"I don't like to be seen by a male provider": health workers' strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria.

BACKGROUND: Ending maternal mortality has been a significant global health priority for decades. Many sub-Saharan African countries introduced user fee removal policies to attain this goal and ensure universal access to health facility delivery. However, many women in Nigeria continue to deliver at home. We examined the reasons for home birth in settings with free maternal healthcare in Southwestern and North Central Nigeria. METHODS: We adopted a fully mixed, sequential, equal-status design. For the quantitative study, we drew data from 211 women who reported giving birth at home from a survey of 1227 women of reproductive age who gave birth in the 5 y before the survey. The qualitative study involved six focus group discussions and 68 in-depth interviews. Data generated through the interviews were coded and subjected to inductive thematic analysis, while descriptive statistics were used to analyse the quantitative data. RESULTS: Women faced several barriers that limited their use of skilled birth attendants. These barriers operate at multiple levels and could be grouped as economic, sociocultural and health facility-related factors. Despite the user fee removal policy, lack of transportation, birth unpreparedness and lack of money pushed women to give birth at home. Also, sociocultural reasons such as hospital delivery not being deemed necessary in the community, women not wanting to be seen by male health workers, husbands not motivated and husbands' disapproval hindered the use of health facilities for childbirth. CONCLUSIONS: This study has demonstrated that free healthcare does not guarantee universal access to healthcare. Interventions, especially in the Nasarawa state of Nigeria, should focus on the education of mothers on the importance of health facility-based delivery and birth preparedness.

The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era.

BACKGROUND: COVID-19 caused significant disruptions to health systems globally; however, restricting the family presence during birth saw an increase in women considering community birth options. This study aimed to quantify the hospital resource savings that could occur if all low-risk women in Australia gave birth at home or in birth centers. METHODS: A whole-of-population linked administrative data set containing all women (n = 44 498) who gave birth in Queensland, Australia, between 01/07/2012 and 30/06/2015 was reweighted to represent all Australian women giving birth in 2017. A static microsimulation model of woman and infant health service resource use was created based on 2017 data. The model was comprised of a base model, representing "current" care, and a counterfactual model, representing hypothetical scenarios where all low-risk Australian women gave birth at home or in birth centers. RESULTS: If all low-risk women gave birth at home in 2017, cesarean rates would have reduced from 13.4% to 2.7%. Similarly, there would have been 860 fewer inpatient bed days and 10.1 fewer hours of women's intensive care unit time per 1000 births. If all women gave birth in birth centers, cesarean rates would have reduced to 6.7%. In addition, over 760 inpatient bed days would have been saved along with 5.6 hours of women's intensive care unit time per 1000 births. CONCLUSIONS: Significant health resource savings could occur by shifting low-risk births from hospitals to home birth and birth center services. Greater examination of Australian women's preferences for home birth and birth center birth models of care is needed.

Homebirth fines and health cards in rural Tanzania: On the push for numbers in maternal health.

Over the last two decades, there has been a global push to improve maternal health by increasing numbers of facility births in low- and middle-income countries like Tanzania. While recent scholarship has interrogated the increasing hegemony of numbers and metrics in global health, few have ethnographically explored how this push for numbers and its accompanying technologies affect the lived experiences of parturients and those who care for them during pregnancy and childbirth in rural communities. Based on seven months of multi-sited ethnographic research conducted in three different rural communities in Mpwapwa District in 2016, this article explores how mothers and nurses in Tanzania experienced the push for numbers in maternal health, particularly as that push is enacted through homebirth fines and health cards. Intended to reduce maternal mortality, policies meant to increase facility births in rural Tanzania can inadvertently decrease access to care for the most marginalized community members, while simultaneously enticing under-resourced and over-burdened health workers to sanction non-compliant women while doing nothing to improve the wider health systems in which they work. Ethnographic interviews with mothers, nurses, and government leaders show how homebirth fines exacerbate structural inequalities in healthcare access, excluding some of the poorest women from the healthcare services they desire. Additionally, weekly participant-observation conducted at each of the community health dispensaries highlights the way female nurses engage in improvised and often punitive tactics with health cards, key documents for women to be able to access free national healthcare services. While the new sanctions can help lessen the heavy workloads of healthcare workers at rural dispensaries, they also lead to worsening relationships between nurses and the communities they serve. By prioritizing the perceptions and negotiations surrounding homebirth fines and health cards, this paper shows the unintended consequences of indicator-driven care, which most negatively affect the poor.

