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OBJECTIVE: This study aimed to examine the associations between detailed maternal nativity (DMN) and two labor and delivery (L&D) characteristics among US-born, Latin American and Caribbean-born, and SSA-born Black women in the US. L&D characteristics included the place of delivery (i.e., hospital, birthing center, or home) and the method of delivery (i.e., vaginal or cesarean). METHODS: Using Natality data, the authors examined the associations between detailed maternal nativity (DMN) and two L&D characteristics among US-born, Latin American and Caribbean-born, and SSA-born Black women in the USA who had a live delivery between 2016 and 2020 (N = 2,041,880). The main predictor was DMN (i.e., maternal country of birth) and the outcomes of interest were the place of delivery and the method of delivery. Associations were evaluated using multivariate multinominal and multivariate logistic regression models. RESULTS: Findings indicated that foreign-born Black women overall had decreased odds of delivering in birthing centers or at home, except for Ghanaian-born women who had increased odds of having an unintended home delivery. All Latin American and Caribbean-born and most SSA-born women had increased odds of delivering via cesarean. CONCLUSIONS: The findings underscore the importance of considering DMN in exploring L&D characteristics. Specifically, increased odds of cesarean delivery among Latin American and Caribbean-born women highlight a potential area for interventions. Further research is warranted to understand the underlying factors driving the observed differences and the diverse needs of the growing population of foreign-born Black women in the US, and to develop effective strategies to promote equitable and optimal birthing experiences for all.

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OBJECTIVE: To evaluate the mother-child separation rate in twin pregnancies delivered in maternity units offering an appropriate level of neonatal care. METHODS: JUMODA is a French, prospective, population-based cohort study of twin deliveries, including 7998 women who gave birth in maternity units with appropriate levels of neonatal care based on thresholds for weeks of gestational age (wGA) and birth weight according to French guidelines: level I (≥36 wGA), IIA (≥34 wGA), IIB (≥32 wGA and ≥ 1500 g), and IIII (<32 wGA or < 1500 g). The primary outcome was mother-child separation, defined as the transfer of at least one twin or the mother to another hospital. RESULTS: Mother-child separation occurred in 2.1% of pregnancies. This rate was significantly higher in level I (4.8%, 95% confidence interval [CI] 1.5-12.5) and IIA (3.4%, 95% CI 2.4-4.7) compared with level IIB (1.6%, 95% CI 1.1-2.3) and level III maternity units (2.1%, 95% CI 1.9-2.8). In level IIA units, the rate of mother-child separation was higher for babies born between 34 and 36 wGA (8.3%) than for those born at 36 wGA or beyond (1.7%). In level IIb, the rate of mother-child separation for babies born between 32 and 34 wGA (7.5%) was higher than for those born between 34 and 36 wGA (2.1%) and at 36 wGA or beyond (0.9%). CONCLUSION: Mother-child separation rates were low but differed by level of care. By using specific thresholds for twins to define levels of care, rather than data from singleton births, one-fifth of mother-child separations could have been avoided.

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BACKGROUND: Unlike other causes such as abortion, obstetric complications like hemorrhage, and hypertensive disorders of pregnancy, which are difficult to resolve for women who give birth out of health facilities are persisted or increased to be the cause of maternal mortality in Ethiopia. Direct obstetric complications resulted in the crude direct obstetric case fatality rate in this country. This study aimed to assess the relationship between Complication Experience during Pregnancy and Place of Delivery among Pregnant Women. METHOD: A community-based cross-sectional study was conducted to assess the baseline information as a part of a randomized control trial study. The sample size that was calculated for the cohort study with the assumptions to detect an increase in a minimum acceptable diet from 11 to 31%, with 95% CIs and 80% power, an intra-cluster correlation coefficient of 0·2 for a cluster size of 10 was used for this study. Statistical analysis was done using SPSS version 22. RESULT: The prevalence of self-reported pregnancy-related complications and home delivery were 79(15.9%, CI; 12.7-19.1) and 46.90% (95%CI; 42.5-51.1) respectively. Women who did not face vaginal bleeding were five times AOR 5.28(95% CI: 1.79-15.56) more like to give birth at home than those who faced this problem. Women who did not face severe headache were nearly three AOR 2.45(95%CI:1.01-5.97) times more like to give birth at home. CONCLUSION: This study concluded that home delivery was high among the study participants whereas pregnancy-related complications such as vaginal bleeding and severe headache were identified as protective factors for facility delivery. Hence, the researchers recommended the incorporation of "storytelling" into the existing health extension program packages to improve facility delivery which shall be applied after the approval of its effectiveness by further research.

