Objective: Infant mortality is a major problem in Nepal, particularly for residents in remote rural
areas. Lack of roads and absence of hospitals and health facilities in remote areas contribute to
the problem. The objectives of this study were to assess infant mortality rate (IMR) in the three
ecological zones of Nepal (Mountain, Hill and Terai) and to examine the effect of distance to
health facility on the association between ecological zone and infant mortality.
Methods: The Nepal Demographic and Health Survey (NDHS) conducted in 2011 was used to
calculate infant mortality rates for the Mountain, Hill and Terai zones of Nepal. Infant mortality
was compared across three ecological zones in a sample of 5,306 live births in the five years
preceding the survey. Logistic regression was used to assess the association between ecological
zones and infant mortality focusing on distance to health facility and adjusting for potential
confounders including maternal age at first birth, education level, total children ever born, birth
interval and infant size at birth.
Results: The weighted IMR in each ecological zone was calculated to be 59 (95% CI: 36-81), 44
(35-53), and 40 (33-47) infant deaths per 1000 live births for the Mountain, Hill and Terai zones,
respectively. Residing in the Mountain zone was associated with a greater risk of infant
mortality compared to those in the Terai zone (OR=1.42, 95% CI: 1.01-2.02, p=0.04). The risk
of infant mortality in the Hill zone did not differ significantly from risk in the Terai zone
(OR=1.17, 95% CI: 0.86-1.57, p=0.30). The elevated risk of infant mortality in the Mountain
Zone compared to the Terai zone was observed only among mothers who perceived distance to
health facility as a major problem (OR=1.55, 95% CI: 1.01-2.40, p=0.04). There was no
significant difference in IMRs in the three ecologic zones among births to women who did not
perceive distance as a big problem. In addition, a greater percent of women in the Mountain zone
reported that distance to health facilities was a big problem (70.8%) compared to 60.0% in the
Hill zone and 45.6% in the Terai zone.