Factors influencing skilled birth attendant utilization among teenage mothers in Lira District, Northern Uganda: a cross-sectional study

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Despite national interventions, home deliveries persist in rural areas like Lira District. This study aimed to determine the utilization level of skilled birth attendants (SBAs) and its associated factors among teenage mothers in this region. Methods: A community-based cross-sectional study was conducted in Lira District from June 2023 to June 2024. Using quota sampling, 316 teenage mothers (aged 13-19 years) who had delivered within the past 12 months were recruited from health facility young child clinics and community immunization outreach posts. Data were collected through interviewer-administered structured questionnaires. Analysis was performed using STATA version 17, employing multivariate logistic regression to identify independent predictors at a 95% confidence interval and p<0.05. Results: Of the 316 participants, 57.3% utilized an SBA for their most recent delivery. Multivariate analysis revealed three key independent predictors. Firstly, educational attainment was a strong enabler: teenage mothers with secondary education had over four times higher odds of SBA use compared to those with no education (AOR=4.45, 95% CI: 1.39-14.25, p=0.012). Secondly, health system trust was critical; a reported lack of trust in providers reduced the odds of SBA utilization by 88% (AOR=0.12, 95% CI: 0.04-0.36, p<0.001). Thirdly, socio-cultural influence was paramount: when family members (versus community elders) influenced the delivery location decision, the odds of choosing a traditional birth attendant over an SBA increased ninefold (AOR=9.04, 95% CI: 3.16-25.81, p<0.001). Conclusions: While over half of teenage mothers utilized SBAs, significant barriers persist. Educational attainment, trust in the health system, and socio-cultural dynamics, particularly family influence, are critical modifiable factors. Interventions must prioritize building respectful, adolescent-friendly health services, enhancing community and family education, and developing pragmatic policies regarding traditional birth practices to improve skilled birth attendance and reduce maternal risks. Skilled birth attendant Teenage mothers Maternal health Utilization Uganda Cross-sectional study Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Globally, maternal health remains a critical public health challenge, with an estimated 287,000 women dying annually from pregnancy and childbirth-related complications, the vast majority (94%) in low- and middle-income countries [ 1 , 2 ]. The World Health Organization (WHO) advocates for skilled birth attendance (SBA) as a cornerstone strategy to prevent maternal and neonatal mortality, defining an SBA as an accredited health professional educated and trained to manage normal pregnancies, childbirth, and the immediate postnatal period, and to identify and refer complications [ 3 , 4 ]. Despite global efforts, the Sustainable Development Goal (SDG) target 3.1 to reduce the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030 remains elusive in many regions [ 5 ]. In sub-Saharan Africa (SSA), coverage of skilled attendance at birth remains low, with significant disparities between and within countries [ 6 , 7 ]. Approximately 50% of deliveries in SSA occur outside health facilities, often assisted by traditional birth attendants (TBAs) or family members [ 8 ]. These home births are associated with increased risks of obstetric complications, such as hemorrhage, sepsis, and obstructed labor, leading to higher maternal and neonatal morbidity and mortality [ 9 , 10 ]. Uganda has made notable progress, reducing its MMR from 336 to 189 deaths per 100,000 live births between 2016 and 2022 [ 11 ]. However, this figure is still high, and the country continues to grapple with preventable deaths. Teenage pregnancy, with a prevalence of 25% among adolescents aged 15–19, is a major contributing factor to poor maternal health outcomes [ 11 , 12 ]. Adolescent mothers face a heightened biological risk of complications like pre-eclampsia, eclampsia, low birth weight, and preterm delivery [ 13 , 14 ]. Furthermore, they encounter significant social stigma, economic vulnerability, and reduced autonomy in healthcare decision-making, which collectively deter them from seeking skilled care [ 15 , 16 ]. The Lango sub-region in Northern Uganda, where Lira District is located, presents a context of particular concern. This region is emerging from a protracted period of conflict and faces challenges of poverty, limited infrastructure, and cultural practices that influence health-seeking behavior [ 17 , 18 ]. District Health Information System 2 (DHIS2) data indicates that 62.7% of mothers in Lira District deliver at home, with 15% of these being teenagers [ 19 ]. This is despite government policies like the provision of free maternity services and the establishment of lower-level health centres (HC IIIs and IVs) to improve geographic access [ 20 , 21 ]. The persistence of home deliveries suggests that factors beyond physical availability and cost are at play. Previous studies in Uganda have identified a range of factors affecting maternal health service utilization, including distance to facilities, cost, education, and cultural beliefs [ 22 , 23 ]. Specific studies in Northern Uganda have examined issues like placental malaria, unintended pregnancy among HIV-positive women, and antenatal care (ANC) initiation [ 24 – 26 ]. Research in Lira has also explored factors associated with teenage pregnancy among refugees and sexual reproductive health service utilization among youth [ 27 , 28 ]. However, a focused, quantitative investigation into the specific determinants of SBA utilization among the vulnerable demographic of teenage mothers in the rural, post-conflict setting of Lira District is lacking. Understanding the interplay of socio-demographic, health system, cultural, and economic factors is crucial for designing effective, context-specific interventions to improve skilled birth attendance and ultimately reduce maternal and perinatal mortality in line with SDG 3 and national health targets [ 29 , 30 ]. This study, therefore, aimed to determine the level of SBA utilization and its associated factors among teenage mothers in Lira District, Northern Uganda. Methods Study design and setting A community-based cross-sectional study was conducted in Lira District, Northern Uganda, from June 2023 to June 2024. A cross-sectional design was chosen as it is efficient for determining the prevalence of an outcome (SBA utilization) and its association with various factors at a single point in time [31]. Lira District is located about 350 km north of Kampala (Fig. 1). It is predominantly rural, with subsistence farming as the main economic activity. Administratively, the district has 11 sub-counties, 68 parishes, and 587 villages, with a projected population of over 250,000 [32]. The district is served by 14 health facilities, including two Health Centre IVs (which act as Health Sub-District hubs), five Health Centre IIIs, and several lower-level facilities (Fig. 2). Conceptual Framework The study was guided by a conceptual framework adapted from Dantas et al. [6] and modified by the researcher (2023) (Fig. 3). The framework posits that the utilization of SBAs among teenage mothers is influenced by a constellation of interrelated factors, which act as either barriers or facilitators. These factors are categorized into four main domains: Socio-demographic factors: Includes age, marital status, education level, employment, and religion, which shape an individual's resources, autonomy, and exposure to health information. Health system factors: Encompasses availability, accessibility, acceptability, and quality of care. This includes distance to facilities, trust in providers, waiting times, and the behavior of health workers. Cultural factors: Involves community norms, traditional beliefs, practices surrounding childbirth (e.g., delivery position, placenta disposal), and the influence of family members and TBAs on decision-making. Socio-economic factors: Relates to family income, affordability of services and transport, out-of-pocket payments, and control over financial resources. The interplay of these factors ultimately determines the choice of delivery attendant (SBA vs. TBA/home), which has direct consequences for maternal and perinatal health outcomes. Study population and sampling The study population comprised teenage mothers aged 13-19 years who were residents of Lira District and had delivered a live baby within the 12 months preceding the study. Mothers who were visibly ill or had severe communication challenges were excluded. The sample size was calculated using the Kish Leslie formula for cross-sectional studies: n=Z²*P(1−P)/E² [33]. Where: n = required sample size, Z = 1.96 (95% confidence level), P = 0.189 (estimated prevalence of teenage pregnancies attending ANC based on MOH 2020 data), E = 0.05 (margin of error). This yielded a minimum sample of 235. A design effect of 1.5 was applied to adjust for the cluster sampling approach (sampling from different health facility catchments), giving a final sample size of 353 [34]. A quota sampling technique was employed (Table 1). All 14 health facilities in the district and their associated