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BACKGROUND: Home delivery is responsible for a high number of maternal and newborn deaths due to the occurrence of obstetric complications during labour and delivery. Little is known about the incidence and predictors of women's place of delivery after utilizing antenatal care services in Ethiopia and the study area. Therefore, the purpose of this study is to fill those gaps in the studies mentioned above by determining the incidence and predictors of women's place of delivery. METHODS: An institutional-based prospective cohort study was conducted among pregnant women in public hospitals of Gedeo zone, Southern Ethiopia between May 1 and October 30, 2021. A total of 390 pregnant women receiving antenatal care at Gedeo zone public hospitals were enrolled using a systematic random sampling technique and followed up to delivery. Data were entered into Epidata version 3.1 and exported to SPSS version 25 for analysis. For both bivariate and multivariable analyses, a poison regression model was used to identify the association between the dependent and independent variables. A statistical significance level was declared at a p-value less than 0.05. RESULTS: In this study, the overall incidence of home delivery and institutional delivery among pregnant women was 37.4% (95% CI: (32.5, 41.9)) and 62.6% (95% CI: 58.1, 67.5)) respectively. Distance from home to nearest health facility(ARR = 1.17:95%:CI (1.01,1.36), poor quality of antenatal care service(ARR = 1.40;95%:CI (1.10,1.79), no formal maternal education(ARR = 1.49;95%:CI (1.21,1.83), previous home delivery history(ARR = 1.38;95%:CI(1.22,1.56), unplanned pregnancy(ARR = 1.23;95%:CI (1.10,1.37) and history of pregnancy-related complication at health facility(ARR = 1.16;95%:CI(1.02,1.33) were predictors of home delivery. CONCLUSIONS: The study indicated a high incidence of home birth after utilizing antenatal care services. As a result, interventions targeting those identified factors during antenatal care services are critical to reducing home births.

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Background:Sub-Saharan African countries have some of the worst maternal mortality ratios in the world sub-regions. Uncoordinated antenatal care practices and delivery outside health institutions are some of the determinants of thesedeaths experienced in the region. The objective of the study is todetermine some of these erring behavioral antenatal practices that are inimical to good obstetric outcomes and how health care planners can use the results to close thesegaps of maternal mortality and save lives.Method:This study was a cross sectional retrospective study of the women who delivered at The Niger Delta University Teaching Hospital, Okolobiri, between 1 st June,2021 to 1st June, 2022. The study compared the maternal and fetal outcomes between the booked andunbooked patients who delivered during this period. Relevant data to the study were extracted from patients' medicalrecords using a proforma and data collected entered SPSS Version 25 foranalysis.Results:Three hundred and forty-six patients participated in the stud, 72.3 % were booked and 27.7%were unbooked. Place of delivery N = 253, 75.5 % delivered in health facilities and 24.5 in non-Health facilities. Unbooked patients have prolonged labor lasting more than 24 hours, suffered more blood loss during delivery, their babies have more unfavorable one minute Apgar, all compared to outcomes of the booked patientsConclusion:Booked patients have more favorable pregnancy outcomes compared to the unbooked patients. Health care planners and care providers should devote more time and resources to unbooked patients to have favorable pregnancy outcomes

