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Predictors of institutional delivery service utilization in Ethiopia: an umbrella review

BMC Pregnancy and Childbirth volume 25, Article number: 332 (2025) Cite this article

Abstract

Introduction

One of the global health’s top priorities is improving maternal health. There is a high maternal mortality ratio, despite its major progress in the past two decades. Many countries in Sub-Saharan Africa, including Ethiopia, have not yet reached the sustainable development goal target. The majority of women die of labor and delivery-related complications, which are preventable if they had access to maternal health service utilization, particularly institutional delivery services. The low institutional delivery services utilization in Ethiopia was related to several factors. There are literature disagreements on these predictors and systematic review and meta-analysis (SRMA) studies reported different contributing factors. Therefore, this umbrella review aimed to identify pooled predictors of institutional delivery service utilization in Ethiopia.

Method

PubMed, Web of Science, Embase, CINAHL, Scopus, Google Scholar and Cochrane were searched for SRMA studies on the predictors of institutional delivery service utilization in Ethiopia. All SRMA studies selected for potential inclusion in the umbrella review were subjected to a rigorous, independent appraisal by two critical reviewers using the Assessment of Multiple Systematic Reviews tool. Authors selected SRMA studies and abstracted data independently, and discrepancies were resolved through discussion or a third author intervened. A random-effects meta-analysis model was used to pool estimates of the included SRMA studies. Studies’ heterogeneity and risk of bias were assessed using I2 and Egger tests, respectively.

Result

The umbrella review revealed that institutional delivery services utilization in Ethiopia was 24% (95% confidence interval, CI: 14 to 34). Further, women education (odds ratio, OR = 3.54, 95% CI: 3.04, 4.12), attitude of the women toward maternal and child health (MCH) service (OR = 2.20, 95% CI: 1.30, 3.74), place of residence (OR = 3.29, 95% CI: 2.02, 5.34), live less than 5 km away from the nearest health facilities (OR = 3.48, 95% CI: 2.58, 4.71) and having at least one antenatal care follow-up (OR = 3.62, 95% CI: 3.03, 4.33) were significantly associated with institutional delivery service utilization.

Conclusion

The proportion of pregnant women using institutional delivery services is low in Ethiopia. The findings highlight women’s education, tailored intervention in the attitude of women toward maternal and child health services, supporting rural communities, improving access and availability of health facilities and promoting antenatal care (ANC) follow-up play a crucial role in enhancing facility childbirth, thereby reducing maternal and neonatal mortality and achieving sustainable development goal 3.1 and 3.2.

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Introduction

Though maternal health improvement is one of the key priorities, approximately 287,000 women die following pregnancy and childbirth in 2020 worldwide, where 95% of these avoidable maternal deaths occurred in low- and middle-income countries (LMICs) [1]. By 2030, the global MMR should be below 70 per 100,000 live births, with no country exceeding 140 per 100,000 live births [2, 3]. Even though there has been a 38% reduction in maternal mortality ratio (MMR) worldwide [4, 5] and a 40% reduction in sub-Saharan Africa (SSA) [6] from 2000 to 2017, reaching these targets needs substantial effort.

The reports of MMR in Ethiopia are inconsistent. In 2020, for example, the World Bank Groups reported an MMR of 267 per 100,000 live births [7]; however, the national study by Geleto et al. showed 149 per 100,000 live births in Ethiopia during the same year [8]. In 2019, Mekonnen et al. reported that the maternal mortality ratio in rural Ethiopia was 326 deaths for every 100,000 live births [9]. Further, the goal set in 2017 during the launching of the quality network to lower MMR from 412 to 199 per 100,000 live births by 2020 has not been achieved [10] and achieving the sustainable development goal (SDG) targets by 2030 will be challenging. Thus, the impact of socioeconomic status, parity, and living in rural areas [11, 12], as well as political upheavals, insurgencies, and economic crises [13,14,15,16], famine, and epidemics [17, 18], as well as the fact that most births occur outside of health facilities, that few women receive antenatal care (ANC), and that less than half of births are attended by skilled birth attendants in Ethiopia, are some of the reasons for this.

