Missed opportunities and associated factors for institutional delivery services among women in Hararghe eastern Ethiopia a mixed methods study  – Nature. Com 01:16 

Missed opportunities and associated factors for institutional delivery services among women in Hararghe eastern Ethiopia a mixed methods study

Scientific Reports , Article number:  (2026) Cite this article

We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply.

Abstract

Maternal mortality remains high globally, with 94% of deaths in low-resource settings. In Ethiopia, only 48% of births take place in health facilities, and just 25–35% in Hararghe. Despite contact with health services, many women still miss institutional deliveries. This study aimed to quantitatively identify factors associated with non-institutional delivery and qualitatively explore contextual, behavioral, and health system factors influencing maternal health service utilization, integrating findings to provide a comprehensive understanding of barriers to institutional delivery. A convergent parallel mixed-methods study with equal weighting of quantitative and qualitative strands (QUAN + QUAL) was conducted in Grawa, Meta, and Haramaya woredas from September 5 to December 5, 2017. For the quantitative component, 357 women who had attended at least one ANC visit were included to identify factors associated with non-institutional delivery. Data were entered into EpiData version 3.1 and analyzed using SPSS version 25, applying multivariable logistic regression at p < 0.05. For the qualitative component, purposive sampling was used to select participants for key informant interviews and eight focus group discussions. Thematic analysis was conducted using Atlas.ti version 8.2. Findings from both strands were integrated during interpretation through triangulation to generate complementary and corroborative insights. Among the 357 ANC-attending women, 41.2% (95% CI: 36.2–46.5) delivered outside health facilities, reflecting a missed opportunity for skilled birth attendance. Notably, women residing in urban areas were significantly more likely to have non-institutional deliveries (AOR = 4.82, 95% CI: 1.97–11.79). Maternal age between 26 and 34 years (AOR = 3.87, 95% CI: 1.18–12.72) and attending fewer than four ANC visits (AOR = 3.26, 95% CI: 1.02–10.39) were also associated with higher odds of non-institutional delivery. Conversely, spontaneous vaginal delivery was linked to lower odds of non-institutional delivery (AOR = 0.18, 95% CI: 0.07–0.44). Meanwhile, respectful treatment and ambulance access showed no statistically significant associations with delivery location. ANC attendance, more than one-quarter of women experienced missed opportunities for institutional delivery, indicating that service contact alone is insufficient to ensure facility-based birth. This underscores persistent gaps in Ethiopia’s efforts to achieve universal facility-based delivery, particularly in rural and underserved areas. Key factors influencing institutional delivery included urban residence, previous delivery experience, antenatal care (ANC) attendance, and maternal age, suggesting that mere contact with health services does not guarantee facility-based births.

Data availability

The data sets used for this study are available from the corresponding authors on reasonable request.

