Determinants of Maternal Delay in Utilizing Institutional Delivery Services in West Gojjam Zone,Ethiopia: A Cross-Sectional Study

Abstract

Background

The time interval between the onset of labor and the decision to use institutional delivery is referred to as a delay in deciding to use institutional delivery services. The delay in deciding to use institutional delivery is the first of the three delays that prevent mothers from accessing appropriate care during the time of delivery. In this study, maternal delay was operationally defined as the time interval of over an hour after the onset of labor before a decision is made to use institutional delivery services, based on prior evidence indicating that early decision-making is critical for preventing obstetric complications. Globally, such delay remains a major challenge affecting both maternal and neonatal health, including in Ethiopia. Therefore, assessing the magnitude of this delay and its associated factors is essential to reducing maternal morbidity and mortality.

Objective

To assess the magnitude of maternal delay in utilizing institutional delivery services among postnatal mothers in government hospitals of the West Gojjam Zone and to identify the factors associated with the delay.

Methods and materials

A cross-sectional study was conducted among 402 postnatal mothers. Systematic random sampling was applied, and data were collected using a face-to-face, interviewer-administered questionnaire. Data entry was performed using EpiData version 4.6, and analysis was carried out with SPSS version 26. Variables with a p-value ≤ 0.25 in the bivariable analysis were included in the multivariable logistic regression model. Statistical significance was declared at an adjusted odds ratio with a 95% confidence interval and a p-value < 0.05.

Results

The magnitude of maternal delay in utilizing institutional delivery services was 39.8% (95% CI: 34.8–45.0). Unable to read and write (AOR = 2.5; 95% CI: 1.15–5.53), mothers with primary education 2.76 (AOR = 2.76 95% CI:1.03,7.41) mothers who could not make decisions independently (AOR = 4.1; 95% CI: 1.37–12.40), unplanned pregnancies (AOR = 3.6; 95% CI: 1.21–10.70), no antenatal care follow-up (AOR = 4.4; 95% CI: 1.11–12.35), did not receive respectful maternity care during previous facility-based childbirth (AOR = 3.8; 95% CI: 1.32–11.16) were significantly associated with delays in deciding to use institutional delivery services.

Conclusion

Almost forty percent of mothers face a delay in deciding on utilizing institutional delivery services. Lack of education in reading and writing, absence of autonomy in decision-making, unplanned pregnancy, absence of antenatal care, and disrespectful care during maternity were found to be significant delays in utilizing institutional delivery services. Improving maternal education, promoting autonomy, improving utilization of antenatal care, and promoting respectful care are critical in reducing delays in utilizing delivery services.

Keywords

decision-making Ethiopia institutional delivery postnatal mother maternal delay

Introduction

The delay in deciding to utilize institutional delivery services refers to the time between the onset of labor pains and the decision to seek obstetric care. It is one of the three phases of delay that prevent laboring mothers from receiving appropriate healthcare during labor and childbirth. (Wanaka et al., 2020b).

Delay in deciding to seek institutional delivery services is a global concern, as it is a major contributor to maternal mortality (UNFPA, 2019). According to the World Health Organization (WHO), despite significant progress over the past two decades, inadequate or absent care during pregnancy and delivery contributed to an estimated 295,000 maternal deaths and 2.4 million newborn deaths within the first month of life in 2017. Nearly three-quarters of all maternal deaths occur during childbirth and the immediate postpartum period (Baharuddin et al., 2019; UNFPA, 2019). The report also indicates that approximately fifteen percent of pregnant women develop life-threatening complications requiring professional obstetric care, and some may need major obstetric procedures. Therefore, the presence of a skilled birth attendant (doctor, nurse, or midwife) is essential for reducing maternal and neonatal mortality (UNFPA, 2019).

Globally, the magnitude of first-phase delay ranges from 10% to 73% (Carvalho et al., 2020; Kamal, 2013) In Africa, delays in utilizing institutional delivery services occur in approximately 46% of mothers (Chavane et al., 2018a; Mgawadere et al., 2017a; Morof et al., 2019). Studies conducted in Ethiopia reported that mothers’ delay in deciding to seek emergency obstetric care ranges from 27.2% to 44.2% (Wondu et al., 2019; Yarinbab & Balcha, 2018).

A key strategy for reducing maternal and neonatal morbidity and mortality is ensuring that all births are attended by skilled birth attendants (Getachew et al., 2017). Evidence shows that complications can arise during childbirth even when antenatal care is adequate; therefore, early -47care-seeking and timely access to healthcare services play a critical role in preventing maternal deaths and disabilities (Thaddeus & Maine, 1994; UNFPA, 2019).

The consequences of maternal delay in deciding to utilize institutional delivery services extend beyond maternal health and also negatively affect neonatal outcomes (Serbanescu et al., 2017; Sk et al., 2019a). A study in India reported that 48.6% of maternal deaths were linked to first-phase delays. In Africa, maternal mortality attributable to delays in deciding to use institutional delivery services ranges from 54.6% to 83%, and approximately, 50% of newborn deaths are also associated with this delay. In Ethiopia, delays in institutional delivery service utilization remain a major contributor to both maternal and neonatal mortality (EDHS, 2019). A study conducted in Bahir Dar found that 44.3% of maternal near-miss cases were due to first-phase delays, 35% to second-phase delays, and 51.2% to third-phase delays (Mekonnin et al., 2019).4.

Although maternal delay in deciding to utilize institutional delivery services remains a significant public health concern, various global and national initiatives have been implemented to address it, including the Safe Motherhood Initiative, international funding to improve maternal health, the Health Extension Program, expansion of health facilities, and improvements in transportation systems. However, delays in maternal health service utilization continue to persist. (EDHS, 2019; WHO, 2017).

While several studies in Ethiopia have investigated maternal delay in deciding to seek institutional delivery services, to the best of our knowledge, no research has been conducted in the study area among postnatal mothers who visit hospitals for delivery care services. This highlights a need for further investigation. In addition, most previous studies in Ethiopia have primarily focused on socio-demographic characteristics, transportation barriers, distance to health facilities, and organizational challenges such as drug shortages, prolonged admission processes, and inadequate staffing (Lire et al., 2017; Wanaka et al., 2020b; Yarinbab & Balcha, 2018). However, other important factors, such as personal factors (e.g., mothers’ knowledge of the importance of institutional delivery services) and organizational aspects like respectful maternity care (RMC) during previous facility-based childbirth and the availability of essential delivery infrastructures, have not been adequately addressed especially in the study area.

Therefore, this study aimed to assess the magnitude of maternal delay in deciding to utilize institutional delivery services and its associated factors among postnatal mothers in government hospitals of the West Gojjam Zone, Amhara Region, Northwest Ethiopia.

Literature Review

Magnitude of Delay in Deciding for Utilizing Institutional Delivery Service

A cross-sectional study conducted in rural Bangladesh found that 80.2% of laboring women had delay in making decisions to utilize institutional delivery services (Abdullah et al., 2017). A cross-sectional study conducted in India discovered that 27- 48.6% of laboring mothers had delay in making decisions to utilize institutional delivery services (Ghumare & Padvi, 2018a) (Sk et al., 2019b).

A study conducted in Malawi on factors associated with maternal mortality, using the application of the three delays model, found 39.7% had delay on making decisions to utilize institutional delivery service (Mgawadere et al., 2017b). A study conducted in Egypt found that 48.5 percent, of near-miss cases, have encountered two or more forms of delays (Abdel-Raheem et al., 2017b). A cross-sectional study conducted in Somalia showed that delay in deciding to seek treatment was 89%, delay in reaching care 78.5% (Aden et al., 2019).

