Assessment of facility and health worker readiness to provide quality antenatal, intrapartum and postpartum care in rural Southern Nepal

Factors affecting antenatal screening for HIV in Nepal: results from Nepal Demographic and Health Surveys 2016 and 2022

OBJECTIVES

Antenatal screening for HIV remains low in Nepal. Identifying factors associated with the uptake of antenatal screening is essential to increase uptake and prevent mother-to-child transmission (MTCT). This study investigated the effects of individual-level and district-level characteristics on the utilisation of antenatal screening for HIV in Nepal and how these effects changed between 2016 and 2022.

DESIGN

We used publicly available cross-sectional data from 2016 to 2022 Nepal Demographic and Health Surveys.

SETTING

Stratified, multistage, random sampling was used to collect nationally representative data.

PARTICIPANTS

1978 and 2007 women aged 15-49 years who gave birth in the 2 years preceding the surveys.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used multilevel models to estimate associations between antenatal screening and potential factors influencing it in 2016 and 2022. We used districts as a random effect and looked at the intraclass correlation coefficients to disentangle the geographical effects. To distinguish barriers to HIV screening from barriers to accessing antenatal care (ANC) services, we performed similar analyses with whether the woman attended at least one ANC visit as the dependent variable.

RESULTS

Factors associated with antenatal screening have not changed significantly between 2016 and 2022. Higher uptake of HIV screening was found among women with higher education, the pregnancy being desired later and women who had four or more ANC visits. Being from a poorer family and having low knowledge of MTCT and the medicines to prevent transmission were associated with lower uptake. From the supply side, no factors had a significant effect on antenatal screening. Factors associated with antenatal screening and those associated with any ANC were different. Our results also showed a partial importance of geographical factors on screening uptake.

CONCLUSIONS

Our results supported that antenatal screening could be improved by enhancing access to information and improving the availability of free screening.

Determinants of institutional delivery service utilization in Nepal

BACKGROUND

Maternal mortality continues to be a pressing concern in global health, presenting an enduring and unmet challenge for healthcare systems worldwide. Utilization of institutional delivery services has been established as a proven intervention to mitigate life-threatening risks for both mothers and newborns. Exploring the determinants of institutional delivery is crucial to improve and enhance maternal and newborn safety. This study aimed to assess the contextual and individual factors associated with institutional delivery in Nepal.

METHODS

This study utilized that data form Nepal Multiple Indicator Survey 2019, which included a sample of 1,932 women who had given birth within the two years prior to the survey. A multilevel logistic regression analysis was performed to determine the significant external environment, contextual and individual predictors of institutional delivery.

RESULTS

The women from Madhesh province [Adjusted Odds Ratio (aOR): 0.32, 95% Confidence Interval (CI): 0.17-0.61], as compared to Bagmati province, women from rural areas (aOR: 0.55, 95% CI: 0.39-0.78) as compared to urban areas, and women from a relatively less-advantaged ethnic groups (aOR: 0.52, 95% CI: 0.35-0.76) as compared to the relatively advantaged ethnic groups were less likely to deliver in health institutions. Similarly, women from the poorest (aOR: 0.09, 95% CI: 0.04-0.22) and second wealth groups (aOR: 0.29, 95% CI: 0.13-0.64) were less likely to attend institute for delivery compared to women from the richest household. Women with formal education (aOR: 1.65, 95% CI: 1.16-2.35) were more likely to deliver in an institution over uneducated women. Moreover, the uptake of institutional delivery increased by 59% (aOR: 1.59, 95% CI: 1.43-1.75) for each additional ANC visit.

CONCLUSION

The findings highlight the importance of stepping up efforts to achieve universal health care from the standpoint of long-term government investment, focusing particularly on illiterate women in rural areas, poorer households, and socially disadvantaged groups. Expanding the benefits of maternal benefit schemes targeting the women from the poorest households in the communities is recommended.

