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Background: The Curamericas/Guatemala Maternal and Child Health Project, 2011–2015, implemented the Census-Based, Impact-Oriented Approach, the Care Group Approach, and the Community Birthing Center Approach. Together, this expanded set of approaches is known as CBIO+. This is the fifth of 10 papers in our supplement describing the Project and the effectiveness of the CBIO+ Approach. This paper assesses causes, levels, and risk factors for mortality along with changes in mortality. Methods: The Project maintained Vital Events Registers and conducted verbal autopsies for all deaths of women of reproductive age and under-5 children. Mortality rates and causes of death were derived from these data. To increase the robustness of our findings, we also indirectly estimated mortality decline using the Lives Saved Tool (LiST). Findings: The leading causes of maternal and under-5 mortality were postpartum hemorrhage and pneumonia, respectively. Home births were associated with an eight-fold increased risk of both maternal (p = 0.01) and neonatal (p = 0.00) mortality. The analysis of vital events data indicated that maternal mortality declined from 632 deaths per 100,000 live births in Years 1 and 2 to 257 deaths per 100,000 live birth in Years 3 and 4, a decline of 59.1%. The vital events data revealed no observable decline in neonatal or under-5 mortality. However, the 12–59-month mortality rate declined from 9 deaths per 1000 live births in the first three years of the Project to 2 deaths per 1000 live births in the final year. The LiST model estimated a net decline of 12, 5, and 22% for maternal, neonatal and under-5 mortality, respectively. Conclusion: The baseline maternal mortality ratio is one of the highest in the Western hemisphere. There is strong evidence of a decline in maternal mortality in the Project Area. The evidence of a decline in neonatal and under-5 mortality is less robust. Childhood pneumonia and neonatal conditions were the leading causes of under-5 mortality. Expanding access to evidence-based community-based interventions for (1) prevention of postpartum hemorrhage, (2) home-based neonatal care, and (3) management of childhood pneumonia could help further reduce mortality in the Project Area and in similar areas of Guatemala and beyond. [ABSTRACT FROM AUTHOR]

Background: A community health programme in Narok County in Kenya aimed to improve skilled birth assistance during childbirth through two demand side interventions. First, traditional birth attendants (TBAs) were co-opted into using their influence to promote use of skilled birth attendants (SBAs) at health facilities during delivery, and to accompany pregnant women to health facilities in return for a Ksh500 (Approximately USD5 as of August 2016) cash incentive for each pregnant mother they accompanied. Secondly, a free Motherpack consisting of a range of baby care items was given to each mother after delivering at a health facility. This paper estimates the impact of these two interventions on trends of facility deliveries over a 36-month period here.Methods: Dependency or inferred causality was estimated between reorientation of TBAs and provision of Motherpacks with changes in facility delivery numbers. The outcome variable consists of monthly facility delivery data from 28 health facilities starting from January 2013 to December 2015 obtained from the District Health Information Systems 2 (DHIS2). Data were collected on the 13th, 14th or 15th of each month, resulting in a total of 35 collections, over 35 months. The intervention data consisted of the starting month for each of the two interventions at each of the 28 facilities. A negative binomial generalized linear model framework is applied to model the relationship as all variables were measured as count data and were overdispersed. All analyses were conducted using R software.Findings: During the 35 months considered, a total of 9095 health facility deliveries took place, a total of 408 TBAs were reached, and 2181 Motherpacks were distributed. The reorientation of TBAs was significant (p = 0.009), as was the provision of Motherpacks (p = .0001). The number of months that passed since the start of the intervention was also found to be significant (p = 0.033). The introduction of Motherpacks had the greatest effect on the outcome (0.2), followed by TBA intervention (0.15). Months since study start had a much lower effect (0.05).Conclusion: Collaborating with TBAs and offering basic commodities important to mothers and babies (Motherpacks) immediately after delivery at health facilities, can improve the uptake of health facility delivery services in poor rural communities that maintain a strong bias for TBA assisted home delivery. [ABSTRACT FROM AUTHOR]

