Prem Bhandari

Factors affecting institutional delivery in rural Chitwan district of Nepal: a community-based cross-sectional study

BackgroundHealth facility delivery is considered a critical strategy to improve maternal health. The Government of Nepal is promoting institutional delivery through different incentive programmes and the establishment of birthing centres. This study aimed to identify the socio-demographic, socio-cultural, and health service-related factors influencing institutional delivery uptake in rural areas of Chitwan district, where high rates of institutional deliveries co-exist with a significant proportion of home deliveries.MethodsThis community-based cross-sectional study was conducted in six rural Village Development Committees of Chitwan district, which are characterised by relatively low institutional delivery rates and the availability of birthing centres. The study area represents both hilly and plain areas of Chitwan. A total of 673 mothers who had given birth during a one-year-period were interviewed using a structured questionnaire. Univariate and multivariable logistic regression analysis using stepwise backward elimination was performed to identify key factors affecting institutional delivery.ResultsAdjusting for all other factors in the final model, advantaged caste/ethnicity [aOR: 1.98; 95% CI: 1.15-3.42], support for institutional delivery by the husband [aOR: 19.85; 95% CI: 8.53-46.21], the decision on place of delivery taken jointly by women and family members [aOR: 5.43; 95% CI: 2.91-10.16] or by family members alone [aOR: 4.61; 95% CI: 2.56-8.28], birth preparations [aOR: 1.75; 95% CI: 1.04-2.92], complications during the most recent pregnancy/delivery [aOR: 2.88; 95% CI: 1.67-4.98], a perception that skilled health workers are always available [aOR: 2.70; 95% CI: 1.20-6.07] and a birthing facility located within one hour’s travelling distance [aOR: 2.15; 95% CI: 1.26-3.69] significantly increased the likelihood of institutional delivery. On the other hand, not knowing about the adequacy of physical facilities significantly decreased the likelihood of institutional delivery [aOR: 0.14; 95% CI: 0.05-0.41].ConclusionWith multiple incentives present, the decision to deliver in a health facility is affected by a complex interplay of socio-demographic, socio-cultural, and health service-related factors. Family decision-making roles and a husband’s support for institutional delivery exert a particularly strong influence on the place of delivery, and this should be emphasized in the health policy as well as development and implementation of maternal health programmes in Nepal.

Family planning in refugee settings: findings and actions from a multi-country study

BackgroundTo address family planning for crisis-affected communities, in 2011 and 2012, the United Nations High Commissioner for Refugees and the Women’s Refugee Commission undertook a multi-country assessment to document knowledge of family planning, beliefs and practices of refugees, and the state of service provision in the select refugee settings of Cox’s Bazar, Bangladesh; Ali Addeh, Djibouti; Amman, Jordan; Eastleigh, Kenya; Kuala Lumpur, Malaysia; and Nakivale, Uganda.MethodsThe studies employed mixed methods: a household survey, facility assessments, in-depth interviews, and focus group discussions.ResultsFindings on awareness and demand for family planning, availability, accessibility, and quality of services showed that adult women aged 20–29 years were significantly more likely to be aware, to have ever used, or are currently using a modern method as compared to adolescent girls aged 15–19 years. Facility assessments showed limited availability of certain methods, especially long-acting and permanent methods. Despite availability, in all sites, focus group discussion participants—especially adolescents—reported many accessibility-related barriers to using existing services, including distant service delivery points, cost of transport, lack of knowledge about different types of methods, misinformation and misconceptions, religious opposition, cultural factors, language barriers with providers, and provider biases.ConclusionBased on gaps, partners to the study developed short and long-term recommendations around improving service availability, accessibility, and quality. There remains a need to scale up support for refugees, particularly around adolescent access to family planning services.

A calendar method of collecting remittance use data in a remittance dependent setting of Nepal

This methodological paper describes the design and refinement of a calendar method of collecting data on remittance receipt and remittance use and its piloting in a rural remittance dependent setting of Nepal. Much of the previous national surveys collected remittance receipt and remittance use cross-sectional data that used a time frame ranging from 12 to 24 months. These surveys collected remittance receipt data by asking, ‘How much money has he/she sent in the past 12 months or 2 years?’ We believe that the long time frame of one to two years adds burden to respondents for unnecessary calculations and is prone to re-call bias. Moreover, these surveys used vague words such as ‘capital formation’ or ‘daily consumption’ to measure the uses of remittances. Thus, the instrument perse is unreliable posing threats to collecting valid responses. Considering these flaws, in 2013, we designed a calendar with shorter timing cues and simple words for collecting longitudinal data on remittance receipt and remittance use. First, we describe the calendar design process. Next, we provide descriptive results of household responses on the amount of remittance received and the remittance used on various socio-economic and cultural dimensions of household activities. The implications of the insights gained from this study are discussed.

Rural Agricultural Change and Individual Out‐migration

We investigate the impact of household use of labor-saving farm technologies on first-time out-migration after the household agriculture and consumption survey was conducted in 1996. Building on the labor substitution framework, we hypothesize that household use of labor-saving technologies (e.g., tractors, farm implements, chemical fertilizers, and pesticides) increases individual out-migration. To estimate the effects of the use of labor-saving farm technologies on out-migration, we use uniquely detailed panel data from the rapidly changing rural agrarian, migrantsending setting of Nepal. The results of our multilevel, discrete-time, event history models suggest that net of other known factors associated with outmigration, household use of farm technology—particularly the use of tractors—significantly increases out-migration.

Strategies for origin-based surveying of international migrants

ABSTRACT This paper addresses methodological challenges of investigations of international migration, including difficulties in obtaining information about representative samples of migrants and both their origin and destination location. Our project used an origin-based sample with a destination-focused survey and interviewed 91% of migrants from a community in Nepal to any destination and shares techniques employed. Our procedures and high response rate constitute a significant improvement in survey methods that permit the creation of unbiased data on migrants and allow the study of migration in conjunction with origin communities.

Postmarital Living Arrangements in Historically Patrilocal Settings: Integrating Household Fission and Migration Perspectives

This study integrates theory and research on household fission (or partition) and migration to better understand living arrangements following marriage, especially in historically patrilocal and primarily agricultural settings. Using panel data from the Chitwan Valley Family Study to analyze the sequential decision-making process that influences men’s living arrangements subsequent to first marriage, we demonstrate the importance of distinguishing among extended family living, temporary migration, and the establishment of an independent household. We find that community economic characteristics, such as access to markets or employment, as well as household wealth affect the initial decision to leave the natal home. Household resources and use of farmland, along with the young men’s own education, media exposure, travel, and marital behavior, influence the decision to make the departure from the natal home permanent. Our findings explain why previous results regarding household fission and those focused on migration have provided such mixed results, and we establish a new framework for thinking about how families and individuals manage living situations.