|Year : 2014 | Volume
| Issue : 2 | Page : 94-100
Pattern of Institutional delivery in Dadeldhura district of Nepal: A cross-sectional study
Damaru Prasad Paneru
Department of Public Health, School of Health and Allied Sciences, Pokhara University, Kaski, Nepal
|Date of Web Publication||20-May-2014|
Damaru Prasad Paneru
Department of Public Health, School of Health and Allied Sciences, Pokhara University, Kaski
Source of Support: University grants commission, Nepal, Conflict of Interest: None
Background: Maternal mortality ratio of Nepal is one of the highest (380/100000 live births) among the South East Asian countries, where majority of the births take place at home without the assistance of skilled attendant. Latest estimates revealed that only 36.0% births were attended by skilled attendants in Nepal. Objective: To examine the pattern of institutional deliveries among the mothers in Dadeldhura District of Nepal. Materials and Methods: A community-based cross-sectional quantitative study was conducted in Dadeldhura district during October 2012 to March 2013 among 516 mothers who delivered within last 1 year. In addition, 3 years records of District Health Office, Dadeldhura were reviewed. Data were collected by trained enumerators through face to face interview using structured interview schedule. Data were analyzed by SPSS (17.0 versions). Percentage, mean, median, standard deviation, and range were calculated. Results: Mean age of the participants was 24.76 ± 3.77 years. The combined proportion of Dalit and Chhetri was 82.8%. About 17.6% participants were illiterates and 81.6% agriculture workers. About 95% had done one time antenatal care (ANC) visit, while only 64.8% had four time ANC visits during index pregnancy. Majority (82.2%) had received ANC services from primary level health facilities. Almost 77.3% had institutional delivery; among them 59.6% delivered at primary level health facilities. About two-third went to facility on foot, where 45.4% accessed delivery care from a health facility with an approximate distance of >5 km. Almost 55.0% had knowledge of at least one complication occurring during delivery and 74.0% were known about the safe delivery incentive program. Conclusions: Institutional delivery rate was good (77.3%) as against national average (37.0%). Majority (59.6%) had delivery at primary level health facilities. Three quarters were known about Safe Delivery Incentive Programme. Strengthening the capacity of primary level health care facilities in terms of skilled attendants and materials to cater the growing acceptance of local level health facility is recommended to scale up safe delivery practices.
Keywords: Dadeldhura, Institutional delivery, pattern, primary level health facilities
|How to cite this article:|
Paneru DP. Pattern of Institutional delivery in Dadeldhura district of Nepal: A cross-sectional study. J Sci Soc 2014;41:94-100
| Introduction|| |
Globally, almost 358000 maternal deaths occur every year; out of which 80% are preventable deaths. Almost all of maternal deaths (99%) occur in developing countries.  It has been witnessed that there is an annual reduction of 2.3% of maternal mortality since 1990 in the world and the highest reduction rate is seen in South East Asia Region (SEAR). This rapid decline in maternal mortality is driven by India, which has experienced an increase in skilled birth attendants.  World Health Organization, International Confederation of Midwives, and International Federation of Gynecology and Obstetrics highlight the essentiality of skilled birth attendants to save the lives of millions of mothers and newborns. 
Maternal mortality ratio of Nepal is one of the (second) highest (380/100000 live births) in the SEAR.  Nepal has experienced a rapid decline in maternal deaths since last decade (415 maternal deaths/100000 live births in 2000 and 229/100000 live births in 2009); however, majority of the expectant mothers still deliver at home without the assistance of skilled attendants.  Majority (69%) of the maternal deaths and pregnancy complications are due to direct causes wherein postpartum hemorrhage and obstructed labor have major contributions. ,, These conditions are unpredictable which requires immediate assistance of health workers to prevent and prompt management for successful pregnancy outcomes.  National Planning Commission of Nepal claims that two-third of maternal deaths occur during intra-partum period (onset of labor to the delivery of child). 
