Abstract
Objectives
To identify the determinants of institutional delivery among young married women in Nepal.
Design
Nepal Demographic and Health Survey (NDHS) data sets 2011 were analysed. Bivariate and multivariate logistic regression analyses were performed using a subset of 1662 ever-married young women (aged 15–24 years).
Outcome measure
Place of delivery.
Results
The rate of institutional delivery among young married women was 46%, which is higher than the national average (35%) among all women of reproductive age. Young women who had more than four antenatal care (ANC) visits were three times more likely to deliver in a health institution compared with women who had no antenatal care visit (OR: 3.05; 95% CI: 2.40 to 3.87). The probability of delivering in an institution was 69% higher among young urban women than among young women who lived in rural areas. Young women who had secondary or above secondary level education were 1.63 times more likely to choose institutional delivery than young women who had no formal education (OR: 1.626; 95% CI: 1.171 to 2.258). Lower use of a health institution for delivery was also observed among poor young women. Results showed that wealthy young women were 2.12 times more likely to deliver their child in an institution compared with poor young women (OR: 2.107; 95% CI: 1.53 to 2.898). Other factors such as the age of the young woman, religion, ethnicity, and ecological zone were also associated with institutional delivery.
Conclusions
Maternal health programs should be designed to encourage young women to receive adequate ANC (at least four visits). Moreover, health programs should target poor, less educated, rural, young women who live in mountain regions, are of Janajati ethnicity and have at least one child as such women are less likely to choose institutional delivery in Nepal.
Keywords: PUBLIC HEALTH, Maternal Health, Adolescent health, Nepal
Strength and limitations of the study.
One of the strengths of this study is the use of data from the most recent nationally representative survey (the Nepal Demographic and Health Survey (NDHS) 2011), so the findings can be generalized to national and regional populations in Nepal.
One limitation is the cross-sectional study design which does not confirm a causal relationship between dependent and independent variables.
Moreover, this study does not explain any programmatic and socio-cultural factors of the determinants of institutional delivery as the NDHS did not collect data related to these factors.
Recall bias, a potential limitation of the NDHS, could have limited the study findings.
Introduction
Over the past 25 years, the global maternal mortality ratio (MMR) has fallen by nearly 44% from an estimated 385 maternal deaths per 100 000 livebirths in 1990 to an MMR of 216 in 2015.1 Despite the significant reduction in maternal mortality, every day about 830 women still die during pregnancy and childbirth. The majority (99%) of these deaths occur in developing countries.2 After sub-Saharan Africa, countries in Southern Asia (including Nepal) have the highest maternal mortality rates.
Several studies have shown that compared with adult women, young women (aged 15–24 years) including adolescent (aged 10–19 years) girls are at higher risk of pregnancy and delivery complications, and even death.2 Preterm delivery, systemic infection, low birth weight, perinatal death and maternal mortality are common among young women, particularly among adolescents.3–5
An important strategy for decreasing maternal mortality is to utilise adequate, quality maternal health services in a timely manner. Delivery complications and death can be averted by a hospital or institution- assisted delivery with the assistance of skilled care providers within an enabling environment, and by effective referral systems.6–9
The government of Nepal has been implementing a free delivery policy since 2009, providing incentives to women who choose to deliver in a designated health facility.9 However, the country continues to have a high MMR (229 per 100 000 live births),1 10 with underutilization of maternal health services one of the reasons contributing to this high maternal death rate in Nepal.11 Recently, a nationwide survey showed that about 6 in 10 pregnant women received antenatal care (ANC) from skilled providers, while only 35% of childbirths occurred in health institutions.10
The literature showed that several socio-demographic, economic and cultural factors play a role in determining whether women in Nepal use skilled birth attendants and institutional delivery. Women’s education, ethnicity, area of residence, autonomy, involvement in a community group and wealth, together with poor infrastructure and lack of services appear to be major factors affecting utilisation of institutional delivery in Nepal.6 9 12–20 However, most studies included all women of reproductive age (15–49 years). So far, no study has explicitly focused on young women’s use of institutional delivery and factors influencing their utilisation of maternal health services (ie, institutional delivery).
As most existing studies conducted in Nepal have examined all women of reproductive age, a broader range of data needed to be collected at a national level and for specific age groups, such as young women (aged 15–24 years). Therefore, this study aimed to identify the determinants of institutional delivery among young women in Nepal.
