Factors Enabling Women to Attend Health Facility Delivery in Gullele Sub City, Addis Ababa Ethiopia, A Qualitative study

Background : - Maternal mortality is the leading cause of death among women of reproductive age in most of the developing world. Globally, an estimated 300,000 women die as a result of Complications related with pregnancy each year. Health facility delivery is one of the recommended approaches in order to reduce maternal and child mortality rates. Understanding the reasons for choosing institutional delivery helps achieving universal coverage. Methods: - A qualitative study design was implemented to collect the required data from mothers in Gullele sub-city of Addis Ababa. Data was collected using semi-structured interview guide questions based on predefined themes. The data was then transcribed in Amharic then translated to English and coded using NVivo Version 10. Result : - A total of 19 women were interviewed and the result showed that awareness about institutional delivery, providers /professionals/ approach, accessibility and availability of materials at health facilities, fear of delivery complication recalling friends or families previous experience, lack of trust on traditional birth attendant and free of charge delivery services at institution level were mentioned as the most important factors for choosing institutional delivery. On the other hand, fear of exposing body to unfamiliar persons, previous normal delivery at home, negligence by health professionals and fear of students who practice at the health institutions were regarded as impeding factors to attend institutional delivery. Conclusion : - Proper counseling of mothers and partners about the importance of health facility delivery, expanding availability of free and quality services, good communication, and interactive approach to mothers, awareness creation and linking mothers to health facility for delivery by health extension workers should be improved.


Plain English summary
Pregnancy related birth complications are claiming the lives of more than 300 000 women globally each year. More than 90% of the death occurs in developing countries, sub Saharan Africa being the worst affected.
Universal coverage of health facility delivery is the recommended approach to reduce the mortality and understanding factors for choosing institutional delivery is important in particular in slum areas of urban city where the figure could be masked by the urban average.
A total of 19 mothers coming for post natal services to health facilities were interviewed using interview guide questions. A qualitative study design was used, and the data coded based on predefined themes, and analyzed with a software designed for such type of data.
The most important factors for choosing institutional delivery were awareness about institutional delivery, provider approach, accessibility of modern equipment at health facility, fear of delivery complication, lack of trust on traditional birth attendant, and free of charge delivery services. On the contrary, fear of exposing body to unfamiliar person, history of normal delivery at home, negligence of health professionals, and fear of students practicing at health institutions were pointed as impeding factors to attend institutional delivery.
In conclusion; improving the awareness of mothers and their partners, provision of respectful and supportive care, expanding accessibility and free services, and linking mothers to health facilities by tracing should be improved to enable the service reach more mothers. Maternal mortality rate (MMR) was shown to have the largest discrepancy between developed and developing countries. It is very high in developing countries, in 2017 it was 462 per 100 000 live births versus 11 per 100 000 live births in high income countries. In line with this, 295,000 maternal deaths occurred during and following pregnancy and childbirth in the same report of which close to 94% occurred in low resource setting. From this Sub-Saharan Africa accounted 196 000 of maternal deaths which is almost two third of the burden (2).
In Ethiopia, maternal and infant mortality and morbidity levels are among the highest in the world. The infant mortality rate was 48 deaths per 1,000 live births and the maternal mortality ratio was 412 per 100,000 live births in the year 2016. The Maternal death which was 676 in the 2011 survey has evidently decreased in 2016 but still remain to be profound (3). Different factors, like income of house hold, education, cost and quality of care in Hospital, family size, knowledge about modern facility, social taboo and traditional belief, access for media and family planning program play important role in choosing modern delivery care system (4).
Despite significant reduction in the number of maternal deaths since 1990, it is still less than half what is required to reach the Millennium Development Goal (MDG). Substantial numbers of women are losing their lives because of lack of proper ANC follow up and SBA. The ANC follow up was 51% and the SBA 64% globally in the fifth MDG report for the period between 2007 and 2014 far less than expected (5).
According to Ethiopian Demographic Health Survey 2016 report, 62%, of mothers received antenatal care (ANC) from health professionals, and yet only 26% of births took place in health facilities (3). In Addis Ababa the ANC coverage and the skilled attendant delivery was 97% and 95% respectively (3,6) whereas ANC coverage of slum areas of Addis Ababa is masked by the city average and it was reported that four or more ANC visits in this slum places is 81% and only 20% received adequate ANC with the full package (7). Considering majority of Gullele sub-city and the health centers we chose for this study are also considered one of the slum areas the ANC visit and SBA would be far less than what is reported. Therefore, this study was conducted to assess utilization of health facility for delivery services and identify the extent and factors influencing use of this service among women in the study population.

