Although access to skilled birth attendance via childbirth in health facility is a key intervention to reduce maternal mortality, our study shows that the national weighted average of institutional delivery in Kenya was low (62.10%). However, this proportion on institutional delivery was higher than the corresponding economic category in Indonesia which showed 42.3% (15), Nepal 35% (20) and from Ethiopia 55% (19).
In this study, institutional delivery has a significant association with women place of residence, educational level, wealth status, birth order, desire for the last pregnancy, and some regions after controlling for potential confounding factors.
The odds of institutional delivery were higher among women whose age range from 15–19 years. This finding is in line to other reports from Ethiopia, Indonesia, Nepal, and five other East African countries (12, 15, 20, 23). For obvious reasons, young women are more educated and have a better knowledge on the direct and indirect causes of maternal mortality as well as the benefits of institutional delivery. On the contrary, older women who have more experiences with home deliveries may be consider it as less risky. Moreover, women who have access to visit the health facility for antenatal checkups were more to utilize institutional delivery than those who did not take any uptake of antenatal care. This significant difference was concurrent to other studies (15, 22).
Perceived distance to health facility is negatively associated with institutional delivery. Long distances are usually having problems with waking distance, lack of transport, cost, and poor road infrastructure which might be making for rural women to decide on non-institutional delivery (2, 3). Former studies from rural coastal Kenya and others reported that, distance to health facility was a fundamental barrier for institutional delivery and an independent factor for home delivery (3, 12, 14, 15, 22, 23) which is in line to our study.
Compared to more than three-fourth of women and partners with secondary & higher education delivering in health facility, only less than one-fifth of those with no education at all delivered in health facility. Therefore, higher educational attainment of both mother and partners were associated with institutional deliveries (Table 2), similar to other studies (14, 15, 18, 23). This highlights knowledge related limitations on institutional delivery utilization is still highly existing among the study population and should be addressed.
Like many other studies in developing and middle-income countries (15, 19, 20, 23, 26), our study revealed that household wealth status is the most important determinant of health facility utilization for delivery. After controlling all sociodemographic factors, household socioeconomic status remained significant predictor, in which women from richest, richer, middle, and poorer families were 11.1 times, 3.9 times, 2.3 times, and 82% more to use institution compared to the poorest category. There is a presumption for lower double or triple burdens on affluent people, better educated, have a better income, better access to media information towards health promotion on the benefits of institutional delivery, live in urban areas proxy to the healthcare service, and accessible transportation service, which makes favorable for optimum institutional utilization for delivery (Figure-1).
Other factors such as wontedness of the last pregnancy and ecological zone were also associated with institutional delivery inline to previously published studies from Nepal, Ethiopia, and five other East African countries (19, 20, 23). The highest percentage of institutional delivery was among mothers from Central and Nairobi regions, which covers more than nine-tenth of mother’s delivery in a health facility. In this regard, women from Central region were 4 times more likely to use institutional delivery compared to the North Eastern after adjustment. Therefore, regional variability factors should continuous be assessed.
Regardless of the number of times a woman gave birth, all women are encouraged to delivery in a health facility where they can receive adequate care and support during and after delivery. However, multivariable logistic regression showed that first birth order women were greater than two-folds more to use health facility than those fourth and above birth orders. This finding is comparable to other studies in Tanzania and other sub-Saharan Africa countries (30, 31).
Even though, many studies on global recommendations have reported that access to information through media has significant implication on institutional delivery promotions (15), no significant association with frequency of listing to radio or watching TV was detected in our study after adjusting other variable.
Our results highlighted that three communality factors (socioeconomic, family support, and women status) were identified as having the major variance on place of delivery (Table 4). The result suggested that women from high (first tertile) of socioeconomic factor tended to receive more institutional delivery than those in the lowest third tertile of socioeconomic group. Moreover, high family support factor was associated with higher odds of institutional delivery. Our findings also emphasized that high women status factor was significant associated with women’s uptake of institutional delivery. Further studies are needed to explore the detail associations in this study settings.
Strength of the study: compared with the similar study, just focus on the association between each explanatory variable with institutional delivery, ignore the correlations between explanatory variables, we use the factor analysis to extract the subpopulation profiles associated with institutional delivery. Our results help government to more accurately locate vulnerable groups that need attention.
Limitation of the study: The low level of institutional delivery among the urban, educated and wealth families may suggest that the quality of service may be an issue, and was not included in this study. Additionally, from this cross-sectional survey, it cannot affirm causal relationships and direction of the association.