1. Introduction
Home birth or unassisted birth means for a woman to make the decision to give birth at home, not alone in absolute terms, but without professional assistance, whether that of a midwife, a doctor or another person with midwifery qualifications [1]. It is estimated that 60% of African women give birth at home without the assistance of a skilled health provider and 18 million births per year take place at home [2]. This state of affairs is due to two main causes: ignorance and poverty [3]. Many mothers do not have access to modern health care services [3]. The link between maternal and infant mortality and the place of delivery is well established, because the place of delivery primarily determines the quality of care received by the mother and her newborn [4]. Home birth aggravates maternal complications such as postpartum hemorrhage, septic shock, and puerperal pyrexia [5]. The determinants that predispose to fatal events during maternity can be grouped into three categories: demographic factors, socioeconomic factors and factors related to the health system [6]. In terms of reducing maternal mortality in sub-Saharan Africa, one thing is clear. Despite the political and health efforts made to this end, there is an under-use of obstetric care services, or even the absence of their use by some women during pregnancy and especially during childbirth. Many women still give birth outside health services, especially at home. The phenomenon is observed both in urban and rural areas, but it remains more observed in rural areas. However, it appears that access to quality obstetric care (in health centers) contributes to a significant reduction in maternal deaths [7].
In Togo, according to survey data, MICS 6 Togo, 2017, the rate of home births without the assistance of qualified personnel is estimated at 18.8% [8]. The aim of this study is to understand why parturient women don’t use health facilities in Dagbati community. We set ourselves the objective of determining the factors favoring home births in the community of Dagbati.
2. Methods
This was a descriptive cross-sectional study conducted among 33 women who gave birth at home, received at USP Dagbati and during advanced strategies; who were or were not registered in the USP Dagbati delivery register and who agreed to participate freely in the survey in an informed manner. The mothers who did not want to participate in the survey (n = 5) and those who had the assistance of a nursing staff at home (n = 0) or who gave birth in the USP Dagbati (n = 15) were not included in our study. This study took place from 04th November to 21st December 2019 and from 17th to 21st August, 2020, in the community of Dagbati, located in the prefecture of Vo more precisely in the health commune Vo 3, of the maritime region in TOGO. This village, which is a hard-to-reach place, is 15 km from the Prefectural Hospital Center (CHP) of Vogan. To carry out our survey, we developed a collection sheet in the form of a pre-established questionnaire which had been tested beforehand. The variables studied were the following: socio-demographic data, parity, number of Antenatal consultations, and reasons for the home birth. Our data was entered using Microsoft Word 2013 software. Data processing, analysis, tables and graphs were done using Microsoft Excel version 2013 software. From an ethical point of view, authorization No. 03/2020/USP/DAG/VO3 was issued by the Chief Medical Officer of the District of Vo. Data collection was done with the consent of the mothers and measures were taken to guarantee their anonymity and confidentiality.
Operational definitions:
➢ Pauciparous: woman who has given birth 2 to 3 times.
➢ Multipara: woman who has given birth 4 to 5 times.
➢ Grand multipara: woman who has given birth more than 5 times.
3. Results
Prevalence of home births:
Of the 48 deliveries that took place in the locality during our study period, 33 took place at home, giving a rate of 68.7%.
Socio-demographic data:
The average age of the women giving birth was 26.33 years with extremes of 15 and 47 years. The age group of [35 - 40[ represented 24.2%. They had a primary education level in 61% of cases. In 42.4% cases, they were farmers. They were married in 75.8% of cases. Twenty-seven women who gave birth had farmer spouses (81.9%). The distance between their house and the health center was greater than 2 km in 78.8% cases (Table 1).
Obstetrical history and evolution of pregnancy
Thirteen women who gave birth were grand multiparous (40%). In 51.5% cases, they had not made an antenatal consultation. Pregnancies were carried to term in 81.8% of cases. Twenty-nine (29) women (87.9%) had had a singleton pregnancy. During their delivery, 21 of them had been helped by their families. Newborns cried immediately after birth in 86.5% of cases (Table 2).
Reasons for home birth
Among the reasons for giving birth at home, the lack of financial means was mentioned in 60.6% (Table 3).
