Nine out of ten (91%) women deliver their babies at home. |
Home is by far the most common place for delivery of babies in Nepal. There is no evidence of any increase in hospital deliveries over recent years. The National Maternity Care Guidelines recognise that the great majority of deliveries will be at home. They advise that the family should prepare a room that is well ventilated but not cold or draughty. This same advice is given to pregnant women seen for antenatal care by TBAs or health facilities (see above).
There are differences among different ethnic groups and geographic regions in the proportion of women delivering at home. These are shown in Annex 5, tables A5.2, A5.6 and Figure A5.8.
Variables Related to Place of Delivery
Area of residence
A woman living in an urban area is 9 times more likely than a woman in a rural area to deliver her baby in a health facility. This is shown in Table 31.
Table 31. Place of delivery in urban and rural areas
Residence |
Place of delivery |
|
Health Facility |
Home |
|
Urban site (%) |
976 (41) |
1429 (59) |
Rural site (%) |
1025 (7) |
13850 (93) |
Odds Ration=9.00 (95% CI 8.33 - 10.0) |
Health problems during pregnancy
The National Maternity Care Guidelines advise that women with health problems during pregnancy should deliver in a health facility rather than at home. Table 32 shows the relationship between health problems during pregnancy and place of delivery. Although women with health problems during pregnancy are 1.6 times more likely to deliver in health facilities, the majority of them still deliver at home.
Table 32. Health problems during pregnancy and place of delivery
Health problem in pregnancy |
Place of delivery |
|
Health Facility |
Home |
|
with problem (%) |
219 (16) |
1126 (84) |
Rural site (%) |
1714 (11) |
13897 (89) |
Odds Ration=1.58 (95% CI 1.35 - 1.85) |
Literacy
A literate woman is much more likely than an illiterate woman to deliver in a health facility. This is shown in table 33.
Table 33. Literacy of mother and place of delivery
Literacy of mother |
Place of delivery |
|
At home |
Health Facility |
|
Illiterate (%) |
12056 (94) |
735 (6) |
Literate (%) |
3212 (72) |
1265 (28) |
Odds Ration=6.46 (95% CI 5.84 - 7.14) |
Age
Younger women are more likely than older women to deliver in health facilities. This is true when literacy and area of residency of the woman are both taken into account. Table 34 compares place of delivery among women older and younger than 35 years, who had deliveries within 5 years prior to the survey.
Table 34. Age of women at time of delivery and place of delivery (deliveries within the last five years)
Age of woman |
Place of delivery |
|
At home |
Health Facility |
|
Up to 35 years (%) |
8591 (88) |
1222 (12) |
> years (%) |
1674 (95) |
98 (5) |
Odds Ration=2.44 (95% CI 1.96 - 3.03) |
Persons Attending During Labour
Less than one in ten deliveries (6%) in the last 5 years is attended by a trained TBA or other trained worker. |
The NMCG advise arranging for the closest available Trained Traditional Birth Attendant to come at the onset of labour. But very few home births are assisted by trained personnel: 69% of deliveries are assisted by other family members, neighbours or only the woman herself, 25% by untrained TBAs, 3% by trained TBAs, and 3% by other trained health workers. There is no evidence of any increase in the proportion of home births attended by trained personnel in recent years.
About half (54%) of families incurred some expenditure for the woman's last delivery. These costs include Home Delivery Kits (HDK) and related materials, attendance, transportation and other costs. The median costs are shown in Table 35.
Table 35. Costs of delivery among families that spent anything for the last delivery
Item |
Median (NRs) |
Number (%) with any expenditure |
HDK Materials |
20 |
233 (1%) |
Attend/medicine |
250 |
3705 (18%) |
Transportation |
1000 |
1278 (6%) |
Other cost |
400 |
7993 (40%) |
Total cost |
400 |
10843 (54%) |
The median total cost of delivery for women with labour problems is higher than for women without labour problems, whether all deliveries are considered or just those where there was any expenditure (see Figure 4).
Figure 4. Median cost of delivery with/without problems
The median total cost of deliveries is higher in urban than rural areas, whether all deliveries or just those with any expenditure are considered (see Figure 5).
Figure 5. Median cost of delivery in urban and rural areasThe cost of delivery varies with type of health facility and type of attendant. This is shown in tables 36 and 37.