community immunization outreach posts were included as sampling clusters. Quotas were allocated proportionally to the level of the health facility (HC II, III, IV) based on patient volume, with larger facilities receiving higher quotas. Within each facility and outreach post, teenage mothers meeting the eligibility criteria were recruited consecutively until the facility-specific quota was filled. This method ensured representation from both facility-based (Young Child Clinic attendees) and community-based populations. Table 1 Participant quotas by the level of health facilities SN Level of health facility Number of health facilities plus their community immunization outreach posts Set target number of participants 1 Health centre IIs 7 100 2 Health centre IIIs 5 153 3 Health centre IVs 2 100 Total 14 353 Data collection tools and procedures Data were collected using a pre-tested, structured questionnaire administered face-to-face by four trained research assistants in the local language (Leb Lango). The tool was developed based on the conceptual framework and reviewed for content validity by experts in midwifery and public health. It covered: Section A: Socio-demographic characteristics. Section B: Health system factors (distance, transport, trust, waiting times, provider type, knowledge of SBA benefits). Section C: Cultural factors (beliefs, TBA presence and influence, decision-makers, birth preparedness). Section D: Economic factors (income, transport cost, out-of-pocket payments, financial control). Section E: Utilization of SBA (timing and frequency of ANC, place of last delivery, attendant type). The primary outcome variable was utilization of SBA, operationally defined as delivery of the last baby in a health facility (coded as 1), as opposed to delivery at home or with a TBA (coded as 0). Data quality control The questionnaire was pre-tested on 10 teenage mothers from a neighboring community to ensure clarity, flow, and cultural appropriateness; these respondents were not included in the main study. Research assistants underwent a two-day training covering the study objectives, ethical conduct, interview techniques, and data handling. The principal investigator provided ongoing supervision and spot-checked completed questionnaires daily for completeness and consistency. Data analysis Data were entered into SPSS version 23, cleaned, and exported to STATA version 17 for analysis. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize the data. Bivariate analysis using the Chi-square test (or Fisher's exact test where appropriate) and crude odds ratios (COR) with 95% confidence intervals (CI) was performed to identify candidate variables for multivariate analysis (see additional files 1-4). All variables with a p-value < 0.05 at the bivariate level were entered into a multivariate binary logistic regression model using a backward stepwise elimination method to identify independent predictors of SBA utilization. Results were reported as adjusted odds ratios (AOR) with 95% CI. The threshold for statistical significance was set at p < 0.05. Ethical considerations Ethical approval was obtained from the Lira University Research Ethics Committee (LUREC-2023-95). Administrative permission was secured from the Lira District Health Office and the in-charges of all participating health facilities. Written informed consent was obtained from all participants. For participants aged 13-17 years, assent was obtained alongside written consent from a parent or guardian. Participants were assured of confidentiality, and data were anonymized using identification numbers. They were informed of their right to withdraw at any time without penalty. Results Socio-demographic characteristics of participants A total of 316 teenage mothers participated, giving a response rate of 89.5% (316/353). Their background characteristics are shown in Table 2. The mean age was 17.9 years (SD=0.93), with 64.2% (n=203) aged 18-19. Over half (51.9%, n=164) were single, and 44.0% (n=139) were married. The majority (65.5%, n=207) had only a primary level of education, while 15.2% (n=48) had no formal education. Most participants were peasants (62.3%, n=197), and Anglicans constituted the largest religious group (45.3%, n=143). Table 2 Background Characteristics of Study Participants Variable Frequency (%) Current age in years 17.9 (0.927) Age category in years 13-17 113 (35.8%) 18-19 203 (64.2%) Marital status Married 139 (44.0%) Single 164 (51.9%) Divorced 13 (4.1%) Highest level of education completed None 48 (15.2%) Primary 207 (65.5%) Secondary 51 (16.1%) Tertiary 10 (3.2%) Current employment status Housewife 107 (33.9%) Peasant 197 (62.3%) Others 12 (3.8%) Religious affiliation Anglican 143 (45.3%) Catholics 97 (30.7%) Muslim 53 (16.7%) Pentecostals 23 (7.3%) Level of Antenatal Care and Skilled Birth Attendant utilization Antenatal care utilization was suboptimal (Table 3). A majority (54.7%, n=173) initiated their first ANC visit after 14 weeks of gestation, and 64.6% (n=204) attended fewer than the recommended four ANC visits. However, 62.7% (n=198) reported having knowledge about delivery conducted by health workers. Concerning the primary outcome, 57.3% (n=181) of teenage mothers delivered their last baby in a health facility with an SBA, while 42.7% (n=135) delivered at home or with a TBA (Fig. 4). Table 3 Level of Utilization of ANC Services Utilization of ANC services Frequency(%) Weeks of gestation started visiting ANC 14 and above 173 (54.7%) 0-13 weeks 143 (45.3%) Number of ANC Visits 4 112 (35.4%) Have any knowledge on delivery conducted by health workers No 118 (37.3%) Yes 198 (62.7%) Place of delivery for your current baby Home/TBA 135 (42.7%) Health facility 181 (57.3%) Factors associated with Skilled Birth Attendant utilization The bivariate analyses for socio-demographic, health system, cultural, and economic factors are presented in Additional Files 1-4, respectively. Key findings from the multivariate logistic regression (Table 4) are summarized below. Socio-demographic factors: In the multivariate model, after adjusting for other factors, having a secondary education remained a significant independent predictor (AOR=4.45, 95% CI: 1.39-14.25, p=0.012) compared to having no education. Health system factors: Trust emerged as a critical factor. Teenagers who reported a lack of trust in healthcare providers had 88% lower odds of utilizing SBAs in the multivariate model (AOR=0.12, 95% CI: 0.04-0.36, p<0.001). Cultural factors: Cultural factors were strongly influential. The most powerful cultural predictor was the influence of family members on the delivery location decision. Compared to decisions influenced by community elders, decisions influenced by family members resulted in nine times higher odds of opting for a TBA over an SBA (AOR=9.04, 95% CI: 3.16-25.81, p<0.001). Economic factors: Economic factors such as family income, transport costs, and challenges with healthcare affordability did not retain statistical significance in the multivariate logistic regression model. Table 4 Multivariate analysis of predictors of Utilization of Skilled Birth Attendants by teenage mothers Variable COR [95% CI] p-value AOR [95% CI] p-value Highest education level attained None 1.00 1.00 Primary 1.41 0.75-2.65 0.282 1.54 0.67-3.57 0.311 Secondary 2.60 1.14-5.96 0.023* 4.45 1.39-14.25 0.012* Tertiary 1.09 0.28-4.25 0.905 1.34 0.23-7.67 0.744 Religion Anglican 1.00 1.00 Catholics 0.66 0.39-1.12 0.125 0.55 0.27-1.10 0.089 Muslim 0.60 0.32-1.14 0.117 1.01 0.39-2.62 0.983 Pentecostals 1.77 0.66-4.76 0.238 1.00 Trust in Health Provider Yes 1.00 1.00 No 0.39 0.19-0.79 0.010* 0.12 0.04-0.36 <0.001* Culture Influences not to reveal pregnancy early Yes 1.00 1.00 No 1.88 1.08-3.25 0.250 1.48 0.69-3.17 0.315 TBA Influences decision Moderately influential 1.00 1.00 Slightly influential 0.61 0.32-1.18 0.142 0.50 0.21-1.20 0.120 Not influential at all 1.02 0.55-1.89 0.955 1.06 0.46-2.41 0.893 Decision maker regarding utilization of TBA Community Elder 1.00 1.00 Family Member 5.01 2.35-10.65 <0.001* 9.04 3.16-25.81 <0.001* My Husband 1.20 0.69-2.10 0.515 1.40 0.65-2.98 0.387 Pregnant women 1.14 0.59-2.20 0.695 0.90 0.34-2.38 0.834 Place of delivery (TBA or health facility TBAs / Home 42.7 37.4 -48.3 1.00 1.00 Health facility 57.3 51.7-62.6 <0.020* 1.64 0.98-2.74 <0.020* *: Variable significant at 5%; AOR=Adjusted odds ratio; CI: Confidence interval Discussion This cross-sectional study among 316 teenage mothers in Lira District found that 57.3% utilized a skilled birth attendant for their most recent delivery. While this indicates that more than half of this vulnerable group accessed professional care, it also reveals that a substantial proportion (42.7%) remained at elevated risk by delivering at home or with a TBA. This utilization rate is higher than the 38% reported among adolescents in Ethiopia [35] and the 47% found in a study from Bubaare Sub-County, Uganda [36], but lower than the 69% reported in Ghana [37] and the 75.3% regional average for adolescents in SSA [38]. This disparity underscores the context-specific nature of maternal health service uptake and the need for localized interventions. A key finding was the strong positive association between secondary education and SBA utilization. Teenage mothers with secondary education had over four times the odds of using an SBA compared to those with no formal education (AOR=4.45, p=0.012). This