% of the mother said that the health facility was either too far or that they did not have transportation. Urban woman were more likely than rural women to report that health facility deliveries are not necessary (64% versus 45%). But rural women were more likely to report that facility deliveries are not customary (33% versus 21%), or that health facilities were too far or they had no transportation (22% versus 15%) [11].

Most decision 78.74% about institutional delivery were decided by both husband, which higher than the study conducted in mizan aman town, Ethiopia 22.97% [13]. From the participants 20.8% of the mothers had the right to choose their delivery to health institutions. Almost all of the participants 99.5 wish to have a baby at health facility for their next delivery. This number is greater than the study done in Mizan Aman town 88% [13].

Conclusion and Recommendation


This study found that the magnitudes of home delivery among mothers who has high number of gravida, no/low educational status, poor arrangement for place of birth, distance from health facility, health education during ANC visit and their plan to home delivery were high. Therefore efforts should be made to address these gaps/factors which affect institutional delivery.


The health care providers better to strengthen Health education for ANC attendants in hospital to encourage institution delivery, convince the advantages of institutional delivery. The Health bureau leaders and concerned body have to arrange transportation, i.e., proper ambulance services for mothers during labor and delivery.

  Place of delivery  
Variable Health facility Home
Number (%) Number (%)  Total # (%)
Total pregnancies
One 31 (51.7) 150 (76.1) 181 (70.4)
Two 29 (48.3) 47 (23.9) 76 (29.6)
If at home who assisted you
Mother and other relatives 16 (26.7) 0 (0) 16 (6.2)
TBA 44 (73.3) 0 (0) 44 (17.1)
Why, at home                         
Easily labor 50 (81) 0 (0) 50 (19.5)
God help me 11 (18.3) 0 (0) 11 (4.3)
Condition of your last baby
Live birth 60 (23.3) 197 (76.7)     257 (100)
If you gave birth at health facility for the recent baby, why
No fee 0 (0) 25 (12.7) 25 (9.7)
Good service 0 (0) 104 (52.8) 104 (40.5)
Family allowed 0 (0) 26 (13.2) 26 (10.1)
Who decide where you gave birth and by whom
Myself 36 (60) 41 (20.8) 77 (30)
My husband 24 (40) 1 (0.5) 25 (9.7)
Both of us 0 (0) 155 (78.7) 155 (60.3)
Do you think there is a difference giving birth at home and health facility
Yes 60 (23.3) 197 (76.7)     257 (100)
If you think health facility if better (question) how and why
Save mothers life 55 (91.7) 152 (77.2) 207 (80.5)
No bleeding 5 (8.3) 20 (10.2) 25 (9.7)
save child life 0 25 (12.7) 25 (9.7)
If you think home if better (question) how and why
There is privacy 60 (100) 42 (21.3) 102 (39.7)
Did you have any history of difficult labor (obstructed labor)?
Yes 24 (40) 54 (27.4) 78 (30.4)
No 36 (60) 143 (72.6) 179 (69.6)
Where do you preferred to give birth for your next delivery
Home 24 (40) 1 (0.5) 25 (9.7)
Health facility 36 (60) 196 (99.5) 232 (90.3)

Table 4: History of the recent delivery (N=257).

Ethical Consideration

Ethical clearance was obtained from the Institutional Review Board of the Hawassa University. Communication with Hawassa university referral hospital administrators through formal letter obtained from Hawassa University. After informing about the purpose and objective of the study, written and verbal consent was obtained from each study participant. Participants were also being informed that participation was on voluntary basis and they can withdraw at any time from the study if they were not comfortable about the questionnaire. In order to keep confidentiality names of the participant was excluding as identification in the questionnaire.

Funding and Sponsorship

This research was funded by Hawassa University for academic staff.

Authors’ Contribution

ZT wrote the proposal, participated in data collection, analyzed the data and drafted the paper. MM approved the proposal with some revisions, participated in data analysis and revised subsequent drafts of the paper. All authors read and approved the final manuscript.


We are very grateful to Hawassa University for approval of ethical clearance, technical and financial support of this study. Then, we would like to thank for all participants who participated in this study for their commitment in responding to our interviews. Finally, we are also grateful to Hawassa university referral hospital for their assistance and permission to undertake the research.


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