` Arba Minch University College of Medicine and Health Sciences, Department of Public Health

Home Delivery and Associated Factors among Child Bearing Age Women Who Gave Birth in the Preceding Two Years in Zala District, Southern Ethiopia

By: Bedilu Kucho Doka (BSc)

A Thesis Submitted to the Department of Public Health, College of Medicine and Health Sciences, Arba Minch University in Partial Fulfillment of the Requirements for the Degree of Masters of Public Health in Epidemiology and Biostatistics

October, 2015 Arba Minch, Ethiopia

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Arba Minch University College of Medicine and Health Sciences, Department of Public Health

Home Delivery and Associated Factors among Child Bearing Age Women Who Gave Birth in the Preceding Two Years in Zala District, Southern Ethiopia

By: Bedilu Kucho Doka (BSc)

Advisors: Amsalu Alagaw (MD, MPH) and

Mesfin Kote (MPH)

A Thesis Submitted to the Department of Public Health, College of Medicine and Health Sciences, Arba Minch University in Partial Fulfillment of the Requirements for the Degree of Masters of Public Health in Epidemiology and Biostatistics

October, 2015

Arba Minch, Ethipia

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Arba Minch University

College of Medicine and Health Sciences,

Department of Public Health

Home Delivery and Associated Factors among Child Bearing Age Women Who Gave Birth in the Preceding Two Years in Zala District, Southern Ethiopia

By: Bedilu Kucho Doka (BSc)

Approve by examining board

______

Head, Department of public health Advisors 1. Dr. Amsalu Alagaw ______2. Mr. Mesfin Kote ______

______Examiner, internal

______

Examiner, external

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Acknowledgement

First and for most I would like to express my deepest gratitude and appreciation to Dr. Amsalu Alagaw and Mr. Mesfine Kote for their skillful guidance, timely support and enriching constructive comment, which have been very helpful in improving and guiding the research process, starting from the proposal development.

My sincere thanks also extends to Arba Minch University, especially College of Medicine and Health Sciences, Department of Public Health, for proper facilitation of this research project.

I would like to thank Zala Woreda administration office for financing and cooperating to the successful accomplishment of this research project.

My deepest gratitude also goes to all the data collectors and supervisors without whom tireless commitment, this research project would have not been successful.

Finally, I would like to acknowledge all the individuals participated in the study, especially the women who have kindly cooperated in providing the information required.

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Table of contents

Acknowledgement ...... iv

Table of contents ...... v

List of Tables ...... viii

List of figures ...... ix

List of Annexes ...... x

Acronyms ...... xi

Abstract ...... xii

1. Introduction ...... 1

1.1. Background ...... 1

1.2. Statement of the problem ...... 1

2. Literature review ...... 3

2.1. Extent of home delivery ...... 3

2.2. Factors associated with home delivery...... 4

2.2.1. Socio-demographic and obstetric factors ...... 4

2.2.2. Cultural factors and Traditional Birth Attendants ...... 7

2.3. Significance of the study ...... 9

2.4. Conceptual framework on factors that affect home delivery ...... 10

3. Objective of the study ...... 11

3.1. General objective...... 11

3.2. Specific objectives...... 11 v | P a g e

4. Methodology ...... 12

4.1. Study design ...... 12

4.2. Study area ...... 12

4.3. Study period ...... 12

4.4. Source population ...... 12

4.5. Study population ...... 12

4.6. Inclusion and exclusion criteria...... 13

4.6.1. Inclusion criteria ...... 13

4.6.2. Exclusion criteria ...... 13

4.7. Sample size and sampling procedure ...... 13

4.7.1. Sample size determination ...... 13

4.7.2. Sampling technique for Quantitative study...... 15

4.7.3. Sampling technique for Qualitative study...... 15

4.7.4. Diagrammatic representation of sampling technique ...... 16

4.8. Variables...... 17

4.8.1. Dependent ...... 17

4.8.2. Independent ...... 17

4.9. Operational definition ...... 18

4.10. Data collection techniques and tools ...... 19

4.10.1. Quantitative ...... 19

4.10.2. Qualitative ...... 19

4.11. Data quality assurance ...... 19

4.12. Data processing and analysis ...... 20

5. Ethical clearance ...... 21 vi | P a g e

6. Results ...... 22

6.1. Socio demographic characteristics ...... 22

6.2. Prevalence and reasons of home delivery ...... 23

6.3. Obstetric and Maternal Characteristics of Respondents ...... 24

6.4. Home delivery and associated factors ...... 26

7. Discussion ...... 29

7.1. Prevalence of home delivery ...... 29

7.2. Associated Factors...... 30

7.3. Strength and Limitation of the study ...... 32

8. Conclusion ...... 34

9. Recommendation ...... 35

10. References ...... 36

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List of Tables

Table 1-Shows sample size calculated using some important determinants of home delivery for the second specific objective ...... 14

Table 2-Socio-demographic characteristics of the respondents, Zala District, Southern Ethiopia, April 2015. (n=447) ...... 22

Table 3- Showing maternal and obstetric factors of respondents, Zala District, Southern Ethiopia, April 2015. (n= 447) ...... 25

Table 4-Bivariate and multivariate analysis of factors associated with home delivery among respondents, Zala Woreda Southern Ethiopia, April 2015 (n = 447) ...... 27

Table 5- Connecting the codes, categories and identifying themes of all four FGDs in relation to perception towards home delivery among women in Zala district, April, 2015(n=38) ...... 28

Table 6 : -Socio-demographic and economic factors of women (Questionnaire table) ... 45

Table 7- Questions related to obstetric factors & service ...... 49

Table 8 - Translated Questionnaire (Goofigna) ...... 57

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List of figures

Figure 1-Conceptual framework on factors that affect home delivery ...... 10

Figure 2-Shows diagrammatic representation of sampling technique ...... 16

Figure 3- Shows reasons of home delivery among respondents, Zala district, Southern Ethiopia, April 2015. (n= 302) ...... 24

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List of Annexes

Annex 1;-Informed Consent, English Version ...... 41

Annex 2;- Informed Consent, Translated Version ( Gofigna) ...... 43

Annex 3;-English Version Questionnaires...... 45

Annex 4;- Translated Questionnaire (Goofigna) ...... 57

Annex 5;- Focus Group Discussion Guide for three groups ...... 68

Annex 6;- Translated Focus Group Discussion Guide for three groups (Goffigna) ...... 73

Annex 7;- Declaration ...... 79

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Acronyms ANC- Antenatal Care

CI- Confidence Interval

CSA- Central Statistical Agency

EDHS- Ethiopian Demographic and Health Survey

FGD- Focus Group Discussion

IRB- Institutional Review Board

MDG- Millennium Development Goal

MMR- Maternal Mortality Ratio

OR - Odds Ratio

PPH- Postpartum Hemorrhage

SNNPR- Southern Nations Nationalities and Peoples Region

SPSS- Statistical Package for Social Science

SSA – Sub- Sahara Africa

SBA – Skilled Birth Attendance

TBA- Traditional Birth Attendants

TTBA- Trained Traditional Birth Attendants

UN -United Nation

WHO – World Health Organization

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Abstract Introduction: A key intervention to achieve the goal of a reduction of maternal mortality is significant reduction of deliveries that occur at home. In Ethipia, the MMR has declined from 676/100,000 live births in 2011 to 420/100,000 live births in 2013 with a skilled attendant of 23% where 77% deliveries occurred at home without proper medical attention and care during childbirth. Little is known about cultural factors that contributed to home delivery. Therefore, this study aims to explore the cultural factors in adition to other factors that previous studies did not address in detail. Objective: To assess prevalence of home delivery and associated factors among child bearing age women who gave birth in the preceding two years in Zala District, Southern Ethiopia. Methods: A community based cross sectional study that triangulates quantitative with qualitative approaches was conducted from March 15 to April 10, 2015 on 447 women. Multistage sampling through simple random technique were employed to select study participants. Ten non-employed diploma and two degree level health professionals were recruited for data collection and supervision repectively after initial traing. Data were collected by pretested and structured questionnaire and entered and analyzed using EPI info 3.5.1 and SPSS version 20. Frequencies, binary and multiple logistic regression analysis were done. Associations were determined by using OR at 95% CI and p ≤0.05. Results: The prevalence of home delivery is found to be 67.6%. The factors that significantly affected home delivery in this study were place of residence (AOR: 5, 95% CI: 2.2, 12),women age at interview (AOR: 2.78, 95% CI: 1.2, 6.5), women’s education (AOR: 5.8, 95% CI: 2.86, 11.8), antenatal care (AOR: 3, 95% CI: 1.3, 8.5), time to reach the nearest health facility (AOR = 4.5, 95% CI = 2.2, 9), family size ( AOR= 3.9, 95% CI=2,16.77) and attitude of the mother on maternal services (AOR=3.7 95% CI= 2.2,6). Conclusions: Home delivery is highest in the study area. The most important factors that determine home delivery appear to be women’s education status, number of ANC visit, time to reach the nearest health facility and age and attitude of the women. Actions targeting the maternal education, encouraging number of ANC visits, making health facilities in accessible distance and conducting behavioral change communication were the crucial areas to tackle giving birth at home. xii | P a g e

1. Introduction

1.1. Background Home delivery refers to childbirth taking place outside health facility, either at home or on the way to the health facility, without attendance of a skilled health service provider. According to the world health organization (WHO), most deliveries that occur at home are assisted by traditional birth attendants (TBAs) and their relative (1). Virtually all the 287,000 annual maternal deaths from pregnancy related complications occur in developing regions, particularly in Africa and Asia. More than 20 million women worldwide become pregnant annually.WHO estimates that at least 15% of all pregnant women require rapid and skilled obstetric care, without which they will suffer serious, long-term morbidities. Delivering at home will unable women receive proper medical attention and care during child birth (1, 2). Previous studies showed that home delivery were associated with many socioeconomic factors such as educational status of mothers and their husbands, income level, preferences of the attentions of their relatives, trust on traditional birth attendants, absence of health problems during pregnancy, antenatal visits during pregnancy, short duration of labor, mothers’ place of residence, age, perceived distance to the nearest health facility and transportation costs (1, 2, 3).

1.2. Statement of the problem The vast majority of women who deliver outside the health facilities give birth at home, where risks of mortality are on the increase in the absence of professional attendance. It has been estimated that only 50% of the women in the world have access to such skilled care in developing countries, however, still most women deliver at home (4, 5). Worldwide, an estimated 529,000 maternal and nearly 4 million neonatal deaths (during first 4 weeks of life) occur annually, 75% of neonatal death in the first week of life. Approximately 99% of these deaths are in low- and middle income countries where 43 percent of births are attended by TBAs, the proportion generally being higher in rural areas. These home deliveries conducted by TBAs may be responsible for an increased risk of maternal and perinatal mortality as the TBAs are illiterate and sometimes not trained in preventing or recognizing complications and promptly referring the patient to an appropriate facility for

1 | P a g e emergency obstetric care. In addition, nearly 4 million stillbirths occur annually, most of them close to the time of delivery. Of the neonatal deaths, nearly 50% occur among children delivered at home. Perinatal mortality (stillbirths and neonatal deaths) is often related to intrapartum complications, and is, thus, higher in countries where highest deliveries are conducted at home environment. It has been estimated that decreasing the proportion of deliveries conducted at home reduces perinatal and maternal deaths by nearly half (4, 5, 6, 7, 9). The five major pregnancy-related complications leading to maternal mortality globally are postpartum hemorrhage (25%), puerperal infections (15%), unsafe abortion (13%), hypertensive disorders of pregnancy (12%) and obstructed labor (8%). About 35% of women in developing countries receive no antenatal care during pregnancy; and 70% receive no postpartum care. In these countries, home deliveries are over 60% taking place largely in rural areas with unskilled attendants (1, 8). According to study in Malaysia (2009), more than 90% of births occur at home with unhygienic conditions and without assistance of trained birth personnel (9). Ethiopia has one of the highest rates of maternal mortality in Africa accounting 676 per 100,000 births in 2010/11 from 871 in 2000/01. Ethiopia was one of the six countries which account more than 50% of all maternal deaths in 2012. The proportion of deaths due to Postpartum Hemorrhage (PPH) that occurred is most likely due to the fact that over 90% of births take place at home, and women with PPH may not be arriving at a health facility in time. In Ethiopia, the proportion of births attended by skilled personnel in health institution is increased in a very slow fashion in the course of 2005 to 2011. The majority of Ethiopian women give birth at home without skilled attendants. Further, as reported in 2011 Ethiopia Demographic and Health Survey (EDHS), the 90% of births at home take place in poor hygienic conditions and associated with adverse infant and maternal outcomes. There is no as such significant difference in proportions of home delivery between EDHS 2005 and 2011 (2, 3, 8, 10, 11). The rate of home delivery in Ethiopia is in the highest bound by sub-Saharan Africa standard (3, 11). According to health and health related indicators’ report of 2013, the SBA of Ethiopia was 23% and the achievement of SNNPR was 20.6% (12). In Ethipia, according to the latest estimate of United Nations, the MMR has declined from 676/100,000 live births in 2011 to 420/100,000 live births in 2013 (13).