Maternal health service utilization, such as family planning, preconception care, ANC, institutional delivery, postnatal care, and vaccination reduce maternal deaths significantly [19]. An institutional delivery service utilization, in particular, is one of the key strategies to reduce maternal mortality and ensure safe births. However, there is a lack of access to medical care during pregnancy in SSA [20], which resulted in low utilization of facility delivery services [21] and the majority of pregnant women across SSA including Ethiopia, still deliver at home. Hence, maternal health service coverage in all areas of the country needs to be ensured to achieve the ambitious goals of SDGs. As a result, Ethiopia is working with partners to address access to quality maternal and newborn healthcare services inequalities, ensuring universal health coverage, tackling all causes of maternal mortality, strengthening health information systems, and ensuring accountability [10].

To this date, the recent pooled analysis reported a varying proportion of institutional delivery service utilization, with studies showing 23.09% by Dessie et al. [22], 31% by Nugusie et al. [23], and 21% by Tenaw et al. [24] compared to the mini Ethiopian demographic health survey (EDHS) 2019 and the 2019 Performance Monitoring for Action survey data set reported the same outcome as 48% [25] and 54.49% [26], respectively.

Likewise, there is inconclusive reporting about the effects of different predisposing, enabling, and need factors on institutional delivery service utilization. Dessie et al., for example, found that ANC attendance, having information about maternal health service fee exemption, short distance to the health facility, and attending formal education [22] were predictors of a health facility delivery in Ethiopia, while Tenaw et al. reported husband involvement in the decision of where to deliver, good knowledge of MCH services among women, having a positive attitude toward MCH services, and availability of health institutions [24]. Moreover, Nugusie et al. reported maternal age at first pregnancy, place of residence, frequency of ANC follow-up, knowledge of danger signs during pregnancy, advantages of institutional delivery, and the place of birth of the elder child [23], and Kebede et al. reported experiencing a problem during pregnancy [27] as predictors of a health facility delivery in Ethiopia. Hence, it is tiresome for information users to design appropriate interventions and decision-making.

The existing systematic review and meta-analysis (SRMA) studies were mainly conducted using different primary studies in Ethiopia. To the best of our knowledge, despite the importance of predictors of institutional delivery service utilization, no synthesis of reviews to date has systematically investigated institutional delivery service utilization and its associated factors and no comprehensive review has yet synthesized the relevant evidence. Since there are multiple reviews, it is essential to perform an umbrella review to compile them by examining the current systematic review and meta-analysis on the use of institutional delivery services in order to find any gaps and build solid evidence.

Thus, the present umbrella review allows summarizing all available data on predictors of institutional delivery service utilization into a concise study, making it the source of evidence-based knowledge to the highest degree. To inform policy and decision-making, identify potential solutions, and contribute to developing better strategies to address challenges, a comprehensive understanding of predictors is needed. Hence, the objective of this umbrella review is to identify predictors of institutional delivery service utilization in Ethiopia, its prevalence, and research gaps.

Method

An umbrella review of multiple systematic review methodology was used to conduct this umbrella review [28]. A systematic synthesis of eligible systematic review and meta-analysis studies on institutional delivery service utilization and its associated factors in Ethiopia was undertaken. We conducted this umbrella review to cover the different areas and manage the large volume of research that has been conducted on the predictors of institutional delivery service utilization. The protocol of this umbrella review was prepared, but not registered.

Information sources

As many databases as possible were searched, especially the main ones such as Medline or PubMed, Embase, Web of Science, CINAHL, Scopus, Google Scholar, and databases specific to systematic review such as the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects, were conducted for SRMA studies on institutional delivery service utilization in Ethiopia as it exploits the chance of gathering all relevant studies. A comprehensive search for an umbrella review encompassed a search for gray literature, and reports using key terms in the title or abstract fields and PICO questions that developed from the following search keywords and/or Medical Subject Headings (MeSH), which combined using the ‘OR’ and ‘AND’ Boolean operators.

