Practice of Non-Institutional Delivery and Its Associated Factors Among Women Who Gave Birth in Southern Ethiopia, 2022

Background: Since 2000, the Ethiopian ministries of health and other stakeholders have taken some measures to enhance institutional delivery. However, the Ethiopian Demographic Health Survey 2019 report indicated that more than 50% of Ethiopian reproductive-age women gave birth outside health facilities. Therefore, the purpose of this study was to assess the practice of noninstitutional delivery among women who gave birth at Boloso Bombe Woreda (district) in southern Ethiopia. Methods: A community-based cross-sectional study was carried out on 252 study participants from June to July 2022 in Boloso Bombe Woreda. Data collection was done using a structured questionnaire and systematic sampling techniques were used to select the study subjects. Data were entered into the EPI data, version 3.1, and analyzed using SPSS, version 25. Adjusted odds ratios (AORs), along with 95% confidence intervals (CIs), were used and the level of statistical significance was declared at a p-value of 0.05. Results: In this study, 252 participants completed the survey, with a 97% response rate. The prevalence of noninstitutional delivery among study participants was 68.7% (95% CI: 63.1–72.9). In this study, mother's occupation, such as working as a daily laborer (AOR = 3.6; 95% CI [1.2–11.2]); absence of antenatal care history (AOR = 3.3; 95% CI [1.3–8.6]); poor knowledge of labor complications (AOR = 3.5; 95% CI [2.2–6.1]); and place of first delivery (AOR = 8.7; 95% CI [3.2–23]) were factors that were positively and significantly associated with the practice of noninstitutional delivery. However, last pregnancy planned was negatively associated with the practice of noninstitutional delivery (AOR = 0.4; 95% CI [0.2–0.8]). Conclusions: This study indicated that the majority of study participants practiced noninstitutional delivery in this study area. Therefore, we strongly recommend that all responsible bodies should take immediate action to reduce the practice of noninstitutional delivery and improve those identified factors.


Introduction
In Africa, only about half of the 123 million women who give birth each year receive antenatal care (ANC), neonatal care, and delivery care. To promote maternal, newborn, and child health, women must have access to basic health care facilities during childbirth. 1 The World Health Organization (WHO) reports that in high-income countries, more than 90% of women give birth at a health center, while in lowincome countries, most women give birth outside a health center with the assistance of an untrained person. 2 Noninstitutional delivery means just giving birth outside a health institution and in the home with the assistance of an unskilled person. 3 Many women, no matter where they give birth, have similar problems after they give birth. These problems include dizziness, tender abdomen, blood loss, fetal death, and uterine rupture. However, these problems are often considered critical if a woman delivers the baby outside a health facility. 4 Most maternal mortality (MM) occurs during the delivery and in the immediate postpartum period.
All women should have access to basic maternity care during their pregnancy, such as clean and safe delivery. They should also have access to emergency obstetric care if necessary. 5 In 2017, due to noninstitutional deliveries, health facilities, and health care providerrelated factors, 462 and 11 children per 100,000 live births died in developed and developing countries, respectively. 6 In addition, women giving birth outside a health institution are at a threefold higher risk of developing complications. In addition, women giving birth outside a health institution are at higher risk of death. 7 The rate of neurological dysfunction and seizure for noninstitutional delivery is three times higher compared with institutional delivery. 8 Increasing delivery rates in the health institution is a crucial approach to prevent the death of a mother and her baby.
However, maintaining the practice of institutional delivery has not consistently changed into reduced maternal death in low-and middle-income countries. 9 Although there are some improvements in reduction of maternal and infant mortality across the world, sub-Saharan African countries and southern Asia accounted for the majority of (86%) estimated world MM in 2017; of this, 2/3 of MM belonged to the sub-Saharan African countries only. 4,6 Ethiopia is 1 of the 15 countries considered to be ''very high alert'' or ''high alert,'' being a fragile state.
Practicing institutional delivery is the key approach that prevents 13%-33% and 20%-30% of maternal and neonatal mortality, respectively. 10 Although the Ethiopian government and nongovernmental organizations have tried to stop women from giving birth outside health facilities, 50% of Ethiopian women have given birth outside these facilities. 11 To reduce noninstitutional delivery utilization, factors that limit access to institutional delivery must be identified and addressed at health system and societal levels. 12 The noninstitutional delivery rate varies from region to region. In addition, no previous study was done in this study area. Therefore, this study was aimed at assessing the practice of noninstitutional delivery among women who gave birth in the study area.

