Prevalence of place of birth, Socio-demographic, and reproductive characteristics of study participants
The prevalence of home delivery in Ethiopia was 52.19% (95% CI: 46.49 – 57.83). Whereas delivery at health facilities was 44.83% (95% CI: 39.57 – 50.20) and only 2.99% (95% CI: 1.68 – 5.25) mothers gave birth in the health posts.
Nearly two-thirds (62.08%) of the mothers who didn’t expose themselves to media access in their household had given birth at home. Similarly, two-third and more mothers, whose family size was greater than six members were delivered at home. Giving birth at home showed a decreasing prevalence as mothers’ level of education and the family wealth index increases.
While most (86.34%) of the mothers who hadn’t get antenatal care, gave birth at home. The majority (66.35%) of grand multiparous mothers similarly delivered at home. Almost one-third of urban and two-third of rural residents gave home birth for their most recent delivery. From the regions in Ethiopia, Afar and Somali were the most common home birth regions in the country (Table 1).
Table 1: Sociodemographic and reproductive characteristics of mothers’ cross-tabulated with the place of birth of last birth in Ethiopian, 2019
Variables
|
Place of birth
|
Health facility
Frequency (%)
|
Health post
Frequency (%)
|
Home
Frequency (%)
|
Maternal age
|
|
|
|
15 - 19 years
|
133.8 (51.11)
|
10.39 (3.97)
|
117.6 (44.93)
|
20 - 34 years
|
1809 (46.41)
|
109 (2.8)
|
1980 (50.79)
|
≥ 35 years
|
488.3 (38.63)
|
42.54 (3.37)
|
733.2 (58)
|
Media access at the household level
|
|
|
|
No
|
1241 (34.57)
|
120 (3.34)
|
2229 (62.08)
|
Yes
|
1190 (64.9)
|
41.87 (2.28)
|
601.6 (32.81)
|
Family size
|
|
|
|
1-5
|
1446 (57.91)
|
69.42 (2.78)
|
981.3 (39.31)
|
6 - 10
|
943 (34.35)
|
92.45 (3.37)
|
1710 (62.29)
|
> 10
|
42.52 (23.44)
|
.0483 (0.03)
|
138.8 (76.53)
|
Maternal educational level
|
|
|
|
No education
|
872.5 (29.96)
|
91.58 (3.14)
|
1948 (66.9)
|
Primary education
|
1062 (55.27)
|
55.08 (2.87)
|
804.2 (41.86)
|
Secondary education
|
321.8 (80.39)
|
14.1 (3.52)
|
804.2 (16.09)
|
Higher education
|
174.9 (92.32)
|
1.157 (0.61)
|
13.41 (7.07)
|
Family wealth index
|
|
|
|
Poorest
|
216.9 (16.62)
|
42.31 (3.24)
|
1046 (80.13)
|
Poorer
|
418 (35.49)
|
38.13 (3.24)
|
721.5 (61.24)
|
Middle
|
408.1 (40.13)
|
35.66 (3.51)
|
573.2 (56.37)
|
Richer
|
542.8 (58.26)
|
36.21 (3.89)
|
352.7 (37.85)
|
Richest
|
845.3 (85.19)
|
9.609 (0.97)
|
137.3 (13.84)
|
Parity
|
|
|
|
I
|
558.3 (70.74)
|
25.51 (3.23)
|
205.4 (26.03)
|
II - IV
|
1237 (48.86)
|
64.73 (2.56)
|
205.4 (48.58)
|
≥ V
|
636.1 (30.25)
|
71.67 (3.41)
|
71.67 (66.35)
|
ANC during the index pregnancy
|
|
|
|
No ANC
|
125.3 (12.59)
|
10.66 (1.07)
|
859.5 (86.34)
|
1 - 3 ANC visits
|
579.9 (48.43)
|
46.65 (3.9)
|
570.9 (47.68)
|
≥ 4 ANC visits
|
1158 (70.5)
|
420.7 (3.9)
|
420.7 (25.61)
|
Residence
|
|
|
|
Urban
|
935.7 (69.34)
|
15.19 (1.13)
|
398.6 (29.54)
|
Rural
|
1495 (36.71)
|
146.7 (3.6)
|
2432 (59.69)
|
Region
|
|
|
|
Tigray
|
2432 (70.88)
|
7.661 (2.1)
|
98.45 (27.02)
|
Afar
|
98.45 (25.74)
|
2.065 (2.41)
|
61.52 (71.85)
|
Amhara
|
535.7 (52.64)
|
22.3 (2.19)
|
459.8 (45.17)
|
Oromia
|
802.3 (36.98)
|
91.65 (4.22)
