Calculations are included in Spreadsheet S1. For multiple responses, only the highest level professional was included. Using the previously derived country-specific wealth quintile disaggregation, respondents citing home births were then aggregated into the above attendance categories. Similarly, weighted averages by population were calculated to provide a SSA regional estimate.
Finally, weighted averages by population were calculated across each category to provide a SSA regional estimate. We downloaded DHS datasets from www. As this study is based on secondary analysis of existing DHS data that are in the public domain, we did not seek approval from an Institutional Review Board. In twenty-three of the 48 countries for which we had data, more than half of births are reported to take place at home Spreadsheet S1. Home birth is most common among the poor. In these three regions, even among the wealthiest households According to survey responses, private hospitals were very rarely used by poor women.
In contrast, wealthy women in all regions commonly gave birth in private facilities.
In contrast, in the three other regions SSA, South Asia, and South East Asia , it was much more common for the richest women to use public facilities than the poorest women e. In SSA, the poorest women were over three times more likely to report giving birth at home than the richest women In SSA, although the poorest women were over three times more likely to report giving birth at home than the richest women, both groups of women reported similar rates of non-attendance by a professional.
About one in four home births among the wealthy were attended by a doctor, clinical officer, or nurse. Country-level data on who attended home deliveries are shown in Spreadsheet S2. Within SSA, only nine countries asked women reporting a home birth their reason for not going to a facility Spreadsheet S2. The responses from these nine countries again showed similarities between wealthy and poor women, but also between those whose births were unattended and those whose birth was attended by a TBA. Access was given as a reason more often than cost, by both poor and rich women.
Our study had two major findings. First, we found that the richest women in developing countries were much more likely than the poorest to report giving birth in a government facility. Second, we found that a very high proportion of poor women in SSA, South Asia, and South East Asia about 8 to 9 out of every 10 women reported giving birth at home.
Our study confirms previous research that found that most poor women in the developing world give birth at home . Home births are either unattended or attended.
Each category presents different challenges for improving delivery outcomes. In our study, of those women in SSA who reported having a home birth, nearly one-half reported that these births were unattended by any experienced assistant. The large number of unattended home births remains an important barrier to reducing maternal mortality worldwide, particularly for the poor .
Our study uses newly available data and updated asset quintile disaggregation to give new insights into which women in developing countries are delivering at home and with what level of assistance. This disaggregation by wealth is critical to targeting efforts to reduce maternal mortality and is an important addition to earlier analyses.
Our work also provides information on delivery locations, offering insights that may be valuable to programs aimed at achieving MDGs 4 and 5 in the coming five years. We found that wealthy women in all regions commonly gave birth in private facilities.
The role of the private sector in delivering health care in developing countries is much debated. For example, recent studies using DHS data have found an association between private sector participation in health care and better health outcomes or improved health systems performance  ,  ,  , . In contrast, specifically examining the issue of maternal health and delivery, recent studies have found that strong public sector participation in health care is correlated with better health outcomes  ,  — .
Our study did not include health outcomes data, so it does not help to resolve the debate. Several previous studies have examined decisions surrounding the place of birth  ,  ,  , and concluded that poor availability of facilities is a critical reason why women in the poor world give birth at home . In our study, however, only about a quarter of the poorest women reported lack of facility access i.
This motivation for delivering at home is likely to be influenced by social and cultural beliefs, at the household and community levels, related to the value of facility-based care. Cost was rarely a motivation for delivering at home. Analysis of DHS data suffers from a number of limitations. Women's reported motivations for delivering at home, which are probably influenced by social, cultural, and economic factors, are likely to be country and region specific, and to change over time.
Similarly, women and household decision-makers in different countries are likely to have different views on what constitutes unacceptable cost for facility care, quality, or access all of which can be motivators for home delivery. But such differences between countries, and such differences over time, could not be detected in our study.