Population

pregnant women, laboring women, postpartum women, intrapartum women, women in labor, reproductive age women, women of reproductive age, 15–49 year women.

Outcome

institutional delivery, institutional delivery service utilization, place of delivery, health facility delivery, facility-based delivery, maternal health service utilization, use of skilled birth attendants, skilled delivery, birth at a health facility, predictors, determinants, associated factors, correlates, risk factors, influencing factors, related factors.

Study design

systematic review and meta-analysis.

Setting/Context

Ethiopia.

Literature searches of published and unpublished studies were conducted from June 2024 until July 2024. Manual searches through the references of the submitted studies to find more research that may not be found by the database’s algorithms were performed. Two independent researchers conducted the literature search, and discrepancies were resolved by discussion and consensus. The detailed search filters were employed sequentially in the appendix for all the databases searched using a combination of MeSH terms and free texts along with the search dates (Additional file 1).

Eligibility criteria

A systematic review and meta-analysis were deemed eligible if it (a) presented a defined literature search strategy, (b) appraised its included studies using a relevant tool, c) reported either the prevalence of institutional delivery service utilization or predictors of institutional delivery service utilization, (d) followed a standard approach in pooling studies and providing summaries estimates, and e) included research synthesis of all quantitative design systematic reviews, and meta-analysis. Publications from January 1990–July 2024 were eligible for inclusion. On the other hand, narrative reviews, editorials, abstracts, and methodological studies were not eligible.

Study selection

Endnote version VIII was used to download and remove duplicates. To select studies, the following steps were used: (a) the studies screened using title and abstract for full-text reviewing and (b) full-text reviews were conducted to identify potentially eligible studies. Independent researchers (KS and GT) conducted these two steps. A third researcher (HB) reviewed and resolved the disagreement where a consensus could not be reached between the researchers.

Data extraction

To reduce the risk of bias in the umbrella review process, two reviewers independently extracted the required data from eligible SRMA using a JBI standardized data extraction form for systematic review and research synthesis [29, 30]. This was developed in an Excel spreadsheet. Once the SRMAs to be included were agreed; disagreement on data extraction was resolved by consensus. Guided by the data extraction tool, the researcher independently extracted the following information: (a) author’s name and publication year, (b) aim, (c) proportion or coverage of institutional delivery service utilization, (d) predictors of institutional delivery service utilization, (e) odds ratio or relative risk with 95% confidence intervals for predictors, (f) number of primary studies included within each SRMA study and their respective design type, (g) total number of sample size included, (h) publication bias assessment methods and scores, (i) quality assessment methods and scores, (j) method of data synthesis and (k) the authors’ main conclusion (see Table 1).

Table 1 Characteristic of the review
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Data items

Institutional delivery service utilization is the outcome variable. It is defined as the proportion of index births delivered in health facilities by skilled birth attendants preceding the surveys/studies.

Risk of bias assessment

To ensure the methodological and evidence quality of the studies, SRMAs that are eligible for inclusion in an umbrella review are critically appraised for validity scoring of their results using the Assessment of Multiple System Review (AMSTAR) tool [31, 32]. The SRMA pooled empirical studies and their summary estimates were evaluated using the tool consisting of 11 questions that measure the quality of the approach used. Thus, quality scores 8 to 11, 4 to 7, and less than 3 indicate high, medium, and low, respectively (see Table 2). Two independent reviewers conducted the appraisal, and the decision whether to include a review was made based on these quality scores.