|
1276 (58.8)
|
Somali
|
94.64 (23.34)
|
0.4412 (0.11)
|
310.3 (76.55)
|
Ben Shangul
|
27.88 (44.65)
|
13.6 (21.78)
|
20.96 (33.57)
|
SNNPR*
|
498 (45.46)
|
22.48 (2.05)
|
574.9 (52.49)
|
Gambela
|
16.4 (67.95)
|
0.5951 (2.47)
|
7.143 (29.59)
|
Harari
|
10.05 (63.23)
|
0.1808 (01.14)
|
5.663 (35.63)
|
Dire Dawa
|
19.23 (66.14)
|
0 .9357 (3.22)
|
8.905 (30.64)
|
Addis Ababa
|
146.5 (95.53)
|
0 (0)
|
6.85 (4.47)
|
* Southern Nations, Nationalities, and People’s Region
Spatial distribution of home birth in Ethiopia
A clustering pattern of home birth was revealed in the global spatial autocorrelation across the EAs (Moran’s index = 0.667563, z-score = 14.541580, p-value < 0.001) (Figure 2). In addition, the ordinary kriging interpolation analysis predicted that home birth was relatively about 40% and higher in most parts of the country and more than 75% of home delivery was widely distributed in the Somali region (Figure 3).
Also, the SaTScan analysis detected a total of seven statistically significant cluster areas with a high magnitude of home birth. The most likely primary cluster areas with the highest home birth were detected in the Somali region, eastern and southern zones of Oromia region with a relative risk (RR)=1.72, and a p-value of <0.001. In addition, the most likely secondary cluster areas with a high magnitude of home birth were spotted in the central zones of Amhara and eastern zones of South Nations, Nationalities, and People’s Region (SNNPR) (Figure 4, Table 2).
Table 2: The most likely SaTScan clusters of areas with significant home birth in Ethiopia, 2019
Location IDs
|
Region (Zone [Woreda])
|
Coordinate/ radius (Km)
|
Relative risk
|
LLR
|
p-value
|
142, 141, 136, 125, 138, 143, 137, 123, 144, 134, 145, 111, 135, 133, 110, 114, 131, 103, 122, 117, 132, 183, 102, 113, 140, 106, 129, 186, 88, 89, 181, 250, 105, 248, 104, 249, 244, 247, 255, 234, 233, 241, 243, 252, 245, 246, 237, 242, 235, 107, 231, 239, 240, 236, 254, 232, 182, 185
|
Somali (Fafan, Jarar, Nogob, Shabelle, Korahe, Doolo, Liben, Afder)
Oromia (East and west Hararghe, East and west Arsi, Bale, Guji, Borena) Hareri
|
(5.479641 N, 42.196835 E) / 428.49 km
|
1.72
|
223.47
|
< 0.001
|
136, 134, 142, 138, 123, 145, 133, 137, 141, 125, 111, 131, 143, 110, 135, 122, 144, 132, 129, 106, 103, 250, 102, 248, 249, 114, 244, 247, 255, 234, 233, 241, 243, 252, 245, 246, 237, 242, 235, 107
|
Somali (Fafan, Jarar, Nogob, Shabelle, Korahe, Doolo, Liben, Afder)
Oromia (East and west Hararghe, East and west Arsi, Bale, Guji, Borena) Hareri
|
(6.459193 N, 42.199432 E) / 317.51 km
|
1.77
|
200.76
|
< 0.001
|
115, 182, 172, 186, 188, 181, 113, 184, 185, 183, 197, 187, 190, 89, 117, 178, 189, 198
|
Oromia (West Arsi, Guji, Borena)
SNNPR (Gedeo, Sidama, Wolayta, Gamo Gofa, Amaro)
|
(6.420265 N, 38.266739 E) / 104.43 km
|
1.54
|
100.72
|
< 0.001
|
80
|
Ahara (Agew Awi)
|
(10.779921 N, 36.711575 E) / 0 km
|
1.92
|
15.63
|
< 0.001
|
58, 60, 61, 83, 78, 57
|
Amhara (South Gondar, North Wollo, Wag Himra, North Gondar)
|
(11.722588 N, 38.322762 E) / 81.75 km
|
1.35
|
15.46
|
< 0.001
|
99, 100
|
Oromia (North and west Shewa)
|
(9.531226 N, 38.081684 E) / 67.38 km
|
1.56
|
13.99
|
