3. RISK ANALYSIS OF DELIVERY OUTCOME
A: Birth weight
Since there is no birth registration system in Nepal and more than 90% of deliveries take place at home, there is no systematic recording of birth weight. Therefore, in this survey, mothers were asked to recall the birth weight of their last born child. The birth weight reported by mothers were divided into four categories: very small, small, normal and big. Their reports are shown in table 65 and Figure 7.
Table 65. Birth weight estimate of last born child reported by mothers.
Birth weight estimate |
Number (%) |
Very small |
440 (3%) |
Small |
2899 (16%) |
Normal |
9677 (56%) |
Big |
4227 (25%) |
Total |
17243 (100%) |
Figure 7. % of bables with
different estimated birth weights
The proportion of very small and small babies amongst recent deliveries (up to ten years prior to the survey) is higher than amongst deliveries prior to this time (Table 66). It seems unlikely that there has been a real increase in the proportion of low birth weight babies of this magnitude, and the difference probably reflects poorer recall of low birth weight for births a long time ago.
Table 66. Birth weight estimate and time since delivery
Time since delivery |
Size of baby |
|
Small/very small |
Big/normal |
|
Up to 10 years (%) |
2963 (20) |
11713 (70) |
> 10 years (%) |
364 (14) |
2167 (86) |
Odds Ration=1.51 (95% CI 1.33 - 1.70) |
The figures certainly provide no suggestion of any decrease in the proportion of low birth weight children in the last decade. While the measure of low birth weight used here is crude, there is no reason to believe it is biased. If anything, it will give an underestimate of the proportion of low birth weight babies, since minor degrees of low birth weight may go unrecognised.
The variation in the reported proportion of low birth weight babies by geographic area and ethnicity is shown in Annex 5, Tables A5.4, A5.8 and Figure A5.13.
Factors related to low birth weight
Clearly, a number of factors affect birth weight. In this section, the effects of a number of different variables individually on birth weight are examined. Their effects in combination are further examined in a later section.
Literacy of mother
Literate mothers are less likely to deliver a baby with low birth weight compared with illiterate mothers. This is shown in table 67.
Table 67. Literacy of mother and low birth weight
Literacy of mother |
Size of baby |
|
Small/very small |
Big/normal |
|
literate (%) |
599 (13) |
3868 (87) |
Illiterate (%) |
2739 (22) |
10027 (78) |
Odds Ration=0.57 (95% CI 0.51 - 0.63) |
Literacy of household head
Women from families with a literate household head have less risk of having babies with low birth weight compared with women from families with an illiterate household head. This is still true when the literacy of mother and area of residence (urban/rural) is taken into account. This is shown in table 68.
Table 68. Literacy of household head and low birth weight
Literacy of household head |
Size of baby |
|
small/very small |
big/normal |
|
Literate (%) |
1524 (17) |
7594 (78) |
Illiterate (%) |
1812 (22) |
6305 (78) |
Odds Ration=0.70 (95% CI 0.65 - 0.75) |
Age of mother
Women younger than 18 years or older than 35 years at the time of giving birth are at increased risk of having low birth weight babies compared with women giving birth at ages 18-35 years. This is shown in table 69.
Table 69. Age of mother and low birth weight
Age of mother |
Size of baby |
|
small/very small |
big/normal |
|
< 19 and > 35 yrs (%) |
670 (22) |
2401 (78) |
18 - 35 (%) |
2669 (19) |
11503 (81) |
Odds Ration=1.20 (95% CI 1.09 - 1.33) |
Area of residence
Women living in urban areas have less risk of having low birth weight babies compared with women from rural areas. This is shown in table 70.
Table 70. Area of residence and low birth weight
Area of residence |
Size of baby |
|
small/very small |
big/normal |
|
Urban (%) |
367 (15) |
2032 (85) |
Rural (%) |
2972 (20) |
11872 (80) |
Odds Ration=0.72 (95% CI 0.64 - 0.81) |
Support received from family
Care and support to a pregnant woman from her family is important. Women were asked how much support they received from their families during their last pregnancy. Table 71 shows that women who report having support from their families during pregnancy have less than half the risk of having babies with low birth weight compared with women whose families did not support them. This is true in both urban and rural areas, and among both literate and illiterate women.
Table 71. Family support and low birth weight
Family support |
Size of baby |
|
small/very small |
big/normal |
|
Yes (%) |
2652 (18) |
12491 (83) |
No (%) |
645 (34) |
1273 (66) |
Odds Ration=0.42 (95% CI 0.38 - 0.47) |
Number of pregnancies
Women with more than four pregnancies (including the one reported on) are slightly more likely to deliver babies with low birth weight compared with women with four or less pregnancies. This is shown in Table 72.
