Women’s traditional birth attendant utilization at birth and its associated factors in Angolella Tara, Ethiopia

Background In developing countries, home delivery without a skilled birth attendant is a common practice. It has been evidenced that unattended birth is linked with serious life-threatening complications for both the women and the newborn. Institutional delivery with a skilled birth assistance could reduce 20–30% of neonatal mortality. This study aimed to assess traditional birth attendants’ (TBAs) utilization and associated factors for women who gave birth in the last two years in Angolella Tara District, Ethiopia. Methods A community-based cross-sectional study was employed among 416 women who gave birth in the last two years at rural Angolella Tara District. Study participants were recruited by using a simple random sampling technique. Data were collected using a structured, pretested, and interviewer-administered questionnaire. Epi Data 4.6 and SPSS version 25 were used for data entry and analysis, respectively. A multivariable logistic regression model was fitted to identify factors associated with women’s utilization of traditional birth attendants. The level of significance in the last model was determined at a p-value of <0.05. Result Overall, 131 (31.5%) participants were used traditional birth attendants in their recent birth. Unmarried marital status (AOR 2.63; 95% CI: 1.16, 5.97), age at first marriage (AOR 2.31; 95%CI: 1.30, 4.09), time to reach health facility (AOR = 3.46; 95% CI: 1.94, 6.17), know danger sign of pregnancy and childbirth (AOR = 5.59, 95% CI; 2.89, 10.81), positive attitude towards traditional birth attendants (AOR = 2.56 95% CI; 1.21,5.52), had antenatal care follow-up (AOR: 0.11 95% CI 0.058, 0.21), and listening radio (AOR = 0.43; 95% CI: 0.18, 0.99) were significantly associated factors with the use of traditional birth attendants. Conclusion Nearly one-third of women used traditional birth attendant services for their recent birth. TBAs availability and accessibility in the community, and respect for culture and tradition, problems regarding infrastructure, delay or unavailability of ambulance upon call, and some participants knowing only TBAs for birth assistance were reasons for preference of TBAs. Therefore, effort should be made by care providers and policymakers to ensure that modern health care services are accessible for women in a friendly and culturally sensitive manner. In addition, advocacy through mass media about the importance of maternal health service utilization, particularly antenatal care would be important.


Abstract:
Background In low and middle-income countries, many childbirths still occur at home without the assistance of trained attendants. It is well known that unattended birth has been associated with serious life-threatening complications that will require appropriate and accessible care. On the other hand, 20-30% of neonatal mortality could be reduced by implementing skilled birth care services. This study aimed to assess reasons for traditional birth attendants' preference, utilization, and associated factors for women who gave birth in the last two yea rs in Angolella Tara District, Ethiopia. Methods A community-based cross-sectional study was employed among 416 women who gave birth in the last two years at rural Angolella Tara District. Study participants were recruited by using a simple random sampling technique. Data were collected using a structured, pretested, and interviewer-administered questionnaire. Epi Data 4.6 and SPSS version 25 were used for data entry and analysis, respectively. A multivariable logistic regression model was fitted to identify factors associated with women's utilization of traditional birth attendants.

Conclusion
In this study, nearly one-third of women used traditional birth attendant services for their recent birth. Therefore, effort should be made by care providers and policymakers to ensure that modern health care services are accessible for women in a friendly and culturally sensitive manner. In addition, avocation through mass about the importance of maternal health service utilization, particularly antenatal care would be important.

ABSTRACT Background
In low and middle-income countries, many childbirths still occur at home without the assistance of trained attendants. It is well known that unattended birth has been associated with serious life-threatening complications that will require appropriate and accessible care. On the other hand, 20-30% of neonatal mortality could be reduced by implementing skilled birth care services. This study aimed to assess reasons for traditional birth attendants' preference, utilization, and associated factors for women who gave birth in the last two years in Angolella Tara District, Ethiopia.

Methods
A community-based cross-sectional study was employed among 416 women who gave birth in the last two years at rural Angolella Tara District. Study participants were recruited by using a simple random sampling technique. Data were collected using a structured, pretested, and interviewer-administered questionnaire. Epi Data 4.6 and SPSS version 25 were used for data entry and analysis, respectively. A multivariable logistic regression model was fitted to identify factors associated with women's utilization of traditional birth attendants. The level of significance in the last model was determined at a p-value of <0.05.