Study setting
The study was conducted at Gullele sub-city which is among the 10 sub cities in Addis Ababa City Administration between December 2016 and September 2017. The sub city has a total population of 284,865, where women account for 51.6% according to the sub city report.
The sub city has three hospitals, 10 governmental and one none governmental health center together with 37 private different level clinics (8).

Study design and sampling
A qualitative study design was used in three randomly selected health centers in the sub city.
Mothers who gave birth in the health facilities and came for post natal services in the health centers were enrolled to the study.
Purposive sampling of criterion method was used to select from those mothers who came for post natal services and a total of 19 women were interviewed.

Data collection method
An In-depth interview was used to collect the data. The interview guide was first prepared in English then translated to the local language "Amharic". The interview lasted on average for 20-30 min and has continued until no further new information was generated from interviews.
Additional concept "cost for delivery" was incorporated after preliminary reviewing of the responses and from field notes taken. Finally a total of 19 interviews were conducted and considered for analysis.

Data analysis
The tape recorded documents were transcribed to "Amharic" the local language, then translated to English and coded based on predefined themes. The PI and the Co-investigator performed the analysis and the coding who had experience of conducting such kind of qualitative study.
Descriptive analysis was done by using NVivo Version 10 (QSR International). Concepts and unique ideas generated were summarized in memos and linked with respective themes and descriptive narratives generated for the themes accordingly.

Data management
The entire tape recorded document and the transcribed file was handled and protected from anyone who was not part of the study.

Socio-economic and demographic background
A total of 19 women had participated in the study, of which more than half of them were in the age range of 20-35 years and during their recent delivery all of them were married. Most of them completed primary level education and few were w i t h college diploma and above.
Most of the mothers were unemployed /house wives/ who depends on their husband"s monthly income. The average monthly income of their husband"s was in the range of 50-100 US Dollar.

Reason for attending health facility for delivery
Among the participants, most of them mentioned the following reason for preferring health facility for delivery; the descriptions are narrated based on these themes; perceived benefit of professional care and adequate facility, provider/professional approach, Perceived susceptibility to complication of pregnancy, previous experience, decision making and the role of partners, awareness of mothers, cost of delivery and accessibility, and perceived fear of delivery in health facility.

Perceived benefit of professional care and facilities
Perceived health benefit of women and their unborn babies from trained professionals, like advises on how to push, checkups to the baby, proper hygiene keeping, getting further service like cesarean section if complications occur were reasons given by most of the participants. Few of them also chose it because of impartiality and safety measures provided by health professionals.
" …..this place is safe and they are here to help us, if I couldn"t give birth normally, the professional can perform cesarean section and give necessary services……." said one mother.
Most of the mothers affirmed that availability of medication and better equipment were additional factors to prefer institutional delivery. They also indicated that the health institution services has improved in recent times and they are no longer being referred elswhere to buy medication and for laboratory tests.
" ……at home you don"t have accesses to blood donation, trained professional, medical supplies and treatment but at facility level they provided what is needed for me and my child, they also assessed my health status before I was discharged…..." one mother said.
"……In the health facility even if they couldn"t save the baby, they could save my life. They gave me glucose, medication and food which I couldn"t get at home….." another mother said.

Providers approach
Respectful and non-negligent approaches during follow up at health institution influenced some of the participants to attend skilled delivery.
"……The professionals were so good, they gave me proper care, the facility was so clean, and they were always with me, created conducive environment that I felt like I was at home….." one participant said.

Perceived susceptibility to complication of pregnancy
Perceived susceptibility could be seen in two ways; susceptibility to obstetrics complication and susceptibility to exposure of disease. Most of the participants stated that fear of obstetrics complications, prolonged labor with high bleeding, retained placenta, arrival of the child in the wrong direction, and breathing problem. Few of them mentioned hypertension and non-opening of uterus. "…..I prefer this health institution for delivery, for the sake of my health and the safety of my child. The baby may come in wrong way, by his feet, which is too dangerous to the child and myself. So, in order to avoid this problem I have to choose health facility and to get cesarean section by professionals in case it is needed……" said one mother.
"……….the placenta may be retained and not completely removed, there could be shortage of breath and the child may face breathing problem, I may also have severe bleeding. Therefore, I have to choose such kind of facilities to avoid the danger….." said another mother Most of the participant especially those who had previously gave birth assisted by traditional birth attendants (TBA) stated that the current TBAs are incapable of managing delivery complication than the previous ones. Some said they have doubt on the knowledge and skill of TBAs to assist delivery and they did not properly clean blood from their body and uterus which could cause problem in the future.
".…..I have decided not to visit traditional birth attendants because the current TBAs lacks skill compared to previous ones. Before this delivery I have attended TBA for my second child, she told me simply to push and push, she didn"t do anything for me. No medications given but health professionals gave me delivery medication……" one mothers said.
During home delivery, the cloth used for covering the baby may not be clean, home bed could be contaminated, the materials TBAs use to cut placenta could cause transmission of HIV/AIDS. Majority of the mothers reasoned out these factors for preferring skilled delivery. "…..there could be blood contact with TBA and from me to my child, this may lead to transmission of HIV/AIDS…." one mother said.
"……..home delivery is not safe and the materials may not be clean, so I may be exposed to infectious diseases like HIV/AIDS and could eventually endanger my self and my child …" another mother said.
Even though the participating mothers stated their thought about complication, most of them did not have good awareness on the danger sign of delivery. But they simply mentioned the consequence of home delivery.

