ASSESSMENT OF KNOWLEDGE, ATTITUDE AND PRACTICE ON

INSTITUTIONAL DELIVERY AMONG WOMEN IN REPRODUCTIVE

AGE IN KEMISSIE TOWN APRIL 2017
INVESTIGATORS ID NUMBER

1. TILAHUN TADESSE………………………………….R/2112/06
2. EWNETU TEREFE……………………………………R/2018/06
3. KASSA ZELEKE……………………………………....R/2055/06
4. HAWLITU BEKA………………………………………R/2047/06
5. KEYRIA SEID……………………………………..........R/2060/06
6. BETELHEM ABATE………………………………….R/3598/06

RESEARCH PAPER SUBMITTED TO WOLLO UNVERSITY COLLEGE

OF MEDICINE AND HEALTH SCIENCES DEPARTMENT OF
MIDWIFERY, FOR PARTIAL FULLFILMENT OF BACHELOR OF
SCIENCE (BSC) IN MIDWIFERY.APRIL, 2017

APRIL, 2017

DESSIE, ETHIOPIA

1
 WOLLO UNIVERSITY

SCHOOL OF NURSING AND MIDWIFERY

DEPARTMENT OF MIDWIFERY
ASSESSMENT OF KNOWLEDGE, ATTITUDE AND PRACTICE ON INSTITUTINAL
DELIVERY AMONG WOME IN REPRODCTIVE AGE IN KEMISE TOWN, NORTH
ETHIOPIA IN 2017

ADVISOR; A. INFANT RANI (Bsc, Msc)

ZENEBE. T (Bsc)

Prepared by ID

1. TILAHUN TADESSE R/2112/06

2. EWUNETU TEREFE R/2018/06

3. KASSA ZELEKE R/2055/06

4. HAWLITU BEKA R/2047/06

5. KEYRIA SEID R/2060/06

6. BETELHEM ABATE R/3598/06

A RESEARCH PAPER SUBMITTED TO WOLLO UNIVERSITY, SCHOOL OF

NURSING AND MIDWIFERY FOR PARTIAL FULFILLMENT OF THE
REQUIREMENT FOR BACHELOR OF SCIENCE (BSC) IN MIDWIFERY

APRIL, 2016

DESSIE,ETHIOPIA

2
 ACKNOWLEDGEMENT

First of all we would like to express our heart full gratitude to almighty to God who helped us
to accomplish this proposal successfully
We are also extended our gratitude to the department of midwifery, college of medicine and
health science, Wollo University for assigning advisors and giving chance to develop this
research proposal

We will like to give grateful attitude to our advisor Ms. Infant Rani (Msc) and Mr. Zenebe
Tefera for their valuable guidance and constructive suggestions and comments while we
develop this research proposal

Finally, we wish to express our gratitude and deep respect to kemise kebele community and
administrator who have share their view on knowledge, attitude and practice on institutional
delivery among reproductive age

3
 ACRONYMY/ ABBREVIATION

FMOH Federal Ministry of Health

HEW Health Extension Workers

TTBA Trained Traditional Birth Attendants

PHC Primary Health Care

HH ` House Hold

EDHS Ethiopian Demographic Health Survey

KAP Knowledge, Attitude, Practice

MDGs Millennium Development Goals

FP Family Planning

HIV Human Immune Virus

IMR Infant Mortality Rate

MMR Maternal Mortality Ratio

NGO Non-Governmental Organization

PPH Post-Partum Hemorrhage

TBA Traditional Birth Attendants

WHO World Health Organization

ANC Antenatal Care

AIDS Acquired Immune Deficiency Syndrome

APH Ante Partum Hemorrhage

CMR Child Mortality Rate

C/S Cesarean section

4
 LISTS OF TABLES
Table 1: Socio-demographic characteristic by marital status, occupational status and monthly
income among women of reproductive age in kemise town, kebele April,2017………22&23

Table 2: Source of information about importance of health institution delivery than home
delivery among women reproductive age kemise town, kebele 01 April,2017…………..24

Table 3: Awareness of women of reproductive age by response on benefit of attending

delivery in health institution -in kemise town, April, 2017.................................................25

Table 4: Attitude of mothers on specific methods practiced by health institution to decrease

maternal and child mortality rate in kemise town, April,2017……….................................26

Table 5: Attitude of women reproductive age regarding negative effect of culture and
religious on institutional delivery in Kemise town,April,2017
……...........................................................................................................27

5
LISTS OF FIGURES
Figure 1: Women’s awareness by response on health institution delivery in Kemise town,
April, 2017………………….................................................................................................18

Figure 2: Mothers place of delivery who were experienced childbirth in the last 12 months in
Kemise town, April,2017......................................................................................................24

6
 ABSTRACT
Introduction: - Institutional delivery is one way of decreasing maternal and neonatal
mortality and morbidity, especially in developing countries. Despite a great public health
effort, many women are still delivering at home either by TBA or relatives. In Ethiopia
almost all birth takes place at home (85.5%) with only 14.5% of women delivered at health
institutions (EDHS-2014). But the prevalence is more in rural areas or those too far from
health facilities.

Objectives:-The main objective of this study is to assess the Knowledge, Attitude and
Practice on women of reproductive age group in Kemise town, April 2017.

Methods and Materials: -The study was conducted in Kemise town, North Ethiopia from
February to April, 2017 by using descriptive community based cross sectional study design to
assess knowledge, attitude and practice on women of reproductive age group in Kemise town,
Kebele 01, 02 & 03. The source population was all women of reproductive age (15-49yrs) in
Kemise town, Kebele 01, 02 & 03 and the sample size was determined by using single
population proportion by considering 95% level of confidence and 5% margin of error. The
sample size of the study subjects was 250 and simple random sampling technique was used to
collect all study subjects.

Results: - Out of 250 study subjects, almost all study participants heard about institutional
delivery. A total of 92% of study subjects had information regarding health institution
delivery. Majority (59.2%) of study subjects got information from mass media. More than
85% of study subjects had information about problem of home delivery either by TBA or
relatives. A total of more than 85% of mothers believed that institutional delivery has benefit
for mothers and the baby. From total of 250 study participants who experienced child birth
for the last 12 months, more than 75% delivered at health institution.