As the survey (Nepal Demographic and Health Survey (NDHS)) did not collect pregnancy or delivery-related information from unmarred young women, this study only included married young women. The findings of the study may be useful for health programme managers and policy makers for generating policy and designing maternal health programs targeting young (including adolescent) women in Nepal.
Methods
Source of data
We analysed the NDHS 2011 data set for this study. NDHS is a nationally representative survey which aims to provide reliable and current data on fertility, family planning, child health and nutritional status, use of maternal health services, domestic violence, and HIV/AIDS-related information. NDHS was conducted under the guidance of the Population Division of the Ministry of Health and Population, Nepal.
Sample size
A total of 12 674 women of reproductive age completed interviews for NDHS 2011. Of those, 4148 had had at least one live birth in the 5 years preceding the survey. Given our study objective, our analysis was based on the 1662 ever-married young women (15–24 years of age) who had had at least one birth in the 5 years preceding NDHS 2011.
Variables
Dependent variable
We used ‘place of delivery’ as a dependent variable. We categorised this variable into home delivery (when birth took place at home) and institutional delivery (when birth took place at a hospital or primary healthcare centre or a health post or sub-health post).
Independent variables
The independent variables included in this study were: age, ethnicity, educational level, religion, ecological zone, place of residence, wealth, parity, sex of the head of household, the woman’s involvement in a community group, number of ANC visits for the most recent live birth, and the woman’s autonomy in household decisions. In the NDHS, the wealth variable has five categories: poorest, poorer, middle, richer and richest. However, for better explanation and given our specific sample, we recoded the variable into three categories where 'poor' included 'poorest' and 'poorer', 'middle' included 'middle', and 'rich' included 'richer' and 'richest'. The variable ‘woman’s autonomy in household decisions’ was categorised based on whether a young woman participated in decision making in the areas of: (1) her healthcare, (2) making major household purchases, and (3) visits to her family and relatives. The category ‘no decision’ meant that none of the three decisions were taken by the woman, ‘moderate autonomy’ indicated that a woman participated in making at least one or two decisions in the three mentioned areas, and ‘higher autonomy’ showed that a woman participated in decision making in all three areas.
Data analysis
Bivariate analysis (Pearson’s χ2 test) was done to assess the relationship between the dependent and independent variables. A binary logistic regression analysis was carried out to determine the adjusted effect of each factor on the dependent variable (place of delivery) taking into account the survey design (strata and sampling weights) and clusters. Multicollinearity was checked before logistic regression. The final logistic regression model was constructed theoretically and included those variables identified in the literature as important for determining the utilisation of maternal health services. The results of the logistic regression analysis were presented by OR with 95% CI. All statistical analyses were performed using SPSS 16.1 for Windows.
Results
Results showed that among all young women who had given birth at least once within the last 5 years preceding the survey, 80% of them were between 20 and 24 years of age. About one-third of the young women did not have any formal education, approximately 85% were Hindu and more than 90% were living in a rural area. Almost 41% of the young women fell into the poorest socio-economic category, 55% had received at least four ANC visits and 43% did not have any household decision-making autonomy (table 1).
Table 1.
