Socio-demographic Characteristics
A total of 635 study participants were included, yielding a response rate of 96.2%. The respondents' ages ranged from 18 to 40 years (mean = 27 years, SD = 6.5 years).The majority (91.2%) were married, and more than half (57.6%) were from rural areas (Table 1).
Table 1
Socio-demographic characteristics of study participants, Dire Dawa Administration, eastern Ethiopia, 2022 (n = 635)
Variables
|
Category
|
Frequencies
|
Percentage
|
Age (in completed years)
|
35 and above
|
240
|
37.8
|
25–34
|
219
|
34.5
|
24 and less
|
176
|
27.7
|
Residence
|
Rural
|
366
|
57.6
|
Urban
|
269
|
42.4
|
Level of education(women)
|
No formal education
|
123
|
19.4
|
Primary level
|
216
|
34.0
|
Secondary level
|
134
|
21.1
|
Post-secondary level
|
162
|
25.5
|
Marital status
|
Married
|
579
|
91.2
|
Single
|
35
|
5.5
|
Divorced
|
13
|
2.0
|
Widow
|
8
|
1.3
|
Level of education (husbands, n = 579)
|
No formal education
|
109
|
18.8
|
Primary level
|
230
|
39.7
|
Secondary level
|
130
|
22.5
|
Post-secondary level
|
110
|
19.0
|
Occupation
|
House wife
|
181
|
28.5
|
Merchant
|
243
|
38.3
|
Private employee
|
61
|
9.6
|
Public employee
|
88
|
13.9
|
Daily laborer
|
62
|
9.8
|
Monthly income
|
< 100USD
|
176
|
27.7
|
100-150USD
|
385
|
60.6
|
> 150 USD
|
74
|
11.7
|
Religion
|
Muslim
|
283
|
44.6
|
Orthodox
|
113
|
17.8
|
Protestant
|
217
|
34.2
|
Catholic
|
22
|
3.5
|
Obstetric characteristics, co-medical illness, and health care facility-related:
More than half (54.8%) of the participants were multiparous, and the majority (94.3%) had ANC visits (Table 2).
Table 2
Obstetric characteristics, co-medical illness, and health care facility related variables, Dire Dawa Administration, eastern Ethiopia, 2022 (n = 635)
Variables
|
Category
|
Frequencies
|
Percentage
|
Parity
|
Primiparas
|
287
|
45.2
|
Multiparous
|
348
|
54.8
|
ANC
|
Yes
|
599
|
94.3
|
No
|
36
|
5.7
|
Number of ANC(n = 599)
|
1–2
|
318
|
53.1
|
3 and more
|
281
|
46.9
|
Pregnancy status
|
Planned
|
347
|
54.6
|
unplanned
|
287
|
45.2
|
Obstetrics complication/s (current)
|
Yes
|
84
|
13.2
|
No
|
551
|
86.8
|
Type obstetrics complication(current)
|
Anemia
|
28
|
33.3
|
post pregnancy
|
9
|
10.7
|
Gestational hypertension
|
22
|
26.2
|
Oligohydramnios
|
11
|
13.1
|
Decreased fetal movement
|
14
|
16.7
|
History of institutional delivery(multiparous = 348)
|
Yes
|
326
|
93.7
|
No
|
22
|
6.3
|
Past obstetrics complication/s(n = 326)
|
Yes
|
54
|
16.6
|
No
|
272
|
83.4
|
Type of obstetrics complication(past, n = 54)
|
Bleeding
|
32
|
59.3
|
Infection
|
13
|
24.1
|
Tear(birth canal and perineum)
|
9
|
16.7
|
Presence of co-medical illness
|
Yes
|
85
|
13.4
|
No
|
550
|
86.6
|
Types of co-medical illness
|
Intestinal parasites
|
29
|
34.1
|
DM
|
10
|
11.8
|
Bacterial infection
|
34
|
40
|
chronic hypertension
|
12
|
14.1
|
Who decided to bypass(n = 196)
|
Self
|
79
|
40.3
|
husband
|
23
|
11.7
|
Friends
|
45
|
23
|
Both(self + husband)
|
28
|
14.3
|
Family and relatives
|
21
|
10.7
|
Perceived health care workers’ behavior
|
“Not good”
|
225
|
35.4
|
“Good”
|
410
|
64.6
|
Perceived cost of obstetrics (child birth) care services
|
“Expensive”
|
264
|
41.6
|
“Affordable”
|
371
|
58.4
|
Perceived quality of obstetric cares
|
“poor”
|
362
|
57.0
|
“Good”
|
273
|
43.0
|
Status and factors associated with bypassing a childbirth center
At childbirth centers, the overall bypass rate was 30.9% (95% CI: 27.1–34.55%).