It has been reported that 81% deliveries in Nepal take place at home and majority of them deliver without the assistance of skilled attendants.  In 2011, only 28% expectant mothers had institutional delivery.  It indicates the Nepal has a long way to achieve the target of 60% births attended by a skilled provider to meet Millennium Development Goals (MDG).  In this context, an attempt has made to examine the pattern of institutional deliveries among the mothers in Dadeldhura District of Nepal.
| Materials and methods|| |
A community-based cross sectional quantitative study was conducted in Dadeldhura district during October 2012-March 2013. Dadeldhura is one of the centrally located hill districts of Far-western Development Region of Nepal. It has 20 Village Development Committees (VDC) and one municipality, 9 Illaka, and 1 electoral constituency. Total population of the district is 153442 and almost all are Hindus. Overall literacy rate is 64.1% (male: 97.5%, female: 48.2%).  Two hospitals situated at the district headquarter serve as referral centers. One Primary Health Care Center at a constituency level, one Health Post/Illaka and one Sub-health Post/VDC are the peripheral outlets of health care system under the allopathic system of medicine. In addition, several Non-governmental organizations, private clinics, polyclinics, and ayurvedic health institutions have been catering health care needs of population. District Health Office serves as a liaison agency for health service delivery in the district.
Sample size for the study was calculated [(n = z 2 p/q/d 2 * coverage 90%)* Design effect] using available statistics: Proportion of institutional delivery (P = 28.45) in Nepal in the year 2009/10 at 95% confidence interval, 5% tolerable error, and the design effect of 1.5. Thus, a total of 516 mothers who delivered within last 1 year were included in the study. The district was divided into 10 clusters with each of the Illaka and a municipality area considered clusters. A total of 50% of 10 clusters (5) were selected randomly. The desired number of eligible mothers from each cluster was determined according to the probability proportionate to the expected pregnancy of Dadeldhura; estimated for the year 2011. House to house visit was made until the desired sample requirement was met. Data were collected by trained enumerators through face to face interview using structured interview schedule. Additionally, 3 years' records of annual report of the District Health Office, Dadeldhura were reviewed to analyze the pattern of institutional delivery. Data were analyzed by SPSS (17.0 Version). Appropriate descriptive statistics were applied wherever required. Ethical approval was taken from Nepal Health Research Council and respective health institutions of the study district.
| Results|| |
General characteristics of participants
Almost half of the participants were 20-24 years with 36.2% being 24-29 years old. Proportion of adolescent (<20 years) and elderly (≥35 years) mothers were 3.3% and 2.7%, respectively (Mean age: 24.76 ± 3.77 years). More than two-fifth were Dalit (A socially low grade caste) and another almost equal proportion was Chhetri (higher caste). The combined proportions of these two groups constitute major mass of the population under study (82.8%). Slightly more than a quarter had primary education, 26.6% were just literates (can just read and write) and 17.6% were illiterates. Only 5.2% participants were found to have their monthly incomes [Table 1]. Great majority of the participants (81.6%) were agriculture workers and only very few had services/business activities [Figure 1].
Information about reproductive health/antenatal care
More than one-third participants (36.2%) were primi gravida followed by almost a quarter (27.9%) was second Gravida (mean: 2.24, median 2). Majority (68.4%) of the participants reported 2-3.9 years birth spacing between last two pregnancies. More than 4/5 th (81.8%) multi gravida mothers had delivered at health facility at least once. More than 95% participants made at least one time antenatal care (ANC) visit during index pregnancy. About 82.2% of the ANC visitors received services from primary level health care facilities (Sub-Health Post/Health Post/Primary Health Care Center), while 16.9% had ANC from hospital. Nearly two-third (64.8%) participants had four time ANC visits, whereas 29.1% had ≤ 3 ANC visits. Almost three quarter participants (72.7%) had first ANC check up in the first trimester followed by a quintile numbers of participants had their first ANC visit during second trimester of the pregnancy [Table 2]. Majority of the participants had their first pregnancy during 20-24 years followed by 28.3% had conceived for the first time during the adolescent period (≤19 years) of life [Figure 2].
