Determinants of maternal health service utilization in Ethiopia: analysis of the 2011 Ethiopian Demographic and Health Survey

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Title:
Determinants of maternal health service utilization in Ethiopia: analysis of the 2011 Ethiopian Demographic and Health Survey
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English
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Tarekegn, Shegaw Mulu
Lieberman, Leslie Sue
Giedraitis, Vincentas
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Bio Med Central (BMC Pregnancy & Childbirth)
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Abstract:
Background: Antenatal Care (ANC), use of skilled delivery attendants and postnatal care (PNC) services are key maternal health services that can significantly reduce maternal mortality. Understanding the factors that affect service utilization helps to design appropriate strategies and policies towards improvement of service utilization and thereby reduce maternal mortality. The objective of this study was to identify factors that affect utilization of maternal health services in Ethiopia. Methods: Data were drawn from the 2011 Ethiopia Demographic and Health Survey. The dependent variables were use of ANC, skilled delivery attendants and PNC services. The independent variables were categorized as socio-cultural, perceived needs and accessibility related factors. Data analysis was done using SPSS for windows version 20.0. Bivariate and multivariate logistic regression models were used in the analysis. Results: Thirty four percent of women had ANC visits, 11.7% used skilled delivery attendants and 9.7% of women had a postnatal health checkup. Education of women, place of residence, ethnicity, parity, women’s autonomy and household wealth had a significant association with the use of maternal health services. Women who completed higher education were more likely to use ANC (AOR = 3.8, 95% CI = 1.8-7.8), skilled delivery attendants (AOR = 3.4, 95% CI = 1.9-6.2) and PNC (AOR = 3.2, 95% CI = 2.0-5.2). Women from urban areas use ANC (AOR = 2.3, 95% CI = 1.9-2.9), skilled delivery attendants (AOR = 4.9, 95% CI = 3.8-6.3) and PNC services (AOR = 2.6, 95% CI = 2.0-3.4) more than women from rural areas. Women who have had ANC visits during the index pregnancy were more likely to subsequently use skilled delivery attendants (AOR = 1.3, 95% CI = 1.1-1.7) and PNC (AOR = 3.4, 95% CI = 2.8-4.1). Utilization of ANC, delivery and PNC services is more among more autonomous women than those whose spending is controlled by other people. Conclusion: Maternal health service utilization in Ethiopia is very low. Socio-demographic and accessibility related factors are major determinants of service utilization. There is a high inequality in service utilization among women with differences in education, household wealth, autonomy and residence. ANC is an important entry point for subsequent use of delivery and PNC services. Strategies that aim improving maternal health service utilization should target improvement of education, economic status and empowerment of women. Keywords: Antenatal care, Delivery, Postnatal care, Maternal health service, Determinants, Skilled delivery attendant, Ethiopia
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Tarekegn et al. BMC Pregnancy and Childbirth 2014, 14:161 http://www.biomedcentral.com/1471-2393/14/161; Pages 1-13
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doi:10.1186/1471-2393-14-161 Cite this article as: Tarekegn et al.: Determinants of maternal health service utilization in Ethiopia: analysis of the 2011 Ethiopian Demographic and Health Survey. BMC Pregnancy and Childbirth 2014 14:161.

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RESEARCHARTICLEOpenAccessDeterminantsofmaternalhealthservice utilizationinEthiopia:analysisofthe2011 EthiopianDemographicandHealthSurveyShegawMuluTarekegn1*,LeslieSueLieberman2andVincentasGiedraitis3AbstractBackground: AntenatalCare(ANC),useofskilleddeliveryattendantsandpostnatalcare(PNC)servicesarekey maternalhealthservicesthatcansignificantlyreducematernalmortality.Understandingthefactorsthataffect serviceutilizationhelpstodesignappropriatestrategiesandpoliciestowardsimprovementofserviceutilizationand therebyreducematernalmortality.Theobjectiveofthisstudywastoidentifyfactorsthataffectutilizationof maternalhealthservicesinEthiopia. Methods: Dataweredrawnfromthe2011 EthiopiaDemographicandHealthSurvey .Thedependentvariableswere useofANC,skilleddeliveryattendantsandPNCservices.Theindependentvariableswerecategorizedas socio-cultural,perceivedneedsandaccessibilityrelatedfactors.DataanalysiswasdoneusingSPSSforwindows version20.0.Bivariateandmultivariatelogisticregressionmodelswereusedintheanalysis. Results: ThirtyfourpercentofwomenhadANCvisits,11.7%usedskilleddeliveryattendantsand9.7%ofwomen hadapostnatalhealthcheckup.Educationofwomen,placeofresidence,ethnicity,parity,women ’ sautonomyand householdwealthhadasignificantassociationwiththeuseofmaternalhealthservices.Womenwhocompleted highereducationweremorelikelytouseANC(AOR=3.8,95%CI=1.8-7.8),skilleddeliveryattendants(AOR=3.4, 95%CI=1.9-6.2)andPNC(AOR=3.2,95%CI=2.0-5.2).WomenfromurbanareasuseANC(AOR=2.3,95% CI=1.9-2.9),skilleddeliveryattendants(AOR=4.9,95%CI=3.8-6.3)andPNCservices(AOR=2.6,95%CI=2.0-3.4) morethanwomenfromruralareas.WomenwhohavehadANCvisitsduringtheindexpregnancyweremorelikely tosubsequentlyuseskilleddeliveryattendants(AOR=1.3,95%CI=1.1-1.7)andPNC(AOR=3.4,95%CI=2.8-4.1). UtilizationofANC,deliveryandPNCservicesismoreamongmoreautonomouswomenthanthosewhose spendingiscontrolledbyotherpeople. Conclusion: MaternalhealthserviceutilizationinEthiopiaisverylow.Socio-demographicandaccessibilityrelated factorsaremajordeterminantsofserviceutilization.Thereisahighinequalityinserviceutilizationamongwomen withdifferencesineducation,householdwealth,autonomyandresidence.ANCisanimportantentrypointfor subsequentuseofdeliveryandPNCservices.Strategiesthataimimprovingmaternalhealthserviceutilization shouldtargetimprovementofeducation,economicstatusandempowermentofwomen. Keywords: Antenatalcare,Delivery,Postnatalcare,Maternalhealthservice,Determinants,Skilleddeliveryattendant, Ethiopia *Correspondence: shegawmulu@gmail.com1DepartmentofHealthManagementInformationSystems,Tulane International,AddisAbaba,Ethiopia Fulllistofauthorinformationisavailableattheendofthearticle 2014Tarekegnetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublicDomain Dedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle, unlessotherwisestated.Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161 http://www.biomedcentral.com/1471-2393/14/161