Methodology
Study area, period, and design A cross-sectional study was carried out from June to July 2022 in the Boloso Bombe Woreda. The district is located about 57 km from the town of Wolaita zone, southern Ethiopia, and 435 km from Addis Ababa, the capital city of Ethiopia. The geographical location of Boloso Bombe is 70 1¢ 32 †-70 11¢ 30 † N latitude and 370 26¢ 18 †-370 39¢ 38 † E longitude.
According to the Boloso Bombe Woreda base plan report of 2013, the Woreda has a total population of 114,342. Of these, 57,400 were females and 56,942 were males and there were 26,642 reproductive-age women. The district has 21 small administrative units (Kebeles) and one primary hospital, 4 health centers, and 8 health posts.

Population and eligibility criteria
Only women who had given birth in the past 6 months and lived in the selected area for at least 1 year were included in the study population. Mothers who did not give full information on the required variables, were unable to hear and speak, and had any mental problems were not included in this study.
Sample size determination and its procedures A sample size of 252 participants was determined using a single population proportion. Five percent margin of error, 95% confidence interval (CI), 19% noninstitutional delivery from the previous study, and 10% nonresponse were considered to calculate the final sample size. 13 According to the WHO recommendation, 30% (7) Kebeles were selected from the total Kebeles by using lottery methods. The total number of mothers who delivered in the selected Kebeles from February 2021 to February 2022 was determined using immunization registration books and health posts in family folders. The sample size in each selected Kebele was proportionally allocated to the total number of deliveries in each Kebele. Then, respondents were recruited using a systematic sampling method. Every other respondent in each Kebele was interviewed.
Operational definitions Nonutilization of institutional delivery. Women who delivered their last baby outside a health facility with the assistance of nonskilled or traditional attendants were classified as those who did not utilize institutional delivery services. 14

Knowledge of labor complications
Those who mentioned greater than or equal to three labor complications were classified as having good knowledge, 15 and those who mentioned less than three complications were assumed to have poor knowledge. 15 Data collection and analysis A structured questionnaire, including four parts, was used to collect data on sociodemographic information, obstetric-related factors for women, health care provider-related factors, and knowledge of labor complications. The last component comprised one question with a list of top six labor complications adapted from a previous study. 15 Women who mention at least three knowledge questions are considered to have good knowledge. Women who mention less than three knowledge questions are considered to have poor knowledge. These four components and their items were independent variables, and the place of last delivery was the dependent variable.
Home-to-home visits and face-to-face interviews were used to collect data. A structured questionnaire was adapted from the previous study. 15 Data were collected by seven BSc nurses and supervised by three health officers. One-day training was given to the data collectors and supervisors on the procedures of data collection. The questionnaire was prepared in English, then translated into the local language by experts, and again translated into English to enhance the consistency. During data collection, data collectors and supervisors were closely supervised by the principal investigator to maintain data consistency and completeness.
The completeness and consistency of data were checked, coded, and entered into EPI Data, version 3.1. For analysis, the data were exported to SPSS, version 25. To present descriptive statistics, frequencies and percentages, means and standard deviations, tables, and pie charts were used. The crude odds ratio with its 95% interval was calculated using a binary logistic regression test to test for associations between dependent and independent variables. Then, variables with p < 0.25 in the bivariate analysis were taken as candidates for the multivariate analysis.
Finally, the multivariate analysis with adjusted odds ratio (AOR) was used to control possible confounders and to determine predictors of prevalence of noninstitutional delivery. A p-value of <0.05 was considered statistically significant.

Sociodemographic features
A total of 252 respondents completed the interview with a response rate of 97%. The mean age of the study participants was 28.07 years with a standard deviation of 5.3 years. The age range of study participants was between 15 and 29 years. One hundred twenty-two (48.4%), 205 (81.3%), 217 (86.3%), and 176 (69.8) participants in the study were housewives, were married, had finished high school, and belonged to the Wolaita ethnic group, respectively (Table 1).
Obstetric-and provider-related factors affecting respondents As for obstetric variables, most of the participants (93.7%) reported having had between 0 and 3 abortions. A total of 196 study participants (77.8%) participated in ANC follow-up during their last pregnancy and 198 (78.6%) planned the pregnancy before the birth of their last child. In addition, 127 (50.4%) participants had a history of 1-3 pregnancies and 138 (55.2%) made a joint decision. In addition, 42.9% of them had 1-3 children. One hundred ninety (75.4%) participants had no abortion history and only 16 of them had a history of more than or equal to 4 abortions. The remaining 46 participants had a history of 1-3 abortions.
Regarding provider-related variables, this finding revealed that 73 (21%) respondents did not receive respectful care during the previous delivery and 85 (34.5%) respondents reported that their privacy was not maintained during a past delivery. On the other hand, poor belief in health facilities (36.4%), sudden onset of labor (16.8%), and no respect from health care providers (23.2%) were the three major reasons that contributed to noninstitutional delivery.

