Magnitude of Institutional Delivery and its Associated Factors among Women Attending Antenatal Care in Kono District, Sierra Leone

Background Improving maternal health is a key Sustainable Development Goal, aiming to reduce maternal mortality to 70 deaths per 100,000 live births by 2030. Women in low-income countries, also face a higher risk of maternal death where institutional delivery is vital for reducing maternal mortality and ensuring safe motherhood. However, Sierra Leone has one of the highest maternal morbidity and mortality rates globally, with low rates of facility-based births. This study examines the magnitude of institutional delivery and its associated factors among women attending antenatal care in Kono district, Sierra Leone. Methods A mixed methods sequential explanatory design was employed. The quantitative component involved a random sample of 384 women who attended antenatal care from July 2021 to June 2023. Descriptive analysis summarized the data, while binary logistic regression identified factors associated with institutional delivery. In the final model, a significance level of 0.05 was considered statistically significant. For the qualitative aspect, 15 respondents (10 clients and 5 health workers) were purposively selected for interviews conducted between August and September 2024, using a pretested interview guide. The data were transcribed, coded and analyzed thematically. Results Findings indicated that 71.4% of the 384 women delivered in health facilities. Significant factors associated with institutional delivery included having four or more antenatal visits (AOR = 4.26; 95% CI: 2.65–6.86) and being a grand multipara (AOR = 0.41; 95% CI: 0.17–0.99). In contrast, maternal age and place of residence did not show a statistically significant association with institutional delivery in the final model. Qualitative findings revealed socio-cultural norms, economic challenges, and geographic barriers as major obstacles, while facilitators included respectful maternity care, availability of supplies, community engagement, free maternity services and social support systems. Conclusion Our study found that a substantial majority of women receiving antenatal care at Wellbody health facility returned to deliver in a healthcare facility. For those who did not, both health system and client-related factors were influential. Addressing cultural, economic, and geographic barriers and improving the accessibility and quality of maternal health services are crucial to maintain and further improve institutional delivery in the study setting.