Statistical analysis

Overall, statistical analysis and data synthesis were conducted using STATA version 16.1 software. Researchers presented a range of estimates, including calculating a pooled estimate when two or more estimates were provided on the prevalence and predictors of institutional delivery service utilization. The between-studies heterogeneity that was assessed using Higgin’s I2 statistics [32] guided the choice of the meta-analysis model. Since there was a high level of difference between studies, the DerSimonian-laird random-effect model was used to pool the estimates [31]. A summary list of the predictors of institutional delivery service utilization (i.e., dichotomous outcome) with their respective odds ratios and 95% confidence interval was prepared. Only five SRMAs were included in this umbrella review; it was not possible to assess publication bias since a minimum of ten studies is needed to evaluate publication bias [33, 34]. When two SRMA included the same primary studies, we calculated corrected covered area (CCA) suggested by Pieper et al. to quantify the degree of overlap in umbrella review; we assessed and documented primary studies’ degree of overlapping as guidelines recommend [35].

Result

Literature search result

We retrieved 1190 records after searching PubMed, Embase, CINAHL, Scopus, Web of Science and other sources. After removing duplicates, 1080 and 20 articles were screened using title/abstract and full-text, respectively. Among the twenty articles that were identified using full-text review, only five were checked for eligibility. Thus, a total of five SRMA studies [22,23,24, 27, 36] that summarized in Fig. 1 were included in this umbrella review.

Fig. 1
figure 1

PRISMA flow chart

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Characteristics of SRMA studies

These SRMA studies were based on observational primary studies (i.e., cross-sectional, case-control, and cohort designs). The included primary studies ranged from nine [22] to thirty-four [27] per SRMA study. Even though two SRMA studies didn’t mention their sample size [22, 27], it ranged from 7660 [24] to 26,350 [36], among others. Kebede et al. and Fekadu et al. assessed factors associated with institutional delivery service utilization [27, 36] whereas the rest of the SRMA studies assessed both prevalence and factors associated with institutional delivery service utilization [22,23,24]. The reported prevalence estimates of institutional delivery service utilization ranged from 21.2% [24] to 31% [23]. Table 1 illustrates the general characteristics of the included SRMA studies.

Primary studies

In five SRMA studies 64 primary studies have been cited 107 times regardless of overlap. Of these, thirty-seven primary studies were included in only one SRMA study, while the remaining studies were incorporated in at least two SRMA studies or based on the same primary evidence. For instance, Wako et al. [37] cited in four SRMA studies [22,23,24, 36], nine primary studies cited in three SRMA studies, and sixty primary studies cited in two SRMA studies. The corrected coverage area was 49% indicating very high overlap. We included all SRMA studies as they provided important information either for overall results or specific primary studies; deletion of some did not decrease overlap (Additional file 2).

Methodological quality of SRMA studies

According to an evaluation of the methodological quality of SRMA studies using the AMSTAR tool, the quality score ranged from 5 to 11 points, with a mean score of 9.2 points, which is high quality. All SRMA studies had a comprehensive search, used appropriate methods to combine the studies’ findings, and acknowledged potential sources of support clearly in both the systematic review and the included studies (Table 2).

Table 2 Methodological quality of the studies included in the SRMA based on the AMSTAR tool
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Systematic review

Both women’s [22,23,24, 27] and husband’s education [27], and pregnant women’s positive attitude toward MCH service [23, 24], knowledge of dangerous signs of pregnancy [23] and the benefits of institutional delivery service utilization and MCH services [24, 26] favored institutional delivery service utilization. Maternal age at first pregnancy of 15–24 years [23] and husband’s involvement in decision-making of place of delivery [24] were associated with institutional delivery service utilization. Rural women [23, 27] and distant women from health facilities [22, 24, 27] have low institutional delivery service utilization. Even though the autonomy of women did not show any influence [27], the availability of information sources [23] and having information on the exemption of MCH service [22] improved the utilization of institutional delivery services. Both women having at least one ANC follow-up [22,23,24, 36] and the frequency of ANC follow-up [23], encountering problems during pregnancy [27] and facility delivery of the elderly child [23] also increased odds of institutional delivery service utilization.