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Based on 2013 annual review report of the Gamo-Gofa zone health department, despite efforts exerted to reduce giving birth at home, the institutional delivery achievement of the zone and the woreda is 22% and 9% respectively where home delivery accounted greater than 80% and 90% (15). Many studies dictated the sociodemographic, socioeconomic and obstetric factors of home delivery. But cultural and traditional factors were not touched in detail. Therefore, the purpose of this study is to assess prevalence of home delivery and associated factors among child bearing age women who gave birth in the preceding two years and this will be helpful for the relevant stakeholders in the planning and implementation of intervention activities to improve the delivery service utilization through significant reduction of giving birth at home.

2. Literature review

2.1. Extent of home delivery A key strategy for reducing maternal morbidity and mortality is ensuring that every birth occurs with the assistance of skilled health personnel. Progress in raising the proportion of births delivered with skilled attendance has been modest over the course of the MDG time frame, reflecting lack of universal access to care. According to MDG report of 2015, globally, the proportion of deliveries attended by skilled health personnel increased from 59 per cent around 1990 to 71 per cent around 2014. Yet this leaves more than one in four babies and their mothers without access to crucial medical care during childbirth. Wide disparities were found among regions in the coverage of skilled attendance at birth. Coverage ranges from 96 per cent in the Central Asia to a low of about 52 per cent in Sub-Saharan Africa (including Ethiopia) and Southern Asia.

The international community set SBA goal of 80%, 85% and 90% in 2005, 2010 and 2015 respectively. But based on the report, SBA was 71%, meaning the MDG target was not was not achieved (3, 6, 7, 10, 14). Home delivery is common in many developing countries. Study conducted in India in June 2009 revealed that the places of delivery in the 30 villages were compared. More than 50% of the deliveries occurred at home. Based on this study, less than 10% of the total number

3 | P a g e of deliveries in the home were assisted by the health personnel (16). Other studies indicated that prevalence of home delivery was 31% in India (2009), 29% in Malawi (2011 ), 40% in Nigeria (2013), 26.5% in Tanzania (2011), 48% in Ghana (2011) (5,16-19). Many studies revealed that, home delivery is also a common practice in Ethiopia. Community based study conducted in Munesa woreda, Oromia regional state showed that only 105 (12.3%) mothers gave birth at health facilities and the vast majority (87.7%) delivered at home (20). As indicated by another community based study conducted in Woldia woreda, Amhara regional state (2013), among 471 respondents, 227 (48.3%) gave their last birth in health institutions and 243 (51.7%) gave birth at home (21). Similarly, the study conducted in Dodota woreda, Oromia regional state (2011), revealed that out of the 506 respondents only 92(18.2%) gave birth to their last child at health facility where as 414(81.8%) gave birth for their last child at home (22). Another cross sectional study conducted in Sodo town in 2012 showed the prevalence of institutional delivery-service utilization in the town was 62.2% and home delivery was 37.8% indicating higher discrepancy between urban rural areas (23).

2.2. Factors associated with home delivery 2.2.1. Socio-demographic and obstetric factors According to the study conducted in Dodota woreda, Oromia regional state in 2011, educational status of mothers was one of the important predictor in determining place of delivery where illiterate mothers are four times (61%) more likely to deliver at home than primary and secondary school complete women (23). Similar finding is obtained from meta-analysis (2000-2013) conducted by Hawassa university in developing countries, predictors of place of delivery indicated illiterate mothers had more than 5 times more risk to deliver at home as compared with mothers with secondary and above education (24). Another studies conducted in different developing countries also showed consistent finding (16, 18).

Mothers living in rural areas were more likely to give birth at home than urban residents. Study conducted in Goba Woreda, Oromia regional state (2013) indicated higher rate of home delivery by rural residents. As compared to urban residents, rural residents were 3.6

4 | P a g e times more likely to deliver at home (25). Similar findings were indicated by different studies in different countries (16, 17, 20).

Findings from the North Gondar study mentioned that the utilization of safe delivery services was about five times higher among those who previously had developed one of the life threatening obstetric history. This implies that significant proportionsof mothers seek help from skilled birth attendants after developing obstetric complications and when other traditional interventions are not successful at home environment (27). Duration of labour were significantly associated with home delivery. Studies from Banja District, Awie Zone, Amhara Regional Sate, Ethiopia (July 2013), indicated that precipitate labour showed significantly positive association with home delivery. As mentioned by mothers; 15% of mother were due to short labor time, but when the length of labor prolonged, the probability of the woman to get assistance and deliver in health institution increases (27). According to the study conducted in Haromaya woreda, Oromiya regional state (2013), if the first delivery ends safe at home, then the probability giving birth at home for the next delivery is more likely (28). Women’s awareness on skill of health care professionals and services were significantly associated with home delivery. The women who did not get health information about the benefit of institutional deliveries increase the probability of choosing home delivery about 3.6 times higher than those who get the information according to the findings from North West, Haramaya woreda in Ethiopia (28). According to study on reasons of maternal delays in utilizing institutional delivery services, Bahir Dar, Ethiopia, 2012; of 422 mothers, 130 (31.7%) mothers reported that they faced transportation problem to the health institutions for getting emergency obstetric services and they went a minimum three hours walking distance to reach the health care facilities which forced them to give birth at home (21). Service and medication availability were common reasons reported by 456 (36.9%) women according to the the study of Bahirdar, 462(37.6%) of women reported availability of qualified professional, 454 (36.7%) provider’s knowledge and reputation and 428 (34.8%) cleanness of the facilities as the reasons for choosing facility delivery.

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One hundred eighty four (14.9%) women reported friendliness of providers. Other studies also found comparable findings (21,25,26,28). ANC status showed association with home delivery. Study revealed that mothers who did not visited ANC during last pregnancy were about four times more likely to deliver at home than mothers who did four and more visit ANC which indicated about 83% of mothers delivered at home (18). This association, however, do not guarantee straight forward interpretation according the study conducted in Nigeria, 2013; despite the higher number of pregnant women who attended ANC, a lot still preferred home delivery, 74% were attending ANC and yet up to 39% choose home delivery in the last pregnancy (29). The study findings show that from the majority of mothers who attended ANC, only a few of them delivered at the hospitals. Firstly, pregnant women needed to be assured that their pregnancy is fine. If the pregnancy is fine, the mothers decided to deliver at home. In the last 5 years, the Lao Reproductive Health Survey (2009) found that 28.5% of births were from women who received ANC and 84.8% of children were born at home (9). Many studies indicate that a woman belongs to the lowest economic status are highly associated with giving birth at home. Study conducted as a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the 2013, in twenty-three of the 48 countries, more than half of births are reported to take place at home. Home birth is most common among the poor. In SSA, South Asia, and Southeast Asia, 74.7–89.9% of women in the lowest two wealth quintiles reported giving birth at home. In these three regions, even among the wealthiest households 20.2–22.24% of surveyed women reported giving birth at home (25, 29, 30).

According to study from Munisa woreda, maternal age was also one of the predictors of home delivery. Mothers with 35 years of age at the time of the interview were about 6 times more likely to give birth at home than mothers aged 20 years and lower (21). This finding was in line with studies done in North Gondar Zone, Nigeria and Kenya which showed that aged women (>30 years) were more likely to give birth at home as compared to younger ones (7,32). The study conducted in three districts of Tanzania, 2010, show that home delivery was lowest (17.3%) among single women and highest at 27.0% among married women (33).

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Multi-gravidity was associated home delivery as it was lowest (16.7%) among primi- gravida women and highest (30%) among women who had more than four pregnancies according to the study in Tanzania (18, 33). Husband educational status was found as one of significant predictors on choice of delivery place. Those women whose husbands illiterate were less likely to choice home as delivery place when compared to women whose husbands were receive secondary education and above (28). Findings demonstrated the fact that obstetric knowledge is an important factor that affects home delivery. According to the study in Bahirdar (2012), those who delivered at heath facility might have been forced to visit care because of presence of serious clinical conditions during pregnancy and childbirth (33).The women who get health information about thebenefit of institutional deliveries increase the probability of choosing health institution 3.6 times higher than those who did not get the information (27). Many studies dictated that mother’s occupation is a significant predictor of giving birth at home. According to meta-analysis conducted in SSA from 1995-2011 where housewives, farmers and hawkers were the majority opting for home delivery than government employees (31). Poor involvement of husbands and relatives on decision to the place of delivery has an increasing effect on home delivery than decision made by their full participation. If women are not encouraged by husbands and relatives, they would not get financial and other social supports to go to health facility which would force them giving birth at home (27).

2.2.2. Cultural factors and Traditional Birth Attendants Almost two-thirds (63.6%) of those who were aware of TBA services had ever used such services, while 44.6% of them were currently using TBA services at the time of the study. About two-thirds (61.9%) of previous users said they were continuing to use TBA services for their current pregnancies (35). Women’s believe TBAs and relatives are affordable and able to meet their expectation during delivery and postpartum period, these services cannot provide at health facilities. Findings by Mrisho in Tanzania shows that labour is kept secret because any complications develops it means the women is adulterous and remedy for that is to

7 | P a g e mention all men have slept with her. It is believed that placenta must be buried in certain manner for a women to continue bearing children, this is contrarily to health facilities where placenta is burned by incinerator (9). The study took place in rural area of Kembatta-Tembaro in Ethiopia, 2013. According to the tradition of the area, the placenta should be buried around the home. It (the placenta) should by no means be thrown out everywhere. However, if mothers deliver in health facilities, the health professionals will not give the placenta. Hence, most of the community members do not prefer to go to health facilities for this reason (36).

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2.3. Significance of the study MDG was targeted 90% of births to be assisted by a skilled attendant by the year 2015 and only the rest (less than 10%) may occur at home. Based on the MDG report of 2015, MMR achievement was an overall decline of 45% globally. In Ethipia, according to the latest estimate of United Nations, the MMR has declined from 676/100,000 live births in 2011 to 420/100,000 live births in 2013, indicating no evidence of a sufficient decline. As a main component of reduction programme, skilled birth attendant was increased slightly from 10% to 23%. Despite availability of health services, exemption of maternal services, and provision of health information by heath extension workers; home delivery is a major problem in Ethiopia in general, and in Zala district particular. Majority of births that occur at home are occurred due to cultural and traditional reasons. Most home deliveries are assisted by non-trained traditional birth attendants who are mostly trusted by the community. Little is known about cultural factors that contributed for home delivery. This paper, therefore, aims to address this gap by attempting to explore the socio-cultural and other factors that were assumed to be contributors of home delivery. This findings will be used as a base line for policy, programming and delivery service interventions for improvement in the reduction of home delivery practice.

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2.4.Conceptual framework on factors that affect home delivery

Socio demographic and economic factors

 Age  Marital status  Education  Place of residence  Family size  Income,

 Occupation  Time to the health facility

Obstetric factors Home  Parity  Gravidity Delivery  ANC status  Duration of labour  Age at the 1st pregnanct  Age at the 1st marriage  Previus information about place of delivery  Place of previous delivery

Socio- cultural factors  Attitude  Preference of TBAs

 Decicion making power

Figure 1-Conceptual framework on factors that affect home delivery Adapted from EDHS 2011 (3)

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3. Objective of the study

3.1. General objective

To assess prevalence of home delivery and associated factors among child bearing age women who gave birth in the preceding two years in Zala district, Southern Ethiopia, 2015.

3.2. Specific objectives

 To determine the prevalence of home delivery in the district.

 To identify factors associated with home delivery in the district.

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4. Methodology

4.1. Study design A community based cross-sectional study design was employed. The study was triangulated with qualitative survey through focus group discussions (FGDs).

4.2. Study area The study was conducted in Zala woreda, which is located 485 kms South of Addis Ababa and 278 kms from Hawassa, the capital city of Ethiopia and SNNPR respectively. Zala is one of the woredas in the Southern Nations, Nationalities and Peoples' Region of Ethiopia, part of the Gamo Gofa Zone. Zala is bordered on the Southwest by Uba Debretsehay, on the Northwest by Demba Gofa, on the Northeast by Kutcha, on the east by Deramalo, and on the Southeast by Kemba woreda. The woreda is divided in to 35 kebeles [lowest admistrative unit]. It has 34 rural and 1 urban kebeles. Based on the 2007 Census conducted by the Central Stastical Agency (CSA), the woreda had a population of 74,369, of whom 37,576 are men and 36,793 women. A 2015 total population projected to be 91,107 and women of child bearing age is 20,954. Concerning health facilities distribution, the woreda has 34 health posts, 5 government health centers, 8 private clinics and 1 rural drug vender (37).

4.3. Study period The study was conducted from March 15 to April 10, 2015.

4.4. Source population All women of child bearing age (15-49 year) who gave birth in the preceding two years (from March 10, 2013 to April 10, 2015) in Zala district, Southern Ethiopia.

4.5. Study population All women of child bearing age who had given at least one birth in the preceding two years prior to data collection in ten selected kebeles of the district.

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4.6. Inclusion and exclusion criteria

4.6.1. Inclusion criteria

 All women who delivered in the preceding two years regardless of pregnancy outcome and marital status.  Those who gave birth by the help of traditional birth attendants (trained or not) are included under home delivery.  Permanent resident (those who lived at least 6 month and gave birth in the area)

 If a mother gave more than one births in the preceding two years, the last birth was included in the study.