Table 72. Number of pregnancies and low birth weight
Number of pregnancies |
Size of baby |
|
small/very small |
big/normal |
|
5 or more (%) |
1102 (21) |
4095 (79) |
Up to 4 (%) |
2237 (19) |
9809 (81) |
Odds Ration=1.18 (95% CI 1.09 - 1.28) |
Antenatal care
Women who attend for antenatal care during pregnancy have a reduced risk of delivering babies with low birth weight compared with women who do not have any antenatal care. This is shown in table 73.
Table 73. Antenatal care visits and low birth weight
Antenatal visit |
Size of baby |
|
small/very small |
big/normal |
|
Any visit (%) |
639 (16) |
3408 (84) |
No visit (%) |
2684 (20) |
10448 (80) |
Odds Ration=0.73 (95% CI 0.66 - 0.80) |
Timing of first antenatal visit
Among women who attended for any antenatal visits, those who had their first visit within 3 months of the start of pregnancy are less likely to deliver babies with low birth weight than those who had their first visit later in pregnancy. This is shown in table 74.
Table 74. Timing of first antenatal visit and low birth weight
First antenatal visit |
Size of baby |
|
small/very small |
big/normal |
|
Within 3 months (%) |
229 (13) |
1572 (87) |
After 3 months (%) |
415 (18) |
1847 (82) |
Odds Ration=0.65 (95% CI 0.54 - 0.78) |
Iron/folate
Anaemia is common in Nepal, especially among pregnant and lactating women. In this survey, only one in ten women received any iron/folate supplementation during pregnancy (see above). Women who do not receive iron/folate have 1.5 times the risk of having babies with low birth weight compared with women who receive any iron/folate supplements. This is shown in table 75.
Table 75. Iron/folate supplementation and low birth weight
Iron/fotate supplementation |
Size of baby |
|
small/very small |
big/normal |
|
No (%) |
2984 (20) |
11797 (80) |
Yes (%) |
310 (15) |
1812 (85) |
Odds Ration=1.48 (95% CI 1.30 - 1.68) |
Smoking
A women who smokes during pregnancy has 1.5 times the risk of delivering a low birth weight baby compared with a woman who does not smoke. This is shown in table 76.
Table 76. Smoking during pregnancy and low birth weight
Smoking during pregnancy |
Size of baby |
|
small/very small |
big/normal |
|
Yes (%) |
1245 (24) |
3979 (76) |
No (%) |
2085 (18) |
9860 (82) |
Odds Ration=1.48 (95% CI 1.37 - 1.60) |
Health problems during pregnancy
Mothers with health problems during pregnancy are 1.5 times more likely to have babies with low birth weight compared with mothers who do not have health problems during pregnancy. This is shown in table 77.
Table 77. Health problems during pregnancy and low birth weight
Problems during pregnancy |
Size of baby |
|
small/very small |
big/normal |
|
Yes (%) |
341 (25) |
1004 (75) |
No (%) |
2910 (19) |
12665 (81) |
Odds Ration=1.48 (95% CI 1.29 - 1.69) |
Quality of antenatal service
Women were asked if they were satisfied with the antenatal service they received during pregnancy. Their level of satisfaction is one measure of the quality of antenatal care provided to them. Women who are not satisfied or only partly satisfied with the antenatal service have about 1.5 times the risk of delivering babies with low birth weight compared with women who are very satisfied. This is shown in table 78.
Table 78. Satisfaction with antenatal care and low birth weight
Satisfaction with antenatal care |
Size of baby |
|
small/very small |
big/normal |
|
Not/somewhat (%) |
482 (18) |
2241 (82) |
Very (%) |
211 (13) |
1414 (87) |
Odds Ration=1.45 (95% CI 1.22 - 1.75) |
Traditional Birth Attendant (TBAs)
Women from communities with trained TBAs (interviewed for this survey) are less likely to have babies with low birth weight than those from communities where the interviewed TBA(s) were untrained, as shown in table 79. This could be because trained TBAs have better maternal care practice. However, this should be interpreted with caution because no TBA was interviewed in 23 of the 144 communities.
Table 79. Training of TBAs in serving community and low birth weight
TBA interviewed |
Size of baby |
|
small/very small |
big/normal |
|
Trained (%) |
1433 (18) |
6738 (82) |
Untrained (%) |
1345 (13) |
5256 (87) |
Odds Ration=0.83 (95% CI 0.76 - 0.90) |
Mothers were asked about the outcome of their last pregnancy, including the survival of the baby. This information is shown in table 80.
Table 80. Outcome of last delivery reported by mothers
Survival of baby |
Number (%) |
Survived healthy |
16530 (95.8%) |
Survived but unhealthy |
281 (1.6%) |
Survived but disabled |
26 (0.2%) |
Lived for short time |
240 (1.5%) |
Still birth |
149 (0.8%) |
Total |
17226 (100%) |
For the analysis of pregnancy outcome, still born babies and babies who lived for a short time are considered together in one category, with all those who survived, even if unhealthy, in another category, as shown in table 81.
