Epidemiology, the Main Reasons and Maternal-Fetal Complications of Unassisted Childbirth in the Health District of V Bamako Commune, Mali

Objective: To describe the epidemiological aspects, to determine the reasons leading women to give birth outside of health facilities and to determine the maternal prognosis. Patients and Methods: This was a cross-sectional, ana-lytical, quantitative and qualitative descriptive study over a period from 1 June to 31 December 2016 (7 months) on unassisted childbirth in the health district of commune V of Bamako. Results: We recorded 70 unsured deliveries, a frequency of 1.04% out of a total of 6719 deliveries. The extreme ages were 15 years and 41 years with an average age of 28 years. 90% of the birth attendants were married and 10% were single. The women's profession: 48% were housewives, 11% saleswomen, 13% hairdressers, 4% female teachers. Education level: 71% were uneducated deaths. For the condition of newborns at the time of admission: 88% of newborns were alive, 11% were stillborn fresh and 1% stillborn macerated. Conclusion: The reasons are multifactorial and seem to be a reflection of our so-ciety.


Introduction
Home births without medical assistance continue to be a concern for all development actors in developing countries [1]. In industrialized countries, almost all births are attended by qualified health workers [2]. In these countries, maternal mortality is very low, while in developing countries, more than 300 million women currently suffer from chronic conditions, as a result of pregnancy and childbirth [3]. In Mali, according to the Demographic and Health Survey VI of 2018 (EDSM 2018) VI, the ratio of maternal mortality is estimated at 373 maternal deaths per 100,000 live births [4]. Mali, like the countries of the sub-region, in recent years has seen the result of numerous maternity units and the recruitment of qualified staff aimed at reducing maternal, perinatal and child morbidity and mortality. At the same time, regular monitoring of pregnancies and the promotion of hospital delivery, family planning have played a major role in reproductive health activities. However, despite these efforts, some women continue to give birth without medical assistance [5]. WHO estimates that more than 20 million women suffer from unsured childbirth-related ailments each year [6]. Many mothers do not have access to modern health care services. It is estimated that between 60% and 80% of women in developing countries continue to give birth at home without any assistance or with the help of unskilled and usually unsafe people. In Mali, in 2012-13, 43% of deliveries took place in the home [7]. Ignorance and poverty have been cited as reasons for home births [8].
Beyond the figures, we initiated this work with the aim of determining the reasons leading women to give birth outside health facilities without the help of qualified staff in commune V of Bamako district.
Objective: the aim was to write down the epidemiological aspects, to determine the reasons leading women to give birth outside health facilities and the maternal prognosis in the health district of commune V of Bamako, Mali.

Patients and Methods
We carried out a cross-sectional, descriptive, quantitative and qualitative prospective study in the health district of the commune V of Bamako (10 health areas) from 1 June to 31 December 2016 (7 months). The study population was represented by all the births recorded in the health district of Commune V.
Sample size: we recorded all cases of unsured births during the 7-month study S. O. Traoré et al. Open Journal of Obstetrics and Gynecology period based on our criteria. Inclusion criteria: All women who met the definition of out-of-maternity delivery without qualified staff were included in this study and who presented themselves for some reason in any of the health structures involved in the study (10 community health centres, and the commune V reference health centre). Exclusion criteria: patients who did not accept the study. A structured questionnaire was developed and a pre-test was administered in the two structures of the neighbouring commune (commune VI) in order to make possible corrections to this questionnaire. We collected patient accounts of the reasons and circumstances that led to this type of unsecured delivery. The information gathered at the interrogation was supplemented from the birthing, admission, reference/evacuation records, obstetric records, antenatal consultation books. As with any human study, we sought and obtained the informed consent of each patient prior to the questionnaire. Confidentiality and anonymity were also respected. The data was entered on Word 2010 and Excel 2010 and analyzed on the Epi-Info Version 3.5.3 software.

Epidemiological Aspects
During the study period, we recorded 70 unsured deliveries, a frequency of 1.04% out of a total of 6719 deliveries. The extreme ages were 15 years and 41 years with an average age of 28 years. Average parity was 4 with extremes of 1 and 8. The women's profession: 48% were housewives, 11% saleswomen, 13% hairdressers, 4% female teachers. 77% of patient procreators were in a non-income-generating profession. 90% of the birth attendants were married and 10% were single. Education level: 71% were uneducated and 29% educated.
Among those who are educated, their level was primary in 50%, secondary in 32% and higher in 18%. 42% had done antenatal consultation. Epidemiological aspects are summarized in Table 1.

The Main Reasons Given for Deliveries outside Health Facilities
There were many reasons why patients gave birth outside the maternity ward without assistance. For example, we noted: 1) Ignorance of the labour was evoked by 44.3% of the patients, as Ms. MS, 15, testified, "it was my first pregnancy, when the pain started, it was coming, it was going, but since I didn't know, for a while I had the urge to go to the saddle, so I went back to the toilet and that's where I gave birth".
2) Accessibility difficulties: 17.1% were patients, resulting in a significant number of unassisted births outside the maternity ward. So to this patient Mrs.
KD 28 years to say "I last live the river in commune I, but I did my prenatal follow-up with my sister-in-law who is Sagefemme here in the Mali district. When I started to get hurt I called my husband who was at work, as soon as he arrived we took the road to the maternity ward of Mali, but on the bridge there was traffic jam so it put us late and I ended up giving birth in the car". Open Journal of Obstetrics and Gynecology The main reasons for unsured births are summarized in Table 2.
Maternal and perinatal prognosis: Complications were mostly hemorrhagic and concerned 27 (39%) Patients. These included uterine atony (13 cases), placental retention (8 cases), soft part lesions (6 cases). We have not recorded any maternal deaths. For the condition of newborns at the time of admission: 88% of newborns were alive, 11% were stillborn fresh and 1% stillborn macerated. The maternal-fetal prognosis is summarized in Table 3.