4.6.2. Exclusion criteria

 Home deliveries with skilled birth attendances  Delivery by health extension workers  Respondents of FGDs for quantitative survey  Women who are mentally not capable of being interviewed.

4.7. Sample size and sampling procedure

4.7.1. Sample size determination 4.7.1.1. Calculating sample size- quantitative study Sample size determination with first objective Sample size calculation for the first objective was made based on the following single population proportion formula

ퟐ ⌊풁휶⌋ 푷(ퟏ−푷)  푵 = ퟐ 풅ퟐ  N=Number sample size

 푍훼/2 = Represents the desired level of statistical significance  P=Proportion of home delivery (The prevalence is taken from previous study took place in Banja District, Awi zone, Amhara regional state Northern Ethiopia, 2013) (P = 84.3%) (24).  d = margin of error

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Assumptions 1. Design effect = 2 2. Non response rate = 10% 3. d = 5% 4.  =0.05 ( z ̳ 1.96) 5. P = 84.3% Using the above formula & assumptions,

⌊ퟏ.ퟗퟔ⌋ퟐퟎ.ퟖퟒퟑ(ퟏ−ퟎ.ퟖퟒퟑ)  퐍 = = 203.4 (ퟎ.ퟎퟓ)ퟐ  Adding 10% non response rate , the result is 223.7  Using design effect of 2, the numbers of women recruited for study were 447. Sample size determination with second objective Table 1-Shows sample size calculated using some important determinants of home delivery for the second specific objective

Proportion Proportion Sample in in non - CI Power Source/ Variable OR size exposed exposed (%) (%) Reference (n) (%) (%)

ANC Status 61.2 79.77 95 2.5 80 309 (22, 24)

Residence 55.5 75.72 95 2.5 80 285 (18,24) Parity 66.2 83 95 2.5 80 339 (24,27) Educational status 64.4 81.89 95 2.5 80 326 (20,24) Attitude 66 82.9 95 2.5 80 338 (24, 36) As we see the table above, all sample sizes determined by some of the factors (calculated by Epi info 7.1.4.) are less than sample size computed for objective one (447). So, 447 was the final sampale size in this study. 4.7.1.2. Sample size for qualitative study Since determining sample size in qualitative design has no formula, it is systematically based on purpose of the study and data collection technique used. It is important to incorporate different homogeneous sub-groups of population with potentially different views on cultural and traditional aspects of home delivery.The study was involved four

14 | P a g e separate groups,one with women, second with TBAs, third with adult and elderly men and women and fourth with health workers. Overall, a total of four focus group discussions were conducted. Ten participants in each group exept only eight women group were selected for discussion based on their convenience, accessibility and knowledge of conveying the information.

4.7.2. Sampling technique for Quantitative study Multi-stage sampling technique was employed to select the study participants. The district had 35 Kebeles (34 rural and 1 urban). Then, ten Kebeles (one urban and nine rural) were selected. After stratifying the kebeles based on the place of residence, nine of 34 rural kebeles were selected by simple random sampling through lottery method. Then to obtain 447 study subjects, census was carried out through involvement of health extension workers in order to identify eligible mothers and sampling frame, that enlists eligible women based on inclusion and exclusion criteria, was prepared and proportional to size allocation was employed and simple random sampling technique through lottery method were applied. If the proposed respondent was absent or the home was closed, the data collectors were tried three times to obtain the selected respondent (see figure 2).

4.7.3. Sampling technique for Qualitative study For qualitative design homogenous purposive sampling technique was conducted on four groups of population (women, TBAs, elderly men and women and health workers) who were expected to convey credible information on cultural and traditional aspects of home delivery. All informants were selected from sampled kebeles and nearby health facilities based on their convenience, accessibility and knowledge of conveying the information. The recruitment of the participants in all group was assisted by the chairpersons and health extension workers of the ten kebeles and managers of the five health centers. Each kebele selected one discussant from women, TBAs, and elderly men and women for each group. The study participants of women group were selected based on the inclusion and exclusion criteria. Each health center selected two healt workers [midwives and/or nurses] from the delivery case team.

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4.7.4. Diagrammatic representation of sampling technique

Zala District

35 kebeles

Stratification

34 rural 1 Urban

SRS

9 rural

Odashabe Dbena Berawiga Gayla Shacha Baysa Kawsa Agayle Gaysa Galma

(239) (200) (258) (348) (259) (304) (216) (183) (533) (294)

Proportional to size allocation

n=84 n=45 n= 38 n=32 n=41 n=56 n=41 n=48 n=34 n=29

N= 447

Figure 2-Shows diagrammatic representation of sampling technique

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4.8. Variables

4.8.1. Dependent

 Home delivery

4.8.2. Independent

 Socio-demographic and economic factors– Age, Marital status, Education, Place of residence, Family size, Time to the health facility, income, occupation.  Obstretric factories – Parity, Gravidity, ANC status, Duration of labour, Age at the first pregnanct, Age at the first marriage, Previus information about place of delivery, Place of previous delivery.  Sociocultural – attitude, preference of TBAs, decision making power.

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4.9. Operational definition Access to health facility: the women being no more than an hour from health facility by local means of transportation, or availability of health facility with in travel distance of five kilometers (1). Health facility; refers to health center and hospital (40) Health extention workers- health workers in health posts in Ethioipa that has not yet been well evaluated whether the skills they have and the extent of delivery care they could provide is up to the WHO definitions of SBA (50). Home delivery; delivering ouside health facility (48) Not home delivery; delivering at health facility (48) Plan pregnancy; prior decision to give birth at health facility for last pregnancy (47). Precipitate labor - labor culminates in less than three hours (4) Traditional birth attendants: a birth attendant who initially acquired the ability by delivering babies herself or through apprenticeship to other TBAs (1). Trained Traditional birth attendants: those TBAs who have undergone subsequent training and integrated to formal health system (1). Definition of attitude (51)  Attitude is an evaluative reactions to home delivery that includes beliefs and positive and negative feelings and it guides experiences and decide the effects of experience.  Good attitude–women who answers at least three (≥60%) of questions (annex 7).  Bad attitude - women who answers two and less (<60%) of questions (annex 7).

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4.10. Data collection techniques and tools

4.10.1. Quantitative Data were collected using a pre-tested structured questionnaire developed and adapted from EDHS and other published literatures. Firs English language questionnaire were prepared and then it was translated to local language, Gofigna, before the data collection and again it was translated back to English to check its consistency. Data were collected through face-face interview of study subjects. A total of ten non-employed diploma level health worker data collectors and two degree level data supervisors were recruited for data collection.

4.10.2. Qualitative Semi-structured open ended and non-directive focus group discussion (FGD) guide was designed in order to triangulate responses obtained by the structured questionnaire on the socio-cultural and traditional practice of home delivery. The discussion in each of four groups were facilitated by principal investigator. Each group constituted ten people except women group which included only eight participants. A total of 38 discussants were participated.Before the FGDs, the moderator introduced all participants, explained the general purpose of the study and topic of the discussions. The participants were informed about the tape-recorder and permission to be recorded was requested. Informed verbal consent was obtained from all individuals participating in the discussion.

4.11. Data quality assurance The quality of data were assured by properly designing and pre-testing of the questionnaire on 23 of the study subjects at kebele other than selected (Shambara kankara). Both the interviwers and supervisors gained and assessed clarity, understandability and completeness of the questionnaire. Training of the interviewers and supervisors on the objective of the study, how to conduct face to face interview and how to keep confidentiality of the information was conducted. Every day, 10% of the completed questionnaires were reviewed and checked for completeness and relevance by the supervisors and principal investigator and the

19 | P a g e necessary feedback were offered to data collectors in the next morning before the actual procedure.

4.12. Data processing and analysis Collected questionnaires were checked visually for completeness, coded and entered into EPI info 3.5.1 and analyzed in SPSS version 20.0 software package. Frequency run and double data entry on 10% of questionnaires were performed to check data entry errors. Binary and multiple logistic regressions were run to assess the putative associations of various factors with home delivery. The outcome variable was dichotomous categorized as yes (coded 1) and no (coded 0). Only the explanatory variables that were resulted in the p-value≤ 0.25 in the bivariate analysis were included in the multivariate analysis. The fitness of the model were checked by Hosmer-Lemeshow goodness of fit test. The assumptions of logistic regression such as meaningful coding, checking multicollinearity presence of linear relationship between logit of dependent and independent variables; were checked. The results were presented in the form of tables, texts, figures and summary descriptive and analytic statistics. The strength of association of predictor variables with home delivery were assessed using odds ratio and significance of variables were reported by using 95% confidence interval and p-values ≤0.05. For qualitative study, prior to analysing the data, all FGDs were transcribed verbatim in Goffigna and then translated into English by the principal investigator and a research assistant to ensure fidelity. The data were analyzed using thematic manual analysis. Information from the interview consists of the discussants’ description and explanation of their cultural and traditional childbirth practices and reason for giving birth at home. Raw notes and tape recordings were used to generate transcripts in the local language, Goffigna. The principal investigator and research assistant translated and transcribed the notes and recordings and read the transcripts many times in order to gain better understanding of the context, and then coding, identification categories and themes were carried out.

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5. Ethical clearance Ethical clearance were obtained from Institutional Review Board of College of Medicine and Health Sciences, Arba Minch University. Permission to conduct the study was also obtained from the Gamo-goffa zone health department, Zalla Woreda Health Office and respective kebeles. Informed consent was obtained from each study participant. Each respondent was informed about the purpose of the study that the findings of the study will inform policy makers and other concerned bodies. Any involvement in the study subjects were after their complete verbal consent were obtained. Study participants were also be informed that all data obtained from them would be kept confidential by using codes instead of any personal identifiers.

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6. Results

6.1. Socio demographic characteristics All 447 women of child bearing age were planned for the study participated with the response rate of 100%. Among the respondents 159(35.6%) were within the age range of 25-29 years, 396(88.6%) were house wives, 187(41.8%) were followed no formal education, 443(99%) were Gofa nationality, 333(74.5%) were protestant and 437(97.8%) were married. Concerning the educational status of respondents’ husband, 135(30, 2%) were had knowledge of read and write. 249(47%) were average monthly income of less than 250 EB, with mean and standard deviation of 489.6 and ±32.3 respectively. The mean family size is 4.3 where 266(59.5%) were greater than or equal to five. About 258(57.7%) of respondents make decision by themselves concerning place of delivery (See table 2).

Table 2-Socio-demographic characteristics of the respondents, Zala District, Southern Ethiopia, April 2015. (n=447) Variables Category Frequency Percent

<25 147 32.9 Age of the 25-29 159 35.6 Mother ≥30 141 31.5

Occupation of Government worker 51 11.4 the mother House wife 396 88.6

<250 210 47 Average 250-499 92 20.6 monthly 500-750 71 15.9 income ( EB) >750 74 16.6

Gofa 443 99 Ethinicity Gamo 4 1

Religion Orthodox 89 19.9

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Protestant 33 74.5 Othes 25 5.6

Married 437 97.8 Marital status Separated/ widowed/ divorced 10 2.2

Educational No formal education 187 41.8 status Primary 182 40.7 of the mother Secondary and above 78 17.4

Illiterate 129 28.9

Educational Read and wite only 135 30.2 Status of the Primary 100 22.3 mother Secondary and above 83 18.6

≤4 181 40.5 Family size ≥5 266 59.5

Making final My self 258 57.7 decision Both 142 31 of delivery Family 47 10.5

6.2. Prevalence and reasons of home delivery From 447 respondents, about 302(67.6%) gave birth at home for their last pregnancy and the rest 145(32.4%) at health facility. Among 302 mothers who gave birth at home, about 78 (24.5%) gave birth at home due to preference of TBAs followed by 70 (23.2%) due to it was their usual practice. (See figure 4 and table 3)

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30

25 24.5 23.2 20 20.5

18.2 15

13.6

10

5

0 Preference of HD as usual Pregnancy said Precipitate labor Poor TBA practice normal transportation

Figure 3- Shows reasons of home delivery among respondents, Zala district, Southern Ethiopia, April 2015. (n= 302)

6.3. Obstetric and Maternal Characteristics of Respondents Among all 447 respondents, 240(53.7%) were at the age range of less than or equal to 20 years at their first pregnancy. From 447 respondents, 337(75.6%) attended ANC visits, from which 218(64.7%) followed about four and above visits, 175(52%) started followed ANC at the second trimester, 216(63.8) attended at health post. From all women included in the study, 182(40.72%) had a history of 2-4 pregnancy, while 104(76.7%) had come across pregnancy problem at their last pregnancy, about 248(55.5%) planned their last pregnancy. Regarding labour time, 240(53.7%) respondents’ labour lasted 2-5 hours. Among 302 mothers who gave birth at home for their last pregnancy, about 74(24.5%) delivered at home, were assisted by TBAs, (See table 3)

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Table 3- Showing maternal and obstetric factors of respondents, Zala District, Southern Ethiopia, April 2015. (n= 447)

Variables Category Frequency Percent Yes 302 67.6 Home delivery No 145 32.4

Age of the mother ≤20 240 53.7 at first pregnancy >20 207 46.3

≤2 41 12.2 No of ANC visits 3 78 23.3 ( n = 337) ≥4 218 64.7

Health facility where Health post 216 63.80 ANC follow up Health center 102 30.20 (n= 337) Hospital 19 6.00

Time when ANC First trimester 152 45 follow up is started Second trimester 175 52 (n= 337) Third trimester 10 3

Attend 337 75.6 ANC status Not attend 110 24.4

1 pregnancy 103 23.04 2-4 Pregnancy 182 40.72 Gravidity ≥5 pregnancy 162 36.24

≤1 hour 65 14.5 2-5hour 240 53.7 Labour time >5hour 142 31.8

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Women who faced Yes 104 76.7 pregnancy problem No 343 23.3 of last pregnancy TBAs 222 73.5 Who assisted at home Relatives 64 21.2 ( n= 302) No one 16 5.3

Plan last pregnancy Yes 248 55.5 No 199 44.5

6.4. Home delivery and associated factors The factors that were found to be associated with home delivery were place of residence, attitude of the mother, educational status of the mother, the time to reach the health facility, family size, age of the mother and number of ANC visits. As compared to urban residents, rural dwellers had 5 times to deliver at home (AOR = 5, 95% CI = 2.2, 12). Mothers educational status was found to be associated with home delivery in which mothers whose educational status of read and write only had 5.8 times to deliver at home as compared to mother who attended secondary and above education ( AOR = 5.8, 95% CI = 2.86, 11.8). Attitude of the mother is another strong predictor of home delivery, mothers with bad attitude had about 3.7 times to deliver at home as compared with mothers with good attitude ( AOR= 3.7 95% CI = 2.2,6.2).

