Barriers to better birth: Scenario in Far West

Efforts to reduce maternal mortality must make institutions safer by expanding to comprehensive emergency obstetric services, as well as targeting the underlying social and economic inequity

A community health worker speaks about a mother in her village, “She wanted to deliver in the hospital but her in-laws did not listen.

Her husband was not in Achham. She didn’t have the courage to come to the hospital by herself so she delivered at home.”

This is a common scenario in the Far West where patriarchal values dominate, labor migration is common, and women do not have the agency to pursue the care they desire and know is safer.

In a recently published study, our team at Possible and Nyaya Health Nepal, interviewed 98 women shortly after birth to understand why they had their babies where they did.

Only 30% of the women in the study had their babies in a hospital or health post (an “institutional birth”). This percentage is consistent with the national figure of home births (35%) in the 2011 Nepal Demographic and Health Survey.

The World Health Organization sees giving birth with a skilled birth attendant, a midwife or doctor, in a healthcare institution as a key strategy in addressing maternal and newborn mortality.

Life-saving treatments, such as cesarean section, blood transfusion, antibiotics and seizure-prevention medications are not available at home.

Why are so many women still having their babies at home? Is it that they prefer home birth? Nearly all women in our study stated they would prefer an institutional birth.

The majority of women also acknowledged that giving birth in a hospital was safer than giving birth at home. 93% of the women who gave birth in an institution were satisfied with their experience, while only 32% were satisfied with their home birth.

So if women prefer to give birth in a hospital, why are most of them delivering at home? We explored this question with demographic information and open-ended questions.

We found that age, income and land ownership were significant factors in predicting whether a woman would have an institutional birth or home birth. Younger women and wealthier women were more successful in achieving institutional birth.

Women with lower land ownership were also more successful in achieving institutional birth.

To understand these results it is important to consider the context of rural Far-Western Nepal. Here the average age of literate women, 23 years old, is significantly younger than that of illiterate women, 27 years old.

This can be credited to the improved opportunities for the education of girls in more recent years. Money means access to transportation in this part of the country, where homes are dispersed and road access is limited.

The average cost of travel for women who delivered in an institution in our study was NR 831.

The most common recommendation by women in this study for increasing institutional delivery was improving ambulance accessibility. Strangely, land ownership showed an opposite effect, as ownership of more land negatively predicted institutional birth.

Perhaps this is due to the specific very rural context of the study as families with more land are unlikely to be earning other sources of cash revenue to pay transport costs.

When we asked women to share the stories of their recent births, we discovered some other interesting barriers to achieving a safer birth. Lack of financial and transportation resources, lack of gender equity or power to independently decide, and poor quality services at facilities all posed barriers.

Family, partner and societal support were important factors in a woman leaving her home in labor and reaching an institution.

This journey required ‘birth planning,’ or making preparations in advance for finances, accompaniment, and childcare. Women in our study, in rural Far-Western Nepal, know what is safest for them and want to deliver their babies in an institution.

A community health worker reported about a mother in her village: “One year ago there was a maternal death in a nearby village while a woman was delivering at home. News of this death changed her mind about having her [next] baby at home.

She wanted to come to the hospital, where there was a doctor and good medical staff to keep her safe.” This awareness and preference is vitally important, but it is not enough.

We must support women by targeting the underlying social and economic inequity and structural barriers that prevent women from achieving their reproductive choices, achieving better birth.

In rural Nepal, socio-economic vulnerability to structural barriers is paramount in understanding who gives birth at home versus an institution and why.

Contrary to data from the Nepal Demographic and Health Survey 2011, where 62 % of the women who gave birth at home believe it was not necessary to give birth in a health facility, most women surveyed in our study, in rural Nepal in 2012, believed that it was safer to have an institutional birth.

Despite this difference in thinking, the majority of women in our study still gave birth at home. Efforts to reduce maternal mortality must both make institutions safer by expanding to comprehensive emergency obstetric services, as well as targeting the underlying social and economic inequity and structural barriers that prevent women from achieving institutional birth.

Dr. Maru is Obstetrician-Gynecology faculty member at Boston University School of Medicine and Boston Medical Center and Poudyal is affiliated with the Faculty of Health and Life Sciences, Department of Biological and Life Sciences, Oxford Brookes University