Demographic and socio-economic characteristics | Number | Percentage (%) | Home delivery (%) | Institutional delivery (%) |
Age*** | ||||
15–19 | 333 | 20.0 | 44.4 | 55.6 |
20–24 | 1329 | 80.0 | 56.0 | 44.0 |
Ethnicity*** | ||||
Brahmin/Chhetri | 449 | 27.0 | 45.4 | 54.6 |
Janajati | 635 | 38.2 | 58.4 | 41.6 |
Dalit | 301 | 18.1 | 56.9 | 43.1 |
Other | 276 | 16.6 | 53.1 | 46.9 |
Educational level*** | ||||
No education | 524 | 31.5 | 70.8 | 29.2 |
Primary | 397 | 23.9 | 58.2 | 41.8 |
Secondary or above | 741 | 44.6 | 39.2 | 60.8 |
Religion* | ||||
Hindu | 1401 | 84.3 | 52.8 | 47.2 |
Buddhist | 142 | 8.5 | 66.4 | 33.6 |
Muslim | 83 | 5.0 | 48.0 | 52.0 |
Kirat/Christian | 36 | 2.2 | 54.4 | 45.6 |
Ecological zone*** | ||||
Mountain | 116 | 7.0 | 66.1 | 33.9 |
Hill | 610 | 36.7 | 60.0 | 40.0 |
The Terai | 935 | 56.3 | 48.1 | 51.9 |
Place of residence*** | ||||
Urban | 146 | 8.8 | 22.3 | 77.7 |
Rural | 1516 | 91.2 | 56.7 | 43.3 |
Wealth*** | ||||
Poor | 679 | 40.9 | 70.7 | 29.3 |
Middle | 410 | 24.7 | 53.5 | 46.5 |
Rich | 572 | 34.4 | 33.7 | 66.3 |
Parity*** | ||||
One | 959 | 57.7 | 42.4 | 57.6 |
Two | 505 | 30.4 | 67.0 | 33.0 |
Three | 165 | 10.0 | 76.0 | 24.0 |
Four or more | 33 | 2.0 | 65.4 | 34.6 |
Sex of head of household | ||||
Male | 1246 | 75.0 | 54.0 | 46.0 |
Female | 415 | 25.0 | 53.0 | 47.0 |
Involvement in a community group | ||||
Not involved in any community group | 1128 | 67.9 | 53.5 | 46.5 |
Involved in a community group | 534 | 32.1 | 54.2 | 45.8 |
Number of ANC visits for the most recent live birth*** | ||||
Less than 4 visits | 745 | 45.0 | 72.0 | 28.0 |
4 or more visits | 917 | 55.0 | 39.0 | 61.0 |
Decisions on own healthcare*** | ||||
Without involvement of respondent | 831 | 50.0 | 58.7 | 41.3 |
Involvement of respondent | 831 | 50.0 | 48.7 | 51.3 |
Decisions on making large household purchases | ||||
Without involvement of respondent | 1092 | 65.7 | 54.8 | 45.2 |
Involvement of respondent | 570 | 34.3 | 51.5 | 48.5 |
Decisions on visits to family or relatives | ||||
Without involvement of respondent | 1046 | 62.9 | 54.3 | 45.7 |
Involvement of respondent | 616 | 37.1 | 52.7 | 47.3 |
Women's autonomy in household decisions** | ||||
No autonomy | 708 | 42.6 | 58.9 | 41.1 |
Moderate autonomy (involved in 1 or 2 issues) | 528 | 31.8 | 48.5 | 51.5 |
High autonomy (involved in all 3 issues) | 426 | 25.6 | 51.6 | 48.4 |
Total | 1662 | 100.0 | 53.7 | 46.3 |
***p<0.001, **p<0.01 , *p<0.05.
ANC, antenatal care.
About 46% of the young women chose an institutional location for their most recent delivery. Young women between 15 and 19 years (adolescents) of age had more institutional deliveries than young adult women (aged 20–24 years) (56% vs. 44%). Other socio-demographic variables which appeared to be associated with place of delivery included ethnicity, level of education, religion, place of residence, wealth, parity, number of ANC visits, and woman’s autonomy in household decisions. Young women who were poor, not pregnant for the first time, had received less than four ANC visits, had a lower level of education, lived in a rural area, and those from the mountain region had the lowest number of institutional deliveries (table 1).
Multivariate analysis (table 2) showed that age had a significant effect on the use of institutional delivery among young women. After controlling for other socio-demographic variables, women between 15 and 19 years of age had a significantly higher percentage of institutional deliveries than young women aged 20–24 years (OR: 1.41; 95% CI 1.050 to 1.895). The probability of institutional delivery was approximately 30% higher among young women belonging to the Brahmin/Chhetri ethnic group compared with women belonging to the Janajati ethnic group. Young women who had a secondary or above level of education were 1.63 times more likely to have an institutional delivery compared with young women who had no formal education (OR: 1.626; 95% CI: 1.171 to 2.258). Young Muslim women were 1.82 times more likely to deliver at an institution compared with young Hindu women. Regarding their place of residence, the probability of giving birth in an institution was about 69% higher among young urban women compared with rural women. Young women from the Terai region were 1.7 times more likely to choose institutional delivery than those from the mountain region (OR: 1.695; 95% CI: 1.044 to 2.751).
Table 2.