A pathway to establish a publicly funded home birth program in Australia.

BACKGROUND: Home births provide women a birth choice where they may feel more comfortable and confident in their ability to give birth. PROBLEM: Most women in Victoria do not have publicly funded access to appropriately trained health professionals if they choose to give birth at home. METHODS: This paper describes the process of setting up a publicly funded home birth service and provide details of description of the set up and governance. We also report outcomes over 9 years with respect to parity, transfer to hospital, adverse maternal and neonatal outcomes. RESULTS: Of the 191 women who were still booked into the home birth program at 36 weeks gestation, 148 (77.5%) women gave birth at home and 43 (22.5%) women were transferred into the hospital. The overall rate of vaginal birth was also high among the women in the home birth program, 185 (96.9%) with no added complications ascribed to home births. Such as severe perineal trauma [n=1] 0.6% PPH [n=4] 2.7%, Apgar score less than 7 at 5min [n=0] admissions post home birth to special care nursery [n=2] 1.35%. DISCUSSION: This unique study provides a detailed road map of setting up a home birth practice to facilitate other institutions keen to build a publicly funded home birth service. The birth outcome data was found to be consistent with other Australian studies on low risk home births. CONCLUSION: Well-designed home birth programs following best clinical practices and procedures can provide a safe birthing option for low risk women.

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.

Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014.

BACKGROUND: The long-term impact of user fee removal policies on health service utilization in low- and middle-income countries may vary depending on the context in which they are implemented, including whether there are policy actions to support implementation. We examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys. METHODS: Data are from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. A total of 5949, 6079 and 20,964 births were reported in respective surveys. We conducted interrupted time series analysis predicting changes in quarterly proportions of births occurring in public and private health facilities as well as at home before and after the 2004, 2007 and 2013 user fee policy shifts in Kenya. RESULTS: There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy. There was also a statistically significant increase in public facility deliveries among women from the two top quintiles, which was accompanied by a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time. CONCLUSION: The findings of this paper provide empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.

Effect of previous utilization and out-of-pocket expenditure on subsequent utilization of a state led public-private partnership scheme "Chiranjeevi Yojana" to promote facility births in Gujarat, India.

BACKGROUND: In Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat. METHODS: This was a retrospective cohort study of multiparous eligible women (after excluding abortions and births at public facility). A structured questionnaire was administered by trained research assistant to those with recent delivery between Jan and Jul 2013. Outcome of interest was CY utilization in subsequent child birth (Jan-Jul 2013). Explanatory variables included socio-demographic characteristics (including category of eligibility), pregnancy related characteristics in previous child birth, before Jan 2013, (including CY utilization, out of pocket expenditure) and type of child birth in subsequent birth. A poisson regression model was used to assess the association of factors with CY utilization in subsequent child birth. RESULTS: Of 997 multiparous eligible women, 289 (29%) utilized and 708 (71%) did not utilize CY in their previous child birth. Of those who utilized CY (n = 289), 182 (63%) subsequently utilized CY and 33 (11%) gave birth at home; whereas those who did not utilize CY (n = 708) had four times higher risk (40% vs. 11%) of subsequent child birth at home. In multivariable models, previous utilization of the scheme was significantly associated with subsequent utilization (adjusted Relative Risk (aRR): 2.7; 95% CI: 2.2-3.3), however previous out of pocket expenditure was not found to be associated with retention in the CY scheme. CONCLUSION: Women with previous CY utilization were largely retained; therefore, steps to increase uptake of CY are expected to increase retention of mothers within CY in their subsequent child birth. To understand the reasons for subsequent child birth at home despite previous CY utilization and previous zero/minimal out of pocket expenditure, future research in the form of systematic qualitative enquiry is recommended.

Association of Household Savings and Expected Future Means with Delivery Using a Skilled Birth Attendant in Ghana and Nigeria: A Cross-Sectional Analysis.

