Research Article: Two thirds of the most disadvantaged Dalit population of Nepal still do not deliver in health facilities despite impressive success in maternal health

Date Published: June 3, 2019

Publisher: Public Library of Science

Author(s): Surendra Prasad Chaurasiya, Nilesh Kumar Pravana, Vishnu Khanal, Dhiraj Giri, Seth Adu-Afarwuah.


The gains in maternal and child health in Nepal was impressive in the last two decade but success was unevenly distributed. The Dalits of Nepal are the most disadvantaged caste group and have benefitted least from the advances in maternal health service. This study investigated the rate of and factors associated with the institutional delivery among the Dalit women of the Mahottari, Nepal.

A cross-sectional study was conducted during July-December 2014 using a structured questionnaire. A total of 328 mothers who had their childbirth within one year were interviewed. Descriptive statistics followed by binary and multivariable logistic regression analyses were computed to find the association of key variables with institutional delivery.

In this study, only 30% of the mother had institutional delivery. Fifty eight percent mothers had no any birth preparedness and complication readiness. Four or more antenatal visits (Adjusted Odds Ratio (AOR): 3.54, CI: 1.82–6.90), birth preparedness (AOR: 3.15, CI: 1.61–6.18), planned pregnancy (AOR: 2.63, CI: 1.37–5.06) and receiving advice from health staffs (AOR: 3.96, CI: 2.00–7.86) and mother’s autonomy (AOR: 2.25, CI: 1.03–4.49) were associated with child birth at the health facility.

This study indicated that birth preparedness, ANC visit frequency, planning of pregnancy, advice for institutional delivery and mother’s autonomy were significantly associated with health facility delivery. Less than one-third mothers had institutional delivery and reasons were feeling of un-necessary, far distance, lack of transportation and associated cost; and birth preparedness is also low. Hence, promotion of birth preparedness, uptake of ANC service, proper counselling for institutional delivery, promoting women autonomy and strengthening women to have planned pregnancy were some recommendation to promote institutional delivery for such disadvantage community.

Partial Text

Institutional delivery and access to referral level facility are essential intervention in saving the lives of mothers and children in many developing countries [1]. Over the last decades, the maternal mortality ratio (MMR) was observed more than ten time higher in developing countries than in developed and almost all of the global maternal death (99%) occurred in developing countries, followed by sub-Saharan Africa region alone accounting for (179,000) and South Asia (69,000) [2]. Millennium Development Goals (MDG) has targeted to reduce MMR by three quarters between 1990 and 2015. Accordingly, the government of Nepal has committed to reducing MMR to 134 deaths per 100,000 live births; increase institutional delivery to 40% and increase delivery assisted by skilled birth attendants (SBA) to 60%,increase at least four Antenatal Care (ANC) visit to 80% [3, 4]. A recent report of the World Health Organization (WHO)shows that globally since 1990, MMR has been dropped by 44% but the world failed to meet the 75% reduction target[5].

This is the first study that explores the rates of health facility delivery and their associated factors in the most disadvantaged Dalit community of Nepal. We found that the health facility delivery among Dalit was very low (30%), despite our setting being plain areas of Nepal where easier access to roads and transport is possible. The reasons for low health facility delivery were: mothers did not feel necessary, far distance, unavailability of transport and associated cost of institutional delivery. In the same way, few previous studies from Nepal and other countries have found similar reasons for not going for facility deliveries [6, 8, 14, 21]. Two important findings of this study were the association of the birth preparedness and attending four or more antenatal care visit to facilities delivery. Birth preparedness counselling and services are parts of antenatal care services in Nepal[14]. Such preparation gives mothers an opportunity to speak to health workers or health volunteers, be more prepared to take themselves to health facilities when necessary, and also a sense of connection with health facilities over the period of four or more visits and birth preparedness counselling. Studies from the Kaski district of Nepal, further analysis from NDHS 2011 and a study in South East Ethiopia showed that birth preparedness was a major determinant of institutional delivery [22–24]. Our findings, association of ANC visits with health facility are consistent with previous studies from rural Nepal, Ethiopia, Kenya and Bangladesh [17–19, 24–28].It has also been hypothesized that attending ANC visits enables mothers to recognize their needs to deliver in health facility critically looking at the dangers that are posed in home deliveries.

Despite having free delivery services and financial incentive for transportation, less than one third (30%) Dalit mothers had institutional delivery in Mahottari. The common reasons for non-institutional delivery were that mother did not feel necessary of institutional delivery, too far distance, lack of transportation and the associated cost to delivery service. Further, more than fifty percentages mother (58%) had no birth preparation and complication readiness at all. This study identified that birth preparedness, ANC visit frequency and planning of pregnancy were the most important factors associated with health facility delivery. Proper counselling to mother about institutional delivery is instrumental and can be provided during ANC visit or when mother visits a health facility. Public health programs should also include such components which improve the mother’s autonomy within and around family and empower the mother to negotiate with husband and/or family to have planned pregnancy. Future studies should focus on exploring the innovative approach to increase such service uptake in highly disadvantaged groups.




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