Trend and Reasons of Women Towards the Choice for Place of Delivery: Evidence from mics 2017-18 Punjab, Pakistan

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INTRODUCTION
The maternal mortality rate (MMR) in Pakistan is 276 deaths per 100,000 live births 1 .Pakistan is the fifth-largest contributor to maternal mortality, and six per cent of the world's maternal deaths occur in Pakistan 2 .Only in 2013, around 289,000 women died due to pregnancyrelated complications in Pakistan.In view of the risk factors involved in maternal mortality, an international effort has focused on increasing the share of births at the proper health facilities (institutional deliveries) or the births attended by skilled birth attendants 3 .About 50 per cent of births in Pakistan take place at home, mainly with the help of untrained birth attendants 4 .The major reason for the home deliveries in Pakistan is found to be the limited role of women in decision-making at the household level, as well as their lower educational status and smaller control over the resources 5 .Some other determinants of the choice of place of delivery are distance to the health care facility, transportation facility, cost of institutional delivery, trust in health attendants and exposure to mass media [6][7][8] .
It is also found that women's preference for home deliveries is also shaped by their past experience of the poor health system, which includes poor availability of drugs, incompetent health workers, and lack of privacy and rude attitudes of health attendants 9 .Furthermore, a study in Pakistan found that mothers' and fathers' education has a significant impact on the decision about the place of delivery 6 .The current study is based on the data collected via (MICS) 2017-18, which was designed for all 36 districts of Punjab, including rural and urban areas, to estimate a large number of indicators about children and women of Punjab.

METHODOLOGY
To estimate children and women health indicators, the MICS 2017-18 was designed for 36 districts of the Punjab, rural and urban.Two-stage stratified cluster sampling was adopted.District's rural and urban areas were the first strata, and the households were the second stage.A total of 53,840 households were drawn as the sample size from 2,692 sample clusters, out of which 1,893 were rural clusters and 799 were urban clusters.From 53,840 households, 52,765 households occupied and 51,660 were successfully interviewed.Further, 79,510 women were eligible for interview age group 15-49 years, 74,010 women were interview successfully.There were 26,980 women who had ever or currently married and 15,656 women gave birth in the last two years.The outcome variable was place of delivery and exposure variables were socio-demographic and socioeconomic characteristics.Chi-square test was applied to identify the association by using SPSS.P-value≤0.05was considered as significant.II).

DISCUSSION
The Study shows the strong association of place of delivery with socio-demographic and socio-economic characteristics.These factors put substantial impact on the changing of place of delivery in the Punjab.Thesefindings are similar wit findings of Wagle et al 10  than the mother who are not working 12 .
Talking about the women empowerment, the pregnancy-related issues with their husbands, significantlyimpacts to choice the place for delivery.The women who discusse with her husbands are 0.34 times low chances to give birth the baby in home than their counterparts having notliberty to expose this matter with her husbands 10 .These results concur with Shah et al 13 and Tabatabaie et al 14 Moreover, those womenwho do not pay heed about the place of delivery with their husbands are more likely to deliver babies at home 12,15,16 .Control variable, including the age of mothers, is the leading factor for the choice of the place of delivery.Further, the mothers who has age group (15 -24 years) are prone to give birth the baby at home than the older mothers 17 .It was found that the region, place of residence and living status of women also led impact on the place of delivery.The education status of the mother has positive impact on the choice for place of delivery, as reported previously (p<0.010;OR 0.683; 95%; CI 0.580-0.804) 18.The women whose education status have middle or above are atmost 0.3 times low chances to deliver the baby in home as as compared to uneducated women (p<0.010;OR 0.334; 95%; CI0.267-0.419) 18.Father education status is also a leading factor to choice the place for delivery of their wives.The educated fathers have 0.91 less chances to choose home for givingbirths than uneducated fathers, (p<0.010;OR 0.757; 95%; CI 0.636-0.901) 18.(This is repetitive discussion: agrarian mothers information has already discussed).
The living status of mothers led a great impact on the choice to deliver their babies.It was found the mothers belongs to the high socio-economic status have low chances to give birth their babies at home as compare the the low socio-economic  17 .
In the Punjab, the health facalities are very costly which may casue to deliver baby at home.Ourfindings revealed that there is a negative impact on the empowerment of women in home birhs.This findings supported of Hussain et al 18 .As traditional trend ,shows rural-women are higher chances to give birth in home as compare to the urban women.

CONCLUSION
The women prefer delivery process in private sector particularly urban women.It may be the facilities present in private sector hospitals in urban areas or healthcare facilities are not accessible especially in rural areas.In modern era, some women still prefer home delivery.Finally, the maternal care and child-care awareness campaigns should be began to improve the knowledge about delivery and child health, free of cost.

Table II : The hypothesis and testing
and Bolam et al. 11.Much parallel findings were observed in previous studies where authors found thatagrarian are 1.5 times more chances to give birth in