Maternal mortality from pregnancy and childbirth remains a major public health problem worldwide resulting in around 830 deaths every day. Majority of these deaths occurred in poor and underdeveloped nations and most were preventable (1). Approximately 295,000 women died in 2017 related to pregnancy and childbirth whereas, 94% of all maternal deaths occur in in low and lower-middle income countries (2). Nepal is one of the countries in the world with a high maternal mortality ratio having slow progress on maternal mortality ratio reduction (3). With a MMR of 239, one out of every 167 women aged between 15 and 49 years in Nepal could die unnecessarily from complications in pregnancy or childbirth (4).
An analysis conducted between 1990–2018 shows that, only 19 out of 74 countries reported that more than 90% of deliveries are conducted at health facilities, whereas, 13 countries had < 50% coverage of institutional delivery services (5). Likewise, it was found that in many developing countries, more than a third of pregnant women have no access to or contact with health professionals before they deliver (6).
Nepal is promoting safe motherhood through initiatives such as providing free delivery care and transportation incentive schemes to women delivering in a health facility. Subsidies are also provided to health facilities for free delivery care on the basis of deliveries conducted (7). Although (NDHS 2016) shows that only 57% of births take place in health facility and only 58% of deliveries are conducted by a skilled provider (NDHS 2016). Also, Institutional delivery was highest among the richest wealth quintile 91% in 2014 and 96% in 2019 (8).
Nepal has made substantial progress in reducing maternal mortality from 539 per 100,000 live births in 1996 to 239 in 2016 (4). Availability, access, and utilization of safe motherhood service along with the quality of the service are important in reducing these maternal deaths (7). SBA policy was endorsed in 2006, that advocate for presence of skilled birth attendant at every Birth (9). Whereas, it has been difficult to retain doctors in primary health care centers in Nepal.
According to Nepal’s Sustainable Development Goals (SDG) implementation plan, Nepal has set targets of reducing MMR to 70 per 100,000 live births and achieving 90% coverage of four antenatal care (4ANC) visits, institutional births by skilled birth attendants (SBA) and instituting postnatal care visits by 2030 (10). Evidence suggests that the reasons for slow progress in MNH outcomes are partly contributed by equity gaps in access to services, and utilization of poor-quality health services. For instance, in 2016, access to institutional delivery among women of the lowest and highest wealth quintile was 34% and 90%, respectively (4).
In many countries, socio-environmental conditions such as gender biases, combined with poverty, stressful work environments and a poor quality of life mean women have inadequate nutrition, experience early marriages and repeated pregnancies thereby exacerbating the risk of morbidity and mortality (11). Shyness, avoiding touch from males during labor and birth, and the dominance of mother-in-law in decision making (even regarding where to give birth) are common. These issues can lead to delays in deciding to seek care (12).
To ensure equitable and accessible services and improved utilization of institutional delivery it is important to identify what progress has been achieved, whether there are vulnerable and disadvantaged groups that need specific attention and what are the key factors affecting the utilization of institutional delivery services (5). Appropriate setting for delivery ensuring life-saving equipment and hygienic conditions can also help to reduce the risk of complications that may cause death or illness to mother and newborn (13).
Over half of health facilities in Nepal provide normal vaginal delivery services. Whereas, eight in 10 facilities that offer normal delivery care services have emergency transport available, and most of facilities (66–99%) have all the equipment items necessary for providing quality care. Only around one-fifth of facilities offering normal vaginal delivery services had all the medicines essential for quality delivery care (14). Despite it, most reported reason for not delivering in health facility was that it was not necessary to deliver in a health facility (56%), followed by the birth taking place before reaching the facility (18%) and the facility being too far away or not having transportation (17%) (4). Also, delays in reaching health facilities due to difficulty in transportation are also reported. When the women do reach health facilities, health workers are absent, unavailable or in some cases, even disrespectful to women (15).
A Study conducted found that Madesh Province has lowest proportion (50.8%) of health facilities providing delivery and newborn care services (16). This might be one of the reasons for only 45% institutional delivery and only 29% delivery is conducted in government health facility (4). Also, 80% of mothers feels that it was not necessary to deliver in a health facility (4). Despite the delivery service being free, a significant amount of out-of-pocket expenses incur accessing delivery service at a health facility, particularly in transportation, medicines, medical tests, and X-rays, staying in maternity waiting homes and supplies (17).
For purposes of encouraging institutional delivery, it’s important to assess women’s choice and preference for a particular type of places (18). But it is so unfortunate that women don’t have decision making power (19).
The government of Nepal is nonetheless trying to increase the utilization of maternal health services. However, service delivery is currently ineffective due to limited information about determinants regarding service utilization by communities and individuals.
A qualitative study conducted mentioned that women have little or no power in their marital home and are almost entirely at the mercy of their mother in law’s perception of their pregnancy and delivery care needs (20). Childbirth in a health facility attended by skilled birth attendant is associated with lower rates of maternal morbidity and mortality than home births (21). A study identified that women of economic, ethnic, geographic disadvantage, and linguistic minorities (e.g., Maithili speaking women) received poor quality MNH services (22).
Place of delivery is critical factor for women and child survival. Delivery is the most dangerous time for both the mother and her baby although the maternal death can occur at any point of time from pregnancy to 42 days after childbirth (23). Delivery in health facility also plays a critical role in preventing still births and improving newborn survival (24). Knowing the established health benefits of institutional deliveries, it is necessary to understand the range of factors associated with the choice of delivery place.
Childbearing is a precious life event for women, therefore choosing an appropriate and safe delivery place is vital to ensure a healthy mother and newborn and reduce maternal deaths and morbidities. Hence, this study aims to assess the preference, reasons for choices and factor influencing place of delivery among the women in Rautahat.