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Factors Affecting the Utilisation of Skilled Birth Attendants for Delivery in a Western Hill District of Nepal Yuba Raj Baral

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Factors Affecting the Utilisation of Skilled Birth Attendants for Delivery in a Western Hill District of Nepal Yuba Raj Baral Factors affecting the utilisation of skilled birth attendants for delivery in a western hill district of Nepal By Yuba Raj Baral A thesis submitted to the Faculty of Social Sciences and Humanities In part of fulfilment of the requirements for the Degree of Doctors of Philosophy in Public Health Policy London Metropolitan University London, UK November 2014 i ii DECLARATION I declare that this thesis has been composed by me and that the research it describes has been done by me. The work contained in this thesis has not been previously submitted to meet requirement for an award at this or any other institution. All the quotations that have been used distinguished by the quotation mark and in italics and the sources of information is clearly acknowledged. Yuba Raj Baral June, 2014 London, UK iii DEDICATIONS I would like to dedicate this work to women all those who are poor, deprived and lack of access to quality skilled birth attendants during pregnancy and childbirth. Yuba Raj Baral June, 2014 London, UK iv ACKNOWLEDGEMENTS Writing this Ph.D. thesis has been in turn a struggle and joy and its completion is a tribute to my supervisors, family, friends, colleagues and the women, mothers-in-law, fathers-in-law and husbands and health professionals who have contributed along the way. I acknowledge and I am very indebted to the London Metropolitan University which provided me with a Vice Chancellor Ph.D. Scholarship. The award and funding have allowed me the space to undertake the research and precious time to write. I would first like to thanks all my supervisors for their constant support and guidance while I have been at the London Metropolitan University. Profound thanks to Professor Karen Lyons, Jo Skinner (London Metropolitan University), and Professor Edwin van Teijlingen (University of Bournemouth). Their unconditional support, clarity in subject, wise counsel and useful feedback helped focus my thinking and kept me on topic. Without their kind attention and support this research work would not have been successfully completed. I would like to thank staff members in the Faculty of Social Sciences and Humanities, London Metropolitan University, who supported me and heightened my confidence to complete this study. I am also grateful to other individuals not mentioned by name for supporting me all the way towards accomplishing this prestigious award. I am most indebted to the women, mothers-in-law, husbands, fathers-in-law who welcomed me into their homes: they provided valuable information and shared their experiences and stories as reflected in this thesis. I would like to thank the staff in the maternity services working in the both public and private hospitals for sharing their views, opinions and experiences, in spite of their busy working schedule. Without the valuable time, information, views and experiences of all respondents none of this work would have been possible. I would also like to thank the female interviewer for her kind support during data collection stage; the local school head teacher who helped connect me to the community; and Anne for her support in editing this thesis. I am very grateful to my family, especially my wife, Rita Baral, for her constant and unconditional support and moral encouragement, her patience and love through the years of this process. I am also very thankful to my daughter, Sampada Baral: her every smile encouraged me and provided me with strength to carry out this piece of work. I wish also to thank other relatives and friends who supported me directly and indirectly during good and hard times throughout the study. Thank you Yuba Raj Baral June, 2014 London, UK v KEYWORDS Access of maternity services Choice of service Developing country Labour and delivery care Maternal health care services Nepal Pregnancy Service utilisation Skilled birth attendance Skilled birth attendants Use of skilled delivery care Women autonomy and status Women’s perceptions vi ABBREVIATIONS & ACRONYMS ADB-Asian Development Bank AHW-Auxiliary Health Workers* AIDS-Acquired Immune Deficiency Syndrome ANC- Antenatal Care ANM-Auxiliary Nurse Midwife* BEOC-Basic Emergency Obstetric Care BOC- Basic Obstetric care CA-Constitutional Assembly CBS-Central Bureau of Statistics CDR-Central Development Region CEDAW-Convention on the Elimination of all form of Discrimination against Women CINAHL-Cumulative Index to Nursing and Allied Health CMACE-Centre for Maternal and Child Enquiries CMA-Community Health Assistant CS-Caesarean Section DAA- Department of Drug and Administration DC-Delivery Care DDA-Department of Drug Administration DFID-Department of International Development DH-Department