Delay in Making Decision to Seeking Care on Institutional Delivery and Associated Factors Among Mothers Who Gave Birth in South Gondar Zone Hospitals,2020. A Cross-sectional Study

Background: Delay to making decision to seeking care contributes to high maternal mortality and morbidity in developing countries. Major factor that contribute to maternal death in developing countries is decision-making to seek care. This study aimed at assessing the prevalence and associated factors of delay in making decision to seeking care on institutional delivery among mothers who gave birth in South Gondar zone hospitals, Ethiopia, 2020. Methods: An institution-based cross-sectional study design was conducted from September1-October30/2020 with 650 mothers were participated in this study using a systematic random sampling technique. Data were collected using a face-to-face interview with pretested semi-structured questionnaires Bi-variable and multi-variable analyses conducted and the Odds ratio with 95% CI was estimated to identify factors of delay to making decision to seeking care. The statistical signicance was declared at p < 0.05. Results: Delay in making decision to seeking care on institutional delivery was found to be 36.3% (95%CI=32.6 to 40.1). The mean age of the respondents was 27.23 with a standard deviation of 5.67. Mothers who reside in rural area (AOR=3.14,95%, CI:2.40-4.01), uneducated mothers (AOR= 3.62, 95%, CI:2.45-5.52), unplanned of pregnancy (AOR: 2.01, 95% CI: 1.84-7.96), and no health facilities in Keble (AOR: 1.62, 95% CI: 1.43-6.32) were statistically associated with delay to making decision to seeking care. Conclusion: One in three delivered mothers had been delayed in making decision to seek care in South Gondar zone. Pregnant mothers living in the rural area, unplanned of pregnancy, uneducated mothers, no health facilities in Keble Therefore, strategies to identify determinants and reduced of delay in making decision to seek care.


Introduction
Delay in making decision to seeking care on institutional delivery refer to the time to deciding to seek emergency care which is happen at the family unit and community level and re ect in deciding to seek care for pregnancy complications [1][2][3] Globally, maternal mortality and morbidity are an alarming public health issue and devastating effect on their children, her family, and her community [1,2] Different study in the world, sub-Saharan Africa and Ethiopia showed that mothers who have experienced delay in making decision to seeking care have faced a number of health problems for both the mother and neonate such as antepartum hemorrhage, premature rupture of membrane, postpartum hemorrhage, uterine rupture [4][5][6][7].
Several factors have been identi ed as barriers to pregnant mothers including access to early and competent care with skilled birth attendants, optimally in a health facility. Research reports that factors associated with women not seeking health facility care include perceived inequality of care received, an inadequate number of skilled health professionals, geographical inaccessibility, and disrespectful service delivery by health care providers. Factors related to accessing skilled health care include a woman's awareness of pregnancy danger signs that require emergent and competent health care management.
Women who do not have autonomous decisions making concerning their health care additionally are challenged by family restricting access to timely emergency maternity care [6,[8][9][10][11][12].

Method Study design and period
Health facility-based cross-sectional study was conducted from September 1 to October 30/ 2020G.C in South Gondar zone hospitals, Northwest Ethiopia.

Study area
The study was conducted in the South Gondar zone hospitals located in the Amhara Region, Northwest, Ethiopia. Debre Tabor is the capital city of the zone which is found 103kilometers away from Bahir Dar (the capital city of Amhara Regional State) and about 667 Kilometers away from Addis Ababa (the capital city of Ethiopia). According to a report from the south Gondar zone administrative o ce, the population of this zone is 2,609,823. Females number 1304,911 in this zone, With the majority who are economically dependent on agriculture. There is one Referral Hospital and seven additional governmental hospitals (Mekane-Eyesus, Andabet, Nifas-Mewucha, Addis-Zemen, Tach Gait, Wogeda, and Event). The zone has 96 public health centers, 140 private clinics, and 403 health posts.

Source population
All mothers who gave birth in South Gondar zone governmental hospitals in 2020.

Study population
All mothers who gave birth in South Gondar zone selected hospitals during a data collection period.

Inclusion criteria
All mothers who gave birth among selected hospitals and resided in the study area.

Exclusion criteria
Mothers who were admitted before the onset of labor for follow up in the waiting room.
Mothers who were not living in the study area for less than six months.

Study variables
Dependent variable: Delay in making decision to seeking care on institutional delivery Independent variables: socio-demographic characteristics; age, residence, marital status, ethnicity, religion, education of the mother, education of husband, occupation of the mother, occupation of husband, family income. Obstetrics related factors; gravidity, parity, ANC follow up, type of pregnancy, mode of delivery in the past, the current mode of delivery. Health facility factors: available health facility, the distance of health facility, means of transportation, previous pregnancy birthplace, know any danger signs of labor, and decision-maker for EOC [13,14].

Operational de nition
Institutional delivery utilization: when a mother gave birth at a health.
Delays of the decision to seeking care: refers to the time taken greater than one hour to decision seek care after the onset of labor [14].

Sample size determination
The sample size was determining using a single population proportion formula by using the following assumptions: the proportion of delay in making decision to seeking care was 26.2% [7], 5% margin of error and 10% non-response rate and design effect of 2 with the nal required minimum sample size estimated to be 653.

Sampling Procedure and Technique
The total sample size was proportionally allocated for ve randomly chosen hospitals as a cluster from eight hospitals in the south Gondar zone. For each hospital, the rst participant selected randomly; then, the subsequent participants were selected by a systematic sampling technique every two interval for each hospital.

