Assessment of Knowledge, Attitude, and Practice of Skilled Assistance Seeking Maternal Healthcare Services and Associated Factors among Women in West Shoa Zone, Oromia Region, Ethiopia

Background This study aimed to assess women's knowledge, attitude, and practice towards skilled assistance seeking maternal healthcare services in West Shoa Zone, Oromia Region, Ethiopia. Methods Cross-sectional survey design was conducted from 1 February to 23 March 2018 in West Shoa Zone, Oromia, Ethiopia. A simple random sampling technique was used to select the participants. The data were collected using a pretested and structured questionnaire. Data were entered using EpiData version 3.1, and descriptive analysis and bivariate and multivariate logistic regression analyses were carried out using SPSS version 20 statistical software package. Results The study revealed that the knowledge, attitude, and practice towards skilled maternal health services were found such that 473.3 (72.4%) of the study participants had good knowledge, 180.7 (27.6%) had poor knowledge, and 400 (61.3%) had positive attitude, 254 (38.84%) had negative attitude, 460.3 (70.4%) had good practice, and 193.7 (29.6%) had poor practice towards skilled maternal health services. Factors that had a significant association with antenatal care utilization were planned pregnancy (AOR = 8.2, 95% CI = 3.39-19.78-0.87) and access to transport (AOR = 3.1, 95% CI = 1.46–6.61). Attending ANC at least once (AOR = 3.1, 95% CI = 1.13–8.41), women's education (AOR = 3.0, 95% CI = 1.18–7.84), and unplanned pregnancy (AOR = 0.3, 95% CI = 0.21–0.75) were factors associated with skilled delivery service utilization. Attending ANC at least once (AOR = 2.1, 95% CI = 1.1–4.2), birth complications (AOR = 2.2, 95% CI = 1.35–3.66), unplanned pregnancies (AOR = 0.3, 95% CI = 0.22–0.68), and awareness about skilled obstetric care (AOR = 3.7, 95% CI = 1.68–12.79) were factors associated with postnatal care utilization. Conclusions This study found that the knowledge, attitude, and practice of skilled maternal health services among the study participants are low, showing less than three-quarters of the total sample size. Therefore, this study implied that interventions are required to improve women's knowledge, attitude, and practice of skilled maternal health services in the study area. Furthermore, women's education is significantly associated with skilled delivery service utilization. Accordingly, this study recommends that improving equity among the marginalized population is needed to increase maternal health service coverage.


Background
Access to skilled health services during pregnancy, childbirth, and postpartum is a crucial element that promotes the health and wellbeing of the mother and newborn. However, maternal mortality and morbidity remains a substantial concern. Globally, an estimated 303 000 mothers died due to maternal causes during pregnancy and childbirth and postpartum [1]. Developing regions account for 99% (302,000) of the global maternal deaths and sub-Saharan Africa accounts for two-thirds (201,000) [2]. Ending preventable maternal mortality by reducing the maternal deaths to less than 710 per 100,000 live births by 2030 requires rigorous improvements in skilled maternal healthcare [3]. However, only half of women in developing regions receive the amount of healthcare services they need. Currently, the Ethiopian government has made considerable progress in reducing maternal mortality. According to the Ethiopian Demographic Health Survey report, maternal mortality ratio has declined from 676 in 2011 to 412 in 2016 per 100,000 live births [4]. Despite improvements in maternal healthcare, there are still significant barriers to access and low utilization of maternal health services. In Ethiopia, an estimated 2.9 million women give birth every year and of these only 62%, 28%, and 17% of women received skilled antenatal care, skilled birth attendants, and postnatal care, respectively [4]. It is evident that maternal healthcare services are the most important interventions to prevent maternal morbidity and mortality but access to care alone is not enough to improve maternal health outcomes. Poor infrastructure, low quality care, and inequality substantially downplay efforts to escalate maternity services in low-and middle-income countries [5].
ere are several factors influencing skilled maternal health services utilizations. Previous literatures show that these factors can be assorted as individual (sociodemographic and obstetric factors) and structural level (Figure 1). At the individual level, maternal level of education and awareness about skilled providers are perpetual predictors of antenatal care [5][6][7][11][12][13]. Conversely, unplanned pregnancy and women giving birth more than once (multiparous) were less likely to utilize antenatal care [14]. At structural level, shortage of basic infrastructures, such as transportation facilities and telecommunications networks, significantly affected access to antenatal care services [8][9][10]. Previous studies in sub-Saharan Africa have revealed that education, women giving birth once (primiparous), previous experience of antenatal care visits, and awareness about skilled providers significantly predictors of skilled delivery [5-7, 11, 12, 15-21]. On the other hand, other studies demonstrate that multiparous had a positive effect on institutional delivery [22,23]. Furthermore, evidence indicates that antenatal care attendance, wanted pregnancy, and birth complications were strong determinants of postnatal care services utilization [17,[24][25][26]. e government of Ethiopia plans to reduce maternal mortality, infant mortality, and morbidity by strengthening maternal healthcare system interventions essentially increasing birth attendants at birth, meeting unmet needs of family planning, improving quality of care at childbirth, and increasing financing of the health system, but still, maternal mortality is an unfinished issue which needs more investigations [27]. Nonetheless, there are many studies conducted on the utilization of maternal health services in Ethiopia [6,7,11,15,18,20], but few studies have substantially addressed the women's level of knowledge and attitude regarding skilled maternal health services. Moreover, scant studies were done at community level in the West Shoa Zone. erefore, this study assesses the women's knowledge, attitude, and practice of antenatal care, skilled birth attendants, and postnatal care and the associated factors in the West Shoa Zone, Ethiopia.

