Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
PLoS One. 2020 Nov 12;15(11):e0242242. doi: 10.1371/journal.pone.0242242. eCollection 2020.
BACKGROUND: Institutional delivery is an important indicator in monitoring the progress towards Sustainable Development Goal 3.1 to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Despite the international focus on reducing maternal mortality, progress has been low, particularly in Sub-Saharan Africa (SSA), with more than 295,000 mothers still dying during pregnancy and childbirth every year. Institutional delivery has been varied across and within the country. Therefore, this study aimed to investigate the individual and community level determinants, and spatial distribution of institutional delivery in Ethiopia. METHODS: A secondary data analysis was done based on the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total weighted sample of 11,022 women was included in this study. For spatial analysis, ArcGIS version 10.6 statistical software was used to explore the spatial distribution of institutional delivery, and SaTScan version 9.6 software was used to identify significant hotspot areas of institutional delivery. For the determinants, a multilevel binary logistic regression analysis was fitted to take to account the hierarchical nature of EDHS data. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and deviance (-2LL) were used for model comparison and for checking model fitness. Variables with p-values<0.2 in the bi-variable analysis were fitted in the multivariable multilevel model. Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) were used to declare significant determinant of institutional delivery. RESULTS: The spatial analysis showed that the spatial distribution of institutional delivery was significantly varied across the country [global Moran's I = 0.04 (p<0.05)]. The SaTScan analysis identified significant hotspot areas of poor institutional delivery in Harari, south Oromia and most parts of Somali regions. In the multivariable multilevel analysis; having 2-4 births (AOR = 0.48; 95% CI: 0.34-0.68) and >4 births (AOR = 0.48; 95% CI: 0.32-0.74), preceding birth interval ≥ 48 months (AOR = 1.51; 95% CI: 1.03-2.20), being poorer (AOR = 1.59; 95% CI: 1.10-2.30) and richest wealth status (AOR = 2.44; 95% CI: 1.54-3.87), having primary education (AOR = 1.47; 95% CI: 1.16-1.87), secondary and higher education (AOR = 3.44; 95% CI: 2.19-5.42), having 1-3 ANC visits (AOR = 3.88; 95% CI: 2.77-5.43) and >4 ANC visits (AOR = 6.53; 95% CI: 4.69-9.10) were significant individual-level determinants of institutional delivery while being living in Addis Ababa city (AOR = 3.13; 95% CI: 1.77-5.55), higher community media exposure (AOR = 2.01; 95% CI: 1.44-2.79) and being living in urban area (AOR = 4.70; 95% CI: 2.70-8.01) were significant community-level determinants of institutional delivery. CONCLUSIONS: Institutional delivery was low in Ethiopia. The spatial distribution of institutional delivery was significantly varied across the country. Residence, region, maternal education, wealth status, ANC visit, preceding birth interval, and community media exposure were found to be significant determinants of institutional delivery. Therefore, public health interventions should be designed in the hotspot areas where institutional delivery was low to reduce maternal and newborn mortality by enhancing maternal education, ANC visit, and community media exposure.
背景：机构分娩是监测可持续发展目标 3.1 进展的一个重要指标，该目标旨在将全球孕产妇死亡率降低到每 10 万活产儿少于 70 人。尽管国际社会专注于降低孕产妇死亡率，但进展缓慢，特别是在撒哈拉以南非洲（SSA）地区，每年仍有超过 29.5 万名母亲在妊娠和分娩期间死亡。机构分娩在国家内部和国家之间存在差异。因此，本研究旨在调查埃塞俄比亚机构分娩的个体和社区水平决定因素及其空间分布。
方法：基于 2016 年埃塞俄比亚人口与健康调查（EDHS）数据进行二次数据分析。本研究共纳入了 11022 名妇女的加权总样本。为了进行空间分析，使用 ArcGIS 版本 10.6 统计软件探索机构分娩的空间分布，并使用 SaTScan 版本 9.6 软件确定机构分娩的显著热点地区。对于决定因素，采用多水平二元逻辑回归分析来考虑 EDHS 数据的分层性质。使用类内相关系数（ICC）、中位数优势比（MOR）、方差比例变化（PCV）和偏差（-2LL）来比较和检查模型拟合度。双变量分析中 p 值<0.2 的变量被纳入多变量多水平模型。使用 95%置信区间（CI）的调整优势比（AOR）来宣布机构分娩的显著决定因素。
结果：空间分析表明，机构分娩的空间分布在全国范围内存在显著差异[全局 Moran's I = 0.04（p<0.05）]。SaTScan 分析确定了在哈拉里、奥罗米亚南部和索马里地区大部分地区存在贫困机构分娩的显著热点地区。在多变量多水平分析中；生育 2-4 次（AOR = 0.48；95%CI：0.34-0.68）和>4 次（AOR = 0.48；95%CI：0.32-0.74）、前次分娩间隔≥48 个月（AOR = 1.51；95%CI：1.03-2.20）、较贫穷（AOR = 1.59；95%CI：1.10-2.30）和最富裕的财富状况（AOR = 2.44；95%CI：1.54-3.87）、接受过小学教育（AOR = 1.47；95%CI：1.16-1.87）、接受过中学和高等教育（AOR = 3.44；95%CI：2.19-5.42）、接受过 1-3 次 ANC 访问（AOR = 3.88；95%CI：2.77-5.43）和>4 次 ANC 访问（AOR = 6.53；95%CI：4.69-9.10）是机构分娩的显著个体水平决定因素，而居住在亚的斯亚贝巴市（AOR = 3.13；95%CI：1.77-5.55）、较高的社区媒体接触（AOR = 2.01；95%CI：1.44-2.79）和居住在城市地区（AOR = 4.70；95%CI：2.70-8.01）是机构分娩的显著社区水平决定因素。
结论：埃塞俄比亚的机构分娩率较低。机构分娩的空间分布在全国范围内存在显著差异。居住地、地区、产妇教育、财富状况、ANC 访问、前次分娩间隔和社区媒体接触是机构分娩的重要决定因素。因此，应在机构分娩率较低的热点地区开展公共卫生干预措施，通过提高产妇教育、ANC 访问和社区媒体接触来降低孕产妇和新生儿死亡率。
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