< 0.001
|
180, 179, 177, 178, 189
|
SNNPR (Kembata Tembaro, Hadiya)
|
(7.415238 N, 37.827221 E) / 44.05 km
|
1.38
|
11.12
|
<0.005
|
Factors associated with place birth
The survey multinomial multivariable analysis identified that the relative probability of giving birth at home rather than health facility was about one and half times higher for mothers who had a family size of six to ten members than less than six members (aRRR = 1.46 (95% CI: 1.10, 1.93)). The marginal effect analysis also indicated that the probability of giving birth at home was on average five percentage (0.05 (0.01, 0.10)) points higher for mothers who had a family size of six to ten members. Whereas, the relative probability of giving birth at health post rather than health institution was 0.02 (aRRR = 0.02 (95% CI: 0.003, 0.20)) for mothers who had a family size greater than ten than less than six members implies that the probability of giving birth at health post on average three percentage (-0.03 (95% CI: -0.04, -0.009)) points lower for mothers who had largest family size than lowest family size.
The family wealth index was also found to be a predictor for a home birth. As compared to the richest family, the relative probability of giving birth at home rather than health facility among mothers was about two times higher for richer aRRR 2.13 (95% CI: 133., 3.43), more than four times higher for the middle (aRRR = 4.29 (95% CI: 2.68, 6.89)) and poorer (aRRR = 4.60 (95% CI: 2.70, 7.85)), and ten times higher for poorest (aRRR = 10.08 (95% CI: 5.66, 17.98)) family. As shown by the marginal effect analysis, the probability of giving birth at home among mothers was higher at 12 percentage points for richer, around 25 percentage points for middle and poorer families. Whereas, home birth was 38 percentage points higher for the poorest family.
In addition, the relative probability of giving birth at home rather than health facility was nearly twice higher for multiparous (aRRR = 1.95 (95% CI: 1.20, 3.15)) and grand multiparous (aRRR = 1.93 (95% CI: 1.08, 3.43)) mothers than primiparous mothers. The marginal effect analysis also revealed that the probability of giving birth at home was about ten percentage points higher among multiparous and grand multiparous than primiparous mothers.
Moreover, as compared to mothers who attended four and more antenatal care visits, the relative probability of giving birth at home rather than at a health facility was more than one times (aRRR = 1.59 (95% CI: 1.22, 2.07)) higher for mothers who attended less than four antenatal care visits and over six times (aRRR = 6.31 (95% CI: 4.27, 9.32)) higher for mothers who didn’t attend antenatal care during the index pregnancy. In the marginal effect analysis, the probability of giving birth at home was eight percentage points higher among mothers who attended less antenatal care visits and 30 percentage points higher among mothers who didn’t attend antenatal care than who attended four and more antenatal care visits. Likewise, the probability of giving birth at health posts on average two percentage (-0.02 (95% CI: -0.04, -0.001)) points lower for mothers who didn’t attend antenatal care.