Table 81. Survival of babies
Status of baby |
Number (%) |
Stillborn or died after birth |
389 (2.3%) |
Survived |
16837 (97.7%) |
Total |
17226 (100%) |
The variation in survival of babies by geographic area and ethnicity is shown in Annex 5, Tables A5.4, and A5.8 and Figure A5.14.
Variables related to the survival of babies
As in the previous section on birth weight, this section examines the effects of a number of variables individually on the survival of babies. The analysis of the effects of these variables in combination is described in a later section.
Use of antenatal care
There is no realtionship between the use of antenatal care and the survival of the baby in this survey. This may reflect poor quality of antenatal care or the fact that most antenatal care in Nepal is in response to health problems rather than being routine preventive care.
Literacy of mother
Newborn babies of literate mothers are less likely to be stillborn or die soon after birth compared with babies of illiterate mothers. This is shown in table 82.
Table 82. Literacy of mother and survival of baby
Literacy of mother |
Survival of baby |
|
Stillborn/died |
Survived |
|
Literate (%) |
71 (1.6) |
4388 (98.4) |
Illiterate (%) |
318 (2.5) |
12439 (97.5) |
Odds Ration=0.63 (95% CI 0.48 - 0.83) |
Literacy of household head
Babies born to women in families with a literate household head are more likely to survive compared with babies in households with an illiterate head. This is shown in table 83.
Babies born to women in families with a literate household head are more likely to survive compared with babies in households with an illiterate head. This is shown in table 83.
Table 83. Literacy of household head and survival of baby
Literacy of household head |
Survival of baby |
|
Stillborn/died |
Survived |
|
Literate (%) |
175 (1.9) |
8935 (98.1) |
Illiterate (%) |
214 (2.6) |
7894 (97.4) |
Odds Ration=0.72 (95% CI 0.59 - 0.89) |
Age of mother
Women giving birth at younger than 19 years or older than 35 years have an increased risk of stillbirth or death of the baby soon after birth. This is shown in Table 84.
Table 84. Age of mother and survival of
baby
Age of mother |
Survival of baby |
|
Stillborn/died |
Survived |
|
< 19 or > 35 years (%) |
75 (3.0) |
2457 (97.0) |
19 - 35 years (%) |
314 (2.1) |
14380 (97.9) |
Odds Ration=1.38 (95% CI 1.08 - 1.82) |
Support received from family
The results in table 85 show that women who receive help from their families during pregnancy have less risk of still birth or death of the baby soon after birth.
The results in table 85 show that women who receive help from their families during pregnancy have less risk of still birth or death of the baby soon after birth.
Table 85. Family support and survival of baby
Family support |
Survival of baby |
|
Stillborn/died |
Survived |
|
Yes (%) |
321 (2.1) |
14813 (97.9) |
No (%) |
63 (3.3) |
1848 (96.7) |
Odds Ration=0.64 (95% CI 0.48 - 0.85) |
Smoking
Women who smoke during pregnancy are more likely to have still born babies or babies who die soon after birth than women who do not smoke, as shown in table 86.
Table 86. Smoking during pregnancy and survival of baby
Smoking during pregnancy |
Survival of baby |
|
Stillborn/died |
Survived |
|
Yes (%) |
140 (2.7) |
5079 (97.3) |
No (%) |
245 (2.1) |
11689 (97.9) |
Odds Ration=1.31 (95% CI 1.05 - 1.64) |
Health problems during pregnancy
Mothers with health problems during pregnancy are more likely to have a stillborn baby or a baby dying soon after birth compared with mothers without health problems in pregnancy. This is shown in table 87.
Table 87. Health problems during pregnancy and survival of baby
Problems during pregnancy |
Survival of baby |
|
Stillborn/died |
Survived |
|
Yes (%) |
63 (4.7) |
1280 (95.3) |
No (%) |
309 (2.0) |
15251 (98.0) |
Odds Ration=2.43 (95% CI 1.82 - 3.42) |
Cutting of umbilical cord
For more than a third (41%) of deliveries in Nepal, the umbilical cord is cut with a non-sterile instrument (see above). If the umbilical cord is cut with a clean instrument, the baby has only half the risk of dying soon after birth compared with if the cord is cut with a non-clean instrument. This is shown in table 88. Note that in this comparison, stillbirths are not considered.
Table 88. Instrument used to cut cord and survival of baby
Instrument for cutting cord |
Survival of baby |
|
Died soon after birth |
Survived |
|
Clean (%) |
93 (1.0%) |
9267 (99.0%) |
Not clean (%) |
109 (1.9%) |
5633 (98.1%) |
Odds Ration=0.52 (95% CI 0.39 - 0.69) |
Problems during labour
Not surprisingly, women reporting problems during labour are 6 times more likely to have a still born baby or a baby that dies soon after birth, as shown in Table 89.
