Missed opportunities and associated factors for institutional delivery services among women in Hararghe eastern Ethiopia a mixed methods study

Maternal mortality remains high globally, with 94% of deaths in low-resource settings. In Ethiopia, only 48% of births take place in health facilities, and just 25-35% in Hararghe. Despite contact with health services, many women still miss institutional deliveries. This study aimed to quantitatively identify factors associated with non-institutional delivery and qualitatively explore contextual, behavioral, and health system factors influencing maternal health service utilization, integrating findings to provide a comprehensive understanding of barriers to institutional delivery. A convergent parallel mixed-methods study with equal weighting of quantitative and qualitative strands (QUAN + QUAL) was conducted in Grawa, Meta, and Haramaya woredas from September 5 to December 5, 2017. For the quantitative component, 357 women who had attended at least one ANC visit were included to identify factors associated with non-institutional delivery. Data were entered into EpiData version 3.1 and analyzed using SPSS version 25, applying multivariable logistic regression at p < 0.05. For the qualitative component, purposive sampling was used to select participants for key informant interviews and eight focus group discussions. Thematic analysis was conducted using Atlas.ti version 8.2. Findings from both strands were integrated during interpretation through triangulation to generate complementary and corroborative insights. Among the 357 ANC-attending women, 41.2% (95% CI: 36.2-46.5) delivered outside health facilities, reflecting a missed opportunity for skilled birth attendance. Notably, women residing in urban areas were significantly more likely to have non-institutional deliveries (AOR = 4.82, 95% CI: 1.97-11.79). Maternal age between 26 and 34 years (AOR = 3.87, 95% CI: 1.18-12.72) and attending fewer than four ANC visits (AOR = 3.26, 95% CI: 1.02-10.39) were also associated with higher odds of non-institutional delivery. Conversely, spontaneous vaginal delivery was linked to lower odds of non-institutional delivery (AOR = 0.18, 95% CI: 0.07-0.44). Meanwhile, respectful treatment and ambulance access showed no statistically significant associations with delivery location. ANC attendance, more than one-quarter of women experienced missed opportunities for institutional delivery, indicating that service contact alone is insufficient to ensure facility-based birth. This underscores persistent gaps in Ethiopia's efforts to achieve universal facility-based delivery, particularly in rural and underserved areas. Key factors influencing institutional delivery included urban residence, previous delivery experience, antenatal care (ANC) attendance, and maternal age, suggesting that mere contact with health services does not guarantee facility-based births.