PLOS ONE

RESEARCH ARTICLE

Antenatal care booked rural residence

women have home delivery during the era of
COVID-19 pandemic in Gidan District, Ethiopia
Desale Bihonegn Asmamaw ID1*, Yohannes Ayanaw Habitu1, Eskedar Getie Mekonnen1,
Wubshet Debebe Negash2
1 Department of Reproductive Health, Institute of Public Health, College of Medicine and Health Sciences,
University of Gondar, Gondar, Ethiopia, 2 Department of Health Systems and Policy, Institute of Public
Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

a1111111111 * [email protected]
a1111111111
a1111111111
a1111111111
a1111111111 Abstract

Background
World Health Organization (WHO) recommends that every pregnant woman receive quality
OPEN ACCESS care throughout pregnancy, childbirth, and the postnatal period. It is estimated that institu-
Citation: Asmamaw DB, Habitu YA, Mekonnen EG, tional delivery could reduce 16% to 33% of maternal deaths. Despite the importance of giv-
Negash WD (2023) Antenatal care booked rural
ing birth at a health institution, in Ethiopia, according to the Ethiopian Demographic Health
residence women have home delivery during the
era of COVID-19 pandemic in Gidan District, Survey report, nearly half of the ANC-booked mothers gave birth at home. Therefore, this
Ethiopia. PLoS ONE 18(12): e0295220. https://doi. study aimed to determine the prevalence and associated factors of home delivery among
org/10.1371/journal.pone.0295220 antenatal care-booked women in their last pregnancy during the era of COVID-19.
Editor: Pracheth Raghuveer, Kasturba Medical
College Mangalore, Manipal Academy of Higher Methods
Education, INDIA
A community-based cross-sectional study was conducted from March 30 to April 29, 2021.
Received: April 13, 2022
A simple random technique was employed to select 770 participants among women booked
Accepted: November 18, 2023 for antenatal care. Interviewer-administered questionnaires were used to collect the data. A
Published: December 5, 2023 binary logistic regression model was fitted. Adjusted odds ratios with its respective 95% con-
fidence interval were used to declare the associated factors.
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of Results
all of the content of peer review and author
The prevalence of home delivery was 28.8% (95% CI: 25.7, 32.2). Rural residence (AOR =
responses alongside final, published articles. The
editorial history of this article is available here: 2.02, 95% CI: 1.23, 3.34), unmarried women (AOR = 11.16, 95% CI: 4.18, 29.79), husband
https://doi.org/10.1371/journal.pone.0295220 education (AOR = 2.60, 95% CI: 1.72, 3.91), not being involved in the women’s development
Copyright: © 2023 Asmamaw et al. This is an open army (AOR = 1.64, 95% CI: 1.01, 2.65), and fear of COVID-19 infection (AOR = 3.86, 95%
access article distributed under the terms of the CI: 2.31, 6.44) were significantly associated factors of home delivery.
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
Conclusion
reproduction in any medium, provided the original
author and source are credited. Even though the government tried to lower the rate of home delivery by accessing health
Data Availability Statement: All relevant data are institutions in remote areas, implementing a women’s development army, and introducing
within the paper and Supporting Information file. maternal waiting home utilization, nearly one in every three pregnant women gave birth at