Objectives This study examined the association between household savings and related economic measures with utilization of skilled birth attendants (SBAs) at last birth among women living in peri-urban households (n = 381) in Ghana and Nigeria. Methods Data were drawn from the 2011-2014 Family Health and Wealth Study. Multivariable logistic regression models were used to estimate the odds of delivery with an SBA for individual and composite measures of household savings, expected financial means, debt, lending, and receipt of financial assistance, adjusting for demographic and reproductive characteristics. Results Seventy-three percent (73 %) of women delivered with an SBA during their last birth (89 %, Ghana; 63 %, Nigeria), and roughly one third (34 %) of households reported having any in-cash or in-kind savings. In adjusted analyses, women living in households with savings were significantly more likely to deliver with an SBA compared to women in households without any savings (aOR = 2.02, 95 % CI 1.09-3.73). There was also a consistent downward trend, although non-significant, in SBA utilization with worsening financial expectations in the coming year (somewhat vs. much better: aOR = 0.70, 95 % CI 0.40-1.22 and no change/worse vs. much better: aOR = 0.46, 95 % CI 0.12-1.83). Findings were null for measures relating to debt, lending, and financial assistance. Conclusion Coupling birth preparedness and complication readiness strategies with savings-led initiatives may improve SBA utilization in conjunction with targeting non-economic barriers to skilled care use.

"Endeavoring to Carry On Their Work": The National Debate Over Midwives and Its Impact in Rhode Island, 1890-1940.

This article analyzes the national discourse over "the problem" of midwifery in medical literature and examines the impact of this dialogue on Rhode Island from 1890 to 1940. Doctors did not speak as a monolithic bloc on this "problem": some blamed midwives while others impugned poorly trained physicians. This debate led to curricula reform and to state laws to regulate midwifery. The attempt to eliminate midwives in the 1910s failed because of a shortage of trained obstetricians, and because of cultural barriers between immigrant and mainstream communities. A decrease in immigration, an increase in trained obstetricians, the growing notion of midwives as relics of an outdated past, and the emergence of insurance plans to cover "modern" hospital births led to a decline in midwifery.

From hospital to home: Australian midwives' experiences of transitioning into publicly-funded homebirth programs.

BACKGROUND: Over the past two decades, 14 publicly-funded homebirth models have been established in Australian hospitals. Midwives working in these hospitals now have the opportunity to provide homebirth care, despite many having never been exposed to homebirth before. The transition to providing homebirth care can be daunting for midwives who are accustomed to practising in the hospital environment. AIM: To explore midwives' experiences of transitioning from providing hospital to homebirth care in Australian public health systems. METHODS: A descriptive, exploratory study was undertaken. Data were collected through in-depth interviews with 13 midwives and midwifery managers who had recent experience transitioning into and working in publicly-funded homebirth programs. Thematic analysis was conducted on interview transcripts. FINDINGS: Six themes were identified. These were: skilling up for homebirth; feeling apprehensive; seeing birth in a new light; managing a shift in practice; homebirth-the same but different; and the importance of mentoring and support. DISCUSSION: Midwives providing homebirth work differently to those working in hospital settings. More experienced homebirth midwives may provide high quality care in a relaxed environment (compared to a hospital setting). Midwives acceptance of homebirth is influenced by their previous exposure to homebirth. CONCLUSION: The transition from hospital to homebirth care required midwives to work to the full scope of their practice. When well supported by colleagues and managers, midwives transitioning into publicly-funded homebirth programs can have a positive experience that allows for a greater understanding of and appreciation for normal birth.

Local adaptations to a global health initiative: penalties for home births in Zambia.

Global health initiatives (GHIs) are implemented across a variety of geographies and cultures. Those targeting maternal health often prioritise increasing facility delivery rates. Pressure on local implementers to meet GHI goals may lead to unintended programme features that could negatively impact women. This study investigates penalties for home births imposed by traditional leaders on women during the implementation of Saving Mothers, Giving Life (SMGL) in Zambia. Forty focus group discussions (FGDs) were conducted across four rural districts to assess community experiences of SMGL at the conclusion of its first year. Participants included women who recently delivered at home (3 FGDs/district), women who recently delivered in a health facility (3 FGDs/district), community health workers (2 FGDs/district) and local leaders (2 FGDs/district). Findings indicate that community leaders in some districts-independently of formal programme directive-used fines to penalise women who delivered at home rather than in a facility. Participants in nearly all focus groups reported hearing about the imposition of penalties following programme implementation. Some women reported experiencing penalties firsthand, including cash and livestock fines, or fees for child health cards that are typically free. Many women who delivered at home reported their intention to deliver in a facility in the future to avoid penalties. While communities largely supported the use of penalties to promote facility delivery, the penalties effectively introduced a new tax on poor rural women and may have deterred their utilization of postnatal and child health care services. The imposition of penalties is thus a punitive adaptation that can impose new financial burdens on vulnerable women and contribute to widening health, economic and gender inequities in communities. Health initiatives that aim to increase demand for health services should monitor local efforts to achieve programme targets in order to better understand their impact on communities and on overall programme goals.

