Introduction
Globally, only 123 million women who give birth each year receive antenatal care, neonatal care, and delivery care. To promote maternal, neonatal, and children’s health, women need to access basic health care settings during delivery [
1]. According to the World Health Organization (WHO), more than 90% of women in high-income countries give birth at health facilities, whereas in low-income countries, most women give birth outside a health center by untrained people [
2]. Non-institutional delivery means just giving birth outside a health institution by an unskilled person [
3].
Many women who give birth outside a health facility can face problems such as dizziness, a tender abdomen, blood loss, fetal death, and uterine rupture. These problems are often considered dangerous for women who give birth outside a health facility [
4]. Most maternal mortality (MM) occurs during delivery and in the immediate postpartum period. All women should have access to basic maternity care during their pregnancy, such as clean and safe births. They should also have access to emergency obstetric care if necessary [
5]. In 2017, as a result of non-institutional deliveries and other-related factors, 462/100,000 mothers and 11/100,000 newborns died in both developed and developing countries, respectively [
6].
In addition, giving birth outside a health institution has a three-fold higher risk of developing complications and has a higher risk of death [
7]. The rate of neurological dysfunction and seizure in non-institutional delivery is three times higher than in institutional delivery [
8]. Increasing delivery in health institutions is a crucial approach to preventing the death of a mother and her baby. However, the practice of institutional delivery has not changed consistently to reduce maternal deaths in low and middle-income countries [
9]. Although there have been some improvements in reducing maternal and infant mortality worldwide, countries in sub-Saharan Africa and South Asia accounted for 86 per cent of the global maternal mortality rate in 2017. Only Sub-Saharan African countries accounted for two-thirds of maternal mortality [
4,
6].
The literature has identified several factors associated with the practice of non-institutional delivery. These include maternal educational experiences, occupation, previous antenatal care contacts, and knowledge of obstetric complications. However, the last pregnancy planned, and complications from previous deliveries were not assessed in previous studies. [
4,
5,
7].
Ethiopia is one of the 15 countries that are in a very high alert or high alert and as being in a fragile state. The practice of institutional delivery is an essential approach to preventing 13–33% and 20–30% maternal and newborn mortality, respectively [
10]. Although the Ethiopian Government and non-governmental organizations try to prevent women from giving birth outside health facilities, more than 50% of Ethiopian women give birth outside health care facilities [
11]. This shows that our country is still facing challenges in non-institutional delivery [
12]. In southern Ethiopia, few studies have been conducted on the scope and factors influencing the non-institutional delivery. The literature available focuses mainly on urban and institutional areas, with little information on updated rural areas. So, the aim of this community-based study is to assess the practice of non-institutional delivery among women delivered in southern Ethiopia.
Methodology
Study area, period and design
A community-based cross-sectional study carried out in Boloso Bombe Woreda from June 1 to July 1 2022. The district is located about 57 km from Wolaita, southern Ethiopia, and 435 km from Addis Abeba, the capital of Ethiopia. Boloso Bombe’s geographical location is 70 1’ 32’’- 70 11’ 30” N latitude and 370 26’ 18’’-370 39’’ 38’’ E longitudinal. According to the Boloso Bombe Woreda Basic Plan Report 2013Woreda has a total population of 114,342. Of these, 57,400 were women, 56,942 were men, and 26,642 were reproductive-age women. The district has 21Kebeles, one primary hospital, four health centers, and eight health posts.
Population and eligibility criteria
Source populations are defined as all women who had given birth during the preceding six months and had resided in the district for at least a year. The study participants included of women who had given birth during the six months prior to the study and had resided for at least a year in the chosen region. Study participants were women who were selected and participated in the study during the data collecting period. The study did not include mothers who had any mental health issues, were deaf or difficulty of hearing, or both.
Sample size determination and its procedures
A total of 260 sample sizes were determined using a single population proportion. 5% margin of error, 95% confidence interval, 19% non-institutional delivery from the previous study, and 10% non-response were considered to calculate the final sample size [
13].
According to the World Health Organization recommendation, 30% of the seven Kebeles (small villages) were selected from the total Kebeles using lottery methods. The total number of mothers who delivered in selected kebeles between 2021 and 2022 was determined using immunization registers and health post family folders. The sample size of each kebeles was proportionally allocated to the total number of deliveries of each kebeles for the selected kebeles. The respondents were then recruited using a systematic sampling method. Every other respondent to each kebeles were interviewed.
Study variables
The practice of non-institutional delivery was a dependent variable. Socio-demographic characteristics (age, educational status, occupational status), obstetric (parity, gravidity, ANC follow-up), and health care provider-related factors (privacy, respecting women, friendly behavior of service providers) were independent variables of the study.
Knowledge on labor complications
Knowledge level on labor complications measured using
six major labor complications, such as failure to labor progress, fetal distress, malposition, fetal distress, excessive bleeding, and cephalopelvic disproportion. Those who mentioned greater than or equal to 3 labor complications were classified as having good knowledge [
15]. And those who mention < 3 complications were assumed to have poor knowledge [
15].
Data collection and analysis
A structured questionnaire, including four parts, was used to collect data. These include socio-demographic information, factors related to women’s obstetrics, factors related to health providers, and knowledge of labour complications. The last component contains a question that contains a list of the six most important labor complications adapted from the previous study [
15].
