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A semi-structured interview guide translated into Tonga, was used for both FGDs and IDIs. The main topics explored included perspectives on home delivery and use of TBAs, decision-making processes regarding use of MHS, and reasons for home delivery and use of TBAs. IDI participants were mainly asked to share their experiences regarding the topic under discussion and provide more insight into the subject.

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All the IDI and FGD participants were aware of the new policy that stopped the training of TBAs. They explained that the new policy also recommended that TBAs stop conducting deliveries and that all women should give birth at the clinic under the supervision of a trained and skilled health staff such as a nurse, midwife or doctor. Moreover, the new policy stopped nurses at the clinic from providing TBAs with delivery packs and other supplies. With the change in policy, TBAs were advised to work with headmen and other community health agents such as NHC members, CHWs, and safe motherhood action groups (SMAGs) to encourage pregnant women to attend ANC services and give birth at the clinic. In contrast, all the FGDs and IDI respondents with the exception of five 5 TBAs argued that many women in their communities still give birth at home, and that TBAs still conduct deliveries.

Concerning the group of women who gave birth at home, respondents had mixed feelings. A quarter (25 %) of the FGD respondents (mainly the older mothers with six or more children) mentioned that both the older and younger women gave birth at home. They explained that, although most old women with many children gave birth at home, a large proportion of teenage girls also gave birth at home, because they were either not sure of the date of delivery or they did not inform their parents about the pregnancy, and thus, did not prepare for childbirth at the clinic.

This theme focused on the reasons for home delivery and use of TBAs. Our findings show that various personal, family and health-related factors as well as social and cultural norms played an important role in influencing women to give birth at home and to seek the services of TBAs.

All the FGD respondents and all the IDI participants indicated that most women gave birth at home because they perceived various barriers preventing them from delivering at the clinic. The main barriers cited included lack of funds for baby clothes and requirements for the mother during and after labour, poor quality of services at the clinic due to non availability of nurses, negative experiences with nurses during ANC visits or delivery during their previous pregnancies, long distances to the clinic and high transport costs, poor state of labour wards and absence of maternity waiting homes (MWHs), where it was present, it was in deplorable state. Other barriers included lack of funds for food for the pregnant woman while waiting for labour at the MWH.

In contrast, all the IDI respondents and most young FGDs respondents and a few (25 %) older mothers (who had given birth at the clinic during their previous pregnancies) argued that, despite their experience, some TBAs were not skilled or trained enough to handle labour complications at home. They explained that TBAs no longer received any logistical support from the health centres, and that they had no instruments or supplies to use in case of complications such as severe bleeding or eclampsia. Moreover, TBAs were believed to have no skills to recognise pregnancy and labour complications, and that sometimes they delayed referral of the woman to the clinic because they did not know when to do so. Furthermore, some young FGD respondents complained that TBAs delayed sending women to the clinic because they expected to receive an incentive in form of a chicken or an agreed-upon amount of money after conducting a successful delivery.

Institutional delivery is a delivery that takes place at any medical facility staffed by skilled delivery assistance. It is estimated that using institutional delivery could reduce 16 to 33% of maternal deaths. Despite the importance of delivering at health institutions, in Ethiopia, mothers prefer to give birth at home. Therefore, the aim of this study was to compare institutional delivery service utilization and associated factors among rural and urban mothers in Mana district, Jimma Zone, Southwest Ethiopia, 2017.

The overall prevalence of institutional delivery was 86.4%. Out of the total respondents, 651(91.3%), of the urban and 580 (81.6%) of the rural mothers gave their last birth at health institutions, and. Among urban mothers who gave birth at home, the main reasons for preferring home delivery were; institutional delivery was not necessary, 23 (37.7%) and husbands or family members did not allow them to give birth at health institutions, 17 (27.9%). Similarly, institutional delivery was not necessary, 61 (46.2%), it was not customary, 25 (18.9%)) and high service cost in the health facilities, 15 (11.4%) were the major reasons provided by rural mothers for preferring home delivery (Table 3). 2ff7e9595c