Maternal mortality remains a major challenge to health systems worldwide. According to assessment of trends in maternal mortality for 181 countries from 1980–2008, it was estimated to be 342,900 maternal deaths worldwide in 2008 decreasing from 526,300 in 1980. More than 50% of all maternal deaths were only from six countries in 2008 (India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of Congo) . Maternal deaths have both direct and indirect causes. About 80% of maternal deaths are due to causes directly related to pregnancy and childbirth . Worldwide, the major causes of maternal mortality are haemorrhage (24%), infection (15%), unsafe abortion (13%), prolonged labour (12%) and eclampsia (12%) whereas primary causes of maternal mortality in Africa are haemorrhage (34%), other direct causes (17%), infection (10%), hypertensive disorders (9%) and obstructed labour (4%), abortion (4%) and anaemia (4%) .
Major causes of maternal deaths in Ethiopia are similar to most developing countries such as infection, haemorrhage, obstructed labour, abortion and hypertension in pregnancy . At the health facility level haemorrhage (PPH) is responsible for 11% of all maternal deaths due to direct obstetric complications. The major direct obstetric complications include haemorrhage (APH & PPH), prolonged/obstructed labour and ruptured uterus, severe pre-eclampsia and eclampsia, sepsis, complications of abortion and ectopic pregnancy which account for 69% of the deaths. The proportion of deaths due to PPH that occurred in facilities is most likely due to the fact that over 90% of births take place at home, and women with PPH may not be arriving at a health facility in time .
One of the objectives of the United Nations Millennium Development Goals (MDGs) was to reduce MMR by an average of 5.5% every year over the period 1990–2015. At the global level, MMR decreased by less than 1% per year between 1990 and 2005 far below 5.5% to reach the target of MGD . Of all 8 MDGs, countries have made the least progress toward MDG 5 . Most Sub- Saharan African countries are not on track for meeting the targets pertaining to MMR. Recent estimates suggest that the average annual rate of reduction in MMR in SSA countries is less than 1% . As Ethiopian EDHS 2011 has shown, the MMR was 676 per 100,000 live births for the seven year period preceding the survey which is not significantly different from EDHS 2005 report (673 per 100,000 live births) .
The proportion of women who delivered with the assistance of a skilled birth attendant is one of the indicators in meeting the fifth MDG. In almost all countries where health professionals attend more than 80% of deliveries, MMR is below 200 per 100,000 live births . However, birth with skilled attendance was low in Southern Asia (40%) and SSA (47%), the two regions with the greatest number of maternal deaths .
In Ethiopia, the proportions of births attended by skilled personnel are very much lower than SSA. Even for women who have access to the services, the proportion of births occurring in health facilities is very low. Only 6% of births were delivered in health facilities and, there is no significant difference in proportions of delivery service utilization between EDHS 2000 and 2005; however this figure moderately increased to 10% in EDHS 2011. Twenty eight percent of mothers delivered by TBAs; while the majority of births were attended by a relative or some other person (61%) and 5% of all births were delivered without any type of assistance at all [8, 11].
The National Baseline Assessment for Emergency Obstetric and Newborn Care in 2008 indicated that skilled delivery service utilization was 7%. The majority of Ethiopian women give birth at home without skilled attendants . According to the Ethiopian health system policy, the health service delivery structure has a four-tier system. This includes Primary Health Care Unit (PHCU), District Hospital, Zonal Hospital and Specialized Hospital. The PHCU includes one health center and five health posts. Each health post provides services to 5,000 people and is staffed by health extension workers. One health center serves a total 25,000 people and is led by a health officer. The PHCU provides comprehensive, integrated and community-based preventive and basic curative services. District Hospital functions as a referral and training center for ten PHCUs. Zonal Hospitals provide specialist services and training while Specialized Hospitals provide comprehensive specialist services, and in some instances serve as centers for research and post basic training. Maternal health services, especially delivery care, are given in health centers and at hospital level but not in health posts .
Institutional delivery service utilization in Amhara region was about 3.5% in EDHS 2005 which in turn was much lower than the national level . In EDHS 2011 it has increased to 10.2% . Hence, this study was conducted to determine the status of skilled delivery service utilization and associated factors in Sekela District, Amhara Regional State, Ethiopia.