Women's utilisation of quality antenatal care, intrapartum care and postnatal care services in Ethiopia: a population-based study using the demographic and health survey data

OBJECTIVE

This study sought to investigate the level and determinants of receiving quality antenatal care (ANC), intrapartum care, and postnatal care (PNC) services by women in Ethiopia. The quality of care a woman receives during ANC, intrapartum care, and PNC services affects the health of the woman and her child and her likelihood of seeking care in the future.

METHODS

Data from the nationally representative Ethiopia Mini Demographic and Health Survey 2019 were analysed for 5,527 mothers who gave birth within five years preceding the survey. We defined quality ANC as having: blood pressure measurement, urine and blood tests, informed of danger signs, iron supplementation, and nutritional counselling during ANC services; quality intrapartum care as having: a health facility birth, skilled birth assistance, and a newborn put to the breast within one hour of birth during intrapartum care services; and quality PNC as having: PNC within two days; cord examination; temperature measurement, and counselling on danger signs and breastfeeding of the newborn; and healthcare provider's observation of breastfeeding during PNC services. We used multilevel mixed-effects logistic regression analyses specifying three-level models: a woman/household, a cluster, and an administrative region to determine predictors of each care quality. The analyses employed sampling weights and were adjusted for sampling design.

RESULTS

Thirty-six percent (n = 1,048), 43% (n = 1,485), and 21% (n = 374) women received quality ANC, intrapartum care and PNC services, respectively. Private healthcare facilities provided higher-quality ANC and PNC but poor-quality intrapartum care, compared to public health facilities. Having four or more ANC visits, commencing ANC during the first trimester, and higher women's education levels and household wealth indices were positive predictors of quality ANC use. Government health posts were less likely to provide quality ANC. Wealthier, urban-residing women with education and four or more ANC contacts were more likely to receive quality intrapartum care. Women who received quality ANC and skilled birth assistance were more likely to receive quality PNC. Teenage mothers were more likely to receive quality intrapartum care, but were less likely to receive quality PNC than mothers aged 20-49.

CONCLUSIONS

We recommend standardizing the contents of ANC provided in all healthcare facilities; and promoting early and four or more ANC contacts, effectiveness, sensitivity and vigilance of care provided to teenage mothers, and women's education and economic empowerment.

Readiness of rural health facilities to provide immediate postpartum care in Uganda

BACKGROUND

Nearly 60% of maternal and 45% of newborn deaths occur within 24 h after delivery. Immediate postpartum monitoring could avert death from preventable causes including postpartum hemorrhage, and eclampsia among mothers, and birth asphyxia, hypothermia, and sepsis for babies. We aimed at assessing facility readiness for the provision of postpartum care within the immediate postpartum period.

METHODS

A cross-sectional study involving 40 health facilities within the greater Mpigi region, Uganda, was done. An adapted health facility assessment tool was employed in data collection. Data were double-entered into Epi Data version 4.2 and analyzed using STATA version 13 and presented using descriptive statistics.

RESULTS

Facility readiness for the provision of postpartum care was low (median score 24% (IQR: 18.7, 26.7). Availability, and use of up-to-date, policies, guidelines and written clinical protocols for identifying, monitoring, and managing postpartum care were inconsistent across all levels of care. Lack of or non-functional equipment poses challenges for screening, diagnosing, and treating postnatal emergencies. Frequent stock-outs of essential drugs and supplies, particularly, hydralazine, antibiotics, oxygen, and blood products for transfusions were more common at health centers compared to hospitals. Inadequate human resources and sub-optimal supplies inhibit the proper functioning of health facilities and impact the quality of postpartum care. Overall, private not-for-profit health facilities had higher facility readiness scores.

CONCLUSIONS

Our findings suggest sub-optimal rural health facility readiness to assess, monitor, and manage postpartum emergencies to reduce the risk of preventable maternal/newborn morbidity and mortality. Strengthening health system inputs and supply side factors could improve facility capacity to provide quality postpartum care.

Investigation of technical quality of antenatal and perinatal services in a nationally representative sample of health facilities in Nepal

Background

Access to routine antenatal and perinatal services is improved in the last two decades in Nepal. However, gaps remain in coverage and quality of care delivered from the health facilities. This study investigated the delivery of technical quality antenatal and perinatal services from health facilities and their associated determinants in Nepal.