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BackgroundWorldwide,approximately800womendieeveryday frompreventablecausesrelatedtopregnancyandchildbirth.In2010,about287,000womendiedworldwide duringandfollowingpregnancyandchildbirth[1,2]. Thoughthisisadeclineof47%fromthe1990level,itis stillfarfromthe2015MillenniumDevelopmentGoal (MDG).ThefifthMDGcallsforareductioninthematernalmortalityratioby75%between1990and2015. ThekeyindicatorstomeasurethisgoalaretheproportionofpregnantmotherswhoreceivedANCandthe proportionofbirthsattendedbyskilleddeliveryattendants[1,3]. Despiteproveninterventionsthatcouldpreventdeath ordisabilityduringpregnancyandchildbirth,maternal mortalityremainsamajorburdeninmanydeveloping countries.Maternalmortalitycontinuestobeamajor challengeinAfricaandthematernalmortalitydisparity betweendevelopinganddevelopedcountriesisvery high.Thematernalmortalityratio(MMR)indeveloping regionsis15timeshigherthaninthedevelopedregions [1,3,4]andsubSaharanAfricancountrieshavethehighestMMRintheworldwithanaverageof500maternal deathsper100,000livebirths,accountingforhalfofthe world ’ stotalmaternaldeaths[1,2,5].Mostwomendie becausetheygivebirthwithouttheattendanceofa skilledhealthworker[1,2]. Ethiopiaisoneofthecountrieswithhighmaternal mortality.TheMMRwas871per100,000intheyear 2000;itwas673per100,000livebirthsin2005and676 per100,000in2011.Maternaldeathsrepresent30%of alldeathstowomenage15 – 49,comparedwith21%in the2005EDHSand25%inthe2000EDHS[6-8]. Evidenceshowsthathighmaternal,neonatalandchild mortalityratesareassociatedwithinadequateandpoorqualitymaternalhealthcare[9].Moreover,evidences alsoshowthatkilledcarebefore,duringandafterchildbirthsavesthelivesofwomenandnewbornbabies.An estimated74%ofmaternaldeathscouldbeavertedifall womenhadaccesstotheinterventionsforpreventingor treatingpregnancyandbirthcomplications,inparticular emergencyobstetriccare[10].Asaresult,theuseof ANC,skilleddeliveryattendantsandPNCarerecognizedaskeymaternalhealthservicestoimprovehealth outcomesforwomenandchildren[1,9]. Theantenatalperiodiscriticallyimportantforreachingwomenwithinterventionsandinformationthatpromotehealth,wellbeingandsurvivalofmothersaswell astheirbabies.Thecoverageofatleastonevisitwitha doctor,nurseormidwifehasprogressivelyincreasedin developingregionsfrom63%in1990to71%in2000, andthento80%in2010.InEthiopia,accordingtothe EDHSreports,thepercentageofwomenwithatleast oneANCvisitbyahealthprofessionalwasonly28%in 2005and33%in2011[7,8].InEthiopia,Only19%had4 ANCvisitsasrecommendedbytheWHO[8]. Sub-SaharanAfricaistheregionwiththelowestcoverageofskilleddeliveryutilization,withonly45%ofwomen havingskilleddeliveryattendants[3].InEthiopia,skilled deliveryutilizationisverylowwithonly10%ofwomen havingdeliveredwithanassistanceofaskilleddeliveryattendant.ThePNCutilizationinEthiopiaisalsoverylow, withonly7%ofwomenhavingpostnatalcareservicein thefirst2daysafterdelivery[8]. Theobjectivesofthisresearchare: 1.TodeterminethelevelofutilizationofANC,skilled deliveryattendantsandPNCservicesinEthiopia. 2.ToidentifyfactorsthataffecttheutilizationofANC, useofskilleddeliveryattendantsandPNCservices inEthiopia. Theresearchanswersthefollowingquestionsrelated withutilizationofmaternalhealthservicesinEthiopia. 1.WhatisthelevelofutilizationofANC,deliveryand PNCserviceinEthiopia? 2.Whichfactors(suchasage,education,parity, ethnicity,religion,geographiclocation)arerelatedto maternalhealthserviceutilizationinEthiopia? ” Understandingthefactorsthataffecttheutilizationof theseimportantmaternalhealthservicescanhelpdesign strategiesanddeveloppoliciestowardimprovementof serviceutilizationinthecountry;andthereby,willaidin decreasingmaternalmortality.MethodsThisstudyutilizedsecondarydatafromthe2011EthiopianDemographicandHealthSurvey(EDHS).Thedata arethoroughlyanalyzedusingbivariateandmultivariate logisticregression.Thesurveydataweredownloaded fromMeasureDHSwebsiteafterdatausepermission wasguaranteed.The2011EDHSispartoftheworldwideMEASUREDHSprojectwhichwasfundedbythe UnitedStatesAgencyforInternationalDevelopment (USAID)andwasimplementedbytheEthiopianCentral StatisticalAgency.ADHSisundertakenevery5years andthe2011surveyisthethirdDHSinEthiopia.The firstDHSwasperformedin2000andthesecondwas performedin2005[11].StudydesignItisacommunitybasedanalyticalcrosssectionalstudy. Thedatawascollectedfromarepresentativesampleof womeninthereproductiveagegroup(age15-49)from allregionsinEthiopia.TheanalysisisbasedondataTarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page2of13 http://www.biomedcentral.com/1471-2393/14/161

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fromwomenwhohadatleastonebirthduringthe 5yearsprecedingthesurvey(8).StudypopulationSourcepopulation: Thesourcepopulationforthis studywasallwomenwhoareinthereproductiveage group(aged15to49years). Studysubjects: Thestudysubjectswerewomenaged 15to49yearswhogaveatleastonebirthinthelast 5yearsprecedingthesurvey.SamplesizeAnationalrepresentativesampleof17,817households wasselectedforthestudy.Fromthesehouseholds,atotal of16,515womeninthereproductiveagegroupwere interviewedusingastructuredquestionnaire(8).Forthis study,womenwhohadatleastonebirthinthelastfive yearsprecedingthesurveywereincludedintheanalysis.SamplingproceduresAstratified,twostageclustersamplingprocedurewas usedtoidentifytherepresentativesamples.Thesampling frameforthe2011EDHSconsistsofatotalof85,057 EnumerationAreas(EAs).AnEAisageographicarea consistingofaconvenientnumberofdwellingunits.On thefirststage,624EAswereselectedfromthetotalEAs usingprobabilitytoproportionalsizemethod.Then,on thesecondstage,afixednumberof30householdswere selectedfromeachEA.Atotalof17,817householdswere includedintheinterview(8). ThesamplingframeexcludedsomespecialEAswith disputedboundaries.TheseEAsrepresentonly0.1%of thetotalpopulation.InSomaliregion,allthelisted householdswerenotincludedintheinterviewdueto droughtandsecurityreasonswhichmakesthedatafor theregionnotrepresentative.However,thenational samplewillnotbeaffectedbecauseofthesmallproportionoftheregion ’ spopulation(8).DatacollectionproceduresAstructuredandpre-testedquestionnairewasusedasa toolfordatacollection.ThequestionnairewasdevelopedinEnglishandthentranslatedintothreedifferent locallanguages(Amharic,OromiffaandTigrigna).The questionnairewasdevelopedbasedonstandardDHS surveyquestionnaires.Structuredinterviewschedules wereperformedbytrainedinterviewers.Inorderto maintainthequalityofdatatobecollected,interviewers weretrained,apretestwasperformedbeforetheactual datacollection,frequentsupervisionwasperformedduringdatacollectionandinterviewswereperformedusing locallanguages(8).OperationaldefinitionsSkilledattendants: Professionalswhohavemidwifery skillsincludingdoctors,midwifesandnurses. ANCbyskilledattendants: Pregnancycareprovided byskilledhealthprofessionals(doctors,midwivesor nurses)duringtherespondent ’ srecentpregnancy. Useofskilleddeliveryattendants: Deliverycareprovidedbyskilledhealthprofessionals(doctors,midwives ornurses)duringtherespondent ’ srecentbirth. Postnatalcare: Careprovidedtowomenwithin 42daysafterdelivery. Woman ’ sautonomy: Amoreautonomouswomanis