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OBJECTIVES: For healthy women entering labor after an uneventful pregnancy, advantages of birth in midwife-led models of care have been demonstrated. We aimed to study the level of awareness regarding care in alongside midwifery units (AMU), factors involved in the decision for birth in obstetrician-led units (OLU), and wishes for care and concerns about birth in women registering for birth in OLU who would have been eligible for care in AMU. METHODS: Healthy women with a term singleton cephalic fetus after an uneventful pregnancy course booking for birth in OLU were prospectively recruited. Data were collected by questionnaire. RESULTS: In total, 324 questionnaires were analyzed. One quarter (23.1%) of participants never had heard of care in AMU. Two thirds (64.2%) of women had made their choice regarding model of care before entering late pregnancy; only 16.4% indicated that health professionals had the biggest impact on their decision. One-to-one care and the availability of a pediatrician were most commonly quoted wishes (30.8 and 34.0%, respectively), and the occurrence of an adverse maternal or perinatal event the greatest concern (69.5%). CONCLUSIONS: Although the majority of respondents had some knowledge about care in AMU, expressed wishes for birth matching core features of AMU and concerns matching those of OLU, a decision for birth in OLU was taken. This finding may be a result of lack of knowledge about details of care in AMU; additionally, wishes and concerns may be put aside in favor of other criteria.

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Institutional delivery at birth is an important indicator of improvements in maternal health, which remains one of the targets of sustainable development goals intended to reduce the maternal mortality ratio. The purpose of the present study was to identify the determinants of utilization of institutional delivery in Zambia. A population-based cross-sectional study design was used to examine 9841 women aged 15-49 years from the 2018 Zambia Demographic and Health Survey. A multiple logistic regression was applied to calculate odds ratios (ORs) with 95% confidence intervals (CIs) to identify determinants of utilization of institutional delivery. Sociodemographic factors were significantly associated with institutional delivery: woman's (OR: 1.76; 95% CI: 1.04-2.99) and husband's (OR: 1.83; 95% CI: 1.09-3.05) secondary/higher education, higher wealth index (OR: 2.31; 95% CI: 1.27-4.22), and rural place of residence (OR: 0.55; 95% CI: 0.30-0.98). Healthcare-related factors were also significantly associated with institutional delivery: 5-12 visits to antenatal care (OR: 2.33; 95% CI: 1.66-3.26) and measuring blood pressure (OR: 2.15; 95% CI: 1.32-2.66) during pregnancy. To improve institutional delivery and reduce maternal and newborn mortality, policymakers and public health planners should design an effective intervention program targeting these factors.

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In 2005 and again in 2011, the Government of India launched schemes to encourage institutional delivery among poor women, with the aim of improving maternal and newborn health outcomes. Partly as a result of these initiatives, the proportion of children born in a health facility rose steeply from 42% in 2000-2005 to 81% a decade later. In this context, the objective of this paper was to determine the association between place of delivery (public sector, private sector, home) and early neonatal mortality, defined as death in the first 7 days after birth. The focus was on early neonatal mortality because over half of all under-five deaths occur in his period and because the protective effect of an institutional place of birth should be strongest in those few early days. Both bivariate methods and multivariate logistic regression analysis were applied to data from the fourth round of the National Family Health Survey conducted in 2015-16. For the country as a whole, it was found that the adjusted odds of death in the early neonatal period were lower for deliveries in public health facilities than for home deliveries (OR 0.833 p<0.01), but no significant difference was found between deliveries in private health facilities and at home. Adjusted odds of death were higher for deliveries in private than public sector facilities (OR 1.41 p<0.01). On further investigation, for the poor in Bihar and Uttar Pradesh, it was found that the risks of dying in the early neonatal period were even higher for babies delivered in private health facilities than for home deliveries with adjusted odds of over 2.0. These results raise serious questions about quality of care in the private sector in India. In the context of increased emphasis on public-private partnerships in health services provision in the country, it becomes imperative to enforce better inspection, licensing and quality control of private sector facilities, especially in the states of Bihar and Uttar Pradesh.

