Why do women attend antenatal care but give birth at home? a qualitative study in a rural Ghanaian District

BACKGROUND

The Sustainable Development Goal Three has prioritised reducing maternal, under-5 and neonatal mortalities as core global health policy objectives. The place, where expectant mothers choose to deliver their babies has a direct effect on maternal health outcomes. In sub-Saharan Africa, existing literature has shown that some women attend antenatal care during pregnancy but choose to deliver their babies at home. Using the Andersen and Newman Behavioural Model, this study explored the institutional and socio-cultural factors motivating women to deliver at home after attending antenatal care.

METHODS

A qualitative, exploratory, cross-sectional design was deployed. Data were collected from a purposive sample of 23 women, who attended antenatal care during pregnancy but delivered their babies at home, 10 health workers and 17 other community-level stakeholders. The data were collected through semi-structured interviews, which were audio-recorded, transcribed and thematically analysed.

RESULTS

In line with the Andersen and Newman Model, the study discovered that traditional and religious belief systems about marital fidelity and the role of the gods in childbirth, myths about consequences of facility-based delivery, illiteracy, and weak women's autonomy in healthcare decision-making, predisposed women to home delivery. Home delivery was also enabled by inadequate midwives at health facilities, the unfriendly attitude of health workers, hidden charges for facility-based delivery, and long distances to healthcare facilities. The fear of caesarean section, also created the need for women who attended antenatal care to deliver at home.

CONCLUSION

The study has established that socio-cultural and institutional level factors influenced women's decisions to deliver at home. We recommend a general improvement in the service delivery capacity of health facilities, and the implementation of collaborative educational and women empowerment programmes by stakeholders, to strengthen women's autonomy and reshape existing traditional and religious beliefs facilitating home delivery.

Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State

OBJECTIVE

To describe rates of maternal and perinatal birth outcomes for community births and to compare outcomes by planned place of birth (home vs state-licensed, freestanding birth center) in a Washington State birth cohort, where midwifery practice and integration mirrors international settings.

METHODS

We conducted a retrospective cohort study including all births attended by members of a statewide midwifery professional association that were within professional association guidelines and met eligibility criteria for planned birth center birth (term gestation, singleton, vertex fetus with no known fluid abnormalities at term, no prior cesarean birth, no hypertensive disorders, no prepregnancy diabetes), from January 1, 2015 through June 30, 2020. Outcome rates were calculated for all planned community births in the cohort. Estimated relative risks were calculated comparing delivery and perinatal outcomes for planned births at home to state-licensed birth centers, adjusted for parity and other confounders.

RESULTS

The study population included 10,609 births: 40.9% planned home and 59.1% planned birth center births. Intrapartum transfers to hospital were more frequent among nulliparous individuals (30.5%; 95% CI 29.2-31.9) than multiparous individuals (4.2%; 95% CI 3.6-4.6). The cesarean delivery rate was 11.4% (95% CI 10.2-12.3) in nulliparous individuals and 0.87% (95% CI 0.7-1.1) in multiparous individuals. The perinatal mortality rate after the onset of labor (intrapartum and neonatal deaths through 7 days) was 0.57 (95% CI 0.19-1.04) per 1,000 births. Rates for other adverse outcomes were also low. Compared with planned birth center births, planned home births had similar risks in crude and adjusted analyses.

CONCLUSION

Rates of adverse outcomes for this cohort in a U.S. state with well-established and integrated community midwifery were low overall. Birth outcomes were similar for births planned at home or at a state-licensed, freestanding birth center.

Newborn Screening Knowledge and Attitudes Among Midwives and Out-of-Hospital-Birth Parents

Midwifery and nursing are collaborative partners in both education and practice. Understanding needs and barriers to clinical services such as newborn screening is essential. This study examined knowledge and attitudes of midwives and out-of-hospital-birth parents about newborn blood spot screening (NBS). Descriptive and cross-sectional surveys were distributed to midwives and out-of-hospital-birth parents from birth center registries and the Utah Health Department of Vital Records. Seventeen midwife surveys (response rate: 17%) and 113 parent surveys (response rate: 31%) were returned. Most midwives and out-of-hospital-birth parents reported satisfactory knowledge scores about NBS. Only 5% of parents (n = 6) did not participate in NBS. Most midwives reported that NBS is important and encouraged patients to consider undergoing NBS. Some concerns included the lack of education for both midwives and out-of-hospital patients and the trauma and accuracy of the heel prick soon after birth. Both midwives and out-of-hospital-birth parents expressed a need for improved NBS education. Additional studies are needed to ascertain whether this trend is seen with similar populations throughout the United States, to further elucidate the factors that drive NBS nonparticipation, and to develop educational resources for midwives and their patients.

Home delivery practice and its predictors in South Ethiopia

BACKGROUND

Institutional delivery is one of the key interventions to reduce maternal death. It ensures safe birth, reduces both actual and potential complications, and decreases maternal and newborn death. However, a significant proportion of deliveries in developing countries like Ethiopia are home deliveries and are not attended by skilled birth attendants. We investigated the prevalence and determinants of home delivery in three districts in Sidama administration, Southern Ethiopia.

METHODS

Between 15-29 October 2018, a cross sectional survey of 507 women who gave birth within the past 12 months was conducted using multi-stage sampling. Sociodemographic and childbirth related data were collected using structured, interviewer administered tools. Univariate and backward stepwise multivariate logistic regression models were run to assess independent predictors of home delivery.

RESULTS

The response rate was 97.6% (495). In the past year, 22.8% (113), 95% confidence interval (CI) (19%, 27%) gave birth at home. Rural residence, adjusted odds ratio (aOR) = 13.68 (95%CI:4.29-43.68); no maternal education, aOR = 20.73(95%CI:6.56-65.54) or completed only elementary school, aOR = 7.62(95% CI: 2.58-22.51); unknown expected date of delivery, aOR = 1.81(95% CI: 1.03-3.18); being employed women (those working for wage and self-employed), aOR = 2.79 (95%CI:1.41-5.52) and not planning place of delivery, aOR = 26.27, (95%CI: 2.59-266.89) were independently associated with place of delivery.

CONCLUSION

The prevalence of institutional delivery in the study area has improved from the 2016 Ethiopian Demography Health Survey report of 26%. Uneducated, rural and employed women were more likely to deliver at home. Strategies should be designed to expand access to and utilization of institutional delivery services among the risky groups.

Experiences of Dutch maternity care professionals during the first wave of COVID-19 in a community based maternity care system

Background and objective

During the COVID-19 pandemic the organization of maternity care changed drastically; this study into the experiences of maternity care professionals with these changes provides suggestions for the organization of care during and after pandemics.

Design

An online survey among Dutch midwives, obstetricians and obstetric residents. Multinomial logistic regression analyses were used to investigate associations between the respondents’ characteristics and answers.

Results

Reported advantages of the changes were fewer prenatal and postpartum consultations (50.1%). The necessity and safety of medical interventions and ultrasounds were considered more critically (75.9%); 14.8% of community midwives stated they referred fewer women to the hospital for decreased fetal movements, whereas 64.2% of the respondents working in hospital-based care experienced fewer consultations for this indication. Respondents felt that women had more confidence in giving birth at home (57.5%). Homebirths seemed to have increased according to 38.5% of the community midwives and 65.3% of the respondents working in hospital-based care. Respondents appreciated the shift to more digital consultations rather than face-to-face consultations. Mentioned disadvantages were that women had appointments alone, (71.1%) and that the community midwife was not allowed to join a woman to obstetric-led care during labour and subsequently stay with her (56.8%). Fewer postpartum visits by family and friends led to more tranquility (59.8%). Overall, however, 48.0% of the respondents felt that the safety of maternity care was compromised due to policy changes.

Conclusions

Maternity care professionals were positive about the decrease in routine care and the increased confidence of women in home birth, but also felt that safety in maternity care was sometimes compromised. According to the respondents in a future crisis situation it should be possible for community midwives to continue to deliver a personal handover after the referral of women to the hospital, and to stay with them.

The role of pandemic-related pregnancy stress in preference for community birth during the beginning of the COVID-19 pandemic in the United States

BACKGROUND

The COVID-19 pandemic introduced unparalleled uncertainty into the lives of pregnant women, including concerns about where it is the safest to give birth, while preserving their rights and wishes. Reports on the increased interest in community births (at home or in birth centers) are emerging. The purpose of this project was to quantitatively investigate psychological factors related to this birth preference.

METHODS

This study included 3896 pregnant women from the COVID-19 Pregnancy Experiences (COPE) Study who were anticipating a vaginal birth. COPE Study participants were recruited online between April 24 and May 15, 2020, and completed a questionnaire that included preference with respect to place of birth and psychological constructs: fear of childbirth, basic beliefs about birth, pandemic-related preparedness stress, and pandemic-related perinatal infection stress.

