Utilization of Institutional Delivery Service and Associated Factors among Women of Child Bearing Age in Bule Hora Town, West Guji Zone, Oromia Regional State, Ethiopia. Community Based Cross- Sectional Study Design, 2018

Background:-Globally at 303,000 women childbirth and approximately 830 women from preventable causes to childbirth. Although institutional delivery has been in The aim of this study was to assess utilization of institutional delivery service and associated factors among women of childbearing age in Ethiopia Methods: - Community-based cross-sectional study design with quantitative methods of data collection was employed from February 01 to March 30/2018. A total of 360 childbearing mothers in the Bule Hora town were involved in the study using a systematic sampling method. The instrument was pre-tested on 5% the sample at Gerba town. The data were analyzed by using binary and multivariable logistic regression and statistical associations were measured using odds ratio and 95%CI. Results: - The prevalence of utilization of institutional delivery services in Bule hora town is 72%. According to this finding age at first pregnancy (AOR: 2.08, 95%CI: 1.768-5.620), educational status of mothers who attended secondary school and above (AOR: 4.613, 95%CI: 1.096-11.912) and primary school attended mothers (AOR:3.18, 95%CI: 2.406-3.443), educational status of husbands who attended secondary school and above (AOR: 4.91, 95%CI: 10.792-30.441)and primary school attended (AOR: 2.13, 95%CI: 8.359-12.616), spousal communication about place of delivery (AOR: 4.27, 95%CI: 1.823-10.004), husbands occupations (AOR: 2.94, 95%CI: 2.734-5.137), current antenatal care (AOR: 46.74, 95%CI: 16.778-30.210), and parity three and less children (AOR: 6.97, 95%CI: 1.305-37.212 a strong statistical association with utilization

of institutional delivery service. Conclusions: -The finding shows the utilization of institutional delivery service in Bule Hora town is higher than a national figure but lower than the national target of skilled delivery. Policymaker and health institutions should have to strength and create awareness of the community on the importance of institutional delivery and use of ANC service in order to screen and detect early signs of disease, followed by timely intervention.

Background
Globally in 2015, roughly 303,000 women died during pregnancy and childbirth and every day, approximately 830 women die from preventable causes related to pregnancy and childbirth (3). Maternal mortality is the global health indicator with the largest disparity between developed and developing countries. The survival, health and well-being of women's are essential to ending extreme poverty, promoting development, achieving the global strategy and sustainable development goals (9).
The average global target is to reduce maternal mortality to less than 70 per 100,000 live births and no country should have an MMR greater than 140/100 000 live births by 2030 and to reduce new born mortality to at least as low as 12 per 1,000 live births in every country (10). The estimated lifetime risk of maternal mortality in high-income countries is 1 in 3300 in comparison with 1 in 41 in lowincome countries and in countries designated as fragile states, the estimated lifetime risk of maternal mortality is 1 in 54 (11).
Although widespread progress has been made in recent decades, in Africa 50 percent of women give birth without a skilled attendant and the average coverage of births with a skilled attendant on the continent has not increased significantly (12). Most maternal deaths occur during labor and delivery, or the first 24 hours postpartum, and most complications cannot be predicted or prevented. Nearly 75% of all maternal deaths on the continent are attributable to the complications of pregnancy and childbirth like severe bleeding, infections, high blood pressure during pregnancy and other complications from delivery and unsafe abortion. The remaining 25% are caused by associated with diseases such as malaria, and HIV/AIDS during pregnancy. Ethiopia is one of the highest maternal mortality ratios.
In order to minimize this national target is to reduce to 199/100,000 (13), But in 2016 maternal mortality ratio was 412 deaths per 100,000 live births (1).
In Ethiopia twenty-six percent of live births were delivered in a health facility that is far lower than in other neighboring African countries, such as Egypt 87% in 2014, Eritrea 34% in 2010, Djibouti 87% in 2012, Kenya 61% in 2014, Sudan 28% in 2014 and Somalia 9% in 2006 were delivered in a health facility. Institutional deliveries for women living in rural areas of Ethiopia has substantially increased in the last 16 years, from 2% in 2000 to 20% in the 2016 EDHS and among urban women has also increased from 32% in 2000 to 79% in 2016. The national target of skilled delivery is 90% (13) but the achievements were 28% of births delivered by a skilled provider. The majority of births are attended by traditional birth attendant (42%), nurses or midwives (20%) followed by doctors (6%), health extension workers (2%), and health officers (0.4%) (1,14).
Institutional delivery service utilization and deliveries attended by skilled provider in Oromia were 19 and 20 percent respectively, which are far less than 57 and 59 percent institutional delivery and deliveries attended by skilled providers in Tigray region (1). In order to achieve global strategies and sustainable development goal it needs to identify facilitators and barriers of institutional delivery (13). Therefore, this community based cross-sectional study was conducted to determine the magnitude of institutional delivery and factors determining place of deliveries and proposed to fill this information gap in west Guji zone with the potential of generalizability of its result to similar settings ( Figure 1).