Demographic and socio-economic characteristics | Institutional delivery | |
OR | 95% CI | |
Age group | ||
15–19 | 1.410* | 1.050 to 1.895 |
20–24 | 1.000 | |
Ethnicity | ||
Brahmin/Chhetri | 1.000 | |
Janajati | 0.697* | 0.509 to 0.954 |
Dalit | 0.923 | 0.643 to 1.343 |
Other | 0.814 | 0.515 to 1.285 |
Educational level | ||
No education | 1.000 | |
Primary | 1.292 | 0.934 to 1.789 |
Secondary or above | 1.626** | 1.171 to 2.258 |
Religion | ||
Hindu | 1.000 | |
Buddhist | 0.818 | 0.517 to 1.295 |
Muslim | 1.820* | 1.017 to 3.258 |
Kirat/Christian | 0.850 | 0.406 to 1.778 |
Ecological zone | ||
Mountain | 1.000 | |
Hill | 0.956 | 0.597 to 1.530 |
The Terai | 1.695* | 1.044 to 2.751 |
Place of residence | ||
Urban | 1.000 | |
Rural | 0.311*** | 0.197 to 0.492 |
Wealth | ||
Poor | 1.000 | |
Middle | 1.611** | 1.197 to 2.169 |
Rich | 2.107*** | 1.532 to 2.898 |
Parity | ||
One | 1.000 | |
Two | 0.436*** | 0.335 to 0.567 |
Three | 0.360*** | 0.228 to 0.567 |
Four or more | 0.730 | 0.319 to 1.670 |
Sex of head of household | ||
Male | 1.000 | |
Female | 0.997 | .0.764 to 1.300 |
Involved in community group | ||
Not involved in a community group | 1.000 | |
Involved in a community group | 0.867 | 0.675 to 1.115 |
Number of ANC visits for the most recent live birth | ||
Less than 4 visits | 1.000 | |
4 or more visits | 3.049*** | 2.402 to 3.870 |
Women's autonomy in household decision | ||
No autonomy | 1.000 | |
Moderate autonomy (involved in 1 or 2 issues) | 1.255 | 0.955 to 1.648 |
High autonomy (involved in all 3 issues) | 1.239 | 0.923 to 1.664 |
***p<0.001, **p<0.01, *p<0.05.
ANC, antenatal care.
Young women in the wealthiest category were 2.12 times more likely to deliver in an institution compared with young women in the poorest category (OR: 2.107; 95% CI: 1.53 to 2.898). Young women who were pregnant for the first time were more likely to choose institutional delivery than those who had given birth previously. Regarding the use of ANC, young women who had received four or more ANC visits were about three times more likely to choose institutional delivery compared with young women who had received less than four ANC visits (OR: 3.049; 95% CI: 2.402 to 3.870).
Discussion
Although institutional delivery rates (46%) were higher among young women compared with the national average (35%) among all women of reproductive age, there were disparities among young women in choosing a health institution for delivery.
According to NDHS 2011, after controlling for available independent factors, young women who were poor, less educated, between 20 and 24 years of age, resided in rural areas, were from a mountainous region, were of Janajati ethnicity, had received less than four ANC visits and had a previous delivery were less likely to give birth in an institution. On the other hand, young women from urban area who were rich, educated, had received at least four ANC visits, were pregnant for the first time, were of Brahmin/Chhetri ethnicity and from the Terai region were more likely to choose institutional delivery.
The use of ANC is strongly associated with institutional delivery among young married women in Nepal. Age, ethnicity, level of education, religion, place of residence, wealth and parity were also potential determinants of institutional delivery.
