Introduction: Birth is a critical time for the health of the mother and newborn; and place of delivery is a crucial factor for the wellbeing of both. Ethiopia is a major contributor to the worldwide death tax of mothers with a maternal mortality ratio of 412 per 100,000 live. Therefore institutional delivery has paramount importance to get skilled care throughout pregnancy from inception to postnatal care. But in the Amhara region, only 27% of mothers gave birth at the health facility. The objective of the study is to assess determinants of home delivery among childbearing age women in Gondar Zuria district of central Gondar, Ethiopia. The study duration was from January 1 to February 30 2020.

Method: Community-based age-matched case-control with the complementary qualitative design was used in Gondar Zuria district. Simple random sampling was used to select study participants for quantitative and purposive sampling used for the qualitative part. The total sample size was 264. Quantitative data were collected by in-depth interviews. Data entry and cleaning was done by epi info and analysis was done using SPSS and results were presented in odd ratios, and tables.

Result: Seventy-one 71 (26.9%) of the mothers were in the age range of 31–35 years and 50 (18.9%) of mothers were in the age range of 26-30 years. Logistic regression analyses revealed that living in the rural area (AOR, 9.53; 95%CI; 3.50-25.90), not in union with husband (AOR, 8.35 95%CI; 3.53-22.09), unable to read and write (AOR, 4.50 95%CI; 1.12-18.07) and having a monthly income of less than 600 ETB (AOR, 6.45 95%CI; 2.26-18.37) were more likely to deliver at home. Being unaccompanied by the husband during antenatal care (AOR, 2.34, 95%CI; 1.30-4.22), having no antenatal care visit (AOR, 4.60; 95%CI; 2.02-10.48), traveling on foot to get maternal services (AOR, 2.89; 95%CI, 1.19-7.01), and giving birth of above four (AOR, 4.12, 95%CI; 1.97-8.62) were also more likely to deliver at home. Mothers having good knowledge about danger signs and importance of skilled birth attendance, deliver at health facility twice (AOR, 1.77; 95%CI; 1.06-2.94) than women having poor knowledge.

Conclusion: Living in the rural area, traveling on foot, not in union with husband, being uneducated and poor, having no antenatal care visit, poor knowledge of danger signs of pregnancy, and giving birth of above four were the determinant factors to home delivery. Actions targeting maternal education; encouraging the number of ANC visits and making health facilities accessible are the recommended interventions to tackle home delivery.

Keywords: institutional delivery, home delivery, determinants

AHB, amhara health bureau; ANC, antenatal care; CD, compact disc; DC, data collector; DHS, demographic health survey; DVD, digital video device; EDHS, ethiopian demographic health survey; ETB, ethiopian birr; HEP, health extension program; HEW, health extension workers; EPHI, ethiopian public health institute; ID, institutional delivery; IRB, institutional review board; MMR, maternal mortality ratio; MoH, ministry of health; PI, principal investigator; SBA, skill birth attendant; SDG, sustainable development goal; SPHMMC, saint paul’s hospital millennium medical college; WHO, world health organization

Background

It’s usually a joyful event when women give birth to a baby she wishes.¹ But birth is a critical time for the health of the mother and baby and place of delivery is a crucial factor that affects the health and wellbeing of the mother and newborn.² Skilled care throughout pregnancy from inception to postnatal care is life-saving for women and the child and institutional delivery is the one which is the most important place to get such services.³ Even though birth is profoundly affected by the environment in which it takes place, childbirth takes place in different forms throughout the world depending on the cultural contexts of each community.⁴ Mothers may go through the process of unattended childbirth and a few seek help from midwives and obstetricians, but two-thirds of birth in the world are assisted by traditional birth attendants who are not trained.⁵ In Ethiopia, even though institutional delivery has been promoted and antenatal care coverage is good, still home birth is high, given the home environment as a place of delivery is shown to be unsafe and may have adverse neonatal and maternal outcomes.⁶

