Standards of care and determinants of women's satisfaction with delivery services in Nepal: a multi-perspective analysis using data from a health facility-based survey.

BACKGROUND: Compliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women's satisfaction with the services they receive. METHODS: Drawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women's overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women's satisfaction with delivery care services. RESULTS: Deliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the "functional referral system" performed highest (92.0%), while "competent, motivated human resources" performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels. CONCLUSIONS: Nepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.

Emergency obstetric and newborn care signal functions: The situation in health facilities in Nepal between 2015 and 2021.

Expanding access to facility-based delivery services and improving the functionality of emergency obstetric and neonatal care (EmONC) are important strategies toward achieving a maternal mortality ratio of 70 deaths per 100,000 live births by 2030. In this study the researchers assess signal functions at designated facilities in Nepal, using Nepal Health Facility Survey data for 2015 and 2021. The functionality of basic and comprehensive EmONC sites was low, declining over the six-year period. Lack of progress may partly be attributed to the COVID-19 pandemic. Nepal needs to expand EmONC sites strategically, strengthen referral systems, improve service readiness, and periodically assess service quality.

Changes in health facility readiness for obstetric and neonatal care services in Nepal: an analysis of cross-sectional health facility survey data in 2015 and 2021.

BACKGROUND: Nepal is committed to achieving the Sustainable Development Goal (SDG) 2030 target 3.1 of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. Along with increasing access to health facility (HF)-based delivery services, improving HF readiness is critically important. The majority of births in Nepal are normal low-risk births and most of them take place in public HFs, as does the majority of maternal deaths. This study aims to assess changes in HF readiness in Nepal between 2015 and 2021, notably, if HF readiness for providing high-quality services for normal low-risk deliveries improved; if the functionality of basic emergency obstetric and neonatal care (BEmONC) services increased; and if infection prevention and control improved. METHODS: Cross-sectional data from two nationally representative HF-based surveys in 2015 and 2021 were analyzed. This included 457 HFs in 2015 and 804 HFs in 2021, providing normal low-risk delivery services. Indices for HF readiness for normal low-risk delivery services, BEmONC service functionality, and infection prevention and control were computed. Independent sample T-test was used to measure changes over time. The results were stratified by public versus private HFs. RESULTS: Despite a statistically significant increase in the overall HF readiness index for normal low-risk delivery services, from 37.9% in 2015 to 43.7%, in 2021, HF readiness in 2021 remained inadequate. The availability of trained providers, essential medicines for mothers, and basic equipment and supplies was high, while that of essential medicines for newborns was moderate; availability of delivery care guidelines was low. BEmONC service functionality did not improve and remained below five percent facility coverage at both time points. In private HFs, readiness for good quality obstetrical care was higher than in public HFs at both time points. The infection prevention and control index improved over time; however, facility coverage in 2021 remained below ten percent. CONCLUSIONS: The slow progress and sub-optimal readiness for normal, low-risk deliveries and infection prevention and control, along with declining and low BEmONC service functionality in 2021 is reflective of poor quality of care and provides some proximate explanation for the moderately high maternal mortality and the stagnation of neonatal mortality in Nepal. To reach the SDG 2030 target of reducing maternal deaths, Nepal must hasten its efforts to strengthen supply chain systems to enhance the availability and utilization of essential medicines, equipment, and supplies, along with guidelines, to bolster the human resource capacity, and to implement mechanisms to monitor quality of care. In general, the capacity of local governments to deliver basic healthcare services needs to be increased.

Histopathological Characterization of a Series of Oral Basaloid Squamous Cell Carcinoma.

Basaloid squamous cell carcinoma (BSCC) is a rare, distinctive, and aggressive variant of squamous cell carcinoma (SCC) primarily seen in the upper aerodigestive tract with epiglottis, soft palate, and base of the tongue being site of high preference in head and neck region. It differs from conventional SCC histologically and immunologically, is most frequently found in males in their sixth and seventh decades, and is frequently linked to alcohol and tobacco use. High stage disease with distant metastases, a high recurrence rate, and a dismal prognosis is how BSCC typically manifests. In the present article, we report four cases of BSCC.

Advancing the WHO-INTEGRATE Framework as a Tool for Evidence-Informed, Deliberative Decision-Making Processes: Exploring the Views of Developers and Users of WHO Guidelines.