Study Area, Period, and Design.
e study was conducted in West Shoa Zone, Oromia Region, Ethiopia. West Shoa is among 18 zones in Oromia region. e administrative center for West Shoa Zone is Ambo city which is located 114 km west of Addis Ababa, the capital city of Ethiopia. e West Shoa Zone has a total population of 2,058,676 of whom 1,028,501 were men and 1,255,010 were women of reproductive age [28]. e zone has 92 health centers, 578 health posts, 3 general hospitals, 4 district hospitals, and one referral hospital. e study was conducted from 1 February to 23 March 2018. Cross-sectional survey design was employed.

Source Population and Study
Population. All women who gave birth in the last 12 months in West Shoa Zone were source of population and all randomly selected women who gave birth in the last 12 months in West Shoa Zone were study population.

Sample Size Determination and Sampling Procedure.
e sample size was calculated using single population proportion formula [(n � (Zά/2) 2 p(1−p)/d 2 )] using a proportion of mother's seeking behavior, P � 73.8% [29], with 5% of marginal error (d) and 95% confidence interval (CI), design effect of 2 to correct the design effect, and 10% nonresponse rate, yielding final sample size of 654. Simple random sampling technique was used to select the study participants.
e regions are divided into zones, woredas, and kebeles which are the lowest level of administration. e woreda is administrative divisions with an average 100,000 population residing, and kebeles are the smallest unit in the local government of Ethiopia [27]. According to the West Shoa administrative office, the West Shoa Zone is composed of 19 Woredas with 528 rural kebeles and 58 urban kebeles. First five woredas such as Cheliya, Toke Kutaye, Nono, Dire Enchini, and Ejerie were purposely selected from a total of nineteen woredas from the zone. en the five woredas were stratified by residence (urban and rural kebeles), and then the kebeles of the five woredas were allocated proportionally. e list of eligible women was obtained from registration books of respective kebeles' administration offices. e sample size was distributed to the urban and rural kebeles proportionate to the size of their population ( Figure 2).

Inclusion and Exclusion
Criteria. Women of reproductive age of 15-49 years who gave birth one year before the survey and residing in the study area for at least six months were included in this study and women with physical and mental illness were excluded from the study.

Study Variables.
e dependent variables in this study were antenatal care, skilled birth attendants, and postnatal care and the independent variables were sociodemographic, obstetric-related factors, and structural factors.

Operational Definitions.
Knowledge of skilled maternal health services is defined such that women who scored above the mean of knowledge assessment questions were categorized as having good knowledge, and if they scored below the mean, they were considered as having poor knowledge. Attitude was measured by using Likert scale (1 � strongly agree, 2 � agree, 3 � disagree, and 4 � strongly disagree). Positive attitude was scored by participants who respond above the mean of the attitude assessment questions and if below the mean they were categorized as having negative attitude. Practice (antenatal care, skilled delivery, and postnatal care utilization) was measured such that participants who respond above the mean of the practice assessment question were considered as having good practice and if below the mean they were considered as having poor practice.  Nursing Research and Practice residence, income, occupation, women's education, and husband education), obstetric history (parity, age at first pregnancy, pregnancy planned, and antenatal care visit), and service-related factors (distance to facility, transport, and telephone access), and questions addressing the women's knowledge, attitude, and practice of skilled assistance seeking maternal healthcare services were items in the questionnaire. e following measures were undertaken to assure the quality of data. e questionnaire was initially prepared in English, translated to the local language Afan Oromo and back to English by different individuals to check for consistency of meaning. e questionnaire was pretested on 33 women of reproductive age who were not participants in this study and lived outside the study area. Cronbach's alpha coefficient was used to ensure the reliability of the tools [30] and was found to be 0.89. Content validity was ensured by measuring content validity ratio and was 0.2. en authors confirmed all items measured the content they were intended to measure. Six BSc nurse/midwife data collectors were recruited. Training was given to the data collectors for two days about the aim of the study, sampling procedures, and collecting the questionnaire data. e structured questionnaire was discussed in detail going through every question and clarification was provided. Informed consent was obtained to ensure the willingness and confidentiality of all of the study subjects. en the collected data was reviewed and cross-checked for completeness and consistency by the principal investigator on daily basis at the spot during the data collection time.