Background: Kenya's high maternal mortality ratio can be partly explained by the low proportion of women delivering in health facilities attended by skilled birth attendants (SBAs). Many women continue to give birth at home attended by family members or traditional birth attendants (TBAs). This is particularly true for pastoralist women in Laikipia and Samburu counties, Kenya. This paper investigates the socio-demographic factors and cultural beliefs and practices that influence place of delivery for these pastoralist women.Methods: Qualitative data were collected in five group ranches in Laikipia County and three group ranches in Samburu County. Fifteen in-depth interviews were conducted: seven with SBAs and eight with key informants. Nineteen focus group discussions (FGDs) were conducted: four with TBAs; three with community health workers (CHWs); ten with women who had delivered in the past two years; and two with husbands of women who had delivered in the past two years. Topics discussed included reasons for homebirths, access and referrals to health facilities, and strengths and challenges of TBAs and SBAs. The data were translated, transcribed and inductively and deductively thematically analysed both manually and using NVivo.Results: Socio-demographic characteristics and cultural practices and beliefs influence pastoralist women's place of delivery in Laikipia and Samburu counties, Kenya. Pastoralist women continue to deliver at home due to a range of factors including: distance, poor roads, and the difficulty of obtaining and paying for transport; the perception that the treatment and care offered at health facilities is disrespectful and unfriendly; lack of education and awareness regarding the risks of delivering at home; and local cultural values related to women and birthing.Conclusions: Understanding factors influencing the location of delivery helps to explain why many pastoralist women continue to deliver at home despite health services becoming more accessible. This information can be used to inform policy and program development aimed at increasing the proportion of facility-based deliveries in challenging settings. [ABSTRACT FROM AUTHOR]

Background: Institution-based childbirth, with the ultimate goal of universal access to skilled birth attendance (SBA), has been selected as a key strategy to reduce the maternal mortality rate in many developing countries. However, the question of how to engage traditional birth attendants (TBAs) in the advocacy campaign for SBA poses a number of challenges. This paper aims to demonstrate how TBAs in rural regions of China have been integrated into the health system under a policy of institutional delivery.Methods: Research was conducted through literature and document reviews and individual in-depth interviews with stakeholders of the safe motherhood program in rural Guangxi Zhuang Autonomous Region, China. A total of 33 individual interviews were conducted with regional and local politicians, policy makers, health managers, health providers, civil society members, village cadres for women affairs, former TBAs, village maternal health workers, mothers and their mother-in-laws.Results: Since 1998, TBA's traditional role of providing in-home care during childbirth has been restructured and their social role has been strengthened in rural Guangxi. TBAs were redesigned to function as the linkage between women and the health system. A new policy in 1999 shifted the role of TBAs to village maternal health workers whose responsibilities were mainly to promote perinatal care and institution-based delivery of pregnant women. This successful transformation involved engaging with government and other actors, training TBAs for their new role, and providing incentives and sanctions for human resources management.Conclusions: The China experience of transforming the role of TBAs in Guangxi rural area is an example of successfully engaging TBAs in promoting institution-based childbirth. [ABSTRACT FROM AUTHOR]

Background: India launched a national conditional cash transfer program, Janani Suraksha Yojana (JSY), aimed at reducing maternal mortality by promoting institutional delivery in 2005. It provides a cash incentive to women who give birth in public health facilities. This paper studies the extent of program uptake, reasons for participation/ non participation, factors associated with non uptake of the program, and the role played by a program volunteer, accredited social health activist (ASHA), among mothers in Ujjain district in Madhya Pradesh, India. Methods: A cross-sectional study was conducted from January to May 2011 among women giving birth in 30 villages in Ujjain district. A semi-structured questionnaire was administered to 418 women who delivered in 2009. Socio-demographic and pregnancy related characteristics, role of the ASHA during delivery, receipt of the incentive, and reasons for place of delivery were collected. Multinomial regression analysis was used to identify predictors for the outcome variables; program delivery, private facility delivery, or a home delivery. Results: The majority of deliveries (318/418; 76%) took place within the JSY program; 81% of all mothers below poverty line delivered in the program. Ninety percent of the women had prior knowledge of the program. Most program mothers reported receiving the cash incentive within two weeks of delivery. The ASHA's influence on the mother's decision on where to deliver appeared limited. Women who were uneducated, multiparious or lacked prior knowledge of the JSY program were significantly more likely to deliver at home. Conclusion: In this study, a large proportion of women delivered under the program. Most mothers reporting timely receipt of the cash transfer. Nevertheless, there is still a subset of mothers delivering at home, who do not or cannot access emergency obstetric care under the program and remain at risk of maternal death. [ABSTRACT FROM AUTHOR]