References

  1. WHO. Maternal mortality. (2023).
  2. WHO. Improving Maternal and Newborn Health and Survival and Reducing stillbirth – Progress Report 2023 34 (WHO, 2022).
  3. Shiferaw, K., Tiruye, G. & Bekele, H. Predictors of institutional delivery service utilization in ethiopia: an umbrella review. BMC Pregnancy Childbirth. 25 (1), 332 (2025).Google Scholar 
  4. CSA, C. S. A. Ethiopia Mini Demographic and Health Survey 2019. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF. (2019).
  5. FMOH., F. M. H. Health Sector Transformation Plan II (HSTP-II): 2020/21–2024/25. Addis Ababa, Ethiopia (Federal Ministry of Health, 2020).
  6. UN, D. & WHO. UNICEF, Sustainable Development Goals Report 2021. (2021).
  7. Actis Danna, V. et al. Utility of the three-delays model and its potential for supporting a solution-based approach to accessing intrapartum care in low- and middle-income countries. A qualitative evidence synthesis. Global Health Action. 13 (1), 1819052 (2020).Google Scholar 
  8. Tarik, Y. D. et al. Factors associated with institutional delivery among mothers who gave birth within 1 year prior to the study at Gilgelbelles town, Northwest ethiopia: a mixed-methods study. BMJ Open. 12 (11), e061218 (2022).Google Scholar 
  9. Habte, F. & Demissie, M. Magnitude and factors associated with institutional delivery service utilization among childbearing mothers in Cheha district, gurage zone, SNNPR, ethiopia: a community based cross sectional study. BMC Pregnancy Childbirth. 15 (1), 299 (2015).Google Scholar 
  10. WHO, W.H.O. Missed Opportunities in Maternal Health: Addressing the gaps. Geneva: WHO (WHO, 2023).
  11. Amentie, M. & Abdulahi, M. and Assosa. Utilization of Institutional Delivery Care Services and Influencing Factors among Women of Child Bearing Age in Assosa District, Benishangul Gumuz Regional State, West Ethiopia (2017).
  12. Bayu, H. et al. Missed opportunities for institutional delivery and associated factors among urban resident pregnant women in South Tigray Zone, ethiopia: a community-based follow-up study. Glob. Health Action. 8, 28082–28082 (2015).Google Scholar 
  13. Assefa, M. et al. Institutional delivery service use and associated factors among women who delivered during the last 2 years in Dallocha town, SNNPR, Ethiopia. Nurs. Open. 7 (1), 186–194 (2019).Google Scholar 
  14. Siraneh, Y. Institutional delivery services utilization and associated factors among mothers who gave birth in the last one year in Jimma Town, Southwest Ethiopia. J. Complement. Med. Altern. Healthcare (2018).
  15. Memirie, S. T. et al. Inequalities in utilization of maternal and child health services in ethiopia: the role of primary health care. BMC Health Serv. Res. 16 (1), 51 (2016).Google Scholar 
  16. Sibley, L. M. et al. Improving maternal and newborn health care delivery in rural Amhara and Oromiya regions of Ethiopia through the maternal and newborn health in Ethiopia partnership. J. Midwifery Women’s Health 59 (Suppl 1), S6–S20 (2014).Google Scholar 
  17. Teferra, A. S., Alemu, F. M. & Woldeyohannes, S. M. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of ethiopia: a community – based cross sectional study. BMC Pregnancy Childbirth. 12 (1), 74 (2012).Google Scholar 
  18. Mesfin, N., Mariam, D. H. & Kassie, G. Assessment of safe delivery service utilization among women of childbearing age in North Gondar Zone, North West Ethiopia. Ethiop. J. Health Dev. 2005, 18 (2005).
  19. Tadele, N. & Lamaro, T. Utilization of institutional delivery service and associated factors in bench Maji zone, Southwest ethiopia: community based, cross sectional study. BMC Health Serv. Res. 17 (1), 101 (2017).Google Scholar 
  20. Abeje, G., Azage, M. & Setegn, T. Factors associated with institutional delivery service utilization among mothers in Bahir Dar City administration, Amhara region: a community based cross sectional study. Reprod. Health 11 (1), 22 (2014).Google Scholar 
  21. Amano, A., Gebeyehu, A. & Birhanu, Z. Institutional delivery service utilization in munisa Woreda, South East ethiopia: a community based cross-sectional study. BMC Pregnancy Childbirth. 12 (1), 105 (2012).Google Scholar 
  22. Yosef, T. Magnitude and associated factors of institutional delivery among reproductive age women in Southwest Ethiopia. Int. J. Women’s Health. 12, 1005–1011 (2020).Google Scholar 
  23. Nigussie, M., Mariam, D. H. & Mitike, G. Assessment of safe delivery service utilization among women of childbearing age in North Gondar Zone, North West Ethiopia. Ethiop. J. Health Dev. 18 (3), 145–152 (2004).Google Scholar 
  24. Abdella, M. et al. Magnitude and associated factors for home delivery among women who gave birth in last 12 months in Ayssaita, Afar, Ethiopia-2016. A community based cross sectional study. Glob J. Fertil. Res. 2 (1), 30–39 (2017).Google Scholar 
  25. Onah, H. E., Ikeako, L. C. & Iloabachie, G. C. Factors associated with the use of maternity services in Enugu, Southeastern Nigeria. Soc. Sci. Med. 63, 1870–1878 (2006).
  26. Wanjira, C. et al. Delivery practices and associated factors among mothers seeking child welfare services in selected health facilities in Nyandarua South District, Kenya. BMC Public. Health. 11 (1), 360 (2011).Google Scholar 