A facility-based cross-sectional study in Hadiya Zone, Southern Ethiopia, found that 40.1 % of mothers experienced delay in making decisions to utilize institutional delivery service (Lire et al., 2017). A study conducted in Gamo Gofa Zone, Southern Ethiopia showed that the magnitude delay in deciding to utilize institutional delivery service was 46.8% (Wanaka et al., 2020a). Another study conducted in Yem special woreda,Southern Ethiopia indicated that the delay in deciding to utilize institutional delivery service was 44.2% (Yarinbab & Balcha, 2018). According to a study conducted in Arsi zone, Oromia, Ethiopia, 27.2% of the participants reported difficulties in deciding to seek emergency obstetric care (Wondu et al., 2019). A study conducted at Jimma Medical Center, Jimma, Ethiopia indicated that the prevalence of delay in seeking institutional delivery service utilization was 46.7% (S. Awel et al., 2021).

Factors Associated With Delay for Utilizing Institutional Delivery Service

Socio-Demographic/Personal Factors

A study conducted in India found that age is an associated factor for delay in seeking institutional delivery service utilization (Sk et al., 2019b). An observational study conducted in low and middle-income countries also indicated that age is associated with delay in seeking institutional delivery service utilization (Zohra S Lassi et al., 2019). Studies conducted in Mozambique, Ghana, and Nigeria indicated that age is an associated factor for the delay in deciding utilizing institutional delivery service (Chavane et al., 2018b; Sageer et al., 2019a; Sumankuuro et al., 2019a). Similarly, cross-sectional studies conducted in Hadiya Zone, Arsi Zone, and Gamo Gofa Zone indicated that age is an associated factor for delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a; Wondu et al., 2019).

A study conducted in India and Nepal indicated that residence is a factor leading to delay in deciding to utilize institutional delivery services (Sk et al., 2019b; Zohra S Lassi et al., 2019). An observational study conducted in low-middle-income countries and sub-Saharan Africa also showed that residence is a factor leading to delay in deciding to utilizie institutional delivery service (Karmacharya et al., 2016; Sumankuuro et al., 2019a). Similarly, studies conducted in Ethiopia, including Hadiya Zone and Gamo Gofa Zone, indicated that residence is a factor leading to delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a).

An observational study conducted in low- and middle-income countries and sub-Saharan Africa indicated that maternal and husband occupation are factors leading to delay in deciding to utilize institutional delivery services (Karmacharya et al., 2016; Sumankuuro et al., 2019a). Studies conducted in Ethiopia, including Hadiya, Yem, Gamo, and Arsi Zones, also showed that maternal and husband occupation are factors leading to delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a; Wondu et al., 2019; Yarinbab & Balcha, 2018). An observational study conducted in India indicated that husband and maternal educational status are factors associated with delay in deciding to utilize institutional delivery services (Sk et al., 2019b). Ross-sectional studies conducted in Hadiya Zone, Yem Special Woreda, Arsi Zone, and Gamo Gofa Zone indicated that husband and maternal educational status are factors associated with delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a; Wondu et al., 2019; Yarinbab & Balcha, 2018).

A study conducted in Nepal and India indicated that decision-making is a factor associated with delay in deciding to utilize institutional delivery services (Sk et al., 2019b; Zohra S Lassi et al., 2019). Another study conducted in Nigeria, Ghana, and Somalia also indicated that decision-making is a factor associated with delay in deciding to utilize institutional delivery services (Aden et al., 2019; Sageer et al., 2019a; Sumankuuro et al., 2019a). Similarly, studies conducted in Ethiopia showed that decision-making is a factor associated with delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a; Wondu et al., 2019). An observational study conducted in sub-Saharan African countries showed that marital status is a factor associated with delay in deciding to utilize institutional delivery services (Karmacharya et al., 2016). Similarly, a cross-sectional study conducted in Arsi Zone, Oromia, Ethiopia showed that marital status is a factor associated with delay in deciding to utilize institutional delivery services (Wondu et al., 2019).

Obstetric Health Related Factors

A study conducted in India indicated that antenatal care (ANC) follow-up is a factor related to delay in deciding to utilize institutional delivery services (Sk et al., 2019b). A study conducted in India indicated that antenatal care (ANC) follow-up is a factor related to delay in deciding to utilize institutional delivery services (Karmacharya et al., 2016). Research conducted in Ghana and Egypt showed that ANC follow-up is a factor related to delay in deciding to utilize institutional delivery services (Abdel-Raheem et al., 2017b; Sumankuuro et al., 2019a). A cross-sectional study conducted in Hadiya, Gamo, and Arsi Zones, Ethiopia indicated that ANC follow-up is a factor related to delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a; Wondu et al., 2019).

A study conducted in Mozambique, Ghana, and Egypt showed that parity is a factor associated with delay in deciding to utilize institutional delivery services (Abdel-Raheem et al., 2017b; Chavane et al., 2018b; Sumankuuro et al., 2019a). A cross-sectional study conducted in Yem Special Woreda and Gamo Gofa Zone, Ethiopia indicated that parity is a factor associated with delay in deciding to utilize institutional delivery services (Wanaka et al., 2020a; Yarinbab & Balcha, 2018). A study conducted in Mozambique indicated that previous pregnancy outcome is a factor associated with delay in deciding to utilize institutional delivery services (Chavane et al., 2018b). Another study conducted in Egypt also indicated that unplanned pregnancy and previous pregnancy outcome are factors associated with delay in deciding to utilize institutional delivery services (Abdel-Raheem et al., 2017b). A study conducted in Ghana showed that unplanned pregnancy is a factor associated with delay in deciding to utilize institutional delivery services (Sumankuuro et al., 2019a).

An observational study conducted in India, Bangladesh, and Nepal showed that mothers’ knowledge of danger signs during labor and childbirth is a factor associated with delay in deciding to utilize institutional delivery services (Abdullah et al., 2017; Sk et al., 2019b; Zohra S Lassi et al., 2019). A study conducted in Nigeria, Egypt, and Somalia indicated that mothers’ knowledge of danger signs during labor and childbirth is associated with delay in deciding to utilize institutional delivery services (Abdel-Raheem et al., 2017b; Aden et al., 2019; Sageer et al., 2019a). Another study conducted in Ghana, sub-Saharan Africa, and Somalia also showed that mothers’ knowledge of danger signs during labor and childbirth is a factor associated with delay in deciding to utilize institutional delivery services (Aden et al., 2019; Karmacharya et al., 2016; Sumankuuro et al., 2019a).A study conducted in Ethiopia also indicated that mothers’ knowledge of danger signs during labor and childbirth is associated with delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a; Yarinbab & Balcha, 2018). Another study conducted in Ghana, sub-Saharan Africa, and Somalia showed that mothers’ knowledge of the importance of giving birth at a health facility is a factor related to delay in deciding to utilize institutional delivery services (Aden et al., 2019; Karmacharya et al., 2016; Sumankuuro et al., 2019a).