Similarly, the relative probability of giving birth at home rather than health facility was more than two times (aRRR = 2.25 (95% CI: 1.20, 4.20)) higher among mothers who residing in the clusters in which 51 - 74% of mothers attended 4+ antenatal care visits than those residing in the clusters of ≥ 75% 4+ antenatal care visits coverage. And it was about five times (aRRR = 4.88 (95% CI: 2.40, 9.9)) higher among mothers who residing in the clusters in which 25 – 50% of mothers attended 4+ antenatal care visits and about seven times (aRRR = 749 (95% CI: 3.54, 15.85)) higher among mothers who residing in the clusters in which < 25% of mothers attended 4+ antenatal care visits as compared to those who residing in the clusters of ≥ 75% 4+ antenatal care visits coverage. The marginal analysis also showed that the probability of giving birth at home was 37 percentage points higher among mothers who residing in the clusters in which < 25% of mothers attended 4+ antenatal care visits, 30 percentage points higher among mothers who residing in the clusters in which 25 – 50% of mothers attended 4+ antenatal care vists, and 14 percentage points higher among mothers who residing in the clusters in which 51 – 74% of mothers attended 4+ antenatal care visits as compared to mothers who residing in the clusters in which ≥ 75% of mothers attended a coverage of 4+ antenatal care visits (Table 3).
Table 3: Survey multinomial multivariable analysis of factors associated with place of delivery in Ethiopia, 2019
Variables
|
Place of birth (the base outcome is Health facility)
|
Home
aRRR (95% CI)
|
Home
Marginal effect (95% CI)
|
Health post
aRRR (95% CI)
|
Health post
Marginal effect (95% CI)
|
Maternal age
|
|
|
|
|
15 - 19 years
|
1
|
1
|
1
|
1
|
20 - 34 years
|
1.22 (0.66, 2.26)
|
0.04 (-0.06, 0.13)
|
0.69 (0.19, 2.57)
|
-0.02 (-0.07, 0.04)
|
≥ 35 years
|
0.88 (0.46, 1.69)
|
-0.01 (-0.11, 0.09)
|
0.54 (0.10, 2.82)
|
-0.02 (-0.08, 0.04)
|
Media access at the household level
|
|
|
|
|
No
|
0.95 (0.69, 1.32)
|
-0.01 (-0.06, 0.04)
|
1.13 (0.54, 2.37)
|
0.004 (-0.01, 0.04)
|
Yes
|
1
|
1
|
1
|
1
|
Family size
|
|
|
|
|
1-5
|
1
|
1
|
1
|
1
|
6 - 10
|
1.46 (1.10, 1.93) *
|
0.05 (0.01, 0.10) *
|
1.44 (0.85, 2.43)
|
0.005 (-0.009, 0.02)
|
> 10
|
1.61 (0.77, 3.36)
|
0.09 (-0.03, 0.19)
|
0.02 (0.003, 0.20) *
|
-0.03 (-0.04, -0.009) *
|
Maternal educational level
|
|
|
|
|
No education
|
3.39 (0.84, 13.67)
|
0.19 (-0.04, 0.42)