Background: Globally, 11.4 million untreated obstetric complications did not receive Emergency Obstetric and Newborn Care (EmONC) services yearly, with the highest burden in low and middle-income countries. Half of the Ethiopian women with obstetric complications did not receive EmONC services. However, essential aspects of the problem have not been assessed in depth. This study, therefore, explored the various aspects of barriers and enablers to women's EmONC services utilization in southern Ethiopia.Methodology: A qualitative case study research design was used in nine districts of the Wolaita Zone. A total of 37 study participants were selected using a purposive stratified sampling technique and interviewed till data saturation. Twenty-two key informant interviews were conducted among front-line EmONC service providers, managers, community leaders, and traditional birth attendants (TBAs). Individual in-depth interviews were conducted among 15 women with obstetric complications. The trustworthiness of the research was assured by establishing credibility, transferability, conformability, and dependability. NVivo 12 was used to assist with the thematic data analysis.Result: Five themes emerged from the analysis: service users' perception and experience (knowledge, perceived quality, reputation, respectful care, and gender); community-related factors (misconceptions, traditional practices, family and peer influence, and traditional birth attendants' role); access and availability of services (infrastructure and transportation); healthcare financing (drugs and supplies, out-of-pocket expenses, and fee exemption); and health facility-related factors (competency, referral system, waiting time, and leadership).Conclusion: Many women and their newborns in the study area suffered severe and life-threatening complications because of the non-utilization or delayed utilization of EmONC services. A key policy priority should be given to enhancing women's awareness, eliminating misconceptions, improving women's autonomy, and ensuring traditional practices' role in EmONC service utilization. Community awareness interventions are required to enhance service uptake. Furthermore, the health systems must emphasize improving the quality of care, inequitable distribution of EmONC facilities, and essential drugs. The financial constraints need to be addressed to motivate women from low socioeconomic status. Furthermore, intersectoral collaboration is required to maintain a legal framework to control and prohibit home deliveries and empower women. [ABSTRACT FROM AUTHOR]

Background: Nearly three-fourths of pregnant women in Ethiopia give birth at home. However, the spatial pattern and spatial variables linked to home delivery in developing regions of Ethiopia have not yet been discovered. Thus, this study aimed to explore the geographical variation of home delivery and its determinants among women living in emerging (Afar, Somali, Gambella, and Benishangul-Gumuz) regions of Ethiopia, using geographically weighted regression analysis. Methods: Data were retrieved from the Demographic and Health Survey program's official database (http://dhsprogram.com). In this study, a sample of 441 reproductive-age women in Ethiopia's four emerging regions was used. Global and local statistical analyses and mapping were performed using ArcGIS version 10.6. A Bernoulli model was applied to analyze the purely spatial cluster discovery of home delivery. GWR version 4 was used to model spatial regression analysis. Results: The prevalence of home delivery in the emerging regions of Ethiopia was 76.9% (95% CI: 72.7%, 80.6%) and the spatial distribution of home delivery was clustered with global Moran's I = 0.245. Getis-Ord analysis detected high-home birth practice among women in western parts of the Benishangul Gumz region, the Eastern part of the Gambela region, and the Southern and Central parts of the Afar region. Non-attendance of antenatal care, living in a male-headed household, perception of distance to a health facility as a big problem, residing in a rural area, and having a husband with no education significantly influenced home delivery in geographically weighted regression analysis. Conclusions: More than three-fourths of mothers in the developing regions of Ethiopia gave birth at home, where high-risk locations have been identified and the spatial distribution has been clustered. Thus, strengthening programs targeted to improve antenatal care service utilization and women's empowerment is important in reducing home birth practice in the study area. Besides, supporting the existing health extension programs on community-based health education through home-to-home visits is also crucial in reaching women residing in rural settings. [ABSTRACT FROM AUTHOR]