BACKGROUND: Decision-making on matters of public health and health policy is a deeply value-laden process. The World Health Organization (WHO)-INTEGRATE framework was proposed as a new evidence-to-decision (EtD) framework to support guideline development from a complexity perspective, notably in relation to public health and health system interventions, and with a foundation in WHO norms and values. This study was conducted as part of the development of the framework to assess its comprehensiveness and usefulness for public health and health policy decision-making. METHODS: We conducted a qualitative study comprising nine key informant interviews (KIIs) with experts involved in WHO guideline development and four focus group discussions (FGDs) with a total of forty health decision-makers from Brazil, Germany, Nepal and Uganda. Transcripts were analyzed using MAXQDA12 and qualitative content analysis. RESULTS: Most key informants and participants in the FGDs appreciated the framework for its relevance to real-world decision-making on four widely differing health topics. They praised its broad perspective and comprehensiveness with respect to new or expanded criteria, notably regarding societal implications, equity considerations, and acceptability. Some guideline developers questioned the value of the framework beyond current practice and were concerned with the complexity of applying such a broad range of criteria in guideline development processes. Participants made concrete suggestions for improving the wording and definitions of criteria as well as their grouping, for covering missing aspects, and for addressing overlap between criteria. CONCLUSION: The framework was well-received by health decision-makers as well as the developers of WHO guidelines and appears to capture all relevant considerations discussed in four distinct real-world decision processes that took place on four different continents. Guidance is needed on how to apply the framework in guideline processes that are both transparent and participatory. A set of suggestions for improvement provides a valuable starting point for advancing the framework towards version 2.0.

A rare case of foreign body aspiration presenting as subglottic stenosis: A case report.

In rare cases, foreign body aspiration may present with similar clinical features and CT findings to subglottic stenosis. A high index of suspicion and additional diagnostic techniques may be required to distinguish them.

Global research priorities for social, behavioural and community engagement interventions for maternal, newborn and child health.

BACKGROUND: Social, behavioural and community engagement (SBCE) interventions are essential for global maternal, newborn and child health (MNCH) strategies. Past efforts to synthesise research on SBCE interventions identified a need for clear priorities to guide future research. WHO led an exercise to identify global research priorities for SBCE interventions to improve MNCH. METHODS: We adapted the Child Health and Nutrition Research Initiative method and combined quantitative and qualitative methods to determine MNCH SBCE intervention research priorities applicable across different contexts. Using online surveys and meetings, researchers and programme experts proposed up to three research priorities and scored the compiled priorities against four criteria - health and social impact, equity, feasibility, and overall importance. Priorities were then ranked by score. A group of 29 experts finalised the top 10 research priorities for each of maternal, newborn or child health and a cross-cutting area. RESULTS: A total of 310 experts proposed 867 research priorities, which were consolidated into 444 priorities and scored by 280 experts. Top maternal and newborn health priorities focused on research to improve the delivery of SBCE interventions that strengthen self-care/family care practices and care-seeking behaviour. Child health priorities focused on the delivery of SBCE interventions, emphasising determinants of service utilisation and breastfeeding and nutrition practices. Cross-cutting MNCH priorities highlighted the need for better integration of SBCE into facility-based and community-based health services. CONCLUSIONS: Achieving global targets for MNCH requires increased investment in SBCE interventions that build capacities of individuals, families and communities as agents of their own health. Findings from this exercise provide guidance to prioritise investments and ensure that they are best directed to achieve global objectives. Stakeholders are encouraged to use these priorities to guide future research investments and to adapt them for country programmes by engaging with national level stakeholders.

Burden of injuries in Nepal, 1990-2017: findings from the Global Burden of Disease Study 2017.

BACKGROUND: Nepal is a low-income country undergoing rapid political, economic and social development. To date, there has been little evidence published on the burden of injuries during this period of transition. METHODS: The Global Burden of Disease Study (GBD) is a comprehensive measurement of population health outcomes in terms of morbidity and mortality. We analysed the GBD 2017 estimates for deaths, years of life lost, years lived with disability, incidence and disability-adjusted life years (DALYs) from injuries to ascertain the burden of injuries in Nepal from 1990 to 2017. RESULTS: There were 16 831 (95% uncertainty interval 13 323 to 20 579) deaths caused by injuries (9.21% of all-cause deaths (7.45% to 11.25%)) in 2017 while the proportion of deaths from injuries was 6.31% in 1990. Overall, the injury-specific age-standardised mortality rate declined from 88.91 (71.54 to 105.31) per 100 000 in 1990 to 70.25 (56.75 to 85.11) per 100 000 in 2017. In 2017, 4.11% (2.47% to 6.10%) of all deaths in Nepal were attributed to transport injuries, 3.54% (2.86% to 4.08%) were attributed to unintentional injuries and 1.55% (1.16% to 1.85%) were attributed to self-harm and interpersonal violence. From 1990 to 2017, road injuries, falls and self-harm all rose in rank for all causes of death. CONCLUSIONS: The increase in injury-related deaths and DALYs in Nepal between 1990 and 2017 indicates the need for further research and prevention interventions. Injuries remain an important public health burden in Nepal with the magnitude and trend of burden varying over time by cause-specific, sex and age group. Findings from this study may be used by the federal, provincial and local governments in Nepal to prioritise injury prevention as a public health agenda and as evidence for country-specific interventions.