A study conducted in India and Bangladesh indicated that mothers’ knowledge of birth preparedness and mothers’ practices of birth preparedness are factors associated with delay in deciding to utilize institutional delivery services (Abdullah et al., 2017; Sk et al., 2019b). Another study conducted in sub-Saharan Africa and Egypt also showed that mothers’ knowledge and practices of birth preparedness are factors associated with delay in deciding to utilize institutional delivery services (Abdel-Raheem et al., 2017b; Karmacharya et al., 2016). A cross-sectional study conducted in Gamo Gofa Zone, Southern Ethiopia also indicated that mothers’ practices of birth preparedness are a factor associated with delay in deciding to utilize institutional delivery services (Wanaka et al., 2020a).

Accessibility of Health Facilities Related Factors

A study conducted in Hadiya, Yem, and Gamo Gofa Zones, Ethiopia showed that unavailability of roads is a factor associated with delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a; Yarinbab & Balcha, 2018). A study conducted in India, Bangladesh, and Nepal showed that distance from health facilities and geographical location are factors related to delay in deciding to utilize institutional delivery services (Abdullah et al., 2017; Karmacharya et al., 2016; Sk et al., 2019b). Another study conducted in low- and middle-income countries and Ghana also indicated that distance from health facilities and geographical location are factors related to delay in deciding to utilize institutional delivery services (Sumankuuro et al., 2019a; Zohra S Lassi et al., 2019). A study conducted in Ethiopia also showed that distance from health facilities and geographical location are factors related to delay in deciding to utilize institutional delivery services (Lire et al., 2017; Wanaka et al., 2020a; Yarinbab & Balcha, 2018).

Health Care System Related Factors

A study conducted in Bangladesh and Nepal indicated that non-respected maternity care is a factor associated with delay in deciding to utilize institutional delivery services (Abdullah et al., 2017; Karmacharya et al., 2016). An observational study conducted in low- and middle-income countries also indicated that non-respected maternity care is a factor associated with delay in deciding to utilize institutional delivery services (Zohra S Lassi et al., 2019).

Methods and Materials

Study Area

The study was conducted in government hospitals located in the West Gojjam Zone of the Amhara Region, northwest Ethiopia. Administratively, the zone comprises 13 rural districts and 2 town administrations, with a total population of 2,611,925, of whom 615,892 (23.58%) are women of reproductive age. The population of West Gojjam Zone primarily depends on agriculture for income generation. Regarding healthcare infrastructure, the zone had ten public hospitals, 103 health centers, and more than 374 health posts. Additionally, there were 115 private health facilities at the time of the survey. Among the ten public hospitals, two are referral hospitals- Felege Hiwot Specialized Comprehensive Hospital and Tibebe Ghion Specialized Comprehensive Hospital. One is a general hospital (Finote Selam General Hospital), and the remaining seven are primary hospitals: Burre Primary Hospital, Dur Bete Primary Hospital, Merawi Primary Hospital, Liben Primary Hospital, Addis Alem Primary Hospital, Adet Primary Hospital, and Feres Bet Primary Hospital.

Study Design and Period

An institution-based cross-sectional study was conducted from February 1 to March 30, 2022.

Population

Source Population

All immediate postnatal mothers who gave birth at the government hospitals of West Gojjam Zone were the source population.

Study Population

Immediate Postnatal mothers who gave birth at the government hospitals of West Gojjam Zone during the data collection period.

Inclusion and Exclusion Criteria

The study population comprised immediate postnatal mothers who delivered in government hospitals of the West Gojjam Zone. Mothers with severe medical conditions that prevented participation during the data collection period, those who used maternal waiting homes, and mothers who were admitted to the ward for medical reasons before labor and remained hospitalized until delivery were excluded from the study.

Sample Size Determination

The sample size required for this study was calculated by using the single population proportion formula with the following assumptions 95% confidence level, 5% margin of error and proportion of maternal delay to decision of utilizing institutional delivery. The proportion of delay to decision of utilizing institutional delivery service in a recent study in Gamo Gofa Zone were 46.80% (Wanaka et al., 2020b).

n = \frac{{(Z α / 2)}^{2} \times P (1 - P)}{d^{2}} = \frac{{(1.96)}^{2} \times (0.468) (0.532)}{{(0.05)}^{2}} = 382

Where; n= desired sample size

Zα/2 = reflects the standard score we use 95 % confidence interval (CI) so the value of Z is 1.96.

P = proportion of magnitude 46.8%

d = margin of error between the sample and population, 5% marginal error is admitted.

Finally, considering a 5% nonresponse rate, the final sample size for this study was 402.

Sampling Procedure

A systematic random sampling technique was used to select the study participants from postnatal mothers in ten government hospitals in the West Gojjam Zone. The total number of mothers who delivered in these hospitals during the reference period was 3390, and the final sample size was 402. To select 402 postnatal mothers from these hospitals, the sample size was proportionally allocated to each hospital based on the number of deliveries. The sampling interval denoted by K was found by dividing the total population by the sample size (k=N/n) =8. The first participant was randomly selected using a lottery method from the first eligible participants in each hospital, and then every 8^th participant was selected until the required sample size for each hospital was obtained (Figure 1).

Figure 1.

Schematic representation of sampling procedure to select study participants in government hospitals of West Gojjam zone, 2022

Study Variable

Dependent Variable

Delay in deciding on utilizing the institutional delivery service.

Independent Variable

Socio-Demographic Factors

Maternal age, marital status, maternal educational level, husband’s educational level, maternal decision-making power, maternal occupation, husband’s occupation.

Obstetric Health-Related Factors

Antenatal care (ANC) follow-up, parity, previous pregnancy outcomes, unplanned pregnancy, maternal knowledge of danger signs during labor and childbirth, birth preparedness and complication readiness, maternal knowledge about the importance of delivering at a health facility.

Accessibility of Facility-Related Factors

Distance to the health facility, lack of transportation, poor road access, absence of respectful maternity care (RMC) during previous facility-based childbirth, and lack of health facility infrastructure.

Data Collection Tool and Procedures

Data were collected using a face-to-face, interviewer-administered, and observational approach with pre-tested semi-structured questionnaires. The questionnaires were initially prepared in English, translated into Amharic, and then back-translated into English to ensure consistency. They included items on socio-demographic characteristics, obstetric and health-related factors, and were adapted from previously published studies conducted in Ethiopia (Lire et al., 2017; Wanaka et al., 2020b; Yarinbab & Balcha, 2018). Items on respectful maternity care were adopted from relevant Ethiopian literature (Wassihun & Zeleke, 2018). Questions regarding knowledge of birth preparedness and complication readiness, knowledge of danger signs during labor and childbirth, and the importance of health facility delivery were adapted from JHPIEGO’s monitoring tools for maternal and newborn health (Kari & Angolkar, 2021). Organizational infrastructure related to labor and delivery services was assessed using items adapted from the WHO Safe Childbirth Checklist (WHO, 2015). Data were collected by one diploma and one BSc midwife, supervised by a BSc midwife from each hospital, using the pre-tested semi-structured questionnaire. The internal consistency of the questionnaires was assessed using Cronbach’s Alpha coefficient. The birth preparedness and complication readiness, respectful maternity care, and knowledge of danger signs tools demonstrated a good internal consistency with a Cronbach’s alpha value of 0.83, 0.78, and 0.87, respectively.

Data Quality Control

The questionnaire was pretested on 5% of the sample (20 participants) two weeks before the main data collection at a hospital in the East Gojjam Zone (Shegaw Motta General Hospital), which was not included in the study. Following the pretest, adjustments were made to improve clarity, sequence, and reduce ambiguity. The questionnaires were also reviewed for face validity by panel experts, including midwifes and public health professionals. For data collectors and supervisors, one day training was given. Data collectors were daily supervised by the supervisors and reported to the principal investigator daily. Filled questionnaires were checked daily for completeness and errors.