PLOS ONE | https://doi.org/10.1371/journal.pone.0295220 December 5, 2023 1 / 14

PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

Funding: The author(s) received no specific home among ANC booked women in their last pregnancy. Thus, improving the husband’s
funding for this work. educational status, providing information related to health institution delivery benefits during
Competing interests: The authors have declared antenatal care, and strengthening the implementation of the women’s development army,
that no competing interests exist. particularly among rural and unmarried women, would decrease home childbirth practices.
Abbreviations: ANC, Antenatal Care; AOR,
Adjusted Odds Rati; CI, Confidence Intervals; COR,
Crude Odds Ratio; COVID-19, Coronavirus disease;
EDHS, Ethiopian Demographic, and Health Survey;
LICs, Low-Income Countries; OR, Odds Ratio; Background
PNC, Postnatal Care; WDA, Women Development
Army; SDGs, Sustainable Development Goals; Maternal mortality is one of the most common public health problems in low and middle-
WHO, World Health Organization. income countries [1]. Reduction of maternal mortality remains a priority agenda under Goal 3
in the United Nations Sustainable Development Goals (SDGs) through 2030. This calls for the
ambition of a maternal mortality ratio reduction of less than 70 per 100,000 live births between
2016 and 2030 [2]. Worldwide, approximately 295,000 women died during and after preg-
nancy and childbirth. The majority (94%) of deaths occurred in developing countries, includ-
ing Ethiopia. Sub-Saharan Africa (SSA) and Southern Asia accounted for approximately 86%
of all maternal deaths worldwide. Of this, two-thirds of the deaths were from SSA [3,4]. The
maternal mortality ratio (MMR) in low-income countries is 462 deaths per 100,000 live births
[3]. Ethiopia is among the countries in which high maternal mortality has occurred. The
MMR in Ethiopia is 412 deaths per 100,000 live births [3].
The continuum of maternal health care is crucial to saving the mother and the child. In
addition, they are indicators of progress toward the achievement of sustainable development
goals [5,6]. The World Health Organization endorsed the need for skilled care for all women
during their labor and immediately afterward [7]. ANC follow-up has increased in many parts
of the world. However, only 46% of developing countries and 26% of Ethiopia benefited from
skilled personnel attendance. Attendance by skilled personnel is advocated as the single most
important factor in preventing maternal mortality and morbidity [6,8].
In SSA, only 17.7% of women chose to deliver at the health institution [9]. If pregnant
women give birth at home, it increases the risk of infection and postpartum hemorrhage [10].
As a result, maternal deaths from hemorrhage, prolonged or obstructed labor, ruptured uterus,
severe pre-eclampsia and eclampsia, sepsis, and abortion complications continue to be a prob-
lem [11]. The aforementioned causes can be detected and managed early during ANC and the
intrapartum period by existing and well-known medical interventions [12]. Most home deliv-
eries, mainly those of unattended births, are not only a problem for the mother, but they also
result in perinatal and neonatal morbidity and mortality. In the SSA, home births were found
to have a 21% higher rate of perinatal mortality than facility births [13].
Home delivery in itself is not a cause of maternal and child deaths, it becomes a risk factor
when home deliveries occur without a skilled attendant due to the possibility of infection or a
lack of equipment in case of complications [14]. Attending an ANC visit does not mean that
deliveries of pregnant women will take place at a health institution. Despite 62% of women
attending ANC, three-fourths of women nationwide gave birth at home [8]. Another study
from Ethiopia revealed that many women unpredictably did not give birth in health institu-
tions despite antenatal care [6].
Because of the COVID-19 infection, countries are facing significant challenges to maintain
high-quality, essential maternal and newborn health services [15]. Mothers with newborns and
pregnant women may experience difficulty accessing healthcare services due to disruptions in
transportation and lockdowns or fear of COVID-19 infection. Thus, pregnancy-related and
newborn healthcare coverage declined by 10% due to the pandemic. This would result in
28,000 maternal deaths [15,16].

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

There are variety of literature reporting factors that affect the use of ANC services and the
place of delivery [17–24], but there is no adequate literature explaining why ANC-booked
women prefer home deliveries. This leaves maternal morbidity and mortality a public health
problem. Therefore, this study aimed to determine the prevalence and associated factors of
home delivery among women who had antenatal care booked in their last pregnancy during
the era of COVID-19. By analyzing this study, policymakers will be able to find the appropriate
strategy for improving maternal and child health in the area.

Methods
Study design and setting
A community-based cross-sectional study design was conducted from March 30 to April 29,
2021, in the Gidan district, North Wollo zone, Northeastern Ethiopia. The district is located
595 Kilometers (km) away from Addis Ababa, the capital city of Ethiopia, and it has two urban
and 21 rural kebeles (the lowest administrative unit). It has an estimated 148,058 population
based on the population projection from the 2007 census through 2020, of which 74,461 and
29,649 are females and reproductive age women, respectively. The district has six health cen-
ters and 23 health posts that provide routine health services for the catchment population [25].
The study was conducted from March 30 to April 29, 2021.