Reproductive health care is a highly focused issue in the development of a country and delivery service to pregnant women is the most important component of reproductive health care to handle high-risk deliveries.⁷ Utilization of essential obstetric care services, including but not limited to antenatal care (ANC), skilled attendants at birth, and postnatal care, contribute to the reduction of maternal and neonatal mortality and morbidity.⁸ Antenatal care provides an opportunity to promote skilled attendance, prevent complications, and ensure that complications are detected and treated early.⁹ The World Health Organization (WHO) has been recommending at least four antenatal care (ANC) visits during pregnancy, and postnatal care should be provided at 6 h, 6 days, 6 weeks, and 6 months after childbirth to ensure women's physical and mental wellbeing but these chances are very low for the women who gave birth at home.¹⁰

Statement of the problem

Despite the international emphasis on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow.¹⁷  Every year, an estimated 300,000 maternal deaths occur worldwide and 12 million suffer from birth complications and particularly in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth.¹⁸ Over three-quarters of maternal deaths is due to causes directly related to pregnancy and childbirth and more than 60% of maternal deaths occur immediately following delivery, with more than half occurring within a day of delivery.¹⁹ The sustainable development goals (SDGs) call for an accelerated reduction in maternal deaths so that the global MMR will fall to 70 or below by 2030, working towards a vision of ending all preventable maternal mortality.²⁰ But it is reported that globally, about 300,000 women die each year due to preventable causes, yielding a maternal mortality rate (MMR) of 210 maternal deaths per 100,000 live births and exposing regional disparities, Sub-Saharan Africa is the region with the worst maternal health outcomes.²¹ Globally, about 80% of preventable maternal deaths are due to severe bleeding, infections, unsafe induced abortion, hypertensive disorders in pregnancy, and obstructed labor.²²

High MMRs are not uniformly distributed across sub-Saharan Africa, and it is also unlikely that barriers are evenly distributed. For instance, for every 100,000 live births in 2013, Sierra Leone had an MMR of 1100, the Central African Republic had 880, South Sudan had 730, Nigeria had 560, and Ghana had 380.²³ The estimated maternal mortality ratio (MMR) for high-income regions was 12/100,000 live births and, for low-income regions was 239/100,000.²⁴ The levels of maternal mortality are “unacceptably high” in sub-Saharan Africa, sharing about 66% of all maternal deaths worldwide.²⁵ These maternal deaths are terrible, particularly when most of these maternal deaths can be prevented by utilizing the services of skilled health personnel as in a health facility.

Ethiopia is a major contributor to the worldwide death tax of mothers with a maternal mortality ratio of 412 per 100,000 live births and 19,000 maternal deaths annually.²⁶ Despite the Ethiopian government’s efforts to expand health service facilities and promote institution-based delivery service in the country, maternal health services are poorly equipped, inaccessible, negligible, and not well documented. The pregnancy-related mortality ratio in Ethiopia was 412 maternal deaths per 100,000 live births according to the 2016 DHS survey. Nearly half of the mothers in Ethiopia who were booked for antenatal care gave home delivery.²⁷ The proportion of deliveries attended at a health facility is only 26% in 2016 in Ethiopia a far lower level than in other African countries, such as Cameroon (62%), Senegal (62%), Malawi (57%), and Lesotho (52%).²⁸ In the Amhara region, only 27% of mothers gave birth at health facilities.²⁹ Still sizable proportion of births continue to occur at home in unhygienic conditions without any skilled care and without the essential infrastructure needed to refer in the case of complications. Underutilization of maternal health care services by a sizeable proportion of women in Ethiopia results in an insignificant decline in maternal mortality ratio. This insignificant decline of maternal mortality ratio might be due to the non-use of institutional delivery services associated with knowledge, educational status, residence, and ANC attendance.³⁰

Significance of the study

Improving maternal and child health requires increasing the percentage of women giving birth in health institutions with the assistance of trained staff, which is the central goal of the safe motherhood and child survival movements. Institutional delivery service (an important component in efforts to reduce health risks to mothers and their children) helps in increasing the proportion of babies that are delivered in health facilities and effective intervention for reducing the risk of maternal morbidity and mortality. However, in many developing countries the majority of births are delivered at home.^31-40