RESULTS

Women who preferred a community birth, on average, had less childbirth fear, had stronger beliefs that birth is a natural process, were less likely to see birth as a medical process, and were less stressed about being unprepared for birth and being infected with COVID-19. In multivariate models, higher stress about perinatal COVID-19 infection was associated with greater likelihood of preferring a community birth. The effect of perinatal infection stress on preference was stronger when preparedness stress was high.

DISCUSSION

Women's birth preferences during the COVID-19 pandemic are associated with psychological processes related to risk perception. Community births are more appealing to women who view being in a hospital as hazardous because of the pandemic. Policies and prenatal care aimed to increase access to safe in-hospital and out-of-hospital birth services should be encouraged.

Home birth preference, childbirth, and newborn care practices in rural Peruvian Amazon

Home birth is very common in the Peruvian Amazon. In rural areas of the Loreto region, home to indigenous populations such as the Kukama-Kukamiria, birth takes place at home constantly. This study aims to understand the preference for home births as well as childbirth and newborn care practices among Kukama-Kukamiria women in rural Loreto. Following a case study approach, sixty semi-structured, face-to-face interviews were conducted with recent mothers who experienced childbirth within one year prior to the interview, female relatives of recent mothers who had a role in childbirth, male relatives of recent mothers, community health workers, and traditional healers. We found that for women from these communities, home birth is a courageous act and an intimate (i.e. members of the community and relatives participate in it) and inexpensive practice in comparison with institutional birth. These preferences are also linked to experiences of mistreatment at health facilities, lack of cultural adaptation of birthing services, and access barriers to them. Preparations for home births included handwashing and cleaning delivery surfaces. After birth, waiting for the godparent to arrive to cut the cord can delay drying of the newborn. Discarding of colostrum, lack of skin-to-skin contact as well as a range of responses regarding immediate breastfeeding and immediate drying of the baby were also found. These findings were used to tailor the educational content of the Mamas del Rio program, where community health workers are trained to identify pregnancy early, perform home visits to pregnant women and newborns, and promote essential newborn care practices in case institutional birth is not desired or feasible. We make recommendations to improve Peru's cultural adaptation of birthing services.

Trends in Home Birth Information Seeking in the United States and United Kingdom During the COVID-19 Pandemic

This cross-sectional study used online search data to assess changes in home birth information-seeking behaviors across the United States and United Kingdom during the COVID-19 pandemic.

What influences home delivery among women who live in urban areas? Analysis of 2014 Ghana Demographic and Health Survey data

BACKGROUND

In Ghana, home delivery among women in urban areas is relatively low compared to rural areas. However, the few women who deliver at home in urban areas still face enormous risk of infections and death, just like those in rural areas. The present study investigated the factors associated with home delivery among women who live in urban areas in Ghana.

MATERIALS AND METHODS

Data for this study was obtained from the 2014 Ghana Demographic and Health Survey. We used data of 1,441 women who gave birth in the 5 years preceding the survey and were dwelling in urban areas. By the use of Stata version 14.2, we conducted both descriptive and multivariable logistic regression analyses.

RESULTS

We found that 7.9% of women in urban areas in Ghana delivered at home. The study revealed that, compared to women who lived in the Northern region, women who lived in the Brong Ahafo region [AOR = 0.38, CI = 0.17-0.84] were less likely to deliver at home. The likelihood of home delivery was high among women in the poorest wealth quintile [AOR = 2.02, CI = 1.06-3.86], women who professed other religions [AOR = 3.45; CI = 1.53-7.81], and those who had no antenatal care visits [AOR = 7.17; 1.64-31.3]. Conversely, the likelihood of home delivery was lower among women who had attained secondary/higher education [AOR = 0.30; 0.17-0.53], compared to those with no formal education.

CONCLUSION

The study identified region of residence, wealth quintile, religion, antenatal care visits, and level of education as factors associated with home delivery among urban residents in Ghana. Therefore, health promotion programs targeted at home delivery need to focus on these factors. We also recommend that a qualitative study should be conducted to investigate the factors responsible for the differences in home delivery in terms of region, as the present study could not do so.

Prevalence, predictors and reasons for home delivery amongst women of childbearing age in Dodoma Municipality in central Tanzania

Introduction

The objective was to determine the prevalence, predictors and reasons for home delivery amongst women of childbearing age in Dodoma, Tanzania.

Methods

A cross-sectional study was conducted amongst women living in Dodoma Municipality. Data were collected using adapted questionnaires and analysed using SPPS version 23. A multivariable logistic regression model was used to assess the independent predictors of home delivery.

Results

A total of 425 women of childbearing age were enrolled in this study. The mean (± SD) age of the participants was 28.7 (±7.1) years. The prevalence of home delivery was 35.5% (n=150, 95% CI 30.9 – 40.2). Women with secondary school and above had 93% less odds of home delivery than women who had no education (AOR=0.0795% CI: 0.03–0.18). Women who lived in rural areas (AOR=3.49, 95% CI: 2.12–5.75), and women living more than 5km from health facilities (AOR=2.67, 95% CI: 1.65–4.37) had higher odds of home delivery. The main reasons for home delivery were transportation cost, and long distance to the nearest health facilities.

Conclusion

In this population, the prevalence of home delivery remained to be high. To address this more collaborative multisectoral effort like strengthening health education and strengthening maternity waiting homes are needed.

Understanding how midwives employed by the National Health Service facilitate women's alternative birthing choices: Findings from a feminist pragmatist study

UK legislation and government policy favour women's rights to bodily autonomy and active involvement in childbirth decision-making including the right to decline recommendations of care/treatment. However, evidence suggests that both women and maternity professionals can face challenges enacting decisions outside of sociocultural norms. This study explored how NHS midwives facilitated women's alternative physiological birthing choices-defined in this study as 'birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth'. The study was underpinned by a feminist pragmatist theoretical framework and narrative methodology was used to collect professional stories of practice via self-written narratives and interviews. Through purposive and snowball sampling, a diverse sample in terms of age, years of experience, workplace settings and model of care they operated within, 45 NHS midwives from across the UK were recruited. Data were analysed using narrative thematic that generated four themes that described midwives' processes of facilitating women's alternative physiological births: 1. Relationship building, 2. Processes of support and facilitation, 3. Behind the scenes, 4. Birth facilitation. Collectively, the midwives were involved in a wide range of alternative birth choices across all birth settings. Fundamental to their practice was the development of mutually trusting relationships with the women which were strongly asserted a key component of safe care. The participants highlighted a wide range of personal and advanced clinical skills which was framed within an inherent desire to meet the women's needs. Capturing what has been successfully achieved within institutionalised settings, specifically how, maternity providers may benefit from the findings of this study.

Home Birth in the Era of COVID-19: Counseling and Preparation for Pregnant Persons Living with HIV

With the coronavirus disease 2019 (COVID-19) pandemic in the United States, a majority of states have instituted "shelter-in-place" policies effectively quarantining individuals-including pregnant persons-in their homes. Given the concern for COVID-19 acquisition in health care settings, pregnant persons with high-risk pregnancies-such as persons living with HIV (PLHIV)-are increasingly investigating the option of a home birth. Although we strongly recommend hospital birth for PLHIV, we discuss our experience and recommendations for counseling and preparation of pregnant PLHIV who may be considering home birth or at risk for unintentional home birth due to the pandemic. We also discuss issues associated with implementing a risk mitigation strategy involving high-risk births occurring at home during a pandemic. KEY POINTS: · Coronavirus disease 2019 pandemic has increased interest in home birth.. · Women living with HIV are pursuing home birth.. · Safe planning is paramount for women living with HIV desiring home birth, despite recommending against the practice..

Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant

BACKGROUND

Planned home births have leveled off in the United States in recent years after a significant rise starting in the mid-2000s. Planned home births in the United States are associated with increased patient-risk profiles. Multiple studies concluded that, compared with hospital births, absolute and relative risks of perinatal mortality and morbidity in US planned home births are significantly increased.

OBJECTIVE

To explore the safety of birth in the United States by comparing the neonatal mortality outcomes of 2 locations, hospital birth and home birth, by 4 types of attendants: hospital midwife; certified nurse-midwife at home; direct-entry ("other") midwife at home; and attendant at home not identified, using the most recent US Centers for Disease Control and Prevention natality data on neonatal mortality for planned home births in the United States. Outcomes are presented as absolute risks (neonatal mortality per 10,000 live births) and as relative risks of neonatal mortality (hospital-certified nurse-midwife odds ratio, 1) overall, and for recognized risk factors.

STUDY DESIGN

We used the most current US Centers for Disease and Prevention Control Linked Birth and Infant Death Records for 2010-2017 to assess neonatal mortality (neonatal death days 0-27 after birth) for single, term (37+ weeks), normal-weight ( >2499 g) infants for planned home births and hospital births by birth attendants: hospital-certified nurse-midwives, home-certified nurse-midwives, home other midwives (eg, lay or direct-entry midwives), and other home birth attendant not identified.

