|Year : 2014 | Volume
| Issue : 1 | Page : 27-33
Utilization of maternal and child health services in western rural Nepal: A cross-sectional community-based study
Vishnu Khanal1, Ramjee Bhandari2, Mandira Adhikari3, Rajendra Karkee4, Chandni Joshi5
1 MPH Candidate, School of Public Health, Curtin University, Bentley, Australia
2 MPH Candidate, Institute of Medicine, Kathmandu, Nepal
3 Population Services International, Nawalparasi, Nepal
4 School of Public Health, BP Koirala Institute of Health Sciences, Dharan, Nepal
5 MPH Candidate, School of Public Health and Community Medicine, The University of South Wales, Sydney, Australia
|Date of Web Publication||5-Mar-2014|
MPH Candidate, Maharajgunj Medical Campus, Institute of Medicine, Kathmandu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Considering the commitment and investment of Nepal to reduce maternal and child mortality, understanding service utilization and factors associated with a child and maternal health services is important. Objectives: This study was examined the factors associated with utilization of maternal and child health services in Kapilvastu District of Nepal. Materials and Methods: A cross-sectional study was conducted in 2010 by interviewing 190 mothers having children of aged 12-23 months using the standardized questionnaire. Results: Immunization status (97.4%) and vitamin A supplementation (98.4%) was high. However, initiation of breastfeeding within an hour of birth was low (45.3%) and 63.2% had practiced exclusive breastfeeding. Majority (69.5%) of respondents delivered their child at home and 39.5% sought assistance from health workers. The mothers who did not have any education, mothers from Dalit/Janjati and the Terai origin were less likely to deliver at the health facility and to seek the assistance of health workers during childbirth. Conclusion: The immunization program coverage was high, whereas maternal health service utilization remained poor. Interventions that focus on mothers from Dalit/Janjati group and with lower education are likely to increase utilization of maternal health services.
Keywords: Antenatal care, Breastfeeding, Cross sectional survey, Delivery services, Immunization, Vitamin A
|How to cite this article:|
Khanal V, Bhandari R, Adhikari M, Karkee R, Joshi C. Utilization of maternal and child health services in western rural Nepal: A cross-sectional community-based study. Indian J Public Health 2014;58:27-33
|How to cite this URL:|
Khanal V, Bhandari R, Adhikari M, Karkee R, Joshi C. Utilization of maternal and child health services in western rural Nepal: A cross-sectional community-based study. Indian J Public Health [serial online] 2014 [cited 2019 Aug 20];58:27-33. Available from: http://www.ijph.in/text.asp?2014/58/1/27/128162
| Introduction|| |
Child and Maternal Health Services are prioritized programs in the health system of Nepal. The Ministry of Health and Population (MoHP) started an expanded program on immunization in 1979. , Routine immunization program in Nepal includes Bacille Calmette Guerin (BCG), diphtheria, pertussis, tetanus, hepatitis B, hemophilus influenza B (Pentavalent), polio and measles. National multiyear immunization plan has targeted to ensure the coverage of all of these vaccines to 90% in each district.  Current service delivery status of the immunization program shows an increasing trend in immunization coverage. ,
There is high (281/100,000 live births) maternal mortality in Nepal.  MoHP has initiated various programs to increase service utilization and to reduce maternal mortality. Besides these, low social status of women, poverty, ethnic and cultural beliefs over sorcery and traditional healers, low priority of women's health in family, low female education and low health literacy are the main determinants of under-utilization of health services and of poor health status of women and children. , However, the exploration of such factors has been infrequent in rural of part of Nepal.
Kapilvastu District has been categorized as having fewer problems in the immunization program but this district still had a higher percentage of BCG versus measles dropout rate (9.7% in 2007/2008, 11.3% in 2008/2009 and 10.99% in 2010/2011) in three consecutive fiscal years since 2007/2008. ,, As of 2008/2009, the utilization of antenatal care (ANC) services (53.26% for four ANC), assistance of deliveries by health workers (31.14%) and institutional deliveries were low in the district. It is essential to find the determinants of such service utilization to design, justify and implement the health programs to increase maternal and child survival. Therefore, the aim of this study was to examine the utilization pattern of maternal and child health services and the factors associated with it in Kapilvastu District of Western Nepal.
| Materials and Methods|| |
The study was conducted in Kapilvastu District of the western region of Nepal. This district has 77 government health facilities and one District Health Office (DHO) to implement the public health programs. Total population of the district in 2011 was 570,612 with an annual population growth rate of 1.69%.  As of 2011, total births attended by skilled birth attendants (SBA) were 14.9%.  Village Development Committee (VDC) is the lowest administrative authority in Nepal. 10 VDCs were included in this study where District Development Committee (DDC) had implemented the community-based social mobilization program (DACAW) with technical assistance of UNICEF. Therefore, the local government authorities prioritized these areas to monitor the health service utilization.