Data
Processing and Analysis. Data were entered and cleaned using EpiData version 3.1 software and then exported to SPSS version 20.0 statistical software packages for analysis. Bivariate and multivariate analysis between dependent and independent variables were performed separately using binary logistic regression. Descriptive statistics such as mean, median, and standard deviation were computed. Bivariate and multivariate logistic regression analysis were employed to examine the statistical association between independent and dependent variables. Variables that have a statistical association in the bivariate logistic regression at P-value <0.25 at 95% CI were entered into a multivariate logistic regression at P-value <0.25 at 95% CI [31]. Finally, adjusted odds ratio (AOR) with 95% CI and value <0.05 were considered statistically significant. Lastly, the results were presented using tables, figures, and texts.

Factors Associated with Skilled Assistance Seeking Antenatal Care Services of Study Participants.
On multivariate analysis, planned pregnancy and access to transport were found to be significantly associated with antenatal care utilizations. Women who had a planned pregnancy were eight times more likely to seek antenatal care than unplanned pregnancy (AOR � 8.2, 95% CI � 3.39-19.78-0.87), women who had access to transportation were three times more likely to seek skilled antenatal care than those who had no transportation access (AOR � 3.1, 95% CI � 1.46-6.61) ( Table 5).

Factors Associated with Skilled Assistance Seeking Delivery
Services of Study Participants. In multivariate analysis, women's education, wanted pregnancies, parity, antenatal care visit at least once, experiencing birth complications, and knowledge about skilled delivery were found to be statistically significant with skilled assistance seeking delivery services. e study found that education increases the probability of women utilizing skilled maternal healthcare services. Women with educational level of secondary and above (AOR � 3.0, 95% CI � 1.18-7.84) were three times more likely to have childbirth at the health facility as compared to those women who had no formal education, women whose previous pregnancies were unwanted had 70% lower odds of attending childbirth at the health facility as compared to those women with wanted pregnancies (AOR � 0.3, 95% CI � 0.21-0.75), primiparous women had 89% lower odds of attending childbirth at health facility than the multiparous women (AOR � 0.11, 95% CI � 0.05-0.24), women having at least one antenatal care in their recent pregnancies were about three times more likely to attend childbirth by a skilled provider compared with those who had no antenatal visit (AOR � 3.1, 95% CI � 1.13-8.41), women who had experienced birth complications were twice more likely to seek skilled provider than those who had not had complications (AOR � 2.3, 95% CI � 1.39-3.75), and women who had awareness about skilled obstetric care were three times more likely to have birth attendance by a skilled provider with their counterparts (AOR � 3.1, 95% CI � 1.13-8.41) ( Table 6).

Factors Associated with Skilled Assistance Seeking Postnatal Services of Study Participants.
In multivariate analysis, number of antenatal care visits, pregnancy complications, unwanted pregnancies, and having awareness about skilled obstetric care were significantly associated with postnatal care by a skilled provider. Women having at least one ANC in their recent pregnancy were twice more likely to attend postnatal care as compared with those who had no antenatal visit (AOR � 2.1, 95% CI � 1.1-4.2.), women who had experienced birth complications were twice more likely to seek postnatal care than those who had not had complications (AOR � 2.2, 95% CI � 1.35-3.66), women with unwanted pregnancies had 70% lower odds of attending postnatal care services as compared to women of wanted pregnancies (AOR � 0.3, 95% CI � 0.22-0.68), and women who had awareness about skilled obstetric care were four times more likely to attend postnatal care with their counterparts (AOR � 3.7, 95% CI � 1.68-12.79) ( Table 7).

Discussion
is study assessed the women's knowledge, attitude, and practice of skilled assistance seeking maternal healthcare services. In this study, the proportion of antenatal care, skilled delivery, and postnatal care services utilization was low as compared to other studies [21,22,25]. Conversely, the institutional delivery in this study was found high as compared to other studies in Ethiopia and Kenya [7,12,13,16]. e reasons for this variation could be explained by the different sample sizes, time gaps, and different socioeconomic conditions of the settings.