RESULTS

The neonatal mortality for US hospital midwife-attended births was 3.27 per 10,000 live births, 13.66 per 10,000 live births for all planned home births, and 27.98 per 10,000 live births for unintended/unplanned home births. Planned home births attended by direct-entry midwives and by certified nurse-midwives had a significantly elevated absolute and relative neonatal mortality risk compared with certified nurse-midwife-attended hospital births (hospital-certified nurse-midwife: 3.27/10,000 live births odds ratio, 1; home birth direct-entry midwives: neonatal mortality 12.44/10,000 live births, odds ratio, 3.81, 95% confidence interval, 3.12-4.65, P<.0001; home birth-certified nurse-midwife: neonatal mortality 9.48/10,000 live births, odds ratio, 2.90, 95% confidence interval, 2.90; P<.0001). These differences increased further when patients were stratified for recognized risk factors.

CONCLUSION

The safety of birth in the United States varies by location and attendant. Compared with US hospital births attended by a certified nurse-midwife, planned US home births for all types of attendants are a less safe setting of birth, especially when recognized risk factors are taken into account. The type of midwife attending US planned home birth appears to have no differential effect on decreasing the absolute and relative risk of neonatal mortality of planned home birth, because the difference in outcomes of US planned home births attended by direct-entry midwives or by certified nurse-midwives is not statistically significant.

Determinants of neonatal mortality in Ethiopia: an analysis of the 2016 Ethiopia Demographic and Health Survey

Background

The first 28 days of life, the neonatal period, are the most vulnerable time for a child’s survival. Neonatal mortality accounts for about 38% of under-five deaths in low and middle income countries. This study aimed to identify the determinants of neonatal mortality in Ethiopia.

Methods

The study used data from the nationally representative 2016 Ethiopia Demographic and Health Survey (EDHS). Once the data were extracted; editing, coding and cleaning were done by using SAS 9.4.Sampling weights was applied to ensure the representativeness of the sample in this study. Both bivariate and multivariable logistic regression statistical analysis was used to identify determinants of neonatal mortality in Ethiopia.

Results

A total of 11,023 weighted live-born neonates born within five years preceding the 2016 EDHS were included this in this study. Multiple logistic regression analysis showed that multiple birth neonates (Adjusted Odds Ratio (AOR)=6.38;95%-Confidence Interval (CI):4.42-9.21), large birth size (AOR=1.35; 95% CI: 0.28-1.62), neonates born to mothers who did not utilize ANC (AOR=1.41; 95% CI: 1.11-1.81), neonates from rural area (AOR=1.88; 95% CI: 1.15-3.05) and neonates born in Harari region (AOR=1.45; 95% CI: 0.61-3.45)had higher odds of neonatal mortality. On the other hand, female neonates (AOR=0.60; 95% CI: 0.47-0.75), neonates born within the interval of more than 36 months of the preceding birth (AOR=0.56; 95% CI: 0.43-0.75), neonates born to fathers with secondary and higher education level (AOR=0.51; 95%CI: 0.22-0.88) had lower odds of neonatal mortality in Ethiopia.

Conclusion

To reduce neonatal mortality in Ethiopia, there is a need to implement sex specific public health intervention mainly focusing on male neonate during pregnancy, child birth and postnatal period. A relatively simple and cost-effective public health intervention should be implemented to make sure that all pregnant women are screened for multiple pregnancy and if positive, extra care should be given during pregnancy, child birth and postnatal.

Predictors of institutional delivery service utilization among women of reproductive age in Gambia: a cross-sectional analysis

BACKGROUND

Over the last two decades, Gambia has made noticeable progress in the reducing the high maternal mortality rates and improving child survival rates. Nonetheless, numerous infrastructural and financial constraints continue to restrict access to institutional delivery care, a key component of achieving the maternal and child health related Sustainable Development Goals (SDG 3.1). This study assesses factors that predict women's choice of mode and place of delivery in urban and rural Gambia.

METHODS

Cross-sectional data from the latest round of Gambia Demographic and Health Survey (2013) on women aged 15-49 years (n = 5351) were analyzed. The outcome measures were place (home vs health facility) and mode of delivery (caesarean vs normal) in urban and rural Gambia. Data were analyzed using descriptive and multivariate regression methods.

RESULTS

About three-fifth (60.8%) of the participants had their last childbirth at a health facility and 39.2% at their home. There was a significant urban-rural difference in the prevalence of facility delivery with 86.9% of the urban women choosing health facility over home compared with 45.8% among the rural women. In the regression analysis, place of residence, education of participants and the husband, employment, parity and use of antenatal care were significantly associated with the use of health facility delivery services. For instance, having secondary [OR = 1.657, 95%CI = 1.337,2.053] and higher education [OR-2.451, 95%CI = 1.166,5.150] showed higher odds for using facility delivery services; and women from the richest wealth quintile had significantly higher [OR = 2.239, 95%CI = 1.525,3.289] odds of using facility delivery compared with those in the lowest quintile.

CONCLUSION

Our findings suggest a sub-optimal use of professional childbirth services among Gambian women which appears to be driven by various geographical, educational, wealth inequality, parity and low use of ANC services. Addressing the socioeconomic and demographic inequalities may lead to a more widespread usage of maternity services in Gambia.

Institutional delivery services utilization and its determinant factors among women who gave birth in the past 24 months in Southwest Ethiopia

BACKGROUND

Institutional delivery is a delivery that takes place at any medical facility staffed by skilled delivery assistance. It is estimated that using institutional delivery could reduce 16 to 33% of maternal deaths. Despite the importance of delivering at health institutions, in Ethiopia, mothers prefer to give birth at home. Therefore, the aim of this study was to compare institutional delivery service utilization and associated factors among rural and urban mothers in Mana district, Jimma Zone, Southwest Ethiopia, 2017.

METHODS

A community based comparative cross sectional study was conducted in Mana district, Southwest Ethiopia from March to June, 2017. A stratified probability sampling technique was used to select a total of 1426 (713 urban, 713 rural) study participants. Data were collected from mothers who gave birth in the past 24 months by using a structured and pretested questionnaire.

RESULTS

The overall prevalence of institutional delivery service utilization was 86.4%. Higher number of antenatal care visits, having good knowledge on the danger signs of labor, increased wealth index, primary and above educational level of the husband, mothers age below 40-year, and less than 30-min travel time to the nearby health institutions had significantly increased the rate of institutional delivery service utilization.

CONCLUSION

Institutional delivery service utilization is high in the study area. Maternal awareness of danger signs of labor, frequent ANC visit and better education of husband, and household wealth predicted the utilization of the service. Therefore, due attention need to be given to enhancing education, expanding health institutions and creating awareness on advantage of antenatal care follow up and danger signs to make all pregnancies delivered at health institutions.

Regional variations in childbirth interventions and their correlations with adverse outcomes, birthplace and care provider: A nationwide explorative study

Background

Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics.

Methods

In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks’ gestation in 2010–2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman’s rank correlations.

Findings

Intrapartum referral rates varied between 55–68% (nulliparous) and 20–32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6–16% (nulliparous) and 16–31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14–42% (nulliparous) and 3–13% (multiparous) and in obstetrician-led births from 46–67% and 14–28% respectively. Rates of postpartum oxytocin varied between 59–88% (nulliparous) and 50–85% (multiparous) and artificial rupture of membranes between 43–52% and 54–61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin.

Conclusions

Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.

Spatial clustering and determinants of home birth after at least one antenatal care visit in Ethiopia: Ethiopian demographic and health survey 2016 perspective

BACKGROUND

All pregnancies are at risk and have to be attended by skilled professionals. In Ethiopia however nearly half (45.7%) of the women were giving birth at home after antenatal care (ANC) visits in which skilled professionals were not available. Therefore, the aim of this study was to assess spatial clustering and the determinant factors of home delivery after antenatal care visits in Ethiopia.

METHODS

A case control study was conducted on 2110 mothers who gave birth at home after ANC (cases), and 2510 mothers who gave birth at health institutions after attending ANC (controls), based on EDHS 2016 data. As per the recommendations of the DHS program, we weighed the data before analysis. ArcGIS 10.3 was used to show spatial pattern and SaTScan™ 9.4 to identify significant clusters. Stata 14 was used for data cleaning, weighing, and the analysis of the determinant factors. Bi variable and multi variable multilevel mixed effect logistic regression was fitted. Finally, the Log-likelihood ratio (LLR) and Relative risk with p-value of spatial scan statistics and AOR with 95% CI for significant determinant factors were reported.