  27. Mpembeni, R. N. et al. Use pattern of maternal health services and determinants of skilled care during delivery in Southern tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth. 7 (1), 1–7 (2007).Google Scholar 
  28. EDHS CSA and ICF: Central Statistical Agency (CSA) [Ethiopia] and ICF (2016) Ethiopia demographic and health survey 2016: Key indicators report. Addis Ababa, Ethiopia, and Rockville, Maryland, USA (2016).
  29. Abebe, F., Berhane, Y. & Girma, B. Factors associated with home delivery in Bahirdar, Ethiopia: a case control study. BMC Res. Notes. 5 (1), 653 (2012).Google Scholar 
  30. Teferra, A. S., Alemu, F. M. & Woldeyohannes, S. M. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of Ethiopia: a community-based cross sectional study. BMC Pregnancy Childbirth. 12 (1), 1–11 (2012).Google Scholar 
  31. Kabakyenga, J. K. et al. Influence of birth preparedness, decision-making on location of birth and assistance by skilled birth attendants among women in south-western Uganda. PloS One. 7 (4), e35747 (2012).Google Scholar 
  32. Doctor, H. V., Nkhana-Salimu, S. & Abdulsalam-Anibilowo, M. Health facility delivery in sub-Saharan africa: successes, challenges, and implications for the 2030 development agenda. BMC public. Health. 18, 1–12 (2018).Google Scholar 
  33. Mitikie, K. A., Wassie, G. T. & Beyene, M. B. Institutional delivery services utilization and associated factors among mothers who gave birth in the last year in Mandura district, Northwest Ethiopia. PLOS ONE. 15 (12), e0243466 (2020).Google Scholar 
  34. Amentie, M., Abera, M. & Abdulahi, M. Utilization of institutional delivery care services and influencing factors among women of child bearing age in Assosa District, Benishangul Gumuz regional State, West Ethiopia. Glob J. Med. Res. 4, 52–59 (2016).Google Scholar 
  35. Bishanga, D. R. et al. Factors associated with institutional delivery: findings from a cross-sectional study in Mara and Kagera regions in Tanzania. PLOS ONE. 13 (12), e0209672 (2018).Google Scholar 
  36. Abebe, F. B. Y. & Girma, B.,() factors associated with home delivery in Bahirdar, Ethiopia: a case control study. BMC Res. Notes 5: 653. (2012).Google Scholar 
  37. Bulto, G. A., Demissie, D. B. & Tulu, A. S. Respectful maternity care during labor and childbirth and associated factors among women who gave birth at health institutions in the West Shewa zone, oromia region, central Ethiopia. BMC Pregnancy Childbirth 20 (1), 443 (2020).Google Scholar 
  38. Bante, A. et al. Respectful maternity care and associated factors among women who delivered at Harar hospitals, Eastern ethiopia: a cross-sectional study. BMC Pregnancy Childbirth. 20 (1), 86 (2020).Google Scholar 
  39. Ferede, W. Y. et al. Respectful maternity care and associated factors among mothers who gave birth at public health institutions in South Gondar Zone, Northwest Ethiopia 2021. Women’s Health 18, 17455057221116505 (2022).
  40. Wochefu, B. B. & Koboto, A. A. Compassionate and respectful maternity care and associated factors among women attending delivery services at public health facilities of Hawassa City, Southern Ethiopia. Int. Arch. Nurs. Health Care. 7, 165 (2021).Google Scholar 
  41. Anagaw, M. et al. Respectful Delivery Care and Associated Factors among Mothers Delivered in Public Health Facilities of Dessie city, Northeast Ethiopia: a cross-sectional Study 22 (BMC Women’s Health, 2022).
  42. Habte, A. et al. The prevalence of respectful maternity care during childbirth and its determinants in ethiopia: a systematic review and meta-analysis. PLOS ONE. 17 (11), e0277889 (2022).Google Scholar 
  43. Shiferaw, S. et al. Why do women prefer home births in ethiopia? BMC Pregnancy Childbirth 13 (1), 5 (2013).Google Scholar 
  44. Abdulahi, I. M. Socio-cultural determinants and missed opportunities of maternal healthcare services in Ethiopia (2018).
  45. Feyissa, T. R. & Genemo, G. A. Determinants of institutional delivery among childbearing age women in Western Ethiopia, 2013: unmatched case control study. PLOS ONE. 9 (5), e97194 (2014).Google Scholar 
  46. Rajvanshi, D. et al. Association of identification of facility and transportation for childbirth with institutional delivery in high priority districts of Uttar Pradesh, India. BMC Pregnancy Childbirth 21 (1), 724 (2021).Google Scholar 
  47. Gage, A. J. Barriers to the utilization of maternal health care in rural Mali. Soc. Sci. Med. 65 (8), 1666–1682 (2007).Google Scholar 
  48. Sialubanje, C. et al. Reasons for home delivery and use of traditional birth attendants in rural zambia: a qualitative study. BMC Pregnancy Childbirth 15 (1), 216 (2015).Google Scholar 
  49. Temesgen Arega, T. M., Alemayehu, A., Mussa, I. & Dheresa, M. Institutional delivery and associated factors among women who gave birth in Benishangul Gumuz region, South West Ethiopia. Front. Public. Health Sec Public. Health Policy 2022, 10 (2022).
  50. Bhaskar, R. K. & Deo, K. K. Determinants of utilization of institutional delivery services in East nepal: a community-based cross-sectional study. J. Natl. Med. Coll. 3 (1), 6–15 (2018).Google Scholar 