aligns robustly with the global literature where maternal education is consistently one of the most powerful social determinants of health service use [39, 40]. Education likely empowers young women with health knowledge, improves their ability to comprehend health messages, increases self-efficacy, and may enhance their negotiation power within households [16, 41,42]. This finding reinforces the imperative of keeping girls in school as a fundamental strategy for improving maternal health outcomes. Perhaps the most striking finding was the profound role of trust in the healthcare system. Teenage mothers who lacked trust in providers had 88% lower odds of utilizing SBAs (AOR=0.12, p<0.001). This echoes qualitative and quantitative studies from similar settings where disrespect, verbal abuse, and neglect by health workers were primary deterrents to facility-based delivery [43, 44,45]. For teenage mothers, who may already feel stigmatized and fearful of judgment, negative encounters with health providers can be particularly devastating [46]. This highlights a critical breakdown in the acceptability dimension of healthcare access. Improving "respectful maternity care" is not merely an ethical imperative but a practical necessity for increasing service utilization [47]. The influence of cultural and familial factors was powerfully demonstrated. The significant association between the presence of TBAs in the community and lower SBA use reflects the entrenched role of traditional practitioners. More importantly, the decision-making power of family members emerged as the strongest predictor in the cultural domain. When family members influenced the delivery location decision, the odds of using a TBA skyrocketed (AOR=9.04, p<0.001). This underscores that childbirth is often viewed as a familial or communal event rather than an individual health decision, with elder women frequently holding sway [48, 49,50]. This suggests that interventions targeting only the pregnant adolescent are insufficient; they must engage families and the wider community to shift social norms. Contrary to many studies [51, 52], direct economic factors were not independent predictors in the final model. This may be partially attributed to Uganda's policy of free maternity services in public health facilities, which could mitigate direct financial barriers for some. However, it may also indicate that in this context, socio-cultural and health system barriers (trust, education, family influence) outweigh pure economic constraints for teenage mothers. Indirect costs and economic dependence, which limit autonomy, may still be influential [53]. Implications for Policy and Practice The findings have several implications: For health systems: There is an urgent need to institutionalize training in adolescent-friendly and respectful maternity care for all maternal health providers. Supervision and accountability mechanisms to ensure compassionate treatment must be strengthened. For education and community engagement: Beyond formal schooling, targeted health education campaigns should be directed at teenagers, their partners, and especially influential family elders. Community dialogues involving local leaders and reformed TBAs could help bridge the gap between traditional and biomedical systems. For policy: The study reveals the limited impact of Uganda's ban on TBA practice. A pragmatic policy review to explore regulated integration, training, and formal linkage of TBAs to the health system for promotion and referral could be more effective than unenforceable prohibition [54]. Limitations This study has limitations. The cross-sectional design cannot establish causality. Social desirability bias may have led to under-reporting of home deliveries or over-reporting of trust in providers. The quota sampling method, while practical, may limit the generalizability of findings. Furthermore, the study did not capture the perspectives of health workers or TBAs, whose views would provide a more complete understanding of the service environment. Despite these limitations, the study provides valuable quantitative evidence on a critically under-researched population in a specific geographic context. Conclusions In conclusion, this study reveals that while a majority of teenage mothers in Lira District utilize skilled birth attendants, a significant vulnerable minority does not. The pathway to skilled care is significantly shaped by the teenager's educational attainment, the level of trust in the health system, and powerful socio-cultural dynamics, particularly decision-making influence wielded by family members. To accelerate progress towards universal skilled birth attendance and improve maternal outcomes among adolescents, interventions must adopt a multi-level approach. This should include ensuring respectful, stigma-free care within health facilities, implementing community-based programs to educate and empower families, and revisiting policies to constructively engage with existing traditional birth practices. Empowering teenage mothers through education and building a trustworthy health system are indispensable strategies for safeguarding their health during childbirth. Abbreviations ANC: Antenatal Care AOR: Adjusted Odds Ratio CI: Confidence Interval COR: Crude Odds Ratio DHIS2: District Health Information System 2 HC: Health Centre LUREC: Lira University Research Ethics Committee MMR: Maternal Mortality Ratio SBA: Skilled Birth Attendant SDG: Sustainable Development Goal SPSS: Statistical Package for the Social Sciences SSA: Sub-Saharan Africa TBA: Traditional Birth Attendant VHT: Village Health Team WHO: World Health Organization. Declarations Ethics approval and consent to participate Ethical approval was granted by the Lira University Research Ethics Committee (Ref: LUREC-2023-95). Written informed consent was obtained from all participants. For participants under 18 years, assent was obtained alongside written consent from a parent or guardian. All methods were performed in accordance with the relevant guidelines and regulations (Helsinki Declaration). Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article (and its supplementary information files). Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. It was self-funded by the principal investigator. Authors' contributions EA: Conceptualization, methodology, investigation, data curation, formal analysis, writing original draft. J PB : Data curation, formal analysis, writing original draft. WI: Supervision, validation, writing review & editing. BO : Data curation, formal analysis, writing original draft. EK: Supervision, methodology, validation, writing review & editing. All authors read and approved the final manuscript. Acknowledgements The authors sincerely thank the Lira University Research Ethics Committee, the Lira District Health Office, and the in-charges of all participating health facilities for their administrative support. We are deeply grateful to the research assistants for their diligent work and, most importantly, to the teenage mothers who generously shared their time and personal experiences for this study. References World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. Kassebaum NJ, Barber RM, Bhutta ZA, Dandona L, Gething PW, Hay SI, et al. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1775-812. World Health Organization. WHO recommendations on health promotion interventions for maternal and newborn health. 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Early age at first childbirth and skilled birth attendance during delivery among young women in sub-Saharan Africa. BMC Pregnancy Childbirth. 2021;21(1):216. Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: implications for maternal health service utilization in developing countries. PLoS One. 2010;5(6): e11190. Kabir S, Hasan MR, Hossain MI, Suraiya S, Islam FB, Nayan MIH, et al. Determinants and Trends of Health Facility Delivery in Bangladesh: A Hierarchical Modeling Approach. Biomed Res Int. 2022; 2022:1359572. Speizer IS, Story WT, Singh K. Factors associated with institutional delivery in Ghana: The role of decision-making autonomy and community norms. BMC Pregnancy Childbirth. 2014; 14:398. Yeshitila YG, Memah P. Birth preparedness and complication readiness among husbands and its association with skilled birth attendance in southern Ethiopia. BMC Pregnancy Childbirth. 2022;22(1):881. Ukke GG, Gurara MK, Boynito WG. Disrespect and abuse of women during childbirth in public health facilities in Arba Minch town, south Ethiopia—a cross-sectional study. PLoS One. 2019;14(4): e0205545. Atukunda EC, Musiimenta A, Atuhumuza E, Mugyenyi GR, Obua C. Experiences of disrespect and abuse during facility-based childbirth in southwest Uganda. Int J Gynaecol Obstet. 2022;156(2):276-284. Jebena MG, Tesfaye M, Abashula G, Balina S, Jackson R, Assefa Y, et al. Barriers and facilitators of maternal health care services use among pastoralist women in Ethiopia: Systems thinking perspective. Pastoralism. 2022;12(1):27. Shiferaw BB, Modiba LM. Why do women not use skilled birth attendance service? An explorative qualitative study in north West Ethiopia. BMC Pregnancy Childbirth. 2020;20(1):496. Sockol LE, Battle CL, Howard M, Davis T. Improving perinatal mood and anxiety disorders through integrated infant mental health care in obstetrics: evidence from a program evaluation study. J Reprod Infant Psychol. 