Result
In this study, 31.5% of the participants were used traditional birth attendants in their recent

Introduction
The World Health Organization (WHO) defines a traditional birth attendant (TBAs) as a person who assists the mother during childbirth, and who initially acquired her skills by delivering babies herself or through an apprenticeship with other TBAs (1,2). TBAs are involved in 60-

80% of all deliveries in rural regions of developing countries (3).
Globally, there is a target to reduce the maternal mortality ratio (MMR) to less than 70/100, 000 live births and no country should have MMR greater than 140/100, 000 live births by 2030 (4). As a WHO report, approximately 810 women died every day in 2017 as a result of pregnancy and childbirth complications; with 94% of them living in low and lower-middleincome countries (5). In Ethiopia, the MMR was 401 per 100,000 live births in 2019, one of the highest in the world (HSTP-II) (6). The large majority of these maternal deaths occur as a result of unavailable, inaccessible, costly, or poor quality maternal health care services (7)(8)(9) Skilled care during the maternal continuum of care can save the lives of women and newborns (5,10). Improving access to skilled care during pregnancy, childbirth, and the postpartum period is a top priority to improve maternal health and meet the sustainable development goals (SDG3) (11). Since the launching of the Health Extension Program in 2003, there has been a change in Ethiopian policy that TBAs are no longer allowed to attend births (12). However, most women in developing countries give birth outside of health facilities with the help of TBAs and their lifetime risk of pregnancy-related death is higher (5,9). In 2017, the MMR in low-income nations was 462/100,000 live births, compared with 11/100,000 live births in highincome countries (5). Although women believed that that complication might arise from TBA care (13), low maternal educational level, rural residence, poor family wealth index, 3 unemployed status, having >5 living children, married, predominantly farmers, married to spouses who were farmers without formal education, user-friendly care from TBAs, easily accessible, delivery environment familiar to the clients' respect from TBAs for the religious beliefs of clients were significant factors for women to used TBAs (9,(13)(14)(15)(16)(17)(18).
Ethiopian mini demographic health survey (EMDHS), 2019 report showed that only 50% of births were attended by skilled birth attendants, nevertheless, the Ethiopian government planned to increase the proportion of skilled birth attendants to 90% by 2020 (6). Hence, home birth rates are much higher in rural parts of the country than in urban areas (urban: 29.6% vs. rural: 60%) (19) Also, a significant proportion of women was not still engaged fully in the continuum of maternal care with significant dropouts. For instance, 74% of pregnant women undergo at least one antenatal care (ANC) visit, 48% of women gave birth in the health institution, and 34% of women received postnatal care in the first 2 days after birth (19).
Though there is a need to improve the utilization of health facility deliveries with skilled birth attendants, still many women gave birth at home with the aid of TBAs in rural and deprived communities of Ethiopia. In this regard, women's attitude towards TBAs and reasons for preference for TBAs were lacking in previous research. Therefore, this study aimed to assess reasons for traditional birth attendants' preference, utilization, and associated factors among women who gave birth in the last two years in Angolella Tara District, Ethiopia.
Research questions: 1. To what extent do women utilize on TBAs?
2. What are the potential factors affecting the utilization of TBAs for child delivery services?

Methods and materials Study design, period, and setting
A community-based cross-sectional study was conducted from June 1 st to 15 th , 2021. This study was conducted in rural Angolella-Tara district, Amhara regional state, Northeast Ethiopia. The

Source population and study population
All women who gave birth in the last two years at Angolella-Tara district were the source populations. All women who gave birth in the last two years in selected kebeles at Angolella -Tara district during the data collection period were the study population.

Sample size determination
The sample size for this study was determined by using a single proportion formula by considering the following assumptions: a 50% proportion of women's utilization of TBAs, 95% level of confidence, and 5% margin of error. By considering a 10% non-response rate, the minimum adequate sample size was 422.

Sampling technique and procedure
From the total of 21 kebeles, nine kebeles were selected randomly using a lottery method. .
The list of the study participants was gained from health extension workers (HEWs) and local administrators. The sampling frame was designed by numbering the list of women. Then, the total sample size was distributed to each selected "kebeles" proportional to the size. Lastly, the eligible women were chosen by a simple random sampling technique.