Increasing the number of women giving birth in a health facility is the most effective and demonstrated intervention and important global strategy to reduce maternal and perinatal deaths. Even though the presence of skilled delivery service utilization at each birth can significantly reduce maternal morbidity and mortality, most of the mortality occurs because of the lack of access to skilled delivery attendance and emergency care at birth.  Despite, the expansion of health infrastructure and the introduction of the health extension program (HEP), there are still many barriers preventing women from accessing skilled birth attendants (SBAs).²⁴ So there is a need to increase the number of institutional deliveries and increasing the rate of institutional delivery and service utilization needs to understand the reasons behind the poor use of health facilities for giving birth.

Institutional delivery services are underutilized in Amhara Region due to different constraints and obstacles. Few studies have been conducted on this area in Ethiopia and Amhara national regional state but didn’t get any study in Gondar Zuria district. Understanding the determinants and constraints of institutional delivery service utilization is very crucial for proper use of the maternal health service, which is one of the most effective strategies for preventing maternal mortality. Conducting a study on the determinants of institutional delivery provides evidence for the improvement of maternal health care strategies. So this study with the objective of assessing the factors associated with low institutional delivery has had information and explored different factors that may impact institutional delivery and influence women’s delivery service utilization provided at health facilities. And also the study has worth relevance for designing intervention programs, design targeted strategies, and address the challenge to reduce maternal and perinatal deaths.

The hypothesis of the study

1. Women who have good knowledge of obstetric complications and danger signs of pregnancy are more likely to have birth at facilities than those who did not.

2. Women who are in extreme poverty and low educational status have more likely to have births at home than those who did not.

Drugs and reagents

The following reagents and drugs were used in the study: commercial ethanol (96%), ethyl alcohol PA (99.5%; Biotec^®), KOH (99% m/m; Vetec^®), HCl (36.5% v/v; Microquímica^®); Ferric chloride, gallic acid, KBr, 2,2-diphenyl-1-picrylhydrazyl (DPPH), Tween 80, flumazenil (Sandoz), granisetron hydrochloride (Kytril), dichloromethane, ethyl acetate, Folin-Ciocalteu, pizotifen maleate (Sandomigran^®), fluoxetine (Teuto), Cyproheptadine (Cobavital^®) and Diazepam (Teuto).

Botanical material

The A. indica bark was collected in the city of Tauá (040º18’05,4” W; 06º01’03,6” S) state of Ceará, Brazil, after obtaining authorization from SISBIO, according to the registration for the collection of botanicals, fungal and microbiological material, nº 29145-4. The botanical identification was carried out in the Prisco Bezerra Herbarium of the Federal University of Ceará, where an exsiccate was deposited under number 56044.

Toxicity

EtCNeem was shown to be toxic to A. salina nauplii (LC₅₀=288.46μg/mL). Through the extract saponification, it was observed that none of the obtained fractions caused the mortality of 50% of the A. salina nauplii (LC₅₀ > 1.000μg/mL), in addition to not being toxic in adult zebrafih within 96 h of analysis (LD₅₀> 5.0 mg/mL). 

Antioxidant activity

F-EtOAc of EtCNeem showed higher antioxidant potential against DPPH (EC₅₀ = 21.6 ± 0.07μg/mL). Pearson’s correlation coefficient (r) indicated that such antioxidant activity was correlated with the phenol (r = 0.4135) and flavonoid (r = 0.9924) contents in 41 % and 99 %, respectively. That is why this fraction was chosen for testing of anxiolytics. 