RESULTS

Home delivery after ANC was spatially clustered in Ethiopia (Moran's Index = 0.91, p-value< 0.01). Attending, 1-3 ANC visits (AOR = 1.41, 95%CI: 1.17-1.71), no information about birth preparedness plan (AOR = 2.21, 95%CI: 1.83-2.69), pregnancies wanted later (AOR = 1.55, 95%CI: 1.20, 2.06), not having health insurance (AOR = 2.16, 95% CI: 1.29, 3.62), Muslim (AOR = 1.57, 95% CI: 1.13, 2.19) and protestant (AOR = 1.72, 95%CI: 1.16, 2.42) religions were positively associated with home delivery; While being rich (AOR = 0.42, 95%CI: 0.32-0.54), middle wealth index (AOR = O.66, 95%CI: 0.51, 0.86), primary education (AOR = 0.45, 95%CI: 0.36-0.55), secondary education (AOR = 0.11, 95%CI: 0.07-0.16), above secondary education (AOR = 0.06, 95%CI: 0.03-0.11) were negatively associated.

CONCLUSIONS

Home delivery after ANC follow ups was spatially clustered. Socio-demographic, health service and pregnancy related factors determined the prevalence of home delivery after antenatal care visits. Strengthening women's education, ANC visit, giving more information about birth preparedness plan, and improving family wealth are vital to reduce home delivery after antenatal care visits.

Determinants of home delivery in Nepal - A disaggregated analysis of marginalised and non-marginalised women from the 2016 Nepal Demographic and Health Survey

INTRODUCTION

In Nepal, a substantial proportion of women still deliver their child at home. Disparities have been observed in utilisation of institutional delivery and skilled birth attendant services. We performed a disaggregated analysis among marginalised and non-marginalised women to identify if different factors are associated with home delivery among these groups.

MATERIALS AND METHODS

This study used data from the 2016 Nepal Demographic and Health Survey. It involves the analysis of 3,837 women who had experienced at least one live birth in the five years preceding the survey. Women were categorised as marginalised and non-marginalised based on ethnic group. Bivariate and multivariable logistic regression analysis were performed to identify factors associated with home delivery.

RESULTS

A higher proportion of marginalised women delivered at home (47%) than non-marginalised women (26%). Compared to non-marginalised women (35%), a larger proportion of marginalised women (64%) felt that it was not necessary to give birth at health facility. The multivariable analysis indicated an independent association of having no or basic education, belonging to middle, poorer and the poorest wealth quintile, residing in Province 2 and not having completed of four antenatal care visits per protocol with home delivery among both marginalised and non-marginalised women. Whereas residing in a rural area, residing in Province 7, and at a distance of >30 minutes to a health facility were factors independently associated with home delivery only among marginalised women.

CONCLUSION

We conclude that poor education, poor economic status, non-completion of four ANC visits and belonging to Province 2 particularly determined either group of women to deliver at home, whereas residing in rural areas, living far from health facility, and belonging to Province 7 determined marginalised women to deliver at home. Preventing mothers from delivering at home would thus require focusing on specific geographical areas besides considering wider socio-economic determinants.

Vaccination Status and Associated Factors among Street Children 9-24 Months Old in Sidama Region, Ethiopia

Background

Childhood non-vaccination can have different short-and long-term negative outcomes on their health. In Ethiopia, in addition to low coverage of full vaccination, street children were among the neglected part of the community who were missed during planning and reporting vaccination coverage. Moreover, there is no related research conducted on this title specifically.

Objective

The objective of the study was to assess the vaccination status and its associated factors among street children 9-24 months old in Sidama zone.

Methods

Community-based cross-sectional study design was conducted in four selected towns of Sidama region, southern Ethiopia. The convenience sampling method was applied to involve mothers of street children younger than two years during the study period. Data entry was done with EpiData version 3.1 and exported to SPSS22 for analysis. Bivariate and multivariable logistic regression analysis were performed to identify factors associated with immunization status of street children.

Results

A significant number (26 [24.3%]) of the street children younger than two years were not vaccinated. Those mothers who are ≤20 years old (P = 0.014, AOR = 0.216, 95% CI: 0.064-0.732) and who gave birth at home (P = 0.029, AOR = 0.292, 95% CI: 0.097-0.879) had less odds of vaccinating their child than those older than 20 and who gave birth at health facility respectively.

Conclusion

A significant number of the street children in this study are not fully vaccinated. Mothers aged <20 years and home births were significantly associated with non-vaccination status.

Humanised childbirth: the status of emotional support of women in rural Bangladesh

The World Health Organization has recently set standards emphasising the importance of emotional support during birth for improving the quality of maternal and newborn healthcare in facilities. In this study, we explore the emotional support status of women during birth in rural Bangladesh. A cross-sectional household survey of 1367 women was administered in 2018 in Brahmanbaria district. Outcomes of interest included: presence of a companion of choice; mobility; intake of fluids and food; and position of choice. Associations between outcomes of interest and background characteristics were explored through binary and multiple logistic regressions. Approximately 68% women had a companion of choice during labour or childbirth, significantly higher among women giving birth at home (75%) than in a health facility. Nearly 60% women were allowed to eat and drink during labour, also significantly higher among women giving birth at home. Seventy-per cent women were allowed to be ambulatory during labour (46% in a facility vs. 85% at home). Only 27% women were offered or allowed to give birth in the position of their choice at facility, compared to 54% giving birth at home. Among women giving birth in a facility who did not have a companion of choice, 39% reported that the health provider/health facility management did not allow this. Ensuring emotional support and thereby improving the quality of the experience of care within health facilities should be prioritised by the Bangladesh government both to improve health outcomes of women and newborns and also to promote more humanised, positive childbirth experiences.

Home childbirth among young mothers aged 15-24 years in Nigeria: a national population-based cross-sectional study

OBJECTIVE

To estimate the prevalence and identify factors associated with home childbirth (delivery) among young mothers aged 15-24 years in Nigeria.

DESIGN

A secondary analysis of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (NDHS).

SETTING

Nigeria.

PARTICIPANTS

A total of 7543 young mothers aged 15-24 years.

OUTCOME MEASURE

Place of delivery.

RESULTS

The prevalence of home delivery among young mothers aged 15-24 years was 69.5% (95% CI 67.1% to 71.8%) in Nigeria-78.9% (95%CI 76.3% to 81.2%) in rural and 43.9% (95%CI 38.5% to 49.5%, p<0.001) in urban Nigeria. Using the Andersen's behavioural model, increased odds of home delivery were associated with the two environmental factors: rural residence (adjusted OR, AOR: 1.39, 95% CI 1.06 to 1.85) and regions of residence (North-East: AOR: 1.97, 95% CI 1.14 to 3.34; North-West: AOR: 2.94, 95% CI 1.80 to 4.83; and South-South: AOR: 3.81, 95% CI 2.38 to 6.06). Three of the enabling factors (lack of health insurance: AOR: 2.34, 95% CI 1.16 to 4.71; difficulty with distance to healthcare facilities: AOR: 1.48, 95% CI 1.15 to 1.88; and <4 times antenatal attendance: AOR: 3.80, 95% CI 3.00 to 4.85) similarly increased the odds of home delivery. Lastly, six predisposing factors-lack of maternal and husband's education, poor wealth index, Islamic religion, high parity and low frequency of listening to radio-were associated with increased odds of home delivery.

CONCLUSIONS

Young mothers aged 15-24 years had a higher prevalence of home delivery than the national average for all women of reproductive age in Nigeria. Priority attention is required for young mothers in poor households, rural areas, North-East, North-West and South-South regions. Faith-based interventions, a youth-oriented antenatal care package, education of girls and access to health insurance coverage are recommended to speed up the reduction of home delivery among young mothers in Nigeria.

Trends and state variations in out-of-hospital births in the United States, 2004-2017

BACKGROUND

Out-of-hospital births have been increasing in the United States, although past studies have found wide variations between states. Our purpose was to examine trends in out-of-hospital births, the risk profile of these births, and state differences in women's access to these births.

METHODS

National birth certificate data from 2004 to 2017 were analyzed. Newly available national data on method of payment for the delivery (private insurance, Medicaid, self-pay) were used to measure access to out-of-hospital birth options.

RESULTS

After a gradual decline from 1990 to 2004, the number of out-of-hospital births increased from 35 578 in 2004 to 62 228 in 2017. In 2017, 1 of every 62 births in the United States was an out-of-hospital birth (1.61%). Home births increased by 77% from 2004 to 2017, whereas birth center births more than doubled. Out-of-hospital births were more common in the Pacific Northwest and less common in the southeastern states such as Alabama, Louisiana, and Mississippi. Women with planned home and birth center births were less likely to have a number of population characteristics associated with poor pregnancy outcomes, including teen births, smoking during pregnancy, obesity, and preterm, low birthweight, and multiple births. More than 2/3 of planned home births were self-paid, compared with 1/3 of birth center and just 3% of hospital births, with large variations by state.