Conclusion: - The result of this study indicates that More than 85% of the participants had
knowledge about attending delivery at health facility. Comparing to national figure (85.5%)
of home delivery, the result of this study is better (11.6%). Majority of the participants had
good attitude toward health institution delivery. This study recommended that there must be
intense and consistent increased mass media regarding risk and potential problem related to
home delivery. Further, it highly recommended that all health facilities in Kemise town and

7
its surrounding must provide regular and ongoing morning health education about
institutional delivery for all clients visiting their institutions.

Contents
WOLLO UNIVERSITY
1

ACKNOWLEDGEMENT...........................................................................................................................3
ACRONYMY/ABBREVIATION..................................................................................................................4
LISTS OF TABLES....................................................................................................................................6
LISTS OF FIGURES...................................................................................................................................7
ABSTRACT..........................................................................................................................................8
CHAPTER ONE........................................................................................................................................9
INTRODUCTION.....................................................................................................................................9
1.1. Background information.............................................................................................................9
2.1. STATEMENT OF THE PROBLEM.................................................................................................10
1.3 JUSTIFICATION AND SIGNIFICANT OF THE STUDY......................................................................11
CHAPTER TWO:................................................................................................................................12
LITERATURE REVIEW........................................................................................................................12
2.1 Knowledge.................................................................................................................................12
2.2 Attitude......................................................................................................................................13
2.3 Practice......................................................................................................................................13
CHAPTER THREE...................................................................................................................................17
OBJECTIVES..........................................................................................................................................17
3.1 General objective.......................................................................................................................17
3.2 Specific objectives......................................................................................................................17
CHAPTER FOUR....................................................................................................................................18
METHODS AND MATERIALS.................................................................................................................18
4.1. Study area and study period.....................................................................................................18
4.2. Study design.............................................................................................................................18
4.3 Population.................................................................................................................................18
4.3.1 Source Population...............................................................................................................18
4.3.2 Study population.................................................................................................................18
4.4 Inclusion and Exclusion Criteria.................................................................................................18
4.4.1 Inclusion Criteria.................................................................................................................18

8
 4.4.2 Exclusion Criteria................................................................................................................19
4.5. Sample size determination.......................................................................................................19
4.6. Sampling technique..................................................................................................................19
4.7. Data collection method............................................................................................................19
4.8 Study Variables..........................................................................................................................20
4.9. Operational definition...............................................................................................................20
4.10 Data quality control.................................................................................................................21
4.11 Data processing and analysis...................................................................................................21
4.12 Ethical Consideration...............................................................................................................21
4.13 Disseminations of the study.....................................................................................................21
CHAPTER FIVE......................................................................................................................................22
RESULTS...............................................................................................................................................22
5.1 .SOCIO-DEMOGRAPHIC CHARASTERISTIC..................................................................................22
5.2. KNOWLEDGE OF WOMEN ON INSTITUTIONAL DELIVERY.........................................................26
5.3. ATTITUDE OF WOMEN TOWARD INSTITUTIONAL DELIVERY....................................................28
5.4. PRACTICE OF WOMEN TOWARDS INSTITUTIONAL DELIVERY...................................................30
CHAPTER SIX: DISCUSSION..................................................................................................................33
6.1. KNOWLEDGE OF WOMEN ON INSTITUTIONAL DELIVERY.....................................................33
6.2. ATTITUDE OF WOMEN TOWARD INSTITUTIONAL DELIVERY....................................................34
6.3. PRACTICE OF WOMEN ON ATTENDING DELIVERY IN HEALTH INSTITUTION.............................34
CHAPTER SEVEN: CONCLUSION...........................................................................................................36
CHAPTER EIGHT: RECOMMENDATION......................................................................................37
Annexes I.........................................................................................................................................38
References.......................................................................................................................................38
ANNEXIS II............................................................................................................................................40
QUESTIONNAIRE..................................................................................................................................40

9
 CHAPTER ONE

INTRODUCTION
1.1. Background information
Institutional delivery is an act of giving birth in hospitals or in health centers or it may in
clinic by skilled birth attendants, that mean by Medical Doctors, Public health officers,
Midwifes or Nurses. In developing countries, despite the great public health effort, many
women are still assisted in delivery either by traditional birth attendants (TBA) or relatively
delivered by themselves at home.

According to report of united nation in 2014, approximately 65% of all pregnant women
received antenatal care (ANC) during pregnancy; only 23% were delivered at health
institutions (1).

Maternal death in sub-Saharan African countries accounts for about half of world’s total
death (FMOH IN 2012). The coverage of skilled obstetric care at delivery improved in all
regions, but it has remained stagnant in African countries an average of 1 in 16 are still die in
child birth in sub-Saharan African countries compared to 1 in 350 in European countries. In
Ethiopia, access to high quality reproductive health service is restricted due to limited health
infrastructure and human power. In Ethiopia almost all birth takes place at home (84.5%)
with only 14.5% of women delivering in clinics or hospitals. Many of those women live in
remote areas that are too far from road and let alone health facilities where they cannot get
emergency obstetric care. The mortality of those births (61%) are assisted by relatives or
untrained birth attendants and (5%0f that are delivered without any assistance. In Ethiopia
maternal mortality rate (MMR) is (412/100,000) and 50% infant mortality rate (IMR)
occupied by under one week neonatal death. 60% of neonatal death occurs within First 24hrs
of delivery and child mortality rate (CMR) is 96.8% per 1000 live birth. (2)

10
1.2. STATEMENT OF THE PROBLEM

WHO 2010, Globally, unattended delivery by skilled health personnel are known to be
associated with high maternal and prenatal morbidity and mortality such as Ante partum
hemorrhage (APH), Birth trauma infection, post partum hemorrhage (PPH) and fistula, high
because of poor delivery practices done at home internationally, 30% neonatal death are due
to problem related to delivery process. The usual cause of this death is birth asphyxia (in
ability of neonate to breath during birth). In other words, delivery attended by unskilled TBA
or family members in the home increases the risk of birth asphyxia. The new born not get the
medical help in case of asphyxia accurse or may be sent to hospital after the long period of
asphyxia get worsen or complicated (3).

Every day, at least 1600 women die worldwide from complication of pregnancy and child
birth, 90% of which occurring in Asia and sub Sahara African countries. Maternal mortality
rate was show to have largest discrepancy between developed and developing countries. A
life time risk of maternal death in developing countries 40 time, higher than that of developed
world. Bleeding, obstructed labor, hypertensive disorder, unsafe abortion, and infection
contribute for up to 80% of maternal death with result increased in fetal loss, premature
morbidity and mortality and neonatal death (4, 5).