Methods

Data for this study were derived from the Nepal Health Facility Survey 2015. The World Health Organization's Service Availability and Readiness Assessment framework was adopted to assess the technical quality of antenatal and perinatal services of health facilities. Outcome variables included technical quality scores of i) 269 facilities providing antenatal services and ii) 109 facilities providing childbirth and postnatal care services (perinatal care). Technical quality scores of health facilities were estimated adapting recommended antenatal and perinatal interventions. Independent variables included locations and types of health facilities and their management functions (e.g., supervision). We conducted a linear regression analysis to identify the determinants of better technical quality of health services in health facilities. Beta coefficients were exponentiated into odds ratios (ORs) and reported with 95% confidence intervals (CIs). The significance level was set at p-value < 0.05.

Results

The mean score of the technical quality of health facilities for each outcome variable (antenatal and perinatal services) was 0.55 (out of 1.00). Compared to province one, facilities of Madhesh province had 4% lower odds (adjusted OR = 0.96; 95%CI: 0.92, 0.99) of providing better quality antenatal services, while health facilities of Gandaki province had higher odds of providing better quality antenatal services (aOR = 1.05; 95% CI: 1.01, 1.10). Private facilities had higher odds (aOR = 1.13; 95% CI: 1.03, 1.23) of providing better quality perinatal services compared to public facilities.

Conclusions

Private facilities provide better quality antenatal and perinatal health services than public facilities, while health facilities of Madhesh province provide poor quality perinatal services. Health system needs to implement tailored strategies, including recruiting health workers, supervision and onsite coaching and access to necessary equipment and medicine in the facilities of Madhesh province. Health system inputs (trained human resources, equipment and supplies) are needed in the public facilities. Extending the safe delivery incentive programme to the privately managed facilities could also improve access to better quality health services in Nepal.

Assessment of health system readiness for routine maternal and newborn health services in Nepal: Analysis of a nationally representative health facility survey, 2015

Access to and utilisation of routine maternal and newborn health (MNH) services, such as antenatal care (ANC), and perinatal services, has increased over the last two decades in Nepal. The availability, delivery, and utilisation of quality health services during routine MNH visits can significantly impact the survival of mothers and newborns. Capacity of health facility is critical for the delivery of quality health services. However, little is known about health system readiness (structural quality) of health facilities for routine MNH services and associated determinants in Nepal. Data were derived from the Nepal Health Facility Survey (NHFS) 2015. Total of 901 health facilities were assessed for structural quality of ANC services, and 454 health facilities were assessed for perinatal services. Adapting the World Health Organization's Service Availability and Readiness Assessment manual, we estimated structural quality scores of health facilities for MNH services based on the availability and readiness of related subdomain-specific items. Several health facility-level characteristics were considered as independent variables. Logistic regression analyses were conducted, and the odds ratio (OR) was reported with 95% confidence intervals (CIs). The significance level was set at p-value of <0.05. The mean score of the structural quality of health facilities for ANC, and perinatal services was 0.62, and 0.67, respectively. The average score for the availability of staff (e.g., training) and guidelines-related items in health facilities was the lowest (0.37) compared to other four subdomains. The odds of optimal structural quality of health facilities for ANC services were higher in private health facilities (adjusted odds ratio (aOR) = 2.65, 95% CI: 1.48, 4.74), and health facilities supervised by higher authority (aOR = 1.96; CI: 1.22, 3.13) while peripheral health facilities had lower odds (aOR = 0.13; CI: 0.09, 0.18) compared to their reference groups. Private facilities were more likely (aOR = 1.69; CI:1.25, 3.40) to have optimal structural quality for perinatal services. Health facilities of Karnali (aOR = 0.29; CI: 0.09, 0.99) and peripheral areas had less likelihood (aOR = 0.16; CI: 0.10, 0.27) to have optimal structural quality for perinatal services. Provincial and local governments should focus on improving the health system readiness in peripheral and public facilities to deliver quality MNH services. Provision of trained staff and guidelines, and supply of laboratory equipment in health facilities could potentially equip facilities for optimal quality health services delivery. In addition, supervision of health staff and facilities and onsite coaching at peripheral areas from higher-level authorities could improve the health management functions and technical capacity for delivering quality MNH services. Local governments can prioritise inputs, including providing a trained workforce, supplying equipment for laboratory services, and essential medicine to improve the quality of MNH services in their catchment.