CONCLUSIONS

Lack of insurance or Medicaid coverage is an important limiting factor for women desiring out-of-hospital birth in most states. Recent increases in out-of-hospital births despite important limiting factors highlight the strong motivation of some women to choose out-of-hospital birth.

Utilization of decentralized health facilities and factors influencing women's choice of a delivery site in Gida Ayana Woreda, western Ethiopia

Introduction

Despite the government’s efforts to decentralize and expand health institutions to promote facility-based child delivery, home delivery and maternal mortality are still widespread problems in Ethiopia. Most mothers continue to give birth at home. This study aims at identifying the socio-cultural practices, perceived benefit or need, and accessibility factors influencing women’s choice of health facilities for delivery services in Gida Ayana Woreda, western Ethiopia.

Methods

We conducted a cross-sectional survey to assess women’s use of delivery care services in Gida Ayana Woreda, from November 2016 to January 2017; 459 women who were selected randomly participated in the study. We evaluated the socio-cultural, perceived benefit or need, and economic and physical accessibility factors in women’s choice of delivery care and used adjusted logistic regression analysis to examine significant predictors of delivery site use decisions.

Results

Over half (56.6%) of the women self-reported using institutional delivery care; 80.9% gave birth at a health center. A socio-cultural variable, maternal education, significantly influenced women’s choice of health facility for delivery care services (AOR 3.4; 95% CI 2.0–5.9). Mothers’ knowledge level of obstetric complications and experience of complications during the last birth were the two perceived benefits or need factors associated with higher odds of receiving delivery care from decentralized local facilities. Utilization of health centers for maternal delivery care was significantly higher than of health posts (AOR 5.0; 95% CI 2.4–10.2). Availability of motorized transportation during labor to nearby delivery site was a significant predictor of institutional delivery.

Conclusion

This study demonstrates the under-utilization of decentralized health facilities for maternal delivery care services in Gida Ayana Woreda, which was significantly influenced by socio-cultural, perceived need, and accessibility factors of women during childbirth. This suggests the need for tailored intervention to improve childbirth services use for mothers in this kind of rural settings.

Planned home births in the Czech Republic, 2018

STUDY AIM

A summary of the current situation regarding issues of planned home births in the Czech Republic.

TYPE OF STUDY

Review and summarization. Affiliations: Department of Obstetrics and Gynecology of the Liberec regional hospital, and the Department of Obstetrics and Gynecology of the First Faculty of Medicine and General Teaching Hospital in Prague.

METHODS

We present a summarization of the available data on the controversial subject of planned home births in the Czech Republic. Planned home births in the Czech Republic are currently the subject of much professional, legal, and ethical discussion. This study also includes a review of the international literature, which describes the influence of planned home births on maternal and perinatal mortality and morbidity. There is as yet no professional organization or legal framework in the Czech Republic for regulating home births, and no precise and dependable data exits on the number, outcomes, or incidence of complications. However, there is an unambiguous consensus among all related specialist organizations in the Czech Medical Association of J. E. Purkyně, which does not support or recommend home births. Despite this, there is a small percentage of women that prefer to give birth at home. Through social networks and public discussion forums that deal with such issues these women find a community that supports and shares, but that also sometimes passes on half-truths and misinformation. Every initially physiological birth can without warning become complicated and require immediate medical intervention. Delays, and inadequate preparation and qualifications can fundamentally influence the further courses and outcomes, complicating the health and life of both mother and child.

CONCLUSION

The aim of all specialists participating in any way with this issue should be the spread of indisputable facts based on evidence and warning of the demonstrable risks associated with planned home births.

Mismatch between antenatal care attendance and institutional delivery in south Ethiopia: A multilevel analysis

OBJECTIVES

Uptake of maternal health services remains suboptimal in Ethiopia. Significant proportions of antenatal care attendees give birth at home. This study was conducted to identify the predictors of non-institutional delivery among women who received antenatal care in the Southern Nations Nationalities and Peoples Region, Ethiopia.

DESIGN

A community-based cross-sectional survey was conducted among women who delivered in the year preceding the survey and who had at least one antenatal visit. Multistage cluster sampling was deployed to select 2390 women from all administrative zones of the region. A mixed-effects multivariable logistic regression analysis was performed to assess the predictors of non-institutional delivery; adjusted ORs (AOR) with 95% CIs are reported.

RESULTS

The proportion of non-institutional deliveries among participants was 62.2% (95% CI 60.2% to 64.2%). Previous experience of short and simple labour (46.9%) and uncomplicated home birth (42.9%), night-time labour (29.7%), absence of pregnancy-related problem (18.8%) and perceived providers poor reception of women (17.8%) were the main reasons to have non-institutional delivery. Attending secondary school and above (AOR=0.51; 95% CI 0.30 to 0.85), being a government employee (AOR=0.27; 95% CI 0.10 to 0.78) and woman's autonomy in healthcare utilisation decision making (AOR=0.51; 95% CI 0.33 to 0.79) were among the independent predictors negatively associated with non-institutional delivery. On the other hand, unplanned pregnancy (AOR=1.67; 95% CI 1.16 to 2.42), not experiencing any health problem during pregnancy (AOR=8.1; 95% CI 3.12 to 24.62), not perceiving the risks associated with home delivery (AOR=6.64; 95% CI 4.35 to 10.14) were the independent predictors positively associated with non-institutional delivery.

CONCLUSIONS

There is a missed opportunity among women attending antenatal care in southern Ethiopia. Further health system innovations that help to bridge the gap between antenatal care attendance and institutional delivery are highly recommended.

Apgar Scoring System in Brazil's Live Births Records: Differences between Home and Hospital Births

OBJECTIVE

 To promote informed choice for women and to compare home and hospital births in relation to the Apgar score.

METHODS

 Mother's profile and Apgar score of naturally born infants (without forceps assistance) in Brazil between 2011 and 2015, in both settings-hospital or home-were collected from live birth records provided by the Informatics Department of the Unified Health System (DATASUS, in the Portuguese acronym). For the analysis, were included only data from low-risk deliveries, including gestational time between 37 and 41 weeks, singleton pregnancy, at least four visits of prenatal care, infants weighing between 2,500 g, and 4,000 g, mother age between 20-40 years old, and absence of congenital anomalies.

RESULTS

 Home birth infants presented significantly higher risk of 0-5 Apgar scores, both in 1 minute (6.4% versus 3%, odds ratio [OR] = 2.2, confidence interval [CI] IC 2-2.4) and in 5 minutes (4.8% versus 0.4%, OR = 11.5, CI 10.5-12.7). Another finding is related to recovery estimates when from an initially bad 1-minute Apgar (< 6) to a subsequently better 5-minute Apgar (> 6). In this scenario, home infants had poorer recovery, Apgar score was persistently < 6 throughout the fifth minute in most cases (71% versus 10.7%, OR 20.4, CI 17-24.6).

CONCLUSION

 The results show worse Apgar scores for babies born at home, compared with those born at the hospital setting. This is a pioneer and preliminary study that brings attention concerning differences in Apgar score related to home versus hospital place of birth in Brazil.

Impact of an employment guarantee scheme on utilisation of maternal healthcare services: Results from a natural experiment in India

We assess the impact of India's National Rural Employment Guarantee (NREG) scheme, the world's largest workfare scheme, on healthcare utilisation - specifically maternal healthcare. The primary objective of NREG is to improve the income of rural households by guaranteeing 100 days of employment. We expect that by improving household income, thereby reducing some of the financial barriers, such as out-of-pocket payments, NREG can increase utilisation of maternal health services. Using a nationally representative household survey and a difference-in-differences approach that exploits the phased rollout of the scheme, we estimate the impact of NREG on utilisation of maternal health services: mainly deliveries at health facilities. We find that NREG did not increase overall facility deliveries, even though it led to an increase in deliveries at public facilities. There is weak evidence to suggest that deliveries at private facilities reduced due to NREG. Furthermore, sub-group analyses reveal that among poorer households, who are more likely to participate in NREG, there is a reduction in facility deliveries while home deliveries increased. Among richer households, NREG increased deliveries at public facilities. There was no impact on households belonging to marginalised castes. We conclude by discussing the possible mechanisms for these effects and its impact on equity in healthcare utilisation.

