Determinants of Skilled Birth Attendance Utilization Among Mothers Who Gave Birth In The Past 24 Months In Kembata Tembaro Zone

Background: Skilled delivery is encouraged as a single most important strategy in preventing maternal and neonatal morbidity and mortality. It ensures safe birth, reduce both actual and potential complications and increase the survival of most mothers and newborns. Little is known on current factors that affect utilization of skilled birth attendance in the study area. Therefore this study was aimed identify determinants of skilled birth attendance utilization among women who gave birth in the last 24 months preceding the study Methods: A community based cross-sectional study was employed among women who gave birth in the last 24 months prior to the survey in Kembata Tembaro zone from April 1 to 30, 2020. 624 study participants were recruited for the study as eligible study participants. Multi-stage stratied sampling was used to select three districts and one town administrative unit of the study area. The data were collected and veried for their completeness, edited, and coded. Multivariate analysis was performed using the back ward LR method to identify factors independently associated with dependent variable. Statistical signicance was declared at p-value of less than 0.05 and the strength of statistical association was measured by adjusted odds ratios and 95% condence intervals. Results: In this study, 375(61.8%) women gave their last birth at health institutions being attended by skilled birth attendants. Place of residence [AOR (95% CI)=0.33(0.215, 0.582)], age at interview [AOR (95% CI=3.41(1.572, 5.449)], maternal education [AOR (95% CI)=1.50(1.336, 4.193)], history of still birth [AOR (95% CI)=3.85(2.144, 6.905)], maternal occupation [AOR (95% CI)=3.35(1.793,6.274)], husband occupation [AOR (95% CI)=2.69(1.701,7.986)], ANC visit [AOR (95% CI) =4.62(3.124, 7.324)], knowledge about obstetric complications [AOR (95% CI) =3.10(1.371,5.214)] and were of birth Conclusion: In this study, about two fth of the respondents were delivering in the home without using unskilled delivery attendant. Place of residence, age at interview, maternal education, history of still birth, maternal occupation, husband occupation, ANC visit, knowledge about obstetric complications and nal decision maker about place of delivery were determinants of utilization of skilled attendant delivery.

hand in hand with the Sustainable Development Goals (SDGs) to reduce child mortality, particularly neonatal mortality (4). Since 2000, the United Nations' MDGs, which included a goal to improve maternal health by the end of 2015, has facilitated signi cant reductions in maternal morbidity and mortality worldwide (5). Despite more focused efforts made especially by low-and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care (6).
Maternal mortality is unacceptably high and every day approximately 810 women died from preventable causes related to pregnancy and childbirth in 2017 (6). Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254 000) of the estimated global maternal deaths in 2017 with sub-Saharan Africa alone accounting for roughly 66% (196 000) (7). Nearly 42.5% of infant deaths each year occur within the rst week of life and are often due to a lack of or inappropriate care during pregnancy, delivery and the post-partum period (8). One third of nearly one million stillbirths occur during labour, and approximately 280,000 babies die of birth asphyxia soon after birth. About 60% of African women and their babies do not receive skilled care during childbirth and fewer receive effective postnatal care (9). This is also the crucial time for other interventions, especially prevention of mother-to-child transmission of HIV and initiation of breastfeeding (10).
In Ethiopia, poor access to SBAs is re ected by its MMR (11). According to the 2016 Ethiopian Demographic and Health Survey (EDHS), MMR was estimated to be 412 per 100,000 live births (12). Major causes of maternal deaths in Ethiopia are similar to most developing countries such as infection, hemorrhage, obstructed labor, abortion and hypertension that could be avoided if preventive measures were taken and adequate care is available particularly during pregnancy, childbirth and postpartum period through obstetric care services (13). Poor access to and use of skilled delivery services have been identi ed as a major contributory factor to high maternal and newborn mortality, which remains a major challenge to health systems and public health issue in the country (14).
Although skilled delivery has been promoted in Ethiopia, home delivery with traditional birth attendants is still common, primarily in rural area that is hard-to-reach (15). The 2016 EDHS showed that only 28% of live births in the 5 years before the survey were delivered by a skilled provider, 26% in the health facility whereas home delivery was 73% and 1% in other places. For rural women, the report showed that 80 percent of births to urban mothers were assisted by a skilled provider as compared to 21 percent in rural area. 80% of them delivered at home (16).
Based on National Reproductive Health Strategy, the country planned to increase the proportion of births attended by skilled health personnel either at home or in the facility to 60% (5). Despite the efforts being made by the Government and other stakeholders to mitigate the problems and subsequent consequences posed by SBA delivery, studies in different parts of the country are showing that most Ethiopian women are giving birth at home and skill birth attendance remains low (17,18). To enhance utilization of SBA in the country, barriers during delivery among women need to be identi ed across the regions. Little is known on current magnitude of utilization of SBAs and its determinants in the study area. Therefore, this study was aimed to assess extent of SBA utilization and attempts to explore its determinant that are assumed to be barriers among mothers who gave birth in the past 24 months in Kembata Tembaro zone, southern Ethiopia.