Table 89. Problems during labour and survival of baby
Problems during labour |
Survival of baby |
|
Stillborn/died |
Survived |
|
Yes (%) |
71 (10.0) |
641 (90.0) |
No (%) |
282 (1.8) |
15904 (98.2) |
Odds Ration=6.03 (95% CI 4.54 - 8.00) |
Duration of labour
If labour is prolonged beyond 12 hours, the risk of the baby being stillborn or dying soon after birth is nearly double that when the labour lasts 12 hours or less. This is shown in table 90.
Table 90. Duration of labour and survival of baby
Duration of labour |
Survival of baby |
|
Stillborn/died |
Survived |
|
> 12 hours (%) |
115 (3.7) |
2989 (96.3) |
Up to 12 hours (%) |
271 (1.9) |
13729 (98.1) |
Odds Ration=1.95 (95% CI 1.55 - 2.45) |
Birth weight
Babies described by the mother as small or very small are more likely to be stillborn or to die soon after birth than those said to be normal or big. This relationship is shown in table 91. Note that the question on size of the baby came before the question about survival of the baby in the questionnaire, making it less likely that the question about size would be biased by a preceding question on death of the baby.
Table 91. Estimate of birth weight and survival of baby
Reported size of baby |
Survival of baby |
|
Stillborn/died |
Survived |
|
Small/very small (%) |
148 (4.4) |
3180 (95.6) |
Normal and big (%) |
232 (1.7) |
13621 (98.3) |
Odds Ration=2.73 (95% CI 2.20 - 3.40) |
Satisfaction with care received during labour
The satisfaction reported by the mother with the care she received during labour is one measure of the quality of care. Mothers who are not satisfied with the care they received during labour have 6 times the risk of having a still born baby or a baby dying soon after birth, compared with mothers who are very or somewhat satisfied with their care during labour. This is shown in Table 92. It is quite possible that a mother's view of the quality of care she received during labour may be biased by whether or not the child survived and this may be part of the reason for the association shown in Table 92.
Table 92. Reported satisfaction with care during labour and survival of baby
Satisfaction with care during labour |
Survival of baby |
|
Stillborn/died |
Survived |
|
Not satisfied (%) |
94 (10.0) |
849 (90.0) |
Satisfied (%) |
293 (1.8) |
15929 (98.2) |
Odds Ration=6.02 (95% CI 4.68 - 7.74) |
Health problems after delivery
Babies of mothers reporting health problems (either of mother or baby) after delivery are more likely to die soon after birth compared with babies of mothers not reporting such health problems. This is shown in table 93. This analysis does not include stillbirths.
Table 93. Reported problems after delivery and survival of baby
Health problems after delivery |
Survival of babies |
|
Died soon after birth |
Survived |
|
Yes (%) |
106 (504) |
1841 (94.6) |
No (%) |
134 (0.9) |
14995 (99.1) |
Odds Ration=6.44 (95% CI 4.92 - 8.44) |
Area of residence
Women living in rural areas have 1.4 times the risk of still birth or death of the baby soon after birth compared with women living in urban areas. This is shown in Table 94.
Table 94. Area of residence and survival of baby
Area of residence |
Survival of baby |
|
Stillborn/died |
Survived |
|
Rural (%) |
348 (2.3) |
14481 (97.7) |
Urban (%) |
41 (1.7) |
2356 (98.3) |
Odds Ration=1.38 (95% CI 0.98 - 1.95) |
Traditional Birth Attendants (TBAs)
Mothers from communities where there is at least one trained TBA (interviewed for this survey) are less likely to have a stillborn baby or a baby that dies soon after birth, compared with mothers in communities where the interviewed TBA was untrained. This is still true when area of residence (urban or rural) and literacy of the mother are taken into account. The association is shown in Table 95. This should be interpreted with caution because no TBA was interviewed in 23 of the 144 communities.
Table 95. Training of TBA interviewed in community and survival of baby
Status of interviewed TBA |
Survival of baby |
|
Stillborn/died |
Survived |
|
Trained (%) |
158 (1.9) |
8004 (98.1) |
Untrained (%) |
164 (2.5) |
6442 (97.5) |
Odds Ration=0.78 (95% CI 0.62 - 0.98) |
RESULTS :II. ANALYSIS FOR ACTION
Analysis in the previous section provides information about a number of variables that apparently increase or decrease the risk of three important adverse outcome variables: lack of antenatal care, low birth weight and death of the baby (still birth and death soon after birth). The effect of each of the potential causal variables separately on the outcome of interest is shown in the relevant part of the Results I section. However, the apparent effect of a variable might in reality be due to its association with another variable (confounding) or two or more variables might interact to produce the effect on the outcome variable (effect modification). In this section of the analysis, the effects of the variables found to change the risk of the outcome variable separately are examined in combination. The focus is on those variables amenable to change and the aim is to indicate how much improvement in the present situation could potentially be achieved by different interventions. For example: how much reduction in the proportion of low birth weight children could be achieved by stopping women smoking during pregnancy, taking the effects of other variables into account? How much could the risk of an individual woman giving birth to a low weight baby be reduced? And how many cases of low birth weight in the population could be prevented?