awomanwhocandecideonhealthcarespendingalone orwithherhusband.Ifthedecisionofhealthcare spendingiscontrolledbyothers(husbandonlyorother people),itisconsideredasnon-autonomous.DataanalysisproceduresAnalysiswasdoneusingSPSSversion20.0.Bivariate andmultivariateanalysistechniqueswereusedduring analysis.Frequencieswerefirstdeterminedfollowedby crosstabulationstocomparefrequencies.Atbivariate level,analysiswasmadebythechisquare(X2)testfor categoricalvariables.Theassociationbetweendependent andindependentvariableswasmeasuredbymeansof oddsratioforwhich95%confidenceintervalwascalculated.Variablesthatshowastatisticallysignificantassociation(p<0.05)atbivariatelevelwerefurtheranalyzed atmultivariatelevelbylogisticregression.Allthevariableswereincludedinthemultivariatemodeloncethey weresignificantlyassociatedatthebivariatelevel.Thisis becausethesevariablesshowedaninfluenceontheoutcomevariableandthereisaneedtoidentifywhether eachhasbeenconfoundedbyanothervariableornot. Theadjustedoddsratio(AOR)wasusedtodetermine thepresenceofassociationbetweenthedependentand independentvariablesforwhich95%CIwasdetermined. Wheneverthereisanon-proportionalallocationof samples,useofsampleweightsisanimportantstepduringanalysis[12].DuringEDHS2011,therewassome non-proportionalallocationofthesamplestothedifferentregionsandtheirurbanandruralareasinorderto compensateforplaceswithverylowfamilyplanning coverageandlowfertilityareas.Inordertoensurethe actualrepresentativenessofsurveyresultsatnational level,samplingweightsareusedduringtheanalysis. ThesamplingusedduringtheEDHS2011isatwostagestratifiedclustersamplemethodology.Asaresult, sampleweightswerecalculatedbasedonsamplingprobabilitiesseparatelyforeachsamplingstageandforeach cluster.Thefirststageissamplingprobabilityofeach clusterineachstratumandthesecondstagecomprises ofsamplingprobabilitywithineachcluster(households selected).ComputationofthesamplingprobabilityforTarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page3of13 http://www.biomedcentral.com/1471-2393/14/161

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clustersandhouseholdsiscomputedbasedonwhatthe EDHShavecomputed.Thecompletesampleweight computationisavailablewiththedatasetthatweget frommeasureevaluation(8).ConceptualframeworkandvariablesofthestudyTheconceptualframeworkforthisstudywasdeveloped basedonAndersen ’ sbehavioralmodelandthethreedelaysmodelofmaternalhealthcareutilization[13,14].The conceptualframeworkofthestudyisshownonFigure1. Andersen ’ sbehavioralmodelexaminestheinfluenceof individuals'demographiccharacteristicsandhealthdeliverysystemvariablesonutilizationpatterns.Ithypothesizes thatthedecisiontoseekmedicalhelpisafunctionof threesetsofvariables: i.Predisposingfactors,suchasage,sex,maritalstatus, familysize,socialstatus,educationandethnicity/race. ii.Enablingfactors:includesthelogisticalaspectsof obtainingcarewhichincludesfamilyincome,health insurance,serviceavailabilityandtravel. iii.Theneedtouseservicefactor:perceivedneed,i.e. "Howpeopleviewtheirowngeneralhealthand functionalstate,aswellashowtheyexperience symptomsofillness,pain,andworriesabouttheir healthandwhetherornottheyjudgetheirproblems tobeofsufficientimportanceandmagnitudetoseek professionalhelp"[ 13 ]. Thethreedelaysmodelidentifiesthreegroupsoffactorswhichmaystopwomenandgirlsaccessingthe levelsofmaternalhealthcarethattheyneed:Theseare Phase1:Delayindecisiontoseekcare:mainly socio-demographicfactors Phase2:Delayinreachingcare:relatedwithfactorsof physicalandeconomicalaccessibility Phase3:Delayinreceivingadequatehealthcare:factors relatedwithqualityofhealthcareinfacilities[ 14 ].EthicalconsiderationEthicalclearanceforthesurvey(EDHS2011)wasprovidedbytheEthiopianHealthandNutritionResearch Institute(EHNRI)ReviewBoard,theNationalResearch EthicsReviewCommittee(NRERC)attheMinistryof ScienceandTechnology,theInstitutionalReviewBoard ofICFInternational,andtheCDC.Respondentswere informedaboutthesurveyandconsentwastakenfor theirparticipation.Voluntaryparticipationwasensured duringinterviews(8).Theresearcherhasreceivedthe surveydatafromMeasureDHSuponsubmissionofa proposal.AfterdataaccessisauthorizedfromMeasure DHS,theresearcherofthisstudyhasmaintainedthe confidentialityofthedata.LimitationsofthestudyDatarelatedtoserviceavailabilityandqualityof healthserviceswerenotcollected.Asaresult,health facilityrelatedfactors,whicharethecausesforthe thirddelayinmaternalmortality,werenotanalyzed.Recallbias:Womenmighthavedifficultyin rememberingthingsthathavehappenedduringthe last5yearsprecedingthesurvey.Womenmayalso havedifficultyrememberingoridentifyingthetype ofhealthprofessionalwhoprovidedtheservice.ResultsTheresultsofthestudyarepresentedbasedonadescriptive,bivariateandmultivariatelogisticregression Figure1 Conceptualframeworkofthestudy. ShowstheconceptualframeworkofthestudyandispreparedbasedonAnderson ’ sbehavioral modelofthedeterminantsofhealthserviceutilizationandthethreedelaysmodelofthedeterminantofmaternalhealthservicesutilization.The figureshowstherelationshipbetweentheindependentvariablesandhowitaffectsthedependentvariablesofthestudy. Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page4of13 http://www.biomedcentral.com/1471-2393/14/161

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analysis.First,descriptionofthestudysubjectswasdone followedbycrudeoddsratioanalysisatbivariatelevel. Then,adjustedOR(AOR)wasdeterminedbyamultivariateanalysis.Factorsthatdetermineutilizationof ANC,skilleddeliveryattendanceandPNCserviceswere organizedintothreecategoriesassocio-cultural,accessibilityandperceivedneedfactors.Socio-demographiccharactersticsofthestudysubjectsAtotalof7,908womenaged15to49yearsofagewho hadatleastonebirthfiveyearsbeforethesurveywere interviewed.Themajority(85%)oftherespondentswere ruralresidents.Mostoftherespondents(91%)wereeither marriedorlivedwithapartnerandonly0.9%werenever married.OromoandAmharaethnicgroupswerethepredominantethnicgroupsaccountingfor35%and28.5%respectively.Themajorityofwomen(69.3%)werebetween theage20to34and5.1%wereaged15to19yearsofage. Regardingthelevelofeducation,67%didnothave anyformaleducation.OrthodoxChristiansandMuslims constitute42%and32%ofthetotalrespectively.The householdwealthwasdistributedsimilarlyamongtherespondents.Forty-twopercentofthestudysubjectswerein thetwopoorwealthquintiles,20.6%wereinthemiddle and36%wereinthetwoupperwealthquintiles.Regardingthetotalnumberofchildren,18%ofthemhadonly onechild,43.8%had2to4childrenand38%had5or morechildren.Thesocio-demographicdescriptionofthe studysubjectsisshownonTable1.PatternofANC,skilleddeliveryandPNCservice utilizationFifty-sevenpercentofwomenhadnoANCvisitswhile 42.9%hadatleastoneANCvisitduringtheirlastpregnancy.ThepercentageofwomenwhohavehadANCbya skilledANCattendantwasonly33.9%.Inthisstudy,only 19.1%ofwomenhadfourormoreANCvisitsduringtheir lastpregnancy.Only26.2%ofthosewhohadANCvisits