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BACKGROUND: Primary Health Centers (PHCs) are crucial in providing primary and secondary level healthcare services in rural India. Despite immense efforts and huge funding, a very small proportion of deliveries are carried out at PHCs. The present study aims to explore the availability of facilities at PHCs and its association with likelihood of delivering the child at PHC. METHODS: We extracted PHC level health infrastructure data from Health Management and Information system (HMIS) and created 'Facility Index' using exploratory factor analysis. We merged the 'Facility Index' with data of the 4th National Family Health Survey (NFHS-4) to explore the relationship between availability of facilities and healthcare-seeking behavior. Bivariate analysis and multilevel logistic regressions were employed to analyze the association between Facility Index and the likelihood of delivering the child at PHC. RESULTS: Availability of facilities (Facility Index) was found to be positively associated with utilization of PHC for childbirth but up to only a certain level of Facility Index. Women living in districts with 'good' Facility index were having 2.45 (OR = 2.45; 95% CI: 2.12-2.84) times higher odds of delivering the child at PHC compared to women living in districts with 'very poor' Facility Index; however, the odds ratio decreased to 2.11 (95% CI: 1.83-2.43) for 'Very Good' Facility Index. The regression line and predicted probabilities also exhibited similar results. CONCLUSION: Based on the findings, we conclude that improvement in availability and quality of facilities might help in improving healthcare utilization from PHCs up to a certain level.

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BACKGROUND: To promote institutional delivery, the Government of India, through the Janani Suraksha Yojana (JSY) program, gives monetary reward to all pregnant women who give birth at the government or private health center. Despite providing cash assistance, a higher number of women are still preferring delivering at home. Therefore, this study sought to determine the prevalence of home births and identifying the factors influencing women's choice of home deliveries. METHODS: Data from the National Family Health Survey (NFHS) conducted during 2005-06 and 2015-16 were used in the study. The respondents were women 15-49 years; a sample of 36,850 and 190,898 women in 2005-06 and 2015-16 respectively were included in the study. Multivariate logistic regression was used to determine the factors influencing home delivery. Income-related inequality in home delivery was quantified by the concentration index (CI) and the concentration curve (CC), and decomposition analysis was used to examine the inequality in the prevalence of home deliveries. RESULTS: The prevalence of home deliveries has reduced from 58.5% in 2005-06 to 18.9% in 2015-16. The odds of delivering babies at home were lower among women who had full ANC in 2005-06 [AOR: 0.34; CI: 0.28-0.41] and in 2015-16 [AOR: 0.41; CI: 0.38-0.45] and were higher among women with four or higher parity in 2005-06 [AOR: 1.70; CI: 1.49-1.92] and in 2015-19 [AOR: 2.16; CI: 2.03-2.30]. Furthermore, the odds of delivering babies at home were higher among rural women and were lower among women with higher education. It was found that the value of CI increased from - 0.25 to - 0.39 from 2005-06 to 2015-16; this depicts that women delivering babies at home got more concentrated among women from lower socio-economic status. CONCLUSION: There is a need to promote institutional deliveries, particular focus to be given to poor women, women with higher parity, uneducated women, and rural women. ANC is the most concurring contact point for mothers to get relevant information about the risks and complications they may encounter during delivery. Therefore, effort should be directed to provide full ANC. Targeted interventions are called for to bring improvements in rural areas.