Background: Home birth is a common contributor to maternal and neonatal deaths particularly in low and middle-income countries (LMICs). We generally refer to home births as all births that occurred at the home setting. In Benin, home birth is phenomenal among some category of women. We therefore analysed individual and community-level factors influencing home birth in Benin.Methods: Data was extracted from the 2017-2018 Benin Demographic and Health Survey females' file. The survey used stratified sampling technique to recruit 15,928 women aged 15-49. This study was restricted to 7758 women in their reproductive age who had complete data. The outcome variable was home birth among women. A mixed effect regression analysis was performed using 18 individual and community level explanatory variables. Alpha threshold was fixed at 0.05 confidence interval (CI). All analyses were done using STATA (v14.0). The results were presented in adjusted odds ratios (AORs).Results: We found that 14% (n = 1099) of the respondents delivered at home. The odds of home births was high among cohabiting women compared with the married [AOR = 1.57, CI = 1.21-2.04] and women at parity 5 or more compared with those at parity 1-2 [AOR = 1.29, CI = 1.01-1.66]. The odds declined among the richest [AOR = 0.07, CI = 0.02-0.24], and those with formal education compared with those without formal education [AOR = 0.71, CI = 0.54-0.93]. Similarly, it was less probable for women whose partners had formal education relative to those whose partners had no formal education [AOR = 0.62, CI = 0.49-0.79]. The tendency of home birth was low for women who did not have problem in getting permission to seek medical care [AOR = 0.62, CI = 0.50-0.77], had access to mass media [AOR = 0.78, CI = 0.60-0.99], attained the recommended ANC visits [AOR = 0.33, CI = 0.18-0.63], belonged to a community of high literacy level [AOR = 0.24, CI = 0.14-0.41], and those from communities of high socio-economic status (SES) [AOR = 0.25, CI = 0.14-0.46].Conclusion: The significant predictors of home birth are wealth status, education, marital status, parity, partner's education, access to mass media, getting permission to go for medical care, ANC visit, community literacy level and community SES. To achieve maternal and child health related goals including SDG 3 and 10, the government of Benin and all stakeholders must prioritise these factors in their quest to promote facility-based delivery. [ABSTRACT FROM AUTHOR]

Background: Haiti's maternal mortality, stillbirth, and neonatal mortality rates are the highest in Latin America and the Caribbean. Despite inherent risks, the majority of women still deliver at home without supervision from a skilled birth attendant. The purpose of this study was to elucidate factors driving this decision. Methods: We conducted six focus group discussions with women living in urban (N = 14) or rural (N = 17) areas and asked them questions pertaining to their reasons for delivering at a facility or at home, perceptions of staff at the health facility, experiences with or knowledge of facility or home deliveries, and prior pregnancy experiences (if relevant). We also included currently pregnant women to learn about their plans for delivery, if any. Results: All of the women interviewed acknowledged similar perceived benefits of a facility birth, which were a reduced risk of complications during pregnancy and access to emergency care. However, many women also reported unfavorable birthing experiences at facilities. We identified four key thematic concerns that underpinned women's negative assessments of a facility birth: being left alone, feeling ignored, being subject to physical immobility, and lack of compassionate touch/care. Taken together, these concerns articulated an overarching sense of what we term "isolation," which encompasses feelings of being isolated in the hospital during delivery. Conclusion: Although Haitian women recognized that a facility was a safer place for birthing than the home, an overarching stigma of patient neglect and isolation in facilities was a major determining factor in choosing to deliver at home. The Haitian maternal mortality rate is high and will not be lowered if women continue to feel that they will not receive comfort and compassionate touch/care at a facility compared to their experience of delivering with traditional birth attendants at home. Based on these results, we recommend that all secondary and tertiary facilities offering labor and delivery services develop patient support programs, where women are better supported from admission through the labor and delivery process, including but not limited to improvements in communication, privacy, companionship (if deemed safe), respectful care, attention to pain during vaginal exams, and choice of birth position. [ABSTRACT FROM AUTHOR]

