1.1 Background to the study

Assurance of healthcare for all segments of the population with special attention given to the health needs of women and children was one of the top priorities in the Ethiopian Health Policy. The endorsement of MDG 5 in the HSDPs is an indication of the commitment or political will of the government towards reducing maternal mortality across the nation. Yet, Ethiopia’s health system is underdeveloped and underfinanced. While some progress has been made in providing basic health services to poor women and their children, the progress may be uneven because many people are not reached with services.

Ethiopia’s total health expenditure as a percentage of the gross domestic product (GDP) has remained stable at 4.3% for years. With emphasis given to publicly funded healthcare, out-of-pocket payment constitutes 42%. The public health sector is the main provider of primary healthcare and serves two-thirds of the population who cannot afford private healthcare. The main objective of the public sector service provision, as stated in the National Health Policy, is “to give comprehensive and integrated primary health care services in a decentralized and equitable fashion” .

Childbirth and its process are one of the most significant life events to a woman . The time of birth as well as shortly thereafter is the most dangerous period in a child’s life especially in the developing world. Hence the choice of place of delivery for a pregnant woman is an important aspect of maternal healthcare. The place of delivery is an important factor often related to the quality of care received by the mother and infant for influencing maternal and child healthcare outcomes. In Addis Ababa, the capital of Ethiopia, though the private health facilities (hospitals and clinics) outnumber public clinics , only 20% of deliveries take place in the private sectors and 17% of mothers deliver at home.

A significant proportion of mothers in developing countries still deliver at home unattended by skilled health workers (Montagu D, Yamey G, Visconti A, Harding A, Yoong J 2011). In diverse contexts, individual factors including maternal age, parity, education and marital status, household factors including family size, household wealth, and community factors including socioeconomic status, community health infrastructure, region, rural/urban residence, available health facilities, and distance to health facilities determine place of delivery and these factors interacting diverse ways in each context to determine place of delivery. In developing countries, pregnancy and childbirth are the leading causes of disability and death among women of reproductive age.  

Indeed, the majority of maternal deaths occur either during or shortly after delivery. According to United Nations Children Fund (UNICEF 2009), pregnancy and childbirth related complications claim lives of at least 585,000 women every year in developing world. Pregnancy related problems include anemia, bleeding, infection, damage of the uterus, obstructed labor and abortion. Nearly all maternal deaths in developing countries occur among the vulnerable and disadvantaged population groups and yet most of these causes are preventable. Although the main causes of maternal mortality are well known and the knowledge as well as appropriate technology to reduce it has been available, maternal health problems are still highly prevalent in most African societies.  

Statistics by (WHO 2010) found that 92% of women receive antenatal care from a trained health worker but when it comes to delivery time, most of them do not deliver at health units, but instead deliver elsewhere. It was estimated that about 15% of deliveries have complications that require skilled medical intervention. Yet only 53% of deliveries in developing countries take place with the assistance of a skilled birth attendant compared to 99% in developed countries. In resource-poor settings, home delivery is usually the cheapest option, but is associated with attendant risks of infection and lack of available equipment should complications occur. (Thind A. et al, 2008). 

According to (Hogan, 2008), Ethiopia is among the top six high burden countries in which half of global maternal deaths occur, with an estimated maternal mortality ratio of 470 per 100, 000 live births. The most recent Ethiopian Demographic and Health Survey (EDHS 2011), very few mothers (34%) make at least one antenatal visit and even less receive delivery care from skilled birth attendants. It reports 28% of births were assisted by a traditional birth attendant (TBA) and 57 percent of births were assisted by a relative, or some other person.