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BACKGROUND: Regionalisation programmes aim to ensure that very preterm infants are born in level III units (inborn) through antenatal referral or transfer. Despite widespread knowledge about better survival without disability for inborn babies, 10%-30% of women deliver outside these units (outborn). OBJECTIVE: To investigate risk factors associated with outborn deliveries and to estimate the proportion that were probably or possibly avoidable. METHODS: We used a national French population-based cohort including 2205 women who delivered between 24 and 30+6  weeks in 2011. We examined risk factors for outborn delivery related to medical complications, antenatal care, sociodemographic characteristics and living far from a level III unit using multivariable binomial regression. Avoidable outborn deliveries were defined by pregnancy risk (obstetric history, antenatal hospitalisation) and time available for transfer. RESULTS: 25.0% of women were initially booked in level III, 9.1% were referred, 49.8% were transferred, and 16.1% had outborn delivery. Risk factors for outborn delivery were gestational age <26 weeks (adjusted relative risk (aRR) 1.37, 95% confidence interval (CI) 1.13, 1.66), inadequate antenatal care (aRR 1.39, 95% CI 1.10, 1.81), placental abruption (aRR 1.66, 95% CI 1.27, 2.17), and increased distance to the closest level III unit ((aRR 2.79, 95% CI 2.00, 3.92) in the 4th versus 1st distance quartile). Among outborn deliveries, 16.7% were probably avoidable, and 25.6% possibly avoidable, which could increase the proportion of inborn deliveries between 85.9% and 92.9%. Avoidable outborn deliveries were mainly associated with gestational age, intrauterine growth restriction, preterm premature rupture of membranes, and haemorrhage, but not distance. CONCLUSIONS: Our study identified some modifiable risk factors for outborn delivery; however, when regionalised care relies heavily on antenatal transfer, as it does in France, only some outborn deliveries may be prevented. Earlier referral of high-risk women will be needed to achieve full access to tertiary care.

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OBJECTIVES: This study aims at exploring the present situation of the delivery place and the impact of social networks on the choice of delivery place among the ethnic women in Bangladesh. METHODS: Data were collected through face to face interviews using a structured questionnaire from a sample of 205 married ethnic - Garo and Mandai - women in Madhupur Upazilla of Tangail district. A stepwise binary logistic regression analysis is run to explain the impact of social networks on the choice of delivery place (the place where the women actually did deliver a baby) of ethnic women in Bangladesh. RESULTS: Descriptive statistics show that of the total deliveries 37.7% among Garo- and 13% among Mandai women take place in institutions (hospitals and clinics). The regression model reveals that next to ethnicity and husband's occupation, network size has a significant positive relationship, while reproductive health-related constraints have a significant negative relationship with the choice of delivery place of ethnic women. Based on these, this study suggests that if the social networks of ethnic women increase, the probability of their institutional delivery may increase. CONCLUSION: The personal social networks of ethnic women may motivate them on their choice of institutional delivery in Bangladesh. This finding may contribute to the development of pathways to stimulate ethnic women's reproductive health behaviour in the developing countries context.

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The effectiveness of health insurance in removing barriers to the utilisation of maternal healthcare in order to curb maternal mortality especially in developing countries is gaining ground. However, in assessing the effects of health insurance on choice of delivery facilities, previous studies either put all delivery services together and used binary techniques or failed to address endogeneity problem. Moreover, the age of data used for such analysis in Ghana may not tell a convincing story. This study used data from the 2014 to 2008 Ghana Demographic and Health Surveys with a sample of 6319 women and employed multinomial endogenous treatment effects models with Conditional Mixed Process estimator to examine the effects of national health insurance scheme (NHIS) on the choice delivery facility in Ghana. We found that NHIS has varied effects on the use of delivery services across service providers in the health system. Relative to home delivery services, being insured increases the probability of using public hospitals, public clinics and private health facilities for delivery by 20.3 percent, 9.1 percent and 2.3 percent respectively. Moreover, relative to an insured woman who gave birth before 2008, her counterpart who gave birth after 2008 is 6.3 percent, 4.9 percent and 0.77 percent more likely to use public hospitals, public clinics and private health facilities respectively for delivery.