Meta-analysis

Prevalence of health facility delivery

According to three SRMA studies, the pooled estimate of institutional delivery services utilization ranged from 21.2% (95% CI: 16.2, 26.1) to 31% (95% CI: 30, 31.2). The umbrella review based on these SRMA studies (18–20) revealed that 24% (95% CI: 14 to 34) of pregnant women utilized institutional delivery services in Ethiopia. As indicated in Table 3, the variation in effect size attributable to heterogeneity (I2) was 99.77%, which is significant. There was no publication bias according to Egger’s test for the small-study effect (P-value = 0.45).

Table 3 Random pooled estimate of institutional delivery service utilization in Ethiopia, 2024
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Predictors of health facility delivery

Predisposing factors

Women’s education [22,23,24, 27](18–20, 23) and pregnant women’s positive attitude toward maternal and child health (MCH) service [23, 24] favored institutional delivery service utilization (Fig. 2). Pregnant women who attended primary and above education had increased odds of the utilization of institutional delivery services compared to those who had no formal education (OR = 3.54, 95% CI: 3.04, 4.12). Pregnant women’s positive attitude toward MCH services favored increased odds of the utilization of institutional delivery service compared to those with a negative attitude (OR = 2.20, 95% CI: 1.30, 3.74).

Fig. 2
figure 2

Forest plot of factors associated with institutional delivery service utilization in Ethiopia, 2024

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Enabling factors

In Fig. 2, place of residence [23, 27] and distance from a health facility [22, 24, 27] influenced institutional delivery service utilization. Thus, urban residents had more than three times the increased odds of utilizing institutional delivery service compared to their rural resident counterparts (OR = 3.29, 95% CI: 2.02, 5.34). Those women who lived less than 5 km away from the health facility had increased odds of delivering at the health facility than those who lived more than 35 km away from the health facility (OR = 3.48, 95% CI: 2.58, 4.71).

Need factors

Women having at least one ANC follow-up [22,23,24, 36] have shown a significant effect on giving birth at a health facility in Ethiopia (Fig. 2). Pregnant women who had at least one ANC visit had increased odds of institutional delivery service utilization compared to those who had no ANC follow-up (OR = 3.62, 95% CI: 3.03, 4.33).

Discussion

The purpose of the present review is to identify predictors of institutional delivery service utilization and the pooled prevalence in Ethiopia. Predisposing factors such as women’s education, the attitude of women toward MCH services; enabling factors, i.e., place of residence, distance from the health facility, and need factors (having at least one ANC follow-up), predicted institutional delivery service utilization in Ethiopia.

The present umbrella review indicates that the pooled prevalence of institutional delivery service utilization in Ethiopia is 24%, which is in line with a review done in Ethiopia that indicated health facility-based delivery of 26.5% [38]. However, it is lower than the SSA (53%) and global (76%) reports in 2017 [39]. This could possibly be attributable to distance, lower education, no ANC visit, non-exposure to media, rural residence, and poverty that hinder Ethiopian women from accessing the majority of healthcare services. Thus, husband education, knowledge of dangerous signs of pregnancy and the benefit of health facility delivery and MCH services, younger age during first pregnancy, husband’s involvement in decision-making of place of delivery, availability of information sources and being informed about MCH service exemption, elder child’s place of birth favor health facility delivery.

Women’s education plays a crucial role in the increased odds of institutional delivery service utilization compared to those who didn’t attend formal education. Similarly, primary, secondary, and higher-educated women were two times more likely to deliver in health institutes than non-educated women in SSA [40]. Maternal education was the factor most consistently associated with facility-based delivery [41] and the odds of non-use of facility-based delivery increased for women who had no education in Nigeria [42]. The largest increase in health facility delivery did not occur among less educated and rural Cambodian women [43]. Vital information about healthcare utilization may be more often accessible to well-educated women, and they are less likely to subscribe to some notions in the community that impede maternal service utilization. It implies the benefit of facility-based delivery should be advocated among those who have formal education or strengthening female education across the nation.