startedtheirANCvisitduringtherecommendedtiming, i.e.duringthefirsttrimesteroftheirpregnancy;themajority(56.4%)startedduringthesecondtrimesterand16.7% startedduringthethirdtrimester. Eighty-eightpercentofwomendeliveredathomeand 11.7%deliveredinahealthfacility.Nowomandelivered athomewiththeassistanceofaskilledattendant.Only 9.3%ofwomenhadahealthcheckupwithinsixweeks afterdelivery.Table2showsthenumberandpercentage ofwomenwhousedANC,skilleddeliveryattendants andPNCservices.BivariateanalysisoftheuseofANC,deliveryandPNC servicesTheuseofANC,skilleddeliveryattendantsandPNC servicesbybackgroundcharacteristicsofrespondentsis Table1Socio-demographiccharacteristicsofwomenwho hadatleastonebirthinthefiveyearsprecedingthe surveyBackgroundCharacteristicsNumberPercent Residence Urban118815.0 Rural672085.0 Age 15-194025.1 20-34548069.3 35-49202625.6 Maritalstatus NeverMarried720.9 Married/livingtogether718590.9 Divorced/separated/widowed6518.2 Religion Orthodox332742.1 Catholics841.0 Protestants176322.3 Muslims256332.4 Others1752.2 Ethnicity Amhara225728.5 Guragie1802.3 Oromo276535.0 Sidama3344.2 Tigrie5246.6 Wolaita2132.7 Others163520.7 Educationalstatus Noeducation527066.6 Primary227028.7 Secondary2262.9 Higher1421.8 HouseholdWealth Poorest173922.0 Poorer169621.5 Middle162820.6 Richer149418.9 Richest135117.1 Parity 1139917.7 2-4346443.8 5ormore304538.5 Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page5of13 http://www.biomedcentral.com/1471-2393/14/161

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shownonTable3below.Thebivariateanalysisshowsthe effectofeachsingleindependentvariableontheutilization ofANC,skilleddeliveryattendantsandPNCservices.UseofANCserviceUseofskilledANCattendantsismorecommonamong residentsofurbanthanrurallocations.Seventysixpercent (76%)ofurbanresidentsusedskilledANCattendants comparedwithonly26%oftheruralwomen.Withregard tomaritalstatus,itisslightlyhigheramongnevermarried womenthanothercategories.Gurageethnicgroupshave thehighestproportionofwomenwhouseskilledANC care:66%ofGuragiewomenuseskilledANCattendants comparedwith38%ofAmharas,51%ofTigresand32.7% ofOromowomen.SkilledANCutilizationincreasesas thelevelofeducationofwomenincreases.Only25%of womenwhohadnoeducationusedskilledANCattendantscomparedwith45.5%ofthosewithprimaryeducation,85.6%ofthosewithhighschooleducationand90%of thosewhohadhigherthansecondaryleveleducation. OrthodoxChristianshavethehighestproportionof womenwhouseskilledANCattendantswith40%of OrthodoxChristiansusingskilledANCattendants.Asthe householdwealthquintileincreases,theproportionofuse ofskilledANCattendantsalsoincreased.Womenfrom therichesthouseholdshavethehighestproportionof ANCattendance(75%)comparedwith17%ofthosefrom thepooresthouseholdwealthquintile.UseofskilleddeliveryattendantsTheproportionofwomenwhohadusedskilleddelivery attendantsismuchhigher(53%)amongurbanresidents thanthosewhoarefromtheruralareas(4.4%).Nevermarriedwomen,OrthodoxChristians,Guragieethnicgroups, thosefromtherichesthousehold,bettereducatedwomen andthosewithonly1birthhadahigherproportionof usingskilleddeliveryattendants(seeTable3).Utilization increasesconsistentlyastheeducationallevelandthe householdwealthincreases.Useofpostnatalcare(PNC)TheuseofPNCserviceissimilartotheuseofskilled deliveryattendants.Theproportionofwomenwhohad PNCwashigher(33.5%)amongurbanresidentsthan ruralresidents(5%).Nevermarriedwomen,Orthodox Christians,Guragieethnicgroups,thosefromtherichest household,bettereducatedwomenandthosewithonly 1birthhadahigherproportiontousepostnatalcare services(seeTable3).MultivariateanalysisoffactorsaffectingtheuseofANC, deliveryandPNCservicesDuringthemultivariateanalysis,adichotomouslogistic regressionwasemployed.Thedependentvariableswere categorizedasuseofANC,skilleddeliveryattendants andPNCservices.Allvariablesthatshowedsignificant associationduringthebivariateanalysiswereincludedin themultivariatemodel.ThePvalues,adjustedoddsratios(AOR)and95%confidenceintervals(CI)arepresentedinTable4below. Table1Socio-demographiccharacteristicsofwomenwho hadatleastonebirthinthefiveyearsprecedingthe survey (Continued)No.ofbirthsinthelast5yrs 1450557.0 2+340343.0 Total(n) 7908100 Table2NumberandpercentageofwomenwhohadANC visit,deliveryandPNCservicesbywomenwhohadat leastonebirthinthefiveyearsprecedingthesurveyVariablesNumberPercent HadatleastoneANC Yes,byskilledprovider267433.9 NoANC450757.0 Missing90.1 FrequencyofANCduringpregnancy None451757.1 Once3524.5 2times5226.6 3times98212.4 4ormore150819.1 Donotknow27.3 TimingoffirstANC Lessthan4months88826.2 4to6months191456.4 6-9months56616.7 Donotknow24.7 Total3391100.0 Usedskilleddeliveryattendant Yes93211.7 No697188.3 Placeofdelivery Home694887.9 Facility92811.7 Other29.4 Missing3.0 Postnatalcare Yes7379.3 No715990.7 Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page6of13 http://www.biomedcentral.com/1471-2393/14/161

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Socio-culturalfactorsandtheutilizationofmaternalhealth servicesReligion UseofskilledANCattendants :Therewasnosignificantassociationbetweenreligionanduseofskilled ANCattendants. Useofskilleddeliveryattendants :Utilizationof skilleddeliveryattendantswassignificantlyassociated withreligionofwomen.OrthodoxChristians(AOR= 5.9,95%CI=1.3-27.3)andProtestants(AOR=4.8,95% CI=1.1-22.2)weremorelikelytouseskilleddeliveryattendantscomparedtowomenofotherreligions.However,nosignificantassociationwasfoundbetweentwo religiousdenominations,i.eCatholicsandMuslims. Useofpostnatalcare :Therewasnosignificantassociationbetweenreligionanduseofpostnatalcareservice. Ethnicity UseofskilledANCattendants :EthnicitywassignificantlyassociatedwiththeuseofskilledANCattendants. GuragieethnicgroupsweremorelikelytouseskilledANC attendantsthanotherethnicgroups(AOR=3.1,95%CI,2.25.4).Ontheotherhand,Wolaitaethnicgroupswerelesslikely touseskilledANCservice(AOR=0.4,95%CI=0.3-0.7). Useofskilleddeliveryattendants :Ethnicitywas foundtobesignificantlyassociatedwithuseofskilled deliveryattendants.Guragie,Amhara,OromoandTigre ethnicgroupsweremorelikelytouseskilleddeliveryattendancebutWolaitaethnicgroupswerelesslikelyto useskilleddeliveryattendants. Useofpostnatalcare :Therewasnosignificantassociationbetweenethnicityandth euseofpostnatalcareservice. Educationofwomenandtheirhusbands/partners UseofskilledANCattendants :Botheducationof womenandtheirhusbandswasfoundtohaveasignificantassociationwiththeuseofskilledANCattendants. Womenwhohavecompletedsecondaryschooland highereducationweremorelikelytouseskilledANC Table3Percentageofwomenwhohadatleastonebirth inthefiveyearsprecedingthesurveywhoreceived skilledANC,deliveryandPNCservice,bybackground characteristicsBackground characteristics Percentagewho receivedANCat leastonce Percentage whoreceived deliverycare Percentage whoreceived PNCcare Residence Urban76.153.733.7 Rural26.44.45.0 Total33.911.79.3 Maritalstatus Never Married 36.428.119.1 Married/ living together 33.811.38.9 Divorced/ separated/ widowed 33.915.812.6 Age 15-19329.89.4 20-3436.013.810.3 35-4928.66.86.8 Religion Orthodox40.117.212.9 Catholics36.214.110.3 Protestants31.58.57.8 Muslims28.17.76.2 Others22.11.22.6 Ethnicity Amhara38.717.310.8 Guragie66.241.624.7 Oromo32.79.87.5 Sidama22.53.06.7 Tigrie51.214.617.0 Wolaita25.35.88.0 Others23.56.06.9 Educationalstatus No education 25.14.74.9 Primary45.618.412.4 Secondary85.572.850.7 Higher90.073.657.4 HHWealth Poorest17.02.03.5 Poorer23.83.05.2 Middle26.83.43.0 Richer35.68.06.9 Richest74.949.632.4 Table3Percentageofwomenwhohadatleastonebirth inthefiveyearsprecedingthesurveywhoreceived skilledANC,deliveryandPNCservice,bybackground characteristics (Continued)Parity 146.025.919.2 2-435.512.58.7 5ormore26.44.55.5 No.ofbirthsinthe last5yrs 139.616.512.4 2+26.35.65.3 Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page7of13 http://www.biomedcentral.com/1471-2393/14/161