In addition, the quantitative survey data do not allow nuanced interpretation of motivation beyond the limited questions asked in nine countries. There has been very little qualitative analysis of the motivation of mothers and other household decision-makers in poor countries for delivering at home. As noted in the methods section above, the aggregation of country data into regional summaries by wealth quintile introduces known errors through combining wealth quintiles from countries at differing wealth levels. Furthermore, the regional summaries are based on only those countries with DHS surveys fitting our inclusion criteria.
In each region a number of countries do not have DHS surveys; our regional aggregates are therefore biased towards countries having a recent DHS survey. While we did not conduct multivariate analysis of the data in our analysis, we acknowledge that more nuanced findings regarding aspects of care seeking may be elucidated through regression analysis. We made a decision to use data that best represented all recent births; however this decision over-weights responses given by mothers of multiple births, adding one form of response bias.
Recall bias may also have affected our findings. We limited our analysis to the most recent five births, given evidence of recall bias for events beyond five years within DHS surveys. While this has reduced the variability of data between countries, we acknowledge that it may have improperly weighted the number of births counted. We have attempted to address these limitations of our data set by restricting our in-depth analysis to one region SSA , and to surveys conducted in the recent past — using only DHS rounds 5 and 6 surveys conducted after This has introduced new limitations; by restricting the interpretation of our findings to SSA, we are unable to draw conclusions about the larger population of developing countries.
While we present summary data in this paper, both the regional and country data are provided in Excel spreadsheet format in Spreadsheets S1 and S2. There are two main policy responses to addressing the high numbers of unattended home births among the poor. The first is to scale up facility-based services, and the second is to increase skilled attendance of home births . Between these two choices, the available data provide little evidence for impact from increased supply of facilities  ; even where facility-based services exist, usage of those facilities remains low .
Systematic reviews of MNCH services in developing countries have not been able to provide explanations for why usage rates of facilities remain low . Possible explanations include the impact of cost, access, perceived quality, and cultural preferences for home deliveries  , . In our study, the proportion of the poorest women reporting home delivery was highest in SSA, which is also the region with the world's highest rates of maternal and child mortality.
In this region, where targeting investment is of paramount importance to health outcomes, our analysis of reasons for delivering at home suggests that the motivations for delivering outside of facilities may be primarily social and cultural. Such motivations are not easily addressed through improved access to, or lower cost of, delivery in facilities. Socio-cultural norms shift over time, and long-term investments in facilities may accelerate this shift; meanwhile, cost and access do remain important barriers to the use of facilities for giving birth.
Nevertheless, our findings suggest that, at least in the short term, efforts to reduce maternal and neonatal deaths among the poor should prioritize community-based interventions aimed at making home births safer. Such interventions include those that improve the quality of attended deliveries or increase the rate of delivery attendance.
Indeed, systematic reviews have found that training traditional birth attendants can reduce perinatal and neonatal deaths and stillbirths . The global health community is currently focusing its efforts to reduce maternal mortality in developing countries upon two main types of intervention. The first, Emergency Obstetric Care EmOC services, have been documented as highly effective at reducing mortality from post-partum hemorrhage, infection, pre-eclampsia, obstructed labor and a range of other causes . The second, community-based interventions with traditional birth attendants TBAs , better linkages to referral networks, and better informed home-birth partners, has a weaker evidence base  , although some pilots have had positive results .
EmOC services, however, are only of value if the services are used. A review of EmOC services around the world found that while availability of services is poor in some countries, even when these services are available, utilization of EmOC remains low  , . Low usage is true for both private and public services; interventions to improve the quality of governmental services have proven ineffective at increasing usage .
Thus, in the short term at least, in those countries where poor women mostly give birth at home, reducing maternal mortality is likely to require expanding, strengthening, and improving community-based approaches. Our study provides a descriptive analysis of DHS data on place and circumstance of birth. Additional analysis of existing data sets will provide more detailed information for individual countries, both on health-seeking behavior for maternal health generally, and on specific decision making surrounding place of delivery.