Data Processing and Analysis

The collected data were checked for completeness, coded, and entered into EpiData version 4.6, then exported to SPSS version 26 for analysis. Descriptive statistics, including frequencies and percentages, were computed to summarize the characteristics of the study population. Bivariate logistic regression was conducted to examine the association between each independent variable and the dependent variable. Variables with a p-value ≤ 0.25 in the bivariate analysis were included in the multivariable logistic regression model to identify independent predictors while controlling for potential confounders. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were used to measure the strength of associations, and statistical significance was declared at a p-value < 0.05. Model fitness was assessed using the Hosmer–Lemeshow goodness-of-fit test, which yielded a p-value of 0.66, indicating an adequate model fit. Multicollinearity among explanatory variables was evaluated using the variance inflation factor (VIF), with the highest VIF observed being 1.04, confirming the absence of multicollinearity.

Operational definition

Operational definitions of variables (Table 1)

Table 1.

Operational Definitions of Study Variables Among Postnatal Mothers in Government Hospitals of West Gojjam Zone, Northwest Ethiopia, 2022 (n=402)

Variables	Operational definition
Delay to decide for utilizing institutional delivery service:	The inability to decide to seek emergency obstetric care within one hour of perceiving the onset of labor pain (Lire et al., 2017; Wanaka et al., 2020b; Yarinbab & Balcha, 2018). It should be noted that though there is no universally accepted cutoff point for the first delay in the three-delay model, this cutoff point has been used in several studies carried out in Ethiopia and similar resource-limited settings.
Prepared for birth and its complications:	A woman is considered prepared for birth and its complications if she has practiced or implemented at least 6 of the 12 components of birth preparedness and complication readiness (Limenih et al., 2019).
Knowledgeable of danger signs of labor and delivery	If a woman lists at least 3 main danger signs of labor and childbirth from the 6th listed, she was considered knowledgeable in this study (Limenih et al., 2019).
Respectful maternity care	If women replied yes to all of the questions evaluating respectful maternity care or verification criteria used for assessing the seven categories (performance standards) of RMC during labor and childbirth, they were classified to have received respectful maternity care during labor and childbirth in this study (Asefa & Bekele, 2015; Bulto et al., 2020).
Knowledge of respondents on the importance of giving birth at a Health facility	In this study, respondents were asked six questions to determine their level of understanding of the importance of giving birth at a health facility. Those who got 3–6 points were considered knowledgeable. (Tefera et al., 2019).

Ethical Consideration

Ethical clearance and approval were obtained from Wollo University College of medicine and health science ethical review committee with a reference number of CMHSMIDW/032/21. The study was conducted based on the ethical standards of the Declaration of Helsinki. Then officials at different levels in the study area communicated through letters from Wollo University, College of Medicine and Health Science. Letters of permission were presented to the West Gojjam Zone hospitals. Written informed consent was obtained from each study participants before the interview, after the purpose of the study was explained to the respondent. Coding was used to eliminate names and other personal identification of respondents throughout the study process to ensure participant confidentiality.

Result

Socio-Demographic Characteristics

A total of 402 respondents participated in the study, yielding a 100% response rate. Of these, 177 (44%) were aged between 20 and 34 years, with a mean age of 26 years (SD ± 6.8). Regarding educational status, 150 (37.3%) of the mothers were unable to read and write and 92 (22.9%) had a diploma or higher. Most respondents, 362 (90%), were married. Regarding husbands’ education, 118 (29.4%) had a diploma or higher (Table 2).

Table 2.

Socio-Demographic Characteristics of Postnatal Mothers in Government Hospitals of West Gojjam Zone, Northwest Ethiopia, 2022 (n=402)

Variable	Category	Frequency	Percent
Age in years	<20	145	36.1
	20-34	177	44.0
	>34	80	19.9
Residence	Urban	265	65.9
Residence	Rural	137	34.1
Religion	Orthodox	322	80.1
	Muslim	40	10.0
	Protestant	20	5.0
	Catholic	20	5.0
Marital status	Married	362	90.0
Marital status	Unmarried^*	40	10.0
Maternal Education	Cannot read or write	150	37.3
	Can read and write	65	16.2
	Primary (1-8)	49	12.2
	Secondary (9-12)	46	11.4
	Diploma and above	92	22.9
Maternal occupation	Housewife	147	36.6
	Farmer	7	1.7
	Merchant	30	7.5
	Student	26	6.5
	Daily laborer	10	2.5
	Employed	182	45.3
Husband Education	Cannot read or write	57	14.2
	Can read and write	44	10.9
	Primary	50	12.4
	Secondary	93	23.1
	Diploma and above	118	29.4
Husband occupation	Employed	190	47.3
Husband occupation	Un employed**	169	52.7
Decision maker for the health facility’s childbirth	Other family members	133	33.2
Decision maker for the health facility’s childbirth	Women	269	66.9

N.B.

^*single, widowed, and divorced.

^**farmer, merchant, student, daily laborer, driver.

Obstetric Health-Related Characteristics of the Study Participant

Among the study participants, more than half, 220 (54.7%), had antenatal care (ANC) follow-up. About 241 (60.0%) of the respondents were multiparous, and 281 (69.9%) of the pregnancies were planned. Among women who had previously given birth, 19 (7.9%) reported a history of stillbirth (Table 2).

Respondent’s Knowledge of Birth Preparedness and Complication Readiness

Among the respondents, 218 (54.2%) practiced or implemented at least 6 of the 12 components, while 184 (45.8%) did not. The most commonly reported components of birth preparedness and complication readiness were identifying an appropriate health facility 262 (65.2%), arranging transportation 267 (66.4%), and saving money for emergencies 269 (61.9%). The least frequently reported component was arranging a blood donor in case of an emergency 7 (1.7%) (Table 3).

Table 3.

Obstetric Health-Related Characteristics Among Postnatal Mothers in Government Hospitals of West Gojjam Zone, Northwest Ethiopia, 2022 (n=402)

Variables	Category	Frequency	Percent
ANC follow up	Yes	220	54.7
ANC follow up	No	182	45.3
Parity	Primi-para	161	40.0
Parity	Multipara	241	60.0
Planned pregnancy	Yes	281	69.9
Planned pregnancy	No	121	30.1
Outcome of previous childbirth (n=241)	Alive	221	91.7
	Dead	19	7.9
	Congenital anomaly	1	0.4

Knowledge of Respondents About the Dangerous Signs of Labor and Childbirth

Among the participants, 268 (66.7%) were able to identify at least three main danger signs and were thus considered knowledgeable. The most frequently mentioned danger signs were retained placenta (205; 51.0%), malpresentation (hand, feet, cord, or face first) (200; 49.8%), and severe vaginal bleeding (196; 48.8%) (Figure 2).

Figure 2.

Knowledge about danger signs of pregnancy among postnatal mothers in government hospitals of West Gojjam Zone, Northwest Ethiopia, May 2022 (n=402)

Knowledge of Respondents About the Importance of Giving Birth at a Health Facility

Knowledge of the importance of giving birth at a health facility was assessed using six related items. Among the participants, 230 (57.2%) were able to identify at least three reasons and were considered knowledgeable, while 172 (42.8%) mentioned fewer than three items and were classified as not knowledgeable.