The multivariate analysis used was a multiple logistic regression, using a step-down from an initial saturated model to find the best-fitting, most parsimonious model.
The three issues of interest to planners considered in this section are: attendance for antenatal care; prevention of low birth weight babies; and prevention of still births and deaths soon after birth. The second two are actual outcomes, while the first is an important process indicator. For individual mothers, the second two (and especially the last one, prevention of death of the baby) are of the most interest.
1. Risk of not attending antenatal care
Variables included in combined analysis of risk of not attending for antenatal care: |
|
1. | Literacy of mother (risk=illiteracy) |
2. | Literacy of household head (risk=illiteracy) |
3. | Smoking during pregnancy (risk=smoking) |
4. | Mother's age at pregnancy (risk=age > 35 years) |
5. | Family support (risk=no support) |
6. | Working during pregnancy (risk=working for > 7 months) |
7. | Number of pregnancies (risk=4 or more) |
8. | Area of residence (risk=rural dwelling) |
A number of variables individually increase the risk of not attending antenatal care and are potentially amenable to change. Eight variables were included in the logistic regression analysis.
Seven out of these eight variables remained in the final model, as shown in table 96.
Table 96. Combined Odds Ratios and Risk Differences of variables affecting the risk of not attending antenatal care visits, from logistic regression analysis
Variable |
Combined OR |
Combined Risk Difference |
Illiterate mother |
2.07 |
17.9% |
Rural residence |
2.01 |
17.2% |
Working >7 months of preg |
1.75 |
13.8% |
Smoking in pregnancy |
1.40 |
8.3% |
Illiteracy of household head |
1.24 |
5.2% |
More than 4 pregnancies |
1.20 |
4.4% |
No family support |
1.12 |
2.7% |
Variables that increase the risk of low birth weight separately were considered together in a logistic regression analysis. The ten variables included in the logistic regression are shown in the box. .
Variables included in combined analysis of risk low birth weight: |
|
1. | Literacy of mother (risk=illiteracy) |
2. | Literacy of household head (risk=illiteracy) |
3. | Smoking during pregnancy (risk=smoking) |
4. | Mother's age at pregnancy (risk=age <19 or > 35 years) |
5. | Number of pregnancies (risk=4 or more) |
6. | Area of residence (risk=rural) |
7. | Taking iron/folate (risk=not taking) |
8. | Health problems in pregnancy (risk=with problem) |
9. | Family support (risk=no support) |
10. | Antenatal care (risk=no care) |
In the final model of the logistic regression, six variables remained, as shown in Table 97.
Table 97. Combined Odds Ratios and Risk Differences of variables affecting the risk of low birth weight, from logistic regression analysis
Variable |
Combined OR |
Combined Risk Difference |
Illiterate mother |
1.26 |
4.0% |
Problems in pregnancy |
1.24 |
3.8% |
Smoking in pregnancy |
1.13 |
2.0% |
Illiteracy of household head |
1.09 |
1.5% |
Rural residence |
1.08 |
1.3% |
No family support |
1.08 |
1.3% |
3. Risk of still birth and death soon after birth
Variables that increase the risk of still birth and death soon after birth separately were considered together. A logistic regression was performed with 12 variables, as shown in the box.
Variables included in combined analysis of risk of not attending for antenatal care: |
|
1. | Literacy of mother (risk=illiteracy) |
2. | Literacy of household head (risk=illiteracy) |
3. | Smoking during pregnancy (risk=smoking) |
4. | Satisfaction with care during labour (risk-not satisfied) |
5. | Health problems in labour (risk=problem) |
6. | Duration of labour (risk=more than 12 hours) |
7. | Family suport (risk=no support) |
8. | Instrument for cutting cord (risk=small or very small) |
9. | Instrument for cutting cord (risk=non-clean instrument) |
10. | Mother's age (risk=age < 19 or >35 years) |
11. | Health problems in pregnancy (risk=with problem) |
12. | Area of residence (risk=rural) |
In the final model of the logistic regression, seven variables remained, as shown in Table 98.
Table 98. Combined Odds Ratios and Risk Differences of variables affecting the risk of still birth or death soon after birth, from logistic regression analysis
Variable |
Combined OR |
Combined Risk Difference |
Problems during labour |
2.04 |
3.4% |
Not satisfied with labour care |
1.86 |
2.9% |
Baby small or very small |
1.56 |
1.9% |
Rural residence |
1.55 |
1.9% |
Illiterate mother |
1.42 |
1.4% |
Problems in pregnancy |
1.21 |
0.70% |
Cord cut with non-clean instrument |
1.20 |
0.70% |
Using the results of the logistic regression analyses, it is possible to estimate the potential benefits of different actions that could be taken to increase the proportion of women attending for antenatal care, to reduce the proportion of low birth weight babies and to reduce the proportion of babies still born or dying soon after birth.