Out-of-pocket expenditure on prenatal and natal care post Janani Suraksha Yojana: a case from Rajasthan, India.

BACKGROUND: Though Janani Suraksha Yojana (JSY) under National Rural Health Mission (NRHM) is successful in increasing antenatal and natal care services, little is known on the cost coverage of out-of-pocket expenditure (OOPE) on maternal care services post-NRHM period. METHODS: Using data from a community-based study of 424 recently delivered women in Rajasthan, this paper examined the variation in OOPE in accessing maternal health services and the extent to which JSY incentives covered the burden of cost incurred. Descriptive statistics and logistic regression analyses are used to understand the differential and determinants of OOPE. RESULTS: The mean OOPE for antenatal care was US$26 at public health centres and US$64 at private health centres. The OOPE (antenatal and natal) per delivery was US$32 if delivery was conducted at home, US$78 at public facility and US$154 at private facility. The OOPE varied by the type of delivery, delivery with complications and place of ANC. The OOPE in public health centre was US$44 and US$145 for normal and complicated delivery, respectively. The share of JSY was 44 % of the total cost per delivery, 77 % in case of normal delivery and 23 % for complicated delivery. Results from the log linear model suggest that economic status, educational level and pregnancy complications are significant predictors of OOPE. CONCLUSIONS: Our results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery. Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened.

Publicly-funded home birth in Victoria, Australia: Exploring the views and experiences of midwives and doctors.

OBJECTIVE: to explore midwives' and doctors' views and experiences of publicly-funded homebirthing models. DESIGN: cross-sectional survey implemented two years after the introduction of publicly-funded homebirthing models. SETTING: two public hospitals in Victoria, Australia. PARTICIPANTS: midwives and doctors (obstetric medical staff). MAIN OUTCOME MEASURES: midwives' and doctors' views regarding reasons women choose home birth; and views and experiences of a publicly-funded home birth program, including intrapartum transfers. FINDINGS: of the 44% (74/167) of midwives who responded to the survey, the majority (86%) supported the introduction of a publicly-funded home birth model, and most considered that there was consumer demand for the model (83%). Most thought the model was safe for women (77%) and infants (78%). These views were stronger amongst midwives who had experience working in the program (compared with those who had not). Of the 25% (12/48) of doctors who responded, views were mixed; just under half-supported the introduction of a publicly-funded home birth model, and one was unsure. Doctors also had mixed views about the safety of the model. One third agreed it was safe for women, one third were neutral and one third disagreed. Half did not believe the home birth model was safe for infants. The majority of midwives (93%) and doctors (75%) believed that intrapartum transfers from home to hospital were easier when the homebirthing midwife was a member of the hospital staff (as is the case with these models). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: responding midwives were supportive of the introduction of publicly-funded home birth, whereas doctors had divergent views and some were concerned about safety. To ensure the success of such programs it is critical that all key stakeholders are engaged at the development and implementation stages as well as in the ongoing governance.

Trends and Characteristics of United States Out-of-Hospital Births 2004-2014: New Information on Risk Status and Access to Care.

BACKGROUND: Out-of-hospital births are increasing in the United States. Our purpose was to examine trends in out-of-hospital births from 2004 to 2014, and to analyze newly available data on risk status and access to care. METHODS: Newly available data from the revised birth certificate for 47 states and Washington, DC, were used to examine out-of-hospital births by characteristics and to compare them with hospital births. Trends from 2004 to 2014 were also examined. RESULTS: Out-of-hospital births increased by 72 percent, from 0.87 percent of United States births in 2004 to 1.50 percent in 2014. Compared with mothers who had hospital births, those with out-of-hospital births had lower prepregnancy obesity (12.5% vs 25.0%) and smoking (2.8% vs 8.5%) rates, and higher college graduation (39.3% vs 30.0%) and breastfeeding initiation (94.3% vs 80.8%) rates. Among planned home births, 67.1 percent were self-paid, compared with 31.9 percent of birth center and 3.4 percent of hospital births. Vaginal births after cesarean (VBACs) comprised 4.6 percent of planned home births and 1.6 percent of hospital and birth center births. Sociodemographic and medical risk status of out-of-hospital births improved substantially from 2004 to 2014. CONCLUSIONS: Improvements in risk status of out-of-hospital births from 2004 to 2014 suggest that appropriate selection of low-risk women is improving. High rates of self-pay for the costs of out-of-hospital birth suggest serious gaps in insurance coverage, whereas higher-than-average rates of VBAC could reflect lack of access to hospital VBACs. Mandating private insurance and Medicaid coverage could substantially improve access to out-of-hospital births. Improving access to hospital VBACs might reduce the number of out-of-hospital VBACs.

