Factors Associated with Utilization of Complete Postnatal Care Service in Baglung Municipality, Nepal.

BACKGROUND: Postnatal period is six weeks after birth. It is critical but is the most neglected period. A large proportion of maternal and neonatal deaths occur during 48 hours following childbirth. The utilization of the recommended three postnatal checkups within seven days after delivery, which plays a vital role in preventing maternal and neonatal deaths, is low in Nepal. OBJECTIVE: This study is aimed at identifying the factors associated with the utilization of complete postnatal care (PNC) among mothers. METHOD: A cross-sectional study was carried out among 318 mothers in wards 1, 2, 3, and 4 of Baglung municipality, Nepal. Data was collected by semi-structured interviews. Descriptive analysis and comparison of characteristics of women/families with complete vs. partial postnatal checkups using multivariable logistic regression were done. RESULTS: Among 314 respondents receiving at least one PNC, 78% had partial and 22% had complete PNC. Relatively advantaged caste/ethnicity- Brahman/Chhetri (aOR = 3.18, 95% CI: 1.24-8.12) and Janajati (aOR = 2.87, 95% CI: 1.09-7.53) - compared to Dalits, husbands working as a job holder in Nepal (aOR = 3.49, 95% CI: 1.50-8.13), and delivery in a private hospital (aOR = 11.4, 95% CI: 5.40-24.2) were associated with having complete PNC. CONCLUSION: Although PNC attendance at least once was high, utilization of complete PNC was low. More focus to mothers from disadvantaged caste/ethnicity, those whose husbands are in foreign employment, and improvement in quality of care in government health facilities may increase the use of complete PNC.

Factors Influencing Birth Preparedness in Rapti Municipality of Chitwan, Nepal.

INTRODUCTION: Birth preparedness is crucial for health quality of mother and newborn and acts as a strong contributor in mitigating maternal and newborn mortalities. Different factors are predicted to have an influence upon birth preparedness practice. This paper aims at exploring relationship between various factors and birth preparedness practice. METHODS: A cross-sectional study design was used to find out the relationship between various factors and birth preparedness practice. One hundred sixty-five women residing at ward number 1 of Rapti Municipality, Chitwan who delivered in the last twelve months were selected consecutively and interviewed using a semistructured questionnaire. The collected data were analyzed using descriptive and bivariate techniques. RESULTS: Three quarters (75.2%) of the respondents had better birth preparedness, institutional delivery was 63.0%, antenatal care (ANC) visit as per protocol was about 62.0%, and about 90% of the respondents had received counseling during ANC. Age, religion, family types, education, age at marriage, parity, number of children, knowledge on birth preparedness, knowledge on danger sign, place for ANC and delivery, and decision-makers were found to be statistically significant (P value < 0.05) with birth preparedness practice. CONCLUSION: Better knowledge on birth preparedness led to a better preparedness status. Age, religion, family type, education of women and partners, parity, and number of children were the factors that influence birth preparedness. Counseling during ANC played a significant role in birth preparedness.

Barriers and facilitators to institutional delivery in rural areas of Chitwan district, Nepal: a qualitative study.

BACKGROUND: Giving birth assisted by skilled care in a health facility plays a vital role in preventing maternal deaths. In Nepal, delivery services are free and a cash incentive is provided to women giving birth at a health facility. Nevertheless, about half of women still deliver at home. This study explores socio-cultural and health service-related barriers to and facilitators of institutional delivery. METHODS: Six village development committees in hill and plain areas were selected in Chitwan district. We conducted a total of 10 focus group discussions and 12 in-depth-interviews with relevant stakeholder groups, including mothers, husbands, mothers-in-law, traditional birth attendants, female community health volunteers, health service providers and district health managers. Data were analyzed inductively using thematic analysis. RESULTS: Three main themes played a role in deciding the place of delivery, i.e. socio-cultural norms and values; access to birthing facilities; and perceptions regarding the quality of health services. Factors encouraging an institutional delivery included complications during labour, supportive husbands and mothers-in-law, the availability of an ambulance, having birthing centres nearby, locally sufficient financial incentives and/or material incentives, the 24-h availability of midwives and friendly health service providers. Socio-cultural barriers to institutional deliveries were deeply held beliefs about childbirth being a normal life event, the wish to be cared for by family members, greater freedom of movement at home, a warm environment, the possibility to obtain appropriate "hot" foods, and shyness of young women and their position in the family hierarchy. Accessibility and quality of health services also presented barriers, including lack of road and transportation, insufficient financial incentives, poor infrastructure and equipment at birthing centres and the young age and perceived incompetence of midwives. CONCLUSION: Despite much progress in recent years, this study revealed some important barriers to the utilization of health services. It suggests that a combination of upgrading birthing centres and strengthening the competencies of health personnel while embracing and addressing deeply rooted family values and traditions can improve existing programmes and further increase institutional delivery rates.