Background: Encouraging institutional birth is an important component of reducing maternal mortality in low-resource settings. This study aims to identify and understand the determinants of persistently low institutional birth in rural Nepal, with the goal of informing future interventions to reduce high rates of maternal mortality.Methods: Postpartum women giving birth in the catchment area population of a district-level hospital in the Far-Western Development Region of Nepal were invited to complete a cross-sectional survey in 2012 about their recent birth experience. Quantitative and qualitative methods were used to determine the institutional birth rate, social and demographic predictors of institutional birth, and barriers to institutional birth.Results: The institutional birth rate for the hospital's catchment area population was calculated to be 0.30 (54 home births, 23 facility births). Institutional birth was more likely as age decreased (ORs in the range of 0.20-0.28) and as income increased (ORs in the range of 1.38-1.45). Institutional birth among women who owned land was less likely (OR = 0.82 [0.71, 0.92]). Ninety percent of participants in the institutional birth group identified safety and good care as the most important factors determining location of birth, whereas 60 % of participants in the home birth group reported distance from hospital as a key determinant of location of birth. Qualitative analysis elucidated the importance of social support, financial resources, birth planning, awareness of services, perception of safety, and referral capacity in achieving an institutional birth.Conclusion: Age, income, and land ownership, but not patient preference, were key predictors of institutional birth. Most women believed that birth at the hospital was safer regardless of where they gave birth. Future interventions to increase rates of institutional birth should address structural barriers including differences in socioeconomic status, social support, transportation resources, and birth preparedness. [ABSTRACT FROM AUTHOR]

Background: In the latest report of Ethiopia Demography and Health Survey (EDHS) 2011, the Maternal Mortality Ratio was estimated at 676/100,000 live births. Most of these deaths are preventable. Increasing the proportion of women who deliver in a health facility can be an important means in reducing maternal mortality in low-income settings including Ethiopia. We aimed to identify factors determining choice of delivery place among child bearing age women.Method: A community based cross sectional survey was conducted in Dega Damot District from April- May, 2014. Mixed methods were employed in the study. Multistage sampling method was used. The primary outcome variable for this study was women who delivered their most recent baby in a health facility.Result: Three hundred sixty one women who gave birth in the past 1 year were included in the study. The mean age of the respondents was 30.9 [SD ±6.006]. One hundred seven (29.6 %) of the respondents were in the age range of 25-29 years. In our study, the proportion of women assisted by skilled health workers during institutional delivery was 89.1 % followed by Health extension workers (8.0 %). Most women (87.4 %) who did not deliver in health facilities were assisted by families, friends or neighbors followed by Health extension workers (7.2 %), and traditional birth attendants (5.4 %), respectively. The qualitative data has described and gave an insight of the contributing factors that influence the women using the health institutions for delivery. These included: ANC attendance, Positive attitude of Health workers and complications during labor and delivery. The preference for a health facility delivery was largely due to the understanding that if complications occurred either during labor or delivery, this was the only place where they could be managed.Conclusion: The study revealed that women's institutional delivery service utilization in the study area is low. Based on these findings, improving the utilization of health facility for delivery through educating women and health promotion have been recommended. This would help reduce the complications and dangers that often characterized home-based, unsupervised delivery. [ABSTRACT FROM AUTHOR]