Costing Alternative Birth Settings for Women at Low Risk of Complications: A Systematic Review.

BACKGROUND: There is demand from women for alternatives to giving birth in a standard hospital setting however access to these services is limited. This systematic review examines the literature relating to the economic evaluations of birth setting for women at low risk of complications. METHODS: Searches of the literature to identify economic evaluations of different birth settings of the following electronic databases: MEDLINE, CINAHL, EconLit, Business Source Complete and Maternity and Infant care. Relevant English language publications were chosen using keywords and MeSH terms between 1995 and 2015. Inclusion criteria included studies focussing on the comparison of birth setting. Data were extracted with respect to study design, perspective, PICO principles, and resource use and cost data. RESULTS: Eleven studies were included from Australia, Canada, the Netherlands, Norway, the USA, and the UK. Four studies compared costs between homebirth and the hospital setting and the remaining seven focussed on the cost of birth centre care and the hospital setting. Six studies used a cost-effectiveness analysis and the remaining five studies used cost analysis and cost comparison methods. Eight of the 11 studies found a cost saving in the alternative settings. Two found no difference in the cost of the alternative settings and one found an increase in birth centre care. CONCLUSIONS: There are few studies that compare the cost of birth setting. The variation in the results may be attributable to the cost data collection processes, difference in health systems and differences in which costs were included. A better understanding of the cost of birth setting is needed to inform policy makers and service providers.

Statewide program to promote institutional delivery in Gujarat, India: who participates and the degree of financial subsidy provided by the Chiranjeevi Yojana program.

BACKGROUND: The Chiranjeevi Yojana (CY) is a large public-private partnership program in Gujarat, India, under which the state pays private sector obstetricians to provide childbirth services to poor and tribal women. The CY was initiated statewide in 2007 because of the limited ability of the public health sector to provide emergency obstetric care and high out-of-pocket expenditures in the private sector (where most qualified obstetricians work), creating financial access barriers for poor women. Despite a million beneficiaries, there have been few reports studying CY, particularly the proportion of vulnerable women being covered, the expenditures they incur in connection with childbirth, and the level of subsidy provided to beneficiaries by the program. METHODS: Cross-sectional facility based the survey of participants in three districts of Gujarat in 2012-2013. Women were interviewed to elicit sociodemographic characteristics, out-of-pocket expenditures, and CY program details. Descriptive statistics, chi square, and a multivariable logistic regression were performed. RESULTS: Of the 901 women surveyed in 129 facilities, 150 (16 %) were CY beneficiaries; 336 and 415 delivered in government and private facilities, respectively. Only 36 (24 %) of the 150 CY beneficiaries received a completely cashless delivery. Median out-of-pocket for vaginal/cesarean delivery among CY beneficiaries was $7/$71. The median degree of subsidy for women in CY who delivered vaginally/cesarean was 85/71 % compared to out-of-pocket expenditure of $44/$208 for vaginal/cesarean delivery paid by non-program beneficiaries in the private health sector. CONCLUSIONS: CY beneficiaries experienced a substantially subsidized childbirth compared to women who delivered in non-accredited private facilities. However, despite the government's efforts at increasing access to delivery services for poor women in the private sector, uptake was low and very few women experienced a cashless delivery. While the long-term focus remains on strengthening the public sector's ability to provide emergency obstetric care, the CY program is a potential means by which the state can ensure its poor mothers have access to necessary care if uptake is increased.

Simulation based training in a publicly funded home birth programme in Australia: A qualitative study.