Study population, sample size determination, and sampling procedures

The study population consisted of all ANC-booked mothers who gave birth within the last
year and resided in the selected kebeles of the district. The required sample size for home deliv-
ery was calculated using the single population proportion formula, considering the following
statistical assumptions: margin of error 5% (0.05), Z-value 1.96 corresponding to 95% confi-
dence level, design effect 2, and the prevalence of home delivery was 35.2% [18], accordingly
the sample size was computed as:
2
ðZa1=2Þ P ð1 PÞ
n¼
d2

2
ð1:96Þ ð0:352Þ ð1 0:352Þ
n¼ ¼ 350
ð0:05Þ2

n = 350
After adding a 10% non-response rate and multiplying it by the design effect of 2, the total
sample size of this study was 770 mothers. A simple random sampling technique was used to
select the participants. From 23 kebeles, seven kebeles were selected by a simple random sam-
pling technique using the lottery method. The list of ANC-booked mothers who gave birth in
the last year was identified by the health center and health extension workers. The sample size
was proportionally allocated to each selected kebele, considering the number of women. Moth-
ers in the sampled kebeles were selected by using a simple random sampling technique (Open
Epi Random Program version 3) (Fig 1). Regardless of the outcome, limiting the participants
to only 1 year and after one month of giving birth was done to minimize potential recall bias
and make the mother stabilized and comfortable. If the respondents were not available at
home during the time of data collection, interviewers revisited the households three times, and
when the interviewers failed to find the eligible respondent after three visits, the next house-
hold was included.

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

Fig 1. Schematic presentation of the sampling procedure.

https://doi.org/10.1371/journal.pone.0295220.g001

Study variables
The outcome variable was home delivery. when a woman gave birth at her home or others’
homes (neighbors, relatives, or family) or when a birth took place outside of health institu-
tions. It was dichotomized and coded as "0" and "1," representing those who had delivered at
health institutions and home, respectively [26]. The independent variables were socio-demo-
graphic (age, educational status of women and husbands, occupation, marital status, resi-
dence), obstetrics-related characteristics (parity, pregnancy status, bad obstetric history),
fear of COVID-19 infection, and other characteristics like membership in the Women’s
Development Army (WDA). Fear of COVID-19 infection means fear of oneself or family
members being infected with COVID-19 infection during pregnancy when visiting health
institutions [27].

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

Data quality assurance

Data collectors and supervisors were trained for two days, focusing on how to ask and fill out
the questionnaires, the selection criteria for women, and how to approach the respondents.
Before starting the actual data collection, the data collectors practiced in the field, and the
questionnaires were pretested on 39 study participants (5%) in the Gubalafto district. Findings
and experiences from the pretest were utilized in modifying the data collection tool. The data
collectors and the supervisors assessed the clarity and completeness of the filled-out question-
naires. The whole data collection process was closely supervised by the principal investigator
(PI).

Data collection tools and procedures

Structured interviewer-administered questionnaires developed from reviewing different
related literature were used for data collection [18,28–33]. First, the questionnaires were devel-
oped in English. Then it was translated into Amharic (the local language) and retranslated
back into the English language to check its consistency by language experts. The questionnaire
was separated into different sections such as socio-demographic characteristics, obstetric-
related characteristics of the participants, and other characteristics like fear of COVID-19
infection, lack of transport, and membership in WDA. Data collectors approached the women
by introducing themselves and interviewing the selected respondent after informed consent
had been obtained. Eight BSc midwifery or nursing data collectors and two supervisors in the
same field with experience in research and fieldwork coordination participated in the data col-
lection process.

Data processing and analysis

The collected data were checked for completeness before being entered into Epi-data version
4.6 statistical software. Then it was exported to STATA version 14 statistical software for clean-
ing, coding, and analysis. Descriptive statistics were described using frequencies, percentages,
mean, and standard deviation, which was further presented using tables, figures, and text. Nor-
mality tests such as kurtosis and skewness were employed to see the normal distribution of the
variables and to identify which summary measures were appropriate to use. Before identifying
the significant factors, multicollinearity was tested using the variance inflation factor (VIF),
and we have a VIF of less than five for each independent variable with a mean VIF of 1.56,
indicating there is no significant multicollinearity between independent variables [34].
According to the Hosmer-Lemeshow test, the model was adequate with a p-value of 0.26. The
case-to-variable ratio showed 12.8 to 1, which indicates a ratio above the required 5 to 1.
A binary logistic regression analysis was carried out to identify factors associated with
home delivery. Those variables with a P-value � 0.25 from the bivariable analysis were entered
into a multivariable logistic regression model to control the possible effects of confounder/s.
The odds ratio with 95% confidence intervals was computed to see if there was an association
between home delivery and associated factors. A P-value of 0.05 was used to declare a statistical
association.

