The study assessed factors that determine the utilization of maternal healthcare services in Holeta town. The revealed that 87.1% women sought at least one ANC from modern health care providers. However, a considerable number do not make the minimal number of visits (four) as recommended by the WHO. The finding of this study is comparable with findings of studies conducted in Jimma town (90%), in Jijiga town (82%) and in Hadiya zone (
86%) respectively [4
]. According to the 2011 Ethiopian Demographic and Health survey (EDHS), 76% of women in urban areas used ANC [2
]. The comparative figures for rural areas and national level was 26% and 34% respectively. Holeta town has higher level of ANC use may be due to the fact that the town is near to the capital city of Ethiopia and could have better opportunities for information and better access to health institutions than the other urban areas. The other explanation could be this study considers women who gave birth three years prior to the survey and the recently started urban health extension program (HEP) is providing equitable access to promotive, preventive and select curative health interventions through health extension workers (HEWs). Among the services based on health packages, maternal health is part of the family health package.
In the study, the primary reasons given for not attending ANC services include being in a state of good health, no or little knowledge about ANC, being too busy, too long waiting time, poor quality of services, husband disapproval and far distance from home to health services etc. Other studies also reported similar reasons [7
Antenatal care is more effective in preventing adverse pregnancy outcomes when it is sought early in pregnancy and is continued throughout pregnancy [10
]. More than half (58%) of women in this study area made their first antenatal visits in their second and third trimester of pregnancy. This indicates that, a considerable number of women in the study area start ANC at relatively late stage of pregnancy.
In the FGDs, women pointed out that the barriers to the utilization of antenatal care services were lack of awareness, apparently being healthy, work overload either in the household or in the other daily activities, long waiting time, financial constraint, and confidence on local TBAs. According to FGDs participants, some women did not attend ANC due to misconception on HIV test during ANC not knowing it is voluntary and confidential.
Home delivery is still a norm in many parts of Ethiopia. In this study, 38.4% of births had taken place at home. This finding is consistent with the findings of the studies in other towns in Ethiopia [6
]. According to the 2011 EDHS, nearly half of births taken place at home in urban areas [2
]. This difference of institutional delivery could be explained by the fact that the present study area was done near to the capital city of Ethiopia where women tend to have better access to health facilities, education, and information about maternal health care service.
Delivery care is an important component of efforts to reduce the health risks of mothers and children and increase the proportion of babies delivered under the supervision of health professionals in different health institution [12
]. According to women on both FGDs groups, the main barriers that affect the utilization of delivery care services are desire to deliver where their relatives in their surrounding when giving birth, bad experience with the health care system, unexpected delivery, transport problem and financial constraint. The FGDs participants also indicated that some women with repeated experience of child birth did not want to go to health institution because of their previous experience which often led them to believe that they do not need assistance from the health professional.
Our multivariate analysis showed that age, education, income, exposure to media, and presences of husband approval were significantly associated with ANC utilization. For instance, when considering age, it was found that women in the age group 35–49 were less likely to use ANC service than women in the age group of 15–19. Several studies found out that women’s age plays a significant role in the utilization of maternal health care [9
]. This might be due to the fact that younger women are more cautious about their pregnancies and sought trained professionals but older women tend to believe that modern health care is not necessary due to experiences and accumulated knowledge from previous pregnancies and births.
The findings of this study revealed that education is strong predictor of maternal health care utilization for both ANC and DC services. The result is similar with other results which revealed that education has a positive relationship with maternal health care utilization [2
]. It is because that educated mothers are considered to have a greater awareness of the existence of maternal health care services and benefited in using such services. They are most likely to have better knowledge and information on modern medical treatment. Education is an opportunity to empower women; and empowered women have greater confidence and capability to make decision to use modern health care services for themselves and for their children.
Quality is also important in maternal health programmes and can increase the likelihood that women facing obstetric emergencies will go to health facilities for life-saving care [16
]. These factors will act as inhibitors of future utilization, thus affecting the decision to seek care. As most of the FGDs discussant indicated in their opinion, there is a problem in the quality of care with some health institutes with low quality and mistreatment from some health professionals, which made some women not to seek the service on both ANC and DC services.
Husband’s or partner’s approval of ANC was most significantly related to antenatal care attendance. The result of the present study is found to be similar with previous studies in Ethiopia [9
]. A study in Addis Ababa showed the risk of non-attendance was high for pregnant women whose husband’s attitude was negative or unknown [13
]. It is expected that having a husband who approves antenatal care significantly increase the likelihood that a woman used antenatal care, irrespective of the husband’s background characteristics. Therefore, efforts to improve husband’s or partner’s attitude would probably increase utilization of health services by women.
Women’s attitude towards their current pregnancy, i.e. whether or not the pregnancy was planned, was found to affect ANC utilization. A woman’s attitude towards her pregnancy and the presence of social support has been found to influence ANC use in developing countries [19
]. The study in Yirgalem and Jimma also revealed the same result [18
]. The uses of ANC were significantly more among women with planned pregnancies [13
]. Unplanned pregnancy is highly suggestive of lack of access to appropriate family planning opportunities. ANC might be an appropriate point of contact for promotion of family planning.
Delivery care utilization may also be affected by the person(s) who make the decision on the place where to give birth. From the result of this study, women for whom the decision on place of birth made by themselves or jointly with their husbands were two times more likely to utilize DC than women whom decision where to give birth made by others. Women, who had low decision-making power, result from lack of access to and control over economic resources [19
]. This could be due to the high cost associated with pregnancy-related healthcare services in private health sector and/or women’s low autonomy to make decision in the household. This study is consistent with the result findings of other study [17
Antenatal care visits had significant positive relation with utilization of DC services. In this study women who were non attendants of ANC were 86.5% less likely to utilize DC than ANC attendants. This is due to the fact that during antenatal care women are provided with information about the necessary follow-ups during pregnancy and after delivery and where to give birth at delivery. The study shows similar result with other studies [5
Limitations of the study
Despite the contribution of the study to the literature on maternal health care, this study has some limitations. First, it is a cross-sectional study in which temporal relations could not be assessed. There could be recall bias since the women were asked for events within the last three years prior to the survey despite the fact that, the most recent births were considered.