|
3.48 (0.44, 27.39)
|
0.02 (-0.02, 0.05)
|
Primary education
|
1.92 (0.51, 7.28)
|
0.09 (-0.12, 0.31)
|
2.44 (0.31, 19.40)
|
0.01 (-0.02, 0.05)
|
Secondary education
|
1.16 (0.28, 4.89)
|
0.01 (-0.22, 0.24)
|
3.79 (0.38, 37.65)
|
0.04 (-0.03, 0.09)
|
Higher education
|
1
|
1
|
1
|
1
|
Family wealth index
|
|
|
|
|
Poorest
|
10.08 (5.66, 17.98) **
|
0.38 (0.27, 0.49) **
|
7.72 (1.14, 52.22) *
|
0.03 (-0.02, 0.08)
|
Poorer
|
4.60 (2.70, 7.85) **
|
0.26 (0.16, 0.35) **
|
3.33 (0.60, 18.41)
|
0.01 (-0.02, 0.05)
|
Middle
|
4.29 (2.68, 6.89) **
|
0.25 (0.16, 0.34) **
|
2.99 (0.59, 15.16)
|
0.01 (-0.02, 0.04)
|
Richer
|
2.13 (1.33, 3.43) *
|
0.12 (0.04, 0.20) *
|
2.72 (0.59, 12.51)
|
0.02 (-0.01, 0.04)
|
Richest
|
1
|
1
|
1
|
1
|
Parity
|
|
|
|
|
I
|
1
|
1
|
1
|
1
|
II - IV
|
1.95 (1.20, 3.15) *
|
0.10 (0.03, 0.18) *
|
1.21 (0.58, 2.51)
|
-0.002 (-0.03, 0.02)
|
≥ V
|
1.93 (1.08, 3.43) *
|
0.09 (0.008, 0.19) *
|
1.71 (0.66, 4.45)
|
0.008 (-0.02, 0.04)
|
ANC during the index pregnancy
|
|
|
|
|
Data not available
|
1.93 (1.48, 2.52)
|
0.11 (0.07, 0.16)
|
1.08 (0.58, 2.00)
|
-0.007 (-0.02, 0.01)
|
No ANC
|
6.31 (4.27, 9.32) **
|
0.30 (0.24, 0.37) **
|
1.22 (0.39, 3.72)
|
-0.02 (-0.04, -0.001) *
|
1 - 3 ANC visits
|
1.59 (1.22, 2.07) **
|
0.08 (0.03, 0.12) *
|
1.24 (0.71, 2.17)
|
-0.0002 (-0.02, 0.02)
|
≥ 4 ANC visits
|
1
|
1
|
1
|
1
|
Residence
|
|
|
|
|
Urban
|
1
|
1
|
1
|
1
|
Rural
|
0.78 (0.39, 1.59)
|
-0.05 (-0.15, 0.06)
|
2.91 (0.77, 11.02)
|
0.02 (-0.002, 0.05)
|
The poverty level of the community
|
|
|
|
|
Low
|
1
|
1
|
1
|
1
|
High
|
0.79 (0.49, 1.26)
|
-0.04 (-0.11, 0.03)
|
1.47 (0.54, 4.04)
|
0.01 (-0.01, 0.04)
|
Community media inaccessibility
|
|
|
|
|
Low
|
1
|
1
|
1
|
1
|
High
|
1.02 (0.69, 1.52)
|
0.01 (-0.05, 0.07)
|
0.64 (0.27, 1.53)
|
-0.01 (-0.04, 0.01)
|
Illiteracy level of the community
|
|
|
|
|
Low
|
1
|
1
|
1
|
1
|
High
|
0.82 (0.56, 1.21)
|
-0.02 (-0.08, 0.03)
|
0.64 (0.28, 1.46)
|
-0.01 (-0.03, 0.01)
|
≥ 4 ANC use at the community level (cluster level coverage)
|
|
|
|
|
< 25%
|
7.49 (3.54, 15.85) **
|
0.37 (0.23, 0.51) **
|
0.46 (0.09, 2.39)
|
-0.05 (-0.12, 0.02)
|
25 – 50%
|
4.88 (2.40, 9.89) **
|
0.30 (0.16, 0.43) **
|
0.59 (0.17, 2.03)
|
-0.04 (-0.11, 0.02)
|
51 – 74%
|
2.25 (1.20, 4.20) *
|
0.14 (0.03, 0.26) *
|
1.17 (0.32, 4.33)
|
-0.01 (-0.08, 0.06)
|
≥ 75%
|
1
|
1
|
1
|
1
|
** p-value < 0.001, * p-value < 0.05 Bold font: Statistically significant variables and categories