Study area and Period
The study was conducted in Hargeisa, capital city of Somaliland from September 30th to December 31st, 2022. Somaliland is an unrecognized self-declared sovereign state that is internationally unrecognizing country, similarly, Somaliland has a borders Djibouti in northwest, Ethiopia south and west, Gulf of Aden in the north and Somalia to east, similarly, Hargeisa is a capital City of Somaliland has a population 1.3 million individuals. Hargeisa has encompassed eight main districts under their local administrative. Hargeisa had a latitude and longitude is 9°.5624” and, 44°.177” respectively and 1,334 meters (4,377 feet) of above the sea level and has a climate which is semi-arid region. Ga’an libah is among the Marodijeh region districts which located east north direction in capital city of Hargeisa, has an estimated population residencies 3588 individuals. [20].
Study design and respondents.
A Community-based cross-sectional study design was employed among mothers who gave birth in the last 12 months prior to the study period.
Population.
Source of population.
The source of population was all childbearing women who gave birth in the last 12 months in the Ga’an libah district, regardless of their birth outcome.
Study Unit.
Mothers those who living and available in Ga’an libah district particularly childbearing women who give birth in the last 12 months, regardless of their birth outcome.
Eligibility criteria.
Inclusion criteria.
All Childbearing women/mothers who gave birth in the last 12 months in the district those who were available at the time of study period in Ga’an libah district, regardless of their birth outcome. Conversely, a childbearing woman who was not living in the study area for last six months, women who difficult hearing and those who was not willing to respond were excluded from the study.
Sample size determination & Sampling procedure.
Sample size of the study was used single population proportion formula from the following assumptions, (P) 21.0% of proportions of institutional delivery service utilization in Somaliland Health and Demographic survey [4], 95% confidence interval (CI) (1.96), and 5% margin. The final sample size of study respondents was 280 including 10% of non-response rate (25).
A mother who gave birth in the last 12 months in the district, regardless of their birth outcome were in the sample. Three clusters in the Ga’an libah district were allocated sample size by using proportional allocation to the size of households found in each cluster. The Sampling was started by selecting an element from the sample frame as a simple random sampling technique. All eligible mothers who gave birth in the last 12 months were recorded as a sample frame, then mothers were upload to an excel sheet then was employed a simple random sampling technique to identify the sampling unit, then the study was follow this sample procedure. For those closed houses or the mother who was not the present at the time of data collection, a maximum of 3 repeated visits was considered, if no has taken them as non-respondents. If there may be more than one mother within the same household randomly selected house was selected one mother to include the sample.
Study Variables.
Dependent Variable:
- Institutional delivery service utilization
Independent Variables
Predisposing factors
- Maternal Age
- Partner education
- Mothers Perception to health providers
Enabling factor
- Place of residence
- Wealthy index
- Distance
- Accessible
Need Factor
- Antenatal care visit
- Delivery service utilization
- Number of ANC visit
- Type of pregnancy (Planned and Unplanned)
Data collection procedure and tools.
The structured questionnaire was used to collect data which was developed by reviewing the existing body of literature [22, 23, & 24] and the questionnaire was also piloted (Field tested) to keep the validity and reliability of the study. This pilot study was pretested in Sheik Nour community which has the same population characteristics as the target location. The data collection tool encompassed the following key sections (predisposing factors, enabling factors, and Need factors). The questionnaire was initially prepared in English and translated to the local language Somali and back translated to English and checked the consistency. The Questionnaire was pretested on 14 women (5% of the entire sample size) in the target community which has a similar context to the study areas. The data was collected by five bachelor’s degree graduate nurses and the researcher were supervised all entire study operations. Those data collectors were recruited from district administration office. One full days of training were provided to the data collectors about the objectives and data collection process by the principal investigator. The data were checked for accuracy and constancy daily by the field supervisors.
The descriptive statistic was used to compute frequencies and percentages for categorical data. bivariate logistic regression was used to determine the association between dependent and independent variables. The P-value of ≤0.2 in the bivariate analysis was entered to generate the candidate variables then will perform a multivariate logistic regression analysis to control confounders. Multivariate logistic regression analysis was performed to determine the relationship between independent variables to the outcome variable. Variables with a p-value of <0.05 was considered significantly associated with the outcome, and an adjusted odds ratio (aOR) with a 95% CI was used to interpret the results.