Previous experience
In this study previous experience of complicated delivery by the mothers themselves or their neighbors were stated as reason to attend institution/skilled delivery. Most of them mentioned that their own mother"s previous delivery complication and problem due to home delivery, like long lasting labor, high bleeding had impacted them to choose skilled delivery. Few mentioned that information about maternal death due to home delivery and benefit of institutional delivery influenced them to attend health facilities. "…..I attended a TBA for my second child, she massaged my belly with white butter for long time, finally when things got complicated, she told me things were out of her capacity and I had to go health facility to safe my life. By the time I arrived at the health center, the baby was already dead. After this horrific experience, I decided to come here for my third delivery……." one mother said.
"…..I have known some mothers who lost their life when they tried to give birth at home, I didn"t want to face this situation, so I decided long ago that I have to come to health facilities to get assistance during delivery…" another mother said.
"……..The major influencing factor for me is my mother painful experience, she had gone through severe pain for five days, when she tried to give birth at home by TBA……". said other mother .

Decision making and the role of partners
Almost all of the mothers stated their husband"s involvement had significant impact for deciding a place of delivery through saving money and partner engagement for ANC follow up. Few mothers whose husbands lack awareness about institutional delivery decided by themselves.
"……..my husband and I decided together to have the ANC follow up at the health center. When I came to the health facility for follow up or any case, he accompanied me, he saved money in case cesarean section is needed to be performed, which may need more money, by doing such things he helped me….." said one participant "…….you don"t know what could go wrong during delivery, to avoid this unexpected risk I decided to give birth at the health facility. My husband also insisted we should have to have the follow up at the health facility. If there is complications, I would have the opportunity to get help form the professionals….." One mother stated. "……..my husband has no awareness on this matter so he had no any contribution, I decided to come here by myself…….."

Awareness of mothers
Information from media and health professionals (counseling given during ANC follow up) were mentioned by most mothers as their source. Information from their neighbors, friends and their family were also stated by few participants. But the contribution of health extension workers was minimal as stated by the participants.
"….I get information from media especially "your health at your house" (a televised program which focuses on health issues), and also from my friends and family….." one mother said.
"……when I was in rural area, health extension workers told me that all mothers should give birth at health institutions in order to avoid risk related to TBAs assisted delivery but here in Addis Ababa the health professionals do not come to our house most often…..." another mother said.

Cost for delivery and accessibility
Cost was one of the reasons that most mothers pointed as a challenge. Most of them are not able to afford to pay for contract taxi or for extra expenses. Previously there was shortage of ambulance but now days the health institutions provide ambulance services. "……..my husband always told me, I should have to go early to health center because he couldn"t cover any extra cost for contract taxi……." Said one mother.
"…….my home is near to the health center that I didn"t need any extra transportation cost to come and I saw the capability of the health center when I came for other purpose. They also give ambulance services and they would come to pick us from our home if we got in labor suddenly……" another mother said.