As compared with less than one hours, mothers with greater than two hours to reach the nearby health facility had 4.5 times to deliver at home ( AOR = 4.5, 95% CI = 2.2,9).

Mothers from family size of greater than or equal to five were about four times to give birth at home as compared to family size less than or equal to four ( AOR = 3.9, 95%CI = 2,16.7). Age of the mother determines giving birth at home where mothers with age of greater than or equal to 30 years were 2.8 times to deliver at home as compared with mothers with the age of less than 25 years ( AOR = 2.8:

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95% CI = 1.2,6.5). Mothers who followed ANC about 3 times or less had 6 times to give birth at home as compared with mothers who attended ANC about four and above ( AOR = 3, 95%CI = 1.3, 8.5) (See table 4).

Table 4-Bivariate and multivariate analysis of factors associated with home delivery among respondents, Zala Woreda Southern Ethiopia, April 2015 (n = 447)

Category Home Delivery COR 95%CI AOR 95% Sig. Variable Sig.

Yes No CI Place of residence Rural 287 115 4.99(2.6, 9.6) 0.001 5.13(2.2, 12) 0.001

Urban 15 30 1 1 Attitude Bad 238 61 5(3.3, 7.9) 0.001 3.74(2.2, 6.2) 0.001

Good 64 84 1 1 Mother Education No formal education 156 31 9(4.9,16.4) 0.001 5.8(2.86, 11.8) 0.001

Primary 118 64 3.29(1.89, 5.73) 0.001 2.85(1.45, 5.6) 0.001

Second. & above 20 50 1 1 Time to Reach Health facility Greater than 2 hr. 165 54 6(3.3, 10.9) 0.001 4.5(2.2, 9) 0.001 1 to 2 hr. 90 22 4.5(2.7, 7.3) 0.001 4(2.23, 7.2) 0.001 Less than 1 hour 47 69 1 1 Family Size ≥5 207 59 1 1

≤4 95 86 3.2(2.12, 4.79) 0.001 3.9(2, 16.7.7) 0.001 Age of the Mother ≥30 103 38 1.3(0.77, 2.3) 0.306 2.78(1.2, 6.5) 0.017

25 – 29 100 59 0.76(0.44, 0.9) 0.04 1.4(0.7, 2.8) 0.32

<25 99 48 1 1 Number of ANC visits ≤ 2 29 12 2.5(1.2, 5.3) 0.011 3(1.3, 8.5) 0.023 3 58 20 3(1.7, 5.4) 0.672 6(1.2, 31) 0.029 ≥ 4 106 112 1 1

6.5. Thematic analysis design Theme one indicates the preference of TBAs by women because of their assistance of birth at home. Theme two shows cultural and traditional beliefs that hamper home delivery. Theme three dictates problems and barriers related to facility delivery. Theme

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four indicates problems and attitudes related to facility based services.some service users deciminate bad message of services the sought from health facility that enhances giving birth at home. Overall four themes, eight categories and 21 codes were organized. (See table 5)

Table 5- Connecting the codes, categories and identifying themes of all four FGDs in relation to perception towards home delivery among women in Zala district, April, 2015(n=38)

Codes Categories Themes

Being comfortable at home and needs assistance by only TBA TBA arrive 1. Preferen Giving birth is secrete and prestigious which only TBAs consider this home ce of TBAs are trusted by the community TBAs Home delivery is habitual process and no need of health facility because they give birth at home Women like the approach of TBA because they feel and sense poor living Treatment condition approach of Community develop shame if educated people observe their poor living TBAs condition

Previous generation born at home 2. Cultural Community Health facility is for sick people Beliefs perception Complicated delivery is due to punishment of mis behaviour Sanctioning and denying service if the facility served adultereted women Influence of culture (Zima culture)

Presure from community’s Placent should be buried in the garden culture Complicated delivery is due punishment to mis behaviour Cost 3. Facility Cheap service of TBAs service Formal and informal expenses during referals problems Accessibility Health facility is far from the dwelling Lack of road access Bad message from women who seek care from health facility concerning Negative 4. Previous lying position, message service Some women do not need to be served by men midwives attitude Bad attitude on facility Refered mothers are exposed for surgical procedure service

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7. Discussion

7.1. Prevalence of home delivery The study showed the prevalence of home delivery is about 67.6% among women of child bearing age who gave birth in the preceding two years prior to data collection. The study is exactly comparable with the study conducted in Kenya in 2013 where 66.7% of women gave birth at home (49).The study had higher prevalence as compared with MDG targets. To ensure reduction of maternal mortality, the international community in general and Ethiopia in particular set a target of SBA 90% in 2015 through the reduction of extent of home delivery less than 10% (42). The prevalence is slightly higher as compared with other findings from Haramaya Woreda, Oromia region, Goba woreda,India, Malawi, Nigeria,Ghana, and Tanzania where the magnitude of the prevalence is about 58%, 53%, 31%, 29, 40%, 48% and 44% respectively (5,16,17,18,25, 28, 38). The probable reason of the difference may be due to socio-economic and cultural factors that may vary among the studies. Cultura and traditional factors play a great role that enhances giving birth at home. TBAs are preferred by women for their birth assistance at home. Women belief as delivering a child is something that needs confidentiality. TBAs are culturally and traditionally trusted as they are more intimate for the community to sense and feel their privacy as mentioned by some of FGD dicussants. ″The … reason they like me is I help them at their home. They belief that delivery is something secret and prestigious. Imagine while a woman gives birth, she experience a bloody condition which she think nobody should see it other than her intimate family or me. Giving birth at health facility means inviting many people to carry her to there, where no other transport facility is accessible. How can people carry these bloody mother? And why do they carry her if she had normal pregnancy and delivery? In this case, women feel disgusted and ashamed if they give birth at health facility. So home is the best place for giving birth…″ (A 48 year old female TBAs from Melabaysa village). However, the finding is lower as compared with similar studies conducted in Ethiopia at Kembata- Tembaro zone (84%), Awi zone (84.3%), Munisa woreda (87.7%), and Dodota woreda (81.8%) (20, 22, 27, 36).This might be due to time gap among the studies. Recently the local government in line with national government is implementing the reduction of home delivery in order to achieve the goal of reduction of maternal mortality through promotion of institutional delivery.

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7.2. Associated Factors Rural residents had about 5 times higher chance of delivering at home as compared with urban residents (AOR = 5, 95% CI = 2.2,12). The study is in agreement with similar cross-sectional study conducted in Sekela dstrict in North west Ethiopia and Meta- analysis conducted by Hawassa University where rural residents had five and ten times chance of delivering at home, respectively (24,39). Another similar studies support this findings (16, 17, 20, 25). The higher chance of rural residents giving birth at home might be due to problems related to transport and accessibility to utilize health services, the lower chance of being educated, poor living standard as well as cultural beliefs, attitudes, and community preference that favour giving birth at home. Based on the survey from FGD, TBAs are opted by the community for the reason of their way of approach and treatment they give for the laboring women. They undertake this service based on the societal living standard and way of life in the community. ″…Mothers were more interested in my service because they like my approach and treatment. Imagine, our community is living in rural area, poor, having lower living standard, wear dirty clothes, their home is not clean, they feel shame if the health worker attends and looks this things. These is why they like me than health workers. They feel more comforted if I were with them while they are in labor.″ (A63 year old TBA from Gaysa village). Mother education is found to be predictor of home delivery in which mothers with no formal education had about six time to give birth at home as compared with mothers who attended secondary and above ( AOR = 5.8, 95% CI = 2.86,11.8). The finding is comparable with the study conducted in Bahirdar where mothers with no formal education had more than four times than educated mothers to give birth at home. Other similar studies conducted in Awi zone Northern Ethipia, East Wollega zone- Western Ethiopia, Afar regional state,Hawassa University-Ethiopia,Dodota woreda-Oromia region- Ethiopia, Inadia and Tanzania support this finding (16,18,23,24,27,40,41). The non- educated women might not have a decision making power on seeking health services, and have ability to travel outside the home, they are more exposed to family pressure and cultural influences. The time spent to reach the nearest health facility is another significant predictor of home delivery. Health facility that spent greater than two hour and above on walking distance

30 | P a g e had 4.5 times more chance of giving birth at home as compared with facility that takes one hour and less ( AOR =4.5, 95% CI = 2.2,9) .The study is consistent with findings from Bahirdar- Ethiopia,Arbaminch Zuria-Ethipia,Kenya, Bangladish (21,44,45,46). Increased time or distance and lack of transfortation might decreases chance of maternal service (ANC, delivery) utilization. It masks them to not get adequate information. Pregnant mother might be disinterested to walk far distance which might influence them to opt home delivery. The qualitative study also found consisitent explanation. Transportation problems and distance as well as challenging and difficult roads are the main issues that contribute for home delivery. The location of health facility from the community’s dwelling is the main factor as six of the FGD discussants suggested. ″The challenge we face during delivery is transportation problem. Health facilities are located far distance from our dwelling. During labor we are expected to be carried by the people to health facilities for more than four hours. It needs labor force which is sometimes difficult to get.″ (A 70 year female TBA from Gaysa village)

Mother with the age of 30 years and above had 2.8 times more chance of giving birth at home as compared with mother with the age of below 25 (AOR = 2.78, 95%CI = 1.2,6.5). The finding coincides with previous studies. According to study from Munisa woreda Oromia regional state, mothers with 35 years of age were about 6 times more likely to give birth at home than mothers aged 20 years and lower (18). This finding was also in line with studies done in North Gondar Zone, Nigeria, Kenya and Sab-Saharan Africa (7, 27, 31, 32). The possible explanation for this could be that older woman tended to consider giving birth at home is not as risky as it has been their usual experience. Besides, older woman might belong to a more traditional cohort, thus less likely to be educated and awared which intern influences them to utilize modern health facilities as compared to younger women. Howeve, disagreement arises with other studies which they found that older women may become knowledgeable during successive ANC visits on the benefits of health facility deliveries. Obstetric complications may increases with age as a result older women may less likely to give birth than younger women (52,53). Number of ANC visit is found to be a significant predictor of giving birth at home. Women who attended two or less times were about 3 times more chance of delivering at home as compared with 4 or above family members (AOR = 3, 95% CI= 1.3,8.5). The

31 | P a g e study is in congruent with the finding obtained from Western Ethiopia where women who were not attended ANC were about 6 times to give birth at home as compared with women who attended about 4 times and above (38). Similar comparable findings from Oromia regional state, Tanzania, Nigeria and Nepal were found (9, 16, 23, 27, 45). The possible reason may be women who made lower visits would be less likely to get adequate information and counselling about advantages of delivering at health facility which favors them to experience home delivery. Nonetheless, some studies argue that ANC would have an inverse association with home delivery as women who are told their pregnancy is fine may feel encouraged to deliver at home (29, 52). Attitude towards maternal service is a significant predictor of home delivery where mothers with bad attitude had about 3.7 times more chance of delivering at home as compared with mothers with good attitude ( AOR =3.7, 95% CI =2.2, 6.2 ). The study fits findings with the previous study from Sekela district North-West Ethiopia and Bahir dar Ethiopia where mothers with unfavourable attitude had about 6 and 4.4 time to deliver at home, respectively (34,39). Most women opt home delivery because of the negative information they get from women who were delivered in the health facility. The embarrassments they face during delivery process prevents them to seek the service in the health facility, which in turn leads to give birth at home as suggested by four FGD discussants. ″The … factor that favors home delivery is the bad message of mothers who previously gave birth at health facility. Delivery process makes mothers expose their secret body parts and makes them to lie in a coach raising or elevating her legs at supine position that they do not like to be embarrassed.″ (65 year elderly man from Berawiga village). Women refuse facility delivery fear of surgical procedure and operation which hampers them not utilize the service in health facility. One FGD participant stated is as; ″I think the main reason that women favor home delivery is that women believe they would experience a surgical procedure if they attend hospital or health center.″ (A 60 year elderly man from Odashabe village)

7.3. Strength and Limitation of the study The study triangulates both quantitative and qualitative design that widens the scope of the study and one method counterbalance the shortcomings of the other method. Besides, the selection bias is minimized as community based study and probability sampling was

32 | P a g e applied. These all could increase the accuracy and contributes greater confidence in the generalizability of findings.