Accessibility of Facility and Health Facility-Related Characteristics of the Study Participant

Among the respondents, 128 (31.8%) lived more than 5 km from the nearest health facility. Regarding transportation, only 134 (33.3%) had access to transport (Table 4).

Table 4.

Birth Preparedness and Complication Readiness Plan Among Postnatal Mothers in Government Hospitals of West Gojjam Zone, Northwest Ethiopia, 2022 (n=402)

Variables (n=402)	Category	Frequency(N)	Percent (%)
Identify an appropriate health facility	Yes	262	65.2
Identify an appropriate health facility	No	140	34.8
Choose a skilled provider	Yes	173	43
Choose a skilled provider	No	229	57
Deciding on transportation means	Yes	267	66.4
Deciding on transportation means	No	135	33.6
Decide on communication means	Yes	179	44.5
Decide on communication means	No	223	55.5
Save money to be used during an emergency	Yes	249	61.9
Save money to be used during an emergency	No	153	38.1
Prepare essential items for a clean and safe delivery	Yes	175	43.5
Prepare essential items for a clean and safe delivery	No	227	56.5
Identify support people to help	Yes	159	39.6
Identify support people to help	No	243	60.4
Be able to identify the signs of an obstetric emergency	Yes	185	46
Be able to identify the signs of an obstetric emergency	No	217	54
Seeking care without delay when a Complication occurs	Yes	150	37.3
Seeking care without delay when a Complication occurs	No	252	62.7
Have a plan to respond immediately in the event of an emergency	Yes	181	45
	No	221	55
Know the location of the nearest health facility for emergency service	Yes	226	56.2
	No	176	43.8
Arranging blood donors in case of an emergency	Yes	7	1.7
Arranging blood donors in case of an emergency	No	395	98.3

Infrastructure

All ten hospitals had a delivery or labor room equipped with a bed and adequate lighting, an autoclave, a waiting area for visitors and family, an examination room, a post-delivery room, and covered waste disposal. However, four hospitals (Adet, Liben, Feres Bet, and Durbete) lacked partitions in the delivery rooms for privacy, adequate ventilation, running water, functioning toilets, and heating.

Study Participant Response Regarding Respectful Maternity Care

Of the study participants, 270 had previously delivered at a health facility, and the overall proportion of women who received respectful maternity care during labor and childbirth was 238 (88.1%). According to the RMC evaluation checklist, 242 (89.6%) of women were protected from the use of force during care, 240 (88.9%) were not denied food or fluids, 238 (88.1%) were encouraged to remain with their companions, and 241 (89.2%) were allowed to move during labor.

The Magnitude of Maternal Delay

In this study, the magnitude of maternal delay in deciding to utilize institutional delivery services was 160 (39.8%) with [95% CI (34.8, 45.0)].

Factors Associated With Maternal Delay in Utilizing Institutional Delivery Service

Logistic regression analysis was performed to identify predictors of delay in deciding to utilize institutional delivery services. In the bivariate logistic regression analysis, maternal educational status, women’s decision-making power, unplanned pregnancy, lack of antenatal care, distance from the health facility, absence of respectful maternity care during previous facility-based childbirth, maternal knowledge of danger signs during labor and childbirth, maternal knowledge of the importance of institutional delivery, and birth preparedness and complication readiness were significantly associated with maternal delay at a p-value ≤ 0.25. To control for potential confounding and identify independent predictors, these variables were entered into a multivariable logistic regression analysis.

Of the nine variables included in the multivariable analysis, five were significantly associated with maternal delay in deciding to utilize institutional delivery services: mothers who could not read and write (AOR = 2.5; 95% CI: 1.16–5.54), mothers who had primary education (AOR = 2.76 95% CI:1.03,7.41), mothers who lacked decision-making power (AOR = 4.1; 95% CI: 1.37–12.40), unplanned pregnancy (AOR = 3.6; 95% CI: 1.21–10.71), no antenatal care follow-up (AOR = 4.4; 95% CI: 1.11–12.35), and absence of respectful maternity care during previous facility-based childbirth (AOR = 3.8; 95% CI: 1.32–11.16). Being prepared for birth was found to be associated with reduced odds of the outcome (AOR = 0.14, 95% CI: 0.02–1.00). The confidence interval was near the null value, implying borderline significance (Table 5).

Table 5.

Accessibility of Facility and Health Facility-Related Factors of the Study Participant of Postnatal Mothers in Government Hospitals of West Gojjam Zone, Northwest Ethiopia, 2022 (n=402)

Variable	Category	Frequency	Percent
Distance to nearest health facility	>5km	128	31.8
Distance to nearest health facility	≤5km	274	68.2
Access to transport	Yes	134	33.3
Access to transport	No	268	66.7
Unavailability of the road	Yes	120	29.6
Unavailability of the road	No	282	70.4
Absence of a Skilled health provider	Yes	63	15.7
Absence of a Skilled health provider	No	339	84.3
Shortage of medical supplies	Yes	62	15.4
Shortage of medical supplies	No	340	84.6
Shortage of health facility infrastructures for labor and childbirth	Yes	131	32.6
	No	271	67.4
Referring to other Health facilities	Yes	89	22.1
Referring to other Health facilities	No	313	77.9

Discussions

This study aimed to assess maternal delay in deciding to utilize institutional delivery services and its associated factors among postnatal mothers. The magnitude of delay in deciding to utilize institutional delivery services was 39.8% (95% CI: 34.8–45.0%). This finding was in line with studies conducted in Yem Special Woreda, Southern Ethiopia (44.2%) (Yarinbab & Balcha, 2018), Hadiya, Southern Ethiopia (40.1%) (Lire et al., 2017), and South Gonder, Northern Ethiopia (36.3%) (Getachew et al., 2017). However, it is lower than a study conducted in India (48.6%) and Somalia (89%) (Aden et al., 2019; Sk et al., 2019a). The possible explanation may be attributed to differences in population characteristics, study setting and period, cultural practices, and health service delivery systems (Sk et al., 2019a), also lower than findings from other areas of Ethiopia, such as Gamo Gofa, Southern Ethiopia (46.8%), and Jimma, Ethiopia (46.7%) (Samira Awel et al., 2021). This discrepancy may be due to differences in study periods, settings, and types of facilities; for example, the study in Gamo Gofa was conducted in rural health centers, while the study in Jimma was limited to a single hospital. Variations in population characteristics and cultural factors may also contribute to these differences (Samira Awel et al., 2021; Wanaka et al., 2020b).

Conversely, the magnitude of delay in deciding to utilize institutional delivery services in this study was higher than findings from Arsi, Oromia, Ethiopia (27.2%) and India (27%) (Ghumare & Padvi, 2018b; Wondu et al., 2019). This discrepancy may be due to the inclusion of both rural and urban women in the current study, whereas the previous studies focused only on urban populations. In rural areas, limited access to information on institutional childbirth, lower coverage of health extension programs, and lifestyle differences may contribute to delays (El Gelany et al., 2015).

Maternal educational status was a significant predictor of delay in deciding to utilize institutional delivery services. Mothers who could not read or write were 2.52 (AOR = 2.52; 95% CI: 1.15–5.53), and mothers with primary education were 2.76 (AOR = 2.76 95% CI:1.03,7.41) times more likely to experience delays compared to those with a diploma or higher. This finding aligns with studies from Hadiya, Southern Ethiopia, Arsi, Oromia, Ethiopia, and India (Lire et al., 2017; Sk et al., 2019a; Wondu et al., 2019). The possible explanation may be that poor literacy may limit women’s access to information on delivery care and reduce their ability to make timely decisions regarding institutional delivery (Wondu et al., 2019).