A proportion of women who delivered with skilled birth attendants are one of the indictor in
meeting the 5th millennium development goal (2000). Moreover, providing skilled care at
birth goes hand in hand with the MDGs to reduce the child mortality, particularly neonatal
mortality. Nearly 3.4 million of the 8 million infant deaths each year occurs within the first
week of life and are often due to lack of inappropriate care during pregnancy, delivery and
post partum period. In other words, the international safe mother hood initiative made
maternal mortality, an international priority by way of access to basic maternity car during
pregnancy, and child birth to all women (6).

WHO In 2011, 147 world leaders endorsed the MDGs where by goals 4 and 5 were intended
to reduce child mortality rate by 2/3 and maternal mortality by ¾ by 2015. To monitor the
progress toward the achievement of the millennium development goal maternal mortality
ratio as the out indicator and the number of attended to by skilled personal simultaneously
and further goal focused on reduction of the child mortality by 2/3 by 2015. These two goals
somehow interrelated since health children need health mother (7).

11
1.3 JUSTIFICATION AND SIGNIFICANT OF THE STUDY
The finding of this study will help to explore and contribute the women’s knowledge, attitude
and practice toward institutional delivery. It also helps governmental or non- governmental
organization by providing necessary information regarding institutional delivery, particularly
in Kemise town. The result of the study could help as the base line data for other study
related to this topic.

Further, the study will provide more information on efficient and effective utilization of the
scarce resource available for health to address issues of reducing maternal mortality and
morbidity related to home delivery or attended by untrained personnel elsewhere. The study
can be used as a base line data for other similar researches, Midwifery student, administrator
& policy maker and health professional concern with the issue. It also used for program
planners to increase attention toward knowledge, attitude & practice on a woman of
reproductive age in institutional delivery.

12
 CHAPTER TWO:

LITERATURE REVIEW
Globally, it estimated that 34% of Women delivered with no skilled attendants; this means
there are 45 million births occurring at home without skilled health personnel each year .
(Skilled attendants in more than 99% of births in developed countries. In five countries
including Ethiopia, the percentage drops to less than 20% (8).

2.1 Knowledge
It has been recognized that lack of formal education, low socioeconomic status has influence
to institutional delivery. Several hospital based study aimed at assessing maternal mortality
have been conducted in South Africa revealed that low proportion of ANC visit and
inadequate knowledge of pregnant women to attend institutional delivery were the major
factor for maternal mortality ratio to be 83 per 100,000 live birth. Exposure to mass media
was one factor that limits the awareness of women to attend delivery at health institution (10).

Study conducted in Nepal 2010, in Northern India showed that the percentage of delivery in
health facilities was nearly double for women at higher educational level compared with
uneducated women (11).

Another study conducted in Ghana 2015 found that women who had access to mass media or
health information via Television were more likely to have institutional delivery than those in
access to mass media (8).

In northern Sudan 2012, 86% of births were delivered at home; only 12% of births were
delivered in government hospital and only 1% of were taken place in private hospital, even in
urban institutional birth accounts for only about 30% of delivery. These were due to
inaccessibility to formal education and lack of awareness regarding institutional delivery
(12). Another study conducted in semi-urban settlement of Zaria 2011; in northern Nigeria
showed that most women (70%) were deliver at home due to lack of awareness about
attending delivery at health institution (13).

Majority of birth in Ethiopia 2010 were attended at home with urban and rural differential of
68.3% and 97.9% respectively, while only 5% of women were attend delivery in health
institution, the proportion showed that major difference was among regions, the lowest(2.8%)
in Amhara and the highest in capital city ,Addis Ababa (66.9%). This difference was due to
accessibility to mass media and formal education in capital city, Addis Ababa (15).

13
Study conducted in Jimma town in 2012 on assessment of women on usage of institutional
delivery, among 249 sampled mothers (45-49years), only 69.2% had good knowledge about
service of institutional delivery (14).

Study conducted in Mekele 2011 revealed that most frequently reason for utilization of
institutional deliver by women were better service given by health facility 206(51%) ,better
outcome from institutional delivery 128(31.7%) and informed by health personnel to deliver
in health institution were 34% ( 23).

2.2 Attitude
Study conducted in Bangladesh 2014, the social stigma and distresses of doctors’
recommendation for C/S were influence women not to attend delivery in health institution
with skilled attendants (16).

In Ghana 2015 manager of health service looked at how midwives behavior affect pregnant
women choice on place of delivery, 476women who participated in the study, only 17% were
attend health institution delivery and the remaining 83% were delivered at home either by
TBA or relatives due to neglected and abused by attitude of midwives, these was midwives
shouted at them, in some cases, they threatened women in labor (9).

Another study conducted in Mozambique 2014, among pregnant women, only 25% were
seek for prenatal, delivery and postnatal medical care due to fear of social stigma and 75%
were hidden their pregnancy at home (16 ).

The study conducted in Jimma university in 2007 on assessment of attitude being attended
by health workers during pregnancy and delivery by total of 275 women who were pregnant
and gave birth, 20(7.3%) of them agreed on importance of ANC and institutional delivery.
Whereas 66 of them were disagree on its positive effect. 62% of those agreed said that easy to
treat pregnancy related problem and 38% of these women said that mother get health
education about need of nutrition during pregnancy (17).

2.3 Practice
Globally, the practice of institutional delivery and reduction of maternal mortality and
morbidity are global priority, particularly in developing countries including Ethiopia where
the maternal mortality ratio is one of the highest in the world. In Africa and Asia, only 46.7%
and 58.3% of women gave birth with assistance of health personnel respectively. In less
developed regions, the lowest level of skilled attendants at birth were ,eastern Africa (34.5%),

14
central Asia (38.9%) and west Africa (40.9%) with highest level in south Africa (86.8%)
(18).

In Ethiopia 2012, institutional delivery at public and private hospital, health center and clinic
were estimated to be only 14.5% for whole country (22). A longitudinal community based
study conducted in south west Ethiopia, only16.7% of the women had delivered in health
institution, while 34.1% of them from urban residents and only 1.9% were rural residents.
The same study showed that 19.6% of deliveries were attended by health personnel with
urban and rural differential of 39.8% and 24% respectively (19).