of Health DoA-Department of Ayurved DoHS-Department of Health Services DPHR-District Public Health Report EDR- Eastern Development Region EMBASE-Excerpta Medica Database EMOC-Emergency Medical Obstetric Care EOC- Emergency Obstetric Care EOC-Emergency Obstetric Complication FCHVs-Female Community Health Volunteers FHD- Family Health Division FPMCHC-Family Planning and Maternal Child Health Care FSSH-Faculty of Social Sciences and Humanities FWDR- Far-Western Development region GDP-Gross Domestic Products GoN-Government of Nepal GOs-Government Organisations GYN-Gynaecologist HA-Health Assistant* vii HBM-Health Belief Model HDI-Human Development Index HIV-Human Immune Virus HoS-Head of State HP-Health Post HRH-Human Resources for Health ICPD-International Conference on Population and Development IEC-Information Education Communication INGOs-International Non-Governmental Organisations KM-Kilo Metre LMU-London Metropolitan University MBBS-Bachelor of Medicine and Bachelor of Surgery* MCHVW-Maternal and Child Health Volunteer Workers* MDG-Millennium Development Goal MDGP-Master Degree in General Practitioners* MMR-Maternal Mortality Ratio MOH- Ministry of Health MOPH-Ministry of Population and Health MWDR-Mid-Western Development Region NDHS-Nepal Demographic Health Survey NGOs-Non-Governmental Organisations NHRC-Nepal Health Research Council NSMNH-LTP-National Safe Motherhood and Newborn Health Long-Term Plan NSMP-National Safe Motherhood Programme OBGYN-Obstetrician/Gynaecologist and Paediatrician* OBs-Obstetricians Ph.D.-Doctor of Philosophy PHCC-Primary Health Care Centre PHC-Primary Health Care PNC-Post Natal care PPP-Purchasing Power Parity PRSP-Poverty Reduction Strategy Paper RCP-Radio Communication Project RHP-Radio Health Program S.L.C-School Leaving Certificate SBA-Skilled Birth Attendance SBAs-Skilled Birth Attendants* SE- Socio-Ecological Model SHP-Sub Health Post SLTHP-Second Long Term Health Plan viii SN-Staff Nurse* SOLID-Society for Local Integrated Development SPSS-Statistical Package for Social Sciences TBAs-Traditional Birth Attendants* TB-Tuberculosis UK-United Kingdom UNDP-United Nation Development Plan UNFPA-United Nations Fund for Population Activities UNICEF-United Nation International Children and Education Fund UN-United Nations US-United States VDC-Village Development Committee WB-World Bank WDR-Western Development Region WHO-World Health Organisation *Definitions are in the glossary-appendix ix Contents STUDENT’S DECLARATION FORM ................................................................................... II DECLARATION ...........................................................................................................................................III DEDICATIONS............................................................................................................................................ IV ACKNOWLEDGEMENTS ........................................................................................................................... V KEYWORDS ................................................................................................................................................ VI ABBREVIATIONS & ACRONYMS .......................................................................................................... VII LIST OF TABLES...................................................................................................................................... XIV LIST OF FIGURES ..................................................................................................................................... XV ABSTRACT ................................................................................................................................................ XVI CHAPTER ONE: INTRODUCTION ............................................................................................................ 1 1.1 INTRODUCTION TO THE STUDY ....................................................................................................... 1 1.2 BACKGROUND INFORMATION OF NEPAL ...................................................................................... 2 1.3 SAFE MOTHERHOOD AND SKILLED BIRTH ATTENDANCE IN NEPAL ................................... 14 1.4 RATIONALE OF THE STUDY ............................................................................................................. 21 1.5 THE AIM OF THE STUDY ................................................................................................................... 23 1.6 OBJECTIVES OF THE STUDY ............................................................................................................ 23 1.7 RESEARCH QUESTIONS .................................................................................................................... 23 1.8 SIGNIFICANCE OF THE STUDY .......................................................................................................
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