This study examined the factors associated with health facility delivery in Ugandan women. We found that almost 80% of the women gave birth from a health facility. This proportion is higher than national studies that have used similar DHS survey data in Kenya , Indonesia , Ghana and in other regional studies done in South Sudan , Kenya  and Ethiopia . Studies that showed a lower proportion of health facility utilization during childbirth compared to our study were done earlier than our study (2011–2014) except Tongun et al. in South Sudan  which could partly explain the lower proportions since health facility utilization during childbirth has been shown to increase with time. Furthermore, the differences in the health facilities’ access, health system capacity and economic development among these Countries could also explain the observed differences. The significantly low proportion of health facility utilization during childbirth (25%, lowest in the region) shown by Tongun et al. in South Sudan could be attributed to the fact that the study was done when the country was experiencing insecurity due to the civil unrest which negatively affected health facility access and led to destruction of infrastructure . South Sudan received independence from Sudan nine years ago and it is still grappling with a weak health infrastructure and system.
Wealth index, residence, level of education, ANC attendance, age and region were positively associated with health facility delivery utilization. Women belonging to higher wealth quintiles were more likely to give birth from a health facility compared to those in the poorest wealth quintile. Given that Uganda has free health care services , our results suggest that, apart from the cost of health services, other economic factors play a key role in influencing the decision-making regarding the place of delivery. This is consistent with findings from other studies have reported economic factors such as transportation costs, and miscellaneous fees paid for healthcare to influence the women’s decision regarding the place of childbirth [17, 24]. Hence there is a need for gaining a deeper understanding of how financial status influences women’s decisions regarding choice of place of childbirth. Women belonging to the lower wealth quintiles are more likely to have difficulties in meeting transport and indirect costs related to childbirth in government facilities which prevents them from utilizing health facilities for childbirth  and this is further worsened by the high costs of private health facilities . Wealth index has also been shown to be a predictor of health facility deliveries in previous studies done in Kenya, Ghana and South Sudan [2, 5, 7, 17, 22].
Urban women were more likely to give birth from a health facility compared to rural women. Urban areas usually have more and better health facilities than rural areas hence easier accessibility of these facilities by urban women unlike rural women who have to cover longer distances to access maternal services, thus ending up giving birth at home [17, 21, 25]. This proximity of health facilities in urban areas ensures better quality of maternal health services through quick referrals and easier use of multidisciplinary teams . In addition, women in urban areas are usually more financially stable, and have more access to media promoting good maternal health [17, 25]. Place of residence has been shown in other studies done in Indonesia, Ethiopia, Nigeria, Kenya and Ghana [5, 13, 17, 21, 25, 26] to influence choice of place of childbirth. With this evidence regarding the association between residence and place of childbirth, the government efforts should prioritize improving rural health services in Uganda
Women with secondary and post-secondary education were more likely to give birth from a health facility compared to women with no education. Women with higher levels of education have been shown to have better maternal health literacy, be more receptive to new health related information, increased awareness of available health resources, better decision-making abilities and more financial resources and access to health insurance, which factors have been shown to increase institutional deliveries [2, 22, 27, 28]. With improved maternal health literacy, women become more informed about maternal health care issues which enables them to make positive health care decisions . Maternal education as a predictor of health facility utilization during childbirth has also been evidenced within several other studies [2, 7, 17, 22, 23, 29]. Therefore. the government of Uganda needs to intensify girl child education to atleast secondary level and also improve or start maternal health programs targeting the less educated women.
Women who had attended antenatal care were more likely to utilize health facilities for childbirth compared to those who had not attended antenatal care. Visiting of health facilities for antenatal care ensures that the women get health education sessions regarding the benefits of institutional delivery and creates rapport between the health workers and the pregnant women [7, 22, 30]. The health education and counselling sessions during antenatal care visits also ensures that women make birth preparedness and complication readiness plans which contributes to increased health facility utilization during childbirth . Antenatal care attendance has also been shown to be a predictor of health facility utilization during childbirth in studies done in similar contexts [7, 8, 22, 23, 29].
Younger women were more likely to utilize health facilities during childbirth compared to their older counterparts. Older women tend to have more traditional cohorts hence can easily resist modern health care services [28, 31], and some tend to have a sense of having gained enough experience when it comes to childbirth, hence have less fear for negative pregnancy outcomes associated with home delivery [32, 33]. Age as a predictor of health facility utilization during childbirth has also been evidenced within several other studies [5, 28, 33–35].
Women from the Northern region were more likely to utilize health facilities during childbirth compared to those in the Central region. This is a surprising finding because the central region is more advanced with a high concentration of health facilities and health care workers. However, our finding is similar to that of Rutaremwa et al. who analyzed the utilization of maternal health services with the 2011 UDHS data . Rutaremwa et al. using Kampala as the reference showed that even if the other four regions were less likely to utilize maternal health services compared to Kampala, Northern region had the highest likelihood of utilizing the desirable maternal health services package compared to the Central, Western and Eastern regions . The differences in health facilities’ accessibility, sociocultural context and economic development contribute to the observed regional differences in utilization of health facility at birth . Following the civil war, the Northern region has had many interventions and humanitarian aid mainly targeting maternal health services improvement . The other possible explanation could be that many people were residing in internally displaced peoples’ camps and these usually have health facilities provided freely near the camps . However, further research is needed to explore the increased utilization of health facilities at birth in Northern Uganda. Region as a predictor of health facility delivery has been shown in studies done in similar contexts [5, 13, 33].