Individual and community level factors associated with home delivery after adequate antenatal care visits: a multilevel analysis of the Ethiopian Demographic and Health Survey 2019

BackgroundDespite the reported increased antenatal care (ANC) utilization in Ethiopia, large numbers of women give birth at home without skilled personnel attendance, even after attending an adequate antenatal care schedule ([≥] four antenatal visits) as recommended by the World Health Organization (WHO). This study aimed to assess individual and community-level factors associated with home delivery after adequate antenatal care visits in Ethiopia. MethodsWe analyzed the 2019 Ethiopian mini demographic and health survey data. A total weighted sample of 1,643 women who had full antenatal care visits for their last childbirth/index birth was included in the analysis. Model comparison was done by using intra-cluster correlation, median odds ratio, and proportional change in variance. A multivariable multilevel logistic regression analysis was conducted to identify the effect of individual and community-level factors on the outcome variable (home delivery). Adjusted odds ratios (AOR), along with a 95% confidence interval (CI) were used to estimate the strength of the associations. ResultsThe intra cluster correlation (ICC) in the null model was 59%, showing that there was a significant difference in the prevalence of home delivery after adequate antenatal care at the community level, and the variability declined to 36.5% in the final model. Therefore, multilevel logistic regression model was utilized. At individual-level, secondary educational level was negatively associated with home delivery [AOR = 0.37; 95%CI: (0.17, 0.80)], and having a household of [≥] 5 members [AOR = 1.70; 95%CI: (1.09, 2.66)], poorest (vs. richest) wealth index [AOR = 6.98; 95%CI (2.89, 16.83)], poorer (vs. richest) wealth index [AOR = 2.77, 95%CI :(1.19,6.45)], and 2-3 birth order [AOR = 2.48; 95% CI(1.45, 4.21)] were associated with home delivery after attending the required adequate ANC visits. Community-level variables associated with home delivery after full antenatal care visits included: poor communities [AOR = 2.13; 95%CI (1.03, 4.40)], and living in a rural area [AOR = 2.74; 95%CI (1.19, 6.30)]. ConclusionThe findings of the current study indicate that in women who had the required number of ANC visits, having a larger household and poorest and poorer (vs. rich) wealth index, being the 2nd or 3rd birth, residing in a rural area, and living in poor communities were predictors of home delivery. Having a secondary education was supportive, against delivering at home. Strategies to improve households socioeconomic empowerment were recommended.