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attendantsthanwomenwhohadnoeducation(forhigher education,AOR=3.8,95%CI=1.8-7.8).Womenwhose husbandswereeducatedtosecondaryandhighereducationlevelwerealsomorelikelythanwomenwhosehusbands/partnerswerenoteducated(forhighereducation, AOR=1.9,95%CI=1.3-2.7). Useofskilleddeliveryattendants: Useofskilleddeliveryattendantswassignificantlyassociatedwithboth educationofwomenandtheirhusbands.Astheeducationlevelofwomenandtheirhusbandsincreased,the likelihoodofusingskilleddeliveryattendantsalsoincreased.Womenwhoareeducatedtohighschoollevel andhigherweremorelikelytouseskilleddeliveryattendants(AOR=3.4,95%CI=1.9-6.2)thanthosewhowere noteducated.Womenwhosehusbandswereeducated tohighschoollevelandhigherwerealsomorelikelyto useskilleddeliveryattendants. Useofpostnatalcare: Asimilarfindingtotheuseof ANCandskilledattendantswasfoundbetweeneducation levelanduseofPNCservice.Thelikelihoodofwomento usePNCservicewashighamongwomenwhohada highereducationallevel(AOR=3.2,95%CI=2.0-5.2). Maternalageandparity Themultivariateanalysis showsthatmaternalagewasnotassociatedwiththeuse ofallthethreematernalhealthservices.However,parity wasfoundtohaveasignificanteffectontheuseofthe threematernalhealthservices.Theeffectofageonserviceutilizationisabsentaftercontrollingforparityof womenduringthemultivariateanalysis. UseofskilledANCattendants: Thenumberofbirths inthelast5yearsbeforethesurveywassignificantlyassociationwithuseofskilledANCservice.Womenwho hadonlyonebirthduringthelastfiveyearsweremore likelytouseANCservice(AOR=1.3,95%CI=1.1-1.5) thanthosewhohadtwoormorebirths. Useofskilleddeliveryattendants :Paritywasalso foundtohaveasignificantassociationwiththeuseof skilleddeliveryattendants.Motherswhohad1births (AOR=2.4,95%CI=1.7-3.4)and2-4births(AOR=1.4, 95%CI=1.1-1.8)weremorelikelytouseskilleddelivery attendantsrespectively. Useofpostnatalcare: Womenwithonlyonebirth weremorelikelytousePNCservicesthanthosewho had5ormorebirths(AOR=1.4,95%CI=1.1-1.9). Maritalstatus Nevermarriedwomenwerefoundtobe morelikelytouseskilledANCattendants(AOR=1.3, 95%CI=1.1-1.6)andPNCservicesthanothers(AOR= 1.8,95%CI=1.1-3.2).Marriedwomenwerelesslikelyto useANCattendantsandPNCservices.Withregardsto theuseofskilleddeliveryattendants,nevermarried women(AOR=0.8,95%CI=0.4-0.9)andmarriedwomen (AOR=0.5,95%CI=0.5-0.8)werefoundtobelesslikely touseskilleddeliveryattendancethandivorced/separated/ widowedwomen. Autonomyofwomenonhealthcarespending Autonomyofwomenonhealthcarespendingwasfoundtohave asignificantassociationwiththeutilizationofskilled ANCanddeliveryattendants.Autonomouswomenwere morelikelytouseANC(AOR=1.4,95%CI=1.2-1.6)and deliveryattendants(AOR=1.3,95%CI=1.1-1.7).Factorsrelatedwithperceivedbenefitsandtheutilization ofmaternalhealthservicesPregnancywantedness Womenwereaskedwhether theirlastpregnancywaswantedornot.Elevenpercentof women(N=858)hadtheirlastpregnancyunwantedand 89.1%(N=7047)ofwomenhadtheirlastpregancy wanted.Wantednessoftheindexpregnancydidnothave anysignificantassociationwiththeuseofANC,skilleddeliveryattendantsandPNCservices[CrudeOR=0.9,95% CI=0.8-1.1forANCandCrudeOR=1.0,95%CI=0.81.2fortheuseofskilleddeliveryattendants;CrudeOR= 0.9,95%CI=[0.7-1.1]forPNC]. Useofpublicinformationsources Readingnewspapers didnothaveanyassociationwiththeutilizationofmaternalhealthservices.Beforecontrollingforothervariablesatbivariatelevelofanalysis,itwassignificantly associatedwithuseofANC(CrudeOR6.6,95%CI= 5.4-8.0).Theeffectisabsentaftercontrollingforother variableslikeeducationandresidenceoftherespondent. Thereasonfortheabsenceofassociationonmultivariateanalysisisbecauseoftheconfoundingeffectofthe othervariables. Listeningradioprogramsandfrequencyoftelevision watchinghavehadasignificantassociationwiththe utilizationofANCservices.Womenwholistentoradio programsweremorelikelytousematernalhealthservices thanthosewhoneverlisten(AOR=1.3,95%CI=1.1-1.6). Theeffectofwatchingtelevisionwasalsosimilartolisteningtoradioprograms.However,therewasnoassociation betweenlisteningradioandwatchingtelevisionprograms withtheuseofdeliveryandPNCservices. EffectofANCuseonuseofskilleddeliveryattendants WomenwhohadANCvisitsduringtheindexpregnancyweremorelikelytouseskilleddeliveryattendantsthanthosewhodidnothaveANCfollowup. WomenwhohavehadANCduringtheindexpregnancyweremorelikelytouseskilleddeliveryattendants(AOR=1.3,95%CI=1.1-1.7).Moreover,women whohadattendedANCvisitsduringtheindexpregnancywerealsomorelikelytoattendPNCservices (AOR=3.4,95%CI=2.8-4.1).Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page8of13 http://www.biomedcentral.com/1471-2393/14/161

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Table4Adjustedoddsratiosand95percentconfidenceintervalsforreceivingANC,deliveryandPNCservicesVariablesUseofskilledANC attendants Useofskilleddelivery attendants UseofPNC AdjustedOR* (95%CI) Pvalue**AdjustedOR* (95%CI) PValue**AdjustedOR* (95%CI) PValue** Residence Urban2.31.9-2.90.0014.93.8-6.30.0012.62.0-3.40.001 Rural1.0 Maritalstatus NeverMarried1.31.1-1.60.0080.80.4-0.90.0271.81.1-3.20.035 Married/livingtogether0.90.8-1.10.1540.70.5-0.80.0010.60.5-0.80.001 Divorced/separated/widowed1.01.01.0 Age 15-190.80.6-1.20.4480.50.3-0.90.0130.80.6-1.40.621 20-341.00.9-1.20.6350.90.7-1.30.7100.90.7-1.10.190 35-491.01.01.0 Religion Orthodox1.30.8-2.10.4185.91.3-27.30.0228.71.2-640.034 Catholics2.20.8-3.50.1835.50.9-31.90.0573.40.4-31.30.284 Protestants1.70.9-2.70.0684.81.1-22.20.0437.71.1-56.40.045 Muslims1.50.8-2.20.2584.20.9-18.90.0667.21.0-53.00.051 Others1.01.00.0190.056 Ethnicity Amhara1.91.4-2.10.0011.10.8-1.50.5410.80.6-1.10.088 Guragie3.12.2-5.40.0012.81.8-4.40.0011.10.7-1.50.806 Oromo1.21.1-1.40.0381.20.9-1.50.2060.80.7-1.10.142 Sidama0.60.5-1.00.0670.30.1-0.90.0271.00.5-1.90.958 Tigrie2.71.9-3.10.0010.50.3-0.70.0010.90.6-1.20.433 Wolaita0.40.3-0.70.0010.20.1-0.50.0010.60.3-1.90.135 Others1.01.00.0010.374 Educationalstatus Noeducation1.00.001 Primary1.61.4-1.90.0011.61.3-2.00.0011.31.1-1.60.026 Secondary3.42.9-5.40.0013.12.0-4.70.0012.41.6-3.40.000 Higher3.81.8-7.80.0013.41.9-6.20.0013.22.0-5.20.000 HHWealth Poorest1.00.0010.0010.001 Poorer1.21.1-1.50.0411.00.6-1.40.7941.30.9-1.80.167 Middle1.51.2-1.80.0010.90.6-1.40.6791.10.8-1.60.475 Richer1.71.4-2.10.0011.41.0-2.00.0511.91.3-2.50.000 Richest3.72.9-4.80.0013.02.1-4.20.0012.41.7-3.50.000 Parity 11.20.9-1.50.1382.41.7-3.40.0011.41.1-1.90.019 2-41.11.0-1.30.1691.41.1-1.80.0171.10.8-1.30.702 5ormore 0.0010.016 Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page9of13 http://www.biomedcentral.com/1471-2393/14/161

