Factors influencing the place of delivery in the rural region of Labrousse, Hati

Objectives The objective of this study is to determine factors that influence the place of delivery in the rural region of Labrousse, Haiti Design This study employed a cross-sectional survey design to collect data using an anonymous interview guide comprising structured questions and made up of two parts: 1- Identification of personal and socio-cultural parameters. 2-Identification of the reasons for the place of the last childbirth.


INTRODUCTION Background
According to the World Health Organization, 500,000 women die each year because of their pregnancy, 99% in low-and middle-income countries. Home delivery remains one of the main causes of maternal and child mortality in these countries. Reducing maternal mortality is one of the elements of Goal 3 of the Sustainable Development Goals. One of the indicators to assess this process is the proportion of births performed by a trained health worker. Despite the progress made; in 2013, 289,000 women died during or after childbirth (1). In Haiti 6 out of 10 deliveries occur at home without medical assistance. Only 36% take place in a health facility (21% in a public facility, 10% in a private facility and 5% in a mixed facility) (2). These proportions are higher in urban areas than in rural communities. (3). In urban areas, 63% of births took place with the help of a health worker compared to 30% in rural areas. 60% of births in urban areas occurs in a health facility compared to 29% in rural communities. (3).

Objectives
The objective of this study is to determine factors that influence the place of delivery in the rural region of Labrousse, Haiti.

Study Setting
The study was conducted from September to November 2017 in Notre-Dame of Lourdes of Labrousse community health center and the area catered to by it. Labrousse is a rural community located in the 3rd communal section of Miragoâne about 19 kilometers from the main road, in the department of Nippes. this mountainous region of about 15,000 inhabitants is divided into many small hamlets that are difficult to access and served by dirt roads with deep crevasses that meander through the mountains. Commonly seen economic activities of the zone are agricultural activities and livestock rearing. The zone has one health center and some dispensaries with roads that are difficult to use throughout the year.

Study population
The study population was women aged 13-46 years, live in the area who had at least one birth in the last 1-3 years by the time of data collection. women who gave birth prematurely or who had been transferred to hospital due to a complication during childbirth were excluded from the study. The survey included 92 women

Study design and data collection
This study is a quantitative cross-sectional study. Data collection included interviews using an anonymous interview guide comprising structured questions and made up of two parts: 1-Identification of personal and socio-cultural parameters. 2-Identification of the reasons for the place of the last childbirth. The questionnaire was developed after a rigorous review of the literature on the determinants of birthplace in similar studies. The variables studied are age, religion, level of education of mothers and fathers, parity, economic activity sector, marital status, distance between home and health facility, availability of transportation and prenatal follow-up.

Data processing and analysis
The data were analyzed using SPSS version 23 statistical software. frequency and proportion analyze were carried out to describe the socio-demographic and pregnancy characteristics of the study subjects. Pearson's correlation tests were used to assess the association between different variables. Those with a statistically significant association with the dependent variable were then evaluated with bivariate and multivariate logistic regressions to determine the magnitude of the correlation between the dependent and independent variables. a confidence interval = 95% is considered with p < 0.05 taken as statically significant association.

characteristics of the study population
The mean age of the respondents was 28.3 ± 4.2 with extremums of 17 and 43. 2.17% are Under 18. a high proportion (73.90%) of mothers were in the age range of 19-32 years.
22.82% of respondents were married. 31.52% were primipara, 52.17% were multipara (2 to 3 children) and 16.30% were grand multipara (more than 3 children). Protestantism remains the dominant practice in this region (50%), followed by Catholicism (44.56%). 8.69% of women have never been to school; 50% have primary level; only 1.98% hold a professional study diploma. Retail business and agriculture are the two main economic activities of women in this region. the fathers were mainly farmers and motorcycle taxi drivers (53.26%).
75% of women gave birth to their last child at home. 76% of home births were assisted by a matron or traditional practitioner. (Tab 1) Age is a statistically significant factor (p <0.05) of home births. women aged 19-25 are more likely to give birth at home (OR=2.6; 95% CI). Childbirth in healthcare facility, however, is not    show that, on the contrary, older women are more likely to give birth at home, unlike younger women who give birth in hospital [8]. The marital status of women does not influence the choice of delivery place (p=0.75 at home; p=0.30 at healthcare facility) which corroborates the findings of other studies [7], [8]. The number of pregnancies and / or previous deliveries has no effect on the place of delivery; Primiparous, multiparous and grand multiparas give birth both in hospital and at home. In a study by Fritz Verly Vernet et al. The majority of primiparous gave birth in a hospital environment, while most multiparas and even more grand multiparas gave birth at home [9]. Diallo F, Diallo T, Sylla M et al. found similar results in a study they conducted in the tropics [16]. the Canadian Public Health Agency has established that nonhospital deliveries are more common among multiparas than first-time mothers [10]. school and those who gave birth at home were mostly illiterate [9]. According to Faye A, Ndiaye P, Tal-Dia A, Bâ I.O. the more the woman's level of education increases, the more the chance of being assisted by qualified personnel during childbirth increases [13]. In Senegal; childbirth in a health institution by women at the primary and secondary level is respectively 1378 more and 3049 more that of women without instructions [13]. this could be explained by that the higher her level of education, the more the woman has the possibility of finding a better job and thus of having a high socioeconomic level and of having the means to give birth at hospital [14]. The level of economic activity of the parents is a determining factor of the delivery place. Thus we were able to find that in the tertiary sector of activity, the probability for these women to give birth at home was lower compared to other sectors of economic activity; it positively influences childbirth in hospital (OR = 1.32, p= 0.004). studies have shown that women's economic health quintile plays a role in the birthplace [7,8]. n this study, women are more likely to give birth at home if they are far from the health center, and this risk increases even more if there is no transport available. According to Faye A, Ndiaye P, Tal-Dia A, Bâ I.O, the prevalence of home birth was correlate to factors such as lack of transportation and long distance [13]. Confidence in health care providers can be a factor that can influence the choice of delivery place [9]. In our study, those who gave birth in healthcare facility in almost 100% of cases said they felt safe with health care providers, but this parameter was not evaluated in the correlation analysis.