Cost-effectiveness analysis of pulse oximetry screening for critical congenital heart defects following homebirth and early discharge

Pulse oximetry (PO) screening is used to screen newborns for critical congenital heart defects (CCHD). Analyses performed in hospital settings suggest that PO screening is cost-effective. We assessed the costs and cost-effectiveness of PO screening in the Dutch perinatal care setting, with home births and early postnatal discharge, compared to a situation without PO screening. Data from a prospective accuracy study with 23,959 infants in the Netherlands were combined with a time and motion study and supplemented data. Costs and effects of the situations with and without PO screening were compared for a cohort of 100,000 newborns. Mean screening time per newborn was 4.9 min per measurement and 3.8 min for informing parents. The additional costs of screening were in total €14.71 per screened newborn (€11.00 personnel, €3.71 equipment costs). Total additional costs of screening and referral were €1,670,000 per 100,000 infants. This resulted in an incremental cost-effectiveness ratio of €139,000 per additional newborn with CCHD detected with PO, when compared to a situation without PO screening. A willingness-to-pay threshold of €20,000 per gained QALY for screening in the Netherlands makes the screening likely to be cost-effective.Conclusion: PO screening in the Dutch care setting is likely to be cost-effective. What is Known: • Pulse oximetry is increasingly implemented as a screening tool for critical congenital heart defects in newborns. • Previous studies suggest that the screening in cost-effective and in the USA a reduction in infant mortality from critical congenital heart defects was demonstrated. What is New: • This is the first cost-effectiveness analysis for pulse oximetry screening in a setting with screening after home births, with screening at two moments. • Costs of pulse oximetry screening in a setting with hospital and homebirth deliveries were €14.71 and is likely to be cost-effective accordint to Dutch standards.

Factors associated with institutional delivery: Findings from a cross-sectional study in Mara and Kagera regions in Tanzania

In Tanzania, maternal mortality has stagnated over the last 10 years, and some of the areas with the worst indicators are in the Lake and Western Zones. This study investigates the factors associated with institutional deliveries among women aged 15-49 years in two regions of the Lake Zone. Data were extracted from a cross-sectional household survey of 1,214 women aged 15-49 years who had given birth in the 2 years preceding the survey in Mara and Kagera regions. Logistic regression analyses were conducted to explore the influence of various factors on giving birth in a facility. About two-thirds (67.3%) of women gave birth at a health facility. After adjusting for possible confounders, six factors were significantly associated with institutional delivery: region (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.54 [0.41-0.71]), number of children (aOR, 95% CI: 0.61 [0.42-0.91]), household wealth index (aOR, 95% CI: 1.47 [1.09-2.27]), four or more antenatal care visits (aOR, 95% CI: 1.97 [1.12-3.47]), knowing three or more pregnancy danger signs (aOR, 95% CI: 1.87 [1.27-2.76]), and number of birth preparations (aOR, 95% CI: 6.09 [3.32-11.18]). Another three factors related to antenatal care were also significant in the bivariate analysis, but these were not significantly associated with place of delivery after adjusting for all variables in an extended multivariable regression model. Giving birth in a health facility was associated both with socio-demographic factors and women's interactions with the health care system during pregnancy. The findings show that national policies and programs promoting institutional delivery in Tanzania should tailor interventions to specific regions and reach out to low-income and high-parity women. Efforts are needed not just to increase the number of antenatal care visits made by pregnant women, but also to improve the quality and content of the interaction between women and service providers.

[Planned location for delivery; no relationship with maternal or neonatal morbidity]

OBJECTIVE

To compare maternal and neonatal outcomes of planned primary-care birth-centre deliveries with those of planned home deliveries and planned outpatient deliveries.

DESIGN

Retrospective cohort study.

METHOD

We used data collected in the period February 2009 to November 2013 from 4 community midwife practices attached to the Sophia birth centre (GCS), which is attached to the Erasmus MC academic hospital in Rotterdam, The Netherlands. We included women with low-risk pregnancies for whom primary-care midwives were responsible at the start of the delivery. Pregnant women were stratified according to planned location of delivery (home, outpatient or GCS). The most important outcome measures were: medical intervention during the delivery, and maternal or neonatal morbidity. We used 'propensity score matching' to correct for confounding factors.

RESULTS

We included a total of 6185 pregnant women in our study. After propensity score matching, no statistically significant difference was seen in the total number of medical interventions during pregnancy, total maternal morbidity and total neonatal morbidity between pregnant women with planned home deliveries and those with planned GCS deliveries. (Medical interventions 13.6% and 12.4%, respectively; p-value 0.56. Maternal morbidity 4.9% and 5.7%, respectively; p-value 0.53. Neonatal morbidity 6.8% and 5.4%, respectively; p-value 0.31.) Similar results were seen when we compared pregnant women with planned outpatient deliveries with pregnant women with planned deliveries in the GCS.

CONCLUSION

In women with low-risk pregnancies the planned location for delivery does not seem to be related to either the number of medical interventions during pregnancy or to maternal or neonatal morbidity. The GCS seems, therefore, to be an appropriate location for these women to deliver, but this should be confirmed by further studies.

Planned private homebirth in Victoria 2000-2015: a retrospective cohort study of Victorian perinatal data

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.

Women's views and experiences of publicly-funded homebirth programs in Victoria, Australia: A cross-sectional survey

BACKGROUND

It is critical women's voices are heard if there is to be more widespread implementation of midwifery-led continuity models. Publicly-funded homebirth is one such model, yet there has been limited systematic evaluation from the women's perspective.

AIM

Examine women's experiences of and views about the two publicly-funded homebirth programs in Victoria, Australia.

METHODS

A cross-sectional design was used. All eligible women enrolled in the two pilot homebirth programs in metropolitan Melbourne whose infants were eight weeks of age or more during the evaluation period were invited to participate in a postal survey. A structured questionnaire was used, with some open-ended questions to enable extra comments. We explored women's reasons for choosing homebirth; views of care; experience of labour and birth; views on transfer; and overall experience of the homebirth program. Data were analysed using descriptive statistics. Simple thematic analysis was used for open-ended questions.

FINDINGS

The survey response rate was 71% (96/136). A high percentage of women rated their care as 'Very good': pregnancy 81%; labour and birth 90%; and the early postpartum period 83%. Women reported low levels of anxiety during labour and birth, were able to express their feelings, felt in control, and coped physically and emotionally better than they had expected. They felt well supported by midwives and overall reported very positive experiences of the homebirth programs.

CONCLUSIONS

These two publicly-funded homebirth pilot programs demonstrated very positive care ratings by women. These findings, along with the clinical outcomes (reported separately), support the continuation and expansion of the program.

Systematic review of community participation interventions to improve maternal health outcomes in rural South Asia

BACKGROUND

This is a systematic review on the effectiveness of community interventions in improving maternal health care outcomes in South Asia.

METHODS

We searched electronic databases to June 2017. Randomised or cluster randomised studies in communities within rural/remote areas of Nepal, Bangladesh, India and Pakistan were included. Data were analysed as risk ratios (RR) or odds ratios (OR), and effects were adjusted for clustering. Meta-analyses were performed using random-effects and evidence quality was assessed.

RESULTS

Eleven randomised trials were included from 5440 citations. Meta-analysis of all community interventions combined compared with control showed a small improvement in the number of women attending at least one antenatal care visit (RR 1.19, 95% CI 1.06 to 1.33). Two community mobilisation sub groups: home care using both male and female mobilisers, and education by community mobilisers, improved the number of women attending at least one antenatal visit. There was no difference in the number of women attending at least one antenatal visit for any other subgroup. There was no difference in the number of women attending 3 or more antenatal visits for all community interventions combined, or any community subgroup. Likewise, there was no difference in attendance at birth between all community interventions combined and control. Health care facility births were modestly increased in women's education groups (adjusted RR (1.15, 95% CI 1.11 to 1.20; 2 studies)). Risk of maternal deaths after 2 years (RR 0.63, 95% CI 0.24 to 1.64; 5 studies), and 3 years (RR 1.11, 95% CI 0.52 to 2.36; 2 studies), were no different between women's education groups and control. Community level mobilisation rather than health care messages at district level improved the numbers of women giving birth at health care facilities (RR1.09 (95%CI 1.06 to 1.13; 1 study)). Maternal health care knowledge scores improved in two community-based interventions, one involving education of male community members.

CONCLUSION

Women's education interventions may improve the number of women seeking birth at a health care facility, but the evidence is of low quality. No impact on maternal mortality was observed Future research should explore the effectiveness of including male mobilisers.

TRIAL REGISTRATION

This systematic review is registered with PROSPERO CRD42016033201 .

Stillbirth surveillance and review in rural districts in Bangladesh

BACKGROUND

An estimated 2.6 million stillbirths occur every year, with the majority occurring in low- and middle-income countries. Understanding the cause of and factors associated with stillbirth is important to help inform the design and implementation of interventions aimed at reducing preventable stillbirths.

METHODS

Population-based surveillance with identification of all stillbirths that occurred either at home or in a health facility was introduced in four districts in Bangladesh. Verbal autopsy was conducted for every fifth stillbirth using a structured questionnaire. A hierarchical model was used to assign likely cause of stillbirth.