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Accessibilityrelatedfactorsandtheuseofmaternalhealth servicesResidence Women ’ splaceofresidencewassignificantly associatedwithuseofskilledANCservices.Womenin urbanresidenceweremorelikelytouseskilledANCattendants(AOR=2.3,95%CI=1.9-2.9).Regardingthe useofskilleddeliveryattendantsandtheuseofPNCservices,asimilarresultwasfound.Womenwhowerefrom urbanresidenceweremorelikelytouseskilleddelivery attendantsthanthosewhowerefromruralresidence (AOR=4.9,95%CI=3.8-6.3).UseofPNCservicewas alsomorelikelyamongurbanresidentscomparedwith ruralresidents(AOR=2.6,95%CI=2.0-3.4). Workstatusofwomenandtheirhusbands/partners Workstatusofhusbandsdidnothaveasignificantassociationwiththeuseofallthethreematernalhealthservices.However,workstatusofwomenhadasignificant associationwiththeuseofskilledANCservices. Womenwhohadajobweremorelikelytouseskilled ANCservices(AOR=1.1,95%CI=1.1-1.3). Table4Adjustedoddsratiosand95percentconfidenceintervalsforreceivingANC,deliveryandPNCservices (Continued)No.ofbirthsinthelast5yrs 11.31.1-1.50.0011.31.0-1.60.025--2+1.01.0 Husbandseducation 0.001 No1.0 Primary1.31.1-1.50.0011.41.1-1.70.0091.10.8-1.30.624 Secondary2.01.5-2.70.0012.11.6-2.90.0011.71.3-2.30.001 Higher1.91.3-2.70.0011.91.3-2.90.0021.61.1-2.40.009 Autonomyofwomanonhealthcarespending Women+-Husband1.41.2-1.60.0011.31.1-1.70.0221.00.8-1.20.853 Husbandonlyorothers1.01.0 Husband ’ sworkstatus Jobless1.0 working1.11.1-1.30.045-----Woman ’ sworkstatus Jobless --working1.11.1-1.30.0330.90.8-1.10.576--Readingnewspaperfrequency Notatall1.0 Lessthanonceaweek1.10.8-1.50.3751.20.9-1.60.1871.00.7-1.30.802 Atleastonceaweek0.90.5-1.60.7262.11.1-3.70.0161.10.7-1.80.548 Listeningradiofrequency Notatall1.0 Lessthanonceaweek1.41.2-1.60.0010.90.7-1.10.4181.00.8-1.20.778 Atleastonceaweek1.31.1-1.60.0020.90.8-1.20.7741.21.0-1.50.099 Watchingtelevisionfrequency Notatall1.0 Lessthanonceaweek1.31.1-1.50.001---Atleastonceaweek1.31.3-2.00.001----USEOFANCduringtheindexpregnancy Yes---1.31.1-1.70.0013.42.8-4.10.001 No---1.0--1.0--*TheAORshavebeenadjustedforallothervariablesinthemodel. **ThestatisticaltestusedwasChisquaretest.A95%CIusedtodeterminesignificantassociation.Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page10of13 http://www.biomedcentral.com/1471-2393/14/161

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Householdwealthindex Householdwealthindexwas significantlyassociatedwiththeuseofallthethreematernalhealthservices.WomenfromwealthierhouseholdsusedskilledANC,deliveryandPNCservicesat significantlyhigherratesthanthosewomenfromless wealthyhouseholds.Womenfromthemiddlewealth households(AOR=1.1,95%CI=1.2-1.8)andwomen fromtherichesthouseholds(AOR=1.1,95%CI=2.94.8)weremorelikelytouseANCservicecomparedwith thosewhowerefromthepoorestwealthquintile.RegardingtheuseofskilleddeliveryattendantsandPNC services,womenfromtherichesthouseholdsweremore likelytouseskilleddeliveryattendants(AOR=3.0,95% CI=2.1-4.2)andPNCservices(AOR=2.4,95%CI=1.73.5)thanthosewhowerefromthepooresthouseholds.DiscussionHealthcareseekingmaybeinfluencedbythecultural backgrounds,beliefs,normsandvaluesofspecificethnic groupsandreligion.Ethnicityandreligionareoften thoughttoinfluencebeliefs,normsandvaluesinrelationtopregnancy,childbirthandutilizationofservices [13,15].Inthisstudy,ChristianandMuslimwomen weremorelikelytousematernalhealthservicesthan traditionalandotherreligions.Thisresultisconsistent withotherstudies.Thismaybebecausewomenwith traditionalreligionmaybelessmodernandmoreinclinedtotraditionalbeliefs.Regardingethnicity,Wolaita ethnicgroupswerelesslikelytouseskilledANCand deliverycarethanotherethnicgroups.Thereasonfor thelowmaternalhealthserviceutilizationbythe Wolaitaethnicgroupmaybeduetothefactthatthese ethnicgroupsculturallymaynotsupportfacilitydelivery duetotheirculturalbeliefsandvaluesonmaternal healthcare,andthisneedsfurtherqualitativestudyto explorethedetailedreasons.AstudybyShiferawand colleaguesidentifiedthatoneofthemostimportantreasonsfornotseekinginstitutionaldeliveryinEthiopia wasthebeliefthatitisnotnecessaryandnotcustomary [16].AstudyinVietnamalsoshowedthattheriskof notgivingbirthinahealthfacilityincreasedsignificantly amongethnicminoritywomenlivinginruralareas[17]. Furtherqualitativeinvestigationontheeffectsofcultural practicesisrequired.Studiesdoneindevelopingcountriesshowedthatmaternalhealthservicesutilizationis affectedbyethnicity,cultureandreligionofwomen. Thiswasexplainedbythefactthatwomen ’ sautonomy, genderrelationshipsandsocialnetworksareaffectedby ethnicity,cultureandreligion[18,19]. Thisstudyhasfoundthateducationofwomenand theirhusbandshashadasignificanteffectonthe utilizationofallthethreematernalhealthservices.The effectofmaternaleducationlevelwasstrongerthanhusband ’ seducation.Theseresultshavebeenconsistently supportedbymanyotherstudieswhichshowedapositiveinfluenceofeducationonmaternalhealthservice utilization[14,20-22].Thispositiverelationshipmaybe explainedbythefactthateducatedwomenaremore knowledgeableontheimportanceofmaternalhealth services;theymayhaveaccesstowritteninformation andmayhaveamoremodernculturalperspective.Educatedhusbandsmayhaveabettercommunicationwith theirwivesandwillingnesstodiscusstheuseofmaternalhealthservices.Theymayalsoprovidemoreautonomytotheirwives[21,23-25]. Physicalaccessibilityisoneofthemostimportantvariablesinhealthserviceutilization.Severalstudieshave identifiedthatphysicalproximityofhealthcareservices playsanimportantroleinserviceutilization.Inthis study,urbanresidencewassignificantlyassociationwith theutilizationofANC,deliveryandPNCservices.This resulthasbeenconsistentwithmanyotherstudies [14-16,18,23,26].Thedifferencemaybeduetotheincreasedavailabilityofinfrastructure(shorterdistanceto healthfacilities,betterroadsandtransportation)in urbanareasthanruralareas.InEthiopia,thereisasignificantdifferenceintheavailabilityofhealthworkers amongregions.AddisAbabaandDireDawacityadministrationswithanurbanpopulationproportionof100% and67.5%respectivelyhaveahighernumberofmedical doctorsthanotherregionsthathaveamoreruralpopulation.AddisAbabaandDireDawacityadministrations haveonemedicaldoctorfor3,056and6,796respectively.OtherregionslikeAmharaandOromia,withan urbanpopulationproportionof12.6%and12.2%respectivelyhaveveryfewdoctorscomparedwiththe otherregions[27].Thisshowsthaturbanareasaremore