According to study conducted in Gulelle district 2014, Addis Ababa, most pregnant
women(55%) were preferred delivery in hospital,18.1% were preferred at health centre ,and
while 24.3% of women preferred to attend delivery at home. Again 67% of women who
preferred to deliver at home said that they wanted their delivery to be conducted by TBA,
while 25% were preferred to be conducted by relatives or others. Similar study conducted in
Addis Ababa showed that most frequent reason for preferring delivery in health institution
was good and high quality service.50% of those respondents who preferred to deliver at home
,42.9% wished home delivery because of influence of relatives and 23.8% of them said that
due to expense for delivery at health institutions were difficult to afford (20).

In EDHS 2O14 Addis Ababa 84% of birth were attended by skilled providers, while 6% were
in SNNP. According to EDHS-2011, 10% of birth in Ethiopia were delivered at health
facility out of which 9% in public facility and 1% in private facility ,while 90% of births were
delivered at home either by TBA or relatives. Based on residents, 50% of women in urban
were delivered at health facility, while 4% of women in rural area were delivered in health
facility. From these, 82% were delivered in health institution, in capital city Addis Ababa. On
the other hand, less than 10% were delivered in health facility in regions of SNNP, Afar,
Oromia, Somali and Benishangul. Out of 10% of birth assisted by skilled providers, 4% by
Doctors, 7% by nurse or midwives, less than 1% by HEW and 57% of birth were assisted by
relatives or some other persons. And 28% of births were assisted by TBA, while 4% of births
were unattended. The proportions of birth were different from regions to Addis Ababa. Again
concerning the reason not to deliver at health facility, 61% of women stated that delivery in
health institution was not necessary, 30% respond that it was not customary and 14% said
that the health facility was either too far or they do not have transportation (21).

15
16
 CHAPTER THREE

OBJECTIVES
3.1 General objective
To assess the knowledge, attitude and practice on institutional delivery among women in
reproductive age at Kemisie town, April 2017.

3.2 Specific objectives

1. To determine the knowledge on institutional delivery among women in reproductive
age at Kemisie town, April 2017.

2. To determine the attitude on institutional delivery among women in reproductive age

at Kemisie town April 2017.

3. To measure the practice on institutional delivery among women in reproductive age at

Kemisie town April 2017.

17
 CHAPTER FOUR

METHODS AND MATERIALS

4.1. Study area and study period
The study was conducted in Kemissie town Northeast Ethiopia. Kemissie is one of the oldest
and the most tourist attracting cities of Ethiopia and it found in northeastern part of the
country. It located 325km from Addis Ababa, the capital city of Ethiopia and the city was
located in East Africa. Far from Dessie by 76km which is the capital city of north wollo
zone .The climate condition of the town is kolla with altitude of 1424 meter above sea level
and the annual rainfall of 760mm. In Kemissie there is one government hospitals and four
private hospitals. A total population of the city is estimated to be over 19, 420 of whom 9782
are men and 9638 women. It consists of 8 kebeles. Our study has been conducted in kebele
01, 02&03. The study was conducted from November to April, 2016/7 . (From kemissie zone
administrative)

4.2. Study design

Quantitative descriptive community based cross-sectional study design was used to assess
knowledge, attitude and practice on women of reproductive age on institutional delivery in
Kemisse town, Kebele 01, 02 & 03.

4.3 Population
4.3.1 Source Population

All women of reproductive age (15-49 years), who were residents in Kemisse town

4.3.2 Study population

All women of reproductive age (15-49years) who has been selected from source population
& mets inclusion and exclusion criteria.

4.4 Inclusion and Exclusion Criteria

4.4.1 Inclusion Criteria
 The women in reproductive age of (15-49) in the study area &who can able to provide
information for the study.
 The women in reproductive age (15-49) who is residing in this place for more than
6months.

18
  Women’s who are volunteers

4.4.2 Exclusion Criteria

 Women who is not able to speak or hear.
 Women who is being severely ill during data collection.
 Women with infertility in respective house hold.
 Women with psychiatric problem.
 Women with nully paras

4.5. Sample size determination

The sample size was determined by using single population proportion formula by
considering the assumption of 95% level of confidence , 5% margin of error and taking the
percentage of 18% of institutional delivery in Northern Gondar in 2013 (12).


( z ) 2 p (1  p )
(1.96) 2 (0.18)(0.82)
n 2 2  227
d (0.05) 2

By adding 10% of non response rate, the final sample size was = 250.

4.6. Sampling technique

In this study we have used simple random sampling technique for selection of kebeles by
using lottery method from the 8 kebeles we have selected 3 kebeles. Then we got the number
of eligible mother (1250) for our study from the local health bureau. We have used
Systematic simple random sampling technique for selecting women and the no of sample
were 250. We get the sampling interval (5), by lottery chance. Individual’s house was choose
at a regular interval(every 4 units) and put special identification mark by chalk on their house
then we start the data collection process from who had got the lottery chance.

4.7. Data collection method

The data was collected by 4 th year midwifery students who were assigned to this particular
topic using semi-structured questionnaires by moving from house to house through face to
face interviewing of child bearing age Women in of kebele 01, 02& 03, Kemise town, until
the desired sample size was achieved. The collected data were checked for completeness and
finally, collected from the students.

19
4.8 Study Variables
 Age
 Ethnicity
 Marital status
 Religions
 Educational status
 Occupation
 Income
 cost of service given
 Distances from health facilities
 Mass media etc.
 Knowledge of women on institutional delivery
 Attitude of women toward institutional delivery
 Practice of women on institutional delivery.

4.9. Operational definition

 ADEQUATE KNOWLEDGE:-The women who were scored from 70-100% of the
question of knowledge about institutional delivery
 MODERAT KNOWLEDGE: - The women who were scored from 40-70% of
questions of knowledge about institutional delivery.
 INADEQUATE KNOWLEDGE: - The women who were scored from 10-40% of
questions of knowledge about institutional delivery.
 FAVORABLE ATTITUDE:- The women who were agree more than 85% of importance
of institutional delivery.
 UNFAVORABLE ATTITUDE:-The women who were agree less than 85% of
importance of institutional delivery.
 ADEQUATE PRACTICE:-Actual action of women giving birth more than two
times at health institutions.
 MODERATE PRACTICE: - Actual action of women giving birth more than one
time at health institutions.
 INADEQUATE PRACTICE:-The women who doesn’t give any birth in health
institution

20
  INSTITUTIONAL DELIVERY:-Births that conducted by skilled health personnel
in health facility.

4.10 Data quality control

Primarily the questionnaire was prepared in English and translated in to Amharic. It was then
translated back into English by the principal investigators. The questionnaire was pre-tested
before the actual study was conducted to verify the validity and reliability of the data. The
appropriate technique of data collection was used. The filled out questionnaire were checked
for completeness on daily basis in the field by principal investigators.