Consistent with the results of other research conducted in Nepal and in other developing countries among all women of reproductive age, this study showed that the use of ANC was positively associated with institutional delivery.6 9 21–24 Studies conducted in Nepal among all women of reproductive age also showed that frequency of ANC visits was associated with the use of institutional delivery .9 25
Adequate use of ANC is likely to raise pregnant women's awareness of possible complications and safe delivery practices, which ultimately encourages them to seek institutional delivery.23 26–30 However, counselling during ANC has been shown to be poor in many settings and reduced ANC effectiveness for increasing institutional delivery.31
The literature revealed that adolescents were less likely to seek skilled maternal health services including institutional delivery compared with adults and young adults.32–35 Inconsistent with the findings of other reports, this study revealed that in Nepal, adolescent women (aged 15–19 years) were more likely to seek institutional delivery compared with older young women (20–24 years) and adult women. However, another study (n=644 women) conducted in the Kaski district of Nepal showed that the woman’s age was not significantly associated with place of delivery.9 One possible reason for the increased use of institutional delivery by adolescent girls (aged 15–19 years) may be that they are more aware of the consequences of adolescent pregnancy because of the ongoing campaigns to decrease the rates of adolescent pregnancies and improve the maternal health of adolescent women in Nepal.36 However, it could also be that adolescent women are typically referred to deliver at a health institution as they are at higher risk of delivery complications compared with adult women.37 38
This study showed that young women of Brahmin/Chhetri ethnicity were more likely to choose delivery at a health institution compared with young women of Janajati ethnicity, which can be explained by the higher socio-economic status of those with Brahmin/Chhetri ethnicity compared to those with Janajati ethnicity.39 However, it should be noted that another study conducted in Nepal showed that ethnicity was not associated with place of delivery.40
Consistent with the findings of other studies in Nepal and Southern Asia, this report also showed that education was one of the most important factors influencing institutional delivery among women of all ages.13 18 22 32 40–42 Women with a higher level of education (who were often wealthier) knew more about maternal health and were more aware of skilled maternal health services including institutional delivery.32 43 44 Also, a study conducted in Nepal showed that women with a higher level of education had greater decision-making autonomy concerning their health and well-being.20 However, this study found that women’s autonomy in household decisions was not significantly associated with the use of institutional delivery. This variation in results could be due to differences in the sample sizes of the studies. This study considered only young women (n=1662) while another considered women of all ages (n=4148).
The literature showed that the accessibility and availability of quality maternal health services influence the use of an institution for delivery.8 9 28 31 45 46 This study demonstrated that young women from the mountain region were less likely to choose institutional delivery compared with women in the Terai region. This could be due to poor access to and availability of quality health services in the mountain region of Nepal. However, another study conducted using NDHS 2011 data showed that region of residence was not associated with place of delivery25: however, the variation in sample sizes among studies might have influenced the results. This study only considered young women, while the other study25 considered all women of reproductive age. Other reasons might be the lack of education and awareness concerning maternal health among young women living in the mountain region.
Studies revealed that the place of residence showed a significant association with institutional delivery among women of reproductive age including young women, which was also identified in other studies.13 19 22 42 Women residing in rural areas are less likely to choose institutional delivery than women living in urban areas. Increased rates of institutional delivery in urban settings could be due to easier accessibility to and better availability of medical facilities for maternal and child healthcare in urban compared with rural settings.
Similar to the findings of other reports, this study also found a strong positive association between women's wealth and their use of institutional delivery.9 13 22 32 34 47 A qualitative study conducted in Nepal showed that financial problems were one of the reasons women did not chose a health institution for delivery.46 Irrespective of their place of residence (rural/urban), wealthy young women always received better health services, such as institutional delivery. Although the government of Nepal subsidises the cost of institutional delivery, poor young women were less likely to choose institutional delivery compared with more wealthy young women, possibly because of hidden costs (eg, medicines, transport) associated with institutional delivery or other cultural barriers that may exist among poorer women. It was found that financial support from the government was not sufficient to cover all relevant costs incurred when delivering in an institution.46
Finally, this study found that parity is a strong predictor of institutional delivery among young women, which is consistent with the results of other studies among all women of reproductive age.6 32 42 Women who were pregnant for the first time were more likely to choose institutional delivery than those with second or later pregnancies. Young women in their first pregnancy might be more careful or anxious about childbirth due to their inexperience regarding pregnancy and delivery. Young women including adolescents might be more aware of the risks and potential complications of pregnancy and delivery because of several campaigns and maternal health projects in Nepal, Therefore, if the first pregnancy occurs during adolescence, it might influence young women to seek institutional delivery. In addition, if there were no complications with a previous home delivery, then the woman might again prefer a home delivery for subsequent pregnancies.
The main strength of this study was the use of a nationally representative data set. However, a limitation was that NDHS did not provide information about accessibility (ie, distance to a health facility) or the quality of healthcare providers which might influence the use of institutional delivery among young women. The fact that the data used in this study were a few years old was also a limitation. However, we analysed the data of the latest NDHS conducted in Nepal, and believe that the study findings are still relevant because of the importance of the topic and the rigorous analysis. We hope that the findings will be relevant and useful for programme planners and policy makers in order to increase the rate of institutional delivery and improve the maternal health of young women in Nepal.
