Bishnu Choulagai

Perceptions of users and providers on barriers to utilizing skilled birth care in mid- and far-western Nepal: a qualitative study.

Background Although skilled birth care contributes significantly to the prevention of maternal and newborn morbidity and mortality, utilization of such care is poor in mid- and far-western Nepal. This study explored the perceptions of service users and providers regarding barriers to skilled birth care. Design We conducted 24 focus group discussions, 12 each with service users and service providers from different health institutions in mid- and far-western Nepal. All discussions examined the perceptions and experiences of service users and providers regarding barriers to skilled birth care and explored possible solutions to overcoming such barriers. Results Our results determined that major barriers to skilled birth care include inadequate knowledge of the importance of services offered by skilled birth attendants (SBAs), distance to health facilities, unavailability of transport services, and poor availability of SBAs. Other barriers included poor infrastructure, meager services, inadequate information about services/facilities, cultural practices and beliefs, and low prioritization of birth care. Moreover, the tradition of isolating women during and after childbirth decreased the likelihood that women would utilize delivery care services at health facilities. Conclusions Service users and providers perceived inadequate availability and accessibility of skilled birth care in remote areas of Nepal, and overall utilization of these services was poor. Therefore, training and recruiting locally available health workers, helping community groups establish transport mechanisms, upgrading physical facilities and services at health institutions, and increasing community awareness of the importance of skilled birth care will help bridge these gaps.Background Although skilled birth care contributes significantly to the prevention of maternal and newborn morbidity and mortality, utilization of such care is poor in mid- and far-western Nepal. This study explored the perceptions of service users and providers regarding barriers to skilled birth care. Design We conducted 24 focus group discussions, 12 each with service users and service providers from different health institutions in mid- and far-western Nepal. All discussions examined the perceptions and experiences of service users and providers regarding barriers to skilled birth care and explored possible solutions to overcoming such barriers. Results Our results determined that major barriers to skilled birth care include inadequate knowledge of the importance of services offered by skilled birth attendants (SBAs), distance to health facilities, unavailability of transport services, and poor availability of SBAs. Other barriers included poor infrastructure, meager services, inadequate information about services/facilities, cultural practices and beliefs, and low prioritization of birth care. Moreover, the tradition of isolating women during and after childbirth decreased the likelihood that women would utilize delivery care services at health facilities. Conclusions Service users and providers perceived inadequate availability and accessibility of skilled birth care in remote areas of Nepal, and overall utilization of these services was poor. Therefore, training and recruiting locally available health workers, helping community groups establish transport mechanisms, upgrading physical facilities and services at health institutions, and increasing community awareness of the importance of skilled birth care will help bridge these gaps.

Women’s experiences and health care-seeking practices in relation to uterine prolapse in a hill district of Nepal

BackgroundAlthough uterine prolapse (UP) occurs commonly in Nepal, little is known about the physical health and care-seeking practices of women with UP. This study aimed to explore women’s experiences of UP and its effect on daily life, its perceived causes, and health care-seeking practices.MethodsUsing a convenience sampling method, we conducted 115 semi-structured and 16 in-depth interviews with UP-affected women during September–December 2012. All interviews occurred in outreach clinics in villages of the Dhading district.ResultsStudy participants were 23–82 years of age. Twenty-four percent were literate, 47.2% had experienced a teenage pregnancy, and 29% had autonomy to make healthcare decisions. Most participants (>85%) described the major physical discomforts of UP as difficulty with walking, standing, working, sitting, and lifting. They also reported urinary incontinence (68%) bowel symptoms (42%), and difficulty with sexual activity (73.9%). Due to inability to perform household chores or fulfill their husband’s sexual desires, participants endured humiliation, harassment, and torture by their husbands and other family members, causing severe emotional stress. Following disclosure of UP, 24% of spouses remarried and 6% separated from the marital relationship. Women perceived the causes of UP as unsafe childbirth, heavy work during the postpartum period, and gender discrimination. Prior to visiting these camps some women (42%) hid UP for more than 10 years. Almost half (48%) of participants sought no health care; 42% ingested a herb and ate nutritious food. Perceived barriers to accessing health care included shame (48%) and feeling that care was unnecessary (12.5%). Multiple responses (29%) included shame, inability to share, male service provider, fear of stigma and discrimination, and perceiving UP as normal for childbearing women.ConclusionsUP adversely affects women’s daily life and negatively influences their physical, mental, and social well-being. The results of our study are useful to generate information on UP symptoms and female health care seeking practices. Our findings can be helpful for effective development of UP awareness programs to increase service utilization at early stages of UP and thereby might contribute to both primary and secondary prevention of UP.