RESULTS

Six thousand three hundred thirty-three stillbirths were identified for which 1327 verbal autopsies were conducted. 63.9% were intrapartum stillbirths. The population-based stillbirth rate obtained was 20.4 per 1000 births; 53.9% of all stillbirths occurred at home. 69.6% of mothers had accessed health care in the period leading up to the stillbirth. 48.1% had received care from a highly trained healthcare provider. The three most frequent causes of stillbirth were maternal hypertension or eclampsia (15.2%), antepartum haemorrhage (13.7%) and maternal infections (8.9%). Up to 11.3% of intrapartum stillbirths were caused by hypoxia. However, it was not possible to identify a cause of death with reasonable certainty using information obtained via verbal autopsy in 51.9% of stillbirths.

CONCLUSIONS

Introducing surveillance for stillbirths at community level is possible. However, verbal autopsy yields limited data, and the questionnaire used for this needs to be revised and/or combined with information obtained through case note review. Most women accessed and received care from a qualified healthcare provider. To reduce the number of preventable stillbirths, the quality of antenatal and intrapartum care needs to be improved.

Social Network Analysis Applied to a Historical Ethnographic Study Surrounding Home Birth

Safety during birth has improved since hospital delivery became standard practice, but the process has also become increasingly medicalised. Hence, recent years have witnessed a growing interest in home births due to the advantages it offers to mothers and their newborn infants. The aims of the present study were to confirm the transition from a home birth model of care to a scenario in which deliveries began to occur almost exclusively in a hospital setting; to define the social networks surrounding home births; and to determine whether geography exerted any influence on the social networks surrounding home births. Adopting a qualitative approach, we recruited 19 women who had given birth at home in the mid 20th century in a rural area in Spain. We employed a social network analysis method. Our results revealed three essential aspects that remain relevant today: the importance of health professionals in home delivery care, the importance of the mother’s primary network, and the influence of the geographical location of the actors involved in childbirth. All of these factors must be taken into consideration when developing strategies for maternal health.

The spillover effect of midwife attrition from the Nigerian midwives service scheme

BACKGROUND

The Nigerian Midwives Service Scheme (MSS) increased use of antenatal services at rural public sector clinics. However, it is unclear if women who would not have otherwise sought care, or those who would have sought care in rural private sector clinics caused this change. Additionally, it is also unclear if the reported midwife attrition was associated with a spillover of the scheme's effect on urban areas. We sought to answer these two questions using data from two nationally representative surveys.

METHODS

We used an interrupted time series model to assess trends in the use of obstetric (i.e. antenatal and delivery) services among rural and urban respondents in the 2008 and 2013 Nigerian demographic and health surveys.

RESULTS

We found that the MSS led to a 5-percentage point increase in the use of antenatal services at rural public sector clinics, corroborating findings from a previous study. This change was driven by women who would not have sought care otherwise. We also found that there was a 4-percentage point increase in the use of delivery services at urban public sector clinics, and a concurrent 4-percentage point decrease in urban home deliveries. These changes are most likely explained by midwives' attrition and exemplify a spillover of the scheme's effect.

CONCLUSION

Midwife attrition from the Nigerian MSS was associated with a spillover of the scheme's effect on the use of delivery services, on urban areas.

Neonatal care practices in sub-Saharan Africa: a systematic review of quantitative and qualitative data

BACKGROUND

Recommended immediate newborn care practices include thermal care (immediate drying and wrapping, skin-to-skin contact after delivery, delayed bathing), hygienic cord care and early initiation of breastfeeding. This paper systematically reviews quantitative and qualitative data from sub-Saharan Africa on the prevalence of key immediate newborn care practices and the factors that influence them.

METHODS

Studies were identified by searching relevant databases and websites, contacting national and international academics and implementers and hand-searching reference lists of included articles. English-language published and unpublished literature reporting primary data from sub-Saharan Africa (published between January 2001 and May 2014) were included if it met the quality criteria. Quantitative prevalence data were extracted and summarized. Qualitative data were synthesized through thematic analysis, with deductive coding used to identify emergent themes within each care practice. A framework approach was used to identify prominent and divergent themes.

RESULTS

Forty-two studies were included as well as DHS data - only available for early breastfeeding practices from 33 countries. Results found variation in the prevalence of immediate newborn care practices between countries, with the exception of skin-to-skin contact after delivery which was universally low. The importance of keeping newborn babies warm was well recognized, although thermal care practices were sub-optimal. Similar factors influenced practices across countries, including delayed drying and wrapping because the birth attendant focused on the mother; bathing newborns soon after delivery to remove the dirt and blood; negative beliefs about the vernix; applying substances to the cord to make it drop off quickly; and delayed breastfeeding because of a perception of a lack of milk or because the baby needs to sleep after delivery or does not showing signs of hunger.

CONCLUSION

The majority of studies included in this review came from five countries (Ethiopia, Ghana, Malawi, Tanzania and Uganda). There is a need for more research from a wider geographical area, more research on newborn care practices at health facilities and standardization in measuring newborn care practices. The findings of this study could inform behaviour change interventions to improve the uptake of immediate newborn care practices.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States

IMPORTANCE

Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown.

OBJECTIVE

To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004.

EXPOSURES

Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas.

MAIN OUTCOMES AND MEASURES

Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks' gestation).

RESULTS

Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric services, and this was followed by a decreasing trend (-0.19 percentage points per year [95% CI, -0.25 to -0.14]).

CONCLUSIONS AND RELEVANCE

In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

Prevalence and correlates of home delivery amongst HIV-infected women attending care at a rural public health facility in Coastal Kenya

BACKGROUND

Home delivery, referring to pregnant women giving birth in the absence of a skilled birth attendant, is a significant contributor to maternal mortality, and is encouragingly reported to be on a decline in the general population in resource limited settings. However, much less is known about home delivery amongst HIV-infected women in sub-Saharan Africa (sSA). We described the prevalence and correlates of home delivery among HIV-infected women attending care at a rural public health facility in Kilifi, Coastal Kenya.

METHODS

A cross-sectional design using mixed methods was used. Quantitative data were collected using interviewer-administered questionnaires from HIV-infected women with a recent pregnancy (within 5 years, n = 425), whilst qualitative data were collected using focused group discussions (FGD, n = 5). Data were analysed using logistic regression and a thematic framework approach respectively.

RESULTS

Overall, 108 (25.4%, [95% CI: 21.3-29.8]) participants delivered at home. Correlates of home delivery included lack of formal education (aOR 12.4 [95% CI: 3.4-46.0], p<0.001), history of a previous home delivery (2.7 [95% CI:1.2-6.0], p = 0.019) and being on highly active antiretroviral therapy (HAART, 0.4 [95% CI:0.2-0.8], p = 0.006).Despite a strong endorsement against home delivery, major thematic challenges included consumer-associated barriers, health care provider associated barriers and structural barriers.

CONCLUSION

A quarter of HIV-infected women delivered at home, which is comparable to estimates reported from the general population in this rural setting, and much lower than estimates from other sSA settings. A tailored package of care targeting women with no formal education and with a history of a previous home delivery, coupled with interventions towards scaling up HAART and improving the quality of maternal care in HIV-infected women may positively contribute to a decline in home delivery and subsequent maternal mortality in this setting.

Born before arrival in NSW, Australia (2000-2011): a linked population data study of incidence, location, associated factors and maternal and neonatal outcomes

OBJECTIVES

To determine incidence, associated factors, outcomes and geographical occurrence of born before arrival (BBA) in New South Wales, Australia.

DESIGN

A linked population data study involving population-based surveillance systems was undertaken for the years 2000-2011.

SETTING

New South Wales, Australia.

PARTICIPANTS

All women who underwent BBA compared with women who birthed in hospital/birth centre settings.

RESULTS

During the time period, there were 1 097 653 births and a BBA rate of 4.6 per 1000 births. The BBA rate changed from 4.2 to 4.8 per 1000 births over time (p=0.06). Neonates BBA were more likely to be premature (12.5% compared with 7.3%), of lower birth weight (209.8 g mean difference) and/or be admitted to a special care nursery or neonatal intensive care unit (20.6% compared with 15.6%). The perinatal mortality rate was significantly higher in the BBA cohort (34.6 compared with 9.3 per 1000 births). Women in the BBA cohort were more likely to be in the lowest socioeconomic decile, multiparous, have higher rates of smoking (30.5% compared with 13.8%) and more likely to suffer a postpartum haemorrhage requiring transfusion than the non-BBA cohort (1.5% compared with 0.7%). The most commonly occurring complications for neonates were suspected infection (6.9%), hypothermia (6.9%), respiratory distress (5.4%), congenital abnormality (4.0%) and neonatal withdrawal symptoms (2.4%). BBA more commonly occurred in geographical areas where the distance to a maternity unit is >2 hours drive and in coastal regions where there is also a high rate of homebirth.

CONCLUSION

BBA occurs more frequently in multiparous women of lower socioeconomic status. There potentially is an effect of geography on the occurrence of BBA, as geographical area of high homebirth and BBA coexists, indicating that freebirth followed by an unplanned transfer to hospital may be occurring.