Table 36. Median total cost of delivery by type of facility in Nepali Rupees
Facility |
All deliveries |
Deliveries with any expenditure |
||
Cost |
No. |
Cost |
No. |
|
Home |
150 |
15279 |
300 |
8902 |
SHP/HP |
1500 |
15 |
1500 |
15 |
PHCC |
800 |
8 |
1000 |
7 |
Private clinic/nursing home |
3000 |
76 |
3000 |
75 |
Hospital |
1300 |
1902 |
1400 |
1837 |
Table 37. Median attendance cost of delivery by type of attendant
Type of attendant |
All deliveries |
Deliveries with any expenditure |
||
Cost |
No. |
Cost |
No. |
|
Family/neighbours |
0 |
10513 |
200 |
509 |
TTBA |
160 |
460 |
250 |
292 |
UTBA |
150 |
3885 |
250 |
2347 |
CHW |
0 |
13 |
500 |
5 |
Paramedics |
200 |
319 |
500 |
193 |
Doctor |
300 |
81 |
575 |
49 |
Use of Home Delivery Kit (HDK)
It is recommended that families preparing for a birth buy a Home Delivery Kit (HDK) or separately prepare a new blade, soap, new thread and clean sheets. In this survey, women were asked about the use of a HDK at their last delivery. Very few women (3%) reported they used a HDK. However, HDKs have only been available on the market for 3 years. The use of HDKs over the last three years is shown in Table 38.
Table 38. Trend of using HDK in the past 3 years (1994-97)
Year of delivery |
No.using HDK |
% of deliveries using HDK |
1996/1997 |
260 |
5% |
1995/1996 |
47 |
2% |
1994/1995 |
23 |
2% |
The proportion of women who recall using an HDK for delivery is higher for deliveries within the last three years, although some women claim they used one before they were available (probably they mean they used the separate components). Women delivering less than three years ago are more than four times more likely to have used an HDK than those delivering more than three years ago (Table 39).
Table 39. Time since delivery and reported use of HDK
Last delivery |
Use of HDK |
|
Used HDK |
Did not use HDK |
|
< 3 Years ago (%) |
330 (4) |
8007 (96) |
> 3 years ago (%) |
62 (1) |
6755 (99) |
Odds Ration=4.49 (95% CI 3.38 - 5.98) |
The variation in the use of HDK by geographic areas and by ethnicity is shown in Annex 5, tables A5.3 and A5.7, and figure A5.9.
Factors Related to the use of HDK
Literacy
A literate woman is 3 times more likely than an illiterate woman to use an HDK. This relationship is shown in Table 40.
Table 40. Literacy of mother and use of HDK, 1995-1997
Literacy of mother |
Use of HDK |
|
Used HDK |
Did not use HDK |
|
Literate (%) |
141 (8.3) |
1554 (91.7) |
Illiterate (%) |
190 (2.8) |
6485 (97.2) |
Odds Ration=3.10 (95% CI 1.96 - 3.9) |
This relationship is still found when area of residence (urban or rural) is taken into account.
Antenatal care
A woman who attends for antenatal care during pregnancy is almost 4 times more likely to use an HDK (Table 41). This is still true when literacy of the woman and area of residence are taken into account.
Table 41. Having antenatal care and use of HDK, 1995-1997
Antenatal care |
Use of HDK |
|
Used HDK |
Did not use HDK |
|
At least one visit (%) |
164 (9.5) |
1556 (90.5) |
No visits (%) |
157 (2.4) |
6457 (97.6) |
Odds Ration=4.33 (95% CI 3.43 - 5.48) |
Birth attendants
Use of HDK is related to the type of birth attendant. Trained TBAs and other trained health workers are more likely to use an HDK than family members and untrained TBAs. This is shown in table 42 and Figure 6.
Table 42. Use of HDK by various birth attendants, 1995-1997
Birth attendant |
Number |
% using HDK |
Family/neighbours |
5614 |
2% |
Untrained TBAs |
323 |
5% |
Trained TBAs |
303 |
10% |
Trained health workers |
231 |
27% |
Figure 6. Proportion of births using HDK in relation to birth attendant
Training of TBAs
Amongst the 2517 births attended by a TBA between 1995 and 1997, those where the TBA was trained were twice as likely to include the use of an HDK. This is shown in Table 43.