|Figure 2: Participants by their age at fi rst pregnancy Mean ± standard deviation = 20.48 ± 2.22 years|
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Out of 516 participants, 77.3% had institutional delivery for the index pregnancy, whereas almost a quarter (22.7%) was home deliveries [Figure 3]. Majority (59.6%) of the institutionally delivered participants had delivered at primary health care facilities and another two-fifth (40.4%) delivered at hospital. Almost 9 out of every 10 had normal vaginal delivery with 3.9% being cesarean sections. Instrumental delivery was considered the assisted delivery, while mothers delivering with the aid of episiotomy were categorized under the normal delivery. Except 5.0%, almost all received free delivery services. About two-third went on foot for delivery at health facility, 18.5% travelled by public vehicles, 14.8% by ambulances, and two had gone with the help of porters. About two-third participants availed delivery services without travel expenses whereas more than one-fifth spent about NRs 1000 (Mean travel expenses: 387.91). Almost a quarter of participants accessed delivery care within 2 km distances, while the highest numbers (45.4%) had accessed with the approximate distance of >5 km from the residence (Median distance: 4 km), which is depicted in [Table 3]. According to the secondary sources, delivery conducted by health workers as percentage of expected pregnancies was 63 at the district level for the year 2011/12 where the cluster-wide variation was reported to be the lowest in Sahasraling (8%) and the highest in Navadurga (55%). Despite the overall percentage of delivery conducted by health workers in Dadeldhura increased by 3% from 2010/11 to 2011/12; however, majority of the clusters showed lower performances with declined achievements as against the immediate last year's performance [Graph 1] [Additional file 1].
|Table 3: Information related to the delivery of index pregnancy (n = 399)|
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Knowledge, health services policy, and practices-related findings
Almost 55.0% participants had knowledge of at least one danger sign/complications occurring during delivery. About three quarter participants opined that delivering at home is unsafe. On the contrary, with the few exceptions (3.5%), almost all opined that delivery at health institution is safe. Almost three quarters (74.0%) were known about the Safe Delivery Incentive Program (SDIP) of Government of Nepal, whereas more than a quarter were unknown about the benefits given under SDIP. Out of 399 participants who had delivered at health facility, more than 95% got incentives under SDIP [Table 4].
|Table 4: Knowledge, health services policy, and practices-related fi ndings|
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| Discussion|| |
In this study, mean age of the participants was reported to be 24.76 ± 3.77 years with majority were 20-24 years age. Dalit and Chhetri jointly constituted major mass (82.8%) of population under study. More than half of the participants had primary level/lower level of education, whereas almost a quintile was illiterates. Almost all participants had no monthly income and a great majority (81.6%) was agriculture workers/housewives. A study from Kavrepalanchok district of Nepal showed that majority were Newar (indigenous population) and Chhetri, three quarters had less than primary education including 50% illiterates, majority were housewives and almost all were Hindus.  Despite some quantitative variations have been observed, the similar trends have been observed in both the studies.
More than one-third participants (36.2%) were primi gravida (mean number of gravida: 2.24). Average number of gravida reported in our study is lower than that was observed in Kavrepalanchok district of Nepal (2.78 ± 1.68).  This reduction in mean numbers of gravida might be attributed to the effective implementation and acceptance of family planning program and increased women's involvement in outdoor service activities. More than four-fifth multi-gravida mothers had reported >2 years spacing between last two pregnancies. Birth spacing reported in our study is lesser than that was reported in Kirtipur Municipality of Kathmandu among the ever married women of reproductive age.  This variation might be due to the differentiation in the profile of participants and residential place with variability in access of delivery services. Four out of every five had ever had institutional delivery at least once, while almost one-fifth had ever delivered at home. It reflects that there has been changing trends with increased adaptation of institutional delivery. Hence, the findings corroborates with the observations of Shrestha et al., 
About 95% mothers had at least one time ANC visit during index pregnancy wherein almost two-third mothers had done four ANC visits. Proportion of first ANC visitors reported in our study were higher than that was reported in several studies conducted in Nepal ,,, and the proportion of first ANC coverage was almost close to the DoHS report 2010/11.  WHO reported that 58% expectant mothers had first ANC visits and 50% had four ANC visits in Nepal in 2012 and these are lesser than the regional average of SEAR.  Findings of this study with respect to first ANC coverage are close to the American/Sri Lankan achievements (95%), and fourth ANC visits are more than regional averages of SEAR (52.0%).  Variations in the ANC coverage might be due to the area specific findings. Although three quarter of the participants had their first ANC visit during the first trimester of pregnancy, it was lower than the standards laid down by WHO for early registration of pregnancy. More than four-fifth received ANC services from primary level health care facilities. Similar observations were made by Gyawali et al., in Midwest region of Nepal.  Majority of the participants had their first pregnancy during 20-24 years, while 28.3% had first conception during adolescent (Mean age at first pregnancy: 20.48 years) period which was slightly higher than that was reported in Kavepalanchok district (20.01 ± 3.07 years) in 2011. 