This cross-sectional study was conducted based on the lot quality assurance survey (LQAS) method as guided by the World Health Organization (WHO) and related studies. , Based on the WHO LQAS guide, 19 household from each strata (VDCs) was obtained, which yielded a total of 190 samples from 10 VDCs.  Mothers who had children aged 12-23 months were included in the study. The list of the household was obtained from the respective VDC office. Where there were more than one children of the age 12-23 months, information of the youngest child was obtained. Mothers were excluded from the study if enumerators could not meet them at their houses in two attempts. Questionnaires were adapted from the WHO's guide on LQAS and UNICEF's generic health questionnaire , and some of the questions were adopted from previously carried out survey by CARE Nepal in Doti and Dadeldhura Districts of Nepal (unpublished source). The English questionnaires were translated into Nepali and back translated into English and were revised if there were any inconsistencies. The questionnaire was pretested in 30 households of the suburbs of district headquarter and modification of the questionnaire was carried out accordingly. Data collection was conducted by using a structured questionnaire in Nepali language.
First association of independent variables with outcome variables was explored using univariate statistics and then further analyzed by multiple logistic regression. Level of statistical significance was set at P-0.05. Statistical Package for Social Sciences (SPSS 17.0.2, release March, 2009) was used for data analysis. We recoded some of the outcome variables into dichotomous variables: Initiation of breastfeeding (within 1 h [early initiation] or after 1 h of birth); exclusive breastfeeding (for 6 months or not for 6 months); and place of delivery (health facility or home). We categorized ethnicity into three groups; Hill origin (Brahmins, Chhetri and Thakuri), Terai origin (Madhesi, Tharu and Muslim), Dalit, Janjati and others (including Hill and Terai).  Involvement in community organization was categorized based on the reported involvements in the mother's group, forest consumers group, community organizations (run by DDC with technical and financial assistance from UNICEF).  For assistance during delivery health workers referred to doctor, nurse, health assistant, auxiliary nurse midwife, auxiliary health worker or maternal and child health worker. , Ethical approval was obtained from Nepal Health Research Council before data collection. Verbal informed consent was taken before each interview.
| Results|| |
Background information of the respondents
A total of 190 mothers were interviewed. The mean age of the mothers was 27.2 years (standard deviations = 5.7). Nearly ½ (47.9%) of the respondents were illiterate. More than ½ (57.4 %) were people of Terai origin [Table 1].
|Table 1: Characteristics and child and maternal health related information of the participants (N = 190)|
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Utilization of child and maternal health services
Immunization coverage was consistently high for all the antigens (more than 97%). Nearly 98% of the children were given vitamin A capsule within last 6 months. The practice of ever breastfeeding was 95.8 % among the respondents. However, initiation of breastfeeding within 1 h of birth was only 45.3%. Less than two-thirds (63.2%) of the mothers had exclusively breastfed their babies for 6 months [Table 1].
One-third (33.9%, n = 189) of the pregnant mothers had four or more ANC visits. Home was the place of delivery in 7 out of 10 (69.5%) cases. Only 39.5 % women had their last delivery assisted by health workers. A quarter (26.3%) of mothers relied on their family members during their deliveries [Table 1].
