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A Study of Perinatal Services Among Maternity Users in a Southern District in Nepal

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A Study of Perinatal Services Among Maternity Users in a Southern District in Nepal A study of perinatal services among maternity users in a southern district in Nepal Preeti K. Mahato In partial fulfilment of the requirements of Bournemouth University for the degree of Doctor of Philosophy Bournemouth University, U.K. June 2019 Abstract: A study of perinatal services among maternity users in a southern district in Nepal Preeti K. Mahato Introduction A birthing centre (BC) is a component of maternal health service delivery at local level and provides a midwifery led model of care in a community or hospital setting to healthy women with uncomplicated or low risk pregnancies. In Nepal, Auxiliary Nurse Midwives (ANMs) provide much of the primary care maternity services delivering care especially at BCs. Literature suggests, BCs in Nepal are often bypassed in order to utilise services available at hospitals. There is a need for study which focuses on the role of BCs in providing good quality maternity and childbirth services. This study evaluated the effects of an intervention consisting of supporting BCs and community-based health promotion programme on increasing access and utilisation of perinatal care facilities in community setting. Methods A longitudinal (cross-sectional) study was undertaken using a mixed methods approach. The quantitative methods consisted of two surveys that were conducted in rural area of a district in Nepal in the year 2012 and 2017 respectively. The qualitative method consisted of interviews and focus group discussion. Survey data were analysed in SPSS and interviews in NVivo. Descriptive analysis along with chi square test for association, Cramer’s V for strength of association and multinomial logistic regression were conducted for quantitative survey whereas qualitative data were analysed thematically. Results The results of quantitative data showed that there was increase in utilisation of perinatal services available from BCs. There was also change in place of childbirth from home to health facilities, mostly the BCs. The results of multinomial logistic regression showed women were significantly more likely to give birth at health facilities, mostly primary care facilities compared to home if decision maker for place of birth were husbands, women and family members; and if women had four or more antenatal care (ANC) visits. Similarly, women were less likely to give birth at primary care facilities if they had only primary level of education. Bearing in mind the small scale of this qualitative component of study, it showed the participants were happy and satisfied with the quality of services and attitude and behaviour of ANMs at the BCs. However, the need for increasing health promotion and awareness among women, need for improving referral services and training needs for health promoters were identified. Conclusion The main conclusion of this thesis on maternity and childbirth care in Southern Nepal is that trained health promoters have potential to increase the births at BCs and decrease home births. The role of health promoters and female community health volunteers are important in rural Nepal, but the socio-economic factors including women’s education, occupation of husbands and decision-making capability of women also affects the access to and utilisation of perinatal services at the health facility, especially the BCs. The importance of four ANC visits cannot be overlooked in understanding the uptake of birth at BCs. Moreover, further training of health promoters along with availability of referral services needs to be ensured. 2 Table of contents CHAPTER 1 Introduction ........................................................................................................... 13 1.1 Background ......................................................................................................................... 13 1.2 State of maternal mortality in South Asia and Nepal .......................................................... 16 1.3 Sustainable Development Goals ......................................................................................... 17 1.4 Skilled birth attendance and birthing centre ....................................................................... 18 1.5 Midwifery and midwives in Nepal...................................................................................... 21 1.6 Background of Nepal .......................................................................................................... 22 1.7 Background of Nawalparasi district .................................................................................... 23 1.7.1 Location ...................................................................................................................... 23 1.7.2 Demographics ............................................................................................................. 25 1.7.3 Health system and maternal health related information .............................................. 26 1.8 Study interventions ............................................................................................................. 27 1.8.1 Supporting birthing centres ......................................................................................... 28 1.8.2 Health promotion and mother group meetings............................................................ 29 1.9 Timeline for study ............................................................................................................... 29 1.10 Researcher’s background .................................................................................................... 30 1.11 Summary ............................................................................................................................. 31 CHAPTER 2 Literature Review ................................................................................................. 33 2.1 Government plans and policies ........................................................................................... 34 2.2 Important figures related to maternal health ....................................................................... 35 2.3 State of birthing centres in Nepal ........................................................................................ 36 2.4 Obstacles/facilitators for utilisation of birthing centres in Nepal ....................................... 37 2.5 Health promotion ................................................................................................................ 41 2.5.1 Maternal health and health promotion interventions .................................................. 42 2.5.2 Community participation and maternal health promotion .......................................... 43 2.5.3 Midwifery and health promotion ................................................................................ 44 2.5.4 ANMs in Nepal and health promotion ........................................................................ 44 2.5.5 Female Community Health Volunteers as health promoter ........................................ 46 2.6 Quality of care..................................................................................................................... 47 2.7 Quality of care in maternal health ....................................................................................... 48 2.7.1 Definition .................................................................................................................... 48 2.7.2 Too little, too late (TLTL) vs Too much, too soon (TMTS) ....................................... 49 2.7.3 Respectul maternity care ............................................................................................. 50 3 2.8 Conceptual framework ........................................................................................................ 53 2.9 Nepal’s earthquake 2015 and birthing centres .................................................................... 56 2.10 Research questions linked with methods and objective ...................................................... 58 2.11 Aims of the study ................................................................................................................ 58 2.12 Objectives of the study ........................................................................................................ 58 2.12.1 Objectives related to quantitative data ........................................................................ 58 2.12.2 Objectives related to qualitative data .......................................................................... 58 2.13 Summary and next steps ..................................................................................................... 59 CHAPTER 3 Scoping review ....................................................................................................... 60 3.1 Introduction ......................................................................................................................... 60 3.2 Method ................................................................................................................................ 62 3.2.1 Search .......................................................................................................................... 62 3.2.2 Eligibility criteria ........................................................................................................ 64 3.2.3 Study selection ............................................................................................................ 65 3.2.4 Data extraction
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