Women who could not make decisions independently were 4.1 (AOR = 4.1; 95% CI: 1.73–12.40) times more likely to delay seeking institutional delivery services than those who could decide for themselves. This result is consistent with studies conducted in Gamo Gofa, Southern Ethiopia, Nigeria, and Ghana (Sageer et al., 2019b; Sumankuuro et al., 2019b; Wanaka et al., 2020b). This may be related to male partners’ dominance in decision-making, which can impede timely access to care (Sageer et al., 2019b).

Mothers with unplanned pregnancies were 3.6 (AOR = 3.6; 95% CI: 1.21–10.71) times more likely to delay in deciding to utilize institutional delivery services compared to those with planned pregnancies. This finding is consistent with studies conducted in Egypt and Ghana (Abdel-Raheem et al., 2017a; Sumankuuro et al., 2019b). The possible reason might be that women with unplanned pregnancies may be less prepared for childbirth, including inadequate birth preparedness, which contributes to delayed decisions to seek institutional delivery care (Abdel-Raheem et al., 2017a).

Mothers who did not attend antenatal care were 4.4 (AOR = 4.4; 95% CI: 1.11–12.35) times more likely to delay seeking institutional delivery services compared to those who attended antenatal care contact. This is supported by studies from Arsi, Oromia, Ethiopia, Ghana, and Egypt (Abdel-Raheem et al., 2017a; Sumankuuro et al., 2019b; Wondu et al., 2019). The possible reason might be that ANC contact provides opportunities for counseling on birth preparedness, decision-making regarding delivery place, and early recognition of obstetric complications, which helps prevent delays (Karmacharya et al., 2017).

Finally, absence of respectful maternity care during previous facility-based childbirth was a significant predictor of maternal delay (AOR = 3.8; 95% CI: 1.32–11.16). Women who did not receive RMC during prior facility deliveries were 3.8 times more likely to experience delays compared to those who received respectful care. This finding is consistent with studies conducted in low- and middle-income countries, including Bangladesh (Abdullah et al., 2017). This might be RMC involves care that promotes dignity, privacy, confidentiality, consent, and freedom from abuse, discrimination, and neglect. Findings from qualitative studies in Ethiopia and other resource-limited countries have consistently shown that women’s past experiences of disrespectful or abusive care, such as verbal abuse, neglect, lack of privacy, or denial of companionship, have contributed to fear, dissatisfaction, and mistrust of health facilities. Such poor experiences have also deterred women from accessing health facilities in subsequent pregnancies (Burrowes et al., 2017; Z. S. Lassi et al., 2019; Mengesha et al., 2020). Although the association of birth preparedness with the outcome was suggestive of reduced odds of the outcome, it was not statistically significant at conventional levels since the upper confidence limit included 1.00. This implies that there is a certain level of uncertainty and that the effect should be viewed with caution. This might be due to insufficient statistical power (Table 6).

Table 6.

Bivariable and Multivariable Logistic Regression Analysis on Factors Associated With Maternal Delay to Decide on Utilizing Institutional Delivery Service Among Postnatal Mothers in Government Hospitals of West Gojjam Zone, Northwest, Ethiopia, 2022 (n=402)

Variable	Categories	Maternal delay		COR [95%CI]	AOR (95%CI)
Variable	Categories	Yes	No	COR [95%CI]	AOR (95%CI)
Maternal education	Cannot read or write	77 (51.3%)	73 (48.7%)	3.79 [2.10,6.84]	2.52[1.15,5.53] *
	Can read and write	24 (36.9%)	41 (63.1%)	2.10 [1.04,4.27]	1.61 [0.64,4.08]
	Primary	24 (48.9%)	25 (51.1%)	3.45 [1.63,7.30]	2.76[1.03,7.41] *
	Secondary and preparatory	15 (32.6%)	31 (67.4%)	1.74 [0.79,3.84]	0.57 [0.17,1.91]
	Diploma and above	20 (21.7%)	72 (78.3%)	1	1
Unplanned pregnancy	Yes	101 (83.5%)	20 (16.5%)	19.00 [10.8,33.2]	3.60[1.21,10.71] *
Unplanned pregnancy	No	59 (21%)	222 (79%)	1	1
Women’s decision-making power	Other family members	111 (83.5)	22 (16.5%)	22.65 [13.03,39.3]	4.12[1.37,12.40] *
Women’s decision-making power	Women’s	49 (18.2%)	220 (81.8%)	1	1
ANC follow-up	No	112 (58.3%)	70 (41.7%)	5.73 [3.70,8.88]	4.39[1.11,14.5] *
ANC follow-up	Yes	48 (21.8%)	172 (78.2%)	1	1
Distance from health facility	>5km	66 (44.8%)	81 (55.2%)	1.39 [0.92,2.10]	1.39 [0.76,2.54]
Distance from health facility	≤5 km	94 (36.9%)	161 (63.1%)	1	1
Respectful maternity care from the previous health facility for childbirth	No	24 (70.6%)	8 (29.4%)	4.36 [1.88,10.11]	3.84[1.32,11.16] *
	Yes	97 (40.8%)	141 (59.2%)	1	1
Knowledge of women about danger signs during labor and childbirth	No	102 (76.1%)	32 (23.9%)	11.54 [7.05,18.87]	1.67 [0.69,4.07]
	Yes	58 (21.6%)	210 (78.4%)	1	1
Birth preparedness and complication readiness	No	111 (60.3%)	73 (39.7%)	5.24 [3.39,8.09]	3.97 [0.80,19.66]
Birth preparedness and complication readiness	Yes	49 (22.5%)	69 (77.5)	1	1
knowledge of the mother on the importance of institutional delivery	No	102 (59.3%)	70 (40.7%)	4.32 [2.82,6.61]	0.14 [0.02,1.00]
	Yes	58 (25.2%)	172 (74.8%)	1	1

1=reference * = p-value < 0.05.

FSCH=Felege Hiwot Specialized Comprehensive Hospital TSCH=Tibebe Ghion Specialized Comprehensive Hospital FGH=Finote Selam General Hospital, BPH= Burre Primary Hospital, DPH=Dur Bete Primary Hospital, MPH= Merawi Primary Hospital, LPH=Liben Primary Hospital, APH=Addis Alem Primary Hospital, FPH= Feres Bet Primary Hospital.

Strengths of the Study

One of the major strengths of this study is that it included all government hospitals in the West Gojjam Zone, which enhances the representativeness and generalizability of the findings. In addition, this study considered variables that were overlooked in previous research, including respectful maternity care, allowing for a more comprehensive assessment of factors influencing delays in utilizing institutional delivery services.

Limitations of the Study

The findings of this study should be interpreted in light of several limitations. First, recall bias may have been introduced, as mothers were interviewed shortly after childbirth, a period during which they might have been physically and emotionally exhausted, potentially affecting the accuracy of their responses. Second, the cross-sectional nature of the study design limits the ability to establish causal relationships between the identified factors and the outcome. Third, there is the possibility of selection bias, as mothers who delivered at home were not included in the study, which may limit the generalizability of the findings to the broader population. In addition, the use of self-reported measures may have introduced social desirability bias, whereby respondents could have overreported socially acceptable behaviors or underreported undesirable ones. Finally, some variables, such as decision-making autonomy, had relatively small sample sizes within subgroups, which means the confidence intervals were wide, indicating less precise estimates.