Table 43. Training of TBAs and use of HDK: births attended by TBA between 1995 and 1997
Status of TBA |
Use of HDK in the delivery |
|
Used HDK |
Did not use HDK |
|
Trained (%) |
30 (10) |
273 (90) |
Un trained (%) |
113 (5) |
2101 (95) |
Odds Ration=2.04 (95% CI 1.30 - 3.19) |
Practice of TBAs in the communities
Use of HDKs in communities is perhaps influenced by the practice of the local TBAs. Nearly a quarter (23%) of the 177 TBAs interviewed reported using HDKs routinely, and 16% reported using HDKs 'sometimes' in their practice. Women in communities where the interviewed TBA(s) report(s) using HDKs are more likely to report using an HDK for their last delivery. This is shown in Table 44. This may indicate an influence of TBA practice on prevailing practice in the community. But it should be interpreted with caution because no TBA was interviewed in 23 of the 144 communities.
Table 44. Practice of TBAs serving the community and use of HDK by households, 1995 -1997
TBA H\practice |
Use of HDK by households |
|
Used HDK |
Did not use HDK |
|
Use HDK (%) |
160 (6) |
2749 (94) |
Do not use HDK (%) |
147 (3) |
4377 (97) |
Odds Ration=1.73 (95% CI 1.37 - 2.20) |
Approaching two thirds (59%)of women reported that their last baby's cord was cut with a clean instrument, mostly a new blade or a boiled old blade. The proprotion using a clean instrument was higher for deliveries in the last 5 years (63%). The variation in how the cord is cut by geographic area and by ethnicity is shown in Annex 5, Tables A5.3 and A5.7, and Figure A5.10.
Factors Related To How The Cord is Cut
Literacy of women
A literate woman is more likely to report using a clean instrument is used to cut the umbilical cord. This is shown in Table 45.
Table 45. Literacy and clean cutting of umbilical cord
Literacy of mother |
Cutting of cord |
|
with clean instrument |
without clean instrument |
|
Literate (%) |
2290 (72.1) |
884 (27.9) |
Illiterate (%) |
7089 (59.2) |
4886 (40.8) |
Odds Ration=1.78 (95% CI 1.63 - 1.95) |
Age of women
Younger women are twice as likely to use a clean instrument for cutting the cord as older women, as shown in Table 46. This is still true when the literacy of the mother and area of residence (urban/rural) are taken into account.
Table 46. Age of mother and clean cutting of cord
Age of mother at delivery |
Instrument used to cut cord |
|
Clean |
Not clean |
|
< 35 years (%) |
6954 (67) |
3361 (33) |
> 35 years (%) |
2440 (50) |
2411 (50) |
Odds Ration=2.04 (95% CI 1.90 - 2.20) |
Trend with time
In more recent deliveries, there is an increased chance of using a clean instrument to cut the cord. Deliveries taking place within the last 5 years are 1.7 times more likely to have the cord cut cleanly than deliveries more than 5 years ago. This is seen in both urban and rural areas, and among both literate and illiterate women. It is shown in table 47.
Table 47. Time since delivery and use of a clean instrument to cut the cord
Time since delivery |
Instrument used to cut cord |
|
Clean |
Not clean |
|
Up to 5 years (%) |
6731 (66) |
3451 (34) |
> 5 years (%) |
2663 (53) |
2321 (47) |
Odds Ration=1.70 (95% CI 1.58 - 1.82) |
Practice of TBAs
Women in communities where the interviewed TBA(s) reported using clean instruments to cut the cord are nearly 3 times more likely to cut the cord with a clean instrument than women in communities where the TBA had less good practice. This is shown in Table 48. This should be interpreted with caution because no TBA was interviewed in 23 of the 144 communities.
Table 48. Practice of TBAs in the community and household use of a clean instrument to cut the cord
TBA practice |
Instrument used by housegolds to cut cord |
|
Clean |
Not clean |
|
Clean instrument (%) |
7757 (69) |
3545 (31) |
Unclean instrument (%) |
1632 (44) |
2121 (56) |
Odds Ration=2.84 (95% CI 2.63 - 3.07) |
Practice of health facilities
Staff in all the health facilities interviewed reported that they cut the umbilical cord with clean instruments: 82% with a new blade, 2%with a boiled old blade, and 16% with boiled scissors.