2022;40(3):225-239. Sumankuuro J, Mahama MY, Crockett J, Wang S, Young J. Narratives on why pregnant women delay seeking maternal health care during delivery and obstetric complications in rural Ghana. BMC Pregnancy Childbirth. 2019;19(1):260. Sychareun V, Hansana V, Somphet V, Xayavong S, Phengsavanh A, Popenoe R. Reasons rural Laotians choose home deliveries over delivery at health facilities: a qualitative study. BMC Pregnancy Childbirth. 2012; 12:86. Muzzafar S, Soofi SB, Khan GN, Hussain I, Rizvi A, Usmani MA, et al. Factors associated with home delivery in rural Sindh, Pakistan: results from the global network birth registry. BMC Pregnancy Childbirth. 2022;22(1):462. Chukwuma A, Wosu AC, Mbachu C, Weze K. Quality of antenatal care predicts retention in skilled birth attendance: A multilevel analysis of 28 African countries. BMC Pregnancy Childbirth. 2017;17(1):152. Yoseph S, Dache A, Dona A, Dheresa M. Opportunity cost of skilled delivery care in rural Ethiopia: A community-based cross-sectional study. BMC Health Serv Res. 2020;20(1):960. Towongo MF, Ngome E, Navaneetham K, Letamo G. Individual and community-level factors associated with women's utilization of postnatal care services in Uganda, 2016: a multilevel and spatial analysis. BMC Health Serv Res. 2024;24(1):185. Sarker BK, Rahman M, Rahman T, Hossain J, Reichenbach L, Mitra DK. Strengths of community and health facilities based interventions in improving women and adolescents' care seeking behaviors as approaches for reducing maternal mortality and improving birth outcome among low income communities of Egypt. BMC Public Health. 2020;20(1):577. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additional Files Additional File 1: Table S1Bivariate analysis for associations between the teenage mother’s socio-demographic factors and the utilization of Skilled Birth Attendants. Additionalfile2.docx Additional File 2: Table S2Bivariate analysis for associations between health system factors and utilization of Skilled Birth Attendants among teenage mothers. Additionalfile3.docx Additional File 3: Table S3Bivariate analysis for associations between cultural factors and utilization of Skilled Birth Attendants among the teenage mothers. Additionalfile4.docx Additional File 4: Table S4Bivariate analysis for associations between economic factors and utilization of Skilled Birth Attendants among the teenage mothers. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 01 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviews received at journal 24 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers invited by journal 20 Jan, 2026 Editor invited by journal 28 Dec, 2025 Editor assigned by journal 25 Dec, 2025 Submission checks completed at journal 25 Dec, 2025 First submitted to journal 13 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8353863","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":560560312,"identity":"11c09b06-3d37-4230-9b5f-0365e55db1bc","order_by":0,"name":"Edmonton 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1","display":"","copyAsset":false,"role":"figure","size":384147,"visible":true,"origin":"","legend":"\u003cp\u003eMap of Uganda showing Lira District in Northern Uganda (adapted from District Biostatistician Lira)\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8353863/v1/2555fcd2a29d808a5657ceed.png"},{"id":98305176,"identity":"3f647845-e3b0-4601-9c59-4addacb04683","added_by":"auto","created_at":"2025-12-16 11:00:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":43430,"visible":true,"origin":"","legend":"\u003cp\u003eMap of Lira District showing administrative sub-counties and major health facility locations.\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8353863/v1/981a5a6408017a421fb2860c.png"},{"id":98436388,"identity":"e3330c32-5d82-4e16-962c-099bd47894eb","added_by":"auto","created_at":"2025-12-17 16:55:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":136789,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual framework for the study on factors influencing the utilization of skilled birth attendants among teenage mothers in Lira District (Adapted from Dantas et al., 2020).\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8353863/v1/f4df768022c11bc4f02aeab4.png"},{"id":98436717,"identity":"57ec9c5e-ec8f-44a0-ac8a-551b5637aee8","added_by":"auto","created_at":"2025-12-17 16:56:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":11659,"visible":true,"origin":"","legend":"\u003cp\u003eLevel of skilled birth attendant utilization among teenage mothers in Lira District, Northern Uganda (n=316).\u003c/p\u003e","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8353863/v1/7a879ab836fe165ec221b82a.png"},{"id":98445427,"identity":"fa908d0e-fece-4b45-af8e-259fc28fa0da","added_by":"auto","created_at":"2025-12-17 17:19:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1799660,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8353863/v1/d5379176-3589-46ac-8792-27170bd806aa.pdf"},{"id":98305179,"identity":"3d3127d2-2d11-4ff4-9e53-16196282c5c6","added_by":"auto","created_at":"2025-12-16 11:00:07","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14740,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional Files\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional File 1: Table S1\u003c/strong\u003eBivariate analysis for associations between the teenage mother’s socio-demographic factors and the utilization of Skilled Birth Attendants.\u003c/p\u003e","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8353863/v1/21f4b327d48ac69e761aaef7.docx"},{"id":98436711,"identity":"f9570b07-79e9-4d4f-9bee-1544695498ea","added_by":"auto","created_at":"2025-12-17 16:56:07","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15175,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional File 2: Table S2\u003c/strong\u003eBivariate analysis for associations between health system factors and utilization of Skilled Birth Attendants among teenage mothers.\u003c/p\u003e","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8353863/v1/47f6426c9b81fae2ccfa945d.docx"},{"id":98305198,"identity":"d180687e-c631-4081-bcc6-02015f73677f","added_by":"auto","created_at":"2025-12-16 11:00:08","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15104,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional File 3: Table S3\u003c/strong\u003eBivariate analysis for associations between cultural factors and utilization of Skilled Birth Attendants among the teenage mothers.\u003c/p\u003e","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8353863/v1/4335bd17d118eda8a7fdff05.docx"},{"id":98437429,"identity":"5b0fccf4-a25c-4f1d-ba3f-c49ecd166617","added_by":"auto","created_at":"2025-12-17 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and middle-income countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The World Health Organization (WHO) advocates for skilled birth attendance (SBA) as a cornerstone strategy to prevent maternal and neonatal mortality, defining an SBA as an accredited health professional educated and trained to manage normal pregnancies, childbirth, and the immediate postnatal period, and to identify and refer complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite global efforts, the Sustainable Development Goal (SDG) target 3.1 to reduce the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030 remains elusive in many regions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn sub-Saharan Africa (SSA), coverage of skilled attendance at birth remains low, with significant disparities between and within countries [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Approximately 50% of deliveries in SSA occur outside health facilities, often assisted by traditional birth attendants (TBAs) or family members [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These home births are associated with increased risks of obstetric complications, such as hemorrhage, sepsis, and obstructed labor, leading to higher maternal and neonatal morbidity and mortality [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUganda has made notable progress, reducing its MMR from 336 to 189 deaths per 100,000 live births between 2016 and 2022 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, this figure is still high, and the country continues to grapple with preventable deaths. Teenage pregnancy, with a prevalence of 25% among adolescents aged 15\u0026ndash;19, is a major contributing factor to poor maternal health outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Adolescent mothers face a heightened biological risk of complications like pre-eclampsia, eclampsia, low birth weight, and preterm delivery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, they encounter significant social stigma, economic vulnerability, and reduced autonomy in healthcare decision-making, which collectively deter them from seeking skilled care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Lango sub-region in Northern Uganda, where Lira District is located, presents a context of particular concern. This region is emerging from a protracted period of conflict and faces challenges of poverty, limited infrastructure, and cultural practices that influence health-seeking behavior [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. District Health Information System 2 (DHIS2) data indicates that 62.7% of mothers in Lira District deliver at home, with 15% of these being teenagers [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This is despite government policies like the provision of free maternity services and the establishment of lower-level health centres (HC IIIs and IVs) to improve geographic access [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The persistence of home deliveries suggests that factors beyond physical availability and cost are at play.