Increase the proportion of women attending for antenatal care
The first question that arises here is whether it is a useful thing to increase the proportion of women attending for antenatal care. The data from this cycle of the NMIS provide little evidence that antenatal care, of the quality currently received by women in Nepal, has benefits for the mother or baby. The number receiving the recommended 4 visits was too small to analyse separately. The fact of receiving at least one visit did not of itself make any difference to the outcome of the pregnancy. The apparent benefit in terms of reducing the proportion of low birth weight babies disappeared when other variables were taken into account. It seems that it is the other variables associated with antenatal care, rather than the antenatal care itself, that are associated with an improved pregnancy outcome.
However, this is not to say that there can never be any benefit of antenatal care. The outcome measures in this survey did not include maternal mortality. It is possible that adequate antenatal care, in conjunction with good delivery care, would reduce maternal mortality in Nepal. Also, good antenatal care could identify pregnancies where there was a risk to the baby, ensuring remedial actions and arranging for delivery in a properly equipped health facility.
It is important to improve the quality of antenatal care and the access to good quality care as well as embarking on a campaign to educate and encourage women to attend for antenatal care. Some possible ways to increase the uptake of antenatal care are suggested by the results of this survey. Table 99 indicates the possible effects on uptake of antenatal care of interventions aimed at different issues. The possible change in the likelihood of an individual woman attending antenatal care is derived from the Odds Ratio; the possible increase in the proportion of women attending is derived from the Risk Difference (see Table 96).
Increase literacy of women of childbearing age
As found repeatedly in different cycles of the NMIS, improving women's literacy, by interventions such as increasing school enrolment of girls and providing literacy classes for adult women, could have important benefits. One benefit, shown here, would be to increase the uptake of antenatal care services. Perhaps literate women would be more likely to press for better quality of such services, so the benefits of attending for antenatal care may be increased.
Improve access to and knowledge of antenatal care in rural areas
The difference in attendance for antenatal care between urban and rural areas may be explained by a number of factors, but access and knowledge seem likely to be key factors. The provision of adequate antenatal care services for rural areas is a big undertaking and may need to be shared between government and other providers. As mentioned above, there is little point in an education campaign about antenatal care aimed at rural women without an improvement in the accessibility and quality of antenatal care in rural areas.
Discourage women from working beyond seven months of pregnancy
Action here needs to be taken at household and community level. Women already have an awareness of the need to reduce their workload during pregnancy, as shown by their responses in focus groups. Men and community leaders need also to be convinced of the need to allow women adequate rest during pregnancy, to allow them to stop their heavy physical work well before their delivery is due, and to allow and encourage them to attend antenatal care. The benefits are on the pregnancy outcome for the baby as well as on increasing the proportion of women attending antenatal care (see below).
Prevent pregnant women smoking
Women who smoke during pregnancy are less likely to attend for antenatal care. They are also more likely to give birth to underweight babies (see below). It is probable that smoking and non-attendance for antenatal care both reflect an underlying behaviour pattern. Tackling this could improve both smoking behaviour and attendance at antenatal care. However, it may not be a straightforward matter to convince Nepali women not to smoke during pregnancy. In Western countries it has proved quite effective to explain to women the possible adverse consequences of smoking on their unborn babies. In Nepal, telling women that if they smoke their babies will be smaller could actually encourage them to smoke, since women fear large babies and the more difficult birth this may entail. They may not be unjustified in this concern, since care for obstetric emergencies (such as obstructed labour) may be hard to find in some areas of Nepal. Any educational programme to stop women smoking in pregnancy should be accompanied by efforts to improve the quality of antenatal care and access to emergency obstetric care. The campaign could be accompanied by education about beneficial actions during pregnancy, including a good diet and adequate rest (see above).
Increase adult literacy
Literacy of the household head has a beneficial effect on the chance of attending for antenatal care and on the risk of low birth weight, over and above the effect of literacy of the pregnant woman herself. This is probably mainly because of better socio-economic status of those households with a literate head. Nevertheless, since decisions about a woman attending for antenatal care are often made by the household head (or at least require the endorsement of the household head), the education level of the household head and his understanding of the benefits of proper care for a pregnant woman are important for a good pregnancy outcome. Programmes of adult literacy for men could include information about antenatal care for their wives and education of boys in school could include this information in the curriculum.
Reduce number of pregnancies per woman
Women with more than 4 pregnancies in this survey are less likely to attend for antenatal care, when other effects are taken into account. This might be because mothers with more children have less time to look after themselves, or they might think that pregnancy and delivery is just a 'normal' routine. It seems sensible to encourage women (and men) to limit the number of pregnancies for each woman to no more than four, as recommended in the National Maternity Care Guidelines. This might be expected to increase the number of pregnant women who actually attend for antenatal care and experience benefits if that care is of good quality.