About a third (37%) women reported that nothing was applied to the cord, 6% treated it with antiseptic and 57% with ash, cowdung or oil. If the cord is cut with a clean instrument, and either antiseptic or nothing is applied, the cord is regarded to have been treated safely. On the other hand, if the cord is cut cleanly but later on the stump is covered with unclean materials, the cord is regarded to have been treated unsafely. Using these criteria, 52% women reported the cord was treated safely.
The geographic and ethnic breakdown of safe treatment of the cord is shown in Annex 5, Tables A5.3, and A5.7, and Figure A5.11.
The TBAs interviewed reported the materials used by them to treat the umbilical cord (Table 49). There is no obvious difference between trained and untrained TBAs in terms of the materials they use to treat the cord.
Table 49. Materials used by TBAs to treat the umbilical cord
Cord treated with |
Number |
% |
Nothing |
62 |
35.6 |
Antiseptic |
88 |
50.6 |
Ash |
24 |
13.8 |
Total |
174 |
100 |
Duration of labour and problems during labour
The median reported duration of labour is 4 hours. However, 19% of reported labours lasted more than 12 hours.
About one in 25 (4%) women reported a health problem during their last labour. The variation in proportion of women having a problem during labour by geographic area and ethnicity is shown in Annex 5, Tables A5.3 and A5.7 and Figure A5.12. The type of problems reported are shown in Table 50.
Table 50. Health problems during labour
Health problems |
No women |
% women |
Excessive bleeding |
222 |
31% |
Baby upside down |
84 |
13% |
Obstructed/prolonged labour |
251 |
36% |
Weakness of mother |
139 |
21% |
Convulsion |
19 |
3% |
Weakness of baby |
8 |
1% |
There is a strong association between health problems during pregnancy and problems during labour. A woman with health problems during pregnancy is more than 5 times more likely to develop problems during labour. This is still true when age of the mother, literacy and area of residence are taken into account (Table 51)
Table 51. Health problems during pregnancy and during labour
Health problems during pregnancy |
Problems during labour |
|
Yes |
No |
|
With problems (%) |
277 (16.2) |
1437 (83.3) |
Without problems (%) |
514 (3.3) |
14902 (96.7) |
Odds Ration=5.59 (95% CI 4.77 - 6.55) |
Women with health problems during labour are three and a half times more likely to deliver in a health facility (Table 52). Nevertheless, even among those reporting a health problem during labour, 71% still deliver at home. There is an urban-rural difference: 25% of urban women with labour problems delivered at home compared with 79% of rural women with labour problems.
Table 52. Health problems during labour and place of delivery
Health problem in labour |
Place of delivery |
|
Health facility |
Home |
|
With problem (%) |
207 (29) |
505 (71) |
No problem (%) |
1687 (10) |
14556 (90) |
Odds Ration=3.54 (95% CI 2.97 - 4.21) |
There is no apparent effect of age at the time of pregnancy on the risk of having a problem during labour. Although women with more previous pregnancies are apparently at some increased risk of problems during pregnancy, this association could easily have been due to chance.
Problems during labour reported by TBAs and health facilities.
TBAs and health facilities were asked about the types of emergency problems during labour that they dealt with. The proportions of different problems reported by TBAs and health facilities are shown in table 53.
Table 53. Health problems during labour seen by TBAs and health facilities
Problems |
TBAs (%) |
Facility (%) |
Obstructed/pro-longed labour |
61 (36.7) |
36 (38.3) |
Bleeding |
42 (25.3) |
53 (56.4) |
Infection |
33 (19.9) |
27 (27.66) |
Retained placenta |
17 (10.2) |
28 (29.8) |
Eclampsia |
10 (6.0) |
10 (10.6) |
High Blood pressure |
1 (0.6) |
7 (7.4%) |
Health facilities see more cases of bleeding and of retained placenta, presumably because these tend to be referred to health facilities when they occur.
Seeking help for labour problems
For three quarters of the women who had health problems during labour, their families sought help. The sources of help approached are shown in Table 54.