Measurement and operational definitions
Traditional birth attendant: A TBA is defined by the WHO as a person, generally a woman, who assists pregnant women during childbirth and who learned the skills by attending homebirths, potentially with the help of other TBAs (1,20).
Skilled attendant: is a professionally trained healthcare provider having the essential skills to manage normal labor and delivery, recognize complications early and perform any essential interventions including early referral (21).
Utilization of traditional birth attendants: when women delivered at home or birth that takes place in a residence without a skilled birth attendant; the possible answers were Yes or No. A score of "1" was given for Yes and a score of "0" was given for No which was dichotomized as utilized and not utilized (2,12).
Women's attitude -Women's attitude towards TBAs was measured using 15 questions: Each question has five points Likert scale (1= strongly disagree, 2= disagree, 3 = neutral, 4= agree, 5= strongly agree). The total score was 15-75 and women who scored 50% and above value were considered as having a positive attitude and those who scored below 50% were considered as a negative attitude. 6 Know obstetric danger signs: women who were able to list at least two of the key danger signs (vaginal bleeding, swelling of face, fingers, severe persistent abdominal pain, blurring of vision, severe recurrent frontal headache, high-grade fever, and swelling of the face) categorized know the danger signs and no otherwise (22).
Planned pregnancy: A woman who plans to become pregnant by making lifestyle choices for optimal health in advance of the planned conception.
Maternity waiting home: If mothers are living far from the delivery center, they shall be admitted to a maternity waiting home (residential facility) which is located near or within hospitals in their final weeks of pregnancy to bridge the geographical gap in obstetric care (23).

Data collection tools and quality control
Data were collected using a pre-tested, structured, and interviewer-administered questionnaire through face-to-face interviews. The questionnaire was prepared by reviewing related literature (references). The questionnaire was first prepared in English and translated into Amharic (local language), and then back to English to maintain the consistency of the questionnaire. Six Bachelor of Science and one MSc midwives were recruited for data collection and supervision, respectively. Before the actual data collection, a pretest was done at Baso district on 5% of the sample size out of the study sites to check language clarity, and appropriateness of the questionnaire based on the pretest, necessary amendments were done.

Data processing and analysis
All information was recorded corresponding to the code given to each respondent. Data were checked, coded, and entered into EpiData version 4.6, and was exported to SPSS version 25 for analysis. Descriptive statistics were used to present the participants' characteristics.
Bivariable and multivariable logistic regressions analysis were employed. Variables with a P value of less than 0.25 on bivariate logistic regression were selected as a candidate for multivariate logistic regression to identify statistically significant factors and the level of significance was determined at a p-value of <0.05 and the strength of association was interpreted using the adjusted odds ratio (AOR) with its 95% confidence interval (CI).

Ethical consideration 7
The study was conducted under the Ethiopian Health Research Ethics Guideline and the declaration of Helsinki. Ethical clearance was obtained from Debre Berhan University ethical committee. A formal letter of administrative approval was gained from the Angolella Tara district and local administrator. Written informed consent was obtained from respondents before data collection by explaining the purpose of the study. The name of participants was not written and confidentiality was maintained throughout the study. The data collector was explained that the respondent can withdraw from the study that participation was voluntary.

Reproductive health service-related characteristics of women
More than half of women (53.4%) used family planning methods. About 76.9% of the pregnancies were unplanned. Two hundred sixty (62%) of women were assisted by a skilled birth attendant for their most recent birth. Moreover, 299 (71.9%) of the respondents had ANC follow-up in the preceding pregnancy (71.4%) ( Table 2).

Utilization and attitude of women towards TBAs
Overall, 131(31.5%; 95% CI: 27%, 36%) of women used TBAs services for their most recent childbirth. More than half of women (58.2%) have a negative attitude towards TBAs.

Women's reason for preference of traditional birth attendants
There are many reasons for women's preference for traditional birth attendants. Among these, TBAs are available in rural areas (36.54%), roads access problems (19.47%), respect of culture and tradition (16.35%), they know only TBAs (14.90%), and unavailability and delay of ambulance upon call (12.74%) (Figure 1).