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BACKGROUND: In low and middle-income countries, pregnancy and delivery complications may deprive women and their newborns of life or the realization of their full potential. Provision of quality obstetric emergency and childbirth care can reduce maternal and newborn deaths. Underutilization of maternal and childbirth services remains a public health concern in Tanzania. The aim of this study was to explore elements of the local social, cultural, economic, and health systems that influenced the use of health facilities for delivery in a rural setting in Northwest Tanzania. METHODS: A qualitative approach was used to explore community perceptions of issues related to low utilization of health facilities for childbirth. Between September and December 2017, 11 focus group discussions were conducted with women (n = 33), men (n = 5) and community health workers (CHWs; n = 28); key informant interviews were conducted with traditional birth attendants (TBAs; n = 2). Coding, identification, indexing, charting, and mapping of these interviews was done using NVIVO 12 after manual familiarization of the data. Data saturation was used to determine when no further interviews or discussions were required. RESULTS: Four themes emerge; self-perceived obstetric risk, socio-cultural issues, economic concerns and health facility related factors. Health facility delivery was perceived to be crucial for complicated labor. However, the idea that childbirth was a "normal" process and lack of social and cultural acceptability of facility services, made home delivery appealing to many women and their families. In addition, out of pocket payments for suboptimal quality of health care was reported to hinder facility delivery. CONCLUSION: Home delivery persists in rural settings due to economic and social issues, and the cultural meanings attached to childbirth. Accessibility to and affordability of respectful and culturally acceptable childbirth services remain challenging in this setting. Addressing barriers on both the demand and supply side could result in improved maternal and child outcomes during labor and delivery.

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BACKGROUND: The first 2 days after childbirth present the highest risk of dying for a mother. Providing postnatal care within the first 2 days after childbirth can help avert maternal mortality because it allows early detection of problems that could result in adverse maternal health outcomes. Unfortunately, knowledge of the uptake of early postnatal care (EPNC), which is imperative for informing policies aimed at reducing maternal mortality, remains low in Uganda. Therefore, the purpose of this study is to investigate the determinants of early postnatal care attendance among Ugandan women. METHODS: This study was based on nationally representative data from the 2016 Uganda Demographic and Health Survey. The study sample comprised 5471 women (age 15-49) who delivered a child in the 2 years preceding the survey. We used logistic regression to identify factors associated with use of early postnatal care. RESULTS: Our findings showed that 50% of mothers used EPNC services for their most recent delivery in the 2 years preceding the survey. Women's residence, education level, religion, wealth status, marital status, occupation, antenatal care attendance, place of delivery, birth order, perceived accessibility of health facilities, and access to mass media messages were associated with greater use of EPNC. The percentage of women receiving EPNC was much higher among women who delivered at a health facility, either a public facility (63%) or private facility (65%), versus only 9% among women who delivered at home. Multivariate analysis showed that delivery at a health facility was the most important determinant of early postnatal care attendance. CONCLUSIONS: To increase mothers' use of EPNC services and improve maternal survival in Uganda, programs could promote and strengthen health facility delivery and ensure that EPNC services are provided to all women before discharge. Even so, the fact that only about two-thirds of women who delivered at a health facility received early postpartum care shows substantial room for improvement. Interventions should target women who deliver at home, women who attend fewer than four antenatal care visits, and women with a primary education.

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Male involvement in maternal health was introduced to improve and sustain maternal and child health in Ghana. The study utilized the 2014 Ghana Demographic and Health Survey data to investigate the relationship between male presence at antenatal and choice of place of childbirth among 1,167 males, 15-59 years. Descriptive and analytical statistical techniques were applied to the data. The binary logistic regression shows no association between male presence at antenatal and place of delivery (OR = 1.197; 95% CI = 0.808-1.773). However, age (OR = 2.647; 95% CI = 1.221-5.736, OR = 3.046; 95% CI = 1.345-6.896, OR = 3.513; 95% CI = 1.478-8.345), level of education (OR = 4.478; 95% CI = 1.412-14.1990, religion (OR = 0.473; 95% CI = 0.237-0.946), ethnicity (OR = 0.400; 95% CI = 0.182-0.877, OR = 0.425; 95% CI 0.194-0.935), marital status (OR = 5.682; 95% CI = 2.093-15.421, OR = 5.669; 95% CI = 1.448-22.198), place of residence (OR = 7.272; 95% CI = 4.231-12.499), and region of residence (OR = 11.515; 95% CI = 2.785-47.618) of males were found associated with health facility based delivery. Regarding policy to promote institutional delivery among women, these socio-demographic factors identified should be considered.

