Use of Skilled Birth Attendants in Nepal: A Study of Influencing Factors, Structural Barriers and Government Strategies and Interventions

Abstract

Background: Most maternal deaths in South-Asia are due to haemorrhage and hypertension. These causes are considered avoidable. Having a skilled birth attendant (SBA) assisting the delivery is most likely a key to reducing morbidity and mortality if complications occur. The objectives of this study are first to present a past and present delivery care situation in Nepal. Second, the study aims to identify and study factors and structural barriers that either facilitate or impede the use of SBA, before exploring strategies and interventions implemented by the government of Nepal, in order to increase use of SBA. Methods: Pluralistic approaches, with elements from traditional medical geography, feminist research and contemporary geographies of health are used. The fieldwork for this study was twofold. The first phase was a three-month long research internship at the World Health Organization’s Department for Reproductive Health and Research in Geneva. In the beginning of this period, quantitative statistical comparisons and analyses were conducted to a determine research country. When Nepal was chosen, the desk study continued with a literature study and a document analysis. The second phase of the fieldwork was carried out in a three-week long stay in Central and Western Nepal. Ethical research approval granted from the Nepal Health Research Council. Altogether six semi-structured interviews were conducted, together with five informal interviews and an observational study. Results: This study argues that urbanity, education, income, low parity, young age and use of antenatal check-ups are factors that contribute to use of SBA. On the contrary, lack of awareness of sources of care, rurality (remoteness), large geographical distances, significant other family members, low autonomy and decision-making power are factors that impede use of SBA. Structural barriers that hinder increased use of SBA are financial barriers and lack of awareness of the financial incentives, time barriers, especially related to travelling time and infrastructure, in addition to organizational barriers related to the shortage of SBAs in rural areas. The most important strategies and interventions implemented by the government in order to increase use of SBA are the National Safe Motherhood Program 2002-2017, the financial incentives program (Aama Surakshya Karyakram), the National policy on SBAs and the in-services training strategy. Conclusions: Further research is needed on different channels where rural women and their families can be reached in order to create awareness of the free maternal services in Nepal today. Keywords: awareness; delivery care; factors; skilled birth attendant; use.