Factors associated with women's utilization of traditional birth attendants
Multivariable logistic regression analysis revealed that being unmarried, age at first marriage, ANC follow up, time to reach a health facility, listening to radio, didn't know obstetric danger signs, and positive attitude towards TBAs were factors associated with utilization of TBAs by women.
Accordingly, this study found that those women with unmarried current marital relations were

Discussion
The key to reducing MMR and improving maternal health is increasing proper utilization of maternal health services by skilled health personnel throughout pregnancy and childbirth.
However, health facility delivery is significantly lower in Ethiopia. In recent years, there has been increasing debate over the usefulness of TBAs in maternal health care. Opponents of TBA care are of the view that TBAs have done little to improve maternal health. After the advent of the World Health Organization's Safe Motherhood initiative, the enthusiasm turned away from TBAs (24) as they are unskilled and unable to prevent or treat the complications during pregnancy or childbirth that leads to maternal deaths (25). Thus, the finding of this study showed that 31.5% of women gave birth by TBAs in their current birth which is lower than the study done in Nigeria; 65% of the women had been delivered by TBAs (26). The possible explanation could be the Nigerian government encourages the integration of TBAs into the health sector for improving maternal health (27).
The current study found that time taken to the nearby health facility was significantly associated with the use of TBAs for childbirth. It has been shown that women who travel for greater than an hour to reach health facilities were 3.46 times high likely to attend their birth by TBAs as compared to those women traveling for less than one hour. This finding is consistent with studies conducted in Ethiopia (28,29), Eretria (30), Kenya (31), and Zambia (32). This could be because the distance to a health facility is one of the well-known barriers to healthcare access especially in developing countries (33,34).
The present study also showed that having ANC follow-up had a significant association with the use of TBA services. Thus, women who have ANC follow-up for their recent pregnancy were 89% less likely assisted by TBAs. This finding is supported by the study conducted in Kenya, in which women who have no ANC follow-up pose an increased utilization of TBAs (35). This could be justified by ANC utilization increasing the use of skilled birth attendants and institutional delivery.
Women's at first marriage was a significant risk factor for TBA utilization. In this regard, women who were married before or at the age of 18-year-old were 2.31 times more likely to use TBA in their current childbirth as compared to their older counterparts. This finding is in agreement with studies conducted in Kenya (31), and Zambia (32). This could be because; experience in pregnancy and pregnancy-related complications increases as women's age advances which could help them to visit health facilities thereby obtaining a comprehensive and favorable awareness on maternal health services in the subsequent pregnancy. Besides, older women could have a higher decision-making power regarding their health and health care utilization as compared to young age women (36,37).
The current study also revealed that the odds of having TBA utilization among women who had a positive attitude were 2.23 times higher as compared to those women who had a negative attitude towards TBAs. This finding is consistent with a previous study conducted in Ethiopia (38). Thus, significant numbers of maternal and neonatal mortality occurred without ever reaching a health facility or due to delays in seeking care in Ethiopia. Hence, interventions that 10 will address health education for women including husbands/spouses, and other family members would be helpful to enhance the utilization of SBAs.
Moreover, this finding indicated that those women who didn't know obstetric danger signs were 5.59 times more likely to use TBAs for their childbirth. This suggests that complications during previous pregnancy and childbirth make women aware of the obstetric danger signs and the benefits of SBAs (39). Consequently, they could get information regarding the danger signs of pregnancy and the importance of utilizing SBAs for subsequent pregnancies.
The odds of TBA service utilization among women who listen to radio at least once per week were less likely to approve TBAs services utilization. The possible explanation could be due to the reality that information, education, and communication regarding maternal, neonatal, and child health improvement could be disseminated through different mass media (40,41).

Limitations of the study
We are pleased to acknowledge some of the limitations of the current study. First, as the area is not well studied, we didn't find adequate studies to compare and contrast our findings with others, which made our discussion shallow. Second, due to the cross-sectional nature of the study design, the cause-effect relationship between the outcome and explanatory variables might be impossible. Third, it is impossible to couch the validity of the responses that social desirability bias may be introduced. Despite these limitations, our findings provide valuable information about women's TBA utilization, factors associated with it, and reasons for preference for TBA services.

Conclusion
The extent of TBA service utilization among women who gave birth in the last two years was high in the study setting. Community-based interventions like health education on obstetric danger signs by giving more emphasis on the benefits of using ANC follow up is the midst for the reduction of TBA service utilizations. Besides, strengthening access to transportation, health information communication mass media will enhance the use of SBAs. Exploring barriers and facilitators of deep-rooted socio-cultural and behavioral factors in this sub-theme would be helpful. In this regard, strengthening respectful maternity care service throughout the continuum of care could help to increase women's preference towards SBAs.