However, the cross sectional nature of the study does not allow establishing causality of associations and the results should be interpreted cautiously. Recall bias cannot be ruled out about events that took place further from the period of data collection. Social desirability bias may also be a problem.

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8. Conclusion This study revealed that the prevalence of home delivery among women of child bearing age who gave birth in the preceding two years prior to data collection was seem to be higher. Factors that were significantly associated with home delivery include place of residence, age of the mother, the average walking time to reach the nearby health facility, number of ANC visits, and family size. Socio-cultural factors such as attitude of the mother on maternal service utilization was also found to be significant predictor of home delivery.

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9. Recommendation District health managers and implementers should meet strong effort to decrease the prevalence of home delivery in the study area. District implementers and relevant stakeholders should be involved to promote empowerment of women by encouragement of girls to complete secondry and above education through integration with concerned bodies will be helpful to enable them decide by themselves about avoiding delivering at home. It is important that additional new facilities are constructed in accessible areas at average walking time less than an hour or increasing staff at health facilities in the accessible cluster is necessary especially deploying of mid wives at cluster health posts is the best approach to address accessibility problems. Encouraging pregnant women to complete at least four ANC visits is a crucial area to alleviate home delivery. Health services should be involved in promoting ANC attendance is helpful minimizing giving birth at home. Improving family planning and child spacing to lower family size are the main areas where the local implementers should give strong emphasis. Promotion and integration of TBAs for referral and conducting health education on negative cultural attitudes is another area of intervention. So, conducting behavioural change communication should be given due attention in order to tackle socio-cultural and traditional factors that favour giving birth at home. Similar studies should be conducted in various settings (both similar and different settings) to come up with more representative findings, which will be helpful in designing interventional activities targeted at alleviating giving birth at home.

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10. References 1. World Health Organization. Traditional birth attendants: a joint WHO/UNICEF/UNFPA statement. Geneva: World Health Organization, 2008. 2. Sibley LM, Sipe TA, Brown CM et al. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. The Cochrane Collaboration and published, 2009.

3. Central Statistical Agency [Ethiopia] and ICF International. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and ICF International.2012. 4. World Health Organization. The World Health Report 2013. WHO. 2013. 5. Folashade B. Okeshola Ismail T. Sadiq.. Determinants of Home Delivery among Hausa in Kaduna, South Local Government Area of Kaduna State, Nigeria. American International Journal of Contemporary Research. May 2013, 3(5). 6. WHO, UNFPA, WB. Maternal mortality estimates. Geneva, Switzerland, 2009, 45. 7. WHO factsheet. Proportion of births attended by a skilled health worker-2008 updates. Geneva: WHO, 2008 8. Mwanakulya E. Simfukwe, Mbbs 4 – Imtu. Factors Contributing To Home Delivery In Kongwa District, Dodoma- Tanzania. Unpublished article. September, 2008

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9. Sychareun, V; Phengsavanh, A; Hansana, V; et al. Cultural Beliefs and Traditional Rituals about Child Birth Practices in Lao PDR. Kuala Lumpur, Malaysia. The Asian- Pacific Resource & Research Centre for Women (ARROW). 2009 10. Ethiopia MDG Report 2013. Assessing Progress Towards The Millenium Development Goals, Addis Ababa, Ethiopia. 2013 11. Pakistan Demographic and Health Survey 2006-07. National Institute of Population Studies Islamabad, Pakistan Macro International Inc. Calverton, Maryland USA. June 2008. 12. Federal ministry of health. Health and health related indicators of Ethiopia. Oct. 2014. 13. United Nations Development Programme. Trends in Maternal Mortality: 1990 to 2013. Available from http://unfpa.org/webdav/site/global/shared/documents/ publications/2014/9789241507226_eng.pdf.

14. The Millennium Development Goals report 2015, United nations.

15. Gamo-Gofa zone. 2013 Annual plan achievement report of Gamo-Gofa health department, Arba Minch, July 2013. 16. Geeta S., Shashank S., Chandrakant R. Pergulwar, Et al :Trends in Choosing Place of Delivery and Assistance during Delivery in Nanded District, Maharashtra, India: Journal of Health Popul Nutr. Feb. 2011 ;29(1):71-76. 17. Lily K., Gunnar B., Ellen C., Et al. Why some women fail to give birth at health facilities: a qualitative study of women’s perceptions of perinatal care from rural Southern Malawi. Journal of Reproductive Health. 2013, 10:9.

18. Amon E., Almamy M. K., Mustafa N., et al. Access to institutional delivery care and reasons for home delivery in three districts of Tanzania. Internaltional Journal of equity health. 2014, 13:48. 19. Halley P. C., Cyril E E., Richard M..Et al . Shifting norms: pregnant women’s perspectives on skilled birth attendance and facility–based delivery in rural Ghana. Unpublished article. 2010. 20. Abdella A., Abebaw G. and Zelalem B. Institutional delivery service utilization in Munisa Woreda, South East Ethiopia: a community based cross-sectional study. Journal of BMC Pregnancy and Childbirth. 2012, 12:105.

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21. Worku A.,,Jemal M., Gedefaw M.. Institutional delivery service utilization in Woldia, Ethiopia. Science Journal of Public Health. 2013, 1(1) :8-10. (http://www.sciencepublishinggroup.com/j/sjph) 22. Addisalem Fikre and Meaza Demissie. Prevalence of institutional delivery and associated factors in Dodota Woreda (district), Oromia regional state, Ethiopia Reproductive Health 2012, 9:33. 23. Feleke H., Mirkuzie W., Fikru T.. Predictors of institutional delivery in Sodo town, Southern Ethiopia. Unpublished article. 2012. 24. Yifru B., Asres B..A meta-analysis of socio-demographic factors predicting birth in health facility. Ethiop Journal of health science. September 2014.

25. Daniel B.O., Desalegn M. S. Institutional delivery service utilization and associated factors among child bearing age women in Goba Woreda, Ethiopia. Journal of Gynecology and Obstetrics. 2014, 2(4): 63-70 26. Abebaw G. W., Alemayehu W. Y., Mesganaw F. A.. Maternal Complications and Women’s Behavior in Seeking Care from Skilled Providers in North Gondar, Ethiopia PLoS ONE. 2013: 8(3): 27. Alemaw W., Mekonnen A.,Worku A.,Institutional delivery service utilization and associated factors in Banja District, Awie Zone, Amhara Regional Sate, Ethiopia:Open Journal of Epidemiology. 2014, 4: 30-35

28. Haymanot M., B., Agumasie S. Factors Affecting Choice of Delivery Place among Women in Haramaya Woreda, Oromia Regional State, Eastern Ethiopia. THE PHARMA INNOVATION – JOURNAL. 2013, 2(3). Online Available at www.thepharmajournal.com 29. Envuladu E.A, Agbo H.A, Lassa S., Et al. Factors determining the choice of a place of delivery among pregnant women in Russia village of Jos North, Nigeria: achieving the MDGs 4 and 5. International Journal of Medicine and Biomedical Research. April 2013, 2(1) 30. Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data. PLoS ONE. 2011, 6(2). e17155. doi:10.1371/journal.pone.0017155

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31. Cheryl A., Moyer, Aesha M. Drivers and deterrents of facility delivery in sub- Saharan Africa: a systematic review. Journal of Reproductive Health. 2013, 10:40 http://www.reproductive-health-journal.com/content/10/1/40 32. Carter Alexandra. "Factors That Contribute to the Low Uptake of Skilled Care During Delivery in Malindi, Kenya" (2010). Independent Study Project (ISP) Collection. Unpublished article. 2010. http://digitalcollections.sit.edu/isp_collection/821 33. Constanze P. and Rosemarie M. Delivering at home or in a health facility? health- seeking behaviour of women and the role of traditional birth attendants in Tanzania. BMC Pregnancy and Childbirth. 2013, 13:55 http://www.biomedcentral.com/1471-2393/13/55 34. Fantu A., Yemane B. and B. G.. Factors associated with home delivery in Bahirdar, Ethiopia: A case control study. ebe et al. BMC Research Notes 2012, 5(6):1026-31. http://www.biomedcentral.com/1756-0500/5/653 35. Olufunke M., Ebuehi IA., Akintujoye. Perception and utilization of traditional birth attendants by pregnant women attending primary health care clinics in a rural Local Government Area in Ogun State, Nigeria International Journal of Women’s Health. 2012:4 25–34 36. Solomon Sh., Mark S., Merijn G., Et al. Why do women prefer home births in Ethiopia? BMC Pregnancy and Childbirth. 2013, 13:5. 37. Zala Woreda. 2013 Annual plan achievement report of Zala Woreda health office, Galma, July 2013. 38. Kihulya M. Elia J. M. Prevalence and predictors of institutional delivery among pregnant mothers in Biharamulo district, Tanzania. African Medical Journal. 2015, 21(4):51 39. Alemayehu Sh. T. Fekadu M. A. and S. M. W. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of Ethiopia.BMC Pregnancy and Childbirth. 2012, 12:74. 40. Tesfaye R. F. Gebi A.G. Determinants of Institutio nal Deliver y among childbearing age women in Western Ethiopia.PLoS ONE. 2014,9(5): 14.

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41. Medhanit G. M.,&, Kassahun N. Y., Jemal Y.U., Muluken M. Determinants of delivery practices among Afar pastoralists of Ethiopia. The Pan African Medical Journal. 2012;13(Supp 1):17. 42. The Millennium Development Goals Report 2014. United Nations. New York, 2014. 43. Atiqul H. Ch., Mehedi H., Sayem A., Charls D., Mohammad S. H., Rabiul H. Socio- demographic Factors Associated with Home Delivery Assisted by Untrained Traditional Birth Attendant in Rural Bangladesh. American Journal of Public Health Research, 2013, 1,( 8): 26-20 44. Emily M., Raymond D., Wendy O., et Al. The influence of distance on place of delivery in a Western Kenya. BMC Health Services Research. 2014, 14:212. 45. Gistane A., Maralign T., Behailu M., Worku A., et Al. Prevalence and associated factors of home delivery in Arbaminch Zuria district, Southern Ethiopia. 2015; 3(1): 6-9 46. Saraswoti K. Sh., Bilkis B., Khursida Kh., Liaquat A., Narbada T.,Babill Stray-P.and Bhimsen D. Changing trends on the place of delivery: why do Nepali women give birth at home? Reproductive Health 2012, 9:25 47. Bereket Y., Mulat T., Wondimagegn P. Utilization of Antenatal Care And Their Satisfaction With Delivery Services In Selected Public Health Facilities Of Wolaita Zone, Southern Ethiopia. International journal of scientific & technology research.2013, 2(2). 48. Jared O. O. Factors Associated with Home Delivery inWest Pokot County of Kenya. 2015, 5(9). 49. Bisrat T. and Negash J. Health extention program as innovative health care system: the socio-cultural factors affecting its implementation in Jimma Zone, South Western Ethiopia. International journal of sociology and anthropology.2014 6(8):6. 50. Ministery of health. Health Management Information System / Montoring and Evaluation Indicator Definitions: Technical Standards: May 2007 version 1.0. 51. Junayde Abdurahmen, Adamu Addissie, Mitike Molla. Preferences of Place of Delivery and Birth Attendants among Women of Shashemene Town, Oromia Regional State. International journal of technology enhancements and emerging engineering research. 2014, vol 2 (7):5-6.

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52. Gabrysch S, Campbell OM: Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 2009, 9:34.

53. Seifu Hagos, Debebe Shaweno, Meselech Assegid et al. Utilization of institutional delivery service at Wukro and Butajera districts in the Northern and South Central Ethiopia. BMC Pregnancy and Childbirth 2014, 14:178 http://www.biomedcentral.com/1471-2393/14/178

Annex 1;-Informed Consent, English Version Arba Minch University College of Medicine and Health Sciences Department of Public Health Consent to participate in the study Greetings, I am ………………………………………..working on this research project from Arbaminch University. As one of theworkers in such units, I would like to talk to you about this issue. Purpose of the study The purpose of this study is to collect information on factors contributing to home delivery among women of reproductive age in zala district. You are being asked to participate in this study because you have particularknowledge and experiences that may be important to the study. What participation Involves If you agree to participate in this study, the following will occur: 1. You will sit with a trained interviewer and answer questions abouthome delivery and associated factors. 2. Findings will be communicated with concerned bodies and yourcomments will be acted upon to improve the situation in this area. 3. You will be interviewed only once for approximately 20-30 minutes in aprivate setting. 4. No identifying information will be collected from you during thisinterview, except your age, marital status and level of education.