At the same time, more targeted primary research on this topic is still needed, particularly operations research that can measure the effect of community-based approaches and assess best practices. Two appropriate next steps for health programmers and researchers are: 1 to undertake country and regional multivariate analysis of DHS data and other surveys with information on decision-making surrounding place of birth; and 2 in parallel, to design and test interventions that focus primarily on improving the quality of home based deliveries. The acceptability of home-based interventions to the poor appears likely to be critical for making significant advances towards MGDs 4 and 5 by Country-level data on who attended home deliveries, and on motivation for delivering at home.
AV declares that he has no competing interests; AH declares that she has no competing interests. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There were no other sources of funding support.
National Center for Biotechnology Information , U. PLoS One. Published online Feb Nancy Mock, Editor. Author information Article notes Copyright and License information Disclaimer. Analyzed the data: DM AV. Received Jul 26; Accepted Jan Copyright Montagu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited.
This article has been cited by other articles in PMC. Spreadsheet S2: Country-level data on who attended home deliveries, and on motivation for delivering at home. Abstract Background In , over , women died during pregnancy or childbirth, mostly in poor countries. Conclusions In developing countries, most poor women deliver at home.
Introduction Reducing the global burden of preventable maternal, neonatal and child deaths is currently a major focus for the global health community. Methods We conducted a secondary analysis of DHS data on maternal deliveries in 48 developing countries. Table 1 DHS countries and survey years. This is still much better than it used to be. In Sierra Leone in the early s, more than women were dying for every , babies that were born alive. In Nigeria, women were suffering the same fate. The situation in both countries has improved dramatically in the past 25 years.
Sierra Leone has more than halved the number of maternal deaths to for every , births, as has Nigeria — where the rate is women for every , births. But this is still way out of kilt with developed countries. In Sweden, there are four deaths for every , births. In the US, there are 28 for every , births. This has been partly as a result of countries adopting the eight Millennium Development Goals. But the drop has been marginal in most West African countries. Several attempts have been made to reduce the rate in the region through programmes such as the Safe Motherhood Initiative — but there has been limited success.
Not all cases of maternal mortality can be prevented, but in most — especially in poorer countries — many women are still dying unnecessarily. One of the explanations for the high maternal mortality is that very few women in the region give birth under skilled care. This decision by most mothers-to-be is due to old customs, a lack of education, and poverty. The next problem is in getting to a hospital and getting access to skilled healthcare personnel such as doctors or midwives.
Much of this is as a result of transportation issues, too few doctors and midwives, and not enough appropriate centres.
99% of all maternal deaths occur in developing countries. from pregnancy- or childbirth-related complications around the world every day. Every day, approximately women die from preventable causes related to pregnancy and childbirth. 99% of all maternal deaths occur in developing countries.
The road networks and public transport systems are still sub-optimal in several parts of West Africa, including Nigeria. Once women get to a hospital or get the attention of the doctor or the midwife, they face another set of problems — getting appropriate healthcare at delivery. This can be due to unreliable electricity supply, unavailability of blood and an inability to pay hospital fees. There are other contributing factors in Nigeria, a country of million people. These range from a lack of political will to a bureaucratic civil service, the unavailability of raw data and a three-tiered health care system — federal, state and local government — all of which are independent of each other.
Without accurate data, planning is ad-hoc at best. The disjointed healthcare system means that primary health care belongs to the local governments and is not adequately linked to secondary and state-controlled health care.
The lack of a properly functional health insurance system particularly for the less privileged , which leads to unaffordable health care for the majority of the population, also has a role to play. Although there are ongoing efforts to improve this, there is not yet a solution. Set up in a few states Ondo State in the South West being the pioneer , this involves the compiling of a confidential maternal death report that encourages the reporting of any maternal death in the state with a no-blame, no-shame caveat.
These strategies will not work in all parts of West Africa. It is also not thought to be economically feasible to offer health care to all pregnant women free of charge. But solutions can be adapted for different environments. As shown in Nigeria, mobile technology can be used to track pregnant women and collect data on them.