Data collection techniques
The data were collected through face -to-face interview with postpartum mothers in private room before discharge. Five diploma Midwives for data collection and two Midwifery professionals for supervision were recruited. The questionnaires were prepared in English, and then translated to Amharic (local language) for simplicity and back to English to maintain consistency of the tool.

Data quality assurance
The questionnaire was pretested to check participant response, language clarity, and appropriateness of the questionnaires. A pretest was conducted on 5% out of the study area called koladiba hospital. At the end of the pretest, ambiguous and culturally sensitive questions were amended, clari ed adjusted before data collection began. One-day training was given for data collectors and supervisors to clarify the purpose of the study and techniques of data collection. The collected data were checked daily for its completeness and consistence. The collected data were kept locked in a le cabinet accessible only for the researchers.

Data Processing, Analysis, and Interpretation
The data were coded and entered into Epi-data version 3.1. Then it was exported to Statistical Package of Social Science (SPSS) version 20.00 for data checking, cleaning, and analysis. Descriptive statistics were performed on numerical value, frequencies, mean, proportion to describe the study population about dependent and independent variables. The results of the study were presented in the text, and tables. Binary logistic regression was used to identify statistically signi cant independent variables, and independent variables having a p-value of less than 0.2 were entered to multivariable logistic regression for further analysis and to adjust for confounding variables. The Adjusted Odds Ratio (AOR) was used to identify determinant variables for delays to institutional delivery service with 95% con dence interval at Pvalue < 0.05.

Results
Socio-Demographic Characteristics of the Respondents: A total of 650 mothers participated in the study with a response rate of 99.54%. About 78.6% were found in the age group 20-34 years. Around 34.5% of participants were living in the rural area, and 96.8% were orthodox Christianity religion followers. Of the study participants, 20.6% were housewives. From the participants, 29.4% unable to read and write, and 37.5% husbands of the respondents had college and above educational levels ( Table 1).   Factors of delay in making decision to seeking care on institutional delivery: Bi-variate analysis was done to assess any relation between independent variables and delay in making decision to seeking care on institutional delivery. In bivariate analysis, residence, education status of the mothers, occupation status of the mothers, ANC visit, planned of pregnancy, number of children, time of labor onset, the distance from home to health institution, and the health facility in the Keble were considered statistically signi cant with delay in making decision to seeking care on institutional delivery. Multi-variable logistic regression analysis showed that participants who reside in rural area were 3.14 times more likely delay in making decision to seeking care on institutional delivery than who lives in urban (AOR = 3.14,95%, CI:2.40-4.01). Likewise, respondents uneducated mothers were 3.62 times more likely delay in making decision to seeking care on institutional delivery than those who did educated mothers (AOR = 3.62, 95%, CI:2.45-5.52), Respondents who had no planned of pregnancy were 2.01 times more likely delay in delay in making decision to seeking care on institutional delivery than those who had planned pregnancy (AOR: 2.01, 95% CI: 1.84-7.96), and those who had no health facilities in Keble were 1.62 times more likely delay in making decision to seeking care on institutional delivery than who had health facilities in Keble (AOR: 1.62, 95% CI: 1.43-6.32) ( Table 4).

Discussion
In this study reveals that two hundred thirty-six (36.3%) with (95%CI = 32.6 to 40.1) of interviewed case made a delay in making decision to seeking care on time for institutional delivery. This was consistent with a study conducted in Hadiya zone (40.1%), [6]. However, delay in making decision to seeking care for institutional delivery was lower than other studies conducted in Dawuro zone42%, [3]. The possible explanation might be due to the difference in the socio-cultural characteristics of the study participants and study designs.
On the other hand, the current study nding was higher as compared to the study conducted in Arsi zone [7], and North Showa [15] where 26.2% and 23.1% respectively. The possible reason might be due to a lack of awareness of mothers and the family as a whole for danger signs of pregnancy. Because 29.4% of the mothers and 21.5% of her husband are unable to read and write in this study. In addition to this, in the current study, 34.5% of informants were rural in residency and are living in poor socioeconomic status. This may affect their delivery service utilization and can contribute the proportion to be high. The other possible reason might be due to bad road construction, long distance of health institutions from their home, and lack of transportation. It might be also due to case overload. Lastly, it might be due to the lack of skill of health care providers and disrespectful service delivery system.
The current study demonstrated that rural residency was found to be a statistically signi cant predictor of the outcome variable. Those mothers who are living in a rural area were more than three times more likely prone to delay in making decision to seeking care for institutional delivery than those who are living in the Urban. This nding is supported by studies conducted in the Dawuro zone [3]. The possible reason might be due to lack of women empowerment for early decision-making autonomy, poor physical access to health facilities that provide safe delivery service, poor road construction, and lack of access to health education regarding complications that would happen during labor and delivery. Rural women are more commonly in uenced by cultural norms. These restrictive socio-cultural norms may hurt the utilization of maternal health care services. On the contrary, urban women are more aware and accessed information concerning the bene ts of health facility delivery through different media. So they are less likely to prone to delay in making decision to seeking care for institutional delivery.
The analysis also showed that uneducated mothers were more than 3.62 times more likely to be delayed as compared to that of educated mothers for institutional delivery.
The result of this study revealed that mothers who had unplanned pregnancy were 2.07 times more likely to be delay as compared to those who had planned pregnancy for institutional delivery.
Lastly, the study also suggested that mothers who had no health facilities in Keble were 1.62 times more likely to prone to delay in making decision to seeking care of institutional delivery than those having health facility in the Keble.
The possible explanation might be due to a similar study design and socio-demographic characteristics of study informants across each nding.