Factors associated with maternal and child health service utilization and practices
Education status of mothers, ethnicity, place of delivery and assistance during delivery were associated with the initiation of breastfeeding within 1 h of birth in the univariate analysis [Table 2]. When these variables were then entered into multiple regression models, only ethnicity remained statistically significant determinants [Table 4]. It was found that mothers who are from Hilly ethnic group were more likely (adjusted odds ratio [aOR]: 6.192; 95% confidence interval [CI]: [2.329-16.466]) to initiate breastfeeding within 1 h of childbirth when compared with the mothers from Dalit/Janjati groups [Table 4]. None of the independent variables in the study were significantly associated with exclusive breastfeeding [Table 2].
|Table 2: Factor associated with initiation of breastfeeding within 1 h of birth and providing exclusive breastfeeding|
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Education, ethnicity and attending antenatal visits were associated with the place of delivery in the univariate analysis [Table 3]. When these significant variables were entered into multiple regression model, only education and ethnicity of mother remained statistically significant [Table 4]. The mothers who had higher education (aOR: 7.510; 95% CI: [2.161-12.101]) and who had secondary education (aOR: 3.391; 95% CI: [1.421-8.093]) were more likely to delivery their child at the health facility than the mothers who did not have any education. When compared to the mothers of Hilly origin, the mothers from Dalit/Janjati (aOR: 0.381; 95% CI: [0.133-1.087]) and Terai origin mothers (aOR: 0.228; 95% CI: [0.093-0.557]) were less likely to delivery at the health facility.
|Table 3: Factor associated with place of delivery and assistance during delivery|
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|Table 4: Factors associated with initiation of breastfeeding in 1 h of birth, place of delivery and assistance during delivery|
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Education of mothers, ethnicity and involvement in community organization were significantly associated with availing assistance of health workers in the univariate analysis [Table 3]. When these significant variables were subjected to multivariable analysis, only education of mothers and ethnicity remained statistically significant [Table 4]. The mothers who had higher education (aOR: 6.507; 95% CI: [1.887-22.445]) and had secondary level education (aOR: 2.522; 95% CI: [1.202-5.292]) as compared to mothers with no education. The mothers who were from Dalit/Janjati group (aOR: 0.549; 95% CI: [0.200-1.513]) and Terai origin group (aOR: 0.283; 95% CI: [0.118-0.675]) were less likely to seek assistance of health workers during delivery when compared to the mothers from Hill origin.
| Discussion|| |
Maternal and child health services are one of the major health programs delivered in Nepal. Adequate utilization of those services is essential to reduce the high burden of mortality and morbidity.
The current finding of a high status of immunization is similar to findings from the Nepal Demographic and Health Survey (NDHS) of 2011 and regular reporting from DHOs. , These findings indicate that immunization is one of the most valued and highly monitored and effective programs in the health system of Nepal. Immunization programs are carried out by continuous supply of vaccines, increased awareness level, trained community health volunteers and with social mobilization through community action process.  Moreover, the easy terrain of the study district is supportive.
Breastfeeding was associated with child's healthy development and survival.  Nepalese society traditionally has preferred breastfeeding. Breastfeeding practice (95.3%) in the current study was similar to the findings of NDHS 2011.  The WHO recommends breastfeeding as early as possible after birth, preferably within an hour of delivery.  The early initiation of breastfeeding helps to establish successful breastfeeding; improve health of the children; increase their survival; and increase emotional bond between mother and child.  Early initiation of breastfeeding was low (45.3%, n = 190) in this study. The reasons behind such delay may be the practice of early bathing (within 1 st h of birth and then only keeping into breast milk) and providing other woman's milk to the new born in the study area. The mothers from Terai caste groups and Dalit/Janjati groups were less likely to initiate breastfeeding within 1 h of childbirth. Ethnicity has been a major determinant of child and other health issues in Nepal as it is one of the factors determining women's status, access to education, economy and services.  In the Terai group and the Dalit groups, in general, situation of women is lower and they do not have decision making power. These two ethnic groups are socially and economically marginalized groups in Nepal.
More than a half of the mothers had breastfed exclusively their children for 6 months in this study and similar findings have been reported by NDHS 2006 (65%) and NDHS 2011 (71%).  In rural Nepalese society, women have high workload. Mothers have very less time to continue exclusive breastfeeding. Further, in this study area, there is also a culture of starting complementary feeding (Pasni in Nepali) to boys when they complete 5 months of age and to girls when they complete 4 month of age.  This practice is a major hindering factor for exclusive breastfeeding. Exclusive breastfeeding needs constant support and education and a number of cultural factors should be considered while educating the mothers. In the study setting, mothers would be in contact with health facilities for immunization of children only. As only less than half of the mothers went for postnatal visits, there was less chance of interaction between health worker/midwives and mothers, which might be another reason for such a low status of optimum exclusive breastfeeding. ,
The utilization of maternal health service is associated with better birth outcomes. Inadequate ANC practice reflects poor health seeking behavior with potential adverse maternal and child health outcomes.  In Nepal, ANC clinics (in health facilities and in outreach clinics) are the conventional platforms for educating pregnant women. The WHO and MoHP recommend a minimum of four timely ANC visits.  In our study, the majority had at least one visit and ⅓ (33.9%) had four ANC visits, more than the finding from a previous study of Kathmandu where 22% of women did not receive ANC.  Delay in the start of ANC visit, low perceived benefit of ANC visits, low education status might explain such low uptake of four ANC visit. 