A cluster randomized implementation trial to measure the effectiveness of an intervention package aiming to increase the utilization of skilled birth attendants by women for childbirth: study protocol

BackgroundNepal is on track to achieve MDG 5 but there is a huge sub-national disparity with existing high maternal mortality in western and hilly regions. The national priority is to reduce this disparity to achieve the goal at sub-national level. Evidences from developing countries show that increasing utilization of skilled attendant at birth is an important indicator for reducing maternal death. Further, there is a very low utilization during childbirth in western and hilly regions of Nepal which clearly depicts the barriers in utilization of skilled birth attendants. So, there is a need to overcome the identified barriers to increase the utilization thereby decreasing the maternal mortality. The hypothesis of this study is that through a package of interventions the utilization of skilled birth attendants will be increased and hence improve maternal health in Nepal.Method/DesignThis study involves a cluster randomized controlled trial involving approximately 5000 pregnant women in 36 clusters. The 18 intervention clusters will receive the following interventions: i) mobilization of family support for pregnant women to reach the health facility, ii) availability of emergency funds for institutional childbirth, iii) availability of transport options to reach a health facility for childbirth, iv) training to health workers on communication skills, v) security provisions for SBAs to reach services 24/24 through community mobilization; 18 control clusters will not receive the intervention package. The final evaluation of the intervention is planned to be completed by October 2014. Primary study output of this study is utilization of SBA services. Secondary study outputs measure the uptake of antenatal care, post natal checkup for mother and baby, availability of transportation for childbirth, operation of emergency fund, improved reception of women at health services, and improved physical security of SBAs.DiscussionThe intervention package is designed to increase the utilization of skilled birth attendants by overcoming the barriers related to awareness, finance, transport, security etc. If proven effective, the Ministry of Health has committed to scale up the intervention package throughout the country.Trial registration numberISRCTN78892490.

Factors associated with underweight among children of former-Kamaiyas in Nepal

Background: Bonded labor was a tradition in Nepal since the 16th century. In 2002, the Government of Nepal freed Kamaiyas and gave the newly freed individuals support for basic living. Many children of former-Kamaiyas live below subsistence level and are vulnerable to undernutrition. The aim of this study was to identify the factors associated with underweight among the children of former-Kamaiyas. Methods: We conducted the community based cross-sectional study from June to December, 2012. Face-to-face interviews were conducted using semi-structured questionnaires with randomly selected mothers of 280 children under 5 years of age from former-Kamaiya families residing in Banke district. We also measured the weight and height of the children. Undernutrition was defined according to the World Health Organization child growth standards. Factors associated with underweight were examined using a Chi-square test followed by multiple logistic regression. Results: Out of 280 children, 116 (41.4%) were underweight (≤2 SD weight-for-age), 156 (55.7%) were stunted (≤2 SD height-for-age), and 52 (18.6%) were wasted (≤2 SD weight-for-height). Females were more likely to be underweight than males [adjusted odds ratio (aOR) = 1.696, 95% confidence interval (CI) = 1.026–2.804]. Children were less likely to be underweight if they were having daily bath (aOR = 0.532; 95% CI = 0.314–0.899) or if their mothers were ≥24 years of age (aOR = 0.440; 95% CI = 0.266–0.727). Conclusion: The proportion of underweight, stunting, and wasting was more than the national average among the children of former-Kamaiyas. Female children were more likely to be underweight whereas children who were being bathed daily and with mothers whose age was ≥24 years were less likely to be underweight.