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Confidentiality I assure you that all information collected from you will be confidential. Onlyindividuals working with me in this research will have access to the information. Wewill be compiling a report, which will contain your responses without any referenceto individuals. We will not put your name or other identifying information on therecords of information you provided. You may refuse to answer any particularquestion and may stop the interview at any time. Right to withdraw and Alternatives Taking part in this study is completely your choice. If you choose not to participatein the study or if you decide to stop participating in the study, you will not get anyharm. You can stop participating in this study at any time, even if you have alreadygiven your consent. Refusal to participate or withdraw from the study will notinvolve penalty or loss of any benefits to which you are otherwise entitled. Benefits The information you provided will help to find out home delivery and associated factors in zala district and we hope to communicate findings to decision markers at the district and region level to plan and implement interventions that willhelp to improve this condition. In Case of Injury We do not anticipate that any harm will occur to you or your family as a result ofparticipation in this study. Who to contact If you ever have questions about this study, you should contact PrincipalInvestigator, Bedilu Kucho, Arbaminch University of public health Epidemiology and Biostatistics unit. Address = 0916725534 Signature: Agreement of the Participant Do you agree? Yes ○ No ○ I ……………………………………….. have read and/or understood the contents inthis form. My questions have been answered. I agree to participate in this study. Signature of participant ………………… Signature of research data collector………………………….. Date of signed consent …………………………………

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Annex 2;- Informed Consent, Translated Version ( Gofigna)

Arbamince yunvustire asa akamonne payatetha saynsse koleje dere asa payatetha shako Pilgethan gelanaw asa amothetha qonciso Sarotho, taani ------haysa Arbamince yunvustireppe yida pilgethan oosan de7iysi. Hayssa ooso shako kifilepe yaada taani neera/intera haysape garssan de7iya yohota bola tobana. Pilgetha kaara qofa Haysa pilgethas kaara qofay macasha son yelaara gahetididi de7iya yohota bola zaala heerape oratha qofata shiishanasa. Neeni hayssa pilgethan new de7iya qofa imora maadanada oyshetasa, gaasoyka new daro akeekay, eratethaynne oyson qoncisida loohoy de7ees.

Neepe ayba koshii Neeni hayssa pilgethan gelanaw koyiya gidiko hayssape kaali de7iya yohoti kaalosona 1. Neeni lo7ida oychiya asara utada aayeta yeluwaara gahetiya oyshata bola zaaro imasa. Ne qofa heran lames go7ees 2. Neeni 20-30 dakika heeran asi bayna besan oyshetasa 3. Nenatetha shaakiya oysha oyshetaka gidope attin ne yeleta laytha, gelone ekethetha hanotanne ne timirtte deetha. Gaatha yoho oytha ( mistier naago) Neepe shiiqiya qofay uba gaatha qofati ubbay naagetees. Taara oothiya yaleti kanche hayssa zarotha be7osona. Nuunin haysa zaaaruwa heetishe ne sunthane nena shaakiya malata go7etoko.

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Zaaro oyshatas immike gaanaw danda7aasa, koyida saaten pilgethaape qanxa keyanaw danda7aasa. Pilgethaape keyana matane doorata Hayssa pilgethan geloyka agoyka ne dooro. Neeni ha pilgethan gelike giiko woyko pilgethaape qanxa keyiko ne bola gakana danoy baawa. Neeni agada keyiko ne dhayanabi baawa . Go7atetha Neeni zaala heeran aayeta yelaara gahetiya yohota bola imiya zaaroy ayeta yelara gahetiya gaasota eranaw maades, ne zaaroy qasi poolise pilganchatasinne ha yoha bola oothiya asaa maades, ye metora gahetiya gaasotaka bilees. Neni gidin ne dabota bola ha pilgetha gisho danoy gakees giidi nunu naagiyaabay baawa. Oona demaneeko Ha pilgethaara gahetidi new oyshi diiko neeni hayssa pilgethas huuphe kafo gidida Arbaminche yunivuriste, heera asa payatethan Epidemolojenne bayo estatisitikise shako kifile tamaare gidida daana Badilu Quco demanaw danda7aasa Demana qonciso = 091672553 Pirma Pilgethan gelana amotethi hayssa pilgethan gelanee? Ee ○ Akay ○ Taani ------haysa nababada/akeeka si7a eras. Ta oyshati ubbay simida. Taani haysa pilgethan gelana. Zaaro imiya mishiree pirma ------Hayssa oysha shiishiya bola kaafo pirma------Haysa giga galasay------

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Annex 3;-English Version Questionnaires

Part I: -Socio-demographic and economic factors of women

Table 6 : -Socio-demographic and economic factors of women (Questionnaire table)

No Questions Coding Categories Code 101 Age of the mother ------years

102 Religion 1. Muslim 2. Orthodox 1 3. Protestant 2 4. Catholic 3 5. Other specify 4 5

103 Ethnicity 1. Goffa 2. Gammo 1 3. Amahara 2 4. wolaita 3 5. other specify 4

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5

104 Educational status 1. no formal education 2. Read & write only 1 3.primary 2 4.Secondary and above 3 4

105 Marital status 1. Single 2. Separated 1 3. Married 2 4. Divorced 3 5. Widowed 4 5

106 Occupational status 1.Governmental worker 2.Farmer 1 3.Merchant 2 4.House wife 3 5.Daily laborer 4 6.Unemployed 5 7.other specify------6 7 107 Place ofResidence? 1.Urban 2.Rural 1 2

108 Average Monthly Income of the family ------ETB in ETB

109 Husband’s age ------years 1

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2 3 4 5 110 Husband’s occupation 1. Governmental worker 1 2. Farmer 2 3. Merchant 3 4. Daily laborer 4 5. Unemployed 5 6. other specify------6 7 111 Husband’s educational status 1. Illiterate 1 2. Read & write only 2 3. primary 3 4. Secondary and above 4

112 Family size ------1

113 Distance to nearest health facility ------km ( health center/hospital) 114 Maximum time to reach the nearest ------minutes health facility ( health center/hospital) Part ii .economic status

S/No Questions Coding categories Code 201 Do you have farm land? 1. Yes(specify by hectare)--- 1 2. No 2 3. No response 77

202 Do you have Ox? 1. Yes(specify by number)--- 1 2. No 2 3. No response 77

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203 Do you have Cow? 1. Yes(specify by number)--- 1 2. No 2 3. No response 77

204 Do you have Goat? 1. Yes(specify by number)--- 1 2. No 2 3. No response 77

205 Do you have Sheep? 1. Yes(specify by number)--- 1 2. No 2 3. No response 77

206 Do you have Donkey? 1. Yes(specify by number)--- 1 2. No 2 3. No response 77

207 Do you have Hen? 1. Yes(specify by number)--- 1 2. No 2 3. No response 77

208 Do you have mobile telephone? 1. Yes(specify by number)--- 1 2.No 2 3. No response 77

209 Do you have Radio? 1. Yes (specify by number) 1 2. No 2 3. No response 77

210 Do you have Television? 1. Yes (specify by number) 1 2. No 2 3. No response 77

211 Do you have motor vehicle? 1. Yes (specify by number) 1

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2. No 2 3. No response 77

212 Compared to your neighbors where do 1. Very poor 1 you classify your family’s economic 2. Poor 2 status? 3. Average 3 4. Rich 4 5. Very rich 5 6. Don’t know 6 7. No response 77 Part iii - Questions related to knowledge, attitude and practice on obstetric factors & service

Table 7- Questions related to obstetric factors & service

No. Questions Coding categories code

301 Age at the first marriage ------years 1 2

3 4 5

302 Age at the first pregnancy ------years 1 2 3 4 5

303 Number of pregnancy (gravidity) ------

304 Children alive ------

305 Children died ------

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306 Problems related to previous preg 1. No problem 1 pregnancies 2. Vaginal bleeding 2 3. Headache 3 4. Severe abdominal 4 5. Drowsiness 5 6. Others, specify 6

307 Pregnancy outcome of last 1. Live 1 delivery? 2. Dead 2

308 Any visit to Health Facility during 1.yes 1 last pregnancy? 2. no 2

309 If yes to Q308,reason for visit to 1. pregnancy related problem 1 Health facility 2. For ANC 2 3. Health Problem not related to 3 pregnancy 4 4. Other, specify------

310 Did you attend ANC for the last 1. yes 1 pregnancy? 2 2. No

311 If yes to the question 210, Number ------of ANC visit(s) to the last pregnancy

312 If yes to the question 210, where 1. Hospital 1 did you attend ANC follow up? 2. Health center ( gov’t) 2 3. Clinic ( private ) 3

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4. Health post 4 5. Others, specify------5

313 If yes to the question 210, when 1. First trimester 1 did you start ANC follow up? 2 2. Second trimester 3 3. Third trimester

314 If yes to the question 210, what do 1. to assess material health conditions 1 you think are advantages of ANC 2. to assess fetal health condition 2 follow up? 3. to assess fetal lie position 3 4. to anticipate possible delivery 4 complications 5 5. I don't know the advantage 6 6. Other advantages, specify------

315 If yes to the question 210, during . 1. Yes 1 ANC follow up, did you receive 2 2. No any information regarding possible pregnancy & deliverycomplications?

316 If yes to Q215, were you informed 1. Yes 1 about danger signs of possible 2 2. No complications

317 If yes to Q216, Which danger 1. Vaginal bleeding 1 signs were you informed about? 2. Head ache 2 3. Marked & fast weight signs 3 4. Drowsiness/dizziness 4 5. Fetal met cessation 5

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6. Other, specify------6

318 If yes to Q216, for which danger 1. Vaginal bleeding 1 signs are you informed to seek 2. Head ache 2 medical help? 3. Marked & fast weight signs 3 4. Drowsiness/dizziness 4 5. Fetal met cessation 5 6. Other, specify------6

319 Do you have TV in your home 1. Yes 1 2. No 2

320 Where did you plan give birth for 1. Home 1 your last pregnancy? 2. Health facility 2

321 Do you think there is 1. Yes 1 difference giving birth at 2. No 2 home or health facility

322 Were you informed about where to 1. Yes 1 deliver? 2. No 2

323 If yes toQ222, what is the primary 1. Health workers & 1 source of information about 2. HEW 2 delivery services 3. Friends& families 3

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4. TBAs 4 5. Media 5 6. Others, specify ------6

324 If yes to 222, where were you 1. Home 1 recommended to delivery? 2. Health facility 2

325 If health facility to Q224, did you 1. yes 1 do based on it? 2 2. no

326 It no to Q225, why? 1. Said normal pregnancy 1 2. Undesirable approach of 2 health professionals 3 3. Transportation problem 4 4. Preference of TBAs 5 5. No access 6 6. Pressure from family members and neighbours 7 7. Others, specify?------

327 Were you informed about who 1. Yes 1 should attend your during 2. No 2 delivery?

328 If yes to 220, who is recommended 1. Skilled delivery attendant 1 to attend your delivery? 2. TBA 2 3. TTBA 3

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4. Relatives 4 5. Health extension workers 5 6. Other family members 6 7. Other, specify------7

329 Did you plan your last pregnancy 1. Yes 1 2. No 2

330 Have you faced any pregnancy 1. yes 1 related health problems prior to or 2. No 2 during labor?

331 If yes to Q230, which of the 1. Ante partum hemorrhage 1 following problems? 2. Excessive bleeding during labor 2 3. premature rupture of membranes 3 4. Intrauterine fetal death 4 5. Elevated pressure 5 6. preterm labour 6 7. others specify ------______7

332 How long was the duration of ------hour 1 labor of your last pregnancy? 2 3 4

333 Who made the final decision about 1. Myself 1 your place of delivery for your last 2. Husband 2 pregnancy? 3. Both 3

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4. Family 4 5. Neighbors and community 5 6. Others------6

334 Where did you give birth for your 1. Home 1 last pregnancy? 2. health facility 2

335 If home for Q234, Why did you 1. I feel more comfortable just being at 1 prefer to deliver at home? home 2. close attention from relatives & 2 family members 3. It is my usual practice 3 4. No/poor transportation 4 5. I don't like the service in the health 5 facility 6 6. Previous bad experience from institutional delivery 7 7. Unwelcoming approach of the health 8 workers 8. Cannot afford to pay for health services 9 9. Precipitate labour

10. Others, specify------10

336 If home for Q234, who assisted 1. TTBA 1 your delivery? 2. TBA 2 3. Relatives or family members 3 4. No one/myself 4 5. Others, specify------5

6

7

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337 If TBAs/TTBA to the Q236, why 1. They are trusted by community 1 do you prefer them? 2. Arrive home 2 3. No/little cost 3 4. Friendly approach 4 5. More experienced than health 5 workers 6 6. Others specify ------338 If health facility to Q222, Why 1. Better service 1 did you prefer to deliver in 2. Better outcomes from health facility 2 health facility? delivery 3 3. proper management of complications 4 4. Close to my home/work 5 5. Required medication/service available 6 6. Provider knowledgeable or good reputation recommendation 7 7. Clean facilities 8 8. Provider friendly/know the staff 9. Had problem during delivery 9 10. can afford the fee 10 11. Had previous surgical delivery

