title: Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis.
abstract: BACKGROUND
  The evaluation of all potential sources of low skilled maternal care utilization is crucial for Ethiopia. Previous studies have largely disregarded the contribution of different levels. This study was planned to assess the effect of individual, communal, and health facility characteristics in the utilization of antenatal, delivery, and postnatal care by a skilled provider.
  
  
  METHODS
  A linked facility and population-based survey was conducted over three months (January - March 2012) in twelve "kebeles" of North Gondar Zone, Amhara Region. A total of 1668 women who had births in the year preceding the survey were selected for analysis. Using a multilevel modelling, we examined the effect of cluster variation and a number of individual, communal (kebele), and facility-related variables for skilled maternal care utilization.
  
  
  RESULTS
  About 32.3%, 13.8% and 6.3% of the women had the chance to get skilled providers for their antenatal, delivery and postnatal care, respectively. A significant heterogeneity was observed among clusters for each indicator of skilled maternal care utilization. At the individual level, variables related to awareness and perceptions were found to be much more relevant for skilled maternal service utilization. Preference for skilled providers and previous experience of antenatal care were consistently strong predictors of all indicators of skilled maternal health care utilizations. Birth order, maternal education, and awareness about health facilities to get skilled professionals were consistently strong predictors of skilled antenatal and delivery care use. Communal factors were relevant for both delivery and postnatal care, whereas the characteristics of a health facility were more relevant for use of skilled delivery care than other maternity services.
  
  
  CONCLUSIONS
  Factors operating at individual and "kebele" levels play a significant role in determining utilization of skilled maternal health services. Interventions to create better community awareness and perception about skilled providers and their care, and ensuring the seamless performance of health care facilities have been considered crucial to improve skilled maternal services in the study area. Such interventions should target underprivileged women.
authors.affiliation: Department of Reproductive Health, Institute of Public Health, University of Gondar, Gondar, Ethiopia. abebawgebeyehu@yahoo.com
authors.forename: Abebaw Gebeyehu
authors.initials: AG
authors.lastname: Worku
authors.forename: Alemayehu Worku
authors.initials: AW
authors.lastname: Yalew
authors.forename: Mesganaw Fantahun
authors.initials: MF
authors.lastname: Afework
mesh_terms: D000293:Adolescent; D000328:Adult; D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D005002:Ethiopia; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008427:Maternal Health Services / Q000592:standards* / Q000706:statistics & numerical data*; D008875:Middle Aged; D055361:Multilevel Analysis; D010342:Patient Acceptance of Health Care / Q000523:psychology* / Q000706:statistics & numerical data; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data; D055815:Young Adult
keywords: Skilled maternal care, Linked survey, Multilevel analysis