BACKGROUND: Birth at home is a safe and appropriate choice for healthy women with a low risk pregnancy. However there is a small risk of emergencies requiring immediate, skilled management to optimise maternal and neonatal outcomes. We developed and implemented a simulation workshop designed to run in a home based setting to assist with emergency training for midwives and paramedical staff. The workshop was evaluated by assessing participants' satisfaction and response to key learning issues. METHODS: Midwifery and emergency paramedical staff attending home births participated in a simulation workshop where they were required to manage birth emergencies in real time with limited availability of resources to suit the setting. They completed a pre-test and post-test evaluation form exploring the content and utility of the workshops. Content analysis was performed on qualitative data regarding the most important learning from the simulation activity. RESULTS: A total of 73 participants attended the workshop (midwifery=46, and paramedical=27). There were 110 comments, made by 49 participants. The most frequently identified key learning elements were related to communication (among midwives, paramedical and hospital staff and with the woman's partner), followed by recognising the role of other health care professionals, developing an understanding of the process and the importance of planning ahead. CONCLUSION: Home birth simulation workshop was found to be a useful tool by staff that provide care to women who are having a planned home birth. Developing clear communication and teamwork were found to be the key learning principles guiding their practice.

Understanding home delivery in a context of user fee reduction: a cross-sectional mixed methods study in rural Burkina Faso.

BACKGROUND: Several African countries have recently reduced/removed user fees for maternal care, producing considerable increases in the utilization of delivery services. Still, across settings, a conspicuous number of women continue to deliver at home. This study explores reasons for home delivery in rural Burkina Faso, where a successful user fee reduction policy is in place since 2007. METHODS: The study took place in the Nouna Health District and adopted a triangulation mixed methods design, combining quantitative and qualitative data collection and analysis methods. The quantitative component relied on use of data from the 2011 round of a panel household survey conducted on 1130 households. We collected data on utilization of delivery services from all women who had experienced a delivery in the previous twelve months and investigated factors associated with home delivery using multivariate logistic regression. The qualitative component relied on a series of open-ended interviews with 55 purposely selected households and 13 village leaders. We analyzed data using a mixture of inductive and deductive coding. RESULTS: Of the 420 women who reported a delivery, 47 (11 %) had delivered at home. Random effect multivariate logistic regression revealed a clear, albeit not significant trend for women from a lower socio-economic status and living outside an area to deliver at home. Distance to the health facility was found to be positively significantly associated with home delivery. Qualitative findings indicated that women and their households valued facility-based delivery above home delivery, suggesting that cultural factors do not shape the decision where to deliver. Qualitative findings confirmed that geographical access, defined in relation to the condition of the roads and the high transaction costs associated with travel, and the cost-sharing fees still applied at point of use represent two major barriers to access facility-based delivery. CONCLUSIONS: Findings suggest that the current policy in Burkina Faso, as similar policies in the region, should be expanded to remove fees at point of use completely and to incorporate benefits/solutions to support the transport of women in labor to the health facility in due time.

Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians.

BACKGROUND: Home birth is available to women in Canada who meet eligibility requirements for low risk status after assessment by regulated midwives. While UK researchers have reported lower costs associated with planned home birth, there have been no published studies of the costs of home versus hospital birth in Canada. METHODS: Costs for all women planning home birth with a regulated midwife in British Columbia, Canada were compared with those of all women who met eligibility requirements for home birth and were planning to deliver in hospital with a registered midwife, and with a sample of women of similar low risk status planning birth in the hospital with a physician. We calculated costs of physician service billings, midwifery fees, hospital in-patient costs, pharmaceuticals, home birth supplies, and transport. We compared costs among study groups using the Kruskall Wallis test for independent groups. RESULTS: In the first 28 days postpartum, we report a $2,338 average savings per birth among women planning home birth compared to hospital birth with a midwife and $2,541 compared to hospital birth planned with a physician. In longer term outcomes, similar reductions were observed, with cost savings per birth at $1,683 compared to the planned hospital birth with a midwife, and $1,100 compared to the physician group during the first eight weeks postpartum. During the first year of life, costs for infants of mothers planning home birth were reduced overall. Cost savings compared to planned hospital births with a midwife were $810 and with a physician $1,146. Costs were similarly reduced when findings were stratified by parity. CONCLUSIONS: Planned home birth in British Columbia with a registered midwife compared to planned hospital birth is less expensive for our health care system up to 8 weeks postpartum and to one year of age for the infant.