4.11 Data processing and analysis

The collected data were processed manually and analyzed after collecting the questionnaires.
The completeness and consistency was checked and tallying system was performed, and then,
the main findings of the study were interpreted in the form of appropriate figures like tables,
percentage/ proportions, frequency and then, the results were compared and discussed with
other already existing data such as literature reviews. Finally the findings of the study were
concluded, recommended and disseminated.

4.12 Ethical Consideration

Before the study was conducted, we were contact institutional Research Ethics Committee of
Wollo University to receive a letter of ethical approval or letter of cooperation. A letter of
cooperation was taken from Wollo University, College of Medicine & Health Sciences,
Department of Midwifery, and disseminated to Kemise twon, kebele 01, 02 & 03
administrative offices. Verbal consent was taken from each participant. Finally, data were
collected in the way in which we were not inflict right of others, culture, norms, and other
ethical issues will be respected.

4.13 Disseminations of the study

The findings of this study will be disseminated to Wollo University, College of Medicine &
Health Science, and Department of Midwifery and further, for Amhara Regional Health
Bureau, all health facility in Dessie town and its surrounding, and other concerned bodies.

21
 CHAPTER FIVE

RESULTS
5.1 .SOCIO-DEMOGRAPHIC CHARASTERISTIC
Concerning socio-demographic characteristics, a total of 250 women of reproductive age
were interviewed and the response rate of 100% included in the study, majority 74(29.6%) of
them were ranged in the age between 25 and 29. The religion distribution of the respondents
show that the largest proportion of them 110(44%) were Muslim, 72(28.8%) orthodox.
Majority of the women176 (70.4%) were married. Most of the respondents were completed
elementary school 68 (27.2%). Most of the women’s are 102(40.7%) house wife. Most
women’s income less than 400 birr 44(62%).

Table 1: The socio demographic data of women on institutional delivery among women in
reproductive age at Kemise town, April 2017

S. No Variable Category Frequency Percentage %

1 Age 15-19 23 9.2
20-24 57 22.8
25-29 74 29.6
30-34 41 16.4
35-39 30 12
40-44 13 5.2
45-49 12 4.8
Total 250 100
2 Religion Muslim 110 44
Orthodox 79 28.8
Protestant 50 20
Catholic 12 4.8
Others 6 2.4
Total 250 100
3 Marital status Married 176 70.4
Single 35 14
Divorced 23 9.2
Widowed 16 6.4
Total 250 100
4 Occupational status House wife 102 40.7
Government 43 17.2
employee
Non government 37 14.8
employee
Merchant 41 16.4
Daily labor 12 4.8
Others 15 6.1

22
 Total 250 100
5 Educational status Illiterate 15 6
Can write and 23 9.2
read
Elementary(1-8) 68 27.2
Secondary(9-10) 55 22
Preparatory 21 8.4
College 44 17.6
BSC/BA 19 7.6
Others 5 2
Total 250 100
6 Monthly income in birr <400 62 24.8
401-800 42 16.8
801-1200 46 18.4
1200-1600 40 16
>1600 60 24
Total 250 100
7 Ethnicity Oromo 110 44
Amhara 79 31.6
Tigre 26 10.4
Afar 25 10
Others 10 4
Total 250 100

5.2. KNOWLEDGE OF WOMEN ON INSTITUTIONAL DELIVERY

Concerning knowledge of women on institutional delivery, from the total of 250 respondents
with response rate of 100%, all of them were heard about institutional delivery. In other
words, out of 250 mothers interviewed about delivery service of health institution, majority
of them, 225 (90%) said that health institutions give delivery service for laboring mothers.
While, 9(3.6%) of them respond that health facility does not give delivery and the remaining
16(6.4%) had not knowledge about delivery service of health institution. in this conducted
research we get 92% had adequate knowledge ,4.8% had moderate knowledge and 3.2 had
inadequate knowledge from the total of 250 respondent

23
 Object 1

Figure.1: women’s awareness by responses on institutional delivery service in Kemise town,

April 2017.

From the total of 250 respondents, two-hundred-thirty (92%) had information on attending
delivery in health institution than home delivery is advantageous. While 12(4.8%) of them
had no and the remaining 8(3.2%) had no idea. Again from the total of women that had
informed about importance of institutional delivery, majority of them,148(59.2%) were get
information from mass media and the remaining 61(24.4%),25(10%) and16(6.4%) were get
from the health extension worker, health workers and others (friends &TTBA) respectively.

TABLE 2: Source of information about importance of health institution delivery than home
delivery among women of reproductive age in Kemise town, April 2017

Variables Categories Frequency Percent

Source of Mass media 148 59.2
Information Health workers 25 10
Health extension 61 24.4
workers
Others TTBA 7 2.8
Friends 9 3.6
Total 250 100

24
Regarding the knowledge of mother on benefit of attending delivery in health facility, out of
250 mothers interviewed, majority of them 230(92%) had information about significance of
attending delivery in health institution. But the remaining 20(8%) had no. From the total of
230 (92%) mothers that had knowledge on attending delivery in health institution, majority
110(44%) of their responses were on minimize of maternal and newborn complication during
labor and delivery.

TABLE 3: Awareness of women on reproductive age by response on specific methods

practiced by health facilities in Kemise town April 2017

Variables Categories Frequency Percent

Awareness of Early detection of problem and referral 52 20.8
mother by
Minimization of bleeding during delivery 46 18.4
response
and postpartum
Reduce risk for puerperal Sepsis 18 7.2

Minimize maternal and new born 110 44

complication during delivery and
postpartum
Give awareness on FP,EPI and BF 24 9.6
Total 250 100

Out of the total of 250 women interviewed regarding problem of home delivery by TBA or
relatives, majority 217(86.8%) of the respondents said that home delivery by TBA or
relatives has a problem to the mother and her baby. But 21(8.4%) of them reported that no
problem with home delivery. And the remaining 12(4.8%) were responded that they did not
know the problem related to home delivery.

