Determinants of quality of care and access to Basic Emergency Obstetric and Neonatal Care facilities and midwife-led facilities in low and middle-income countries: A Systematic Review

Background: Maternal mortality is a major challenge to health systems in Low and Middle-Income Countries (LMICs) where almost 99% of maternal deaths occurred in 2015. Primary-care facilities providing Basic Emergency Obstetric and Neonatal Care (BEmONC) facilities, and facilities that are midwife-led are appropriate for normal birth in LMICs and have been proposed as the best approach to reduce maternal deaths. However, the poor quality of maternal services that leads to decreased utilisation of these facilities is among the major causes of maternal deaths worldwide. This systematic review studied factors affecting the quality of care in BEmONC and midwife-led facilities in LMICs. Methods: A number of public health and social science databases were searched using the following search terms: birth centre, skilled birth attendant, low-income/developing countries and quality of care. Articles in English discussing components of quality of care of BEmONC facilities published since 1990 were included. Of the 67 full-text articles reviewed, 28 were included in the study based on inclusion and exclusion criteria. Data were extracted on a standard form and analysed thematically. Results: Most articles were from Africa (n=20) and were quantitative surveys or cohort studies (n=14). Thematic analysis of the main ideas revealed various factors affecting quality of care including facility level determinants and other determinants influencing access to care. Facility-level determinants included these barriers: lack of equipment and drugs at the facility, lack of trained staff, poor attitudes and behaviour of service providers, and poor communication with women. Facility level positive determinants were: satisfaction with services, emotional support during delivery and trust in health providers. The access-to-care determinants were: socio-economic factors, physical access to the facility, maintaining privacy and confidentiality, and cultural values. Conclusion: Improving quality of care of birthing facilities requires addressing both facility level and non-facility level determinants in order to increase utilization of the services available at the BEmONC and midwife-led facilities in LMICs

Birthing centres in Nepal: Recent developments, obstacles and opportunities

Background: Establishing and promoting birthing centers (BCs) can be one strategy to increase access to emergency obstetric care and skilled attendants at birth, to avert many maternal deaths. BCs are a component of local health service delivery, whereby midwives (or health care professionals with midwifery competencies) provide maternity services to generally healthy women with uncomplicated pregnancies, mostly in the community setting. Methods: A literature review was carried out involving searches and appraisals of relevant literature on birthing centers in Nepal, South Asia, and other similar settings. Findings//Conclusion: In Nepal, midwife-led care in BCs was found to be appropriate for pregnant women, with no complications, for giving birth. BCs have the potential to improve both (a) the institutional delivery rate and (b) the proportion of births that benefit from the presence of a skilled birth attendant (SBA). However, accessibility, socio-demographic characteristics, and cultural factors act as barriers to pregnant women attending birthing centres and hospital facilities. Moreover, there is an increasing trend of bypassing BCs to give birth in hospitals. The increase in facility-based births requires more monitoring of the quality of care provided

Factors affecting health facility delivery in rural Nawalparasi district of Nepal

Objective: In Nepal, both percentage of women giving birth at health facility and proportion of birth assisted by skilled birth attendant is very low. The purpose of this research was to investigate the factors related to health facility delivery in two levels of care in Nepal: primary health care and tertiary health care facilities. Methods: A cross-sectional household survey was conducted in seven villages of a district lying in plain area of Nepal: Nawalparasi. A structured interview questionnaire was developed and administered face-to-face. Descriptive analysis along with chi-square test and multinomial logistic regression was used to identify the predictors of institutional delivery. Results: Women were significantly more likely to deliver at health care facilities compared to home if the distance was less than one hour, belonged to advantaged caste, had radio, television and motorbike/scooter, decision maker for place of delivery was husband, reported their frequency of antenatal (ANC) visits at 4 or more and belonged to age group 15-19. Conclusion: Women have less control over making decisions related to their choice for place of birth rather it is mostly made by husbands. The findings highlight importance of having four or more ANC visits to the health institutions and that it should be located within one-hour walking distance. Inequity in utilisation of delivery services at health institutions exists as showed by low utilisation of such services by disadvantaged caste

Nepal needs midwifery

This paper is published as a Commentary. It has no abstract, but the paper links the Millennium Development Goals to the maternity workforce in Nepal and highlights to need for recognition of the midwifery profession in that country

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal.

INTRODUCTION: Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings. METHODS: This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys. RESULTS: The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014). CONCLUSION: BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility

Stakeholders' perceptions of continuing professional development among Nepalese nurses: A focus group study.

AIM: This study explores perceptions of Continuing Professional Development (CPD) opportunities among stakeholders in the profession of nursing in Nepal. DESIGN: Qualitative study using focus group discussions (FGDs). METHODS: Eight FGDs were conducted in three major cities of Nepal with nursing stakeholders including nurse managers, matrons and directors/managers of private and public nursing colleges, representatives of nursing organizations, government officials, nursing academics and practitioners from the government and private sectors. The data were analysed thematically using Creswell's six steps of analysis and the Standards for Reporting Qualitative Research (SRQR) guideline was followed. RESULTS: The study generated three major themes: (a) policy level including the national situation of CPD, political influence and training guided by the policy; (b) organizational level incorporating perceptions towards forms of CPD, staff shortage, poor staff retention, seniority for training, financial constraints and lack of continuity of training; and (c) individual level including motivation for training and lack of relevant training

Birthing centre infrastructure in Nepal post 2015 earthquake

We suggest that a focus on improving facility delivery services starting from the most severely affected districts could be the necessary step towards achieving universal health care. Technical and financial support offered by international development partners can play a crucial role in enhancing the capabilities of health care facilities including birthing centres.</jats:p

Effects of COVID-19 during lockdown in Nepal.

Nepal started its full lockdown on March 24, 2020 and has been extended until 14 June 2020 as a precaution for prevention of COVID-19 infection. However, the strict lockdown has been criticised by many as not all the deaths are caused by COVID-19. The long and strict lockdown have had some negative effects in many aspects of health of an individual in the community. Many women are facing barriers to access maternity health care during the lockdown period and there has been rise in the suicidal behaviour such as sucidal attempt and actual suicide itself among the general population. As the lockdown began in Nepal, all the school and colleges were suspended, and children were forced to spend their time indoors and exams has been postponed leaving the students stressed about the uncertainty of their future. Social distancing, isolation and quarantine at home can result in isolated in an abusive home where there could be even more increase in abuse during such crisis. Millions of babies are missing the routine vaccinations which is a threat to global achievement in immunization. Apart from the rise in negative impact on health of Nepali people, there are other impacts related to health such as serious impacts on logistics and supply management including shortage of medicine and food supply; and impacts on farming including both production and sale. Nepal took several precautionary measures as a response towards COVID-19 such as First, limiting international air travel, sealing the land border-crossings with India and introduction of social distancing measures. However, with rise in deaths due to non COVID related causes and negative impacts on economic and financial condition of the country, there is a need for the country to ease its lockdown. Contact tracing, making face mask mandatory along with social distancing measure can be an alternative to lockdown for Nepal while the country is preparing to ease its lockdown. Social distancing, hygiene, lifestyle factors and PPE measures need to continue for long term, whilst we need to keep working on the big public health issues such as poverty reduction, improving access to health service to achieve universal health coverage

National Workshop on Mental Health Education & Research

Bournemouth University, Liverpool John Moores University and Tribhuvan University in Nepal organised a two-day National Workshop on Mental Health Education & Research in Kathmandu in August 2016. The workshop handbook is a combination of update on the project as well as training materials for nurses and public health lecturers