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The World Health Organization-recommended rate of delivery by Caesarean section (C-Section) is 10-15% of all live births, but in Punjab, the largest province of Pakistan, this rate was 23% in 2014. The perception is that an inadequate public health sector forces women toward the private sector where C-Section is routinely conducted without valid medical reasons, posing risks to women's health and incurring catastrophic out-of-pocket expenditures. This study identified the correlates of C-section delivery and whether they differed by the urban/rural residence of women and place of delivery (public vs. private). Using multivariate logistic regression analyses of data from the Multiple Indicators Cluster Survey (MICS) collected from June-October, 2014 for all women who gave birth in the prior two years (N = 10,558), we found that rich women were statistically no different from poor women in their odds of delivery by C-section in the generally more expensive private health facilities (adjusted odds ratio [aOR] 1.23; 95% confidence interval [CI] 0.88-1.71); rich women were more likely to deliver by C-section in the less expensive public health facilities (aOR 2.03; 95% CI 1.13-3.63). This paradox may reflect the inefficiency of the health system and suggests limited affordable alternatives for poor women in the public sector.

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BACKGROUND: In Meghalaya, only 51.4% expectant mothers go for any institutional delivery with a wide rural-urban gap causing morbidity and mortality in the mothers and the neonates. OBJECTIVES: The objective of this study is to find out the factors influencing the choice of the place of delivery in rural women. METHODOLOGY: The present qualitative cross-sectional study was conducted from October to December 2016 in Bhoirymbong community health center (CHC) and the area catered to by it. This CHC was selected by purposive sampling. Data collection methods included focused group discussions and in-depth interviews. The data were analyzed manually using thematic content analysis. RESULTS: Most of the women in the study area opted for home delivery by traditional birth attendants (TBAs), on whose skills the community had strong faith. Financial constraints, fear of out-of-pocket expenditure, ignorance of available schemes, unavailability of transport, bad roads, and distant hospitals were found to be important causes of this choice. Home delivery apparently offered the women privacy and the opportunity to attend to their household chores and older children. Illiteracy, increasing age, and parity were risk factors for home delivery. Perceived need for institutional delivery was low. Staff attitudes and unnecessary referrals had an impact on the choice of place of delivery. CONCLUSION: In the rural areas of this study, home deliveries are the preferred norm. The wide range of factors identified in this study for the preference of TBA and home deliveries could help policy makers and program implementers to adopt socially and culturally appropriate community-based interventions that can contribute to the reduction of maternal, fetal, and neonatal mortality and morbidity and increase service utilization.

