title: Multilevel analysis of individual and community level factors associated with institutional delivery in Ethiopia.
abstract: BACKGROUND
  Improving maternal health is one of the eight millennium development goals to reduce maternal mortality (MM) by three quarters between 1990 and 2015. Institutional delivery is considered to be the most critical intervention in reducing MM and ensuring safe motherhood. However, the level of maternal morbidity and mortality in Ethiopia are among the highest in the world and the proportion of births occurring at health facilities is very low. This study examined the individual and community level factors associated with institutional delivery in Ethiopia.
  
  
  METHODS
  Data from the 2011 Ethiopian demographic and health survey were used to identify individual and community level factors associated with institutional delivery among women who had a live birth during the 5 years preceding the survey. Taking into account the nested structure of the data, multilevel logistic regression analysis has been employed to a nationally representative sample of 7757 women nested with in 595 communities.
  
  
  RESULTS
  At the individual level; higher educational level of the women (AOR = 3.60; 95% CI 2.491-5.214), women from richest households (AOR = 1.74; 95% CI 1.143-2.648) and increased ante natal care attendance (AOR = 4.43; 95% CI 3.405-5.751) were associated with institutional delivery. Additionally, at the community level; urban residence (AOR = 4.74; 95% CI 3.196-7.039), residing in communities with high proportion of educated women (AOR = 1.71; 95% CI 1.256-2.319) and residing in communities with high ANC utilization rate (AOR = 1.55; 95% CI 1.132-2.127) had a significant effect on institutional delivery. Also region and distance to health facility showed significant association with institutional delivery. The random effects showed that the variation in institutional delivery service utilization between communities was statistically significant.
  
  
  CONCLUSIONS
  Both individual and community level factors are associated with institutional delivery service uptake. As a result, further research is needed to better understand why these factors may affect institutional delivery.
authors: Health Promotion and Disease Prevention Directorate, Federal Ministry of Health, P.O. Box. 1234, Addis Ababa, Ethiopia. zelekeabebaw@yahoo.com.
authors: Zeleke A
authors: ZA
authors: Mekonnen
authors: Department of Public Health, Mekelle University, Mekelle, Ethiopia. kidwonyt@gmail.com.|Tulane International, Addis Ababa, Ethiopia. kidwonyt@gmail.com.
authors: Wondwossen T
authors: WT
authors: Lerebo
authors: Department of Public Health, Mekelle University, Mekelle, Ethiopia. tesfig@gmail.com.
authors: Tesfay G
authors: TG
authors: Gebrehiwot
authors: Oromia Regional Health Bureau, Addis Ababa, Ethiopia. Samirawl2007@gmail.com.
authors: Samir A
authors: SA
authors: Abadura
mesh_terms: D000293:Adolescent; D000328:Adult; D004522:Educational Status; D005002:Ethiopia; D005260:Female; D006801:Humans; D008427:Maternal Health Services / Q000458:organization & administration*; D008875:Middle Aged; D011247:Pregnancy; D055815:Young Adult