In the multivariable logistic regression analysis, women’s age group of 35 or older (AOR = 2.34, 95% CI: 1.43–3.82), rural residence (AOR = 1.89, 95% CI: 1.11–3.22), no formal education (AOR = 2.26, 95% CI: 1.23–4.16), failure in obstetric care needs during antenatal care (AOR = 2.37, 95% CI: 1.33–4.22), and health professionals’ behavior (AOR = 3.10, 95% CI: 1.99–4.78) were associated with bypassing childbirth health facility (Table 3).
Table 3
Bivariate and multivariable analysis of factors associated with bypassing the childbirth center among postpartum women, Dire Dawa Administration, Ethiopia, 2022 (n = 635)
Variables
|
Category
|
Bypassing birth center
|
COR (95% CI)
|
AOR (95% CI)
|
P-value
|
Yes
|
No
|
Age (in completed years)
|
35 and above
|
50(20.8%)
|
190(79.2%)
|
2.82(1.83–4.34)***
|
2.34 (1.43–3.82)
|
0.002.
|
25–34
|
71(32.4%)
|
148(67.6%)
|
1.55(1.03–2.34)*
|
1.32 (0.83–2.10)
|
0.001
|
24 and less
|
75(42.6%)
|
101(57.4%)
|
1
|
1
|
|
Residence
|
Rural
|
87(23.8%)
|
279(76.2%)
|
2.18(1.55–3.08)***
|
1.89(1.11–3.22)
|
0.020
|
Urban
|
109(40.5%)
|
160(59.5%)
|
1
|
1
|
|
Education level
|
No formal education
|
23(18.7%)
|
100(81.3%)
|
2.70(1.55–4.70)***
|
2.26(1.23–4.16)
|
.008
|
Primary level
|
53(24.5%)
|
163(75.5%)
|
1.91(1.22–2.97)**
|
1.86(1.13–3.08)
|
.015
|
Secondary level
|
58(43.3%)
|
76(56.7%)
|
0.81(0.51–1.30)
|
1.05(0.62–1.76)
|
.865
|
Post-secondary level
|
62(38.3%)
|
100(61.7%)
|
1
|
1
|
|
Occupation
|
House wife
|
44(24.3%)
|
137(75.7%)
|
2.10(1.14–3.87)*
|
1.46(0.73–2.89)
|
.283
|
merchant
|
72(29.6%)
|
171(70.4%)
|
1.60(0.90–2.86)
|
1.46(0.77–2.78)
|
.249
|
private employee
|
20(32.8%)
|
41(67.2%)
|
1.38(0.66–2.90)
|
1.43(0.63–3.25)
|
.387
|
public employee
|
35(39.8%)
|
53(60.2%)
|
1.02(0.53–1.99)
|
1.26(0.61–2.60)
|
.537
|
daily laborer
|
25(40.3%)
|
37(59.7%)
|
1
|
1
|
|
Parity
|
multiparity
|
76(26.5%)
|
211(73.5%)
|
1.46(1.04–2.06)*
|
0.81(0.45–1.44)
|
0.473
|
primiparity
|
120(34.5%)
|
228(65.5%)
|
1
|
1
|
|
Presence of obstetric complication
|
Yes
|
16(19.0%)
|
68(81.0%)
|
2.06(1.16–3.66)*
|
1.30(0.41–4.10)
|
0.668
|
No
|
180(32.7%)
|
371(67.3%)
|
1
|
1
|
|
Co-medical illness
|
Yes
|
16(18.8%)
|
69(81.2%)
|
2.10(1.18–3.72)*
|
1.90(0.60–5.96)
|
0.271
|
No
|
180(32.7%)
|
370(67.3%)
|
1
|
1
|
|
ANC needs
|
1–2
|
83(24.4%)
|
257(75.6%)
|
1.92(1.37–2.70)***
|
2.37(1.33–4.22)
|
0.003
|
3 and more
|
113(38.3%)
|
182(61.7%)
|
1
|
1
|
|
Health professionals’’ behavior
|
“Not good”
|
36(16.0%)
|
189(84.0%)
|
3.36(2.23–5.05)***
|
3.10(1.99–4.78)
|
0.000
|
“Good”
|
160(39.0%)
|
250(61.0%)
|
1
|
1
|
|
Health service cost
|
expensive
|
70(26.5%)
|
194(73.5%)
|
1.42(1.01–2.02)*
|
1.14(0.80–1.68)
|
0.522
|
affordable
|
126(34.0%)
|
245(66.0%)
|
1
|
1
|
|
Perceived quality
|
“Low”
|
70(26.5%)
|
194(73.5%)
|
1.98(1.41–2.78)***
|
1.08(0.63–1.85)
|
0.772
|
“Good”
|
126(34.0%)
|
245(66.0%)
|
1
|
1
|
|
Significant at:*p = < 0.05, **p = < 0.01, ***p = 0.000, 1 = reference, Hosmer-Lemeshow test = 0.129 |
Qualitative Results: In the qualitative part, a total of 16 participants were interviewed (in-depth interview). Their average age was 32.1 years; the majority (80% and 73.3%) were multiparous and rural residents, respectively; nearly half (46.7%) were housewives, and all had more than three ANC visits. Three major themes, and under each many sub-themes, were driven for the reasons of bypassing a childbirth health facility: the health care facility, health professionals, and health care facility service users’ perception-related reasons.
