Factors determining satisfaction among facility-based maternity clients in Nepal.

BACKGROUND: With an increasing number of institutional deliveries, the Nepalese health system faces a challenge to ensure a quality of service provision. This paper aims to identify the determinants of client satisfaction with maternity care in Nepal using data from a nationally representative health facility survey. METHODS: A total of 447 exit interviews, with women who had either recently delivered or who had experienced obstetric complications, were conducted across 13 districts in Nepal (87% in hospitals, 8% in Primary Health Care Centres (PHCCs), and 5% in Sub/Health Posts(S/HPs). Client satisfaction was measured using an eight item scale that covered accessibility, interpersonal communication, physical environment, technical aspect of care and decision making. A client satisfaction index was computed using ordinal principal component analysis. A multivariate probit model was used to assess the net effect of explanatory variables on client satisfaction. RESULTS: Longer waiting times and overcrowding increased the likelihood of dissatisfaction. Having an opportunity to ask questions was positively associated with client satisfaction. Respondents from hill districts and rural areas were more likely to be satisfied in comparison to respondents from mountain, terai and urban areas. Socio-demographic factors (age, parity, caste/ethnicity, education, and ecological zone) and supply side factors (the time taken to reach a facility, type of facility, payment for services, and unknown heath worker or anyone entering the delivery room) were not statistically associated with satisfaction. CONCLUSIONS: The findings suggest client satisfaction with the quality of maternity services in Nepal could be improved by reducing waiting times and overcrowding, and giving the mothers adequate time to ask questions. If clients are more satisfied they are more likely to use the facility again/recommend to a friend.

Trends and Inequalities in Use of Maternal Health Care Services in Nepal: Strategy in the Search for Improvements.

BACKGROUND: Nepal has made significant progress against the Millennium Development Goals for maternal and child health over the past two decades. However, disparities in use of maternal health services persist along geographic, economic, and sociocultural lines. METHODS: Trends and inequalities in the use of maternal health services in Nepal between 1994 and 2011 were examined using four Nepal Demographic and Health Surveys (NDHS), nationally representative cross-sectional surveys conducted by interviewing women who gave birth 3-5 years prior to the survey. Sociodemographic disparities in maternal health service utilization were measured. Rate difference, rate ratios, and concentration index were calculated to measure income inequalities. FINDINGS: The percentage of mothers that received four antenatal care (ANC) consultations increased from 9% to 54%, the institutional delivery rate increased from 6% to 47%, and the cesarean section (C-section) rate increased from 1% in 1994 to 6% in 2011. The ratio of the richest and the poorest quintile mothers for use of four ANC, institutional delivery, and C-section delivery were 5.08 (95% CI: 3.82-6.76), 9.00 (95% CI: 6.55-12.37), and 9.37 (95% CI: 4.22-20.83), respectively. However, inequality is reducing over time; for the use of four ANC services, the concentration index fell from 0.60 (95% CI: 0.56-0.64) in 1994-1996 to 0.31 (95% CI: 0.29-0.33) in 2009-2011. For institutional delivery, the concentration index fell from 0.65 (95% CI: 0.62-0.70) to 0.40 (95% CI: 0.38-0.40) between 1994-1996 and 2009-2011. For C-section deliveries, an increase in concentration index was observed, 0.64 (95% CI: 0.51-0.77); 0.76 (95% CI: 0.64-0.88); 0.77 (95% CI: 0.71-0.84); and 0.66 (95% CI: 0.60-0.72) in the periods 1994-1996, 1999-2001, 2004-2006, and 2009-2011, respectively. All sociodemographic variables were significant predictors of use of maternal health services, out of which maternal education was the most powerful. CONCLUSION: To increase equitable use of maternal health services in Nepal there is a need to strengthen the health system to increase access to and utilization of services among poorer women, those with less education, and those living in remote areas. Beyond the health sector stronger efforts are needed to tackle the root causes of health inequality, reduce poverty, increase female education, eradicate caste/ethnicity based social discrimination, and invest in the development of remote areas.

Addressing the needs of people with disability in Nepal: The urgent need.

Health planners and policy makers often overlook the needs of people with disability (PWDs) in less developed countries such as Nepal. The aftermath of conflict and earthquake has further escalated the need of people with disability in Nepal. While the country is preparing for the implementation of a national health sector strategy for the next five years and when the health system is being restructured, we believe that this is the right time to address needs of people with disability by strengthening the health system and operationalizing community based rehabilitation. Furthermore, there is a need of a standard database and monitoring system to regularly assess social inclusion of people with disability.

Women's Satisfaction of Maternity Care in Nepal and Its Correlation with Intended Future Utilization.

The impact of rapid increase in institutional birth rate in Nepal on women's satisfaction and planned future utilization of services is less well known. This study aimed to measure women's satisfaction with maternity care and its correlation with intended future utilisation. Data came from a nationally representative facility-based survey conducted across 13 districts in Nepal and included client exit interviews with 447 women who had either recently delivered or had experienced complications. An eight-item quality of care instrument was used to measure client satisfaction. Multivariate probit model was used to assess the attribution of different elements of client satisfaction with intended future utilization of services. Respondents were most likely to suggest maintaining clean/hygienic health facilities (42%), increased bed provision (26%), free services (24%), more helpful behaviour by health workers (18%), and better privacy (9%). Satisfaction with the information received showed a strong correlation with the politeness of staff, involvement in decision making, and overall satisfaction with the care received. Satisfaction with waiting time (p = 0.035), information received (p = 0.02), and overall care in the maternity care (<0.001) showed strong associations with willingness to return to facility. The findings suggest improving physical environment and interpersonal communication skills of service providers and reducing waiting time for improving client satisfaction and intention to return to the health facility.

Unmet need for family planning in Nepal during the first two years postpartum.

Contraceptive use during the postpartum period is critical for maternal and child health. However, little is known about the use of family planning and the determinants in Nepal during this period. This study explored pregnancy spacing, unmet need, family planning use, and fertility behaviour among postpartum women in Nepal using child level data from the Nepal Demographic and Health Surveys 2011. More than one-quarter of women who gave birth in the last five years became pregnant within 24 months of giving birth and 52% had an unmet need for family planning within 24 months postpartum. Significantly higher rates of unmet need were found among rural and hill residents, the poorest quintile, and Muslims. Despite wanting to space or limit pregnancies, nonuse of modern family planning methods by women and returned fertility increased the risk of unintended pregnancy. High unmet need for family planning in Nepal, especially in high risk groups, indicates the need for more equitable and higher quality postpartum family planning services, including availability of range of methods and counselling which will help to further reduce maternal, perinatal, and neonatal morbidity and mortality in Nepal.