Nursing Research and Practice
Among the predisposing factors, access to transport and planned pregnancy were found to be associated with the use of antenatal care. Transport access is often reported readily available in the study settings which delays women's timely healthcare. e findings suggest that women who had access to transport were more likely to seek antenatal care service than those women who had no transport access. is implies that basic infrastructure inevitably has an effect on antenatal care utilization.
is finding is consistent with the study done in Ghana, Kenya, and Malawi emphasising that the availability of vehicles such as public transport and taxis significantly determined the pregnant women's decision to seek antenatal care [10]. Furthermore, other studies in sub-Saharan Africa also ascertained that access to transport services plays a critical role in women's antenatal care attendance [8,9]. Moreover, this study found that planned pregnancies were significantly associated with antenatal care utilization. However, this finding is congruent with a study in the Democratic Republic of Congo [14].
Regarding the predisposing factors to skilled delivery, women's education was significantly associated with skilled delivery utilization. Women with secondary school and above were more likely to deliver at a health facility as compared to women with no education. e findings of this study are similar with other studies in Africa [5-7, 11, 12] which highlighted that utilization of maternal health services

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Nursing Research and Practice increases consistently as the educational level increases. e higher utilization of skilled childbirth services among welleducated women may be attributed to their level of understanding, which may make women who are more concerned about their health and their illness need to seek appropriate healthcare services. Furthermore, women with unplanned pregnancies were 70% less likely to have childbirth at the health facility as compared to those mothers with wanted pregnancies. is finding is also supported by a study in the Democratic Republic of Congo [14]. is might be because the occurrence of unintended pregnancy is likely to reduce maternity care-seeking behavior of women, which is associated with discouragement and feeling less pregnancy experience.
Our finding showed that parity is significantly associated with a skilled birth attendant. Primiparous women were more likely to deliver in a health facility than the multipara. is finding is consistent with other studies done in Kenya and Ethiopia [16,20]. is might be because the low parity women give more attention to childbirth experiences and might have fear of complications than high parity women. is finding is in contrast with the previous studies in Ethiopia and Nigeria [22,23]. Women who had experienced birth complications were found to have a significant association with seeking skilled delivery. is finding is also supported by other studies in the Oromia region of Ethiopia [18]. Access to information on the importance of skilled maternal healthcare is also associated with the utilization of skilled birth attendants. is finding is similar to the study done in Ethiopia [13]. e number of antenatal care visits tended to increase the utilization of skilled delivery. is study has found that women who had to attend at least one antenatal care for their previous pregnancies were more likely to seek skilled delivery compared with those who did not have antenatal care visits. is finding is similar to that of studies in Ethiopia, Tanzania, South Sudan, and Nepal, respectively [15,17,19,21]. is might be because antenatal care is a significant intervention in contributing women into contact with the health system, facilitating women's access to skilled childbirth and including postnatal care. is implies that undergoing constant antenatal care visits have predominant importance to increase the utilization of facility delivery services.
is study illustrates that having at least one antenatal care visit in women's recent pregnancies was a significant predictor of postnatal care services. is finding is supported by other studies in Nigeria [26]. Likewise, wanted pregnancies were significantly associated with the postnatal care utilization. Women of unwanted pregnancies were less likely to attend postnatal care services compared to women of wanted pregnancies. is is consistent with the study done in Tanzania [17].
is implies that unwanted pregnancy influences maternal healthcare services. e study found that experiencing obstetric complications was a significant predictor to seek postnatal care. For instance, women tend to visit the health facility for postnatal care only when they encountered complications. is implies that postnatal care services do not give much attention in the study area. is finding also agrees with a study conducted in Nepal and Tanzania [24,25].

Limitation of the Study.
e study has encountered certain limitations. e study used a cross-sectional study design that has considerable methodological limitations in drawing cause and effect relationships between the variables. e information obtained from the participants could be affected by social desirability due to recall bias; thus the study attempts to minimize this by including women who gave birth in the last year.

Conclusions
is study found that the knowledge, attitude, and practice of the study participants towards skilled maternal health services are low, which is less than three-quarters of the total sample size. erefore, the findings of this study indicate that interventions are required to improve women's knowledge, attitude, and practice of skilled maternal health services in the study area. Moreover, unplanned pregnancy and lack of transportation were significantly associated with the nonutilization of maternal health services. erefore, the study suggests that integrated family planning and maternal healthcare services should be reconsidered to assist women with unplanned pregnancies to utilize maternal healthcare services and improvement to infrastructures are needed to increase access to maternal health services. Likewise, women's education is significantly associated with skilled delivery services utilization. Accordingly, this study recommends that improving equity among the marginalized population is needed to increase maternal health services coverage.
Data Availability e datasets used during the current study are available from the corresponding author upon reasonable request.

Ethical Approval
is study was approved by the College Research and Community Service Ethical Committee (CRCSEC) of Ambo University. Official permission to conduct the study was obtained from the respective district health offices. e purpose of the study, potential risks and benefits, and rights of participants were explained. e participants were assured about the confidentiality of the information they provided.

Consent
All study participants provided written informed consent. For participants whose age is <18 years, a written consent paper was obtained from their parents or guardians. Disclosure e authors acknowledge that the work was previously published in the preprint server.

Conflicts of Interest
e authors declare that they have no conflicts of interest.