Jhaukhel-Duwakot Health Demographic Surveillance Site, Nepal: 2012 follow-up survey and use of skilled birth attendants

Background Estimates of disease burden in Nepal are based on cross-sectional studies that provide inadequate epidemiological information to support public health decisions. This study compares the health and demographic indicators at the end of 2012 in the Jhaukhel-Duwakot Health Demographic Surveillance Site (JD-HDSS) with the baseline conducted at the end of 2010. We also report on the use of skilled birth attendants (SBAs) and associated factors in the JD-HDSS at the follow-up point. Design We used a structured questionnaire to survey 3,505 households in the JD-HDSS, Bhaktapur, Nepal. To investigate the use of SBAs, we interviewed 434 women who had delivered a baby within the prior 2 years. We compared demographic and health indicators at baseline and follow-up and assessed the association of SBA services with background variables. Results Due to rising in-migration, the total population and number of households in the JD-HDSS increased (13,669 and 2,712 in 2010 vs. 16,918 and 3,505 in 2012). Self-reported morbidity decreased (11.1% vs. 7.1%, respectively), whereas accidents and injuries increased (2.9% vs. 6.5% of overall morbidity, respectively). At follow-up, the proportion of institutional delivery (93.1%) exceeded the national average (36%). Women who accessed antenatal care and used transport (e.g. bus, taxi, motorcycle) to reach a health facility were more likely to access institutional delivery. Conclusions High in-migration increased the total population and number of households in the JD-HDSS, a peri-urban area where most health indicators exceed the national average. Major morbidity conditions (respiratory diseases, fever, gastrointestinal problems, and bone and joint problems) remain unchanged. Further investigation of reasons for increased proportion of accidents and injuries are recommended for their timely prevention. More than 90% of our respondents received adequate antenatal care and used institutional delivery, but only 13.2% accessed adequate postnatal care. Availability of transport and use of antenatal care was associated positively with institutional delivery.

Uterine prolapse and its impact on quality of life in the Jhaukhel–Duwakot Health Demographic Surveillance Site, Bhaktapur, Nepal