Conclusions
This study showed that inequality exists in the use of institutional delivery among young married women in Nepal. Several factors were associated with and influenced young women’s use of institutional delivery. Among all factors, receipt of an adequate number (at least four) of ANC visits had a strong and positive association with the use of institutional delivery. Therefore, it is important to encourage and ensure the use of at least four ANC visits for young pregnant women in Nepal. Moreover, rural, poor and less educated women from the mountain region and of Janajati ethnicity should be included in health interventions as these particular groups of young women were less likely to choose institutional delivery. Coverage as well as the quality of existing interventions needs to be improved for this group of young women. Young women who have already given birth should also be included in the health intervention as they were more reluctant to deliver in an institution. Finally, there is a need for more qualitative research, particularly among young women, to explore their utilisation of maternal health services.
bmjopen-2016-012446supp001.doc (42.4KB, doc)
Supplementary Material
Acknowledgments
The authors would like to acknowledge the European Commission and the Department of Economy, Science and Innovation of the Flemish Government, Belgium for funding. Also, the authors wish to thank Robert Suarez for editing the manuscript. The authors are also thankful to the Demographic and Health Surveys (DHS) programme for providing the data.
Footnotes
Contributors: Nepal Demographic and Health Survey 2011 data (secondary data) were used for this study. These data are public and freely available to anyone from MEASURE DHS, on request. The website for MEASURE DHS is
Funding: This study, part of a PhD research, was funded by the European Commission and the Department of Economy, Science and Innovation of Flemish Government, Belgium.
Competing interests: None declared.
Ethics approval: This study was exempt from review by the ethics committee as publicly available data was used and no identifying participant information was obtained. With the permission of MEASURE DHS, we downloaded the Demographic and Health Survey (DHS) data sets of Nepal from the website of MEASURE ().
Provenance and peer review: Not commissioned; externally peer reviewed.
Data sharing statement: AS, TD, RA and VDB designed and planned the study. RA and AS extracted, analysed and interpreted the data. AS drafted the article, about which all authors made important suggestions. TD, AD, AB, RA and VDB revised the article for important intellectual content. All authors revised and approved the final version of the article for publication.
References
- 1. WHO, UNICEF, World Bank G. Trends in maternal mortality: 1990 to 2015. 31, 2015:1–55. ISBN 97892 41503631. [Google Scholar]
- 2. World Health Organization. Maternal mortality: fact sheet. Geneva, 2015. http://www.who.int/mediacentre/factsheets/fs348/en/ [Google Scholar]
- 3. Beydoun H, Itani M, Tamim H, et al. ; National Collaborative Perinatal Neonatal Network. Impact of maternal age on preterm delivery and low birthweight: a hospital-based collaborative study of nulliparous Lebanese women in greater Beirut. J Perinatol 2004;24:228–35. 10.1038/sj.jp.7211064 [DOI] [PubMed] [Google Scholar]
- 4. Althabe F, Moore JL, Gibbons L, et al. . Adverse maternal and perinatal outcomes in adolescent pregnancies: the global network's Maternal Newborn Health Registry study. Reprod Health 2015;12 (Suppl 2):S8. 10.1186/1742-4755-12-S2-S8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Ganchimeg T, Ota E, Morisaki N, et al. ; WHO Multicountry Survey on Maternal Newborn Health Research Network. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG 2014;121 (Suppl 1):40–8. 10.1111/1471-0528.12630 [DOI] [PubMed] [Google Scholar]
- 6. Dahal RK. Central Department of Population Studies, Tribhuvan University, Kathmandu, Nepal. Factors influencing the choice of place of delivery among women in Eastern rural Nepal. International Journal of Maternal and Child Health 2013;1:30–7. 10.12966/ijmch.07.03.2013 [DOI] [Google Scholar]
- 7. Assarag B, Dujardin B, Delamou A, et al. . Determinants of maternal near-miss in Morocco: too late, too far, too sloppy? PLoS One 2015;10:e0116675 10.1371/journal.pone.0116675 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. De Brouwere V, Richard F, Witter S. Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn. Trop Med Int Health 2010;15:901–9. 10.1111/j.1365-3156.2010.02558.x [DOI] [PubMed] [Google Scholar]
