In 2015, globally about 830 women die from pregnancy or childbirth-related complications every day(1). It was estimated that around 303 000 women died during and following pregnancy and childbirth. Almost all (99%) of these deaths occurred in low-resource settings, and most could have been prevented (1). Ethiopia is among the low -resource setting country countries with a maternal mortality ratio (MMR) 412/100,000 in 2016(2). Maternal mortality in Ethiopia remains over 20 times higher than in European countries(3). From the total maternal mortality, around 75% are linked to pregnancy and child birth complications(1). This was also a result of poor utilization of institutional delivery. Skilled care before, during and after childbirth can save the lives of women and new born babies(4)Though global institutional delivery service has been seen an improvement from the 1990s coverage, there are still greater disparities across the regions. Worldwide about 81% and 61% of skilled birth attendants were discovered in the urban and rural, respectively. Whereas, in Sub Saharan countries, where the the resource is limited, an approximate of 75% of urban and 40% of rural births taken place at health facilities(6). In 2016, 74%, in Ethiopia, 73% in Amhara and in the study area in 2019, 68% child birth had taken place at home without the assistance of skilled personnel(2). More over, evindece showed that more than two third of the births in the study area, Yilmana densa district, took place at home (Ref) Try to smooth transition between these paragraphs Reasons for minimal access to quality services are multi-faceted; however, challenges of insufficiently skilled health workers and inequitable distribution of the health workforce play a great role(5). This is especially the case in countries like Ethiopia, where a large population lives in rural areas with low health worker per population density. In total, over 80% of the population of Ethiopia lives in rural areas(6).The ratio of available health workers (including: doctors, health officers, nurses and midwives) is 0.84 per 1000 population(6), far below the World Health Organization-recommended minimum threshold of 2.3 per 1000 population required to provide basic health coverage(7). Community health workers can contribute to maternal health and child survival through basic curative care and preventive services, and act as a conduit to professional care(8). In Ethiopia, the Health Extension Program (HEP) is a community-based health service delivery system, launched in 2004 to provide equitable access to promotive, preventive and limited curative health interventions, with emphasis to the needs of the majority, less-privileged, rural population(9). The HEP has brought reductions in maternal and child mortality, through providing basic health services and bridging the gap between the community and health facilities(9).However, to enhance these efforts and improve geographical penetration and equity, in 2011 the Ethiopian Government introduced a complementary initiative, the Women’s Development Army (WDA) strategy, also known as the Health Development Army. WDA members are organized by their neighborhood and are commonly called “one-to-five” networks (denoting one leader and five member households). Based on the neighborhood, five or six “one-to-five “networks are grouped into a women’s development team that comprises 25 to 30 households, called“one-to-30” (denoting one team leader to about 30 member households)Currently, the health extenstion worker HEWs and WDA network is believed to be the best approach to enhanc women’s seeking behavior in attending skilled maternity services (10, 11). However, no or only little known about the association of skilled delivery care service utilization with the establishment of this army. Therefore, this study is planned to assess skilled delivery care service utilization and associated factors at individual and WDT levels in Yilmana Densa District, Northwest Ethiopia. 1.2. Statement of the problemsGlobally, each year about 303,000 women die as result of pregnancy related complication, and about 99% (302,000) of these deaths occurred in developing regions, and subsub-Saharan Africa alone accounting approximately 66% (201,000) and most could have been prevented(1, 12) A large part of the under-5 mortality rate encompass neonatal deaths as the neonatal period is the most vulnerable time for every child. Due to preventable and treatable causes, every year, 3 million newborn die, amounting to 1 million of neonates on the first day and 2 million in the first week of life, with an additional 2.6 million stillbirths (13).Over the past decades, there was a continuous downward trend in maternal