Concerning payment by the mothers for health institution at the time of delivery, from total of
250 mothers interviewed, majority 169(67.6%) of them were reported that no payment for
pregnant women who attend delivery in health institution. But the remaining 81(32.4%) of
the participants said that pregnant women pay fee for delivery service in health institution.

25
5.3. ATTITUDE OF WOMEN TOWARD INSTITUTIONAL DELIVERY
Concerning attitude of women toward institutional delivery, of total numbers of study
subjects 217 more than 85% were believed that attending delivery in health institution can
decrease maternal and child mortality rate (had favorable attitude). But 10(4%) of them were
not. And the remaining 23 (9.2%) of them had no idea (had unfavorable attitude)

TABLE 4: perception of women of reproductive age on specific methods practiced by health

institution to decrease maternal and child mortality in Kemise town, April 2017.

Variables Categories Frequency Percentage%

Perception of Using sterility technique 24 9.6
women Decreasing blood loss during 33 13.2
delivery and postpartum
Early detection of problem and 30 12
referral
Giving all delivery services 163 65.2

Total 250 100

26
TABLE 5:- Attitude of women of reproductive age regarding negative effect of culture and
religion on health institution delivery in Kemise town, April 2017.

Variables Categories Frequency Percentage%

Mother’s level of Strongly agree 5 2
perception Agree 22 8.8
Neutral 20 8
Strongly disagree 80 32
Disagree 123 49.2
Total 250 100
Concerning the attitude of health personnel 80% of the participants say that the attitude of
health personnel doesn’t influence mother use of institutional delivery while the remaining
50(20%) of the participant say that it can influence. Concerning religious and cultural
influences, more than 80% of the participants perceived that religion and culture have no
negative effect on mothers not to attend delivery in health facilities. On the contrary, about
10% of the respondents were believed that culture and religion can influence pregnant
mothers no to deliver in health facility and the remaining 8% reported that they had no ideas
regarding religion and cultural influences.

5.4. PRACTICE OF WOMEN TOWARDS INSTITUTIONAL DELIVERY

Among total number of 250 women interviewed on experienced childbirth for the last 12
month, 157(62.8%) of them had experienced child births and the remaining 93(37.2%) of
them were not. From the total of 157 women who experienced child birth in the last 12
months, majority 125(79.61%) of them were delivered in health institution, the 29(18.47%)
were gave birth at their home & the remaining 3(1.91%) were gave birth on the way to health
facilities.

Table 6: Number of women experienced and not experienced child birth in the last 12
months in Kemise town, April2017.

Variables Categories Frequency Percentage%

Women Experienced child birth in the last 12 months 157 62.8

Not experience child birth in the last 12 93 37.2

months
Total 250 100

27
Figure 2: Women’s place of delivery that was experienced child birth in the last 12 months in
Kemise town, April 2017.

Object 3

Concerning reason for home delivery, out of 29(18.47%) respondents delivered at home in
the last 12month, 18(62.1%) of them were reported that gave birth at home was due to their
preference of home delivery and the remaining 2(6.89%),3(13.79%) and 5(17.24%) were due
to religion & culture, financial& transport problem and lack of awareness respectively.

Out of total 250 study subjects interviewed on future plan regarding institutional delivery,
majority 222(88.8%) of them were report that they had plan to attend their next delivery at
health facility. While the remaining twenty eight (11.2%) had no plan. Among those
participants who had no plan to attend health institution for the next delivery, more than thirty
percent of them said that the reason not to have planned to attend their delivery in facility was
due to their preference. In other words, five(17.9%) of them were due to negative attitude of
health profession, and the remaining 3(10.7%), 3(10.7%),4(14.3%) ,4(14.3%)of them were
report that it was due to fear of family, financial and transportation problem, fear of religion
& culture & others respectively.

Regarding distance of catchment health unit from participants’ catchment area, more than
50% of them were reach health facility within 15-30 minute duration. While the remaining
110(44%) of them were report that the time taken to seek health care from nearest health

28
facilities was less than ten minutes. Concerning distance estimation by participants in terms
of kilometer, more than ninety percent of respondents were resident in the range of 1-5
kilometer from nearest catchment health unit. On the other hand, 12(4.8%) of them were
resident in less than one kilometer from health institution and the remaining eight (3.2%) of
them said that the health institutions were far more than five kilometer from their catchment
areas.

29
 CHAPTER SIX:

DISCUSSION

6.1. KNOWLEDGE OF WOMEN ON INSTITUTIONAL DELIVERY

A large majority (90%) of study participants said that they knew delivery service given by
health facility. This was a higher percentage than 51% in Mekelle 2011 (23). This might be
due to increased mass media and health education about institution delivery.

From the total of 250 study participants, majority (92%) of them had adequate knowledge
regarding institutional delivery than home delivery. This finding was higher than findings
from Jimma town which was 69.2% (14).This may be due to increased mass media and
morning health education program in health facility about attending delivery at health
institution.

From the total of 250 study subjects, majority (59.2%) of them were get information from
mass media and only 10% were informed from health personnel. When it compared with the
findings study conducted in Mekelle regarding information from health workers which was
34% (23). This was much lower and this discrepancy might be due to social stigma and
cultural attitude of the society toward health care providers.

Out of the total of 250 women interviewed regarding problem of home delivery by TBA or
relatives, majority (86.8%) of respondents said that home delivery has relative effect on
health of mothers and the baby. This was higher than that of capital Addis Ababa which was
66.9% (15).This might be due to expansion of health extension program, increased morning
health education program at health facility and increased mass media about institutional
delivery.

30
6.2. ATTITUDE OF WOMEN TOWARD INSTITUTIONAL DELIVERY

Out of the total 217 study subjects, more than 85% were believed that attending delivery in
facility can decrease maternal and child mortality rate. This finding was slightly higher than
the findings of study conducted in Ghana 2015 which was 83% (9).But it was higher than
75% of study conducted in Mozambique 2014 (16). Among the total participants that
interviewed, more than eighty-five percent were agreed that attending delivery in catchment
health unit has positive benefit for both mother and the baby. When we compare this with
similar study conducted in 2007 Jimma University which was 7.3% (17), it was much higher.
This might be due to increased mass media about institutional delivery, ANC utilization and
expansion of health facilities and government consideration on maternal and child health, so
that health extension program was expanded.
Concerning the attitude of health personnel on mother use of institutional delivery 80% of the
participant say that the attitude of health personnel doesn’t influence mother use of
institutional delivery this was much higher than the study conducted in Ghana 2015 (9) this
was due to the training given by Government and Non-Governmental organization to the
health worker to change their attitude.