Ethical considerations
Ethical clearance was obtained from the Institutional Review Board (IRB) of the University of
Gondar (Ref. No: IPH/142/2013). Similarly, a supportive letter was taken from the district
administrative office to be given to the selected kebeles. Verbal informed consent was obtained
from each participant. Participants were also informed that participation was voluntary and

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

that they had the right to withdraw from the study at any time they wanted. All data obtained
from participants was kept confidential and used only for this study. The study was conducted
according to the Helsinki Declaration.

Results
Socio-demographic characteristics of the respondents
About 760 women participated, giving a response rate of 98.7%. The mean age of the study
participants was 27 (SD±5.3) years, and 306 (40.3%) of them fell within the age category of 26–
30 years. Three-fourths (75.4%) of the respondents were rural dwellers, and almost all (99.6%)
participants were orthodox Christian followers (Table 1).

Obstetrics and other related factors

Among the study participants, 612 (80.5%) and 650 (85.5%) of the mothers were multiparous
and had an ANC visit for their index child, respectively. One hundred and fifty-six (20.5%) of
the participants were involved in the Women’s Development Army (WDA). About 532 (70%)
of the mothers feared COVID-19 infection (Table 2).

Place of delivery
The prevalence of home delivery in Gidan district was 28.8% (95% CI: 25.7%, 32.2%).

Factors associated with home delivery

In bivariable logistic regression, rural residence, unmarried women, husband education, not
being involved in WDA, and fear of COVID-19 infection were statistically significant factors
for home delivery among ANC-booked women. Accordingly, the odds of home delivery were
2.02 times higher among rural residents (AOR = 2.02, 95% CI: 1.23, 3.34) compared to urban
residents. Similarly, the odds of women having a home delivery were 11.16 (AOR = 11.16, 95%
CI: 4.18, 29.79) times higher among unmarried women compared to married women.
Pregnant women who had no formally educated husbands had 2.60 times (AOR = 2.60,
95% CI: 1.72, 3.91) higher odds of home delivery compared to their counterparts. The likeli-
hood of home delivery was 1.64 times higher (AOR = 1.64; 95% CI: 1.01, 2.65) among respon-
dents who were not involved in WDA as compared to their counterparts. Home delivery was
3.86 times higher among women who feared COVID-19 infection (AOR = 3.86, 95% CI: 2.31,
6.44) than their counterparts (Table 3).

Discussion
This study is a community-based study in randomly selected kebeles that includes both urban
and rural settings. During pregnancy, childbirth, and the immediate postpartum period, the
continuum of maternal health care is crucial. Even though health institutions are relatively
accessible in remote areas, a significant number of pregnant women still give birth at home,
contrary to the plan of health institution delivery. The purpose of this study was to determine
the prevalence and associated factors of home delivery among ANC-booked mothers in their
last pregnancy during the era of COVID-19 in Gidan District, Northeastern, Ethiopia.
The prevalence of women who gave birth at home among ANC-booked women was 28.8%
(95%CI: 25.7–32.2). This finding is higher than studies conducted in Southern Ethiopia 22.8%
[35] and in Bench Maji zone, Ethiopia 21.7% [36]. This difference might be due to the fear of
COVID-19 transmissions and interruptions of services [37,38]. In addition, possibly due to
internal conflicts (war) in the area, war can result in the distraction of infrastructure like roads,

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

Table 1. Socio-demographic characteristics of the respondents in Gidan District, Northeastern Ethiopia, 2021
(N = 760).
Variables Frequency(n) Percentage (%)
Age of the mother in years
<20 74 9.7
20–25 197 25.9
26–30 306 40.3
>30 183 24.1
Religion
Orthodox 757 99.6
Muslim 3 0.4
Educational status of the mother
No formal education 346 45.5
Primary school 302 39.7
Secondary school and above 112 14.8
Occupation of the mother
Housewife 645 84.9
Government employed 83 10.9
Self-employed 24 3.1
Other * 8 1.1
Current marital status
Married 671 88.3
Single 63 8.3
Widowed 18 2.4
Other** 8 1
Educational status of the husband
No formal education 361 53.8
Primary school 202 30.1
Secondary school and above 108 16.1
Occupation of the husband
Farmer 541 80.6
Government employed 51 7.6
Self-employed 61 9.1
Other*** 18 2.7
Residence
Rural 573 75.4
Urban 187 24.6

*student
**divorced, separated
***daily labor, soldier.