Methodology
Study area and period A study was conducted in Kembata Tembaro Zone from April 1 to 30, 2020. The zone is located in S/N/N/P/R (South Nations, Nationalities and People republic) of Ethiopia and its capital town, Durame, which is located Southern, 293 kilometers away from Addis Ababa and western, 118 KM far from Hawassa, capital town of S/N/N/P/R government of Ethiopia. In this zone, there are 8 woreda health o ces and 3 health administrative units, 1 general and 3 primary hospitals, 28 governmental and 3 nongovernmental health centers, 136 health posts and 1170 different types of health professionals.

Study design
Community based cross-sectional study design was employed Population All women who gave birth in the last 24 months prior to the survey in the study area were the source population while selected women who had given birth in the last 24 months, irrespective of the outcome of the birth were included as study population

Sample size determination
To determine the sample size, two-population proportion formula was used and the following assumptions were considered. ANC visit during last pregnancy was considered as predictor factor for utilization of SBAs. Study subjects were categorized in to women who visited or not ANC during last pregnancy (19). ANC visit during last pregnancy gives the maximum sample size among other predictor variables such as having place of residence, educational status and etc. Based on the above assumptions and design effect of 1.5 and 5% non response rate, 624 study participants who gave birth in the past 24 months were selected for the study as eligible study participants.

Sampling procedures
Multi-stage strati ed sampling was used to select three districts (Angacha, Doyogena and Kedida Gamela) and one administrative town, Durame from the total of eight districts and three administrative towns of the zone. First, the zone was strati ed into rural districts and urban administrative towns, and then 15 kebeles were chosen by lottery method. House-to-house visit was carried out in selected kebeles to identify households with women who gave birth in the last 24 months prior to the survey and 13806 households were identi ed ful lling eligibility criteria. By allocating the sample size proportionally to each kebele, systematic random sampling was used to select study subjects. If the houses were closed or the mother was not present at the time of data collection, revisits were made until data collectors got the women for the data collection.

Operational de nition
Skilled birth attendance delivery: The outcome variable, utilization of SBA delivery was assessed by asking the mother if she gave birth within the last 24 months assisted by professionally trained health worker having the essential midwifery skills to manage normal labour and delivery.
Knowledgeable on danger signs of pregnancy: A woman was considered as knowledgeable if she can mention at least three danger signs that could occur during pregnancy (17,20) Knowledgeable on danger signs of labour/childbirth: A woman was considered as knowledgeable if she can mention at least three danger signs that could occur during Labor/childbirth and not knowledgeable if otherwise (17,20).
Knowledgeable on key danger signs of postpartum: A woman was considered as Knowledgeable if she can mention at least the three danger signs that could occur during postpartum period /after delivery and not knowledgeable if otherwise (17,20).

Data collection procedures
Data were collected using self administered structured questionnaires that were developed after reviewing different relevant literatures (17,(19)(20)(21)(22). Socioeconomic and demographic factors, obstetric factors (parity, complications experienced like prolonged labor and history of still birth), ANC follow up, husband factors (occupation and education), knowledge and attitude on key danger signs of pregnancy, and labor/childbirth were included as contents of the questionnaires. Six Bsc nurses and one health o cer were recruited to collect the data and supervise the data collection process respectively. Two days training was provided concerning the purpose of study and method of data collection. The supervisors were informed about the strict supervision and cross-checking procedures about the data abstraction forms and completeness at the end of the day. The principal investigator supervised the overall activities.

Data Quality control
The quality of data was assured by proper designing of the questionnaires and by training the data collectors and supervisors for two days before the data collection. Every day after data collection, questionnaires were reviewed and checked to maintain its accuracy and completeness by the supervisors. The English version questionnaires were translated into Kambatissa and Amharic languages (local languages) and again translated back to English version and comparisons was made on the consistency of these versions. Data collection tools were pretested at 5% of sample and it was done to pretest the tool to identify any weakness in the structuring of the research instruments prior to its actual use in data collection. Following the pre-test, the tools were improved in terms of their clarity, understandability and simplicity in collecting the data required for the study.
Data management and statistical analysis Data was checked for its completeness; edited, coded and cleaned then it was entered into Epidata 3.1 and exported to SPSS version 20 for analysis. Descriptive statistics was computed and results were presented by tables, graphs and numerical summary was used to present the quantitative results. Before bivariate analysis, all variables were checked by cross tabulation for ful lling chi-squared test assumptions of 80% expected frequency greater than ve and all cells expected frequency greater than one. Variables with p-value of < 0.25 in bivariate analysis were considered as candidates for multivariate analysis. Multivariate analysis was performed using back ward LR method to identify factors independently associated with dependent variable. Statistical signi cance was declared at P-value of less than 0.05 and the strength of statistical association was measured by adjusted odds ratios and 95% con dence intervals. Hosmer-Lemeshow goodness-of-t statistics were used to check the goodness of t of the model with a p-value of 10%

