Delivery assisted by skilled providers is the most proven intervention in reducing maternal mortality and one of the targets of United Nations’ (UN) Sustainable Development Goals (SDG) (23). This community-based study identified very important determinants that are related to skilled birth attendant utilization among study subjects. The findings of the study revealed that the proportion of women who delivered in the facility assisted by skilled birth attendant was 51.8%. This finding is higher than study conducted in different parts of Ethiopia (17, 19, 24, 25). This might be because of increasing in functions of multipurpose health extension workers on improvements in ANC follow up and facilitating a referral services to HCs and hospitals for delivery service assisted by skilled healthcare provider. Health extension workers improved the utilization of maternal health services including skilled birth attendance delivery by bridging the gap between communities and health facilities (26). However, it was lower than study conducted in rural southern Ghana where 68.8% mothers were assisted by skilled person during their last delivery (27). The difference could be explained by the fact that women in those countries had better socio-economic status.
In this study, place of residence was statistically significant and negatively associated with outcome variable. The result showed that mothers who lived in rural area were less likely to utilize skilled birth attendant than those who lived in urban area. This finding is supported with studies conducted in different regions of the country (17, 19, 22, 25, 28–30). The possible reason might be prevailing of traditional thinking/views, presence of low education and income, lack of awareness on maternal health services like ANC, birth preparedness and complication readiness, remoteness/lack of transportation to the health facility for mothers in rural than urban area (31). History of still birth was another predictor of utilization of SBA. This study revealed that mothers who had previous history of still birth were more likely to utilize SBAs than mothers who didn’t have still birth. The finding from cross-sectional survey conducted in Dembecha district of Northwest Ethiopia shows the negative association (24). The possible reason might be the fact that ladies who had still birth in their life time may have a fear to develop the complication during the delivering of their child and prefer skilled provider to give birth in the health facility.
Older women were more likely to give birth assisted by skilled birth attendants than young women. This finding is similar with study done in rural residents of Southern Ghana (27). However, the finding opposes other studies conducted in Raya district of North Ethiopia and Ghana which found as young women were more likely to utilize SBA than older women (19, 32). This might be older women were able to consider that giving birth at home is risky as they had experienced previously and they might get additional information regarding risk of home delivery with TBAs during different visits (child care, immunization services and etc) to health facilities. The higher age of women can influence their status in the society which has been found to increases the ability of decision making (33).
Mothers’ educational status was other predictor of utilization of skilled birth attendant which was statistically significant. Mothers who had ability to read and write as well as mothers who learned secondary and above were more likely to utilize SBA than those who were unable to read and write. This finding is consistent with report from EDHS 2016 which found strong correlation between mothers’ educational status and skilled birth attendant delivery. EDHS 2016 found 17% of births to mothers with no education were assisted by a skilled provider as compared to 93% and 92%, respectively of births to mothers with more than a secondary education (16). This might be because of educated women are likely to make their own healthcare decisions more and seek proper health care than their counterparts. In this study, parity was negatively associated with SBA utilization.
Maternal occupation is an important predictor of utilization of SBAs. The study showed that both the government employees and merchants were more likely to utilize skilled birth attendance delivery than house wives. It was supported by study conducted in Northern Ethiopia and rural area of southern Ghana, which showed an important association between occupational status of mothers and utilization of SBA delivery (19, 21). Mothers with government employed husband were also more likely to utilize skilled birth attendance delivery than farmers. This finding was supported with study done in Gamo Gofa zone, southern Ethiopia (20). The possible reason might be due to the fact that those government employee and merchant ladies and their husbands might have more income and awareness for identifying skilled provider and place of delivery, searching for money for incurred costs, finding transportation, and other things which may contribute to home delivery.
In this study, it was found that ANC visit during last pregnancy of the respondents was significant with utilization of skilled birth attendance delivery. Women who had ANC visit with skilled professional during their last pregnancy were more likely to deliver in health facility with skilled birth attendant than those who had no visit. This finding was also supported with the report from EDHS of 2011 and other studies conducted in different part of Ethiopia (17, 19, 28, 34). This might be women during Antenatal care (ANC) follow up can obtain counseling services on birth preparedness including place of delivery and selection of birth attendant and complication readiness. Antenatal care (ANC) from a skilled provider is important to monitor pregnancy and reduce morbidity and mortality risks for both the mother and child during pregnancy, delivery, and the postnatal period so that those mothers who had history of ANC follow up can easily give attention to deliver in the HF with SBAs (16).
Knowledge regarding health problems during pregnancy and child birth was other important predictor of skilled birth attendance delivery. Those respondents who had knowledge were more likely to utilize skilled birth attendance delivery as compared to those who didn’t have knowledge on danger sign of pregnancy and child birth. It is consistent with studies conducted Raya district of North Ethiopia and Gura Dhamole Woreda, Bale zone, southeast Ethiopia (17, 19). Women can take action by seeking appropriate health care by recognizing danger signs during pregnancy which can help them to deliver in the health facility with skilled birth attendant (35).
Moreover, Final decision maker about place of delivery in last pregnancy was another important predictor which is significantly associated with utilization of skilled attendant delivery. Respondents who jointly (both wife and husband) decided about place of delivery were more likely to utilize SBA delivery as compared to respondents who decided herself about place of delivery. This finding is supported with different studies conducted(17, 19, 24, 28, 36). If women are encouraged by husbands, they would also get financial and other social supports to go to health facility which will allow them to have health provider assisted delivery (37). In contrast to this, studies conducted in western Ethiopia have showed that women whom the decision on place of delivery made by themselves were two times more likely gave birth in health institution with SBA compared to mothers whom decision made by others on place of delivery(38).
Limitations Data was collected from mothers about their experience since 24 months that might lead to a recall bias. Due to the cross-sectional study design, no causal inferences can be made regarding the temporal association between the potential factors and utilization of SBAs