advantagedintermsofaccessinghealthprofessionals thanruralareas. Othersimilarstudiesidentifiedresidenceasafactorfor maternalhealthserviceutilization.Thestudiesshowed thatmaternalhealthserviceutilizationishigheramong urbanresidentsthanruralresidents[16,22,26,28].Astudy doneinEthiopiaonwhywomenchoosetodeliverat homeshowedthatlackoftransportationwasoneofthe majorfactors[16]. Thisstudyhasfoundthathouseholdwealthstatusissignificantlyassociatedwiththeutilizationofallthethree maternalhealthservices.Womenwhoarefromahouseholdwithahigherwealthquintilearemorelikelytoutilize allthematernalhealthservicesthanthosewhoarefrom thepoorwealthhouseholds.Thisresultisconsistentwith othersimilarstudies[21,29].Thisisexpectedsinceaccess tohealthservicesutilizationinEthiopiamainlydepends onoutofpocketpayment[30].Thoughtheservicesfor ANC,deliveryandPNCareexempted,womenareexpectedtopayformedicationsandadditionaltransportationcostscontributetothehighcostofseekingcareandTarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page11of13 http://www.biomedcentral.com/1471-2393/14/161

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maydeterwomenfromutilizingservices.Thishasalso beenrevealedinothersimilarstudies[21].Asimilarstudy inGhanahasrevealedthatwealthhasasignificantinfluenceontheuseofskilleddeliveryattendants.Itshowed thattheoddsofhavingaskilledattendantatdeliveryfor womeninthepoorestwealthquintileare94%lowerthan thatforwomeninthehighestwealthquintileandalmost 5timeshigherforwomenwithcompletedprimaryeducationrelativetothoselesseducated[29]. Thisstudyhasshownthatparitydetermineshealthserviceutilizationmorethanmaternalage.Womenwhohad onlyonebirthweremorelikely touseskilleddeliveryattendantsandPNCservices.Thismaybeduetothefactthat womenwithhigherparitymayhavedevelopedselfconfidencetodeliverathomeandmaynotbemotivatedto useahealthprofessional.Mor eover,primiparawomenmay beafraidofpregnancycomplicationsandoutcomessince theyhavehadnopriordeliveryexperience.Thismaybebecauseoftheperceivedriskoffirstpregnancyonhealth.A studyinBangladeshhasshownasimilarresultwhichfound thatawomanismorelikelytoseekmaternalhealthcare servicesforfirstorderthanhigher-orderbirthsbecauseof perceivedriskassociatedwithfirstpregnancy[31].Astudy inKenyaalsoshowedthatwomenofhighparityareless likelytoinitiateANContimeortomaketherecommended numberofvisits,assumingthattheyareexperienced[28]. Theotherreasonmaybebecauseofpriorbadhealthfacility experiences.Havingmorechildrenmayalsocauseresource constraints,whichhaveanegativeeffectonhealthcare utilization[31].Manystudieshaveshownconsistentfinding onthelowlikelihoodofhavingahealthfacilitydeliveryas numberofchildreneverbornincreased[32,33]. Decisionmakingpowerofwomencanhaveasignificant effectontheabilityofwomentoseekhealthservicesand/ orcontributetodelaysinaccessingandreceivingmedical careeveninplaceswhereservicesarereadilyavailable[21]. Inthisstudy,womenwhohavebeenabletodecideon healthcarespendingbythemselvesweremorelikelythan womenwhosehealthcarespendingwascontrolledbyother people.Thismaybebecauseifresourcesarecontrolledby others,womendonothavethefreedomtouseservices whenevertheyneedcare.Autonomymayalsobeassociated withothervariableslikewitheducationofwomenand urbanresidence,bothofwhicharefactorsthatincreasethe likelihoodoftheuseofmaternalhealthservices. TheuseofANCcareduringpregnancywasfoundto significantlyaffecttheuseofskilleddeliveryattendants. Thismaybebecausewomenwillbeawareoftheimportanceofattendingdeliveryinhealthfacilitiesastheymight beeducatedduringtheANCsession.Manyotherstudies havefoundasimilarresult[22,34].Thisresultshowsthat useofANCisoneofthestrongestdeterminantsforthe useofskilleddeliveryattendantsduringdeliveryandPNC servicesafterdelivery. Womenwhoareworkingearnmoneysothattheycan havetheeconomicabilitytopayforhealthservices.However,workstatusofwomenwasfoundtobeassociated withtheuseofANCservicesonly.Itisnotassociatedwith theuseofdeliveryandPNCservices.Thereasonforthe absenceofassociationmaybeexplainedbecauseeven thoughtheyareworking,thedecisiononhealthspending maybemadebytheirhusbands. Useofpublicmediasourceslikelisteningradio,watching televisionandreadingnewspapersincreasestheawareness ofpeopleonhealthandothermatters.Inthisstudy,useof thesepublicmediasourcessignificantlyaffectedtheuseof ANCservices.However,theassociationisnotconsistent withtheuseofdeliveryattendantsandPNCservices, whichmaybeduetothefactthatthemajorityofwomen areilliterateandliveinruralareaswheretelevision,radio andnewspapersarenotavailable.Therefore,thismaybe duetothelowproportionofhouseholdswhohaveradio andtelevisioninEthiopia.AstudyinNigeriahasshown thatcommunitymediasaturationwasfoundtobeastrong predictorofmaternalhealthserviceutilization[35].ConclusionThisstudyhasexaminedthedeterminantsofANC,useof skilleddeliveryattendantsan dPNCservicesinEthiopia. Itshowsthatutilizationofmaternalhealthservicesin Ethiopiaisverylowandisaffectedbyanumberofsociocultural,perceivedbenefitsandac cessibility-relatedfactors. Educationlevelofwomenandtheirhusbandsisoneof thestrongestdeterminants oftheuseofmaternalhealth services.Serviceutilizationincreasedconsistentlyasthe educationlevelofwomenandtheirhusbandsincrease. Thereisahighinequalityinserviceutilizationbetween urbanandruralareas.Householdwealthandlevelof autonomyofwomenonhealthspendingareimportantdeterminantsofserviceutilization.Ethnicityisalsoadeterminantfactorofserviceutilization,whichshowsthe importanceofgivingadueattentiontotheempowerment ofwomenfromlessadvantagedethnicgroups.Useof ANCduringpregnancyisamajorpredicatorofsubsequent useofskilleddeliveryandPNCservices,whichshowsthe importanceofANCasanimportantentrypointtoincrease thelowutilizationofskilleddeliveryandPNCservices. Thefindingsofthestudyshowtheimportanceof womeneducation,empowermentandeconomicimprovementforwomen.Moreover,infrastructuralimprovements likeimprovingroadsandprovidingtransportationservices forpregnantwomeninruralareasisrecommended. Ingeneral,thestudyfindingsshowthatthedeterminants ofmaternalhealthserviceutilizationaremulti-sectoralsignifyingamulti-sectoralapproachtotackleit.Thehealth, education,socialservice,agriculture,transportation,employment,andothersectorsshouldbeinvolvedfor longtermimprovementinserviceaccessandutilization.Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page12of13 http://www.biomedcentral.com/1471-2393/14/161