- 9. Karkee R, Binns CW, Lee AH. Determinants of facility delivery after implementation of safer mother programme in Nepal: a prospective cohort study. BMC Pregnancy Childbirth 2013;13:193. 10.1186/1471-2393-13-193 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Ministry of Health and Population (MoHP), Nepal New ERA and ICF International Inc. Nepal Demographic and Health Survey 2011. Kathmandu, 2011. [Google Scholar]
- 11. Gill K, Pande R, Malhotra A. Women deliver for development. Lancet 2007;370:1347–57. 10.1016/S0140-6736(07)61577-3 [DOI] [PubMed] [Google Scholar]
- 12. Adhikari R. Effect of women’ s role on household decision making on institutional delivery of the recent child in Nepal. Journal of Mangt and Devt Studies 2015;26:51–61. [Google Scholar]
- 13. Baral YR, Lyons K, Skinner J, et al. . Determinants of skilled birth attendants for delivery in Nepal. Kathmandu Univ Med J 2010;8:325–32. [DOI] [PubMed] [Google Scholar]
- 14. Dhakal S, van Teijlingen E, Raja EA, et al. . Skilled care at birth among rural women in Nepal: practice and challenges. J Health Popul Nutr 2011;29:371–8. 10.3329/jhpn.v29i4.8453 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Furuta M, Salway S. Women's position within the household as a determinant of maternal health care use in Nepal. Int Fam Plan Perspect 2006;32:17–27. 10.1363/3201706 [DOI] [PubMed] [Google Scholar]
- 16. Khanal V, Adhikari M, Karkee R, et al. . Factors associated with the utilisation of postnatal care services among the mothers of Nepal: analysis of Nepal Demographic and Health Survey 2011. BMC Womens Health 2014;14:19 10.1186/1472-6874-14-19 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Nawal D, Goli S. Birth preparedness and its effect on place of delivery and post-natal check-ups in Nepal. PLoS One 2013;8:e60957 10.1371/journal.pone.0060957 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Sharma SR, Poudyal AK, Devkota BM, et al. . Factors associated with place of delivery in rural Nepal. BMC Public Health 2014;14:306 10.1186/1471-2458-14-306 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Shrestha SK, Banu B, Khanom K, et al. . Changing trends on the place of delivery: why do Nepali women give birth at home? Reprod Health 2012;9:25. 10.1186/1742-4755-9-25 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Situ KC. Women’ s autonomy and maternal health care utilization in Nepal, 2013. University of Tampere; Finland. [Google Scholar]
- 21. Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues 2012;22:e407–e414. 10.1016/j.whi.2012.05.001 [DOI] [PubMed] [Google Scholar]
- 22. Kamal SM, Hassan CH, Alam GM. Determinants of institutional delivery among women in Bangladesh. Asia Pac J Public Health 2015;27:NP1372–NP1388. 10.1177/1010539513486178 [DOI] [PubMed] [Google Scholar]
- 23. Berhan Y, Berhan A. Antenatal care as a means of increasing birth in the health facility and reducing maternal mortality: a systematic review. Ethiop J Health Sci 2014;24 (Suppl):93–104. 10.4314/ejhs.v24i0.9S [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Akazili J, Doctor H V, Abokyi L, et al. . Is there any relationship between antenatal care and place of delivery ? Findings from rural northern Ghana. Afr J Health Sci 2011;18:62–73. [Google Scholar]
- 25. Karkee R, Lee AH, Khanal V. Need factors for utilisation of institutional delivery services in Nepal: an analysis from Nepal Demographic and Health Survey, 2011. Bmj Open 2014;4:e004372 10.1136/bmjopen-2013-004372 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Chakraborty N, Islam MA, Chowdhury RI, et al. . Determinants of the use of maternal health services in rural Bangladesh. Health Promot Int 2003;18:327–37. 10.1093/heapro/dag414 [DOI] [PubMed] [Google Scholar]
- 27. Feyissa TR, Genemo GA. Determinants of institutional delivery among childbearing age women in western Ethiopia, 2013: unmatched case control study. PLoS One 2014;9:e97194–7. 10.1371/journal.pone.0097194 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Gitimu A, Herr C, Oruko H, et al. . Determinants of use of skilled birth attendant at delivery in Makueni, Kenya: a cross sectional study. BMC Pregnancy Childbirth 2015;15:1–7. 10.1186/s12884-015-0442-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Kamal SM. Preference for institutional delivery and caesarean sections in Bangladesh. J Health Popul Nutr 2013;31:96–109. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Rahman M, Mosiur R. Deliveries among adolescent mothers in rural Bangladesh: who provides assistance? World Health Popul 2009;11:5–14. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=20057269 10.12927/whp.2009.21039 [DOI] [PubMed] [Google Scholar]