https://doi.org/10.1371/journal.pone.0295220.t001

and most of the participants in the study areas are far from the health institutions, so it takes a
long time to reach them by walking without an ambulance, and it is difficult to go to a health
institution during the war. Scholars indicated that low maternal healthcare service utilization
was higher in conflict areas than in non-conflict affected areas [39]. This seems to be an impor-
tant determinant, which may preclude women from accessing delivery services.
On the other hand, the result of this study is lower than studies from the 2016 Ethiopian
Health Survey report (EDHS), where 67.2% of the mothers delivered at home [22], and
another Ethiopian pooled prevalence of 66.7% [40]. The possible justification for the difference

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

Table 2. Obstetrics and other related factors of the respondent in Gidan District, Northeastern Ethiopia, 2021
(N = 760).
Variables Frequency (n) Percentage (%)
Parity
Primipara 148 19.5
Multipara 612 80.5
Antenatal care
Yes 650 85.5
No 110 14.5
Pregnancy status
Planned 703 92.5
Unplanned 57 7.5
Membership for WDA
Yes 156 20.5
No 604 79.5

Bad obstetrics history

Yes 102 13.42
No 658 86.58
Interruption and diversion of
maternal health care service
Yes 585 76.9
No 175 23.1
Fear of COVID-19
Yes 532 70
No 228 30
Lack of transport access
Yes 103 13.6
No 657 86.4

Abbreviations; Women development army; COVID-19, coronavirus diseases.

https://doi.org/10.1371/journal.pone.0295220.t002

might be differences in the study area and source population. The current study included only
women who had ANC follow-up, while the previous studies included women who did not
have ANC follow-up. In addition to this, the decrease in home delivery in the current study
could be because the government and other supporting organizations are working strongly to
increase institutional delivery service utilization [17,21].
In addition, the strengthening of the health extension program and the implementation of
WDA facilitate maternal health care services, including institutional delivery [41]. The estab-
lishment of maternal waiting homes also played a greater role (80% of the reduction of mater-
nal deaths) in improving the current reduction in home delivery [42]. This implied that
strengthening the above activities would result in a better outcome.
Women from rural dwellers had 2.02 times more odds of delivering at home than women
from urban dwellers; this finding is consistent with studies conducted in Ethiopia [31],
Uganda [43], and Nigeria [44]. The possible reason might be that rural women were less edu-
cated and less exposed to media messages [45]. Inaccessibility of services due to a lack of trans-
portation and long distances to travel to the health institutions. Furthermore, rural women
have less decision-making autonomy, less knowledge of pregnancy complications, and less
access to information than urban women [23,46].

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

Table 3. Multi-variable regression for factors associated with home delivery in Gidan District, Northeastern, Ethi-
opia, 2021(N = 760).
Variables Home delivery COR(95%CI AOR (95%CI)
Yes No
Age (years)
<20 25 49 1.16 (0.65–2.06) 1.43(0.67–3.04)
20–25 56 141 0.90 (0.58–1.14) 0.89 (0.51–1.57)
26–30 82 224 0.83 (0.55–1.24) 0.86(0.53–1.38)
>30 56 127 1 1
Educational status respondents
No formal 111 235 2.05 (1.21–3.46) 1.47 (0.78–2.79)
Education
Primary 87 215 1.75 (1.03–3.00) 1.51 (0.81–2.29)
Secondary and above 21 91 1 1
Education of husband
No formal education 118 250 1.98(1.38–2.84) 2.60(1.72,3.91)
Formal education 58 245 1 1
Residence
Urban 43 144 1 1
Rural 176 397 1.48 (1.01–2.18) 2.02 (1.23–3.34)*
Current marital
status
Married 168 503 1 1
Unmarried 51 38 4.02 (2.55–6.33) 11.16 (4.18–29.79)*
Parity
Primipara 38 110 1 1
Multipara 181 431 1.22 (0.81–1.83) 1.38 (0.79–2.38)
Membership for WDA
Yes 36 120 1 1
No 183 421 1.45 (0.96–2.19) 1.64 (1.01–2.65)*
Fear of COVID-19
No 33 195 1 1
Yes 186 346 3.18 (2.11–479) 3.86 (2.31–6.44)*
Lack of transport
No 175 482 1 1
Yes 44 59 2.05 (1.34–3.15) 1.54 (0.90–2.64)*

Notes; *significantly associated; 1, reference.