Bypassing birthing centres for child birth: a community-based study in rural Chitwan Nepal.

BACKGROUND: Child delivery in a health facility is important to reduce maternal mortality. Bypassing nearby birthing facility to deliver at a hospital is common in developing countries including Nepal. Very little is known about the extent and determinants of bypassing the birthing centres in Nepal. This study measures the status of bypassing, characteristics of bypassers and their reasons for bypassing. METHODS: A community-based cross-sectional study was carried out in six rural village development committees of Chitwan district of Nepal. Structured interviews were conducted with 263 mothers who had given birth at a health facility and whose nearest facility was a birthing centre. Descriptive statistics, univariate and multivariable logistic regression analysis were performed. RESULTS: More than half of the mothers had bypassed the nearer birthing centres to deliver at hospital. Living in plain area [aOR: 2.467; 95 % CI: 1.005-6.058], higher wealth index [aOR: 4.981; 95 % CI: 2.482-9.999], advantaged caste/ethnicity [aOR: 2.172; 95 % CI: 1.153-4.089], older age [aOR: 2.222; 95 % CI: 1.050-4.703] and first birth [aOR: 2.032; 95 % CI: 1.060-3.894] were associated with higher likelihood of bypassing. Among the reasons of bypassing as reported by the bypassers, lack of operation, video x-ray, and blood test facilities were the most common ones, followed by the lack of medicines/drugs and equipment, lack of skilled service provider, and inadequate physical facilities, among others. CONCLUSIONS: Quality of service at the birthing centres needs to be given a high consideration to increase their use as well as to ensure an equitable access to the quality care by all.

Factors associated with neonatal deaths in Chitwan district of Nepal.

BACKGROUND: Neonatal mortality has remained unchanged since 2006 in Nepal. Reducing neonatal mortality is indispensable to reduce child mortality. The objective of this study was to investigate the factors associated with neonatal mortality. This study assesses socio-demographic factors, maternal health care and newborn care practices contributing to neonatal deaths in Chitwan district of Central Nepal. METHODS: A case-control study was conducted during April-July 2012. The study used a mixed-method approach, in which records of neonatal deaths were obtained from the District Public Health Office and a comparison group, survivors, was obtained from the same community. A total of 198 mothers (of 99 neonatal deaths and 99 survivor neonates) were included in the survey. Focus group discussions, in-depth interviews and case studies were also conducted. Maternal characteristics were analyzed using descriptive statistics, Mc Nemar's Chi square test and multivariable backward conditional logistic regression analysis. Qualitative data were analyzed by narrative analysis method. RESULTS: More than four-fifth of mothers (86%) had antenatal check-up (ANC) and the proportion of four or more ANC was 64%. Similarly, the percentage of mothers having institutional delivery was 62%, and postnatal check-up was received by 65% of mothers. In multivariable analysis, low birth weight [adjusted odds ratio: 8.49, 95% CI (3.21-22.47)], applying nothing on cord [adjusted odds ratio: 5.72, 95% CI (1.01-32.30)], not wrapping of newborn [adjusted odds ratio: 9.54, 95% CI (2.03-44.73)], and no schooling of mother [adjusted odds ratio: 2.09, 95% CI (1.07-4.11)] were significantly associated with an increased likelihood of neonatal mortality after adjusting for other confounding variables. Qualitative findings suggested that bathing newborns after 24 h and wrapping in clean clothes were common newborn care practices. The mothers only attended postnatal care services if health problems appeared either in the mother or in the child. CONCLUSION: Results of this study suggest that the current community based newborn survival intervention should provide an even greater focus to essential newborn care practices, low birth weight newborns, and female education.