Factors Affecting Enrollment in Government Health Insurance Program in Kailali District.

BACKGROUND: Health care financial burden on households is high in Nepal. High health care expenditure is a major obstacle in achieving universal health coverage. The health insurance is expected to reduce healthcare expenditure. However, only small segments of the population are covered by health insurance in Nepal.This study assessed the factors affecting enrollment in government health insurance program in the first piloted district, Kailali, Nepal. METHODS: A cross-sectional survey was conducted among 1048 households located in 26 wards of Kailali district after 21 months of the implementation of social health insurance program, Nepal. The sample was selected in two stages, first stage being the selection of wards and second, being the households. RESULTS: The higher level of household economic status was associated with increased odds of enrollment in health insurance program (ORs=4.99, 5.04, 5.13, 8.05, for second, third, fourth, and the highest quintile of households, respectively). A higher level of head's education was associated with increased odds of health insurance enrollment (ORs = 1.58, 1.78, 2.36, for primary, secondary, tertiary education, respectively). Presence of chronic illness in the household was positively associated with increased odds of health insurance enrollment (OR= 1.29). CONCLUSIONS: The poor and low educated groups were less benefited by social health insurance program in Kailali district, Nepal. Hence, policymakers should focus to implement income-based premium scheme for ensuring equal access to healthcare.Since household with chronic illness leads to high odds of being enrolled, a compulsory health insurance scheme can make the program financially sustainable.

Barriers and facilitators to institutional delivery in rural areas of Chitwan district, Nepal: a qualitative study.

BACKGROUND: Giving birth assisted by skilled care in a health facility plays a vital role in preventing maternal deaths. In Nepal, delivery services are free and a cash incentive is provided to women giving birth at a health facility. Nevertheless, about half of women still deliver at home. This study explores socio-cultural and health service-related barriers to and facilitators of institutional delivery. METHODS: Six village development committees in hill and plain areas were selected in Chitwan district. We conducted a total of 10 focus group discussions and 12 in-depth-interviews with relevant stakeholder groups, including mothers, husbands, mothers-in-law, traditional birth attendants, female community health volunteers, health service providers and district health managers. Data were analyzed inductively using thematic analysis. RESULTS: Three main themes played a role in deciding the place of delivery, i.e. socio-cultural norms and values; access to birthing facilities; and perceptions regarding the quality of health services. Factors encouraging an institutional delivery included complications during labour, supportive husbands and mothers-in-law, the availability of an ambulance, having birthing centres nearby, locally sufficient financial incentives and/or material incentives, the 24-h availability of midwives and friendly health service providers. Socio-cultural barriers to institutional deliveries were deeply held beliefs about childbirth being a normal life event, the wish to be cared for by family members, greater freedom of movement at home, a warm environment, the possibility to obtain appropriate "hot" foods, and shyness of young women and their position in the family hierarchy. Accessibility and quality of health services also presented barriers, including lack of road and transportation, insufficient financial incentives, poor infrastructure and equipment at birthing centres and the young age and perceived incompetence of midwives. CONCLUSION: Despite much progress in recent years, this study revealed some important barriers to the utilization of health services. It suggests that a combination of upgrading birthing centres and strengthening the competencies of health personnel while embracing and addressing deeply rooted family values and traditions can improve existing programmes and further increase institutional delivery rates.

Donation programme of returned medicines: role of donors and point of view of beneficiaries.

Background: Donation of returned medicines is a debated health policy issue as it is discouraged by WHO, but accepted in some countries. Methods: Lessons learned from a donation programme of returned medicines carried out in Europe were documented. Results: The donation programme we reviewed followed a strict protocol for collection, sorting and distribution of returned drugs, in order to avoid the major limitations associated with unused medicine donations. Over a period of 3 years, 23 145 boxes of medicines were donated to 14 organizations operating in Europe, Africa and Latin America. Conclusions: The donations covered about one-third of the volume of medicines used by beneficiary organizations. The programme helped to decrease expenditure by both patients and health facilities.

Impact of the community-based newborn care package in Nepal: a quasi-experimental evaluation.