Abbreviations; COR, crude odds ratio; AOR, adjusted odds ratio; COVID-19, coronavirus disease.

https://doi.org/10.1371/journal.pone.0295220.t003

According to the findings of this study, unmarried women were 11.16 times more likely to
deliver at home than married women. This finding is supported by other studies conducted in
Jimma [47] and Southern Ethiopia [48]. The reason behind this might be that unmarried
women do not receive support from husbands, and the health delivery system of Ethiopia
favors married women over unmarried women [30].
Pregnant women whose husbands have no formal education have higher odds of delivering
at home compared to those with formal education. This is consistent with studies reported in
our country and abroad [19,20,22,49,50]. The possible explanation might be that non-educated
husbands are more conservative towards the cultural practices of home delivery. Besides, non-
educated husbands are unaware of the difficulties and complications associated with

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

pregnancy and childbirth. As a result, they are less likely to support their wives’ use of maternal
health care services [51,52]. It suggests that education is a major key strategy to increase mater-
nal and child health care service utilization.
In this study, the odds of home delivery among women who were not involved in WDA
were 1.65 times more likely to deliver at home as compared to women who were involved in
WDA. This finding is incongruent with a study conducted in Southern Ethiopia [53]. The pos-
sible reason might be that women who are not part of WDA are less likely to discuss their
health issues, including place of birth, among each other as well as with other health care pro-
viders. Moreover, scholars found that for women who live in an area with advanced WDA net-
works, the utilization of maternal health care services, including intuitional delivery, has
greatly improved [28,29].
The findings of this study revealed that fear of COVID-19 infection was another factor that
affected the place of delivery. Women who feared COVID-19 infection had 3.84 times higher
odds of delivering at home than women who did not fear COVID-19 infection. This finding
was consistent with a study done in India [32]. The reason behind this might be low awareness
about the preventive measures for COVID-19. In addition, a study conducted in Italy among
pregnant women found that there was a fear of visiting health institutions for delivery because
of the COVID-19 infection [54].

Strengths and limitations of the study

The main strength of the current study is that being a community-based study, it might reflect
the actual experiences of the women during the study period. Even though all possible strate-
gies were used, such as providing training for data collectors, employing pretests, and using
standardized tools, the study might not be free of recall bias due to the data collected from
women about their experiences one year ago. However, the cross-sectional nature of the study
means that it cannot establish a cause-and-effect relationship. Another limitation of the cur-
rent study is that, because it used only quantitative methods, some of the factors that affect the
outcome variable may not have been addressed.

Conclusion
Even though the government tried to lower the rate of home delivery by accessing health insti-
tutions in remote areas, implementing WDA, and introducing maternal waiting home utiliza-
tion, nearly one in every three pregnant women had given birth at home among ANC-booked
women in their last pregnancy. Factors such as being a rural resident, husband’s education,
unmarried women, not being involved in WDA, and fear of acquiring COVID-19 infection
were found to be significant with home delivery. Improving the husband’s educational status,
providing information related to health institution delivery benefits during antenatal care, and
strengthening the implementation of the women’s development army, particularly among
rural and unmarried women, would decrease home childbirth practices. Future researchers
interested in the area should address why ANC-booked pregnant women preferred to deliver
at home through a qualitative approach, which might have a tremendous effect on institutional
service delivery utilization.

Supporting information
S1 File. Amharic version questionnaires.
(DOCX)

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PLOS ONE Rural residence women have home delivery during the era of COVID-19 pandemic, in Ethiopia

S2 File. English version questionnaire.

(DOCX)
S3 File. Data used for analysis including data on home delivery and associated factors.
(XLS)

Acknowledgments
We thank the University of Gondar for approving the ethical clearance. We are also pleased to
extend our appreciation to the Gidan District administrative offices, study participants, data
collectors, and supervisors.

Author Contributions
Conceptualization: Desale Bihonegn Asmamaw.
Data curation: Desale Bihonegn Asmamaw, Eskedar Getie Mekonnen.
Formal analysis: Yohannes Ayanaw Habitu, Eskedar Getie Mekonnen, Wubshet Debebe
Negash.
Funding acquisition: Desale Bihonegn Asmamaw.
Investigation: Yohannes Ayanaw Habitu.
Methodology: Desale Bihonegn Asmamaw.
Software: Desale Bihonegn Asmamaw, Yohannes Ayanaw Habitu, Eskedar Getie Mekonnen.
Supervision: Eskedar Getie Mekonnen.
Visualization: Wubshet Debebe Negash.
Writing – original draft: Desale Bihonegn Asmamaw.
Writing – review & editing: Yohannes Ayanaw Habitu, Eskedar Getie Mekonnen, Wubshet
Debebe Negash.

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