Out of 516 participants, 77.3% had institutional delivery for the index pregnancy. Our findings are higher than that was reported by Kesterton et al., and Varma et al., for India, several studies conducted in Nepal; and a study from Nigeria. ,,,,,, Furthermore, institutional deliveries reported in this study were lesser than that was observed in Dhanusa and Kathmandu districts of Nepal, where almost 90% had institutional deliveries.  Majority (59.6%) of the participants delivered at primary health care facilities and 40.4% delivered at hospital. Hospital deliveries were reported from 31.0% to 88.0% among all institutional deliveries in Nepal. ,, Majority of the participants in our study delivered at primary health care institutions; however, hospitals were found to be more utilized in others studies from conducted in Nepal. ,, The differences in findings might be due to the limited access to hospital services and improved delivery care facilities at primary health care institutions. Further, Government of Nepal has adopted to develop some of the primary level health care facilities into birthing centers which synergized the service delivery. About two-third went on foot for delivery at health facility where one-third had accessed delivery services by ambulance/vehicle. About two-third participants had no travel expenses as they had accessed care on foot while almost half received care with and approximate distance of >5 km from the residence. These findings are in agreement with one of the national level Indian study where almost one third had access to delivery care <5 km distance.  It indicates that there is limited access to means of transportation and access to care in the district.
Delivery conducted by health workers as percentage of expected pregnancies was 63.0% in Dadeldhura for the year 2011/12 according to the statistics of District Health Office and the large variation was reported from 8.0% 55.0% within the study clusters. Department of Health Services (DoHS), Nepal also reports the wide ecological and regional variation in the deliveries conducted by health workers in Nepal with 93.0% in Dhanusa (plain) Nepal and 7.0% in Manag (mountain) districts of Nepal.  Within the country, the least proportion of deliveries were assisted by health workers was observed in western and the highest in central region. Similarly, World health statistics reveals that the highest proportions of birth attended by SBA were there in Europe (98.0%), while only 59% births were attended by SBA in SEAR. Wide variation has been seen in SEAR, that is, 99% births are attended by Skilled Birth Attendants (SBA) in Sri Lanka, only 36% in Nepal, and almost 47% in India. These differences indicate that Nepal has a long way to achieve the target of 60% births attended by SBA to achieve Millennium Development Goals.
Almost 55.0% participants were known about at least one danger sign/complications occurring during delivery. About three quarter participants said that home delivery is unsafe, while almost all (96.5%) opined that institutional delivery is safe. Almost three quarters were known about the SDIP and 95% of institutionally delivered mothers got incentives under SDIP. Bhusal et al., reported that 100% women delivering at health facility were known about the SDIP and 95% got incentives, while DoHS reports incentive received status of 89.0%.  Results of this study are closer to the DoHS reports.
| Conclusion|| |
Quite excellent (95.0%) antenatal registration practice was observed among the participants; however, only two third had four ANC visits. About 77.3% had institutional delivery which was higher than that of national averages (37.0%). Majority (59.6%) had delivered at primary health care facilities, where majority accessed care on foot with an approximate >5 km distance from the residence. Only 55.0% were known about at least one complication occurring at delivery and three quarters were known about SDIP and 95.7% got incentives. Establishment of pregnancy monitoring and counseling system at system to improve their compliance and strengthening the primary level health care facilities will further increase institutional delivery.
| Acknowledgment|| |
The author is thankful to the University Grants Commission, Nepal for the financial support, District Health Office, Dadeldhura for the permission to conduct this study in its jurisdiction; and participants and the team members for their cooperation.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]