Methods
The study was conducted from February 01 to March 30/2018 in western Guji zone in Oromia Region, Ethiopia. It is found 467 Km a long way from Addis Ababa toward the south direction at 5°35′ N Latitude and 38°15′E Longitude. A Community based cross-sectional study design with quantitative techniques for information gathering was utilized. The source populations were all women of childbearing age who gave birth over the most recent two years preceding the time of data collection in Bule Hora town. Inclusion criteria were women who gave birth in the last two years and resident in the area for at least 6 months available during data collection period were included and women who gave birth in other places but living in the study area at the time of data collection and critically ill, cannot talk or listen were excluded.
The determined sample size was 360 childbearing women by utilizing single population proportion, considering the prevalence of institutional delivery service utilization 57% (25), a margin of error 5%, 95% confidence interval, 10% nonresponse rate, and correction formula were utilized. Systematic sampling methods were applied. First, an enumeration was conducted in the kebeles to distinguish women who gave birth within the previous 2 years in Bule Hora town and lived at least a half year in the town before the investigation. Bule Hora town has three kebeles and all kebeles were incorporated into the study and in each kebeles, the households having the eligible women were distinguished by the house to house.
The eligible women in kebele ones, kebele two and kebele three were 602, 867, and 913 independently. After eligible women were identified, the sampling frame was prepared. The proportional probability to size sampling technique was used to allocate proportional sample size for each kebeles. Then systematic sampling technique was used after determining the interval by dividing the number of all women who gave birth in the last two years in Bule Hora town to final sample size.
Every seventh who are voluntary to participate were interviewed according to their sequence of house numbers. Whenever two or more eligible women were found in the same household only one of them was selected randomly and included in the study ( Figure 2). Data were gathered using an organized questionnaire which intended to cover all contents of socio-demographic, socio-economic, socio-cultural, obstetric factors and perceived quality of health care factors variables to accomplish the goal of this study. The quality of the data was assured by using validated pre-tested questionnaires and questionaries' were translated into Afaan Oromo. Data collectors were prepared for one day seriously on the investigation instrument and data collection procedure that includes the relevance of the study, the objective of the study, confidentiality of the information, informed consent and interview technique.
The data collectors were worked under the nearby supervision of the supervisors to guarantee adherence to address data collection procedures and the supervisors and investigators review the filled questionnaires at the end of data collection every day for completeness.
Data were cleaned, coded, checked for completeness and inconsistencies and entered into Epi-Data Version 3.1 and exported to SPSS Statistics Version 25 for analysis. Percentage, frequency and mean were determined. Binary logistic regression analysis independent variables significant at p < 0.25 was considered for adjustment in the multivariable logistic regression. By multivariable logistic regression analysis, the strength of statistical association was measured by adjusted odds ratios and 95% confidence intervals and statistical significance was declared at P<0.05. Finally, the result was presented using texts, tables, figures and charts.

Results
Results: -Out of 360 sample size, 357 participants were engaged in the study with a 99% response rate and the most regular respondents' age groups were 20-24 age groups which account for 147(41.2%). The mean age of the respondent was 24.

Utilization of institutional delivery service
The greater part (72%) of the mothers gave birth at the health facility and the rest of them gave birth at home (Figure 4 and 5). The reason given by mothers those gave birth at homes were:-it is their usual experience, had short labor, had a bad experience from past health facility delivery, felt more comfortable when giving birth at home and their family gives close attention.