Increase family support for pregnant women
Convincing families (especially husbands and mothers-in-law) to support and help women during pregnancy could be expected to increase the proportion of women who are allowed and encouraged to attend for antenatal care. It would also have benefits for pregnancy outcome (see below). It is related to the benefits of women stopping heavy physical work before term. Lack of family support for pregnant women reflects their low status in some communities.
Table 99. Possible benefits of different interventions to increase the proportion of women attending for antenatal care
Intervention |
Potential individual benefit (from OR) |
Potential population benefit (from RD) |
Proptn of population who could benefit |
Relative cost of possible interventions |
Ensure literacy of women of child bearing age |
Double the chance of ANC |
18% more women to attend ANC |
Three quarters of pregnant women |
Moderate |
Improve access and knowledge in rural areas |
Double the chance of ANC |
17% more women to attend ANC |
Nine out of ten pregnant women |
High |
Discourage women from working up to end of pregnancy |
Nearly double the chance of ANC |
14% more women to attend ANC |
Nine out of ten pregnant women |
Low |
Stop-smoking campaign for pregnant women |
Increase chance of ANC by half |
8% more women to attend ANC |
About a third of pregnant women |
Low/moderate |
Ensure adult literacy (for household head) |
Increase chance of ANC by a fifth |
5% more women to attend ANC |
About half of pregnant women |
Moderate |
Encourage limit of 4 pregnancies |
Increase chance of ANC by a fifth |
4% more women to attend ANC |
Over a third of pregnant women |
Low/moderate |
Ensure family support for pregnant women |
Increase chance of ANC by 10% |
3% more women to attend ANC |
About one out of ten women |
Low |
Note: The proportion of the population who could benefit is that proportion not currently having the favourable level of the variable. For example, the proportion of pregnant women currently illiterate.
The potential benefits of different interventions to reduce the problem of low birth weight babies are shown in Table 100.
Increase literacy of women of childbearing age
As well as increasing the number of women attending for antenatal care, programmes to increase adult female literacy could be expected to improve the outcome of pregnancy, reducing the problem of low birth weight babies. This indicates the importance of empowerment of women.
Identify and manage health problems during pregnancy
Although it is impossible to avoid health problems during pregnancy, recognition and proper management can avoid most of their adverse consequences for mother and baby. The low rate of reported problems in this survey and the low rate of seeking help for recognised problems suggest there is a need for better education about health during pregnancy. At the same time it is necessary to ensure that accessible and adequate quality help for reported problems is available.
Prevent pregnant women smoking
As mentioned above, pointing out the relationship between smoking during pregnancy and low birth weight babies may not help to stop women smoking during pregnancy and may even have the opposite effect as they favour small, easy-to-deliver babies. But stressing the adverse consequences of low birth weight for the baby may help to convince them (see below).
Increase adult literacy
The effect of literacy of the household head on low birth weight is probably mainly because of better socio-economic status of those households with a literate head. Nevertheless, there can be direct benefits of better educated and more knowledgeable men in a household who can ensure that women have good support and care during pregnancy and labour.
Improve situation in rural areas
The difference in risk of low birth weight babies between urban and rural areas could be explained by differing socio-economic status and by differing levels of access to services. The improvement of access to adequate services for rural areas will be a big undertaking.
Increase family support for pregnant women
Increasing family support for pregnant women could be expected to reduce the problem of low birth weight babies. This need not cost much, but families need to be convinced of the benefits of supporting women, in a society where women often have low status. It may be that the expected benefit of increasing the weight (and overall health) of babies may help to encourage men to give more support to their women, during pregnancy as well as at other times.
Table 100. Possible benefits of different interventions to decrease the risk of low birth weight babies
Intervention |
Potential individual benefit (from OR) |
Potential population benefit (from RD) |
Proptn of population who could benefit |
Relative cost of possible interventions |
Ensure literacy of women of child bearing age |
Decrease risk of LBW by a quarter |
4% less LBW babies |
Three quarters of pregnant women |
Moderate |
Identify and manage pregnancy problems |
Decrease risk of LBW by a quarter |
4% less LBW babies |
A tenth of pregnant women |
High |
Stop-smoking campaign for pregnant women |
Decrease risk of LBW by 13% |
2% less LBW babies |
About a third of pregnant women |
Low/moderate |
Ensure adult literacy (for household head) |
Reduce risk of LBW by 10% |
2% less LBW babies |
About half of pregnant women |
Moderate |
Improve access and knowledge in rural areas |
Reduce risk of LBW by 8% |
1% less LBW babies |
Nine out of ten pregnant women |
High |
Ensure family support for pregnant women |
Reduce risk of LBW by 8% |
1% less LBW babies |
About one out of ten women |
Low |
Note: The proportion of the population who could benefit is that proportion not currently having the favourable level of the variable.
Reduce the risk of still birth and death soon after birth
The potential benefits of interventions to reduce the risk of still birth or death soon after birth are shown in Table 101. Most of these interventions would be relatively high-cost.