Socio-demographic and socio-economic characteristics of the respondents
In this study, out of 624 study subjects sampled, 607 of them provided information with a response rate of 97.3%. About two third of study subjects were in the age range of 25-34 years with a mean and standard deviation age of 27.3 and 5.6 respectively and 479(68.6%) were residing in the rural area.
Regarding educational level of respondents, about half, 306(50.5%) of them attended secondary and above school. (Table-1 were pregnant before the age of 20. More than half, 354 (58.3%) didn't follow up ANC during their last pregnancy and those who had ANC follow up history, only 192(31.6%) had four visits and above. Among the respondents, about half, 232(49.1%) reported that they gave their last birth at home and more than half, 168 (56.4%) were attended by TBAs. (Table-2) Regarding the reason for home delivery, nearly three fourth, 232(77.9%) of the respondents reported the main reason for home delivery as feeling of more comfortable. (Figure-1) Accessibility characteristics of respondents About half of study participants, 305(50.2%) had health facility within one to two hour distance while 220(36.2%) and 82(13.5%) had health facility within one hour and less than one hour distance respectively. Regarding availability of functional media, 351(57.8%) and 109(18%) had functional media (radio and/or television) but 147(24.2%) had no functional media at all.
Knowledge on key obstetric danger signs during pregnancy, labor and child birth, and after delivery