Epidemiological Aspects
During the study period, we recorded 6719 deliveries, 70 of which were non-assisted, representing a frequency of 1.04%. This rate does not reflect reality. This is a hospital rate, not taking into account cases of childbirth in the community (not seen in a health structure). A community survey on the subject could have led to an increase in this rate. In Mali's Demographic and Health Survey VI (2018) [4], it is reported that one in three women (33%) gave birth at home in the previous 5 years. The same observation was made by many authors in Côte d'Ivoire (44%) [3], in Niamey, Niger (26%) St. Louis, Senegal (50%) [9].   [11].
In our study, 26 (37.1%) patients were multiparous with an average parity of 4 (with extremes of 1 and 8). In Guinea, Diallo FB et al. [12] found that 48.67% of women who gave birth at home were large multiparous.

The Main Reasons Cited by Women
The reasons for non-assisted motherhood are multifactorial, varying from continent to continent, country to country and study to study with some consistency. Thus, in this study, we noted: ignorance of the labour of childbirth: it was evoked by 44.3% patients. The problem of accessibility, be it geographical, financial has led to unassisted maternity births in 17.1%. In Mali's Demographic and Health Survey VI (2018) [4], it is reported that distance, inaccessibility, and lack of adequate infrastructure have led one in three women to give birth at home without assistance (33%). Diallo et al. [12] in Guinea (Conakry) showed that the remoteness of the health structure was the reason for home birth for 58.41 per cent of women. In an Ivorian study [3], the cost of care was reported by women. In this study, more than half of the women who gave their opinion on the issue, found the cost of childbirth too high, not to mention the racketeering that contributed greatly: affordability is therefore a factor that can help the decision to give birth at home according to these authors. Religious beliefs and modesty were mentioned in 7 patients or 10.0%. Poor quality of care may have been the cause of non-assisted maternity delivery in 12.7% of patients. Ivorian authors [3] have found that there is twice as much risk of having a birth at home when the reception is not of quality at the maternity ward. The poor quality of

S. O. Traoré et al. Open Journal of Obstetrics and Gynecology
reception perceived by women is often due to long queues in Ivorian health facilities. This is due not only to the lack of health personnel, but also to the delay in hours of health care. In the same study, the authors reveal that the quality of care revealed that one-third of women who found care to be poor, gave birth at home. Statistical analysis showed that there was a three-times increased risk of giving birth at home when the woman was convinced that she would not be cared for in the maternity ward. The cost of care has been reported by women; more than half of the women who gave their opinion on the issue found the cost of childbirth too high, not to mention the racketeering that contributed greatly to it: affordability is therefore a factor that can help the decision to give birth at home [3].
A previous successful home birth, often experienced by women as an act of bravery, can be a factor in the recurrence of this often perilous experience for the mother-child couple. Thus, in our series 2.9% patients had a history of home birth. In other qualitative studies on home birth, authors report that [13] "10 percent of women talk about a well-lived home birth" and that others say "giving life at home is a positive event, giving a sense of power, and very satisfying".
The haunting or fear of caesarean section may be grounds for women to be detained in the community where they give birth. Also, in our study, 4.3% of patients reported having had the haunting or fear of being caesareanized again.
According to the National Birthday Trust Fund [13], 11% of women who have given birth at home cite as the reason for this choice, "a hospital birth poorly lived" and 10%, "the fear of the hospital, the rejection of protocols and regulations". Some authors [3] report that the main reasons cited by these women were the misuse of certain medical practices such as episiotomy, the lack of psychological assistance thus increasing the stress associated with childbirth or the untimely prescribing of caesarean sections showing the incompetence of midwives to perform a vaginal delivery.
The insecurity of recent years may have been a barrier to access to maternity services for some women. Thus 2.9% patients in our series blamed insecurity.
According to the National Birthday Trust Fund [13], for women, the choice of place of delivery is based on different reasons: 30% evoke intimacy, respect; 25% mention the practicality, convenient, the presence of the family; 24% talk about reduced stress, better control and involvement; 11% mention a hospital birth that is poorly lived; 4% mention overall support and continuity of care.
In other qualitative studies on home birth, women say that giving life at home is a positive event, giving a sense of power, and very satisfying.

Maternal and Perinatal Prognosis
Complications were mainly hemorrhagic and affected 27 (39%) patients. These included uterine atony (13 cases), placental retention (8 cases), soft part lesions (6 cases). This result contrasts with the literature. For almost all studies agree that women who give birth at home have significantly fewer perineal tears than Open Journal of Obstetrics and Gynecology the same women who give birth in hospital. Olsen's meta-analysis, including six studies, found ORs less than 1 consistently in favour of home [14]. Hemorrhages are less common at home and statistically significant in half of the studies [15].
However, it should be noted that all of these meta-analyses focused on home births planned and assisted by qualified medical personnel (Wise Women or Physicians) in highly medicalized countries. Maternal mortality in our study was zero like many other studies [16] [17] [18] [19] [20].
For the condition of newborns at the time of admission: 88% of newborns were alive, 11% were stillborn fresh and 1% stillborn macerated.