\u003c/p\u003e \u003cp\u003ePrevious studies in Uganda have identified a range of factors affecting maternal health service utilization, including distance to facilities, cost, education, and cultural beliefs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Specific studies in Northern Uganda have examined issues like placental malaria, unintended pregnancy among HIV-positive women, and antenatal care (ANC) initiation [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Research in Lira has also explored factors associated with teenage pregnancy among refugees and sexual reproductive health service utilization among youth [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, a focused, quantitative investigation into the specific determinants of SBA utilization among the vulnerable demographic of teenage mothers in the rural, post-conflict setting of Lira District is lacking. Understanding the interplay of socio-demographic, health system, cultural, and economic factors is crucial for designing effective, context-specific interventions to improve skilled birth attendance and ultimately reduce maternal and perinatal mortality in line with SDG 3 and national health targets [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This study, therefore, aimed to determine the level of SBA utilization and its associated factors among teenage mothers in Lira District, Northern Uganda.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA community-based cross-sectional study was conducted in Lira District, Northern Uganda, from June 2023 to June 2024. A cross-sectional design was chosen as it is efficient for determining the prevalence of an outcome (SBA utilization) and its association with various factors at a single point in time [31]. Lira District is located about 350 km north of Kampala (Fig. 1). It is predominantly rural, with subsistence farming as the main economic activity. Administratively, the district has 11 sub-counties, 68 parishes, and 587 villages, with a projected population of over 250,000 [32]. The district is served by 14 health facilities, including two Health Centre IVs (which act as Health Sub-District hubs), five Health Centre IIIs, and several lower-level facilities (Fig. 2).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eConceptual Framework\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study was guided by a conceptual framework adapted from Dantas et al. [6] and modified by the researcher (2023) (Fig. 3). The framework posits that the utilization of SBAs among teenage mothers is influenced by a constellation of interrelated factors, which act as either barriers or facilitators. These factors are categorized into four main domains:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocio-demographic factors:\u003c/strong\u003e Includes age, marital status, education level, employment, and religion, which shape an individual\u0026apos;s resources, autonomy, and exposure to health information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth system factors:\u003c/strong\u003e Encompasses availability, accessibility, acceptability, and quality of care. This includes distance to facilities, trust in providers, waiting times, and the behavior of health workers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural factors:\u003c/strong\u003e Involves community norms, traditional beliefs, practices surrounding childbirth (e.g., delivery position, placenta disposal), and the influence of family members and TBAs on decision-making.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocio-economic factors:\u003c/strong\u003e Relates to family income, affordability of services and transport, out-of-pocket payments, and control over financial resources.\u003c/p\u003e\n\u003cp\u003eThe interplay of these factors ultimately determines the choice of delivery attendant (SBA vs. TBA/home), which has direct consequences for maternal and perinatal health outcomes.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eStudy population and sampling\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study population comprised teenage mothers aged 13-19 years who were residents of Lira District and had delivered a live baby within the 12 months preceding the study. Mothers who were visibly ill or had severe communication challenges were excluded.\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated using the Kish Leslie formula for cross-sectional studies: n=Z\u0026sup2;*P(1\u0026minus;P)/E\u0026sup2; [33].\u003cbr\u003e\u0026nbsp;Where: n = required sample size, Z = 1.96 (95% confidence level), P = 0.189 (estimated prevalence of teenage pregnancies attending ANC based on MOH 2020 data), E = 0.05 (margin of error). This yielded a minimum sample of 235. A design effect of 1.5 was applied to adjust for the cluster sampling approach (sampling from different health facility catchments), giving a final sample size of 353 [34].\u003c/p\u003e\n\u003cp\u003eA quota sampling technique was employed (Table 1). All 14 health facilities in the district and their associated community immunization outreach posts were included as sampling clusters. Quotas were allocated proportionally to the level of the health facility (HC II, III, IV) based on patient volume, with larger facilities receiving higher quotas. Within each facility and outreach post, teenage mothers meeting the eligibility criteria were recruited consecutively until the facility-specific quota was filled. This method ensured representation from both facility-based (Young Child Clinic attendees) and community-based populations.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1 Participant quotas by the level of health facilities\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"618\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eSN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eLevel of health facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eNumber of health facilities plus their community immunization outreach posts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eSet target number of participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eHealth centre IIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eHealth centre IIIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003eHealth centre IVs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 174px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e353\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003ch2\u003e\u003cstrong\u003eData collection tools and procedures\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData were collected using a pre-tested, structured questionnaire administered face-to-face by four trained research assistants in the local language (Leb Lango). The tool was developed based on the conceptual framework and reviewed for content validity by experts in midwifery and public health. It covered:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSection A:\u003c/strong\u003e Socio-demographic characteristics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSection B:\u003c/strong\u003e Health system factors (distance, transport, trust, waiting times, provider type, knowledge of SBA benefits).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSection C:\u003c/strong\u003e Cultural factors (beliefs, TBA presence and influence, decision-makers, birth preparedness).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSection D:\u003c/strong\u003e Economic factors (income, transport cost, out-of-pocket payments, financial control).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSection E:\u003c/strong\u003e Utilization of SBA (timing and frequency of ANC, place of last delivery, attendant type).\u003cbr\u003eThe primary outcome variable was utilization of SBA, operationally defined as delivery of the last baby in a health facility (coded as 1), as opposed to delivery at home or with a TBA (coded as 0).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData quality control\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe questionnaire was pre-tested on 10 teenage mothers from a neighboring community to ensure clarity, flow, and cultural appropriateness; these respondents were not included in the main study. Research assistants underwent a two-day training covering the study objectives, ethical conduct, interview techniques, and data handling. The principal investigator provided ongoing supervision and spot-checked completed questionnaires daily for completeness and consistency.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData were entered into SPSS version 23, cleaned, and exported to STATA version 17 for analysis. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize the data. Bivariate analysis using the Chi-square test (or Fisher\u0026apos;s exact test where appropriate) and crude odds ratios (COR) with 95% confidence intervals (CI) was performed to identify candidate variables for multivariate analysis (see additional files 1-4). All variables with a p-value \u0026lt; 0.05 at the bivariate level were entered into a multivariate binary logistic regression model using a backward stepwise elimination method to identify independent predictors of SBA utilization. Results were reported as adjusted odds ratios (AOR) with 95% CI. The threshold for statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eEthical approval was obtained from the Lira University Research Ethics Committee (LUREC-2023-95). Administrative permission was secured from the Lira District Health Office and the in-charges of all participating health facilities. Written informed consent was obtained from all participants. For participants aged 13-17 years, assent was obtained alongside written consent from a parent or guardian. Participants were assured of confidentiality, and data were anonymized using identification numbers. They were informed of their right to withdraw at any time without penalty.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cstrong\u003eSocio-demographic characteristics of participants\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA total of 316 teenage mothers participated, giving a response rate of 89.5% (316/353). Their background characteristics are shown in Table 2. The mean age was 17.9 years (SD=0.93), with 64.2% (n=203) aged 18-19. Over half (51.9%, n=164) were single, and 44.0% (n=139) were married. The majority (65.5%, n=207) had only a primary level of education, while 15.2% (n=48) had no formal education. Most participants were peasants (62.3%, n=197), and Anglicans constituted the largest religious group (45.3%, n=143).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2 Background Characteristics of Study Participants\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent age in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e17.9 (0.927)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge category in years\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; 13-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e113 (35.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; 18-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e203 (64.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e139 (44.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Single\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e164 (51.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Divorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e13 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest level of education completed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e48 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Primary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e207 (65.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Secondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e51 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Tertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e10 (3.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent employment status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Housewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e107 (33.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Peasant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e197 (62.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e12 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligious affiliation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Anglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e143 (45.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Catholics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e97 (30.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Muslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e53 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp; Pentecostals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e23 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003eLevel of Antenatal Care and Skilled Birth Attendant utilization\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAntenatal care utilization was suboptimal (Table 3). A majority (54.7%, n=173) initiated their first ANC visit after 14 weeks of gestation, and 64.6% (n=204) attended fewer than the recommended four ANC visits. However, 62.7% (n=198) reported having knowledge about delivery conducted by health workers. Concerning the primary outcome, 57.3% (n=181) of teenage mothers delivered their last baby in a health facility with an SBA, while 42.7% (n=135) delivered at home or with a TBA (Fig. 4).\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;3 Level of Utilization of ANC Services\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" style=\"margin-right: calc(0%); width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUtilization of ANC services \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeeks of gestation started visiting ANC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp; 14 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e173 (54.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp; 0-13 weeks\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e143 (45.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of ANC Visits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026lt;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e204 (64.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e112 (35.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave any knowledge on delivery conducted by health workers\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e118 (37.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e198 (62.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of delivery for your current baby\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp; Home/TBA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e135 (42.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp; Health facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54.2948%;\"\u003e\n \u003cp\u003e181 (57.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003eFactors associated with Skilled Birth Attendant utilization\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe bivariate analyses for socio-demographic, health system, cultural, and economic factors are presented in Additional Files 1-4, respectively. Key findings from the multivariate logistic regression (Table 4) are summarized below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocio-demographic factors:\u003c/strong\u003e In the multivariate model, after adjusting for other factors, having a secondary education remained a significant independent predictor (AOR=4.45, 95% CI: 1.39-14.25, p=0.012) compared to having no education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth system factors:\u003c/strong\u003e Trust emerged as a critical factor. Teenagers who reported a lack of trust in healthcare providers had 88% lower odds of utilizing SBAs in the multivariate model (AOR=0.12, 95% CI: 0.04-0.36, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural factors:\u003c/strong\u003e Cultural factors were strongly influential. The most powerful cultural predictor was the influence of family members on the delivery location decision. Compared to decisions influenced by community elders, decisions influenced by family members resulted in nine times higher odds of opting for a TBA over an SBA (AOR=9.04, 95% CI: 3.16-25.81, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEconomic factors:\u003c/strong\u003e Economic factors such as family income, transport costs, and challenges with healthcare affordability did not retain statistical significance in the multivariate logistic regression model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003eMultivariate analysis of predictors of Utilization of Skilled Birth Attendants by teenage mothers\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e[95% CI]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e[95% CI]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHighest education level attained\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.75-2.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.282\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.67-3.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.311\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e2.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1.14-5.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.023*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e4.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1.39-14.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.28-4.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.905\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.23-7.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.744\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eCatholics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.39-1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.27-1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.32-1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.39-2.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.983\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003ePentecostals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.66-4.