AIDS: Acquired Immune Deficiency Syndrome; ANC: Antenatal Care; CI: Confidence Interval; HD: Home Delivery; HF: Health Facility; HIV: Human Immunodeficiency Virus; HSDP: Health Survey Demographic Program; ID: Institutional Delivery; KM: Kilo Meter; MCH: Maternal Child Health; OR: Odd Ratio; TBA: Traditional Birth Attendant; TTBA: Trained Traditional Birth Attendant; WHO: World Health Organization

According to WHO, safe delivery service is one of the most important maternity care issues for women who are pregnant. Delivery is performed by someone with midwifery skills who is able to manage a normal delivery and who can recognize and manage obstetric complications and can refer in a timely manner [1].

Safe delivery practices and antenatal care are among the most effective health interventions for preventing maternal morbidity and mortality particularly in places were general health status of the women is poor. The antenatal period presents an important opportunity for identifying threats to the mother and unborn baby’s health status, as well as for counseling on birth preparedness, delivery care and family planning options after the birth [2,3]. Globally, 211 million pregnancies and 136 million births occur every year. Pregnancy and child birth process put every woman at risk of complications but 99% of the maternal complication/deaths that occur in developing countries are avoidable or preventable.

Maternal mortality is the highest by far in sub-Saharan Africa, where the life time risk of death from pregnancy related conditions is 1 in 16, compared with 1 in 2800 in rich countries [1,4]. According to EDHS 2005 and 2011 the levels of maternal and infant morbidity and mortality Ethiopia, are among highest in the world. There are 673 and 676 maternal deaths for every 100,000 live birth and the infant mortality rate was 39 and 37 per 1, 000 live births but the rate of institutional delivery, ANC follow up and MCH are remain lower even though they are major indicators of health service utilization in one country. Institutional deliveries at public and private hospitals, health centers and clinics were estimated to be 6%-10%. This implies that majority of pregnant women depend on assistance of non-medical personal like relatives, neighbors and TBA during their delivery [3]. By contrast, the rate of institutional deliveries for developed countries is about 95% [5-7].

Study conducted in Tanzania and WHO indicated as perceived key determinants of selection of place of delivery were lack of socio economic status/money, lack of transport, sudden onset of labor, short labor duration, staff attitudes, lack of privacy, reproductive behaviour, traditions and cultures and the patterns of decision making power within household [2,8-12].

Also amidterm assessment of the third Ethiopian Health Sector Development Program (HSDP III) identified poor quality skilled birth attendance as one of the critical bottlenecks for improving the lower utilization of hospital delivery. The study also suggested not only the quality of clinical care but also gender sensitivity, preservation of dignity and cultural sensitivity are among the factors explained the low utilization of health services for delivery [13-19].

In general identifying factors that determining the choice of place of delivery is greatly contribute to reduce maternal mortality and morbidity. In view of the fact that our country Ethiopia is among the developing country in which the maternal mortality rate estimates the range between 720 per100.000 live births and it is among the means thus used to reduce maternal mortality and morbidity [20]. But in Ethiopia, specifically in Jimma, studies showing the clear picture of predictors of choice of place of delivery have not been conducted. Thus, this study is proposed to fill this information gap in Jimma zone with the potential of generalizability of its result to similar settings and population of the country at large.

A community-based cross-sectional study was conducted from February-April 2014, in Jimma town which is one of the biggest towns in Ethiopia. It is located 352 Kms Southwest of the capital city Addis Ababa. The town hasthree districts (Woredas) and 13 sub-districts (kebeles). The number of households reported in the town is about 32,191 and the total population of Jimma town is 120,960. Total number of pregnant women, non-pregnant women and women of child bearing age as estimated from the total populations of town in the 2007 population and housing census of Ethiopia comprises 5738, 27,786, and 33,373 respectively [3].

Study population for this study were all sampled pregnant women and selected by systematic sampling technique using the house number as sampling frame. The first house was selected using lottery method. In cases the absence for eligible subject the immediate next house was considered.

Data were collected through face to face interview using pre–tested structured questionnaire which were grouped and arranged according to the particular objectives that they can address.

Prior to analysis, data cleaned and entered into SPSS version 16.0.statistical packages, checking for normality, completeness, and inconsistencies was also done. In addition to descriptive statistics, chisquare test was employed to assess for association between dependent and independent variables of the study. Statistical significance was declared at P<0.05.

Ethical consideration

A copy of research proposal was submitted to Jimma University College of Public Health and Medical Sciences Department of Nursing and Midwifery and Ethical clearance was obtained and permission from respective authorities and verbal consent of respondents’ was obtained before the data collection. To get full co-operation, respondents were reassured about the confidentiality of their response. They were also ensured their voluntarily participation and right to take part or terminate at any time they wanted.