Respondents' knowledge of obstetric complications
Among the 252 participants, around 60% of women had poor knowledge and 40% had good knowledge of obstetric complications ( Table 2).

Prevalence of noninstitutional delivery
Among the total study participants, 68.7% practiced noninstitutional delivery and 31.3% practiced institutional delivery (Table 2).
Factors affecting the practice of noninstitutional delivery Findings from this study indicated that mother's occupation, such as working as a daily laborer (AOR = 3.6; 95% CI [1.  (Table 3).

Discussion
The rate of noninstitutional delivery in the study was 68.7%. This finding is higher than in studies done in the South Wollo Zone, Delanta District (35.2%) 16 ; Nepal (41.9%) 17 ; and Brazil (11.7%). 18 Findings from the study are in line with the study done in Afar (71%). 19 However, the variation in both cases may be due to differences in sociodemographic status, sample size and study period, geographic location, and methodological variation. A study done in eastern Africa using Demographic Helath Survey indicated that noninstitutional delivery was highest among Ethiopian women (72.5%), which is in line with this study.
This consistency might be due to similarity in sociodemographic characteristics and geographic location. However, it indicated a lower value in the other East African countries, such as Tanzania (34.7%), Kenya (37%), Mozambique (2.8%), Rwanda (6.8%), and Malawi (7.1%). 20 Possible reasons for the discrepancies could be differences in study participant characteristics, quality of delivery services, policies and strategies, research areas, sampling methods, and participant sample size.
In this study, respondents' occupational status was significantly associated with noninstitutional delivery; mothers who were daily laborers were 3.6 times more likely to give birth in noninstitutions than mothers who were civil servants. This study is supported by studies done in Gambela 14 and Benishangul Gumuz. 21 This may be due to the following: being a daily laborer can inhibit easy access to health-related information, such as advantages of institutional delivery and/or disadvantages of noninstitutional delivery; they may easily be exposed to economic problems that might inhibit access to a health facility; they may be more exposed to family pressure and cultural influences; and they may not have enough time to reach a health facility. Place of previous delivery was significantly associated with noninstitutional delivery. Women who gave their last birth outside a health center were 8.7 times more likely to give birth outside a health center than their counterparts. This study was in line with studies done in Ethiopia. 22,23 The reason can be due to mothers lacking adequate information on the advantages of institutional deliveries and considering them as less risk for complications if they gave birth outside a health institution.
The study found that women with no ANC followup were 3.3 times more likely to give birth outside a health center than those with ANC follow-up, which is consistent with studies done in Delanta District, 16 Zala Woreda, 24 and Nigeria. 19 This may be because mothers who attend ANC visits have a chance to find out the importance of institutional delivery.
On the other hand, study participants who had no previous knowledge of labor and delivery complications were 3.5 times more likely to give birth outside  a health center than their control group. The reason for this could be that these women did not know the outcomes of a difficult labor and were not looking for health care from the hospital. Complications that occurred at the previous delivery were identified as explanatory variables significantly associated with noninstitutional delivery.
Respondents who had complications at the last delivery were 2.5 times more likely to give birth outside health facilities compared with their counterparts. The possible explanation might be occurrence of complications that can contribute to stress, dissatisfaction, and limit the utilization of institutional delivery.
Finally, a planned pregnancy was negatively and significantly associated with nonutilization of institutional delivery; mothers who planned their last pregnancy were 60% less likely to practice noninstitutional delivery compared with their counterpart group. This may be because mothers who planned their last pregnancy may have an interest in seeking health care, following health care recommendations, and cooperating with their partners.

Conclusions
In general, 68.7% of mothers have given birth outside a health care facility. The main reasons for this are poor belief in the health care provider and the sudden onset of labor, as well as a lack of respect from health care providers. Respecting mothers and providing health education are two of the most strongly recommended actions that health providers must take. In addition, the district health office and zonal health department should facilitate ambulance services and a maternal waiting area to prevent the sudden onset of labor.
In addition, respondents' occupation, last planned pregnancy, place of previous birth, ANC follow-up of last pregnancy, and knowledge of delivery and birth complications were relevant factors. Health care extension workers, health care providers, and other stakeholders should raise women's awareness of the benefits of ANC follow-up and pregnancy planning and complications associated with home birth.
Finally, zonal health departments and top health institution managers should monitor, evaluate, and supervise the utilization of delivery services provided at each facility.