Women's knowledge about the conditional cash incentive program and its association with institutional delivery in Nepal

Financial incentives and delivery care: Evidence from the Safe Delivery Incentive Program in Nepal

This paper examines the effects of the Safe Delivery Incentive Program in Nepal, a cash transfer program that reduced the costs of childbirth in healthcare facilities. Women giving birth for the first, second, or third time (below-cutoff) became eligible in 2005, and women giving birth for the fourth time or more (above-cutoff) became eligible two years later. Using a difference-in-differences design, I find that below-cutoff women in high Human Development Index (HDI) districts increased facility delivery by 8.8 percentage points. Despite larger cost reductions, below-cutoff women in low HDI districts did not increase facility delivery but increased home delivery with skilled personnel by 4.8 percentage points. The program had no impact on above-cutoff women, who become eligible 2 years into the program. I suggest that pre-existing barriers such as poor infrastructure of roads and facilities, customs, liquidity constraints, and lack of program awareness limited the program's effectiveness.

Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal

Objectives: (a) To quantify the level and changes in socioeconomic inequality in the utilization of antenatal care (ANC), institutional delivery (ID) and postnatal care (PNC) in Nepal over a 20-year period; (b) identify key drivers of inequality using decomposition analysis; and (c) identify geographical clusters with low service utilization to inform policy. Methods: Data from the most recent five waves of the Demographic Health Survey were used. All outcomes were defined as binary variables: ANC (=1 if ≥4 visits), ID (=1 if place of delivery was a public or private healthcare facility), and PNC (=1 if ≥1 visits). Indices of inequality were computed at national and provincial-level. Inequality was decomposed into explanatory components using Fairile decomposition. Spatial maps identified clusters of low service utilization. Results: During 1996-2016, socioeconomic inequality in ANC and ID reduced by 10 and 23 percentage points, respectively. For PND, the gap remained unchanged at 40 percentage points. Parity, maternal education, and travel time to health facility were the key drivers of inequality. Clusters of low utilization were displayed on spatial maps, alongside deprivation and travel time to health facility. Conclusion: Inequalities in the utilization of ANC, ID and PNC are significant and persistent. Interventions targeting maternal education and distance to health facilities can significantly reduce the gap.

Development of an imputation model to recalibrate birth weights measured in the early neonatal period to time at delivery and assessment of its impact on size-for-gestational age and low birthweight prevalence estimates: a secondary analysis of a pregnancy cohort in rural Nepal

OBJECTIVES

In low-income countries, birth weights for home deliveries are often measured at the nadir when babies may lose up of 10% of their birth weight, biasing estimates of small-for-gestational age (SGA) and low birth weight (LBW). We aimed to develop an imputation model that predicts the 'true' birth weight at time of delivery.

DESIGN

We developed and applied a model that recalibrates weights measured in the early neonatal period to time=0 at delivery and uses those recalibrated birth weights to impute missing birth weights.

SETTING

This is a secondary analysis of pregnancy cohort data from two studies in Sarlahi district, Nepal.

PARTICIPANTS

The participants are 457 babies with daily weights measured in the first 10 days of life from a subsample of a larger clinical trial on chlorhexidine (CHX) neonatal skin cleansing and 31 116 babies followed through the neonatal period to test the impact of neonatal massage oil type (Nepal Oil Massage Study (NOMS)).

OUTCOME MEASURES

We developed an empirical Bayes model of early neonatal weight change using CHX trial longitudinal data and applied it to the NOMS dataset to recalibrate and then impute birth weight at delivery. The outcomes are size-for-gestational age and LBW.

RESULTS

When using the imputed birth weights, the proportion of SGA is reduced from 49% (95% CI: 48% to 49%) to 44% (95% CI: 43% to 44%). Low birth weight is reduced from 30% (95% CI: 30% to 31%) to 27% (95% CI: 26% to 27%). The proportion of babies born large-for-gestational age increased from 4% (95% CI: 4% to 4%) to 5% (95% CI: 5% to 5%).

CONCLUSIONS

Using weights measured around the nadir overestimates the prevalence of SGA and LBW. Studies in low-income settings with high levels of home births should consider a similar recalibration and imputation model to generate more accurate population estimates of small and vulnerable newborns.

Antenatal care processes in rural Southern Nepal: gaps in and quality of service provision-a cohort study

OBJECTIVES

This study aimed to compare a standard quality of care definition to one that reflected focused antenatal care (FANC) guidelines and examine associations with receipt of good quality of care.

DESIGN

This study was a longitudinal cohort study.

SETTINGS

Five government health posts in the Sarlahi district of Southern Nepal PARTICIPANTS: Pregnant women between the ages of 15 and 49 who presented for their first antenatal care (ANC) visit at the study health posts.

MAIN OUTCOMES

There were two quality of care definitions: (1) provision of seven services at least once during pregnancy (QOC1) and (2) provision of services to reflect the FANC guidelines by incorporating a frequency of care dimension for certain services (QOC4+).

RESULTS

There was variation in service provision both in terms of frequency of provision and by gestational age at the visit. There were 213 women (49.1%) that received good quality care by the first definition, but when the frequency of service provision was included for the second definition the percentage dropped to 6.2%. There were significant differences in provision of quality care by health post for both definitions. The number of visits (QOC1 adjusted risk ratio (aRR) 1.18, 95% CI 1.13 to 1.23; QOC4+ aRR 1.46, 95% CI 1.11 to 2.80) and care during the first trimester (QOC1 aRR 1.22, 95% CI 1.01 to 1.49) and maternal age (QOC1 aRR 1.27, 95% CI 1.03 to 1.58) were associated with greater likelihood of good quality ANC.

CONCLUSION

This analysis demonstrated that measuring quality of care by receipt of services at least once during pregnancy may overestimate the true coverage of quality of ANC. Future efforts should improve feasibility of including frequency of care in quality of care definitions.

The Role of Women's Autonomy and Experience of Intimate Partner Violence as a Predictor of Maternal Healthcare Service Utilization in Nepal

This study aims to identify the relationship of women’s autonomy and intimate partner violence (IPV) with maternal healthcare service utilization among married women of reproductive age in Nepal. This study used data from the 2016 Nepal Demographic and Health Survey (NDHS), which is a nationally representative sample survey. The association between outcome variables with selected factors were examined by using the Chi-square test (χ²), followed by multiple logistic regression. The sample was adjusted for multi-stage sampling design, cluster weight, and sample weight. Of the total sample, 68.4% reported attending sufficient Antenatal care (ANC) visits throughout their pregnancy, while 59.9% reported having a health facility delivery. The factors associated with both, sufficient ANC visits and institutional delivery includes ethnicity, place of residence, household wealth status, and the number of living children. Women who have access to media, and who have intended pregnancy were more likely to have sufficient ANC visits. Exposure to some forms of violence was found to be the barrier for maternal health service utilization. Attending ANC visits enables mothers to make the decision regarding skilled attendance or health facility delivery. Preventing any forms of violence need to be considered as a vital element in interventions aimed at increasing maternal health service utilization.