Background: The high rate of home deliveries conducted by unskilled birth attendants in resource-limited settings is an important global health issue because it is believed to be a significant contributing factor to maternal and newborn mortality. Given the large number of deliveries that are managed by unskilled or traditional birth attendants outside of health facilities, and the fact that there is on-going discussion regarding the role of traditional birth attendants in the maternal newborn health (MNH) service continuum, we sought to ascertain the practices of traditional birth attendants in our catchment area. The findings of this descriptive study might help inform conversations regarding the roles that traditional birth attendants can play in maternal-newborn health care.Methods: A structured questionnaire was used in a survey that included one hundred unskilled birth attendants in western Kenya. Descriptive statistics were employed.Results: Inappropriate or outdated practices were reported in relation to some obstetric complications and newborn care. Encouraging results were reported with regard to positive relationships that traditional birth attendants have with their local health facilities. Furthermore, high rates of referral to health facilities was reported for many common obstetric emergencies and similar rates for reporting of pregnancy outcomes to village elders and chiefs.Conclusions: Potentially harmful or outdated practices with regard to maternal and newborn care among traditional birth attendants in western Kenya were revealed by this study. There were high rates of traditional birth attendant referrals of pregnant mothers with obstetric complications to health facilities. Policy makers may consider re-educating and re-defining the roles and responsibilities of traditional birth attendants in maternal and neonatal health care based on the findings of this survey. [ABSTRACT FROM AUTHOR]

Background: Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Delivery with a skilled birth attendant is a vital intervention for saving lives. Yet many women, particularly where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. In Uganda, only 58 % of women deliver in a health facility, despite approximately 95 % of women attending antenatal care (ANC). This study aimed to (1) identify key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery; (2) examine the association between advice during antenatal care to deliver at a health facility and actual place of delivery; (3) investigate whether antenatal care services in a post-conflict district of Northern Uganda actively link women to skilled birth attendant services; and (4) make recommendations for policy- and program-relevant implementation research to enhance use of skilled birth attendance services.Methods: This study was carried out in Gulu District in 2009. Quantitative and qualitative methods used included: structured antenatal care client entry and exit interviews [n = 139]; semi-structured interviews with women in their homes [n = 36], with health workers [n = 10], and with policymakers [n = 10]; and focus group discussions with women [n = 20], men [n = 20], and traditional birth attendants [n = 20].Results: Seventy-five percent of antenatal care clients currently pregnant reported they received advice during their last pregnancy to deliver in a health facility, and 58 % of these reported having delivered in a health facility. After adjustment for confounding, women who reported they received advice at antenatal care to deliver at a health facility were significantly more likely (aOR = 2.83 [95 % CI: 1.19-6.75], p = 0.02) to report giving birth in a facility. Despite high antenatal care coverage, a number of demand and supply side barriers deter use of skilled birth attendance services. Primary barriers were: fear of being neglected or maltreated by health workers; long distance and other difficulties in access; poverty, and material requirements for delivery; lack of support from husband/partner; health systems deficiencies such as inadequate staffing/training, work environment, and referral systems; and socio-cultural and gender issues such as preferred birthing position and preference for traditional birth attendants.Conclusions: Initiatives to improve quality of client-provider interaction and respect for women are essential. Financial barriers must be abolished and emergency transport for referrals improved. Simultaneously, supply-side barriers must be addressed, notably ensuring a sufficient number of health workers providing skilled obstetric care in health facilities and creating habitable conditions and enabling environments for them. [ABSTRACT FROM AUTHOR]