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.238\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrust in Health Provider\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.19-0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.04-0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCulture Influences not to reveal pregnancy early\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1.08-3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.69-3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBA Influences decision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eModerately influential\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eSlightly influential\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.32-1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.21-1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eNot influential at all\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.55-1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.955\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.46-2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.893\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDecision maker regarding utilization of TBA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eCommunity Elder\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eFamily Member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e5.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e2.35-10.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e9.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3.16-25.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eMy Husband\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.69-2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.65-2.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003ePregnant women\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e0.59-2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.695\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.34-2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.834\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of delivery (TBA or health facility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eTBAs / Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e42.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;37.4 -48.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eHealth facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e57.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;51.7-62.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.020*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.98-2.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.020*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*: Variable significant at 5%; AOR=Adjusted odds ratio; CI: Confidence interval\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis cross-sectional study among 316 teenage mothers in Lira District found that 57.3% utilized a skilled birth attendant for their most recent delivery. While this indicates that more than half of this vulnerable group accessed professional care, it also reveals that a substantial proportion (42.7%) remained at elevated risk by delivering at home or with a TBA. This utilization rate is higher than the 38% reported among adolescents in Ethiopia [35] and the 47% found in a study from Bubaare Sub-County, Uganda [36], but lower than the 69% reported in Ghana [37] and the 75.3% regional average for adolescents in SSA [38]. This disparity underscores the context-specific nature of maternal health service uptake and the need for localized interventions.\u003c/p\u003e\n\u003cp\u003eA key finding was the strong positive association between secondary education and SBA utilization. Teenage mothers with secondary education had over four times the odds of using an SBA compared to those with no formal education (AOR=4.45, p=0.012). This aligns robustly with the global literature where maternal education is consistently one of the most powerful social determinants of health service use [39, 40]. Education likely empowers young women with health knowledge, improves their ability to comprehend health messages, increases self-efficacy, and may enhance their negotiation power within households [16, 41,42]. This finding reinforces the imperative of keeping girls in school as a fundamental strategy for improving maternal health outcomes.\u003c/p\u003e\n\u003cp\u003ePerhaps the most striking finding was the profound role of trust in the healthcare system. Teenage mothers who lacked trust in providers had 88% lower odds of utilizing SBAs (AOR=0.12, p\u0026lt;0.001). This echoes qualitative and quantitative studies from similar settings where disrespect, verbal abuse, and neglect by health workers were primary deterrents to facility-based delivery [43, 44,45]. For teenage mothers, who may already feel stigmatized and fearful of judgment, negative encounters with health providers can be particularly devastating [46]. This highlights a critical breakdown in the acceptability dimension of healthcare access. Improving \"respectful maternity care\" is not merely an ethical imperative but a practical necessity for increasing service utilization [47].\u003c/p\u003e\n\u003cp\u003eThe influence of cultural and familial factors was powerfully demonstrated. The significant association between the presence of TBAs in the community and lower SBA use reflects the entrenched role of traditional practitioners. More importantly, the decision-making power of family members emerged as the strongest predictor in the cultural domain. When family members influenced the delivery location decision, the odds of using a TBA skyrocketed (AOR=9.04, p\u0026lt;0.001). This underscores that childbirth is often viewed as a familial or communal event rather than an individual health decision, with elder women frequently holding sway [48, 49,50]. This suggests that interventions targeting only the pregnant adolescent are insufficient; they must engage families and the wider community to shift social norms.\u003c/p\u003e\n\u003cp\u003eContrary to many studies [51, 52], direct economic factors were not independent predictors in the final model. This may be partially attributed to Uganda's policy of free maternity services in public health facilities, which could mitigate direct financial barriers for some. However, it may also indicate that in this context, socio-cultural and health system barriers (trust, education, family influence) outweigh pure economic constraints for teenage mothers. Indirect costs and economic dependence, which limit autonomy, may still be influential [53].\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eImplications for Policy and Practice\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe findings have several implications:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eFor health systems:\u003c/strong\u003e There is an urgent need to institutionalize training in adolescent-friendly and respectful maternity care for all maternal health providers. Supervision and accountability mechanisms to ensure compassionate treatment must be strengthened.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFor education and community engagement:\u003c/strong\u003e Beyond formal schooling, targeted health education campaigns should be directed at teenagers, their partners, and especially influential family elders. Community dialogues involving local leaders and reformed TBAs could help bridge the gap between traditional and biomedical systems.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFor policy:\u003c/strong\u003e The study reveals the limited impact of Uganda's ban on TBA practice. A pragmatic policy review to explore regulated integration, training, and formal linkage of TBAs to the health system for promotion and referral could be more effective than unenforceable prohibition [54].\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch2\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study has limitations. The cross-sectional design cannot establish causality. Social desirability bias may have led to under-reporting of home deliveries or over-reporting of trust in providers. The quota sampling method, while practical, may limit the generalizability of findings. Furthermore, the study did not capture the perspectives of health workers or TBAs, whose views would provide a more complete understanding of the service environment. Despite these limitations, the study provides valuable quantitative evidence on a critically under-researched population in a specific geographic context.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this study reveals that while a majority of teenage mothers in Lira District utilize skilled birth attendants, a significant vulnerable minority does not. The pathway to skilled care is significantly shaped by the teenager\u0026apos;s educational attainment, the level of trust in the health system, and powerful socio-cultural dynamics, particularly decision-making influence wielded by family members. To accelerate progress towards universal skilled birth attendance and improve maternal outcomes among adolescents, interventions must adopt a multi-level approach. This should include ensuring respectful, stigma-free care within health facilities, implementing community-based programs to educate and empower families, and revisiting policies to constructively engage with existing traditional birth practices. Empowering teenage mothers through education and building a trustworthy health system are indispensable strategies for safeguarding their health during childbirth.