Investigating health service availability and readiness for antenatal testing and treatment for HIV and syphilis in Papua New Guinea

BACKGROUND

Papua New Guinea (PNG) has one of the highest burdens of HIV and syphilis in pregnancy in the Asia-Pacific region. Timely and effective diagnosis can alleviate the burden of HIV and syphilis and improve maternal and newborn health. Supply-side factors related to implementation and scale up remain problematic, yet few studies have considered their impact on antenatal testing and treatment for HIV and syphilis. This study explores health service availability and readiness for antenatal HIV and/or syphilis testing and treatment in PNG.

METHODS

Using data from two sources, we demonstrate health service availability and readiness. Service availability is measured at a province level as the average of three indicators: infrastructure, workforce, and antenatal clinic utilization. The readiness score comprises 28 equally weighted indicators across four domains; and is estimated for 73 health facilities. Bivariate and multivariate robust linear regressions explore associations between health facility readiness and the proportion of antenatal clinic attendees tested and treated for HIV and/or syphilis.

RESULTS

Most provinces had fewer than one health facility per 10 000 population. On average, health worker density was 11 health workers per 10 000 population per province, and approximately 22% of pregnant women attended four or more antenatal clinics. Most health facilities had a composite readiness score between 51% and 75%, with urban health facilities faring better than rural ones. The multivariate regression analysis, when controlling for managing authority, catchment population, the number of clinicians employed, health facility type and residence (urban/rural) indicated a weak positive relationship between health facility readiness and the proportion of antenatal clinic attendees tested and treated for HIV and/or syphilis.

CONCLUSION

This study adds to the limited evidence base for the Asia-Pacific region. There is a need to improve antenatal testing and treatment coverage for HIV and syphilis and reduce healthcare inequalities faced by rural and urban communities. Shortages of skilled health workers, tests, and medicines impede the provision of quality antenatal care. Improving service availability and health facility readiness are key to ensuring the effective provision of antenatal care interventions.

Best and worst performing health facilities: A positive deviance analysis of perceived drivers of primary care performance in Nepal

Primary care services are on average of low quality in Nepal. However, there is marked variation in performance of basic clinical and managerial functions between primary health care centers. The determinants of variation in primary care performance in low- and middle-income countries have been understudied relative to the prominence of primary care in national health plans. We used the positive deviance approach to identify best and worst performing primary health care centers in Nepal and investigated perceived drivers of best performance. We selected eight primary health care centers in Province 1, Nepal, using an index of basic clinical and operational activities to identify four best and four worst performing primary health care centers. We conducted semi-structured, in-depth interviews with managers and clinical staff from each of the eight primary health care centers for a total of 32 interviews. We identified the following factors that distinguished best from worst performers: 1) Managing the facility effectively, 2) engaging local leadership, 3) building active community accountability, 4) assessing and responding to facility performance, 5) developing sources of funding, 6) compensating staff fairly, 7) managing clinical staff performance, and 8) promoting uninterrupted availability of supplies and equipment. These findings can be used to inform quality improvement efforts and health system reforms in Nepal and other similarly under-resourced health systems.

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Local leaders and health workers felt good management was key to best performance.

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Best performers reported strong leadership at both the facility and local levels.

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Community accountability was also seen as a critical enabler of top performance.

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Leaders of worst performers were less responsive to facility and community needs.