6.3. PRACTICE OF WOMEN ON ATTENDING DELIVERY IN HEALTH

INSTITUTION
From the total one-hundred-fifty-seven (62.8%) of study subjects who were experienced child
birth for the last 12 months of preceding the study, majority (79.6%) were attend delivery in
health facility where the remaining 18.5% were delivered at home& 1.9% were delivered on
the way to health facility. When we compare these findings with findings of EDHS-2011,
Addis Ababa which was 82% (21), it was lower in percentage. But, comparing with the total
national figure of institutional delivery of EDHS-2014, which was 14.5% of whole country
(22), the result of this study was much higher than that the national figure. This might be due
to increased mass media about institutional delivery, accessibility in terms of distance
location of health facility and transportation, increased number and collaboration of health
extension workers with respective health facility and increased number of Ambulance at rural
areas. Again, comparing with the urban total national figure of institutional delivery of
EDHS-2011 which was 50%, the result of this study was higher in percentage than that of
national figure (21). But, the result was lower than that of South Africa which was 86.8% of
institutional delivery (18).

31
Concerning reason for home delivery, out of total 29 (18.5%) respondents who delivered at
home in the last 12 months preceding the study, 18(62.1%) were due to their preference of
home delivery by relatives. When we compare with the findings of study conducted in
Gulelle district, Addis Ababa ,home delivery in which home delivery was 25%(20 ), the
result of this study was higher in magnitude. The other reason for home delivery was
culture& religion influence (6.9%), financial& transport problem (13.8%) and lack of
awareness (17.2%). When compared with the findings of study conducted in Addis Ababa,
preferring of home delivery were due to family influence (42.9%), financial problem (23.8%)
(20).These was higher than the result of this study in magnitude.

32
 CHAPTER SEVEN:

CONCLUSION
The findings of this research revealed that all participants were heard about institutional
delivery. Despite having information of attending health institution delivery, still more than
11% of the women are attending their child birth at home. These indicate the need for
increasing clients’ knowledge on attending delivery in health facility. According to this study
results, more than 85% of the participants had knowledge regarding problem of home
delivery either by TBA or relatives. Even though the majority reported a good attitude toward
institutional delivery one-ninth of them were still practiced home delivery. However,
comparing to national (85.5%) of home delivery, the results of this study was much better,
which was 11.6% of the mothers attending delivery at home. Out of the total 250interviewed
on future plan of attending institutional delivery, majority of them had planned to attend their
sequent delivery at health facility. In general, the knowledge about institutional delivery, the
attitude toward attending delivery at health facility, the majority of the respondents was
encouraging.

33
 CHAPTER EIGHT:

RECOMMENDATION
 It is recommended that there must be intense and consistent mass media regarding
risk and potential problem related to home delivery.
 On the other hand, there should be increased availability of free service regarding
institutional delivery in all government health sectors.
 In addition to this, health education with focused and culturally sensitive information,
education, communication and behavioral change is highly recommended in mass
media, in all health facilities and at community gathering.
 Further, research on knowledge attitude and practice on prevalence and associated
factor of institutional delivery can be conducted.
 The other recommendation is belongs to Amhara regional health bureau to initiate it
to launch an intensive and continuing education campaign to increase the knowledge
of pregnant women and their partners about health institution delivery and problem of
home delivery either by TBA or relatives.
 Finally, it is highly recommended that all health facilities in Kemise town and its
surrounding must provide regular and ongoing health education, sessions for all ANC
attendants and those in postnatal after delivery, and even those who visit hospital for
family planning or another services.

34
Annexes I

References
1. WHO, World Health Organization, World population data sheet, 2006.
2. FMOH, Federal Ministry of Health, Maternal health, 2006, 89-91.
3. WHO, Trend Maternal Mortality: 1990 to 2010 Estimated developed by WHO,
UNICEF, UNFPA and the World Bank, Geneva: 2012.
4. WHO, UNICEF and UNFPA .MM in 1995; estimated developed by WHO/ UNICEF;
Geneva 2001.
5. UNICEF .Progress on MM, Geneva; 2016.
6. Central statistics agency (Ethiopia) and ORC macro: Ethiopian demographic and health
survey 2005. Addis Ababa Ethiopia and Calverton, Maryland USA, 2006.
7. WHO/UNICEF, revised, 1996 estimated “maternal mortality” a new approach by WHO
Geneva 2001.
8. WHO, world health organization fact sheet maternal mortality 2007, 16(4): 42-76.
9. K. Sugathan; Vinod MI. shira and report, D. Rutherford “ promoting institutional
delivery in rural Ghana, the role of ANC service, National family health survey sub-
report, December 2004: 20(1): 12-14.
10. Nigussie H and Mitike G. “Assessment of safe delivery safe service utilization among
child bearing age in northern Gondar”. 2004; 72:58.
11. Kesterton A.J.J. Cleland; A. Sloggett, and C. Ronsman. 2010 “institutional delivery in
rural India: the relative importance of accessibility I the economic status”. BMC
pregnancy and child birth 10(30): 1-20.
12. WHO (Sudan) maternal mortality (2012), URK(25_27)
13. N. Prota, P. Passion, T. Rowan, S. Beck, G. Walsh “Attendant journal of few birth in
rural area of Nigeria”. Health institutions. 2011, 29(2): 81-91.
14. Haile Miriam. A, Tselish M, Nicolas S. knowledge and partner use of maternal and child
care on improving and expansion of family planning service, NGO and private sector in
Ethiopia. Family health international 2002: 70(73): 38-43.
15. Federal democratic of Ethiopia, ministry of health. Health and health related indicator.
2004, 17(25): 41-43.
16. N. KetrahAmparasah, E. I. sageo Moses, 2009 ”expectant mother and the demand for
institutional delivery. Do house hold income and access to health information matter?
Some site from developing countries, European journal social science 8(3): 469.