12. Other, specify------11

12

339 Preference of husband to your 1. Home 1 place of delivery 2. health facility 2

340 preference of other family 1. Home 1 members as your place of delivery 2. health facility 2

Part iv – Questions related to attitude of mothers Table 7 – showing factors related to attitude of study subjects

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No. Questions Coding Codes categories 1 ANC & PNC follow up is the best option to avoid delivery 1. Yes 1 complications: 2. No 2 2 Delivering at health facility is safe for a woman: 1. Yes 1 2. No 2 3 Taking care from skilled birth attendant during delivery 1. Yes 1 avoids maternal death and delivery complication: 2. No 2 4 Making financial preparation at home prior to child birth 1. Yes 1 is good to seek a helf from health institution: 2. No 2 5 Immediate seeking of care during danger signs avoids 1. Yes 1 delivery complications, maternal and infant death: 2. No 2

Annex 4;- Translated Questionnaire (Goofigna)

Part I: - Asa hanota darotthanne shalo wogata qonciso

Table 8 - Translated Questionnaire (Goofigna)

Qoda oyshata Malate suntha malata 101 Aaye laytha ------laythi 102 Goynyo hanota 1. islaame 2. Ortodokise 3. Protestante 4. Catolike 5. hara, qoncisa 103 Heera 1. Goffa 2. Gammo 3. Amahara 4. wolaita 5. other specify

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Timirte detha 1. timirte so gelabeyku 104 2. nababone xaafo eraws 3.koyro deetha 4.nam7antho deethane hesape bola

105 Ekone gelo hanota 1. geela7o/sele 2. shaaketadus 3. gelada azinara da7awsi 4. sayo 5. azinay hayqis 106 Ooso hanota 1. kawo oosancho 2.goshancha 3.zal7ancho 4.keetha aayo 5.oothi aqiya ase 6.oosoy demona ase 7.haray diiko qoncisa------107 Duusa heera 1.katama 2.gaxare 108 Gidoole agina keetha shalo ------tophiya bira

109 Azin laytha ------laytha 110 Azina ooso 1. kawo oosancho 2.goshancha 3.zal7ancho 4.5.oothi aqiya ase 6.oosoy demona ase 7.haray diiko qoncisa------111 Azina timirte deetha 1. timirte so gelabeyna 2. nababone xaafo erees 3.koyro deetha 4.nam7antho deethane hesape bola

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112 Keetha asa qooda ------113 Heeran de7iya payatetha naago ------kilo metire keetha ( teena taabe/hospitaale) 114 Heeran de7iya payatetha naago ------sate ( tohon hamutin) keetha gakanaw de7iya haahotethi ( teena taabe/hospitaale)

Shako2- Shalo hanota

# oysha Suntha malaata malaata 201 Newu gadey de7ii? 1. ee (hektaaren yoota)--- 1 2. akay 2 3. zaaroy baawa 77

202 Newu boori de7ii? 1. ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

203 Newu maca miizi de7ii ? 1. ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

204 Newu deesh de7ii? 1 . ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

205 Son dorsi de7ii ? 1. ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

206 Son harey de7ii? 1. ee ( qoodan yoota)--- 1 2. akay 2

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3. zaaroy baawa 77

207 Son kutoy de7ii? 1. ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

208 Son/newu mobile de7ii? 1. ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

209 Son iraadoney de7ii? 1. ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

210 Son televijiney de7ii? 1. ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

211 Son motorey de7ii? 1. ee (qoodan yoota)--- 1 2. akay 2 3. zaaroy baawa 77

212 Heera asara nena gedarishin nena 1. daro hiyeesa 1 waata shaakay? 2. hiyeesa 2 3. gidoole 3 4. dure 4 5. daro dure 5 6. taani erike 6 7. No response 77 Shako3. Yelora gahetiya gaasotane hagazota bola eratethi, xeelo hanotanne ooson qonciso wogata

Qoda oyshata Malate sunthata malaata

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301 Gelo wode yeleta laytha ------laytha

302 Koyro qantha wode laytha ------laytha

303 Qantha qooda ------

304 Shempora de7iya nayta qooda ------

305 Hayqida nayta qooda ------

306 kase qanthara gahetiya metota 1. Metoy baawa 2. Yelo wode suutha

3. zawre 4. Yelo wode ulo ganxo 5. Bola gidon deexo 6. Haray diiko qoncisa

307 Wursetha qantha qonciso 1. Shempora de7is 2. hayqis

308 Wursetha qanthatetha woden 1. Ee payatetha keetha badii 2. akay

309 Oysha qooda 208 Ee gidiko, 1. qanthatethara gahetiya meto payatetha keetha bida gaasoy 2. qantha kaalos 3.qanthape hara gaasora

4. hara diiko qoncisa

310 Aadhida qanthatas/qanthatas 1. Ee kaalos payatetha keetha badii? 2. Akay

311 Oysha qooda210 Ee gidiko, ------visits qantha kaalanaw payathetha keeth aapun yuusha badii!

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312 Oysha qooda 210 ee gidiko, 1. Hospitalalen qantha awan kaaladi? 2. Kawo teena taaben 3. Asa kiliken 4. Teena keelan 5. Haray diiko qoncisa-----

313 Oysha qooda 210 ee gidiko, 1. koyro heezu aginan qantha kaalo awude doomadi? 2. usupun agina gaso de7iya woden

3. udupun agina gaso de7iya woden

314 oysha 210 ee gidiko, kantha 1. Aaye metota uba kaalanaw kaalos ay go7atethay de7ees 2. Ulon de7iya na7a payatetha gaada ekay? kaalanaw 3. Ulon de7iya na7i waani de7iyaako be7anaw 4. Yelo wode gakana metota sinthara qofiso 5. Go7atetha erike 6. hara go7ati diiko qoncisa------

315 Oysha 210 ee gidiko, qantha 1. Ee kaalo wode qanthane yelora 2. akay de7iya korqata bola eratethi ekadi?

316 Oysha 215 ee gidiko, qanthara 1. Ee gahetiyakorqane iita malatata 2. Akay bola eratthi demadi?

317 Oysha 216 ee gidiko,ay 1. Yelo wode suutha malatatane korqata bola 2. Zawre eratethi ekadi? 3. Elesida bola deexo gujo

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4. waqalees 5. na7a qaaxo eqo 6. haray diiko erisa------

318 Oysha 216 ee gidiko, ay 1. Yelo wode suutha malatatane korqata bola 2. Zawre eratethi demadi? 3. Elesida bola deexo gujo 4. waqalees 5. na7a qaaxo eqo 1. haray diiko erisa------

319 Keethan televijiiney de7ii 1. ee 2. akay

320 Wursetha qantha awan yeladi? 1. Son 2. Payatetha keetha

321 Son woyko payatetha keethan 1. Ee yeloy dumatethi de7ees gaada 2. Akay ekay! 322 Awan yelanako eratethi 1. Ee kasetada demadi? 2. Akay

323 Oysha 222 ee gidiko, yelo bola 1. Payatetha oosanchota eratetha/ akeeka emida besay 2. Teena ekistenshineta 3. Lagetanne soo asata 4. Eran yelisiya heera hiilanchata 5. Televijine,iraadone, gaazexa 6. Haray de7iko qoncisa ------

324 Oysha 222 ee gidiko, awan 1. Son yelanaada zore ekadi? 2. Payatetha keethan

325 Oysha 224 payatetha keetha 1. ee gidiko, zoriya oosan peeshadi?

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2. akay

326 Oysha 225 akay gidiko, gaasoy 1. Qanthay lo7o getetida gisho aybe? 2. Payatetha kawo oosanchoti shiiqoy suurena gisho 3. Baana dooro dhayo 4. Heera yeliso hiilanchata dooro 5. Payatetha keethay matan baawa 6. Keetha asapenne heera asape beetiya qofa wolqantho 7. Haray de7iko erisa ?------

327 Ne yeliya wode ooni nena 3. Ee maadaneko akeeka demadi? 4. Akay

328 Oysha 220 ee gidiko, nena 1. Tamarida yelo hiilanchata ooni kalanada zore demadi? 2. Heera yelo eranchata 3. Loohida heera hiilanchata 4. dabota 5. teena ekistenshineta 6. hara keetha asa 7. haray diiko qoncisa------

329 Wursetha qantha halchadi! 1. Ee 2. Akay 330 Qanthe dishin qanthara 1. Ee woyko yelora gahetiya metoy 2. akay nena gakide?

331 Oysha 230 ee gidiko, metoti 1. Yelanappe kasetidi betiya awusatee? suuthi 2. Yele wode yiya cora suuthu 3. Miixoy buro oykiya wode dhuuqidi beetiya puge

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4. Ulo gidon na7a hayko 5. Loythi gujida suutha dirgo 6. Wodey gakona miixo 7. Haray diiko qoncissa______330 Wurseth qanthas miixoy ay 1. ≤ 3 saate mala gam77ide? 2. 3- 6 saate 3. 6-11 saate 4. 12 saate

331 Yelo besa new 1. Tani tarka erisanaw/wosananaw danda7ey 2. Azina oone? 3. Nam7ay

4. Keetha asa 5. Shoorone heera asa 6. Hara gidiko qoncisa------332 Wursetha qantha awan yeladi? 1. son 2. payatetha keetha

333 Oysha 232 soo gidiko, soo 1. Son yeliko tana ufaysees doorisada gaasoy aybe? 2. So asaynne dboti tana matan kaalosona 3. Tani uba wode son yeliya gisho 4. Payatetha keetha baanaw caamey bayna gisho 5. Payatetha keethan imiya maadiya taani dosike 6. Kase payatetha kethan yelishin tana lo7ibona gisho 7. Kawo oosanchota kandoy shaates 8. Bira cigaw danda7ona gisho 9. Elesida miixone yelo

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10. Haray diiko qoncisa------

336 Oysha 234 soo gidiko, nena 1. Loohid yelo hiilancho oone yelishin maadiday? 2. Teena ekistenshineta 3. Loohida heera hiilanchota 4. Heera hiilanchota 5. Dabota woyko keetha asa 6. Oonoka/tarka 7. Haray diiko qoncisa------337 Oysha 236 heera woyko 1. Intani nu heera asa qofan loohida heera hiilanchata amanthiya asata gidiya gisho gidiko, entana aybis dooradi? 2. Intani soo yiidi yelisiya gisho 3. Bira ekona/guuthi ekiy gisho 4. Inta gahetethay/shiikoy lo7iya gisho 5. Kawo hilanchatappe aadho loohida gisho 6. Haray diiko qoncisa------

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338 Oysha 222 payatetha 1. Imetiya go7atethay ufaysees keetha gidiko aybis 2. Wursethay lo7o gidiya gisho dooradi? 3. Korqa yelo loythidi yelisiya gisho 4. Taw matan de7iya gisho 5. Koshiya go7ay ubay imetees 6. Yelisiya hiilanchay daro loohida gisho 7. Geisha heera 8. yelisiya hiilanchay siiqetiya gisho 9. yelo wode metoy dida gisho 10. bira cigisona gisho /cigisiya bira taani danda7iya gisho 11. Kase aakime soon daakidin yelida gisho 12. Hara qoncisa------

339 Neeni yelana besas ne azina 1. so dooroy awe? 2. payatetha keetha

340 Neeni yelana besas ne herane 1. so soo asa dooroy awe? 2. payatetha keetha

Shako iv- xeelo akeekara gahetiya oyshata . Oyshata Shako malaata Pay. malaata 1 Shaara dishene yeli agidi kaaloy yelora gahetidi yiya 1. Ee 1 danotape maadetanaw daro lo7o: 2. Akay 2 2 Payatetha keethan yeloy aayeta payatethas daro lo7o: 1. Ee 1 2. Akay 2

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3 Yelo wode tamaarida hiilanchatappe maade demoy 1. Ee 1 aayetanne nayta hayqo dhaysanaw daro maades 2. Akay 2 4 Shaara wode bira giigisoy payatetha keethan yelanaw daro made 1. Ee 1 imees: 2. Akay 2 5 Iita malaati beetishin elesidi made ekoy yelo wode gakiya danotape, 1. Ee 1 aayetanne nayta hayqopene nayta hayqoppe 2. Akay 2 ashees:

Annex 5;- Focus Group Discussion Guide for three groups

Introduction Good morning and thank you all for coming. My name is------and I came from the Arbaminch University Read the following as it is: “After we conduct some brief introduction, we will be talking about several different issues. We will be asking you questions about your overall experience pertaining to home delivery and

68 | P a g e associated factors . Then, we will conclude the session by asking you for your recommendations on how such program might be implemented in your community in any way in the future. Would you be willing to participate in the discussion? If yes, proceed, if no, thank and stop the discussion. Name of the moderator. ------Sign------. (Signature of the moderator certifies that consent has been obtained verbally). Date------Time------.

