Predictors of home- <i>vs</i> . facility-based delivery among women living in rural Niger: a cross-sectional survey within the AVENIR cluster-randomised trial

Background: Niger has one of the highest maternal mortality rates, and facility delivery can help prevent these deaths. While distance to health facilities predicts home delivery in other sub-Saharan African settings, few studies have examined this relationship in Niger. Methods: This cross-sectional survey, an ancillary study to the AVENIR trial, included women aged 12-59 years old with a child participating in a sub-trial of AVENIR. Trained workers collected survey data on potential predictors of a home-based delivery, and separately documented primary health care centre (Centre de Santé Integré, CSI) services through site visits. Distance from household to CSI was split into three categories: less than five km, 5-10 km, and over 10 km. Generalised estimating equations (GEE) evaluated the association between distance to CSI and likelihood of a home-based delivery, adjusting for clustering by community. As a secondary analysis, backwards stepwise model selection determined the best set of predictors for a home-based delivery. Results: 49.2% of women indicated their last birth occurred at home. Compared with women living <5 km from a CSI, those living 5-10 km away had 1.72 times the odds of home delivery (95% confidence interval (CI) = 1.00-2.96), and those >10 km away had 2.67 times the odds (95% CI = 1.44-4.95). Model selection identified three significant predictors: number of prenatal care visits, distance to CSI, and number of living children. Conclusions: Home delivery remains highly prevalent in rural Niger. Access to prenatal consultations, the number of living children a mother has, and distance from the household to the local CSI are key predictors of delivery location. Interventions for women who prefer or must give birth at home along with those aimed to increase facility-based delivery may support efforts to decrease maternal mortality in rural Niger. Trial registration: This trial was registered at clinicaltrials.gov (NCT04224987) on 13 January 2020.