Are Bangladeshi healthcare facilities prepared to provide antenatal care services? Evidence from two nationally representative surveys

Identifying high-risk pregnancies through antenatal care (ANC) is considered the cornerstone to eliminating child deaths and improving maternal health globally. Understanding the factors that influence a healthcare facility's (HCF) preparedness to provide ANC service is essential for assisting maternal and newborn health system progress. We aimed to evaluate the preparedness of HCFs to offer ANC services among childbearing women in Bangladesh and investigate the facility characteristics linked to the preparedness. The data for this study came from two waves of the Bangladesh Health Facilities Survey (BHFS), conducted in 2014 and 2017 using a stratified random sample of facilities. The study samples were 1,508 and 1,506 HCFs from the 2014 and 2017 BHFS, respectively. The outcome variable "ANC services preparedness" was calculated as an index score using a group of tracer indicators. Multinomial logistic regression models were used to identify the significant correlates of ANC service preparedness. We found that private hospitals had a lower chance of having high preparedness than district and upazila public facilities in 2014 (RRR = 0.04, 95% CI: 0.01-0.22, p-value = <0.001) and 2017 (RRR = 0.23, 95% CI: 0.07-0.74, p-value = 0.01), respectively. HCFs from the Khulna division had a 2.84 (RRR = 2.84, CI: 1.25-6.43, p-value = 0.01) and 3.51 (RRR = 3.51, CI: 1.49-8.27, p-value = <0.001) higher likelihood of having medium and high preparedness, respectively, for ANC service compared to the facilities in the Dhaka division in 2017. The facilities that had a medium infection prevention score were 3.10 times (RRR = 3.10, 95% CI: 1.65-5.82; p-value = <0.001) and 1.89 times (RRR = 1.89, 95% CI: 1.09-3.26, p-value = 0.02) more likely to have high preparedness compared to those facilities that had a low infection prevention score in 2014 and 2017 respectively. Facilities without visual aids for client education on pregnancy and ANC were less likely to have high (RRR = 0.29, 95% CI: 0.16-0.53, p-value = <0.001) and (RRR = 0.55, 95% CI: 0.30-0.99, p-value = 0.04) preparedness, respectively, than those with visual aids for client education on pregnancy and ANC in both the surveys. At all two survey time points, facilities that did not maintain individual client cards or records for ANC clients were less likely to have high (RRR = 0.53, 95% CI: 0.31-.92, p-value = 0.02) and (RRR = 0.41, 95% CI: 0.25-0.66, p-value = <0.001) preparedness, respectively, compared to their counterparts. We conclude that most facilities lack adequate indicators for ANC service preparedness. To improve the readiness of ANC services, government authorities could focus on union-level facilities, community clinics, private facilities, and administrative divisions. They could also make sure that infection control items are available, maintain individual client cards or records for ANC clients, and also ensure ANC clients have access to visual aids.

Causes and age of neonatal death and associations with maternal and newborn care characteristics in Nepal: a verbal autopsy study

BACKGROUND

In Nepal, neonatal mortality fell substantially between 2000 and 2018, decreasing 50% from 40 to 20 deaths per 1,000 live births. Nepal's success has been attributed to a decreasing total fertility rate, improvements in female education, increases in coverage of skilled care at birth, and community-based child survival interventions.

METHODS

A verbal autopsy study, led by the Integrated Rural Health Development Training Centre (IRHDTC), conducted interviews for 338 neonatal deaths across six districts in Nepal between April 2012 and April 2013. We conducted a secondary analysis of verbal autopsy data to understand how cause and age of neonatal death are related to health behaviors, care seeking practices, and coverage of essential services in Nepal.

RESULTS

Sepsis was the leading cause of neonatal death (n=159/338, 47.0%), followed by birth asphyxia (n=56/338, 16.6%), preterm birth (n=45/338, 13.3%), and low birth weight (n=17/338, 5.0%). Neonatal deaths occurred primarily on the first day of life (27.2%) and between days 1 and 6 (64.8%) of life. Risk of death due birth asphyxia relative to sepsis was higher among mothers who were nulligravida, had <4 antenatal care visits, and had a multiple birth; risk of death due to prematurity relative to sepsis was lower for women who made ≥1 delivery preparation and higher for women with a multiple birth.

CONCLUSIONS

Our findings suggest cause and age of death distributions typically associated with high mortality settings. Increased coverage of preventive antenatal care interventions and counseling are critically needed. Delays in care seeking for newborn illness and quality of care around the time of delivery and for sick newborns are important points of intervention with potential to reduce deaths, particularly for birth asphyxia and sepsis, which remain common in this population.

Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia

BACKGROUND

Actionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO's Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme's Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO's quality of maternal and newborn care standards.

METHODS

We used cross-sectional data from Performance Monitoring for Action Ethiopia's 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume.

RESULTS

Indices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices.

CONCLUSION

SARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness.

Utilisation of quality antenatal, delivery and postnatal care services in Nepal: An analysis of Service Provision Assessment

BACKGROUND

Nepal has improved access and utilisation of routine maternal and newborn health (MNH) services. Despite improved access to routine MNH services such as antenatal care (ANC), and delivery and postnatal care (PNC) services, the burden of maternal and neonatal deaths in Nepal remains high. Most of those deaths could be prevented by improving utilisation of evidence-informed clinical MNH interventions. However, little is known on determinants of utilisation of such clinical MNH interventions in health facilities (HFs). This study investigated the determinants of utilisation of technical quality MNH services in Nepal.

METHODS

This study used data from the 2015 Nepal Services Provision Assessment. A total of 523 pregnant and 309 postpartum women were included for the analysis of utilisation of technical quality of ANC, and delivery and PNC services, respectively. Outcome variables were utilisation of better quality i) ANC services, and ii) delivery and PNC services while independent variables included features of HFs and health workers, and demographic characteristics of pregnant and postpartum women. Binomial logistic regression was conducted to identify the determinants associated with utilisation of quality MNH services. The odds ratio with 95% confidence interval (CIs) were reported at the significance level of p < 0.05 (two-tailed).

RESULTS

Women utilised quality ANC services if they attended facilities with better HF capacity (aOR = 2.12;95% CI: 1.03, 4.35). Women utilised better quality delivery and PNC services from private HFs compared to public HFs (aOR = 2.63; 95% CI: 1.14, 6.08). Women utilised better technical quality ANC provided by nursing staff compared to physicians (adjusted odds ratio (aOR) =2.89; 95% CI: 1.33, 6.29), and from staff supervised by a higher authority compared to those not supervised (aOR = 1.71; 95% CI: 1.01, 2.92). However, compared to province one, women utilised poor quality delivery and PNC services from HFs in province two (aOR = 0.15; 95% CI: 0.03, 0.63).

CONCLUSIONS

Women utilised quality MNH services at facilities with better HF capacity, service provided by nursing staff, and attended at supervised HFs/health workers. Provincial and municipal governments require strengthening HF capacities (e.g., supply equipment, medicines, supplies), recruiting trained nurse-midwives, and supervising health workers.

Content of antenatal care and perception about services provided by primary hospitals in Nepal: a convergent mixed methods study

BACKGROUND

Nepal has made significant strides in maternal and neonatal mortality over the last three decades. However, poor quality of care can threaten the gains, as maternal and newborn services are particularly sensitive to quality of care. Our study aimed to understand current gaps in the process and the outcome dimensions of the quality of antenatal care (ANC), particularly at the sub-national level. We assessed these dimensions of the quality of ANC in 17 primary, public hospitals across Nepal. We also assessed the variation in the ANC process across the patients' socio-economic gradient.

METHODS

We used a convergent mixed methods approach, whereby we triangulated qualitative and quantitative data. In the quantitative component, we observed interactions between providers (17 hospitals from all 7 provinces) and 198 women seeking ANC and recorded the tasks the providers performed, using the Service Provision Assessments protocol available from the Demographic and Health Survey program. The main outcome variable was the number of tasks performed by the provider during an ANC consultation. The tasks ranged from identifying potential signs of danger to providing counseling. We analyzed the resulting data descriptively and assessed the relationship between the number of tasks performed and users' characteristics. In the qualitative component, we synthesized users' and providers' narratives on perceptions of the overall quality of care obtained through focus group discussions and in-depth interviews.