Table 54. Sources of help approached for problems during labour
Source |
Number |
% |
Hospital |
280 |
31 |
Private doctor / clinic |
159 |
17 |
Traditional healer |
79 |
9 |
TBA |
58 |
6 |
HP, SHP, PHCC |
91 |
10 |
Other |
23 |
3 |
Did not seek help |
224 |
25 |
Reasons for not seeking help for problems during labour
Women with problems during labour who did not seek help for the problem were asked their reasons for not seeking help. Their responses are shown in Table 55.
Table 55. Reasons for not seeking help for problems during labour
Reasons |
Number of Responses |
% |
Not necessary |
85 |
44 |
Too far away |
67 |
35 |
Too expensive |
30 |
16 |
Family not allow |
16 |
8 |
No transport |
8 |
4 |
Too late |
5 |
3 |
Total respondents |
194 |
|
Danger signs reported by TBAs
The 177 TBAs interviewed reported that excessive bleeding, obstructed labour, convulsions and excessive pain are the danger signs during delivery. Trained TBAs knew more danger signs than untrained TBAs. The proportions of trained and untrained TBAs mentioning each danger sign are shown in Table 56.
Table 56. The proportions of trained and untrained TBAs mentioning different danger signs during labour
Danger signs |
Trained TBAs (%) |
Untrained TBAs(%) |
Bleeding |
62 (40) |
27 (17) |
Convulsion |
39 (25) |
23 (15) |
Obstructed/prolonged labour |
54 (35) |
41 (27) |
Infection |
57 (37) |
40 (26) |
Causes of maternal death and prevention, as reported by TBAs and health facilities
The TBAs interviewed reported 105 cases of maternal death in total during delivery and soon after birth, in the three years prior to the survey. Causes of death were identified in 60 cases. Among these 60 cases, TBAs thought that 41 cases of death (68%) could have been prevented if proper management had been available, including early referral to a suitably equipped and staffed health facility. The common causes of death reported were obstructed labour and prolonged labour, bleeding, eclampsia and infection. (Table 57).
Table 57. Causes of maternal deaths and deaths that could have been prevented, as reported by TBAs
Causes of death |
No. |
No. (%) preventable |
Bleeding |
44 |
32 (82) |
Convulsion |
8 |
4 (50) |
Obstructed Labour |
4 |
2 (50) |
Infection |
4 |
3 (75) |
Total |
60 |
41 (68) |
The nearest health facilities serving the communities surveyed were visited. The staff situation, essential equipment and medicine, antenatal check up, delivery, and emergency referral in the last 12 months were reviewed.
Table 58 shows the mean number of deliveries and maternal deaths per year reported by different types of health facilities.
Table 58. Mean number of deliveries and maternal deaths per year reported by health facilities
Type of Facility |
No. of facility |
No. of deliveries Per year |
No. of death per year |
SHP |
70 |
5 |
0.806 |
HP |
35 |
22 |
3.294 |
PHCC |
7 |
4 |
1.000 |
Dist. Hosp |
14 |
96 |
7.000 |
Referral of Obstetric Emergencies
The sub health posts, health posts, PHCCs and FPA clinics reported that they manage less than 15% of emergency cases referred to them. The rest of the emergency cases, 85% of them, are further referred to district hospitals. This might be due to limited emergency care capacity and availability of trained health professionals in other facilities.
There is no relationship between how soon a woman is referred during an obstetric emergency and the type of health facility nearby. Nor is there a clear relationship between the distance from a community to the nearby health facility and the timing of emergency obstetric referrals. Referral of obstetric emergencies relies not only on access to a health facility, but also on attendants during labour having adequate information and knowledge to make prompt decisions to refer women with danger signs during delivery.
In the focus group discussions held in 142 of the 144 communities women were asked what happens if there is an emergency health problem during pregnancy or childbirth. In half of the communities the focus group reported calling a health worker, 42% arranged transport, 29% turned to spiritual healing, and 27% called an experienced woman for help. Focus groups suggested that some communities prefer herbal treatment, massage and other traditional methods.
More than 80% of the focus groups mentioned that it is the household head who makes the decision when to seek help during an emergency, followed by other reputable/educated persons (29%) and TBAs (14%). The focus group responses in relation to obstetric emergencies are shown in Annex 3.
When discussing how to reduce maternal death during pregnancy and childbirth, more than 90% of the focus groups suggested it is necessary to recognise and refer emergencies as early as possible. A third suggested having more health facilities nearby, and another 20% suggested improving transport. (See Annex 3).