mortality ratio (MMR) in Ethiopia, estimating at 673 per 100,000 live births in 2005, 676 in 2011, 412 in 2016 and according to world bank report in 2019 was 353/100,000, with average 5% decline from 1990-2015(2, 12, 14). Despite its improvement, there was a gap to meet the HSTP target of 267per 100,000 live births by the end of 2012 E.C(15).Ethiopia is among the world’s highest rates of maternal deaths and disabilities in the world. Women have a one-in-52 chance of dying from childbirth-related causes each year. Every year, more than 257,000 children under the age of five die and 120,000 die in the neonatal period. More than 60 percent of infant and 40 percent of under-five deaths in Ethiopia are neonatal death (16).The infant mortality rate (IMR) has also dropped to 48 in 2016. However, the country remained off-track to fulfill the HSTP target of 20 per 1,000 live births by 2020(2, 12). Stillbirth rate was 19.8 per 1,000 live births, and neonatal mortality rate was 29 per 1,000 live births in 2016 in the country(2). Most maternal and neonatal deaths occur at the time of delivery or immediate after delivery during the postpartum period, which can be preventable up to 80% through available and accessible quality maternal and child health services (17). In Ethiopia, every year, about one million women give birth a child and 74% of deliveries takes place at home(2). Neerly 90% of all maternal deaths can be prevented if mothers accessed quality health care services timely(18). It estimated that 42% of maternal deaths occur during the intra-and-early postpartum period(18). According to WHO 2018, severe bleeding (mostly bleeding after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia), complications from delivery unsafe abortion are most causes of mortality rate(19)Moreover, not only maternal and neonatal mortality but also maternal morbidity like vaginal prolapse or puerperal psychosis can cause unwanted physical, mental, social, and economic consequences for the respective families (20). Besides, maternal morbidity or mortality can largely contribute to negative impacts on neonates, who are often dependent on their mothers.Even though the problem is very serious, but do not have enough attention.Studies revealed that socio-demographic and educational variables of mothers such as educational status, residency,age are associated with maternal institutional delivery service utilization and ANC utilization also were determine institutional delivery service utilization.On the other hand mothers’ participation in pregnancy health conference and women health developemental aremy leaders performance was not evaluated in the stated articles .However, this study aimed to skilled delivery service utilization and its association with the establishment of women’s health development army in Yilmana Densa District North West Ethiopia.General comment:- Try to write on what astatement problem need to have: defining the problem, show magnitude, the known factors/causes, its impact/negative influences/consequence due to the problems, the possible solutions/ remedies, and show the gaps that are not yet filled by researchers. Note that your focus should be about maternal service utilization than maternal /child morbidities/mortalities. The later may be the consequence of poor service utilization.- Arrange ideas based on their natural occurance. For instance, before talking about the solutions(e.g80% of maternal deaths are avoidable) it is wise to show the factors /causes of ….. 1.3. Justification of the studyIf pregnant mothers can deliver their babies in any facility which can assist with skilled care and necessary equipment under hygienic conditions, the risks of death or illness to both mother and babies can reduce to a certain extent(21). It is, therefore, important for pregnant women to use the health services during labor, delivery and postpartum for the sake of both lives(21).ThusHowever, the challenge is the way to provide a comprehensive package of maternal delivery services that is affordable and accessible to the people most in need in the country in general and the study are in particular(22). Similarly the trend of study area institutional delivery service utilization in the study area shows decline pattern over the last three years:becoming in decline manner, that is 38% in 2009 E.C, 36% in 2010 E.C and 32% in 2011E.C. However, the Factors factors poor health seeking behaviors, a lack of access to a health facility services and poor-structured health systems,low population to health professional ratio, that affect service utilization are not clearly understandabledefined. But, they are necessary and important factors to understand and address to promote pregnant