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eANC:\u003c/strong\u003e\u0026nbsp; Antenatal Care\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAOR:\u003c/strong\u003e\u0026nbsp; Adjusted Odds Ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCI:\u003c/strong\u003e\u0026nbsp; Confidence Interval\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOR:\u003c/strong\u003e\u0026nbsp; Crude Odds Ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDHIS2:\u003c/strong\u003e\u0026nbsp; District Health Information System 2\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHC:\u003c/strong\u003e\u0026nbsp; Health Centre\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLUREC:\u003c/strong\u003e\u0026nbsp; Lira University Research Ethics Committee\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMMR:\u003c/strong\u003e\u0026nbsp; Maternal Mortality Ratio\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSBA:\u003c/strong\u003e\u0026nbsp; Skilled Birth Attendant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSDG:\u003c/strong\u003e\u0026nbsp; Sustainable Development Goal\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSPSS:\u003c/strong\u003e\u0026nbsp; Statistical Package for the Social Sciences\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSSA:\u003c/strong\u003e\u0026nbsp; Sub-Saharan Africa\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTBA:\u003c/strong\u003e\u0026nbsp; Traditional Birth Attendant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVHT:\u003c/strong\u003e\u0026nbsp; Village Health Team\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO:\u003c/strong\u003e\u0026nbsp; World Health Organization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the Lira University Research Ethics Committee (Ref: LUREC-2023-95). Written informed consent was obtained from all participants. For participants under 18 years, assent was obtained alongside written consent from a parent or guardian. All methods were performed in accordance with the relevant guidelines and regulations (Helsinki Declaration).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article (and its supplementary information files).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. It was self-funded by the principal investigator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEA:\u003c/strong\u003e Conceptualization, methodology, investigation, data curation, formal analysis, writing original draft. J\u003cstrong\u003ePB\u003c/strong\u003e: Data curation, formal analysis, writing original draft. \u003cstrong\u003eWI:\u003c/strong\u003e Supervision, validation, writing review \u0026amp; editing. \u003cstrong\u003eBO\u003c/strong\u003e: Data curation, formal analysis, writing original draft. \u003cstrong\u003eEK:\u003c/strong\u003e Supervision, methodology, validation, writing review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank the Lira University Research Ethics Committee, the Lira District Health Office, and the in-charges of all participating health facilities for their administrative support. We are deeply grateful to the research assistants for their diligent work and, most importantly, to the teenage mothers who generously shared their time and personal experiences for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023.\u003c/li\u003e\n\u003cli\u003eKassebaum NJ, Barber RM, Bhutta ZA, Dandona L, Gething PW, Hay SI, et al. 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J Reprod Infant Psychol. 2022;40(3):225-239.\u003c/li\u003e\n\u003cli\u003eSumankuuro J, Mahama MY, Crockett J, Wang S, Young J. Narratives on why pregnant women delay seeking maternal health care during delivery and obstetric complications in rural Ghana. BMC Pregnancy Childbirth. 2019;19(1):260.\u003c/li\u003e\n\u003cli\u003eSychareun V, Hansana V, Somphet V, Xayavong S, Phengsavanh A, Popenoe R. Reasons rural Laotians choose home deliveries over delivery at health facilities: a qualitative study. BMC Pregnancy Childbirth. 2012; 12:86.\u003c/li\u003e\n\u003cli\u003eMuzzafar S, Soofi SB, Khan GN, Hussain I, Rizvi A, Usmani MA, et al. Factors associated with home delivery in rural Sindh, Pakistan: results from the global network birth registry. BMC Pregnancy Childbirth. 2022;22(1):462.\u003c/li\u003e\n\u003cli\u003eChukwuma A, Wosu AC, Mbachu C, Weze K. Quality of antenatal care predicts retention in skilled birth attendance: A multilevel analysis of 28 African countries. BMC Pregnancy Childbirth. 2017;17(1):152.\u003c/li\u003e\n\u003cli\u003eYoseph S, Dache A, Dona A, Dheresa M. Opportunity cost of skilled delivery care in rural Ethiopia: A community-based cross-sectional study. BMC Health Serv Res. 2020;20(1):960.\u003c/li\u003e\n\u003cli\u003eTowongo MF, Ngome E, Navaneetham K, Letamo G. Individual and community-level factors associated with women\u0026apos;s utilization of postnatal care services in Uganda, 2016: a multilevel and spatial analysis. BMC Health Serv Res. 2024;24(1):185.\u003c/li\u003e\n\u003cli\u003eSarker BK, Rahman M, Rahman T, Hossain J, Reichenbach L, Mitra DK. Strengths of community and health facilities based interventions in improving women and adolescents\u0026apos; care seeking behaviors as approaches for reducing maternal mortality and improving birth outcome among low income communities of Egypt. BMC Public Health. 2020;20(1):577.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Skilled birth attendant, Teenage mothers, Maternal health, Utilization, Uganda, Cross-sectional study","lastPublishedDoi":"10.21203/rs.3.rs-8353863/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8353863/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e In Uganda, many teenage mothers deliver without skilled assistance, contributing to high maternal and perinatal mortality. Despite national interventions, home deliveries persist in rural areas like Lira District. This study aimed to determine the utilization level of skilled birth attendants (SBAs) and its associated factors among teenage mothers in this region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A community-based cross-sectional study was conducted in Lira District from June 2023 to June 2024. Using quota sampling, 316 teenage mothers (aged 13-19 years) who had delivered within the past 12 months were recruited from health facility young child clinics and community immunization outreach posts. Data were collected through interviewer-administered structured questionnaires. Analysis was performed using STATA version 17, employing multivariate logistic regression to identify independent predictors at a 95% confidence interval and p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Of the 316 participants, 57.3% utilized an SBA for their most recent delivery. Multivariate analysis revealed three key independent predictors. Firstly, educational attainment was a strong enabler: teenage mothers with secondary education had over four times higher odds of SBA use compared to those with no education (AOR=4.45, 95% CI: 1.39-14.25, p=0.012). Secondly, health system trust was critical; a reported lack of trust in providers reduced the odds of SBA utilization by 88% (AOR=0.12, 95% CI: 0.04-0.36, p\u0026lt;0.001). Thirdly, socio-cultural influence was paramount: when family members (versus community elders) influenced the delivery location decision, the odds of choosing a traditional birth attendant over an SBA increased ninefold (AOR=9.04, 95% CI: 3.16-25.81, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e While over half of teenage mothers utilized SBAs, significant barriers persist. Educational attainment, trust in the health system, and socio-cultural dynamics, particularly family influence, are critical modifiable factors. Interventions must prioritize building respectful, adolescent-friendly health services, enhancing community and family education, and developing pragmatic policies regarding traditional birth practices to improve skilled birth attendance and reduce maternal risks.\u003c/p\u003e","manuscriptTitle":"Factors influencing skilled birth attendant utilization among teenage mothers in Lira District, Northern Uganda: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-16 11:00:02","doi":"10.21203/rs.3.rs-8353863/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"41966275957267579117673814089875158431","date":"2026-02-01T14:51:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138003911765482941484688036805391440197","date":"2026-02-01T09:35:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T06:53:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162541383961841877465420931016375096454","date":"2026-01-20T18:57:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T11:16:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-28T18:29:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-26T03:23:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-26T03:22:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-12-13T15:46:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f77e6476-af24-473e-bdaf-2b51c44713b7","owner":[],"postedDate":"December 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T11:52:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-16 11:00:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8353863","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8353863","identity":"rs-8353863","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}