Health care facility related: Many women, especially multiparous mothers, choose to bypass the nearby childbirth health facility for the reason that it fails to meet the obstetric needs during women’s antenatal care.
A 29-year-old postpartum woman shared her experience as follows: A laboratory test was ordered during my ANC visit, but it was not available at that health center; another time, a drug called ranitidine for my gastric problem was ordered, but when I asked the pharmacist, she said it was finished...(interviewee-11).
A 37-year-old multiparous woman stated, "I previously had ANC follow-up in a... health center, but they did not provide me iron sulfate even though it was there, and the health care workers did not care for me; they did not give me their full attention.". (interviewee-9).
A 35-year-old respondent stated that the health care facility is not fully functional, especially during the night. In my last experience, as you know, people coming from rural villages pay a lot of money for transportation. Nevertheless, when we reach there, it is possible that the health care facility is either closed or that health professionals are not there or have gone to sleep. Even if they are open, medications and equipment are often in short supply. Eventually, we end up taking prescriptions to buy from private drugstores. In addition, if the health care workers are woken up from sleep, many times they refer laboring mothers to other health care facilities, like hospitals. These and other issues discourage us from visiting a health facility, even if one is nearby. (interviwee-14)
A lack of empowerment or the husband's decision may be reasons for bypassing in some cases.
After I was teared in my previous childbirth, my husband discouraged me from going to that health care facility for labor, claiming that they used to have a better past when there were no modern healthcare services, including a vacuum. (interviewee-8)
Health care workers’ related: The qualitative study report revealed that health care workers' behavior (like a lack of respectful care and abuse like insulting, breaking their privacy) is one of the reasons mentioned for bypassing the nearby childbirth health facility.
A 30-year-old mother said that "health professionals disrespect and insult me in a nearby health center; I do not want to be insulted; I hate such behavior." Also, they use abusive language that is unexpected from health professionals. ( interviewee-5). Another mother said that health care workers lack ethics; they break my privacy as they want; when I say a word, they replay, "Did you come here to be treated or to order us? .( interviewee-15).
Women also justified choosing to bypass the nearby childbirth health facility due to the negligence of health professionals.
A 33-year-old rural resident respondent said, "Some of the professionals had a gap in performing their responsibilities appropriately, and even they had a trend of neglecting their duties." During my ANC follow-up, they did not always check my blood pressure, did not inquire about any problems that occurred between my ANC visits, did not provide adequate counseling, and did not inquire about my concerns. (interviewee-3).
Women also stated a lack of trust in health professionals as a reason for avoiding the nearby childbirth health facility.
A 36-year-old participant stated her experience as follows: "I had antenatal follow-up at a... health center, and I was told that it was a twin pregnancy, but was later confirmed to be ‘single" in a different facility." Not only this, my neighbor also had an ANC follow-up at a... health center, and at the ninth month of her pregnancy, she experienced severe crampy abdominal pain for which the health care provider advised her to take medications, assuming it was caused by gastro-intestinal parasites. Later on, she realized that she was actually in true labour and after that, she and I were thus forced to have our child delivered at another health care facility. That experience really eroded my confidence and trust in health professionals’ competence, as a result of which I decided to deliver at another health care facility for all of my subsequent children, even if it was very far away.
Health care facility service users’ perceptions related: Expensive costs and poor quality
Women also avoid the nearby childbirth health facility due to their perception of the cost of obstetric care.
The cost of health care in a... health center, according to a 31-year-old mother, is prohibitively expensive; I cannot afford their costs, such as drug and glucose costs. (interviewee 1).
A 34-year-old mother said that: "The obstetric care provided there is of poor quality; for example, the bed for physical examination and the blood pressure measuring equipment are old, even torn, the walls are filthy, and they touch different pregnant women with the same glove, so I was concerned about infection, including HIV transmission". (Interviewee-2).