women to utilize health services for institutional delivery for the sake of both mothers and babies’lives. However, there are a limited number of studies related to the pregnant women’s utilization of institutional delivery service in Ethiopia. The factors that affect service utilization, therefore, are not clearly defined. ThereforeHence, it is necessarily important to understand what factors are influencing the pregnant women’s choose to deliver at home or at in facilityof the place of delivery to be able to understand deeper, and to compare drivers and determinants for them to undergo for institutional delivery……………. The results of the study can also provide valuable information to the Ministry of Health and other authority concerned to make the necessary measures to support the efficient maternal delivery services for pregnant women, especially who do not deliver at a health facility. It can also contribute to a reduction in mortality and morbidity of both mothers and babies, which can further improve the welfare of the societies in Ethiopia.1.4. Literature review 1.4.1 Magnitude of Health institution delivery service utilization A cross sectional study in Nepal the rate of institutional delivery ranges from 46%-78.3% deliver at health facility (23, 24). Similar study conducted in Biharamulo district, Tanzania: shows 56% of women delivered in a health facility(25). Another cross-sectional study in Ghana 93.3% of them delivered in a health facility (26). A study conducted in SNNPR, Ethiopia the proportion of pregnant women delivered in the health institution were ranges from23%-78.3% (27-31). The rate of institutional delivery in Oromia region vary from 13.9% -18.2% (32, 33) . More over around 51% of pregnant women in Benishangul-Gumez region, North-West of Ethiopia delivered the recent child at health facility (34). A community based cross sectional study in Amhara region the prevalence of institutional delivery service shows the minimum of 12.1% and to the maximum of 80.14(35-40). 1.4.2 Factors associated with institutional delivery service utilization1.4.3 Socio demographic and Educational factorsA community based cross sectional study conducted in western Nepal shows more educated women’s had a strong positive association (odds ratio=24.11,CI=9.43±61.64)(41). Similar study in Nepal shows women who had secondary or above secondary level education were 1.63 times more likely to choose institutional delivery than young women who had no formal education (OR: 1.62; 95% CI: 1.17 to 2.25) and the probability of delivering in an institution was 69% higher among young urban women than among young women who lived in rural areas(24) A cross-sectional study rural district in Ghana Mother’s educational attainment can affect institutional delivery service utilization (26). A cross-sectional study conducted in Tanzania living in urban were 7 times more delivered at health institution with the odds of 7.16(4.32-35.72), and pregnant women educated primary and secondary were higher to use health institutions 5.74(3.64-9.07) 18.27(9.34-35.72) respectively (25). Systematic review in Ethiopia shows urban residency (OR =13.16, CI =1.24, 3.68), pregnant and husband education primary and above (OR =4.95, CI =2.3, 4. 8, and OR =4.43, CI =1.14, 3.36, respectively) were factors that enable institutional delivery service utilization(42).A community based cross sectional study Cheha district, Gurage zone, SNNPR, Ethiopia: mothers residing in urban areas were 3.3 times more likely to give birth at health facility than mothers residing in rural areas (AOR = 3.26, 95 % CI: 1.33, 7.97)(28). A study conducted in Bench Maji zone, Ethiopia shows mothers in the age groups 35–44 were less likely to deliver in health institution (AOR = 0.4 and 0.3) respectively in comparison with those mothers in the age group of 15–24 (31). A study conducted in Zala district, Southern Ethiopia, mothers whose educational status of read and write only were 5.8 times likely to deliver at home as compared to mother who had secondary and above education (AOR = 5.8, 95% CI = 2.86, 11.8), urban residence (AOR: 5, 95% CI: 2.2, 12), Mothers with age greater than or equal to 30 years were 2.8 times likely to deliver at home as compared to mothers with the age of less than 25 years (AOR: 2.78, 95% CI: 1.2, 6.5)(30). A study conducted in Dodota district, Oromia regional state, Ethiopia Urban residence were 22.8(AOR=22.8: 95% CI, 10.57- 49.42), more likely to use health institutions to deliver their child compared to rural residence, and mothers educated secondary and above were 3.94 more (AOR=3.94: 95% CI, 1.3,11.99) delivered at health facility compared with illiterate(32). A community-based cross-sectional study