RESULTS

Out of the 59 tasks recommended by the World Health Organization, providers performed only 22 tasks (37.3%) on average. The number of tasks performed varied significantly across provinces, with users in province 3 receiving significantly higher quality care than those in other provinces. Educated women were treated better than those with no education. Users and providers agreed that the overall quality of care was inadequate, although providers mentioned that the current quality was the best they could provide given the constraints they faced.

CONCLUSION

The quality of ANC in Nepal's primary hospitals is poor and inequitable across education and geographic gradients. While current efforts, such as the provision of 24/7 birthing centers, can mitigate gaps in service availability, additional equipment, infrastructure and human resources will be needed to improve quality. Providers also need additional training focused on treating patients from different backgrounds equally. Our study also points to the need for additional research, both to document the quality of care more objectively and to establish key determinants of quality to inform policy.

Who are dying and why? A case series study of maternal deaths in Nepal

OBJECTIVES

To identify delays and associated factors for maternal deaths in Nepal.

DESIGN

A cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis.

SETTING

Sixty-two maternal deaths in six districts in three provinces of Nepal.

RESULTS

Nearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60-180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths.

CONCLUSIONS

The first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal.

Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal’s transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal’s maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.

Availability and readiness to provide sexually transmitted infections and HIV testing and counselling services in Nepal: evidence from comprehensive health facility survey

OBJECTIVE

We assessed the availability and readiness of health facilities to provide sexually transmitted infections (STI) and HIV testing and counselling (HTC) services in Nepal.

DESIGN

This was a cross-sectional study.

SETTING

We used data from the most recent nationally representative Nepal Health Facility Survey (NHFS) 2015. A total of 963 health facilities were surveyed with 97% response rate.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome of this study was to assess the availability and readiness of health facilities to provide STI and HTC services using the WHO Service Availability and Readiness Assessment (SARA) manual.

RESULTS

Nearly three-fourths (73.8%) and less than one-tenth (5.9%) of health facilities reported providing STI and HTC services, respectively. The mean readiness score of STI and HTC services was 26.2% and 68.9%, respectively. The readiness scores varied significantly according to the managing authority (private vs public) for both STI and HTC services. Interestingly, health facilities with external supervision had better service readiness scores for STI services that were almost four points higher than compared with those facilities with no external supervision. Regarding HTC services, service readiness was lower at private hospitals (32.9 points lower) compared to government hospitals. Unlike STI services, the readiness of facilities to provide HTC services was higher (4.8 point higher) at facilities which performed quality assurance.

CONCLUSION

The facility readiness for HTC service is higher than that for STI services. There are persistent gaps in staff, guidelines and medicine and commodities across both services. Government of Nepal should focus on ensuring constant supervision and quality assurance, as these were among the determining factors for facility readiness.

Situation of labour room documentation at secondary level public health facilities of Cuttack district, Odisha, India - A SWOT analysis

Background:

Poor documentation practices in labour rooms have been a challenge especially in resource limited countries. This hinders the efforts towards improving quality of maternal healthcare services. Little effort has been made on this regard in many countries including India. SWOT analysis on labour room documentation would be the first step in understanding the situation, barriers and to formulate strategies for improvement.

Materials and Methods:

Facility based cross-sectional study was carried out in five secondary health facilities of Cuttack district, Odisha, India. A qualitative method using in-depth interviews among 26 healthcare providers was adopted for data collection and inductive content analysis approach for analysis. Strategies like pioneering, positive, conservative and resistive were formulated under each of the three major components identified.

Results:

Three major components emerged were i) Adherence and completeness of labour room records and reports, ii) Status of the monitoring and supervision and iii) Utilization of labour room data. Improving knowledge and skill through training and supportive supervision, adopting computer-based application for data management, better coordination among supervisors and labour room staff, infrastructural strengthening for documentation and its security, making documentation a priority, more accountability would improve the documentation. Ensuring data analysis and interpretation, discussion in review meetings and regular monitoring and supervision will improve performance.

Conclusion:

Ensuring documentation of labour room records, regular quality monitoring and supervision, and analysis and interpretation of data are critical to improve labour room performance. Making it a priority and adopting the strategies will achieve the same, thereby better labour outcome.