Download references

Acknowledgements

The authors are very thankful to the University of South Africa, the Head and Staff of Haramaya, Grawa, and Meta, the study participants, data collectors, and field supervisors.

Funding

The University of South Africa provided financial support for this study. However, the funding agency had no role in the collection, analysis, and interpretation of the data, as well as the writing of the manuscript.

Competing interests.

The authors have no competing interests in this work.

Author information

Authors and Affiliations

  1. School of Public Health, College of Health and Medical Sciences, Haramaya University, P. O. Box 138, Harar, EthiopiaIbsa Mussa
  2. Department of Health Studies, College of Human Sciences, School of Social Sciences, University of South Africa, Pretoria, South AfricaOn Makhubela-Nkondo

Contributions

IM conceived and designed the study. IM and ON drafted the manuscript and IM was the PI of the review. . IM and ON developed search strings. Both reviewers IM and ON screened and selected studies. . IM and ON evaluated the quality of the studies. . IM and ON performed analyses and interpretations. Both authors have rigorously reviewed, read, and approved the final version of the manuscript.

Corresponding author

Correspondence to Ibsa Mussa.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethical approval

Ethical approval for this was obtained from the University of South Africa, Research Ethics Committee Department of Health Studies (REC-012714-039 (NHERC) on date 2 August 2017. Support letters from the university were written to the Oromia Health Bureau and then to the selected kebele where the study was conducted. After getting all permission letters from the responsible body, informed consent was obtained from all subjects and/or their legal guardian(s) and use plain language by study participants. Confidentiality was maintained by using codes instead of the participant’s name. Participants were also informed that they have the full right to refuse participation or withdraw any time from the research. All methods were performed in accordance with relevant guidelines and regulations in the Declaration of Helsinki.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Cite this article

Mussa, I., Makhubela-Nkondo, O. Missed opportunities and associated factors for institutional delivery services among women in Hararghe eastern Ethiopia a mixed methods study. Sci Rep (2026). https://doi.org/10.1038/s41598-026-39471-x

Download citation