Implications for Practice

The implications of the results of this study are relevant to the Ministry of Health and other relevant institutions such as the regional health bureaus, hospital management, and particularly nurses and midwifes who are directly involved in maternal care. The results are vital in the design of interventions that are effective in promoting decision-making for institutional delivery service utilization.

First, the association between the educational level of mothers and the delay in decision-making is very high. This implies that health education, which is a critical role of midwifes and nurses, interventions are essential. Health educators particularly nurses and midwifes in the community and in institutions should design innovative and specific strategies to empower mothers, particularly those without formal education. The success of such interventions could be evaluated by the percentage of women who are aware of institutional delivery services and the percentage reduction in decision-making delay.

Second, the lack of decision-making power is a major contributing factor to decision-making delay. This indicates the need for nurse or midwife led family centered care approaches. This implies that interventions should include the husbands and families of the women via active involvement of nurses or midwifes. Strategies that promote male involvement in reproductive health and decision-making are essential. Key indicators could include the percentage of women who have the autonomy to make healthcare decisions and the percentage of the population that practices joint decision-making.

Third, the delayed care-seeking behavior observed among women with unplanned pregnancies underscores the need to improve family planning activities. This can be achieved by providing access to contraceptive means through comprehensive counselling and education about family planning options by nurses or midwifes, thereby enabling the woman to adequately prepare for delivery. This can be measured using contraceptive prevalence rates and planned pregnancy rates.

Fourth, the lack of antenatal care (ANC) attendance is significantly associated with delayed care-seeking behavior. This underscores the need to improve ANC attendance by encouraging early attendance. This can be achieved by the nurse or midwifes by encouraging pregnant women to start the care early, provide appointment reminders and conduct follow-ups for missed contacts through community outreach programs. The nurse-patient relationship in ANC services can also benefit from strengthening during ANC contact to foster trust and continuity of care. The effectiveness of this intervention can be measured by using ANC coverage, at least one antenatal care contact, and four or more antenatal care contact.

Lastly, negative past experiences with institutional delivery, especially with regards to disrespect from maternity care providers, are associated with delayed care-seeking behavior. This can be addressed by providing respectful maternity care by midwifes and nurses. This can be achieved by providing training to maternity care providers particularly nurses and midwifes. The effectiveness of this intervention can be measured by using patient satisfaction, patient experience, and institutional delivery rates.

Generally, improvement in these areas through concerted efforts of various key stakeholders and constant monitoring through the use of measurable indicators would be instrumental in reducing maternal delays.

Conclusions

This study assessed the magnitude of maternal delay in deciding to utilize institutional delivery services and its associated factors among postnatal mothers. Nearly forty percent of laboring mothers in the government hospitals of the West Gojjam Zone experienced delays in making this decision. Maternal education, decision-making autonomy, unplanned pregnancy, lack of antenatal care follow-up, and absence of respectful maternity care during previous facility-based childbirth were identified as significant factors associated with maternal delay in deciding to utilize institutional delivery services.

Footnotes

Acknowledgments

The authors gratefully acknowledge the support of the persons at West Gojjam zone hospitals, the data collectors, and all study participants for their cooperation and for providing essential information during the data collection process. Appreciation is also extended to colleagues and friends who offered encouragement and assistance throughout the study.

ORCID iDs

Mangistu Abera

Aynalem Belay

Author Contributions

L.G. and A.B. Conceptualization, methodology, and writing- original draft. M.A. and A.B. Data curation, Supervision, and writing-review & editing. T.M. and D.T. Methodology, Formal Analysis, and Writing: Original Draft.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.*

Appendix

References

Abdel-Raheem

S. S.

Al-Attar

G. S.

Mahran

D. G.

Qayed

M. H.

Alib

Z.-A. Z.

Othman

E. E.-D. R.

(2017). Delays associated with maternal near-miss cases admitted in Women's Health Hospital, Assiut University. Journal of Current Medical Research and Practice, 2(1), 1–9. https://doi.org/10.4103/jcmrp.jcmrp_22_16

Abdullah

A. S. M.

Hossain

Rahman

Halim

Biswas

(2017). Community Delay in Decision Making and Transferring Complicated Mothers at Facilities Caused Maternal Deaths: A Qualitative Study in Rural Bangladesh. J. Glob. Health, 1(3), 1–6.

Aden

J. A.

Ahmed

H. J.

Östergren

P.-O.

(2019). Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach. Global health action, 12(1), 1672314. https://doi.org/10.1080/16549716.2019.1672314

Asefa

Bekele

(2015). Status of respectful and non-abusive care during facility-based childbirth in a hospital and health centers in Addis Ababa, Ethiopia. Reproductive health, 12(1), 33. https://doi.org/10.1186/s12978-015-0024-9

Awel

Bagilkar

V. V.

Fekecha

(2021). Delay in seeking institutional delivery service utilization and associated factors among mothers attending Jimma Medical Center, Jimma, Ethiopia. Risk Management and Healthcare Policy, 14, 1255–1262. https://doi.org/10.2147/RMHP.S295683

Baharuddin

Amelia

Suhowatsky

Kusuma

Suhargono

M. H.

Eng

(2019). Maternal death reviews: A retrospective case series of 90 hospital-based maternal deaths in 11 hospitals in Indonesia. International Journal of Gynecology & Obstetrics, 144(Suppl 1), 59–64. https://doi.org/10.1002/ijgo.12736

Bulto

G. A.

Demissie

D. B.

Tulu

A. S.

(2020). Respectful maternity care during labor and childbirth and associated factors among women who gave birth at health institutions in the West Shewa zone, Oromia region, Central Ethiopia. BMC pregnancy and childbirth, 20(1), 443. https://doi.org/10.1186/s12884-020-03135-z

Burrowes

Holcombe

S. J.

Jara

Carter

Smith

(2017). Midwives’ and patients’ perspectives on disrespect and abuse during labor and delivery care in Ethiopia: a qualitative study. BMC pregnancy and childbirth, 17(1), 263. https://doi.org/10.1186/s12884-017-1442-1

Carvalho

O. M. C.

Junior

A. B. V.

Augusto

M. C. C.

Leite

Á. J. M.

Nobre

R. A.

Bessa

O. A. A. C.

de Castro

E. C. M.

Lopes

F. N. B.

Carvalho

F. H. C.

(2020). Delays in obstetric care increase the risk of neonatal near-miss morbidity events and death: a case-control study. BMC pregnancy and childbirth, 20(1), 437. https://doi.org/10.1186/s12884-020-03128-y

10.

Chavane

L. A.

Bailey

Loquiha

Dgedge

Aerts

Temmerman

(2018). Maternal death and delays in accessing emergency obstetric care in Mozambique. BMC pregnancy and childbirth, 18(1), 71. https://doi.org/10.1186/s12884-018-1699-z

11.

Edhs

(2019). Ethiopia Mini Demographic and Health Survey 2019:Rockville, Maryland, USA: EPHI and ICF . 2019. https://www.unicef.org/ethiopia/media/1721/file/The_2019_Ethiopia_Mini_Demographic_and_Health_Survey_pdf

12.

El Gelany

Mansour

M. G.

Hassan

(2015). The three delays of maternal mortality in a public-sector tertiary teaching hospital: is there a paradigm shift? Gynecology and Obstetrics Research, 2(2), 52–56. https://doi.org/10.17140/goroj-2-112

13.