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Furtherstudyneedtobedoneonhealthfacilityrelated factors,whicharethemajorcausesofthethirddelayin maternalmortality.Competinginterests Theauthorshavenofinancialandnon-financialcompetinginterests. Authors ’ contribution SMT:Conceptualizedthedesignandoverallstudy,wrotetheresult,madethe analysisandinterpretation,andwrotetheresult,discussionandconclusion sections.LSL:Wrotesectionsofthemanuscriptandledtheliteraturereview part.Participatedinanalysisandreviewedthefinalmanuscript.VG:Participated inliteraturereviewanddataanalysis,wrotetheresultssectionandreviewed draftofthemanuscript.Allauthorsreadandapprovedthefinalmanuscript. Authors ’ information SMT:-GraduateofMasterofPublicHealth(MPH)inreproductivehealthin 2007fromAddisAbabaUniversityandalsograduatedwithEuropean mastersinSustainableRegionalHealthSystemsin2013fromVilnius Universityandcurrentlyworkingasregionalhealthinformaticscoordinator atTulaneInternationalinAddisAbaba,Ethiopia. LSL:-AprofessorattheUniversityofCentralFloridaandalsoamanaging directorofLiebermanconsultinginFlorida,USA.Experiencedresearcherin biomedicalAnthropology,NutritionandPublicHealth VG:-AprofessoratVilniusUniversity,Lithuania.Alsoacoordinatorof RegHealthMasterProgramofEuropeanCommissionExperiencedin researchesrelatedwitheconomicsandPublichealth. Acknowledgements Theauthorswouldliketoacknowledgethegeneralscientificsupportofthe facultyofpublichealthofVilniusUniversity.Theauthorswouldalsoliketo acknowledgeMeasureDHSforallowingaccesstothe2011DHSdatasetfor Ethiopia. Authordetails1DepartmentofHealthManagementInformationSystems,Tulane International,AddisAbaba,Ethiopia.2DepartmentofAnthropology, UniversityofFlorida,Orlando,FL32816-0955,USA.3FacultyofEconomics, VilniusUniversity,Vilnius,Lithuania. Received:8October2013Accepted:26April2014 Published:7May2014 References1.WorldHealthOrganization: WHO2012maternalandchildhealthfactsheet. http://www.who.int/mediacentre/factsheets/fs348/en/. 2. UNFPA2013factsheet. http://www.unfpa.org/public/home/mothers/pid/4381. 3.UN: TheMillenniumDevelopmentGoalsReport2012. NewYork:United Nations;2012. 4.UNandAfricanUnionCommision: ReportonProgressinAchievingtheMillennium DevelopmentGoalsinAfrica,2013. Abidjan:Cted'Ivoire;2013.E/ECA/COE/32/3. RetrievedApril10,2013,fromhttp://www.uneca.org/sites/default/files/ document_files/report-on-progress-in-achieving-the-mdgs-in-africa.pdf. 5.WHO,UNFPA,UNICEFandWorldbank: Trendsinmaternalmortality:19902010. Geneva:WHO,UNICEF,UNFPAandTheWorldBankestimates;2012. 6.CSA[Ethiopia]andORCMacro: EthiopiaDemographicandHealthSurvey 2000. AddisAbaba,EthiopiaandCalverton,Maryland,USA:Centralstatistical AgencyandICFInternational;2001. 7.CSA[Ethiopia]andORCMacro: EthiopianDemographicandHealthSurvey 2005. AddisAbaba,EthiopiaandCalverton,Maryland,USA:Centralstatistical AgencyandICFInternational;2006. 8.CSA[Ethiopia]andICFInternational: EthiopiaDemographicandHealth Survey2011. AddisAbabaEthiopiaandCalverton,Maryland,USA:Central statisticalAgencyandICFInternational;2012. 9.CarroliG,RooneyC,VillarJ: Howeffectiveisantenatalcareinpreventing maternalmortalityandseriousmorbidity?Anoverviewoftheevidence. PaediatrPerinatEpidemiology 2001, 15 (suppl1):1 – 42. 10.WagstaffA,ClaesonM: TheMillenniumDevelopmentGoalsforHealth:Rising totheChallenges. Washington,DC:TheWorldBank;2004. 11.USAID: MeasureDHS:DemographicandHealthSurveys. 2011.Retrievedfrom MeasureDHS:http://dhsprogram.com/Data/. 12.Levy,Lemeshow: SamplingofPopulations. NewYork:JohnWileyandSons;2001. 13.AndersenR,NewmanJF: SocietalandIndividualDeterminantsofMedical CareUtilizationintheUnitedStates. MilbankQ 2005, 83 (4):1 – 28.Retrieved fromhttp://www.milbank.org/uploads/documents/QuarterlyCentennialEdition/ Societal%20and%20Indv.pdf. 14.Thadeus,Maine: Toofartowalk:Maternalmortalityincontext. SocSci Med 1994, 38 (8):1109 – 1120. 15.GabryschS,CampbelO: Stilltoofartowalk:Literaturereviewofthe determinantsofdeliveryserviceuse. BMCPregnancyChildbirth 2009, 9: 34. 16.ShiferawS,SpigtM,GodefrooijM,MelkamuY,TekieM: Whydowomen preferhomebirthsinEthiopia? BMCPregnancyChildbirth 2013, 13: 5. 17.MlqvistM,LincettoO,DuNH,BurgessC,HoaDTP: Maternalhealthcare utilizationinVietNam:increasingethnicinequity. BullWorldHealthOrgan 2013, 91: 254 – 261. 18.SayL,RaineR: Asystematicreviewofinequalitiesintheuseofmaternal healthcareindevelopingcountries:examiningthescaleoftheproblem andtheimportanceofcontext. BullWorldHealthOrgan 2007,85: 812 – 819. 19.SinghP,RaiR,AlagarajanM,SinghL: DeterminantsofMaternityCare ServicesUtilizationamongMarriedAdolescentsinRuralIndia. PLoSOne 2012, 7 (2):e31666.DOI:10.1371/journal.pone.0031666. 20.BellJ,CurtisSL,AlaynS: TrendsinDeliveryCareinsixCountries.DHS AnalyticalStudiesNo.7. Calverton,Maryland:ORCMacroandInternational ResearchPartnershipforSkilledAttendanceforEveryone(SAFE);2003. 21.AhmedS,AndreeaA,Creangamail,GillespieDG,TsuiAO: EconomicStatus, EducationandEmpowerment:ImplicationsforMaternalHealthService UtilizationinDevelopingCountries. PLoSOne 2010, 5 (6):e11190. doi:10.1371/journal.pone.0011190. 22.MengeshaZB,BiksGA,AyeleTA,TessemaGA,KoyeDN: Determinantsof skilledattendancefordeliveryinNorthwestEthiopia:acommunity basednestedcasecontrolstudy. BMCPublicHealth 2013, 13: 130. 23.SharmaS,SawangdeeY,SirirassameeB: Accesstohealth:women ’ sstatus andutilizationofmaternalhealthservicesinNepal. JBiosocSci 2007, 39 (5):671 – 692. 24.AnyaitA,MukangaD,OundoB,NuwahaF: Predictorsforhealthfacility deliveryinBusiadistrictofUganda:Acrosssectionalstudy. BMCPregnancyandchildbirth 2012, 12: 132. 25.ChamM,SundbyJ,VangenS: MaternalmortalityintheruralGambia,a qualitativestudyonaccesstoemergencyobstetriccare. BiomedCentral: ReprodHealth 2005, 2: 3. 26.StephensonR,MatthewsZ: MaternalhealthcareserviceuseamongruralurbanmigrantsinMumbai,India. AsiaPacPopulJ 2004, 19 (1):39 – 60. 27.CSA[Ethiopia]: SummaryandStatisticalReportofthe2007Populationand HousingCensus. AddisAbaba:FederalDemocraticRepublicofEthiopia PopulationandCensusCommission;2008. 28.FotsoJC,EzehA,OronjeR: ProvisionandUseofMaternalHealthServices amongUrbanPoorWomeninKenya:WhatDoWeKnowandWhatCan WeDo? JUrbanHealth 2008, 85 (3):428 – 442. 29.ArthurE: Wealthandantenatalcareuse:implicationsformaternalhealth careutilisationinGhana. HealthEconRev 2012, 2: 14. 30.MinistryofHealthofEthiopia: Ethiopia'sFourthNationalHealthAccounts, 2007/2008. AddisAbaba:MinistryofHealth[Ethiopia];2010. 31.ChakrabortyN,AtaharulIslamM,IslamChowdhuryR,BariW,Hanumakhter H: Determinantsoftheuseofmaternalhealthservicesinrural Bangladish. HealthPromotInt 2003, 18 (4):327.32.MekonnenY,MekonnenA: Factorsinfluencingtheuseofmaternal healthcareservicesinEthiopia. JHealthPopulNutr 2003, 21 (4):374 – 382. 33.EijkV,BlesH,OdhiamboF,AyisiJ,BloklandI,RosenD: Useofantenatal servicesanddeliverycareamongwomeninruralwesternKenya:a communitybasedsurvey. ReprodHealth 2006, 3: 2. 34.AbebeF,BerhaneY,GirmaB: Factorsassociatedwithhomedeliveryin Bahirdar,Ethiopia:Acasecontrolstudy. BMCResNotes 2012, 5: 653. 35.BabalolaS,FatusiA: Determinantsofuseofmaternalhealthservicesin Nigeria-lookingbeyondindividualandhouseholdfactors. BMC PregnancyChildbirth 2009, 9: 43.doi:10.1186/1471-2393-14-161 Citethisarticleas: Tarekegn etal. : Determinantsofmaternalhealth serviceutilizationinEthiopia:analysisofthe2011Ethiopian DemographicandHealthSurvey. BMCPregnancyandChildbirth 2014 14 :161.Tarekegn etal.BMCPregnancyandChildbirth 2014, 14 :161Page13of13 http://www.biomedcentral.com/1471-2393/14/161