conducted in Sekela District, Amhara Region, Ethiopia being urban resident (AOR [95% CI] = 4.6 [1.91, 10.9]), maternal education level secondary and above (AOR [95%CI] =11.98 [3.36, 41.4]) were significantly affect institutional delivery utilization (38). A community-based survey was conducted in the Tigray region of Ethiopia, women educated secondary school and above were two times more use institutional delivery 2.15 (1.31, 3.52)(43). Te study conducted in Akansha Guagusa district, Awi zone, Amhara Regional State of Ethiopia shows, the odds of skilled birth attendance were AOR=6.12:95%CI(1.39,26.92) times higher among those mothers whose educational level was secondary and above compared with those with no education (39). However a cross sectional study conducted in rural areas in Ethiopia: variables place of residence and age didn’t show any significant association with institutional delivery service utilization(44).1.4.4. Antenatal visitsA study conducted in Nepal shows, women who had more than four antenatal care (ANC) visits were three times more likely to deliver in a health institution compared with women who had no antenatal care visit (OR: 3.05; 95% CI: 2.40 to 3.87)(24). Similar study in Nepal ANC visit four or more (AOR = 10.03, 95 % CI = 1.02-98.29) was factors positively affect institutional delivery(23) A cross-sectional study in rural district Ghana having four or more ANC visit were strongly associated with institutional delivery (26). A cross-sectional study conducted in Tanzania ANC visits especially of >4 visit was associated with SBA use (OR 2.66; 95% CI [1.94-3.66]) compared with ANC of less than 4 visit (25). Another cross-sectional study in Bench Maji Zone, Southwest Ethiopia those mothers who had ANC visits (i.e. within recommended four, and above visits) were more likely to deliver in health institution (AOR =7.6 and 26.2)(31). A study conducted in Zala Woreda, southern Ethiopia Mothers who followed ANC are about 3 times or less than 6 times likely to give birth at home as compared to mothers who attended ANC about four and above (AOR = 3, 95%CI = 1.3, 8.5)(30) A cross-sectional study Conducted in Hossanna town, South Ethiopia Reported that women who attended ≥4 ANC visits were 1.6 times more likely attend SBA for delivery compared to women who attended ANC less times(45). A cross-sectional study Conducted in Wukro and Butajera districts in the northern and southern parts of Ethiopia Reported that women who had ≥4 ANC visit are almost two times likely to delivery in health facilities than those who followed ANC less times (46). A cross-sectional study Conducted in Yeky district, Sheka zone, SNNPR. In this study, women who had ≥4 ANC visit were 7.44 times more likely to use SBA as compared to those women who did not have any ANC follow up visits for the pregnancy of their last birth(27). Community-based survey was conducted in the Tigray region of Ethiopia. not using antenatal care, were five times lower to deliver at health facility 0.17 (0.12, 0.25)(43). A cross-sectional study Conducted in three districts of South West Shoa, Four or more ANC visit was not associated with increased SBA at delivery(47).Community-based cross-sectional study was conducted Sekela District, Amhara Region, Ethiopia ANC visit during last pregnancy (AOR [95% CI] = 4.26 [1.1, 16.4]) (38). A cross-sectional study conducted in Dangila district, North West Ethiopia having ANC follow up during pregnancy were 12 times more to deliver their child in health institution [AOR=12.9, 95% CI: (5.0, 33.3)] (40) A cross-sectional study conducted in Akansha Guagusa Woreda of Awi zone, Amhara Regional State Reported that mothers who had ≥4 ANC visits were 17 times more likely to attend institutional delivery than those mothers who had three and less ANC visits(39). A similar study in Farta District, Northwest Ethiopia tells mothers who had followed ANC were 2 times more likely (AOR=2.4; 95% CI: 1.21, 4.90 )to have birth at health facility compared to their counter parts). Women who attend pregnant women monthly health conference were more likely to deliver at health facility than those who have no exposure to conference (AOR=6.6; 95% CI: 3.22, 13.42)(48). Pregnant women found with in higher graded women development army team were 9 times more to use institutional deliveries compared with graded as low (AOR=9:95%CI: 1, 17)(49). However a study conducted in Yeky district, South West Ethiopia: the performance level of WHDT does not have significant effect on institutional delivery (AOR=2.14: 95% CI: 0.38, 12.27)(27)A case-control study in rural Tigray, northern Ethiopia, Women who are not members of WHDGs are two times at risk of experiencing maternal death in the study area(50) .