Factors associated with contraceptive use in rural Nepal: Gender and decision-making.

INTRODUCTION: Gender norms and roles influence many decisions related to reproductive health behaviours including contraceptive use. There are very few studies related to gender norms and decision-making in contraceptive use in Nepal, hence this paper addresses these issues in a quantitative study. METHODS: A secondary data analysis of a primary study conducted in 2012 as a quantitative cross-sectional study in four villages of a hilly district in Nepal. This study included data that were collected from either the woman or the man in 440 couples of childbearing age with at least one child. The secondary analysis included (adjusted) regression analysis to investigate factors associated with contraception use with the variables of interest being gender roles and decision-making, whilst considering demographic and socio-economic controls. RESULTS: The secondary data analysis found gender roles were associated with current/ever use of contraceptives as reported by the respondents. Socio-economic factors such as husband's and wife's education and gender roles such as indicators showing sharing of childcare responsibilities affected contraceptive use positively. However, decision making regarding contraceptive use was not found to be associated with current/ever use of contraceptives. CONCLUSION: Gender has a role in the use of contraceptive, however decision-making may not be associated with contraceptive use. Educational, health promotional and family planning programmes are recommended to promote use of contraceptives. It is important that husbands get involved in these programmes to encourage discussions related to contraceptive use.

Qualitative evaluation of mental health training of auxiliary nurse midwives in rural Nepal.

BACKGROUND AND OBJECTIVES: Mental illness is increasingly recognized as a global health problem. However, in many countries, including Nepal, it is difficult to talk about mental health problems due to the stigma associated with it. Hence a training programme was developed to train auxiliary nurse midwives, who otherwise are not trained in mental health as part of their pre-registration training in rural Nepal, on issues related to maternal mental health. After the training programme a selection of auxiliary nurse midwives were interviewed to establish their views on the training, its usefulness and ways to improve it. METHODS: This qualitative study reports on the analysis of interviews conducted with auxiliary nurse midwives who participated in the training programme. The interviews addressed issues associated with the training programme as well as perceptions around mental health in rural Nepal. Transcripts were thematically analysed. RESULTS: Three themes emerged from analysis: (1) issues related to training; (2) societal attitudes; and (3) support for women. The 'training' theme describes the benefits and limitations of training sessions. 'Societal attitudes' describes society's attitude towards mental health which is largely negative. 'Support' describes the positive behaviour and attitude towards pregnant women and new mothers. CONCLUSION: The study supports the need for continued training for auxiliary nurse midwives who are based in the community. This gives them the opportunity to reach the whole community group and potentially have influence over reduction of stigma; offer support and diagnosis of mental ill-health. There is still stigma around giving birth to a female child which can lead to mental health problems. It is imperative to increase awareness and educate the general public regarding mental health illnesses especially involving family members of those who are affected.

Social autopsy: a potential health-promotion tool for preventing maternal mortality in low-income countries.

Despite significant global improvements, maternal mortality in low-income countries remains unacceptably high. Increasing attention in recent years has focused on how social factors, such as family and peer influences, the community context, health services, legal and policy environments, and cultural and social values, can shape and influence maternal outcomes. Whereas verbal autopsy is used to attribute a clinical cause to a maternal death, the aim of social autopsy is to determine the non-clinical contributing factors. A social autopsy of a maternal death is a group interaction with the family of the deceased woman and her wider local community, where facilitators explore the social causes of the death and identify improvements needed. Although still relatively new, the process has proved useful to capture data for policy-makers on the social determinants of maternal deaths. This article highlights a second aspect of social autopsy - its potential role in health promotion. A social autopsy facilitates "community self-diagnosis" and identification of modifiable social and cultural factors that are attributable to the death. Social autopsy therefore has the potential not only for increasing awareness among community members, but also for promoting behavioural change at the individual and community level. There has been little formal assessment of social autopsy as a tool for health promotion. Rigorous research is now needed to assess the effectiveness and cost effectiveness of social autopsy as a preventive community-based intervention, especially with respect to effects on social determinants. There is also a need to document how communities can take ownership of such activities and achieve a sustainable impact on preventable maternal deaths.

Factors related to choice of place of birth in a district in Nepal.

OBJECTIVE: In Nepal, both percentage of women giving birth at health facility and proportion of birth assisted by skilled birth attendant is very low. The purpose of this research was to identify predictors for choice of place of birth: either at home, primary health care facility (including birthing centres) or at tertiary health care facilites (hospitals and clinics). METHODS: A cross-sectional household survey was conducted in seven village development committee of a district lying in plain area of Nepal: Nawalparasi. A structured interview questionnaire was developed and administered face-to-face. Descriptive analysis along with chi-square test and multinomial logistic regression was used to identify the predictors of giving birth at a health care facility. RESULTS: Women were significantly more likely to give birth at health care facilities compared to home if the distance was less than one hour, belonged to advantaged caste, had radio, television and motorbike/scooter, decision maker for place of birth was husband, reported their frequency of antenatal (ANC) visits at 4 or more and belonged to age group 15-19. CONCLUSION: The analysis indicates that husbands of women giving birth influence the choice of place of birth. The findings highlight importance of having four or more ANC visits to the health institutions and that it should be located within one-hour walking distance. Inequity in utilisation of childbirth services at health institutions exists as showed by low utilisation of such services by disadvantaged caste.

Access to free health-care services for the poor in tertiary hospitals of western Nepal: a descriptive study.

BACKGROUND: Nepal is an underdeveloped country in which half of the total health expenditure is from out-of-pocket payments. Thus, the Government of Nepal introduced universal free health-care services up to the level of district hospitals, and targeted these services to poor and marginalized people in regional and subregional hospitals. The aim of this descriptive study was to explore the implementation and utilization of free health-care services by the target population (poor and marginalized people) in two tertiary-care hospitals in western Nepal, one with a social care unit (Western Regional Hospital) and one without a social care unit (Lumbini Zonal Hospital). METHODS: Medical records maintained by the two hospitals for one Nepali calendar year were collected and analysed, along with information from key informant interviews with staff from each hospital and patient exit interviews. RESULTS: Utilization of free health-care services by poor and marginalized people in the two tertiary-care hospitals was suboptimal: only 8.4% of patients using services were exempted from payment in Western Regional Hospital, whereas it was even fewer, at 2.7%, in Lumbini Zonal Hospital. There was also unintended use of services by nontarget people. Qualitative analysis indicated a lack of awareness of free health-care services among clients, and lack of awareness regarding target groups among staff at the hospitals. Importantly, many services were utilized by people from rural areas adjoining the district in which the hospital was situated. CONCLUSION: Utilization of free health-care services by the target population in the two tertiary-care hospitals was very low. This was the result of poor dissemination of information about the free health-care programme by the hospitals to the target population, and also a lack of knowledge regarding free services and target groups among staff working in these hospitals. Thus, it is imperative to implement educational programmes for hospital staff and for poor and marginalized people. Unintended use of free services was also seen by nontarget groups; this suggests that there should further simplification of the process to identify target groups.