Determinants of skilled birth attendance utilization
Among the variables in bivariate analysis, 14 of them had a p-value of less than 0.25; hence they were candidates for multivariate analysis. They were again entered in to multiple logistic regression models to obtain variables which were independently associated with outcome variable, utilization of skilled birth attendance. The variables with p-value of less than 0.05 in multivariate analysis were taken as signi cant predictors of outcome variable.
Therefore, the nal model showed that there was statistically signi cant association between ANC follow up and utilization of SBA delivery (p-value < 0.001) so that, mothers who had at least four ANC visits were 4.62 times more likely to utilize skilled birth attendance than those who had less than four ANC visits during their last pregnancy [OR (95% CI) = 4.62 (3.12, 7.32)]. In this study, it was found that there was negative association between place of residence and utilization of skilled birth attendance (p < 0.001). Mothers who lived in rural area were 67% less likely to utilize SBA than those who lived in urban area [OR (95% CI) = 0.33(0.22, 0.58)]. (Table-5) Discussion Delivery assisted by skilled providers is the most proven intervention in reducing maternal mortality and one of the targets of United Nations' (UN) Sustainable Development Goals (SDG) (23). This communitybased study identi ed very important determinants that are related to skilled birth attendant utilization among study subjects. The ndings of the study revealed that the proportion of women who delivered in the facility assisted by skilled birth attendant was 51.8%. This nding is higher than study conducted in different parts of Ethiopia (17,19,24,25). This might be because of increasing in functions of multipurpose health extension workers on improvements in ANC follow up and facilitating a referral services to HCs and hospitals for delivery service assisted by skilled healthcare provider. Health extension workers improved the utilization of maternal health services including skilled birth attendance delivery by bridging the gap between communities and health facilities (26). However, it was lower than study conducted in rural southern Ghana where 68.8% mothers were assisted by skilled person during their last delivery (27). The difference could be explained by the fact that women in those countries had better socio-economic status.
In this study, place of residence was statistically signi cant and negatively associated with outcome variable. The result showed that mothers who lived in rural area were less likely to utilize skilled birth attendant than those who lived in urban area. This nding is supported with studies conducted in different regions of the country (17,19,22,25,(28)(29)(30). The possible reason might be prevailing of traditional thinking/views, presence of low education and income, lack of awareness on maternal health services like ANC, birth preparedness and complication readiness, remoteness/lack of transportation to the health facility for mothers in rural than urban area (31). History of still birth was another predictor of utilization of SBA. This study revealed that mothers who had previous history of still birth were more likely to utilize SBAs than mothers who didn't have still birth. The nding from cross-sectional survey conducted in Dembecha district of Northwest Ethiopia shows the negative association (24). The possible reason might be the fact that ladies who had still birth in their life time may have a fear to develop the complication during the delivering of their child and prefer skilled provider to give birth in the health facility.
Older women were more likely to give birth assisted by skilled birth attendants than young women. This nding is similar with study done in rural residents of Southern Ghana (27). However, the nding opposes other studies conducted in Raya district of North Ethiopia and Ghana which found as young women were more likely to utilize SBA than older women (19,32). This might be older women were able to consider that giving birth at home is risky as they had experienced previously and they might get additional information regarding risk of home delivery with TBAs during different visits (child care, immunization services and etc) to health facilities. The higher age of women can in uence their status in the society which has been found to increases the ability of decision making (33).
Mothers' educational status was other predictor of utilization of skilled birth attendant which was statistically signi cant. Mothers who had ability to read and write as well as mothers who learned secondary and above were more likely to utilize SBA than those who were unable to read and write. This nding is consistent with report from EDHS 2016 which found strong correlation between mothers' educational status and skilled birth attendant delivery. EDHS 2016 found 17% of births to mothers with no education were assisted by a skilled provider as compared to 93% and 92%, respectively of births to mothers with more than a secondary education (16). This might be because of educated women are likely to make their own healthcare decisions more and seek proper health care than their counterparts. In this study, parity was negatively associated with SBA utilization.
Maternal occupation is an important predictor of utilization of SBAs. The study showed that both the government employees and merchants were more likely to utilize skilled birth attendance delivery than house wives. It was supported by study conducted in Northern Ethiopia and rural area of southern Ghana, which showed an important association between occupational status of mothers and utilization of SBA delivery (19,21). Mothers with government employed husband were also more likely to utilize skilled birth attendance delivery than farmers. This nding was supported with study done in Gamo Gofa zone, southern Ethiopia (20). The possible reason might be due to the fact that those government employee and merchant ladies and their husbands might have more income and awareness for identifying skilled provider and place of delivery, searching for money for incurred costs, nding transportation, and other things which may contribute to home delivery.
In this study, it was found that ANC visit during last pregnancy of the respondents was signi cant with utilization of skilled birth attendance delivery. Women who had ANC visit with skilled professional during their last pregnancy were more likely to deliver in health facility with skilled birth attendant than those who had no visit. This nding was also supported with the report from EDHS of 2011 and other studies conducted in different part of Ethiopia (17,19,28,34). This might be women during Antenatal care (ANC) follow up can obtain counseling services on birth preparedness including place of delivery and selection of birth attendant and complication readiness. Antenatal care (ANC) from a skilled provider is important to monitor pregnancy and reduce morbidity and mortality risks for both the mother and child during pregnancy, delivery, and the postnatal period so that those mothers who had history of ANC follow up can easily give attention to deliver in the HF with SBAs (16).
Knowledge regarding health problems during pregnancy and child birth was other important predictor of skilled birth attendance delivery. Those respondents who had knowledge were more likely to utilize skilled birth attendance delivery as compared to those who didn't have knowledge on danger sign of pregnancy and child birth. It is consistent with studies conducted Raya district of North Ethiopia and Gura Dhamole Woreda, Bale zone, southeast Ethiopia (17,19). Women can take action by seeking appropriate health care by recognizing danger signs during pregnancy which can help them to deliver in the health facility with skilled birth attendant (35).
Moreover, Final decision maker about place of delivery in last pregnancy was another important predictor which is signi cantly associated with utilization of skilled attendant delivery. Respondents who jointly (both wife and husband) decided about place of delivery were more likely to utilize SBA delivery as compared to respondents who decided herself about place of delivery. This nding is supported with different studies conducted (17, 19, 24, 28, 36). If women are encouraged by husbands, they would also get nancial and other social supports to go to health facility which will allow them to have health provider assisted delivery (37). In contrast to this, studies conducted in western Ethiopia have showed that women whom the decision on place of delivery made by themselves were two times more likely gave birth in health institution with SBA compared to mothers whom decision made by others on place of delivery(38).
Limitations Data was collected from mothers about their experience since 24 months that might lead to a recall bias. Due to the cross-sectional study design, no causal inferences can be made regarding the temporal association between the potential factors and utilization of SBAs

Conclusion
In this study, about half of the study subjects gave birth in the HF attended by skilled birth attendants. Ethical approval of this study was obtained from the institutional review board of Pharma College of Hawassa campus and SNNPR health bureau research and technology core process. Then data was collected after getting written consent from Kembeta Tembero Zone health department. After clear discussion about the actual study or explaining of purpose of the study, verbal informed consent was obtained from each study subjects and privacy was maintained during data collection.
Consent for publication: "Not applicable" Availability of data and materials The data sets used and/analyzed during this study are available from the corresponding author up on reasonable request.

Competing interests
The authors declare that they have no competing interests Funding: The authors received no funding for the present study.
Authors' contributions EM carried out the conception and design, developed the methodology, carried out the analysis, and prepared the manuscript. BK participated in the acquisition of data, carried out the analysis, participated in interpretation of data and drafting. Both read, revised, and approved the manuscript for publication.      The reasons for home delivery among the respondents in Kembata Tembaro zone, South Ethiopia Utilization of SBAs of study subjects in Kembata Tembaro zone, 2020