Independent predictor variables
The binary logistic regression analysis was performed to identify variables candidate for multivariable logistic regression analysis with the utilization of institutional delivery services. Consequently, maternal age, educational status of mothers, educational status of husbands, spousal communication, decision-maker on place of delivery, mothers occupations, husbands occupations, current antenatal care, family size, parity, competence of skill attendants, shortage of skilled attendants in health facility, prefer of sex of care provider during labor/delivery are variables candidate for multiple logistic regression, since their p-values were less than 0.25 (Tables 4). In this study multivariable logistic regression analysis was performed to identify factors which had a strong association with utilization of institutional delivery service (Table 5).
According to this finding age at first pregnancy, educational status of mothers, educational status of husbands, spousal communication, husbands occupations, current antenatal care, and parity were had a strong statistical association with utilization of institutional delivery service.
A multivariable logistic regression analysis shows as age at first pregnancy greater than 18 years were 2.077 (1.768-5.620) times more likely to give birth at a health facility than those who became pregnant before 18 years of age. Mothers' education was very important factors determine the place of delivery, thus mothers attended secondary school and above were 4.613(1.096-11.912) times and primary school attended mothers were 3.183(2.406-3.443) times more likely to give birth at a health facility than illiterate mothers.
Husband education had also a statically significant association with utilization of institutional delivery service. A wife whose husbands' attended secondary school The study finds out occupations of a husband had a statistically significant association with utilization of institutional delivery services. Mothers whose husbands' the government employs 2.942 (2.734-5.137) times more likely to give birth at a health facility compared with private employ. Another strong factor for the utilization of health care for delivery is parity. Mothers who gave birth three times and less(<=3) and four to six(4-6) were 6.969(1.305-37.212) and 4.449(2.787-25.138) times more likely to give birth at health facility respectively as compared with mothers who gave birth seven times and more.

Discussion
This study assessed the utilization of institutional delivery service and associated factors among women of childbearing age who delivered two years preceding to the survey in Bule Hora town, West Guji Zone, Oromia regional state, Ethiopia. The study shows that the prevalence of the utilization of institutional delivery services in Bule Hora town is 72%. This finding was higher than the previous study conducted in Dodota Ethiopia (18%), Benishangul Ethiopia (24.8%), Gurage zone Ethiopia (31%), Sodo town Ethiopia (62.2%), Boricha southern Ethiopia (4.9%), Horro Guduru Wollega Ethiopia (57%), Awi zone Amhara Ethiopia (18.8%), Abuna Gindebret Ethiopia (14.4), Bihar Amulo Tanzania (56%) respectively gave birth at a health facility (16,17,19,22,24,25,26,31,21). It is also high compared to the national average (26%) in Ethiopia of 2015. Additional efforts are needed to ensure that the Ethiopia national target of 90% is achieved (13). The difference between this study and others may be due to the residence of respondents, level of awareness of mothers about importance institutional delivery services and currently Ethiopian ministry of health using different strategies to increase institutional delivery services like free delivery services at all health facility. This finding is consistent with a study done in the Gamo Gofa zone in which 73.2% of women gave birth in health institutions (20). However, a study conducted in Bahir Dar city administration (78.8%), Benchi Maji (78.3%) and Debra Berhan (80.2%) were higher than our finding. The possible justification might be the infrastructure and the cultural differences that might exist across these regions. In this study, factors influencing institutional delivery services were the age at first pregnancy, educational status of mothers, educational status of husbands, spousal communication, husband's occupations, current antenatal care and parity of women.
According to this study, age at first pregnancy was important variables predictors of institutional delivery services. This study in line with the finding in Benishangul (17) and Bahir Dar city administration (18). In case of this study as an age of mothers increase from eighteen and above the possibility to give birth at health facility increase, the possible reason might be as their age increase they will get more information about the importance of giving birth at a health facility. The educational status of the mother is also a positive statistically significant association with institutional delivery services. The finding is consistent with studies done in Dodota Parity is another variable strongly determine the utilization of institutional delivery services. Mothers who gave birth three times and less were 6.97 times and who gave birth four to six were 4.45 times more likely to give birth at health facility respectively compared with mothers whose gave birth seven times and more. A similar study in line with this finding done in Sodo town Ethiopia (22). The justification might be due to the expansion of the health extension worker program and education in the last two decade in Ethiopia. This indicates mothers those gave birth more than seven times were using their experience at home birth and less utilize institutional delivery service.
Our study also revealed that the educational status of husbands increases institutional delivery service of mothers compared with uneducated husbands.
Similar studies in line with this finding sodo town Ethiopia and reviewed web-based search study (22,30)

Conclusion
The finding shows the utilization of institutional delivery service is higher than a national figure but lower than the national target. Since all study participants were from urban, the finding was higher than a

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Author's Contributions
ZJ have made substantial contributions to beginning and design, collection of data, analysis and interpretation of data and develop this manuscript.
UG have also made substantial contributions to beginning and design, collection of data, analysis and interpretation of data and develop this manuscript.
Both author and co-author read and approved the final manuscript     Figure 1 The schematic representation of the conceptual frame developed after reviewing different lit Figure 2 The schematic representation of the sampling procedures The reasons given by the mothers gave birth at health facility of women of childbearing age Figure 4 shows the utilization of institutional delivery service among women of childbearing age in Bu Figure 5 Shows who assisted mothers gave birth at home among women of childbearing age in Bule H