The data were collected through face-to-face interviews. 10%of the questionnaires were pre-tested in unselected kebeles before the actual data collection began. The data were collected by seven B.Sc. nurses and supervised by three health officers. One day training was provided to data collectors and supervisors on data collection procedures. Firstly, the questionnaire was written in English, translated by experts into the local language, and again translated into English to increase consistency. In order to maintain data quality, the data collectors were closely supervised by the supervisor before and during the data collection process. The principal investigator (PI) supervised the correct implementation of the procedure and checks the completeness and logical coherence of the data collection after collecting the data.
The completeness and coherence of the data have been checked, encoded and entered into EPI Data Version 3.1. To analyze it, it was exported to SPSS version 25. In order to present descriptive statistics, frequencies, percentages, mean, standard deviations, and tables were used. The crude odd ratio (COR) of 95% of the confidence interval was calculated using a bivariate logistic regression test to test correlation between the dependent and the independent and select a the candidate variables. Then the variables that were found to be P < 0.25 in the bivariate analysis are taken as candidates for the multivariable logistic regression. Finally, multivariable logistic regression with AOR was used to control possible errors and to identify associated factors of the prevalence of non-institutional services. A P value < 0.05 was considered statistically significant.
Discussion
The non-institutional delivery practice in this study was 68.7%. This study is higher than the study done in the South Wollo Zone, Delanta district [
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 socio-demographic status, sample size, study period, geographic location, and methodological variation.
In this study, respondents’ occupational status was significantly associated with non-institutional delivery. Mothers who were daily laborers were three times more likely to give birth in non-institutions than mothers who were civil servants in occupation status. This study is supported by a study done in Gambela [
14] and Benshangul Gumuz [
20]. This may be due to the fact that being a daily laborer can inhibit them from getting health-related information easily, such as an advantage of institutional delivery and/or a disadvantage of non-institutional delivery; they may be easily exposed to economic problems that might inhibit access to a health facility; they are more exposed to family pressure and cultural influences. In addition, daily laborers had less awareness regarding complications of pregnancy, delivery, and labor, as well as the postnatal period, since they spent most of their time at work. Thus, this could increase the utilization of non-institutional delivery among them.
The place of previous delivery was significantly associated with non-institutional 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 [
21,
22]. The reason for this could be that mothers who lack adequate information about the benefits of institutional delivery may believe they are at lower risk of complications. As a result, this could increase the likelihood of non-institutional delivery and require close monitoring.
ANC is the most favorable period of contact for pregnant women to get adequate information about the risks and problems they may face during pregnancy, labor, delivery, and the postpartum period. The World Health Organization recommends that women without complications should have at least eight ANC contacts [
23]. The study found that who had not followed were 3.3 times more likely to give birth outside a health center than those who had ANC follow-up. Which is consistent with studies done in the Delanta district [
16], Zala Woreda [
24] and, Nigeria [
19]. This could be related to the fact that women who had no ANC might be less aware of birth preparedness and complications, danger signs of a pregnancy readiness plan, when to visit a health facility, and the danger of giving birth at a non-institutional place, which increases the chance of a non-institutional delivery.
Knowledge is an important factor that affects intentions, attitudes, and behavior. Lack of risk perception of delivery and labour could increase the use of non-institutional delivery [
1,
22]. Study participants who had no previous knowledge of labor and delivery were 3.5 times more likely to give birth outside a health facility than their opposite group. The possible explanation might be that knowledge of labor and delivery complications is essential for early recognition of the problem and appropriate for timely utilization of institutional delivery services. Thus, women who do not have good knowledge of labor and delivery complications, tend to deliver at non-institutional places. Teaching mothers and the community about the complications of non-institutional delivery increases the need for a preference for place of delivery, which is likely to be more useful in contributing to decision-making.
Previous deliveries’ complications were identified as explanatory variables significantly associated with non-institutional delivery. Respondents who had complications were 2.5 times more likely to give birth outside of health facilities compared to their counterparts. The possible explanation might be the occurrence of complications that can contribute to stress and dissatisfaction and limit the utilization of institutional delivery. No previous literature indicated an association between complications occurring in previous health facilities and non-institutional deliveries [
13‐
22]. Finally, the last pregnancy planned was negatively and significantly associated with the non-utilization of institutional delivery. Mothers who planned their last pregnancy were 60% less likely to practice non-institutional delivery compared to the opposite 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. No previous literature indicated an association between the last pregnancy plan and non-institutional delivery practice [
13‐
22]. The main strength of the study was that, being community-based; it could reflect the experiences of the women during the study period. The limitation of the study was that it included mothers who gave birth one year prior to the survey, which might result in a recall bias.
Conclusion
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. Respondents’ occupation, last pregnancy planned, place of previous delivery, ANC follow-up, and knowledge of labor and delivery complications were associated factors. So, we strongly recommend that all stakeholders, such as health extension workers, health care providers, the district health office, and the district city administration, take immediate strategic actions to reduce the prevalence of non-institutional delivery and work more on the main reasons and factors that increase the practice of non-institutional delivery. Furthermore, actions aimed at maternal health education, encouraging ANC visits for pregnancy planning, and raising awareness about labor and delivery complications were critical to address for women giving birth outside of health facilities.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.