Background Uterine prolapse (UP) is a reproductive health problem and public health issue in low-income countries including Nepal. Objective We aimed to identify the contributing factors and stages of UP and its impact on quality of life in the Jhaukhel–Duwakot Health Demographic Surveillance Site of Bhaktapur, Nepal. Design Our three-phase study used descriptive cross-sectional analysis to assess quality of life and stages of UP and case–control analysis to identify contributing factors. First, a household survey explored the prevalence of self-reported UP (Phase 1). Second, we used a standardized tool in a 5-day screening camp to determine quality of life among UP-affected women (Phase 2). Finally, a 1-month community survey traced self-reported cases from Phase 1 (Phase 3). To validate UP diagnoses, we reviewed participants’ clinical records, and we used screening camp records to trace women without UP. Results Among 48 affected women in Phase 1, 32 had Stage II UP and 16 had either Stage I or Stage III UP. Compared with Stage I women (4.62%), almost all women with Stage III UP reported reduced quality of life. Decreased quality of life correlated significantly with Stages I–III. Self-reported UP prevalence (8.7%) included all treated and non-treated cases. In Phase 3, 277 of 402 respondents reported being affected by UP and 125 were unaffected. The odds of having UP were threefold higher among illiterate women compared with literate women (OR=3.02, 95% CI 1.76–5.17), 50% lower among women from nuclear families compared with extended families (OR=0.56, 95% CI 0.35–0.90) and lower among women with 1–2 parity compared to >5 parity (OR=0.33, 95% CI 0.14–0.75). Conclusions The stages of UP correlated with quality of life resulting from varied perceptions regarding physical health, emotional stress, and social limitation. Parity, education, age, and family type associated with UP. Our results suggest the importance of developing policies and programs that are focused on early health care for UP. Through family planning and health education programs targeting women, as well as women empowerment programs for prevention of UP, it will be possible to restore quality of life related to UP.Background Uterine prolapse (UP) is a reproductive health problem and public health issue in low-income countries including Nepal. Objective We aimed to identify the contributing factors and stages of UP and its impact on quality of life in the Jhaukhel–Duwakot Health Demographic Surveillance Site of Bhaktapur, Nepal. Design Our three-phase study used descriptive cross-sectional analysis to assess quality of life and stages of UP and case–control analysis to identify contributing factors. First, a household survey explored the prevalence of self-reported UP (Phase 1). Second, we used a standardized tool in a 5-day screening camp to determine quality of life among UP-affected women (Phase 2). Finally, a 1-month community survey traced self-reported cases from Phase 1 (Phase 3). To validate UP diagnoses, we reviewed participants’ clinical records, and we used screening camp records to trace women without UP. Results Among 48 affected women in Phase 1, 32 had Stage II UP and 16 had either Stage I or Stage III UP. Compared with Stage I women (4.62%), almost all women with Stage III UP reported reduced quality of life. Decreased quality of life correlated significantly with Stages I–III. Self-reported UP prevalence (8.7%) included all treated and non-treated cases. In Phase 3, 277 of 402 respondents reported being affected by UP and 125 were unaffected. The odds of having UP were threefold higher among illiterate women compared with literate women (OR=3.02, 95% CI 1.76–5.17), 50% lower among women from nuclear families compared with extended families (OR=0.56, 95% CI 0.35–0.90) and lower among women with 1–2 parity compared to >5 parity (OR=0.33, 95% CI 0.14–0.75). Conclusions The stages of UP correlated with quality of life resulting from varied perceptions regarding physical health, emotional stress, and social limitation. Parity, education, age, and family type associated with UP. Our results suggest the importance of developing policies and programs that are focused on early health care for UP. Through family planning and health education programs targeting women, as well as women empowerment programs for prevention of UP, it will be possible to restore quality of life related to UP.

Knowledge on uterine prolapse among married women of reproductive age in Nepal

Background Uterine prolapse (UP), which affects about 10% of women of reproductive age in Nepal, is the most frequently reported cause of poor health in women of reproductive age and postmenopausal women. Currently, women’s awareness of UP is unknown, and attempts to unravel the UP problem are inadequate. This study aims to assess UP knowledge among married reproductive women, and determine the association between UP knowledge and socioeconomic characteristics. Methods Our cross-sectional descriptive study investigated 25 districts representing all five administrative regions, three ecological zones, and urban and rural settings. We used structured questionnaires to interview 4,693 married women aged 15–49 years. We assessed UP knowledge by asking women whether they had ever heard about UP, followed by specific questions about symptoms and preventive measures. Descriptive statistics characterized the study population regarding socioeconomic status, assessed how many participants had ever heard about UP, and determined UP knowledge level among participants who had heard about the condition. Simple regression analysis identified a possible association between socioeconomic characteristics, ever heard about UP, and level of UP knowledge. Results Mean age of participants was 30 years (SD [standard deviation] 7.4), 67.5% were educated, 48% belonged to the advantaged Brahmin and Chhetri groups, and 22.2% were Janajati from the hill and terai zones. Fifty-three percent had never heard about UP. Among women who had heard about UP, 37.5% had satisfactory knowledge. Any knowledge about UP was associated with both urban and rural settings, age group, and education level. However, satisfactory knowledge about UP was associated with administrative region, ecological zones, caste/ethnic group, and age group of women. Conclusion Fifty-three percent of participants had never heard about UP, and UP knowledge level was satisfactory in 37.% of those who had ever heard about UP. Any knowledge was associated with urban/rural setting, age group, and education level, whereas satisfactory knowledge was associated with geography, caste/ethnic group, and age group. UP-related health promotion programs should target women from all caste/ethnic groups, age groups, and education levels, including urban and rural communities.