35
17. Ministry of health and World health organization on assessment of reproductive health
in Ethiopia 2011. P 13-22.
18. Paul and Ramsey. Maternal health and level of knowledge, 2009; 20(1): 12-14.
19. Mesfin; N. HM. Damen, and M. Getnet. 2004”assessment of safe delivery service
utilization among women child bearing age in south west Ethiopia” Ethiopia health
development 18(3): 146-152.
20. World health report, 2008, makes every mother count. P 5-11.
21. EDHS-2011: p (2): 127-130.
22. EDHS- 2014; p MDG indicator-xi.
23. CSA (Ethiopia) and ICF Intel. Ethiopia demographic health survey 2011. Addis Ababa
Ethiopia and Calverton, Maryland USA: CSA and ICF Intel, 2012.

36
ANNEXIS II

QUESTIONNAIRE

WOLLO UNIVERSITY COLLEGE OF MEDICINE AND HEALTH SCIENCE

DEPARTMENT OF MIDWIFERY
QUSTIONNAIRE FORMAT
Dear respondent;
This questioner is prepared by Wollo university, college of Medicine & Health
sciences ,graduate students of 4th year midwifery students in order to assess knowledge,
attitude and practice among women of child bearing age(15-49) toward institutional delivery
in kemisse town in 2017.
This questionnaire contains four parts:-
Part one:-Socio-demographic characteristic
Part two:-knowledge assessment questions
Part three:-attitude assessment questions
Part four:–practice assessment questions
So, we would like to ask you some questions and your answers for the questions will be only
for study purposes and remain confidential and we will not jot down your name. Each of your
answers depends on your view and situation.
Thank you
Name of data collectors__________________ sign_________________
Date of data collection ___________________
Address ___________________Woreda_________________kebele___________________
House number________________
Starting time___________________________
Ending time____________________

37
Part 1:- Socio-demographic information
1.1 age of the mother_____________
1.2 occupation

A) housewife D) Merchant
B) Government employee E) Daily labor
C) Private employed F)Other(specify)

1.3 Religion
A) Muslim D) catholic
B) Orthodox E) Other specify
C) Protestant
1.4 Ethnicity
A) Oromo D) Afar
B) Amhara E) Other specify_____________
C) Tigre
1.5 marital statuses
A) Single B) Married C) Divorced D) Widowed
1.6 Educational status
A) illiterate E) Preparatory (11-12)
B) Can write and read F) College (10+3)
C) Elementary (1-8) G) BSC/BA
D) Secondary (9-10) H) Other specify
1.7 monthly incomes in birr
A) < 400 D) 1201-1600
B) 401-800 E) >1600
C) 801-1200
Part2: Knowledge Related Questions
2.1Have you ever heard institutional delivery?
A) Yes B) No
2.2 Does the catchment health unit give services for delivery?
A) Yes B) No C) I don’t know

38
2.3 If the answer for question number 2.2 is “yes” go to question number 2.4,if the answer is
no what do you think the reason(more than one answer is possible)
A) NO trained health worker B) NO delivery room
C) No delivery coach D) NO delivery instruments
E) No delivery waiting room F) others (specify)-
2.4 Do you know that institutional delivery is better than home delivery for both health of the
mother and the baby?
A) Yes B) NO
2.5 If the answers for question number 2.4 yes how do you know?
A) I informed from mass media B) Told by health care workers
C/Told by extension workers D) Get informed from TTBA
E) Others (specify) _______________
2.6 Do you know the benefit of attending delivery in catchment health unit?
A) YES B) NO
2.7 If the answer for question Number 2.6 is” NO “go to question number 2.8, if the answer is
YES what are the benefit?
A) Early detection of complication & referral
B) Minimize blood loss during delivery &postpartum
C) Minimize risk factors for puerperal sepsis
D) Minimize delivery related complication of both baby & mother
E) Give adequate knowledge on family planning, breast feeding &baby immunization
F) Other (specify) ____________
2.8. Is there any problem if pregnant woman delivered by TBA or her relatives in home?
A) YES B) NO C) I DON’T KNOW
2.9 If your answer for question no. 28 is NO what the reason is?
A) Baby delivered by itself B) Placenta delivered by itself C) tear of genital area
healed by it. D) TBA can perform episiotomy and deliver the baby E) other specify

Part Three: Attitude related question

3.1 Attending delivery in catchment health unit can decrease maternal & neonatal death due
to labor & delivery?
A) Strongly agree B) agree
C) Neutral D) strongly disagree
E) Disagree
39
3.2 If the answer for question number 3.1 is disagree why_________________
If the answer is agree, by what aspects?
A) By prevention of infection using aseptic techniques
B) By minimization of blood loss during delivery &post partum
C) By early detection of complication and referral
D) All service are given in health institution
E) Other (specify)_____________
3.3 Attending delivery in health institution has positive benefit for both baby &mother
A) Strongly agree B) agree
C) Neutral D) strongly disagree
E) Disagree
3.4 If the answer for question NO 3.3 is agrees go to question no 3.5, if the answer is disagree
what is your reason_______________
3.5 Religion and culture has negative impact on pregnant mother to attend delivery in
catchment health unit
A) Strongly agree B) Agree
C) Neutral D) strongly disagree
E) Disagree
3.6 If your answer is disagree, what is your reason (Q3.5) __________________
3.7 Do you think that catchment health unit need payment from pregnant women to attend
delivery?
A) Yes B) no
3.8 Do you think that the attitude of health personnel neglect the use of institutional delivery
for woman of reproductive age?
A) YES B) NO

40
4. Part four:-practice related question
4.1 How many children do you have? __________________( IF married)
4.2 have you got delivered for the last 12 month? (If married)
A) Yes B) no
4.3. If the answer for Q no 4.2 is yes where you had been attend for your delivery?
A) In the home B) in the health institution
C) On the way of transport to the health unit
4.4 If the answer Q 4.3 is “A” what is your reason?
A) My preference
B) Distance of health institution
C) Financial and transport problem
D) Religion and cultural influence
E) Lack of awareness
F) Other (specify) _____________-
4.5 Do you have a plan to attend delivery in catchment health unit for the future?
A) Yes B) no
4.6 If the answer for Q number 4.5 is” no “what is your reason?
A) Fear of family influence
B) Fear of religion and cultural influence
C) Fear of financial and transport problem
D) Negative attitude of health personal
E) Other (specify) ________________
4.7 How far catchment health unit form your living area?
A) In kilometers_______ B) in hours___________

THANK YOU FOR YOUR RESPONSE

41
42