Factors affecting institutional delivery in rural Chitwan district of Nepal: a community-based cross-sectional study.

BACKGROUND: Health facility delivery is considered a critical strategy to improve maternal health. The Government of Nepal is promoting institutional delivery through different incentive programmes and the establishment of birthing centres. This study aimed to identify the socio-demographic, socio-cultural, and health service-related factors influencing institutional delivery uptake in rural areas of Chitwan district, where high rates of institutional deliveries co-exist with a significant proportion of home deliveries. METHODS: This community-based cross-sectional study was conducted in six rural Village Development Committees of Chitwan district, which are characterised by relatively low institutional delivery rates and the availability of birthing centres. The study area represents both hilly and plain areas of Chitwan. A total of 673 mothers who had given birth during a one-year-period were interviewed using a structured questionnaire. Univariate and multivariable logistic regression analysis using stepwise backward elimination was performed to identify key factors affecting institutional delivery. RESULTS: Adjusting for all other factors in the final model, advantaged caste/ethnicity [aOR: 1.98; 95% CI: 1.15-3.42], support for institutional delivery by the husband [aOR: 19.85; 95% CI: 8.53-46.21], the decision on place of delivery taken jointly by women and family members [aOR: 5.43; 95% CI: 2.91-10.16] or by family members alone [aOR: 4.61; 95% CI: 2.56-8.28], birth preparations [aOR: 1.75; 95% CI: 1.04-2.92], complications during the most recent pregnancy/delivery [aOR: 2.88; 95% CI: 1.67-4.98], a perception that skilled health workers are always available [aOR: 2.70; 95% CI: 1.20-6.07] and a birthing facility located within one hour's travelling distance [aOR: 2.15; 95% CI: 1.26-3.69] significantly increased the likelihood of institutional delivery. On the other hand, not knowing about the adequacy of physical facilities significantly decreased the likelihood of institutional delivery [aOR: 0.14; 95% CI: 0.05-0.41]. CONCLUSION: With multiple incentives present, the decision to deliver in a health facility is affected by a complex interplay of socio-demographic, socio-cultural, and health service-related factors. Family decision-making roles and a husband's support for institutional delivery exert a particularly strong influence on the place of delivery, and this should be emphasized in the health policy as well as development and implementation of maternal health programmes in Nepal.

Field test results of the motherhood method to measure maternal mortality.

BACKGROUND & OBJECTIVES: Measuring maternal mortality in developing countries poses a major challenge. In Nepal, vital registration is extremely deficient. Currently available methods to measure maternal mortality, such as the sisterhood method, pose problems with respect to validity, precision, cost and time. We conducted this field study to test a community-based method (the motherhood method), to measure maternal and child mortality in a developing country setting. METHODS: Motherhood method was field tested to derive measures of maternal and child mortality at the district and sub-regional levels in Bara district, Nepal. Information on birth, death, risk factors and health outcomes was collected within a geographic area as in an unbiased census, but without visiting every household. The sources of information were a vaccination registry, focus group discussions with local health workers, and most importantly, interview in group setting with women who share social bonds formed by motherhood and aided by their peer memory. Such groups included all women who have given birth, including those whose babies died during the measurement period. RESULTS: A total of 15,161 births were elicited in the study period of two years. In the same period 49 maternal deaths, 713 infant deaths, 493 neonatal deaths and 679 perinatal deaths were also recorded. The maternal mortality ratio was 329 (95%CI: 243-434)/100,000 live birth, infant mortality rate was 48 (44-51)/1000LB, neonatal mortality rate was 33 (30-36)/1000LB, and perinatal mortality rate was 45 (42-48)/1000 total birth. INTERPRETATION & CONCLUSIONS: The motherhood method estimated maternal, perinatal, neonatal and infant mortality rates and ratios. It has been field tested and validated against census data, and found to be efficient in terms of time and cost. Motherhood method can be applied in a time and cost-efficient manner to measure and monitor the progress in the reduction of maternal and child deaths. It can give current estimates of mortalities as well as averages over the past few years. It appears to be particularly well-suited to measuring and monitoring programmes in community and districts levels.