Perceived fear of delivery in health facility
Even though most of them explained the enabling factors which influenced them to attend skilled delivery, some of them mentioned barriers which may hinder them not to attend skilled delivery, like disrespect and insulting by health professionals, negligence of professionals (there are some fear they might leave scissors and gauzes inside their body after surgery), fear of disclosing body to unfamiliar person, and lack of trust on students who practice at health facility.
""I saw the nurse shouting loudly on one mother when I was there for my follow up. The nurse was not polite and she didn"t have any respect for mothers, after that I hesitated to come back" …….. said one mother I don"t trust students practicing in the health facilities, they don"t know what to do if complications occur, and most of the time the senior and experienced professionals are not available to help us in this situation……." another mother explained

Discussion
The study found that women in the study area strongly preferred health facility attributes, trained health care providers, safe and clean environment, reliable supply of medicines, and better equipment for deciding place of delivery. Provider/professional attitude and approach were also important. Convenient access (i.e. being near to home and referral cost) were stated as additional factors.
A study in Cambodia indicated women choice of health facility is influenced by their perception of safety and staff attitude where some women preferred private health facilities because they considered them safe and receive better care (9). Moreover, respectful approach of workers, continuous and non-negligent follow up, good communication and spending time with mothers and creating home like environment were reported to be key factors to attend health facilities in this and other similar studies (10)(11)(12)(13)(14)(15). There for, provision of training and education to health professionals to address attitude issues and behavior is indicated to be a successful approach (16). However, there should be a balance not to frustrate health professionals where they are overburdened with work load and underpaid in lower income countries. reported the challenge of family pressure to adhere to traditional birth norms which further undermines skilled delivery practice (10). In line with this, a study in Iran revealed factors which caused delay in referring women with obstetric complication to emergence obstetric care facilities; socio cultural and familial reasons, disrespect and insulting by physicians, and lack of health insurance (17). Previous experiences of life threatening obstetric complications either to themselves or to their neighbors and friends would influence the utilization of institutional delivery in the current study, this was also reported in other research done in Indonesia (18) and Ethiopia (19).
Partner support in terms of saving money, accompanying during ANC follow up and awareness about skilled delivery had great role to prefer institutional delivery over home delivery as observed i n this and other similar studies (13,17,20). The participants mentioned, they benefit from free ambulance, fast referral system and cheap cost or no cost at all when they visit health facilitates. One study in rural Gambia in particular indicated women are not privileged during pregnancy period, did not have the resources or the means to access prenatal care and the decision to receive skilled delivery is often beyond their control, further making birth related complications a challenge (21). A demographic and health survey from 48 developing countries also reported 68% of women said it was designated "not necessary" to attend a skilled delivery by the house hold decision makers (22), clearly not the mothers. Hence, empowering women, persuading and teaching their partners to provide support and care is vital under such circumstances. A study in rural Tanzania also emphasized the importance of teaching husbands and family members where despite 90% antenatal care only half of them used skilled delivery services (23).
This study also found awareness of mothers about institutional delivery from different information sources influenced their preference to choose place of delivery, such as medias, relatives and health professionals. Counseling given during ANC follow up and closeness of their home to health facility had substantial contribution to choose facility delivery in the current study. Other similar studies done before reported that mothers who had at least 3 ANC visit and who lives near the health facilities are more likely to deliver at the facility (4,25).
Some mothers also mentioned factors which may hinder them from attending health institutions for delivery such as; fear of exposing body to unfamiliar persons, previous normal delivery at home, negligence by health professionals and fear of students who practice at the health institutions. The notion of fear of practicing students is not good because it is today"s students that become tomorrow"s professionals. The trust and the confidence should be reestablished and this can only happen when both students and the mothers know that senior and experienced professionals are close by in case any complication may occur. A study in India in a resource poor setting indicated; trust in TBA, belief of a child should be born only in natural event and health facility may be needed only if there is complication as major impeding factors to attend institutional delivery (26).

Conclusion
The current study showed that provider approach, provision of respectful and supportive care, awareness about skilled delivery and partner support on decision making have considerable impact in preferring health facility for delivery. H ealth care providers should have to use every opportunity to properly counsel and teach women along with their husbands about the importance of skilled delivery and they should have to develop good communication and interactive approach, be friendly to mothers who come for ANC follow up.
Awareness creation by health extension workers was low as compared to media contribution and the role of health extension worker in teaching and linking mothers to health facility should be improved. The education would be more fruitful if accompanied by influential local peoples and mothers who experienced the suffering of home delivery. Finally, we

Ethics approval and consent to participate
Ethical approval was obtained from the ethical review board of Addis Continental Institute of public health prior to the actual data collection procedure. The respondents were informed about the purpose and significance of the study and asked to cooperate for an interview through verbal consent. This method of consent was acceptable for this type of study by the ethics committee.
Recorded and transcribed materials including personal data were coded and accessible only to investigators.

Availability of data and materials
The datasets analyzed during the current study are available from the corresponding author on reasonable request Mikias Negash (Assistance professor of Clinical laboratory science). Lecturer at Addis Ababa University College of Healthy Sciences, Department of Medical Laboratory Sciences