- 31. Duysburgh E, Zhang WH, Ye M, et al. . Quality of antenatal and childbirth care in selected rural health facilities in Burkina Faso, Ghana and Tanzania: similar finding. Trop Med Int Health 2013;18:534–47. 10.1111/tmi.12076 [DOI] [PubMed] [Google Scholar]
- 32. Kamal SM. Preference for institutional delivery and caesarean sections in Bangladesh. J Health Popul Nutr 2013;31:96–109. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3702364&tool=pmcentrez&rendertype=abstract 10.3329/jhpn.v31i1.14754 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Godha D, Hotchkiss DR, Gage AJ. Association between child marriage and reproductive health outcomes and service utilization: a multi-country study from South Asia. J Adolesc Health 2013;52:552–8. 10.1016/j.jadohealth.2013.01.021 [DOI] [PubMed] [Google Scholar]
- 34. Shahabuddin AS, Delvaux T, Abouchadi S, et al. . Utilization of maternal health services among adolescent women in Bangladesh: a scoping review of the literature. Trop Med Int Health 2015;20:822–9. 10.1111/tmi.12503 [DOI] [PubMed] [Google Scholar]
- 35. Bayu H, Fisseha G, Mulat A, et al. . Missed opportunities for institutional delivery and associated factors among urban resident pregnant women in South Tigray Zone, Ethiopia: a community-based follow-up study. Glob Health Action 2015;8:28082. 10.3402/gha.v8.28082 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Mobilizing married youth in Nepal to improve reproductive health: the Reproductive Health for Married Adolescent Couples Project, Nepal, 2005-2007. Evaluation and research report. New York: EngenderHealth/The ACQUIRE Project, 2008. http://www.acquireproject.org/archive/files/11.0_research_studies/er_study_12.pdf [Google Scholar]
- 37. Conde-Agudelo A, Belizán JM, Lammers C. Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: cross-sectional study. Am J Obstet Gynecol 2005;192:342–9. 10.1016/j.ajog.2004.10.593 [DOI] [PubMed] [Google Scholar]
- 38. Nove A, Matthews Z, Neal S, et al. . Maternal mortality in adolescents compared with women of other ages: evidence from 144 countries. Lancet Glob Health 2014;2:e155–e164. 10.1016/S2214-109X(13)70179-7 [DOI] [PubMed] [Google Scholar]
- 39. Lynn B, Dahal DR, Govindasamy P. Caste, ethnic and regional identity in Nepal: further analysis of the 2006 Nepal Demographic and Health Survey. Calverton, Maryland, USA: Macro International Inc, 2008. [Google Scholar]
- 40. Wagle RR, Sabroe S, Nielsen BB. Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: an observation study from Nepal. BMC Pregnancy Childbirth 2004;4:8. 10.1186/1471-2393-4-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Bolam A, Manandhar DS, Shrestha P, et al. . Factors affecting home delivery in the Kathmandu Valley, Nepal. Health Policy Plan 1998;13:152–8. 10.1093/heapol/13.2.152 [DOI] [PubMed] [Google Scholar]
- 42. Singh PK, Rai RK, Alagarajan M, et al. . Determinants of maternity care services utilization among married adolescents in rural India. PLoS One 2012;7:e31666 10.1371/journal.pone.0031666 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43. Aggarwal R, Thind A, Rakesh A, Amardeep T. Effect of maternal education on choice of location for delivery among indian women. Natl Med J India 2011;24:328–34. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=22680256 [PubMed] [Google Scholar]
- 44. Nawal D, Goli S. Birth preparedness and its effect on place of delivery and post-natal check-ups in Nepal. PLoS One 2013;8:e60957. 10.1371/journal.pone.0060957 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. Gebrehiwot T, San Sebastian M, Edin K, et al. . Health workers' perceptions of facilitators of and barriers to institutional delivery in Tigray, Northern Ethiopia. BMC Pregnancy Childbirth 2014;14:1–10. 10.1186/1471-2393-14-137 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46. Morrison J, Thapa R, Basnet M, et al. . Exploring the first delay: a qualitative study of home deliveries in Makwanpur district Nepal. BMC Pregnancy Childbirth 2014;14:89. 10.1186/1471-2393-14-89 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47. Singh A, Kumar A, Pranjali P. Utilization of maternal healthcare among adolescent mothers in urban India: evidence from DLHS-3. PeerJ 2014;2:e592 10.7717/peerj.592 [DOI] [PMC free article] [PubMed] [Google Scholar]
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