Background: In the past few decades many countries have worked to increase the number of women delivering in facilities, with the goal of improving maternal and neonatal health outcomes. The purpose of this study is to explore the current situation of facility deliveries in Africa and Asia to understand where and with whom women deliver. Furthermore, we aim to test potential drivers of facility delivery at the individual, household, and community-level. Methods: Demographic and Health Survey data collected since 2003 from 43 countries in Africa and Asia is explored to understand the patterns of where women are delivering. We look at patterns by region and wealth quintile and urban/rural status. We then run a series of multi-level models looking at relationships between individual, household and community-level factors and the odds of a woman delivering in a facility. We explore this for Asia and Africa separately. We also look at correlates of delivery with a trained provider, in a public facility, in a private facility, with a doctor and in a hospital. Results: The majority of women deliver in a facility and with a provider; however, about 20% of deliveries are still with no one or a friend/relative or alone. Rates of facility delivery are lower in Asia overall, and a greater proportion of deliveries take place in private facilities in Asia compared to Africa. Most of the individual level factors that have been found in past studies to be associated with delivering in a facility hold true for the multi-country-level analyses, and small differences exist between Asia and Africa. Women who deliver in private facilities differ from women who deliver in public facilities or at home. Conclusions: Most women in Africa and Asia are delivering in a facility, and drivers of facility delivery identified in smaller level or country specific studies hold true in multi-country national level data. More data and research is needed on other drivers, especially at the country-level and relating to the quality of care and maternal health complications. [ABSTRACT FROM AUTHOR]

Background: Maternal mortality in Kenya increased from 380/100000 live births to 530/100000 live births between 1990 and 2008. Skilled assistance during childbirth is central to reducing maternal mortality yet the proportion of deliveries taking place in health facilities where such assistance can reliably be provided has remained below 50% since the early 1990s. We use the 2008/2009 Kenya Demographic and Health Survey data to describe the factors that determine where women deliver in Kenya and to explore reasons given for home delivery. Methods: Data on place of delivery, reasons for home delivery, and a range of potential explanatory factors were collected by interviewer-led questionnaire on 3977 women and augmented with distance from the nearest health facility estimated using health facility Global Positioning System (GPS) co-ordinates. Predictors of whether the woman's most recent delivery was in a health facility were explored in an exploratory risk factor analysis using multiple logistic regression. The main reasons given by the woman for home delivery were also examined. Results: Living in urban areas, being wealthy, more educated, using antenatal care services optimally and lower parity strongly predicted where women delivered, and so did region, ethnicity, and type of facilities used. Wealth and rural/urban residence were independently related. The effect of distance from a health facility was not significant after controlling for other variables. Women most commonly cited distance and/or lack of transport as reasons for not delivering in a health facility but over 60% gave other reasons including 20.5% who considered health facility delivery unnecessary, 18% who cited abrupt delivery as the main reason and 11% who cited high cost. Conclusion: Physical access to health facilities through distance and/or lack of transport, and economic considerations are important barriers for women to delivering in a health facility in Kenya. Some women do not perceive a need to deliver in a health facility and may value health facility delivery less with subsequent deliveries. Access to appropriate transport for mothers in labour and improving the experiences and outcomes for mothers using health facilities at childbirth augmented by health education may increase uptake of health facility delivery in Kenya. [ABSTRACT FROM AUTHOR]

Background: Skilled attendants during labor, delivery, and in the early postpartum period, can prevent up to 75% or more of maternal death. However, in many developing countries, very few mothers make at least one antenatal visit and even less receive delivery care from skilled professionals. The present study reports findings from a region where key challenges related to transportation and availability of obstetric services were addressed by an ongoing project, giving a unique opportunity to understand why women might continue to prefer home delivery even when facility based delivery is available at minimal cost. Methods: The study took place in Ethiopia using a mixed study design employing a cross sectional household survey among 15-49 year old women combined with in-depth interviews and focus group discussions. Results: Seventy one percent of mothers received antenatal care from a health professional (doctor, health officer, nurse, or midwife) for their most recent birth in the one year preceding the survey. Overall only 16% of deliveries were assisted by health professionals, while a significant majority (78%) was attended by traditional birth attendants. The most important reasons for not seeking institutional delivery were the belief that it is not necessary (42%) and not customary (36%), followed by high cost (22%) and distance or lack of transportation (8%). The group discussions and interviews identified several reasons for the preference of traditional birth attendants over health facilities. Traditional birth attendants were seen as culturally acceptable and competent health workers. Women reported poor quality of care and previous negative experiences with health facilities. In addition, women's low awareness on the advantages of skilled attendance at delivery, little role in making decisions (even when they want), and economic constraints during referral contribute to the low level of service utilization. Conclusions: The study indicated the crucial role of proper health care provider-client communication and providing a more client centered and culturally sensitive care if utilization of existing health facilities is to be maximized. Implications of findings for maternal health programs and further research are discussed. [ABSTRACT FROM AUTHOR]

The article presents the findings of a study conducted on determining the factors that hinder midwives and parturient women from using hospitals when complications occur during home birth in Sistan and Baluchestan province in Iran, where 23 percent of all deliveries take place in non- hospital settings. It discusses the methodology used for the study. It concludes that hospitals must be safe and comfortable environments for parturition.