Data analysis and quality assurance
Data was entered, cleaned and analyzed Statistical Package for Social Science window (SPSS IBM Version 25.0) by cross checking it’s completeness, the questionnaire was firstly prepared in English and then translated in local language, which is Somali, furthermore, data was pretested by 5% of study participant with a similar characteristics district. The descriptive statistics was used to compute frequencies and percentages for categorical data. Bivariate logistic regression was done to determine the association between dependent and independent variables. The P-value of <0.2 in the bivariate analysis was entered to generate the candidate variables then was perform multivariate logistic regression analysis to control confounders. Multivariate logistic regression analysis was done to perform the determine the relation independent variables to the outcome variable. Variables with a p-value of <0.05 was considered significant associated with the outcome, and adjusted odds ratio (aOR) with a 95% CI.
Operational Definitions.
Antennal care service utilization: A women were considered to have used ANC if she were got a check by a health professional (Doctor, Nurse, and Midwife) at least once during her pregnancy. The variable was categorized into four categories: 1: NO ANC, 2: One ANC visit, 3: Two or three ANC visits, 4: fourth, and more ANC visits [25].
Maternal marital status: Current marital status of women at the time of the study. It was categorized into two groups: 0-Not married and 1-Married. Classification of this variable were developed by putting the never married, widowed, divorced, and not living together as currently not married, and putting married and living together as currently married [26].
Institutional Delivery: Institutional delivery is a delivery that takes place at any medical facility staffed by skilled delivery assistance. This variable was categorized as 1. Number of women delivered at the health facility 2: number of women delivered at home [27].
Maternal education: The highest level of education attained. This were categorized into secondary level was merged because the number of women in the highest education level was very small [28].
Wealth index: This variable in the data set were recorded into five groups, however, for this study, it was categorized into three groups by assigning the same value as that of the original variable. The three categories were Poor, Middle and Rich [29].
Place of residence: Where the women in the study lived at the time of the study. This variable was categorized into two groups and coded as 1 Urban and 2 rural.
Gravidity/ Parity: Number of pregnancies reaching viability and not the number of features delivered. This variable was categorized as the number of pregnancies without regarding its outcome. 1: Number of pregnancies Yes/No / A total number of pregnancies. This variable was categorized 1- One child, 2: Two children 3. Three children 4: fourth and more children. Respectively [30]
Utilization: This means the extent to which a given group of people uses services in a specific period. This variable was measured the number of women who received institutional delivery service utilization or did not receive any medical services at any health facility [31].
Ethical Declarations
Ethics approval and Consent to participate.
Ethical approval was received from the ethics committee or IRB Jimma University Department of health policy and Management with reference number of IHIRB/591/2022. also, Permission letter was obtained from local administration. Before the data collection, the participants were informed about the purpose of the study, their right to refuse participation and discontinue the interview. Written and Verbal consent were obtained from each participant before to interview to confirm willingness for participation. The participants were informed on the information obtained was kept confidential throughout the process of this study. Similarly, any identification information including the name of the participants were not written on the questionnaire due to confidential kept purpose.
The informed consent was verbally explained bit by bit to the illiterate participants and requested permission to proceed, if they weren’t happy, had given a rejection option. All illiterate participants gave verbal informed consent.
All study subjects, both literate and illiterate, provided informed consent. For instance; The illiterate respondents were informed verbally, and their guardians signed on their behalf, while the literate respondents signed their consent. This study was conducted ethically according to the IRB-provided criteria since Mohamoud Askar, a member of the IRB Committee, was designated as an ethical compliance checker during the study period and presented all necessary documentation with supporting data.
To maintain confidentiality, no identification information, including the names of the participants, was recorded on the questionnaire. Respecting the principles of ethics, the study followed the principles outlined in the Declaration of Helsinki, underscoring our commitment to ethical practices in human research. In addressing the local context, permission was obtained from relevant Somaliland authorities to conduct this study. This underscores our commitment to respecting the autonomy and rights of individuals involved in the study while aligning with ethical committee-approved procedures.
The study didn’t involve experimental and human sample study, likewise the study participants were given a consent/permission both verbal and written form for study respondents. The Authors had declared the study are followed the principle of Helsinki declarations and no human sample were involved.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no potential competing of interests.