Getachew

Kassa

G. M.

Ayana

Amsalu

(2017). Knowledge of direct obstetric causes of maternal mortality and associated factors among reproductive age women in aneded woreda, northwest Ethiopia; a cross-sectional study. The Pan African Medical Journal, 27, 32. https://doi.org/10.11604/pamj.2017.27.32.10274

14.

Ghumare

J. P.

Padvi

N. V.

(2018). Assessment of maternal deaths using three delay model at a tertiary care centre in rural Maharashtra, India: retrospective six-year study. Int J Reprod Contracept Obstet Gynecol, 7(8), 3043–3047. https://doi.org/10.18203/2320-1770.ijrcog20182956

15.

Kamal

S. M.

(2013). Preference for institutional delivery and caesarean sections in Bangladesh. Journal of health, population, and nutrition, 31(1), 96–109. https://doi.org/10.3329/jhpn.v31i1.14754

16.

Kari

Angolkar

(2021). Assessment of knowledge & practice of Birth Preparedness and Complication Readiness among ASHAs–A pilot study. Clinical Epidemiology and Global Health, 9, 175–178. https://doi.org/10.1016/j.cegh.2020.08.010

17.

Karmacharya

Jasienska

Bissell

Wasti

S. P.

Bajracharya

(2016). Factors influencing the utilization of health facilities for childbirth in a disadvantaged community of Lalitpur, Nepal. Nessa Journal of Gynecology, 1(1).

18.

Karmacharya

Jasienska

Bissell

Wasti

S. P.

Bajracharya

(2017). Factors influencing the utilization of health facilities for childbirth in a disadvantaged community of Lalitpur, Nepal. Journal of Gynecology, 1(1), 1–27.

19.

Lassi

Z. S.

Middleton

Bhutta

Z. A.

Crowther

(2019). Health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review of observational and qualitative studies. F1000Res, 8, 200. https://doi.org/10.12688/f1000research.17828.1

20.

Limenih

M. A.

Belay

H. G.

Tassew

H. A.

(2019). Birth preparedness, readiness planning and associated factors among mothers in Farta district, Ethiopia: a cross-sectional study. BMC pregnancy and childbirth, 19(1), 171. https://doi.org/10.1186/s12884-019-2325-4

21.

Lire

Beyamo

Tadele

Facha

(2017). Delays for utilizing institutional delivery and associated factors among mothers attending public health facility in Hadiya Zone, Southern Ethiopia. Science, 5(6), 149–157.

22.

Mekonnin

A. W.

Mengesha

E. W.

Dinku

(2019). Delay in maternal near miss case and associated factors among women admitted in Felege Hiwot comprehensive specialized hospital, Northwest Ethiopia.

23.

Mengesha

M. B.

Desta

A. G.

Maeruf

Hidru

H. D.

(2020). Disrespect and Abuse during Childbirth in Ethiopia: A Systematic Review. Biomed Res Int, 2020, Article 8186070. 2020. https://doi.org/10.1155/2020/8186070

24.

Mgawadere

Unkels

Kazembe

van den Broek

(2017). Factors associated with maternal mortality in Malawi: application of the three delays model. BMC pregnancy and childbirth, 17(1), 219. https://doi.org/10.1186/s12884-017-1406-5

25.

Morof

Serbanescu

Goodwin

M. M.

Hamer

D. H.

Asiimwe

A. R.

Hamomba

Musumali

Binzen

Kekitiinwa

Picho

Kaharuza

Namukanja

P. M.

Murokora

Kamara

Dynes

Blanton

Nalutaaya

Luwaga

Schmitz

M. M.

Clark

(2019). Addressing the third delay in Saving Mothers, Giving Life districts in Uganda and Zambia: ensuring adequate and appropriate facility-based maternal and perinatal health care. Global Health: Science and Practice, 7(Supplement 1), S85–S103. https://doi.org/10.9745/GHSP-D-18-00272

26.

Sageer

Kongnyuy

Adebimpe

W. O.

Omosehin

Ogunsola

E. A.

Sanni

(2019). Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria. BMC pregnancy and childbirth, 19(1), 1–8. https://doi.org/10.1186/s12884-019-2202-1

27.

Serbanescu

Goldberg

H. I.

Danel

Wuhib

Marum

Obiero

McAuley

Aceng

Chomba

Stupp

P. W.

Conlon

C. M.

(2017). Rapid reduction of maternal mortality in Uganda and Zambia through the saving mothers, giving life initiative: results of year 1 evaluation. BMC pregnancy and childbirth, 17(1), 42. https://doi.org/10.1186/s12884-017-1222-y

28.

M. I. K.

Paswan

Anand

Mondal

N. A.

(2019). Praying until death: revisiting three delays model to contextualize the socio-cultural factors associated with maternal deaths in a region with high prevalence of eclampsia in India. BMC pregnancy and childbirth, 19(1), 314. https://doi.org/10.1186/s12884-019-2458-5

29.

Sumankuuro

Mahama

M. Y.

Crockett

Wang

Young

(2019). Narratives on why pregnant women delay seeking maternal health care during delivery and obstetric complications in rural Ghana. BMC pregnancy and childbirth, 19(1), 1–13. https://doi.org/10.1186/s12884-019-2414-4

30.

Tefera

E. G.

Abdisa

F. W.

Erena

M. M.

(2017). Assessment of Knowledge, Attitude and Practice of skilled assistance seeking for maternal healthcare services and associated factors among Women in West shoa zone, Oromia, Region, Ethiopia. Research Square, 1(1), 1–23. https://doi.org/10.21203/rs.2.15907/v1

31.

Thaddeus

Maine

(1994). Too far to walk: maternal mortality in context. Social science & medicine, 38(8), 1091–1110. https://doi.org/10.1016/0277-9536(94)90226-7

32.

Unfpa

(2019). Organization WH, Group WB, Division the UNP. Trends in Maternal Mortality: 2000 to 2017| UNFPA-United Nations Population Fund. WHO, UNICEF. UNFPA, World Bank Gr. theUnited Nations Popul, 504, 104.

33.

Wanaka

Hussen

Alagaw

Tolosie

Boti

(2020). Maternal delays for institutional delivery and associated factors among postnatal mothers at public health facilities of Gamo zone, Southern Ethiopia. International journal of women's health, 12, 127–138. https://doi.org/10.2147/IJWH.S240608

34.

Wassihun

Zeleke

(2018). Compassionate and respectful maternity care during facility based child birth and women’s intent to use maternity service in Bahir Dar, Ethiopia. BMC pregnancy and childbirth, 18(1), 294. https://doi.org/10.1186/s12884-018-1909-8

35.

WHO . (2015). WHO safe childbirth checklist implementation guide: improving the quality of facility-based delivery for mothers and newborns.

36.

WHO . (2017). Global strategy for women's, children's and adolescents' health (2016-2030). Organization, 2016(9).

37.

Wondu

Dibaba

Amdemichae

(2019). Prevalence and associated factors with maternal delays in seeking emergency obstetric care in Arsi Zone, Oromiya, Ethiopia cross-sectional study design. Gynecol Obstet (Sunnyvale), 9(496), 2161–2932. 1000496.

38.

Yarinbab

T. E.

Balcha

S. G.

(2018). Delays in utilization of institutional delivery service and its determinants in Yem Special Woreda, Southwest Ethiopia: health institution based cross-sectional study. J Gynecol Women’s Health, 10(3), 555793.