Population attributable risk of key modifiable risk factors associated with non-exclusive breastfeeding in Nigeria

BACKGROUND

Non-exclusive breastfeeding (non-EBF) is a risk factor for many of the 2300 under-five deaths occurring daily in Nigeria - a developing country with approximately 40 million children. This study aimed to quantify and compare the attributable burden of key modifiable risk factors associated with non-EBF in Nigeria to inform strategic policy responses and initiatives.

METHODS

Relative risk and exposure prevalence for selected modifiable risk factors were used to calculate population attributable fractions based on Nigeria Demographic and Health Surveys data for the period (1999-2013). Scenarios based on feasible impact of community-based interventions in reducing exposure prevalence were also considered to calculate comparative potential impact fractions.

RESULTS

In Nigeria, an estimated 22.8% (95% Confidence Interval, CI: 9.2-37.0%) of non-EBF was attributable to primary and no maternal education; 24.7% (95% CI: 9.5-39.5%) to middle and poor household wealth, 9.7% (1.7-18.1%) to lower number (1-3) and no antenatal care visits; 18.8% (95% CI: 6.9-30.8%) to home delivery and 16.6% (95% CI: 3.0-31.3%) to delivery assisted by a non-health professional. In combination, more than half of all cases of non-EBF (64.5%; 95% CI: 50.0-76.4%) could be attributed to those modifiable risk factors. Scenarios based on feasible impacts of community-based approaches to improve health service access and human capacity suggest that an avoidable burden of non-EBF practice of approximately 11% (95% CI: -5.4; 24.7) is achievable.

CONCLUSION

Key modifiable risk factors contribute significantly to non-EBF in Nigerian women. Community-based initiatives and appropriate socio-economic government policies that specifically consider those modifiable risk factors could substantially reduce non-EBF practice in Nigeria.

Intrapartum and neonatal mortality among low-risk women in midwife-led versus obstetrician-led care in the Amsterdam region of the Netherlands: a propensity score matched study

OBJECTIVE

To compare intrapartum and neonatal mortality in low-risk term women starting labour in midwife-led versus obstetrician-led care.

STUDY DESIGN

We performed a propensity score matched study using data from our national perinatal register, completed with data from medical files. We studied women without major risk factors with singleton pregnancies who gave birth at term between 2005 and 2008 in the Amsterdam region of the Netherlands. Major risk factors comprised non-vertex position of the fetus, previous Caesarean birth, hypertension, (gestational) diabetes mellitus, post-term pregnancy (≥42 weeks), prolonged rupture of membranes (>24 hours), vaginal bleeding in the second half of pregnancy or induced labour. Groups were devided by midwife-led versus obstetrician-led care at the onset of labour. The primary outcome was intrapartum and neonatal (<28 days) mortality. Secondary outcomes included obstetric interventions, 5 min Apgar scores<7 and neonatal intensive care admittance for >24 hours.

RESULTS

We studied 57 396 women. Perinatal mortality occurred in 30 of 46 764 (0.64‰) women in midwife-led care and in 2 of 10 632 (0.19‰) women in obstetrician-led care (OR 3.4, 95% CI 0.82 to 14.3). A propensity score matched analysis in a 1:1 ratio with 10 632 women per group revealed an OR for perinatal mortality of 4.0 (95% CI 0.85 to 18.9).

CONCLUSION

Among low-risk women, midwife-led care at the onset of labour was associated with a statistically non-significant higher mortality rate.

Back to Bed: From Hospital to Home Obstetrics in the City of Chicago

This article analyzes the role of doctors and activists in Chicago who successfully redefined the practice and politics of childbirth both locally and ultimately nationwide. It begins with the story of Joseph DeLee's Chicago Maternity Center, responsible for supervising over 100,000 home births between 1932 and 1972. Most of the mothers cared for by the Center were nonwhite, poor, and had little or no access to prenatal care, yet their babies had a far higher survival rate than the nationwide average. Thousands of medical students from all over the Midwest experienced their first deliveries not in hospitals, but in these homes. The article then addresses a very different demographic: a rising number of middle-class white families in the suburbs of Chicago who, beginning in the 1950s, opted for out-of-hospital births. Many of them learned about home birth through their involvement in La Leche League, the breastfeeding organization formed in a Chicago suburb in 1956. Seemingly separated by class, race, and locale, the link between these two groups of home birthers was the philosophy and training in place at the Chicago Maternity Center.

Factors Associated with the Utilization of Institutional Delivery Service among Mothers

BACKGROUND

Assessment of utilization of institutional delivery services is crucial to reduce risk of maternal mortality and morbidity in countries like Nepal. This study was conducted to find out the proportion of utilization of institutional delivery service and associated factors among mothers.

METHODS

Data was collected from the total of 129 mothers of Kathar VDC, Chitwan district who delivered baby within last one year proceeding the period of data collection using census method. Descriptive statistics and binary logistic regression analysis were applied.

RESULTS

Out of 129 mothers, 78.3% had their delivery in the health facilities. Binary logistic analysis showed number of factors associated with utilization of institutional delivery service such as ethnicity, respondents educational level, number of pregnancy, number of ANC visit and birth preparedness status. But in the multivariable logistic regression analysis, no. of ANC visit (AOR = 10.03, 95 % CI = 1.02-98.29) was only independent factors affecting institutional delivery service utilization.

CONCLUSIONS

A number of factors have been shown to affect the utilization of institutional delivery. Therefore, concerned authority should plan and implement awareness programme aiming at increasing antenatal clinic visits and utilization of institutional delivery service.

Differences in optimality index between planned place of birth in a birth centre and alternative planned places of birth, a nationwide prospective cohort study in The Netherlands: results of the Dutch Birth Centre Study

OBJECTIVES

To compare the Optimality Index of planned birth in a birth centre with planned birth in a hospital and planned home birth for low-risk term pregnant women who start labour under the responsibility of a community midwife.

DESIGN

Prospective cohort study.

SETTING

Low-risk pregnant women under care of a community midwife and living in a region with one of the 21 participating Dutch birth centres or in a region with the possibility for midwife-led hospital birth. Home birth was commonly available in all regions included in the study.

PARTICIPANTS

3455 low-risk term pregnant women (1686 nulliparous and 1769 multiparous) who gave birth between 1 July 2013 and 31 December 2013: 1668 planned birth centre births, 701 planned midwife-led hospital births and 1086 planned home births.

MAIN OUTCOME MEASUREMENTS

The Optimality IndexNL-2015, a tool to measure 'maximum outcome with minimal intervention', was assessed by planned place of birth being a birth centre, a hospital setting or at home. Also, a composite maternal and perinatal adverse outcome score was calculated for the different planned places of birth.

RESULTS

There were no differences in Optimality Index NL-2015 for pregnant women who planned to give birth in a birth centre compared with women who planned to give birth in a hospital. Although effect sizes were small, women who planned to give birth at home had a higher Optimality Index NL-2015 than women who planned to give birth in a birth centre. The differences were larger for multiparous than for nulliparous women.

CONCLUSION

The Optimality Index NL-2015 for women with planned birth centre births was comparable with planned midwife-led hospital births. Women with planned home births had a higher Optimality Index NL-2015, that is, a higher sum score of evidence-based items with an optimal value than women with planned birth centre births.

The ResQu Index: A new instrument to appraise the quality of research on birth place

Objective

Place of birth is a known determinant of health care outcomes, interventions and costs. Many studies have examined the maternal and perinatal outcomes when women plan to give birth in hospitals compared with births in birth centres or at home. However, these studies vary substantially in rigour; assessing their quality is challenging. Existing research appraisal tools do not always capture important elements of study design that are critical when comparing outcomes by planned place of birth. To address this deficiency, we aimed to develop a reliable instrument to rate the quality of primary research on maternal and newborn outcomes by place of birth.

Study design

The instrument development process involved five phases: 1) generation of items and a weighted scoring system; 2) content validation via a quantitative survey and a modified Delphi process with an international, multi-disciplinary panel of experts; 3) inter-rater consistency; 4) alignment with established research appraisal tools; and 5) pilot-testing of instrument usability.

Results

A Birth Place Research Quality Index (ResQu Index) was developed comprising 27 scored items that are summed to generate a weighted composite score out of 100 for studies comparing planned place of birth. Scale content validation indices were .89 for clarity, .94 for relevance and .90 for importance. The Index demonstrated substantial inter-rater consistency; pilot-testing confirmed feasibility and user-friendliness.

Conclusion

The ResQu Index is a reliable instrument to evaluate the quality of design, methods and interpretation of reported outcomes from research about place of birth. Higher-scoring studies have greater potential to inform evidence-based selection of birth place by clinicians, policy makers, and women and their families. The Index can also guide the design of future research on place of birth.