One in ten (10%) mothers reported health problems for themselves or for their babies after delivery. Sometimes more than one health problem was reported by one respondent. The common health problems reported are shown in table 59.
Table 59. Reported health problems after birth
Problems |
Number |
% |
Fever/infection (mother) |
365 |
24% |
Delayed discharge of placenta |
307 |
20% |
Excessive Bleeding |
304 |
20% |
Weakness of mother |
282 |
19% |
Fever/infection (baby) |
270 |
18% |
Weakness of baby |
125 |
8% |
Baby breathing problem |
80 |
5% |
Convulsion (mother) |
51 |
3% |
Convulsion (baby) |
10 |
1% |
There was no apparent difference in the type and pattern of problems reported by women of different ages and with different numbers of previous pregnancies.
There is a strong relationship between health problems during pregnancy and health problems after delivery. This is still true when age of the mother, literacy and area of residence are taken into account (Table 60).
Table 60. Health problems during pregnancy and after delivery
Health problems during pregnancy |
Problems during delivery |
|
Yes |
No |
|
With problems (%) |
530 (30) |
1251 (70) |
Without problems (%) |
1335 (9) |
14160 (91) |
Odds Ration=4.49 (95% CI 3.99 - 5.06) |
Among women with problems after delivery, nearly three quarters (73%) sought help. Table 61 shows where these women seek help for problems after delivery.
Table 61. Sources of help for problems after delivery
Source of help |
Number |
% |
No where |
495 |
27 |
District Hospital |
420 |
23 |
Private clinic |
378 |
21 |
Traditional healer |
193 |
11 |
Health post |
137 |
8 |
Dispensary |
65 |
4 |
Sub health post |
60 |
3 |
Untrained TBAs |
47 |
3 |
Trained TBAs |
25 |
1 |
Total |
1838 |
100 |
Of women who did not seek help for their health problems after labour, 57% thought it was not necessary, 22% said facilities were too far away, 13% thought it too expensive, 9% said their families did not allow them to go, and 3% blamed lack of time.
Traditional Birth Attendants (TBAs)
A total of 177 TBAs were interviewed in the survey. No TBA was interviewed in 23 of the 144 communities and up to 4 were interviewed in others. The average age of these TBAs was 45 years, and on average they have been working as TBAs for 8 years. Less than a third of them can read and write. Two thirds (67%) of TBAs interviewed learnt their skills from their mothers or other family members, 26% from Government TBA training programme, 4% were trained by NGOs and 3% by the private sector.
On average, TBAs are paid more for delivering a boy than a girl (Table 62). Perhaps surprisingly, an untrained TBA is paid more for a delivery than a trained TBA. Perhaps people think that trained TBAs are paid or subsidised by the Government, therefore they need to be paid less by the community members. This is not likely to encourage TBAs to go through a training programme.
Table 62: Payment to TBAs for delivery (Nepali Rs)
|
Trained TBA |
Untrained TBA |
||
Boy |
Girl |
Boy |
Girl |
|
Mean |
115 |
85 |
143 |
142 |
Median |
50 |
23 |
125 |
100 |
A trained TBA is more likely to use a HDK for delivery than an untrained TBA, as shown in Table 63.
Table 63. Training of TBA and use of HDK (1)
Use HDK |
Trained TBAs |
Untrained TBAs |
Always |
38 (40%) |
3 (4%) |
Sometimes |
23 (24%) |
5 (6%) |
Do not use |
34 (36%) |
72 (90%) |
A trained TBA is 16 times more likely to use an HDK sometimes or always, compared with an untrained TBA (Table 64).
Table 64. Training of TBA and use of HDK (2)
Training or TBA |
Use of HDK by TBA |
|
Sometimes/always |
Not used |
|
Trained (%) |
61 (64) |
34 (34) |
Untrained (%) |
8 (10) |
72 (90) |
Odds Ration=5.59 (95% CI 4.77 - 6.55) |
85%(148 out of 174) TBAs reported that they washed their hands with
water and soap; 10.3%(18/174) washed hands with water only before attending a delivery; 4%
(7/174)did not wash hands, and 0.6% (1/174) used ash. There is no apparent difference
between trained and untrained TBAs in hand washing practice.