Socio-demographic characteristics

Out of the total 281 filled interview questioner 277(98.6%) were included in analysis and four were incomplete and rejected. Of the total 277,78 (28.16%) were in age range of 25-29, 125(45.13%) Muslim, 120(43.32%) had primary level of education, 265(59.57%) were house wife, 157(56.68%) were Oromo and 270(97.47%) had family support (Table 1).

Table 1: Distribution of respondents by their socio demographic characteristics Jimma, February - April, 2014.

Obstetric characteristics

From 277 respondents majority 228(82.31%) had ANC follow up, out of this 138(60.53%) visit on the first 3 months of pregnancy, 96(34.66%) were para one, 259(93.5%) were delivered normally and 263(94.95%) had wanted pregnancy (Table 2).

Table 2: Distribution of the respondent by their obstetric characteristics Jimma, February - April, 2014.

Attitude (perception at home versus at health facility) towards institutional delivery

Out of 277 mothers participated in the study 96.03% had positive attitude towards institutional delivery and the rest 11(3.97%) had negative (Figure 1).

Figure 1: Distribution of the respondents by attitude towards institutional delivery Jimma, February - April, 2014.

Knowledge on choice of place of delivery

Out of the total 277 (98.56%) all of them were knew about safe delivery practice.

Choice of place of delivery

Out of the total 277 (98.56%) who were interviewed 179(64.62%) had choice to deliver in health institution (Figure 2).

Figure 2: Distribution of the respondents by choice of place of delivery in Jimma, February - April, 2014.

Table 3 indicates the relationship among socio-demographic and obstetric characteristics and place of delivery.

Table 3: Distribution of the study population by Socio-demographic and Obstetric characteristics and place of delivery, Jimma, February - April, 2014.

Reason for home delivery

Economy and short duration/uncomplicated labour were the predominant reason given by 86.74% of the women who had home delivery of their last child. Fear of interventions and repeated examinations (attitude) at hospitals was the concern of 13.26% of the women who preferred home delivery and 14(14.3%) of them were less than 40 minute away in terms of time from health facility and it is not their problem (Table 4).

Table 4: Distribution of the study population by reason for home delivery and Distance from health facility in terms of time in Jimma, February - April, 2014

Association between dependent and independent variables

There was a significant association between age group, level of education, religion, Ethnicity, ANC follow up, parity and choice of place of delivery (p-value <0.05) (Table 5).

Table 5: Association between factors and place of delivery in Jimma, February - April, 2014.

In this study 98(35.38%) of the study participants selected home delivery. This result was less than what have been observed in the study conducted in Kenya, Nyandarua, South Distrrict in which 51.8% is home delivery, in Ethiopia (EDHS 2005 and 2011) where home delivery accounts for 96.3% , 91.5% in Oromia region respectively and Jimma zone in which home delivery was 71% [3,10,17]. The possible explanation for this difference may be the difference in study period, socio-economic characteristic and educational level variation which influences positively selection of place of delivery, current strategies of governments for better access to information, awareness about the advantages of institutional delivery.

The predictors for choice of place of delivery were: income, feeling of privacy and being surrounded by family members and friends, fear of interventions (medical - surgical), repeated vaginal examination, educational status, parity, religion, age of the mothers and history antenatal follow up. This finding is consistent with what have been observed in the study conducted in Northern Nigeria [9], Northern Gondar Zone [11], Tigray, Samre Saharti District [20], Jimma zone, Shabe Town [12] where the stated predictors for choice of place of delivery were: income, privacy, fear, repeated vaginal examination, educational level, parity, age of the mothers, history antenatal follow up, history of complicated obstetric history, attitude of the mothers, Advice given during follow up.

This study identified that, more than one third 98(35.38%) were selected of home delivery. The predictors for selection of place of delivery were: income, privacy, fear intervention, repeated vaginal examination, mothers’ level of education, parity, age of the mothers, history antenatal follow up and advices given during follow up.

Thus responsible authorities, policy makers and interested body should have to discuss on this issue to provide community based health education, awareness creation and improve better access to information for mothers regarding maternal institutional delivery. Moreover, further prospective studies are recommended in terms of the involvements of husbands as their involvement is believed crucial for selected of place of delivery.

We would like to thank Jimma University for providing usfinancial support. We also wish to express our deepest appreciation to all friends for their continuous guidance, constructive comments and suggestions. Last but not least we would like to acknowledge Jimma town administrators and all of the study participants for their willingness to provide the necessary information required for this study.