Assistance during childbirth
In 63.6% cases, the family had assisted the women in giving birth (Table 4).
Condition of the newborn at birth
There had been 37 newborns taking into account the 4 twins delivered.
At birth, 32 newborns cried immediately (86.5%) (Table 5).
Maternal and neonatal complications
Maternal complications
Fourteen women who delivered (42.4%) had not presented any complication. Among the 19 women who gave birth who presented complications, postpartum hemorrhage represented 57.9% of cases, followed by puerperal infection (42.1%) cases.
Neonatal complications
In 70.3% cases, the newborns had not presented any complication.
Among the neonates who presented complications (11), 63.6% presented a neonatal infection. Stillbirths were recorded in 27.2% of cases and one perinatal death (9%).
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Table 1. Distribution of women giving birth according to socio-demographic data.
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Table 2. Obstetric history and course of pregnancy.
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Table 3. Distribution of women according to the reasons for their home birth.
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Table 4. Distribution of women according to assistance during childbirth.
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Table 5. Distribution of newborns according to their condition at birth.
4. Discussion
The average age of women who gave birth at home was 26.33 years. Our results are similar to those of Oumar S et al. [9] in Mali in 2020, who reported an average age of 28 years. This average age was probably due to the fact that women are sexually active at this period and it is the best fertility period. They had a primary education level in 61% of cases. Sialubanje C et al. in 2015 [10] reported 58% primary education level. This high schooling rate is probably due to the free primary education decreed by the Togolese government [11]. In 42.4% of the cases, they were farmers and were married in 75.8% of cases. Their spouses were also farmers in 81.9% of cases. Living in a rural environment with a low socio-economic level in 60.1% cases, they had mentioned the lack of financial means as the reason for not attending USP. Intone A. et al. in 2020 [12] reported that 68.8% of mothers belonged to families below the poverty line. The distance between their house and the health center was greater than 2 km in 78.8% cases. Bennie Bi Vero J et al. in 2009 reported in their study that the nearest health center is 1.5 kilometers away [13]. This distance, combined with the condition of the rural ways, do not encourage pregnant women to plan a delivery in the USP of Dagbati . They were multiparous in 73% of cases, and had not performed any prenatal consultation in 51.5% of cases. Oumar S et al. in 2020 reported 83.23% multiparous in Sabalibougou [9]. Indeed, these women think they have acquired experience in terms of pregnancy and childbirth, and therefore they allow themselves to do without the services of health personnel and the USP of the locality, whereas they are more prone to complications including immediate postpartum hemorrhage [9]. In 63.6%, the family had assisted the women in giving birth. Bennie Bi Vero J et al., had reported the assistance of a parent during childbirth, in 48.57% [13]. This fact is probably due to the legendary African solidarity which is more pronounced in rural areas. We recorded 57.9% cases of postpartum hemorrhage. These results are lower than those of Oumar S. et al. who reported 72.92% [9]. This hemorrhage observed in our new mothers is due to the non-application of the AMTSL (Active Management of the Third Stage of Labour) which helps to prevent hemorrhage during delivery. Especially since they are multiparous most of the time (73% cases), this worsens their situation in immediate postpartum. In 63.6% cases, newborns presented a neonatal infection, this is due to the conditions of childbirth where no measure is taken to apply even a little bit of asepsis.
5. Conclusions
Home birth is still a reality in our communities, despite the increase in health structures. It remains a public health problem in developing countries. The identified risk factors are, among others, the low level of education, the lack of antenatal follow-up, the lack of financial means and multiparity.
The sensitization of the population, the improvement of the conditions of accessibility to the health center, the quality of obstetric care and also, the improvement of the living conditions of women will surely allow a total abandonment of home births.
Limit of the Study
The investigation was short-lived and we did not have access to all those concerned. There are some who refused to participate in the survey, despite the time taken to discuss with them and gain their confidence in order to obtain informed consent. Also, it is a small village. This explains the fact that we only obtained 33 cases. Since our study focused on women who gave birth at home, it was difficult to get honest answers for questions that seemed embarrassing to them. Despite these difficulties, we were able to collect interesting and useful information for our study.