The study identified very important predictors that are related to geographic access such as living in rural area; social factors such as being illiterate; lack of access to information such as having poor knowledge about obstetric complications and delay in starting first ANC visit.
The recall period in the present study was maintained at 4 months or less than 4 months, that should be counted as strength of the study.
Among the social factors, education of mothers appeared to be the most important predictor in determining the utilization of institutional delivery care after controlling other variables. Many previous studies conducted in developing countries have found education of mothers to be among the most important determinants of skilled delivery care utilization [20, 21]. There are a number of explanations that speculate as to why education is a key determinant of skilled care demand. For example education is likely to enhance female autonomy so that mothers develop greater confidence and capabilities to make decision regarding their own health, as well as their children. It is also more likely that educated women demand higher quality service and pay more attention to their health in order to insure better health for themselves. Moreover, educated women are more likely to be aware of difficulties during pregnancy and as a result, they are more likely to use maternal health care services .
Another predictor that has also shown an important influence on maternal health care utilization was place of residence. Mothers living in rural area were less likely to use institutional delivery services than urban mothers. This finding is consistent with the previous studies done in Ethiopia, Kenya and Uganda [8, 26, 27], which suggested that place of residence has a statistical significance variable on the use of skilled care. It is consistent with the fact that rural mothers have limited financial and transport access to receive institutional delivery service . Similarly according to the data from DHS report (2005) , large disparities exist in many key health indicators in relation to place of residence, signifying that living in a rural area is a barrier to seek modern health care.
Having poor knowledge about pregnancy and delivery for instance was strongly associated with home delivery. Similarly having lack of knowledge about danger signs of pregnancy was very strongly associated with home delivery.
This finding demonstrated the fact that obstetric knowledge is an important factor that affects attitude, intention and behavior of mother. [22, 29, 30]. Another explanation for this could be knowledge of danger signs of obstetric complication is the first step in the appropriate and time referral for essential obstetric care . Moreover the main reasons leading to poor use of skilled care services include the personal belief, knowledge, attitude and life style of pregnant mother .
These findings are consistent with those of previous studies in Ethiopia, Ghana, Kenya and Vietnam [8, 21, 27, 28] respectively. The more knowledge they have about the importance of skilled obstetric care the more likely they have a positive attitude towards skilled obstetric care utilization [28, 32].
In this study, level of antenatal attendance was high (80.9%) and this figure is higher than the national or regional estimate [8, 25, 34, 35], the reason for this disparity may be due the high number of mothers from urban residence. those mothers who delayed presentation for ANC until the end of second trimester were more likely to attend home delivery than those came earlier. This can be best explained by the fact that ANC is more effective when received earlier in the pregnancy. This finding is consistent with previous studies [20, 33, 36].
In this study women who did not receive counseling where to deliver were more likely to deliver at home in the bivariate analysis. This result wasn’t retained in the multivariate analysis. Failing to counsel women about preferred place of delivery during antenatal care can be considered as a missed opportunity to improve the rate of skilled deliveries.
With regard to other correlates of skilled delivery care utilization, our finding did not reveal any supporting evidence that age, monthly income, number of surviving children and history of abortion to show a statistically significant difference between cases and controls. These findings could be related to difference in research methodology, sample size and the difference in other social and demographic factors that might not be accounted in this study.
Case control studies are not able to establish temporal relationships. So it is difficult to establish causal relationship in this study.
A non-response rate of 6% also affects estimate of a parameter and power of a test. Selection bias may be inevitable since cases and control were selected among mothers who only visit postnatal care or immunization for their children, this may affect generalizability and internal validity. Those who have limited access for all kinds of service may not be included in the study. This may result in differential misclassification obscuring some potential differences.
Those who delivered at heath facility might have been forced to visit care because of presence of serious clinical conditions during pregnancy and childbirth.
Tools used to measure knowledge and attitude were not standardized and tested for their reliability which would affect its comparability.
Inclusion of other variables like perceptions of the existing quality of delivery service, direct and indirect cost of health services and ability of the participants to pay for the service could have provided a comprehensive picture.