Pooled prevalence and associated factors of health facility delivery in East Africa: Mixed-effect logistic regression analysis
Authors: Tesema Getayeneh Antehunegn , Tessema Zemenu Tadesse 
Published: April 2021

Background
Many mothers still give birth outside a health facility in Sub-Saharan Africa particularly in East African countries. Though there are studies on the prevalence and associated factors of health facility delivery, as to our search of literature there is limited evidence on the pooled prevalence and associated factors of health facility delivery in East Africa. This study aims to examine the pooled prevalence and associated factors of health facility delivery in East Africa based on evidence from Demographic and Health Surveys.

Methods
A secondary data analysis was conducted based on the most recent Demographic and Health Surveys (DHSs) conducted in the 12 East African countries. A total weighted sample of 141,483 reproductive-age women who gave birth within five years preceding the survey was included. All analyses presented in this paper were weighted for the sampling probabilities and non-response using sampling weight (V005), primary sampling unit (V023), and strata (V021). The analysis was done using STATA version 14 statistical software, and the pooled prevalence of health facility delivery with a 95% Confidence Interval (CI) was presented using a forest plot. For associated factors, the Generalized Linear Mixed Model (GLMM) was fitted to consider the hierarchical nature of the DHS data. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), and Likelihood Ratio (LR)-test were done to assess the presence of a significant clustering effect. Besides, deviance (-2LLR) was used for model comparison since the models were nested models. Variables with a p-value of less than 0.2 in the bivariable mixed-effect binary logistic regression analysis were considered for the multivariable analysis. In the multivariable mixed-effect analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the strength and significance of the association between the independent variable and health facility delivery.

Results
The proportion of health facility delivery in East Africa was 87.49% [95% CI: 87.34%, 87.64%], ranged from 29% in Ethiopia to 97% in Mozambique. In the Mixed-effect logistic regression model; country, urban residence [AOR = 2.08, 95% CI: 1.96, 2.17], primary women education [AOR = 1.61, 95% CI: 1.55, 1.67], secondary education and higher [AOR = 2.96, 95% CI: 2.79, 3.13], primary husband education [AOR = 1.19, 95% CI: 1.14, 1.24], secondary husband education [AOR = 1.38, 95% CI: 1.31, 1.45], being in union [AOR = 1.23, 95% CI: 1.18, 1.27], having occupation [AOR = 1.11, 95% CI: 1.07, 1.15], being rich [AOR = 1.36, 95% CI: 1.30, 1.41], and middle [AOR = 2.14, 95% CI: 2.04, 2.23], health care access problem [AOR = 0.76, 95% CI: 0.74, 0.79], having ANC visit [AOR = 1.54, 95% CI: 1.49, 1.59], parity [AOR = 0.56, 95% CI: 0.55, 0.61], multiple gestation [AOR = 1.83, 95% CI: 1.67, 2.01] and wanted pregnancy [AOR = 1.19, 95% CI: 1.13, 1.25] were significantly associated with health facility delivery.

Conclusion
This study showed that the proportion of health facility delivery in East African countries is low. Thus, improved access and utilization of antenatal care can be an effective strategy to increase health facility deliveries. Moreover, encouraging women through education is recommended to increase health facility delivery service utilization.