Although the anxiolytic activity of A. indica leaf extracts has already been investigated in rodents,¹⁶ the present study is the first to report the ability of A. indica bark ethanolic extract to reverse acute and chronic anxiety in zebrafish adult. The absence of toxicity after the saponification of the Neem bark ethanolic extract indicates its use in pharmacological anxiety tests, since the fractions obtained after the saponification were not toxic for A. salina and adult zebrafish. This absence of Neem toxicity was also demonstrated in the study by Kanagasanthosh et al.²⁶

The phenolic and flavonoid compounds present in ethanolic extracts of medicinal plants constitute classes of secondary metabolites responsible for the antioxidant action against DPPH radicals.²⁷ Our results showed F-EtOAc antioxidant action against the DPPH radical, being the most promising in relation to the presence of phenolic compounds (41.35%) and flavonoids (99.24%).

The present study showed the pharmacological potential of the ethanolic extract of Neem bark. Our findings demonstrated that the F-EtOAc, obtained after saponification of EtCNeem, showed to be rich in phenolic and flavonoid compounds with antioxidant potential, as well as a nontoxic.

None.

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1. Depression and other common mental disorders: global health estimates. World Health Organization; 2017. 1–24 p.
2. Benneh CK, Biney RP, Mante PK, et al. Maerua angolensis stem bark extract reverses anxiety and related behaviours in zebrafish-Involvement of GABAergic and 5-HT systems. Journal of Ethnopharmacology. 2017;207:129–145.
3. Kato H, Tsuji M, Miyagawa K, et al. Repeated exposure to stress stimuli during ethanol consumption prolongs withdrawal-induced emotional abnormality in mice. European Journal of Pharmacology. 2013;721(1-3):29–34.
4. Carmichael O, Lockhart S. The Role of Diffusion Tensor Imaging in the Study of Cognitive Aging. Curr Top Behav Neurosci. 2012;11:289–320.
5. Hood SD, Norman A, Hince DA, et al. Benzodiazepine dependence and its treatment with low dose flumazenil. British Journal of Clinical Pharmacology. 2014;77(2):285–294.
6. Graf H, Walter M, Metzger CD, et al. Antidepressant-related sexual dysfunction-Perspectives from neuroimaging. Pharmacology Biochemistry and Behavior. 2014;121:138–145.
7. López-Rubalcava C, Estrada-Camarena E. Mexican medicinal plants with anxiolytic or antidepressant activity: Focus on preclinical research. Journal of Ethnopharmacology. 2016;186:377–391.
8. Harro J. Animals, anxiety, and anxiety disorders: How to measure anxiety in rodents and why. Behavioural Brain Research. 2018;352:81–93.
9. Frantz S. Therapeutic area influences drug development costs. Nature reviews Drug Discovery. 2004;3(6):466–467.
10. Panula P, Sallinen V, Sundvik M, et al. Modulatory Neurotransmitter Systems and Behavior: Towards Zebrafish Models of Neurodegenerative Diseases. Zebrafish. 2006;3(2):235–247.
11. Venuprasad MP, Kumar Kandikattu H, Razack S, et al. Phytochemical analysis of Ocimum gratissimum by LC-ESI-MS/MS and its antioxidant and anxiolytic effects. South African Journal of Botany. 2014;92:151–158.
12. Fernandez SP, Nguyen M, Yow TT, et al. The flavonoid glycosides, myricitrin, gossypin and naringin exert anxiolytic action in mice. Neurochemical Research. 2009;34(10):1867–1875.
13. Batista FLA, Luiza MG, Araújo JIB, et al Antinociceptive activity of ethanolic extract of Azadirachta indica A. Juss (Neem, Meliaceae) fruit through opioid, glutamatergic and acid-sensitive ion pathways in adult zebrafish (Danio rerio). Biomedicine & Pharmacotherapy. 2018;108:408–416.
14. Khosla P, Singh BSJ, Srivastava RK. Antinociceptive Activity of Azadirachta Indica Antinociceptive Activity of Azadirachta Indica (Neem ) in Rats. Indian Journal of Pharmacology. 2000;32(6):372–374.
15. Maiti R, Kumar S, Acharya S, e al. Role of aqueous extract of Azadirachta indica leaves in an experimental model of Alzheimer′s disease in rats. International Journal of Applied and Basic Medical Research. 2013;3(1):37–47.