Background: Although the debate on the safety and women's right of choice to a home delivery vs. hospital delivery continues in the developed countries, an undesirable outcome of home delivery, such as high maternal and perinatal mortality, is documented in developing countries. The objective was to study whether socio-economic factors, distance to maternity hospital, ethnicity, type and size of family, obstetric history and antenatal care received in present pregnancy affected the choice between home and hospital delivery in a developing country. Methods: This cross-sectional study was done during June, 2001 to January 2002 in an administratively and geographically well-defined territory with a population of 88,547, stretching from urban to adjacent rural part of Kathmandu and Dhading Districts of Nepal with maximum of 5 hrs of distance from Maternity hospital. There were no intermediate level of private or government hospital or maternity homes in the study area. Interviews were carried out on 308 women who delivered within 45 days of the date of the interview with a pre-tested structured questionnaire. Results: A distance of more than one hour to the maternity hospital (OR = 7.9), low amenity score status (OR = 4.4), low education (OR = 2.9), multi-parity (OR = 2.4), and not seeking antenatal care in the present pregnancy (OR = 4.6) were statistically significantly associated with an increased risk of home delivery. Ethnicity, obstetric history, age of mother, ritual observance of menarche, type and size of family and who is head of household were not statistically significantly associated with the place of delivery. Conclusions: The socio-economic standing of the household was a stronger predictor of place of delivery compared to ethnicity, the internal family structure such as type and size of family, head of household, or observation of ritual days by the mother of an important event like menarche. The results suggested that mothers, who were in the low-socio-economic scale, delivered at home more frequently in a developing country like Nepal. [ABSTRACT FROM AUTHOR]

Background: The outcomes for planned homebirth in Victoria are unknown. We aimed to compare the rates of outcomes for high risk and low risk women who planned to birth at home compared to those who planned to birth in hospital.Methods: We undertook a population based cohort study of all births in Victoria, Australia 2000-2015. Women were defined as being of low or high risk of adverse pregnancy outcomes according to the eligibility criteria for homebirth and either planning to birth at home or in a hospital setting at the at the onset of labour. Rates of perinatal and maternal mortality and morbidity as well as obstetric interventions were compared.Results: Three thousand nine hundred forty-five women planned to give birth at home with a privately practising midwife and 829,286 women planned to give birth in a hospital setting. Regardless of risk status, planned homebirth was associated with significantly lower rates of all obstetric interventions and higher rates of spontaneous vaginal birth (p ≤ 0.0001 for all). For low risk women the rates of perinatal mortality were similar (1.6 per 1000 v's 1.7 per 1000; p = 0.90) and overall composite perinatal (3.6% v's 13.4%; p ≤ 0.001) and maternal morbidities (10.7% v's 17.3%; p ≤ 0.001) were significantly lower for those planning a homebirth. Planned homebirth among high risk women was associated with significantly higher rates of perinatal mortality (9.3 per 1000 v's 3.5 per 1000; p = 0.009) but an overall significant decrease in composite perinatal (7.8% v's 16.9%; p ≤ 0.001) and maternal morbidities (16.7% v's 24.6%; p ≤ 0.001).Conclusion: Regardless of risk status, planned homebirth was associated with significantly lower rates of obstetric interventions and combined overall maternal and perinatal morbidities. For low risk women, planned homebirth was also associated with similar risks of perinatal mortality, however for women with recognized risk factors, planned homebirth was associated with significantly higher rates of perinatal mortality. [ABSTRACT FROM AUTHOR]