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Background Despite Bhutan’s remarkable progress in the area of maternal and child health duringthe era of the Millennium Development Goals, a large proportion of pregnant women are still deliveringat home with no skilled attendant. Limited empirical studies have been carried out to understand thefactors associated with delivery at home in Bhutan.Methods This cross-sectional analytical study used secondary data collected in the nationallyrepresentative National Health Survey 2012. The survey included a total of 2213 women aged15–49 years who had a live birth in the 2 years preceding the survey and were selected usingmultistage stratified cluster sampling. Weighted analysis was done to evaluate determinants for theplace of delivery. Unadjusted and adjusted prevalence ratios with 95% confidence intervals (CIs) werecalculated to assess the possible association of factors with home delivery.Results Out of 2213 women aged 15–49 years who had a live birth in the 2 years preceding thesurvey, 73.7% had an institutional delivery. Coverage of institutional delivery ranged from 49.4% inZhemgang district to 96.1% in Paro district. Women in the poorest wealth quintile were 7.35 timesmore likely to have a birth at home compared to women in the richest quintile (adjusted prevalenceratio [aPR]: 7.35, 95% CI: 2.59–20.9). The older mothers aged 30–49 years were 0.79 times(aPR: 0.79, 95% CI: 0.70–0.88) less likely to have a home delivery than mothers aged 15–19 years.Women who had fewer than four antenatal care visits were 1.50 times (aPR: 1.50, 95% CI: 1.35–1.66)more likely to give birth at home compared to those who had four or more visits. The mothers givingbirth for a third or more time were 1.88 times (aPR: 1.88, 95% CI: 1.60–2.22) more likely to give birthat home compared to those giving birth for the first time. Women living in rural areas were 2.87 times(aPR: 2.87, 95% CI: 1.42–5.77) more likely to deliver at home compared to those living in urban areasand women living in the eastern region of the country were 1.35 times (aPR: 1.35, 95% CI: 1.17–1.55)more likely to have a home delivery compared to those living in the western region.Conclusion Lower socioeconomic status, rural location, eastern location, non-first birth, and havingfewer than four antenatal visits were significant factors associated with home delivery. These findingsshould inform further research and policy to build on Bhutan’s progress in promoting institutionaldelivery as the key strategy towards improving maternal and child health and achieving the relevanttargets of Sustainable Development Goal 3.

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Background: Despite Bhutan's remarkable progress in the area of maternal and child health during the era of the Millennium Development Goals, a large proportion of pregnant women are still delivering at home with no skilled attendant. Limited empirical studies have been carried out to understand the factors associated with delivery at home in Bhutan. Methods: This cross-sectional analytical study used secondary data collected in the nationally representative National Health Survey 2012. The survey included a total of 2213 women aged 15-49 years who had a live birth in the 2 years preceding the survey and were selected using multistage stratified cluster sampling. Weighted analysis was done to evaluate determinants for the place of delivery. Unadjusted and adjusted prevalence ratios with 95% confidence intervals (CIs) were calculated to assess the possible association of factors with home delivery. Results: Out of 2213 women aged 15-49 years who had a live birth in the 2 years preceding the survey, 73.7% had an institutional delivery. Coverage of institutional delivery ranged from 49.4% in Zhemgang district to 96.1% in Paro district. Women in the poorest wealth quintile were 7.35 times more likely to have a birth at home compared to women in the richest quintile (adjusted prevalence ratio [aPR]: 7.35, 95% CI: 2.59-20.9). The older mothers aged 30-49 years were 0.79 times (aPR: 0.79, 95% CI: 0.70-0.88) less likely to have a home delivery than mothers aged 15-19 years. Women who had fewer than four antenatal care visits were 1.50 times (aPR: 1.50, 95% CI: 1.35-1.66) more likely to give birth at home compared to those who had four or more visits. The mothers giving birth for a third or more time were 1.88 times (aPR: 1.88, 95% CI: 1.60-2.22) more likely to give birth at home compared to those giving birth for the first time. Women living in rural areas were 2.87 times (aPR: 2.87, 95% CI: 1.42-5.77) more likely to deliver at home compared to those living in urban areas and women living in the eastern region of the country were 1.35 times (aPR: 1.35, 95% CI: 1.17-1.55) more likely to have a home delivery compared to those living in the western region. Conclusion: Lower socioeconomic status, rural location, eastern location, non- first birth, and having fewer than four antenatal visits were significant factors associated with home delivery. These findings should inform further research and policy to build on Bhutan's progress in promoting institutional delivery as the key strategy towards improving maternal and child health and achieving the relevant targets of Sustainable Development Goal 3.

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