Preparation Topic; Community perception of preferences to home delivery Target audience: TBAs, religious & community leaders and health workers. Objective of the discussion  To explore the community’s understanding and perceptions of preference to home delivery in Zala district  To assess factors affecting home delivery Description of the participants A total of three focus groups, comprising ten in each group participants will beinvolved. Description of the focus group The participant and the facilitator will sit in a circle or around a table for the discussion. The facilitator will begin thesession by introducing himself and explain the purpose of the focus group. The focus group meeting will last about60 to 90 minutes. Potential use of data The gathering of this information will have an effort to gain further insight about factors contributing to home delivery among child bearing age women in the District. Ground rules Issue of confidentiality Please be assured that any information collected here is strictly confidential. The staff of research and otherparticipants will not directly share the information in a way that would reveal an individual’s personal identity. Consent for participation and tape-recording At this point it is important that we obtain your consent for conducting the session. Understand that this is more foryour protection than anything else. Read consent form out loud to the group:

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“Your remaining in the session indicates that you voluntarily agree to participate in this discussion program. You have the right to refuse to answer any questions and to end the discussion if you find it necessary to do so. Forthe sake of accuracy and efficiency, we will take notes and tape recording this sessions, unless any one has anyobjections.” Role of moderator and note taker The moderator will be in charge of facilitating the discussion .The moderator will bring the discussion back to thetopic at hand should it go beyond the main issues. The moderator will not give any indication (verbal or physical)that would encourage certain types of comments or discourage other types of comments. In short, the moderator will guide the discussion when necessary, with carefully not to lead the discussion. It is ourrole to facilitate, but your role to tell us what you think. The note taker will have the sole responsibility of capturingthe sessions accurately as possible. This will include not only participants’ responses, but also nonverbal actions,physical environment, atmosphere of the session, as well as other vital characteristics of the session. Importance of total group In this group everybody should feel free to talk. Each and every opinion is important and wanted. It is very importantthat all the people in the group get a chance to express their opinions. Agreement to disagree In this group there are no right or wrong answers. Everybody should express the opinions or attitude pertinent to himor her. When you express your opinions you are encouraged to be honest in your views of factors contributing to home delivery. We want you to focus your comments on the program and not toward each other or members of the staff. FGD topic guide Theme 1. Introduction At this point, we would like to ask you to introduce yourself to the rest of the group. Let us start with the research team (Name, age, education status) and each of you please tell me your name, howlong you have lived in this area and your job. Theme 2.Warm up questions 1. Next we would like to hear a little about your experience or knowledge about antenatal care and delivery practice 1.1. Who can tell us about is antennal care? 1.2. Who can tell us about delivery care services?

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1.3. Who would like to tell us dangerous health problems related to pregnancy and childbirth? 1.4 What are the causes? 1.5 What are the consequences? 1.6 What are the prevention methods? Probes 1. Would you explain further? 2. Would you give me an example? 3. Has anyone else had similar experience? 4. Is there anything else? 5. ”I don’t understand.”

Theme 3. Pregnancy related risks, antenatal care and delivery practice 2. Now we would like to ask you specific questions about health problems related pregnancy and childbirth. 2.1. Do you think that a healthy pregnant woman should attend institutional delivery? 1.Yes 2.N0, why? What are the advantages? Probes 1. Would you explain further? 2. Would you give me an example? 3. Has any one else had similar experience? 4. Is there any thing else? 5. ”I don’t understand.” 5. Where do you think the best place for delivering a child? Why? What are the advantages and disadvantages? Probes. 1. Would you explain further? 1. Would you give me an example? 2. Has any one else had similar experience? 3. Is there any thing else? 4. ”I don’t understand.” 6. Who do think the best person to assist during delivery? Why? Probes 1. Would you explain further?

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2. Would you give me an example? 3. Has any one else had similar experience? 4. Is there any thing else? .”I don’t understand 7. What are the advantages and disadvantages? Probes 5. Would you explain further? 6. Would you give me an example? 7. Has any one else had similar experience? 8. Is there any thing else? 9. .”I don’t understand.” 8. What is your opinion about preferences to place of delivery from traditional, cultural and religion point ofview? Probe 1. Would you explain more? 2. Would you give me example an example? 3. Anyone else similar experiences 4. Is there anything else? 5.”I don’t understand.” 9. What are the cultural influences of delivering at home ? Probe 1. Would you explain more? 2. Would you give me example an example? 3. Anyone else similar experiences 4. Is there anything else? 5.”I don’t understand Ending questions Are there any issues, questions, comments that you would like to raise or points to you wanted to add? Debriefing I would like to thank you for your participation. I also want to restate that what you have shared with us isconfidential. No part of our discussion that includes names or other identifying information will be used in any

72 | P a g e reports, displays or other publicly accessible media coming from this research. Finally, I want to provide you with a chance to ask any questions that you might have about this research. Do you have any questions for me? This is the end of our questionnaire. Thank you very much for taking time to answer these questions. We appreciate your help.

N.B please recheck that you have filled all the questions.

Name of data collector------

Interviewer signature ______Date------

Name of examiner------date------

Supervisor------date------

Annex 6;- Translated Focus Group Discussion Guide for three groups (Goffigna)

Eriso 5; Cuga duulata oyshata

Gelo Aymala gam7adi, hashu lo7ora yadasa. Ta sunthay ------taani Arba Mince Yunivurstipe yadis

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Read the following as it is: Hayssape kaali dediya qofata nababa; Nuni koyro gelo gahetethi gahetidape kaalidi, daro yohota bola tobana. Nuuni nenaa macasha Son yelora gahetidi de7iya yotanne gaasota bola daro oyshata oychana. Hesappe kaalidi nu dulata nuuni kuuyanay haysamala makisoti waanidi haroodes ooson pe7anako neena oychidi neepe qofa ekana. Haysa duulatan nuura beetane? Ero giiko, doomana, akay giiko duulata agada baanaw danda7aasa. ( oysha shiishiya yaliya pirmay oyshetanaw besiya yohoti duunan oyshetoyssa qoncisees) Galassay ------saatey ------

Makiso kaara ; son yelo bola asas de7iya dooratanne qofa duulata cuga asata : heera gela hiilanchata, goynonne heera ayso awatanne payatetha loohida osanchota. Duulata kaara qofa  zaala heeran son yelora gahetidi de7iya yohota bola asas de7iya eratetha, akeekanne dooro qofatha  son yelora gahetidi de7iya gaasota pilgethi duulata asa qonciso Isis isi cugan tamu asi oykida heezu cugati duulatosona Duulata cuga qonciso Hayssa duulatan beetiya assaynne duulata kaalehiya uray yuusha uttidi duulatoosona. Duulata kaalethiya uray banatetha eisidinne qoncisidi doomees, kaalidi duulatas de7iya huuphe amuwaka qoncisees. Duulatay 60-90 dakika ungees. Oyshan shiiqida yoota naago Son yelonne gaasotara yelo bola de7iya aaytara gahetidi shiiqiya naqaashay he yoha bola qofa dalgan eranaw maades. Wogata Gaatha qofa( mistire) naago yohota Haysan ciiqiya yohaas ubaas gaatha gofay minora naagetees. Haysa pilgetha yaletine hara assay inte imida qofa isas isa shaakidi oykokona Duulta qofatanne asa kooshiya teepen oytha hanotata

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Haysan enttera nuuni duulata efisa bola siiqidaysa qoncisees. Haysi entena naagope attin hara kiiti baawa Cugas siiqo qofa kaali de7iya maaran nababada kooshe doqusitada sisa Hayssa duulatan inte gam7idayssi inteni duulata siiqidayssa besees. Oysha zaarike gaanaw entew maati de7ees kaalidi duulatape agidi baanaw maati de7ees. Entew duma qofi baynna gidiko, ente zaara loythi oykanawnne pilgi eranaw nuuni zaaruwa xaafi oykana qasika teepenka kooshiya oykana Kaaletho uraynne xaafo yaletas de7iya aawatethi Kaaletho yaley duulata kaafo. Duulata yohoti yafaraffe keyiya wowode guye yafaraako ehidi kaara kaara qofata hasayssees. Haysara ba giidi oge besena, eta gidina lo7o giidi qofa kuyanaw eyaw maati baawa. Qanthara , kaleetho yaley koshiko duulata yafara besees, gishin lo7one iita giidi kuyena. Iyaw awatethay yafara beso gidishin entteysi qasi koyida qofa imo. Xaafo yaley duulata oyshatanne zaarota loythidi xaafo awathetha ekes. Hesika asa qofa kanche gidona de7ishin assay zaro imishi besiya malatata, heeraba, duulata haonta uba. Cugata go7atetha Cugan uba assay qofa imanaw shuushanaw besena. Qofi ubay koshiyaabanne eketiyaaba. Ase ubay dalgara qofa imoy maata. Aganaw danda7o hanota Haysa duultan likene like gidona zaaro giyaabi baawa. Uba asi daanidaba qofanne amo odanaw danda7ees. Ayeta son yeluwaara gahetidi de7iya qofan inteni imiya qofay nuusi xilo qofa giidi ekoos. Inte qofa bolla minthi oditeppe attin asa qofa bola minthoy gidena. duulata qofa kaaletho Makiso 1; Gelo hayssa kaaran, inte intenatetha hanko cuga yaletas intena erisite. Ane nuuni pilgetha kaalethiya yaleta suntha, yeleta laytha, timirte deetha erison doomana. Kaalidi inte sunthanne inte hayssa heeran ay mala laythi gam7idaako qoncisite. Makiso2 : denthetho oyshata 1. kaalidi qantha ayeeta kaalora gahetiya inte ooso gam7o bola de7iya eratethanne akeeka eranaw koyiya. 1.1. qantha aayeta kaalo odanay oone? 1.2. yelora gahetiya yoha bola qofa imanay oone? 1.3. qantharanne na7a yelora gahetiya danota bola nuus qofa imanay oone? 1.4 gaasoti aybee?

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1.5 gakiya danoti aybee? 1.6 teqetha ogeti aybee? Xomooso 1. Yohiw dalgisada nashanee? 2. Leemiso nashanne? 3. Ha yohe bola daro erayssi giya asi oone? 4. Hara qofi dee7ii ? 5. ”Taw gelibeynna.”

Makiso 3 .shaarara gahetidi de7iya daafanata, qanthanne yelo kaalo oosota 1. Shaara macasharane yelora gahetiya oyshata 1.1. Lo7one paya shaara ayeyeti payathetha keeth yiidi yeliwuna. 1. Ee 2.akay , aybis ? Go7ati aybee ? Xomooso 1. Yohiw dalgisada nashanee? 2. Leemiso nashanne? 3. Ha yohe bola daro erayssi giya asi oone? 4. Hara qofi dee7ii ? 5. ”Taw gelibeynna.” Na awan yeliyaako lo7o giidi ekeeti? Aybis? Go7atinne qohati aybee ? Xomooso 1. Yohiw dalgisada nashanee? 2. Leemiso nashanne? 3. Ha yohe bola daro erayssi giya asi oone? 4. Hara qofi dee7ii ? 5. ”Taw gelibeynna.” 8. Who do think the best person to assist during delivery? Why? Yelo wode made imanaw besey oone? Aysi? Xomooso 1. Yohiw dalgisada nashanee? 2. Leemiso nashanne? 3. Ha yohe bola daro erayssi giya asi oone?

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4. Hara qofi dee7ii ? 5. ”Taw gelibeynna.” 9. Heera wogan, goyno woganne era wogan yelo besi awusa giidiko lo7o? Xomooso 1. Yohiw dalgisada nashanee? 2. Leemiso nashanne? 3. Ha yohe bola daro erayssi giya asi oone? 4. Hara qofi dee7ii ? 5. ”Taw gelibeynna.”

10. Heera wogara yelo besi awusee? Xomooso 1. Yohiw dalgisada nashanee? 2. Leemiso nashanne? 3. Ha yohe bola daro erayssi giya asi oone? 4. Hara qofi dee7ii ? 5. ”Taw gelibeynna.”

Kuusha oyshata New kuusha bola denthanaw koyiya yohoti, oyshatinne, qofati diiko. Zaaridi poo7iso taani neni duulatan beetidi qofa immida gisho galataysi. Taani kuushan gujanaw koyey inte gaatha qofa naagana. Asa suntha oykiya duulata shaakoy baawa. Kuushan, haysa pilgethaara gahetiya oysha inte denthanada koyaysi. Intew oyshi de7ii? Haysi oysha kuusha. Galataysi !

Eriso: oyshay ubay kumidayssa zaarada be7a.

Oysha shiishiya aawa sunthay ------

Pirma ______galasa ------

Kaaletho aawa ------galasaa------

Kaali xeeliya bola kaafo ------galasaa ------

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Annex 7;- Declaration I, the undersigned, Public Health student declare that this thesis report is my original work in partial fulfillment of the requirement for the degree of Master of Public Health in Epidemilogy and Biostatistics Name: Bedilu Kucho Signature: ______Place of submission: Department of public Health, College of Medicine and Health Sciences, Arba Minch University. Date of Submission: ______This thesis work has been submitted for examination with my/ our approval as university advisor(s). Advisors 1. Dr. Amsalu Alagaw ______2. Mr. Mesfin Kote ______

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