The prevalence of institutional delivery in this study was 13.9% (95% CI: 11.5–16.3%). Women who had readily available cash when labor onset, delivered the birth preceding the most recent one in a health institution and faced birth related complications during the birth preceding the most recent one were more likely to have institutional delivery.
Prevalence of institutional delivery in this study is similar with a study in Banja District, Amhara regional state of Ethiopia. In Banja District, 15.7% of women delivered in health institutions . However, the prevalence in this study is much lower than the prevalence in Goba Woreda of Oromia regional state among urban and rural women where 47% (95% CI: 42.9–51.1%) delivered in health institutions . In Ethiopia, evidences show that prevalence of institutional delivery among rural women is lower than among urban women [4, 7]. The current study shows lower prevalence of institutional delivery compared to the study in Goba Woreda, probably because of inclusion of urban women in the later. In addition to rural–urban difference, the difference in institutional delivery may be due to difference in socio-economic settings. Pastoral communities have limited access to social service infrastructures, including health care . The limited access to health care might influence utilization of institutional delivery. However, the prevalence in the current study is a bit higher than the national rural average of institutional delivery in Ethiopia . Mini Ethiopian Demographic and Health survey of 2014(EDHS 2014), reported that 10.4% (95% CI: 9.6–11.2%) of rural women gave their most recent birth in a health institution .
Women who had readily available cash at the time of labor onset were almost three times more likely to deliver at a health institution compared to those who did not have cash. Though delivery services are free of charge at government health institutions; indirect health care costs may be a barrier. Ninety percent of women who gave birth at the health institutions delivered at health centers or hospitals. Almost all of these health institutions are found at more or less urban areas, whether it is a small rural or urban town. Moving to such health institutions may demands rural women and/or accompanying persons to have at least some money to cover essential expenses like food. In pastoral communities, however, money consists of livestock, which might be difficult to sell any time unlike other assets. First, market centers where livestock are to be sold might be located far away at urban areas, requiring a long distance drive with their livestock to the market centers. Second, despite the distant market centers, market days are limited within a given week. In the study area, for instance there are only 2 market days per week. Third, because livestock are highly valued and major income resources, its sell may require discussion among family members. All these three above conditions make livestock an unreliable source of money during emergencies of a woman in labor, unless livestock is sold prior to onset of labor. This may be further evidenced by the fact that livestock possessions did not affect institutional delivery. This study did not assess birth preparedness and complications readiness, which includes capital preparation. A study in Goba Woreda showed that women who were birth prepared and had complication readiness were more likely to deliver at health institutions.
Provided that delivery services are given free of charge for all women, the current findings support the importance of indirect health care costs on institutional delivery. Work done in five low income countries showed that even in the presence of fee waiver and exemption systems women continue to pay for maternal health services, a large proportion of which is informal payments . The same work demonstrated that fee waiver and exemption mechanisms will not alleviate the burden of out of pocket costs, because more than 80% of out of pocket costs for maternal health services are informal costs. Poor clients do not benefit from government fee subsidies because of poor awareness of fee waiver and exemption mechanisms . In the current study, majority (84.2%) of the women had good knowledge of delivery service including free ambulance service and free delivery services at government health institutions. However, institutional delivery was not significantly different between women who had unfavorable and favorable attitudes towards institutional delivery.
The women who delivered the birth preceding the most recent birth at health institutions were almost seven times more likely to deliver at health institutions than those who delivered such birth elsewhere. The finding is in line with a study in Banja District of Amhara regional state, Ethiopia . This may due to the fact that women who delivered at health institutions may better appreciate the advantages of institutional delivery, and this may encourage seeking health institutional delivery for subsequent deliveries.
The women who had complications during the birth preceding the most recent birth were more likely to deliver in health institutions. This finding is similar to a study in northern Ethiopia, which showed that women who had a history of obstetric complications tend to deliver at health institutions . Also in current study, the majority of the women who delivered at the health institutions did so because of the complications they faced during labor. Among women who gave the most recent birth at the health institutions, only about 27.3% of them had planned to give birth at a health institution. The rest delivered at the health institutions because of perceived complications during labor.
Socio-demographic characteristics of women like age, literacy, religion and family size did not seem to affect the place of delivery. Place of delivery was not associated with current maternal age, consistent with a study in northern Ethiopia . But it is inconsistent with many others which reported current maternal age as the factor affecting place of delivery [4, 7, 8]. Contrary to many studies, the current study reported that women’s literacy status did not an have association with place of delivery [7,8,9, 11, 12]. Consistent with many other studies, the current study reported that decision maker [8, 9, 11], husbands’ education  and habit of listening radio [8, 9, 11], did not significantly influence the choice of place of childbirth. Even though pastoral mobility was claimed as one cause of the difficulty in providing health care to pastoralists, the current study did not show a significant association between extent of household mobility and the place of childbirth. Similarly, distance to the nearest health institution and functional transport road were not associated with the place of childbirth. Similar findings were reported in a study from Goba Woreda . However, 51.1% of the women who delivered outside health institutions mentioned lack of transportation and/or distance to health institution as one of the reasons for not delivering in a health institution.
Unlike many studies [7, 9, 12], antenatal care utilization was not associated with place of delivery in the current study. Also marital status and parity were not associated with the place of birth. These findings are consistent with studies done in Gondar and Goba, Ethiopia [9, 11]. In this study, the area of the district that considered hosting the mobile pastoralist and housing characteristics were criteria to distinguish mobile from settled pastoralists. But these criteria are not perfect in distinguishing the two from each other. So, chance of including some settled pastoral women in the study is possible. Therefore, this should be taken into account while interpreting the study.