Managing problems during labour
It is not surprising that health problems during labour have an important effect on the risk of still birth and death of the baby soon after birth. In order to improve this situation, it will be necessary to find a way to give timely access to emergency obstetric care, even for women in remote rural communities. One way forward is to place more emphasis on arranging hospital delivery for women with health problems during pregnancy, as these are strongly related to problems during labour. At present, most hospital deliveries are as a result of urgent transfers once problems during labour have developed, often too late to save the baby.
Improve quality of delivery care
The index of quality of delivery care used here is satisfaction with delivery care. This is a crude measure. Nevertheless, there is clearly much room for improvement in the current care for women during delivery, most of which is currently provided by untrained people. There is some evidence in this survey that trained TBAs provide better pregnancy and delivery care than untrained TBAs. There is no real possibility of providing delivery care from doctors for all women. But delivery care from trained TBAs or other trained health workers, who know how to manage straightforward deliveries and some complications and when to refer for further help, could feasibly be provided and could improve the current situation.
Reduce problem of low birth weight
The relationship between low birth weight and high perinatal mortality is well known and is confirmed in this survey. Giving pregnant women and other family members information about this relationship could help to explain to them why it is better to avoid babies who are small or very small (for example, by avoiding smoking during pregnancy). All the actions that help to reduce the problem of low birth weight would be expected also to help to reduce the rate of still birth and death soon after delivery, via their effect on low birth weight.
Improve situation in rural areas
The poorer access and quality of services in rural areas are reflected in a higher rate of still births and deaths of babies soon after birth. Measures to improve rural services, while expensive, would be expected to reduce deaths of babies for the majority of the population. They may also, of course, help to reduce maternal mortality.
Increase literacy of women of childbearing age
The findings of this survey indicate that increasing female literacy could have benefits for all three of the outcome measures considered, including reducing the rate of still birth and death soon after birth. Thus the benefits of improving female literacy are the combined benefits on all three outcomes.
Identify and respond to health problems during pregnancy
The relationship between health problems during pregnancy and still birth or death soon after birth emphasizes the importance of arranging delivery with access to emergency obstetric care services (usually in hospital) for women who have health problems in pregnancy. At present this does not happen (only 16% of women with health problems in pregnancy deliver in a health facility).
Ensure that the cord is cut with a clean instrument
This intervention is simple and cheap, affordable by every family in Nepal. It requires informing families of the benefits of using a clean instrument, either as part of an HDK or as a separate item. The relationship with death of the baby indicates that perinatal infection (including neonatal tetanus) remains an important cause of death of babies in Nepal.
Table 101. Possible benefits of different interventions to reduce risk of still birth and death soon after birth
Intervention | Potential individual benefit (from OR) |
Potential population benefit (from RD) |
Proportion of population who could benefit |
Relative cost of possible interventions |
Identify and manage labour problems |
Reduce risk of death twofold |
3% less babies dying |
One in twenty pregnant women |
High |
Improve quality of delivery care |
Reduce risk of death twofold |
3% less babies dying |
One in twenty women |
High |
Actions to prevent LBW (Table 100) |
Reduce risk of death by two thirds |
2% less babies dying |
A fifth of pregnant women |
High |
Improve access and knowledge in rural areas |
Reduce risk of death by more than half |
2% less babies dying |
Nine out of ten pregnant women |
High |
Ensure literacy of women of child bearing age |
Reduce risk of death by 40% |
1% less babies dying |
Three quarters of pregnant women |
Moderate |
Identify and manage pregnancy problems |
Reduce risk of death by a fifth |
1% less babies dying |
A tenth of pregnant women |
High |
Ensure cord cut with clean instrument |
Reduce risk of death by a fifth |
1% less babies dying |
Four out of ten pregnant women |
Low |
Note: The proportion of the population who could benefit is that proportion not currently having the favourable level of the variable.
Several interventions will have effects on more than one of the outcomes in the survey. They are shown in Table 102.
Table 102. Interventions affecting several outcomes
Intervention |
Outcomes |
||
ANC |
LBW |
Death of baby |
|
Reduce illiteracy of pregnant women |
+ |
+ |
+ |
Manage pregnancy problems |
+ |
+ |
|
Prevent smoking in pregnancy |
+ |
+ |
|
Improve rural antenatal and delivery services | + |
+ |
+ |
Reduce illiteracy of household heads |
+ |
+ |
|
Ensure more family support in pregnancy | + |
+ |
The multiple potential benefits of these interventions suggest that they should be given some priority.
Another way of deciding the priority of different interventions is on the basis of the magnitude of the potential benefits (either for individual women or for the whole population of pregnant women) in relation to their costs. The magnitude of benefits of different interventions is indicated in Tables 99, 100 and 101, together with an indication of their likely relative cost to the government and other service providers. Clearly, many of the interventions, to be successful, will require actions at several levels. They will need support from central government, and action at local level. Local actions will include those from NGOs as well as from government bodies.