Skilled Delivery Care Service Uptake Among Socially Marginalized Women in Kambata-Tembaro Zone, Southern Ethiopia

Background: Globally, 358,000 women die during pregnancy and childbirth every year. Poor skilled delivery health care uptake remains a signicant problem in developing countries. In Ethiopia, skilled delivery care service uptake was law. Marginalized women are vulnerable for poor delivery care uptake and addressing woman’s’ social marginalization could play an important role in increasing uptake of skilled delivery care service among minorities in the study area. Thu, the study was aimed to access the utilization of delivery care uptake and associated factors among women from socially marginalized minorities in the Kambeta-Temabaro, Zone Southern Ethiopia. Methods: Community based cross-sectional study was conducted from April 01 to March 30, 2019. Multistage sampling procedure was employed to enroll 521 study participants. An interviewer administered questionnaire was used to collect the data. Data was entered using EPI- INFO and exported to Statistical Package for Social Science (SPSS)-21 for analysis. The degree of association was assessed using odds ratio with 95% condence interval and the variable with p-value <0.05 were declared as statistically signicant. The model tness was checked using Pearson’s Chi-square with the value of 3.45 and signicance 0.026 Result: The magnitude of skilled delivery care service uptake among socially marginalized minorities was 19% in the study area. Maternal education, occupation, and awareness on delivery care, pregnancy plan, and number of birth, mothers’ life-style, and social discrimination were signicantly associated with the delivery care service uptake among women from socially marginalized minorities. Conclusion: prevalence of the delivery service


Background
Globally, maternal mortality ratios (MMRs) recent estimate suggests a substantial decline in latest years (1). Worldwide, 358 000 women die during pregnancy and childbirth every year. Poor maternal health care remains a signi cant problem in developing countries (2).
Skilled delivery care service is a key element of the safe motherhood service that aimed to improve maternal health. Proving focused antenatal care visit during pregnancy improve the maternal and newborn wellbeing(3)(4) (5). In developing countries, maternal health care utilization is varying due to different factors, the most ndings showing the differences between a uent and poor women, and between women living in urban and rural areas (6).
Study conducted in Ghena on accessibility to and utilization of skilled delivery care services shown that large gradients of inequities exist between geographic regions, urban and rural areas, and different sociodemographic, religious and ethnic groupings (7).
According to Ethiopian Demographic Health Survey 2011, the killed maternal health service utilization was low and associated with women education, household wealth, autonomy and residence (8). Studies revealed that socioeconomic and cultural factors; like women age, ethnicity, education, culture, need for care and decision making power are account for variation in maternity health care utilization in large (9) (10) (11).
In Ethiopia, study conducted previously revealed that parity, literacy status of women, average monthly family income, media exposure, decision where to give birth, perception of distance to health institutions and antenatal care visiting were found to be meaningfully associated with skilled delivery service utilizations (12).
Studies conducted shown that women from socially disadvantaged minorities are less likely to access skilled maternal health service dues their social status in the community (13)(14).
Skilled maternity care service utilization inequities persist among vulnerable minorities due to the services do not socially and culturally sensitive; in contrast to the every woman, everywhere has the right to have good quality care before, during pregnancy and child birth (14) (15).
Unless the health care service does not take into account necessary beliefs, attitude or cultural of all pregnant women, even the best and most physically accessible may remain underused (16).
Social discrimination with in health care system is directly contributing to the process of marginalization through perpetuating negative stereotypes and social isolation (17).
In general, marginalized women are vulnerable for poor health care and negative stereotyping of poverty, social status, parenting styles, preferences and unsupportive feedback from the care givers. Marginalized women consistently report constraints in access to skilled delivery care which range from physical and psycho-social barriers to economic constraints (18).
According to Ethiopian Demographic health Survey (2016), maternal mortality ration remains high 412per 100,000 live births. And also, there is discrepancy in skilled delivery care utilization among different social groups and areas in the county (19).
While it is not yet frequently articulated, addressing social marginalization could play an important role in increasing access to and uptake of skilled delivery care service among minorities in the study area.
Thu, the study was aimed to access the utilization of skilled delivery care utilization and associated factors among women from socially marginalized minorities in the Kambeta-Temabaro, Zone Southern Ethiopia.

Method And Materials
Study area, design and period The Kembata-Tembaro zone is located in the Southern Nations, Nationalities and People Republic (SNNPR) region and one of the most densely populated areas in Ethiopia. The Zone Eight districts and one town three administrations (26). The community based cross-sectional study was conducted from April 01 to March 30, 2019.
Source population: All postnatal women in the Kambeta-Tembaro Zone, Southern Ethiopia Study Population: Selected postnatal care women during data collection in the study area.

Sample size determination
Single population formula was used to determine the sample size. The computation was made with the inputs of 95% con dence level (Zα/2=1.96), the margin of error (d=5%), prevalence of skilled care (P=29%) (27), and design effect of (DE) of 1.5. Finally, 10% of non-response rate was considered to determine the total sample size (N=521).

