Date Published: April 19, 2019
Publisher: Public Library of Science
Author(s): Binaya Chalise, Mala Chalise, Bihungum Bista, Achyut Raj Pandey, Subash Thapa, Vijayaprasad Gopichandran.
Continuum of Care (CoC) is an essential strategy to prevent maternal and child deaths where health services are arranged in a pathway throughout pregnancy, childbirth and after delivery. However, CoC is still a challenge in Nepal. This study aimed to investigate the correlates of CoC from pregnancy to the postnatal period in Nepalese women aged 15 to 49 years. Secondary analysis was performed on the data from Nepal Multiple Indicator Cluster Survey. This led to a sample size of 2086 women who had a live birth within two years preceding the survey. We constructed three outcome models and conducted multivariable logistic regression, to assess socio-economic and demographic correlates of CoC from pregnancy to childbirth to postnatal period. Overall, 41% of the women received Antenatal Care (ANC), delivery from Skilled Birth Attendant (SBA) as well as the Postnatal Care (PNC) during their most recent birth. Women from rural areas (aOR 0.25, 95%CI: 0.18, 0.36) had reduced odds of receiving CoC while women belonging to advantaged ethnic group (aOR 1.61, 95%CI: 1.18 2.19), from middle wealth status (aOR 2.56, 95%CI: 1.68, 3.91) and upper (aOR 4.50, 95%CI: 3.07, 6.59) wealth status, and women having access to media (aOR 1.76, 95%CI: 1.31, 2.37) had higher odds of receiving CoC from pregnancy to postnatal period. Having more than two births reduced the odds of CoC by 30% (aOR 0.70, 95%CI: 0.50, 0.98). These factors were also significantly associated with ANC services and the continuum from ANC to delivery SBA. The findings suggest that the majority of Nepalese women lack a continuity of care during their pregnancy and childbirth, and several socioeconomic factors affect the spectrum of CoC. Efforts to improve maternal health services utilization in a continuum require strategies that remove demand and supply barriers of health care utilization.
Globally, Maternal Mortality Ratio (MMR) declined from 385 to 216 deaths per 100000 live births between 1990 and 2015 with the highest rate of decline occurring in developing countries . Similarly, the under five mortality rate declined from 91 to 43 deaths per 1000 live births between 1990 and 2015 . Maternal and under five mortality dropped substantially in South Asia with overall reduction of MMR by 68% and the under five mortality rate by almost 50% during this period [1, 2]. Consistent with the Global trend, maternal mortality in Nepal halved from 539 per 100000 live births in 2001 to 239 per 100000 live births in 2016, and neonatal mortality dropped from 50 to 21 deaths per 1000 live birth during the period . Although the declines are a remarkable progress, neonatal and maternal mortality rates in Nepal are still the highest in the region. The trends imply that Nepal still lags behind in achieving health targets as stated in Sustainable Development Goals (SDGs) .
The Government of Nepal is explicitly focused on improving maternal and newborn health outcomes and the CoC has been one of its core strategies. It calls for an integrated health care system for providing ANC, SBA and PNC at all levels. However data on CoC is limited, which means, we are not able to precisely gauge where the country stands in terms of CoC, at which stage along the pathways of CoC do major dropouts occur and what factors might contribute this loss [6, 8]. The aim of this study was, therefore, to analyze the status of CoC in Nepal and further explore factors that affect women’s continuity of care from delivery to post-partum period.
The study provides information about the socio-economic and demographic factors influencing the continuity of maternal health services among Nepalese women. For instance, poorer and uneducated women, who belonged to disadvantaged group and those residing in the rural areas are more likely to discontinue maternal health services during pregnancy and after childbirth. Community based health care programs are needed to address the supply and demand side barriers faced by the high risk women in utilizing maternal health services.