OBJECTIVE: To evaluate the impact of the community-based newborn care package (CBNCP) on six essential practices to improve neonatal health. METHODS: CBNCP pilot districts were matched to comparison districts using propensity scores. Impact on birth preparedness, antenatal care seeking, antenatal care quality, delivery by skilled birth attendant, immediate newborn care and postnatal care within 48 hours were assessed using Demographic and Health Survey (DHS) and Health Management Information System (HMIS) data through difference-in-differences and multivariate logistic regression analyses. FINDINGS: Changes over time in intervention and comparison areas were similar in difference-in-differences analysis of DHS and HMIS data. Logistic regression of DHS data also did not reveal any significant improvement in combined outcomes: birth preparedness, adjusted OR (aOR)=0.8 (95% CI 0.4 to 1.7); antenatal care seeking, aOR=1.0 (0.6 to 1.5); antenatal care quality, aOR=1.4 (0.9 to 2.1); delivery by skilled birth attendant, aOR=1.5 (1.0 to 2.3); immediate newborn care, aOR=1.1 (0.7 to 1.9); postnatal care, aOR=1.3 (0.9 to 1.9). Health providers' knowledge and skills in intervention districts were fair but showed much variation between different providers and districts. CONCLUSIONS: This study, while representing an early assessment of impact, did not identify significant improvements in newborn care practices and raises concerns regarding CBNCP implementation. It has contributed to revisions of the package and it being merged with the Integrated Management of Neonatal and Childhood Illness programme. This is now being implemented in 35 districts and carefully monitored for quality and impact. The study also highlights general challenges in evaluating the impacts of a complex health intervention under 'real life' conditions.

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.

Cause of Death in Women of Reproductive Age in Rural Nepal Obtained Through Community-Based Surveillance: Is Reducing Maternal Mortality the Right Priority for Women's Health Programs?

We used a community surveillance system to gather information regarding pregnancy outcomes and the cause of death for women of reproductive age (WRA) in Kanchanpur, Nepal. A total of 784 mother groups participated in the collection of pregnancy outcomes and mortality data. Of the 273 deaths among WRA, the leading causes of death reported were chronic diseases (94, 34.4%) poisoning, snake bites, and suicide (grouped together; 55, 20.1%), and accidents (29, 10.6%), while maternal mortality accounted for 7%. Nevertheless, the calculated maternal mortality ratio was quite high (259.3 per 100,000 live births).

Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality.

BACKGROUND: Nepal has made substantial progress in reducing under-five mortality and is on track to achieve Millennium Development Goal 4, but advances in neonatal health are less encouraging. The objectives of this study were to assess relative and absolute inequalities in neonatal mortality over time, and to review experience with major programs to promote neonatal health. METHODS: Using four nationally representative surveys conducted in 1996, 2001, 2006 and 2011, we calculated neonatal mortality rates for Nepal and for population groups based on child sex, geographical and socio-economic variables using a true cohort log probability approach. Inequalities based on different variables and years were assessed using rate differences (rd) and rate ratios (rr); time trends in neonatal mortality were measured using the annual rate of reduction. Through literature searches and expert consultation, information on Nepalese policies and programs implemented since 1990 and directly or indirectly attempting to reduce neonatal mortality was compiled. Data on timeline, coverage and effectiveness were extracted for major programs. RESULTS: The annual rate of reduction for neonatal mortality between 1996 and 2011 (2.8 percent per annum) greatly lags behind the achievements in under-five and infant mortality, and varies across population groups. For the year 2011, stark absolute and relative inequalities in neonatal mortality exist in relation to wealth status (rd = 21.4, rr = 2.2); these are less pronounced for other measures of socio-economic status, child sex and urban-rural residence, ecological and development region. Among many efforts to promote child and maternal health, three established programs and two pilot programs emerged as particularly relevant to reducing neonatal mortality. While these were designed based on national and international evidence, information about coverage of different population groups and effectiveness is limited. CONCLUSION: Neonatal mortality varies greatly by socio-demographic variables. This study clearly shows that much remains to be achieved in terms of reducing neonatal mortality across different socio-economic, ethnic and geographical population groups in Nepal. In moving forward it will be important to scale up programs of proven effectiveness, conduct in-depth evaluation of promising new approaches, target unreached and hard-to-reach populations, and maximize use of financial and personnel resources through integration across programs.

Successful use of tablet personal computers and wireless technologies for the 2011 Nepal Demographic and Health Survey.

Computer-Assisted Personal Interviewing (CAPI), coupled with the use of mobile and wireless technology, is growing as a data collection methodology. Nepal, a geographically diverse and resource-scarce country, implemented the 2011 Nepal Demographic and Health Survey, a nationwide survey of major health indicators, using tablet personal computers (tablet PCs) and wireless technology for the first time in the country. This paper synthesizes responses on the benefits and challenges of using new technology in such a challenging environment from the 89 interviewers who administered the survey. Overall, feedback from the interviewers indicate that the use of tablet PCs and wireless technology to administer the survey demonstrated potential to improve data quality and reduce data collection time-benefits that outweigh manageable challenges, such as storage and transport of the tablet PCs during fieldwork, limited options for confidential interview space due to screen readability issues under direct sunlight, and inconsistent electricity supply at times. The introduction of this technology holds great promise for improving data availability and quality, even in a context with limited infrastructure and extremely difficult terrain.