Sampling procedures
To enroll the study population multistage sampling technique was used. Sample size was proportionally allocated to the selected three rural districts and then to each selected six kebeles. Systematic random sampling was used to enroll study units.

Inclusion and exclusion criteria
All married women who gave birth with in last six weeks were included in the study population. But, those who were critically ill during data collection will be excluded.

Data Collection tools and procedures
Data were collected using interviewer administered questionnaire. The questionnaire included Sociodemographic characteristics of participants, maternal health care service utilization during prenatal, intrapartum and postpartum. The tool was adapted from the demographic health science and other previous different studies.

Data management and analyses
The data was entered using the Epi-Info version 3.6 software and exported to Statistical Package for Social Science (SPSS)-21 for analysis. Descriptive statistics were and presented in tables with frequency and percentages. Both bivariate and multiple variable logistic regression analysis were used to determine association of independent variable with outcome variable. The degree of association between independent and outcome variables were assessed using odds ratio with 95% con dence interval and the variable with p-value <0.05 was declared as statistically signi cant. The model tness was checked using Pearson's Chi-square with the value of 3.45 and signi cance 0.026 Operational de nition Marginalization: de ned as how the people are pushed to the edge of society through their perceived identities, place of residence, friendship association and daily activities.
Social marginalized: de ned as social distances of an individual or group being excluded, discriminated against, or not have right to access doe services in the community.
Skilled delivery care; refers to the care provided to a women and newborn during childbirth by an accredited and competent health care provider at health facilities.
Minority groups; describe groups that are subordinated or lack of access in the society due to some their perceived identities, place of residence, their friendship association and their daily activities.
Anticipated stigma: Women may avoid seeking delivery care services as they have anticipated that they found to be from minorities group.

Ethical considerations: Research Ethical approval was received from College of Medicine and Health
Science, Wachemo University and permission letter was obtained from corresponding health administration O ces. Written informed consent was obtained from each study participant during data collection and the issue of con dentiality was maintained.

Result
From the total of 521 study participants, ve hundred ten (510)  Ethiopia. The factors that signi cantly associated with low utilization of delivery care service were maternal education and Occupation, awareness on delivery care service, pregnancy intention weather planned or not, and number of giving birth, mothers' peculiar life-style or culture, and social discrimination/subordination in the community.
In this study, the prevalence of delivery care utilization among mothers from socially marginalized minorities at health facilities was found to be low [19%]. The nding in this was found to be lower as compared to previous studies conducted in Ethiopia, and Timor-Leste (17,19,20). This difference might be due to difference in study time, approach, demographic characteristics and social status of women in the marginalized community. This, also further indicates that the intervention of health care service for all not yet effective for socially marginalized minorities in the study area.
In this study, mothers' educational level and occupation were found to be signi cantly associated with delivery care service utilization among study participant from health facilities. This nding was similar with others previous studies ndings in Holata, Tigray region, Ethiopia(8) (21). These similarities of the study ndings indicate that universal access for education was vital for all to use health care service. Thus, education and employment of women have been advancing the uptake of the health service in the different socioeconomic communities. This indicates that accessing education for women within the marginalized minorities might breakthrough the cultural taboo that hinders health care service uptake.
The study nding shown that, awareness on skilled delivery and number of birth were signi cantly associated with skilled delivery care utilization among the marginalized mothers in the study area. The awareness of mothers about delivery care is comparable with ndings of the previous study, but conversely, number of birth was not similar with previous ndings (12,22). This discrepancy of the ndings might be due to difference in access to health service in different communities. However, health education and promotion on skilled maternity care crucial to improve the uptake of delivery care service among mothers from marginalized minorities.
In this study, social discrimination within the society was found to be negatively affecting factor to uptake delivery care service among marginalized women and it was consistent with the previous research ndings in Ethiopia, India and China (9,10,12,27). The similarity of the nds indicated that social marginalization has comparable negative effect on uptake of the health services in the different communities and women within the marginalized minorities were more disadvantaged from maternal care. In fact, Ethiopian health policy status that health for all; but conversely, mothers from marginalized minorities needs further interventions to overcome core barriers like distorted self-esteem, fear of stigma and subordination by health care providers and communities.

Conclusion
Even though, skilled delivery care service is key intervention to reduce maternal and child morbidity and mortality; the prevalence of the delivery service utilization among marginalized mothers was found to be low [19%] in Kambata-Tembaro zone, Southern Ethiopia. Mothers' education, occupation, life-style, awareness, number of birth and social discrimination was signi cantly associated with delivery service uptake from health facilities. Thus, intervention on social discrimination in the community to breakthrough core barriers; improving women awareness though health education and promotion; and accessing education and employment for women are highly recommended.