Women’s positive/favorable attitude of women toward MCH services increases the odds of institutional delivery service utilization. This is in line with the review in SSA; the belief, behavior, and attitude ascribed to the nomad in particular are identified as barriers to health service utilization at fixed-post or outreach [44]. Women and their families believe childbirth has become medicalized and dehumanized due to the emphasis placed on increasing health facility delivery by public health entities; women in LMICs may fear several undesirable procedures and prefer home delivery with support from traditional birth attendants [45]. It could be due to demand-side barriers such as a lack of information on healthcare services, cultural beliefs/practices, stigma, women’s self-esteem/assertiveness, and ignorance about required obstetric health services [21].

Further, women’s subjection to disrespectful and abusive behavior and enduring psychological humiliation may also hinder the use of facility-based childbirth [46]. Since maternal and neonatal healthcare-related cultural beliefs and practices are intergenerational, community-specific education to enhance changes of behavior and adopting practical approaches such as involving husband/partners and communities in maternal health services are required [47]. This implies a health workforce that is knowledgeable, skillful, and companionable, respectful and performance-based financing, community-based health insurance, and better governance and leadership are needed. An establishment of a welcoming environment for women coming for MCH services (i.e., improved the quality of MCH services) and tailored interventions on women’s attitudes are also among the implications.

Urban dwellers have increased odds of institutional delivery service utilization compared to their rural-dweller counterparts. A systematic review in SSA revealed that urban/rural residence was most consistently associated with facility-based delivery [41]. The use of health facilities was relatively high due to the availability of health centers for city dwellers [48]. Home delivery persists in rural areas due to social and economic issues and cultural meanings attached to childbirth, including challenges related to the accessibility and affordability of respectful and culturally acceptable services in rural settings [49]. Having home delivery is more convenient for a particular group of families in rural areas due to the strong religious and cultural beliefs that have been embedded in families’ beliefs and families’ decisions that affected women’s place of delivery [50,51,52,53]. The finding highlights addressing inequalities associated with maternal education, improving access to health facilities, and narrowing gaps between urban and rural resident women to achieve the SDG agenda of leaving no one behind by 2030.

Residing a short distance from a health facility compared to a long distance has increased the odds of institutional delivery service utilization, which is in line with a study in SSA where a short distance from home to a health facility increased the odds of institutional delivery service utilization [40] and the distance to the nearest health facility was the factor most consistently associated with health facility delivery [41]. The review is also in line with a study in Tanzania identifying maternal deaths that are associated with distance to health facilities. Despite a different health and cultural setting, women who live more than 35 km away from health facilities find it difficult to access maternal services compared to those who live less than 5 km from health facilities, hence having a higher mortality ratio [54]. Sociocultural, economic, health facility accessibility, and healthcare delivery-related factors hinder ANC and health facility delivery [55].

Similarly, physical distance between health facilities and service users’ residences is among the supply-side barriers that could be worsened by demand-side barriers such as limited income, non-availability of means of transportation, and indirect cost of transportation [21]. Moreover, distance from health services is a factor that influences reproductive healthcare-seeking behavior in Bangladesh [56]. Thus, they receive maternal health services from unskilled people, which potentially creates negative impacts on maternal health. Empowering women via education, access to transportation, capacity building and staffing can improve institutional delivery service utilization. Delivery at health facilities increased among women who received incentives and information about the incentive program in Nepal that impacted the use of maternal health services positively. It may focus on women who live in rural, far distances and have low socio-economic status [57]. This implies revising Ethiopia’s healthcare availability, facilitating transportation incentives, or improving maternity waiting home services for those in need.