Delivery assistance by health workers and institutional delivery are in increasing trend over the last decade in Nepal.  Initiation of maternity incentive system (Aama Surakshya Program) and abolition of user fee for these services increased institutional delivery in Nepal by two folds.  Despite such efforts, our study showed that only 30.0% women delivered in the health facilities and only 39.5% received assistance from health workers. This finding was similar to previous findings from other places of Nepal. , There can be many reasons behind low proportion of deliveries in health facilities. One recent study reported that although Aama Surakshya (maternity incentive) program gives incentive for transportation of pregnant mothers from home to health facilities for childbirth, none of the mothers knew the cash was for transportation cost. 
Educated mothers were more likely to deliver at the health facility and seek assistance from health workers. This finding is consistent with previous Nepalese study.  Educated mothers are more likely to be empowered, have paid job, have access to service, have decision making power in regards to her health and also likely to have more capacity to process and understand the message provided by the health workers and other awareness programs. Therefore, the mothers with lower education status need further focus to increase the utilization of maternity services.
Mothers who were from Terai origin and the Dalit/Janjaati groups were less likely to deliver at a health facility and seek assistance from health worker. In our study setting, decision about the place of delivery is made by mothers-in-law or the head of the household (usually male) who are rarely counseled by the health professionals during ANC visit of the pregnant women. , There is still a culture of veiling of the young women, restriction of movement during pregnancy and restriction to make a decision by women themselves especially in Muslim and Madhesi ethnic groups. Such restriction on the pregnant women has an adverse effect on service utilization. 
Though these were the points from the demand side, there are a lot of other causes which hinder the utilization of health service and institutional delivery in Kapilvastu. During the survey period, only two birthing centers were serving the entire district.  The health workers, who are trained, often fail to provide proper service due to inadequate space and equipment. This study's finding that ethnicity based service utilization pattern in the study area has a major implication for health planners. In our study, both the Dalit/Janjati and the Terai origin people were found to be utilizing the services lesser than other communities. Therefore, these ethnic groups need more focus. Our study has several limitations. The missing values in some of the variables might have influenced our analysis. The cross-sectional nature of this study precludes us from drawing causal inference from the findings. Due to low number of observations in unimmunized population, we could not explore the causes of not using immunization services. Some of the variables have less number of observations and as a result it was not possible to perform logistic regression analysis. The study was related to a limited number of variables within the service delivery process of health services of Nepal and did not include a wider number of independent socio-economic variables. Another major caution should be taken while interpreting the result from LQAS method is that the findings may lead to false positive results.  Despite these, the results presented in the study gives an account of maternal and child health services in the district.
| Conclusion|| |
This study found the high rate of utilization of immunization and consumption of vitamin A supplementation among children; lower proportion of mothers who initiated breastfeeding within 1 h of childbirth; and lower rate of institutional delivery and assistance of delivery by health workers. Based on these findings, breastfeeding promotion program, provision of 24-h birthing centers with SBA, educational interventions to increase awareness and demand of institutional delivery service will help to improve maternal and child health. Further, the Dalit/Janjati and illiterate mothers should be on focus for interventions.
| Acknowledgements|| |
We would like to acknowledge the mothers for their time and information, Health and Nutrition Section, UNICEF Nepal and DHO Kapilvastu. We like to thank Dr. Sudhir Khanal, Mr. Purushottam Acharya and Mr. Madhab Chandra Baral of UNICEF; Mr. Dinesh Kumar Chapagain (Chief of DHO, Kapilvastu), Mr. Diwakar Maharjan (Immunization Officer, DHO) and Dr. John Fielder for their support. The views expressed in this paper are solely of authors and does not necessarily reflect the view of District Public Health Offices or UNICEF.
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[Table 1], [Table 2], [Table 3], [Table 4]