Having at least one ANC follow-up increases the odds of institutional delivery service utilization. In line with this, the review indicated that those women who had ANC visits were more likely to deliver in a health facility compared to those who had no ANC visits [58, 59]. ANC and the primary and secondary prevention of complications during delivery by skilled attendants avert the risk of maternal and child death that increases with home delivery [55, 58]. This could be contributed by health education during ANC that informs women about the importance of facility birth to timely diagnose, prevent, or manage complications.

In contrast, some women do not need to seek out skilled birth attendants during labor and delivery, thinking attending ANC guarantees health during pregnancy and childbirth [45] and despite high ANC sessions, there was a low rate of health facility delivery, an indication that there is the need to improve health education in timely ANC visits, a sign of true labor and benefit of institutional delivery service utilization [60]. This could be due to healthcare providers’ training and supervision gap, workload, limited staff numbers, lack of incentives, poor infrastructure in the health facility, and absence of teamwork and communication [61]. Hence, the review highlights strengthening ANC contact, advocating an importance of facility-based delivery during ANC contact and tailored intervention for those who had no ANC contact to contribute to an institutional delivery service utilization.

The review implies tailored interventions incorporating health extension workers, mHealth (i.e., text messages), incentives, and implementation of community-level initiatives may increase the use of institutional delivery services to reduce labor and delivery-related mortality [62]. Interventions that target improving primary health care (PHC) services (i.e., community engagement, improving an effectiveness of the health extension program using community scorecard, managerial accountability for PHC, network of care, establishing health extension program unit at each health facility, and improving health post capacity and functionalities) thorough research on its effectiveness to improve maternal health service utilization, health facility birth in particular are needed.

Strength and limitation

Multiple databases were searched to minimize risk of selection bias independently. The AMSTAR tool was used to assess SRMA studies’ risk of bias. In contrast, even though an overlap of the data among primary studies that were included in SRMA studies were mapped, there is a potential to overestimate the strength of the findings due to summarizing multiple meta-analysis data that included overlapping primary studies with increased sample size. Since aggregated group data was used to identify confounding factors that were not possible, the readers should be mindful while interpreting and using this finding in the context of both the inherent limitations of primary studies and umbrella review analysis.

Conclusion

Only about one in four pregnant women in Ethiopia give birth in a health facility. The findings highlight that improving women’s education, applying targeted intervention to change women’s attitudes towards MCH services, supporting rural residents, improving the access and availability of health facilities, and promoting ANC utilization are key implications for enhancing health facility’s childbirths.

Data availability

Data is provided within the manuscript or supplementary information files.

Abbreviations

ANC:

Antenatal care

AMSTAR:

Assessment of multiple systematic reviews

MMR:

Maternal mortality rate

MCH:

Maternal and child’s health

LMICs:

Low- and middle-income countries

OR:

Odds ratio

PHC:

Primary healthcare

SDG:

Sustainable development goal

SRMA:

Systematic review and meta-analysis

SSA:

Sub-Saharan Africa

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Acknowledgements

We would like to thank the authors of the studies included in this umbrella review.

Funding

The authors of this research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. College of Health and Medical Sciences, School of Midwifery, Haramaya University, Harar, Ethiopia

    Kasiye Shiferaw & Habtamu Bekele

  2. College of Health Sciences, Arsi University, Assela, Ethiopia

    Getahun Tiruye

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  1. Kasiye Shiferaw
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  2. Getahun Tiruye
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  3. Habtamu Bekele
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Contributions

Kasiye Shiferaw: conceived and designed the experiments; performed the experiments; analyzed and interpreted the data; wrote the paper. Getahun Tiruye and Habtamu Bekele: analyzed and interpreted the data; reviewed the paper.

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Correspondence to Kasiye Shiferaw.

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Shiferaw, K., Tiruye, G. & Bekele, H. Predictors of institutional delivery service utilization in Ethiopia: an umbrella review. BMC Pregnancy Childbirth 25, 332 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07464-9

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BMC Pregnancy and Childbirth

ISSN: 1471-2393

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