Influence of family members on utilization of maternal health care services among teen and adult pregnant women in Kathmandu, Nepal: a cross sectional study.

BACKGROUND: In some developing countries a woman's decision to utilize maternal health care services is not made by the woman herself but by other family members. The perception of family members regarding who is the most influential person for making the decision to utilize these services is inconclusive. Hence, this study aimed to determine the perceived influential person on utilization of antenatal care (ANC) and delivery care services among teen, young adult and adult pregnant women from the perspective of the woman themselves, their husband and their mother-in-law, identify the factors associated with the woman being the most influential person, and assess the level of agreement between the woman's and her husband's response to the woman being the most influential person. METHODS: A cross-sectional study was conducted at Paropakar Maternity and Women's Hospital and Tribhuvan University Teaching Hospital. Purposive sampling technique was used to select 315 women of which 105 were from each age group and their accompanied husbands (n = 315) and mothers-in-law (n = 315). The proportion of perceived influential person and mean priority score of the perceived influence with its 95% confidence interval was calculated. The factors associated with the woman perceived as the most influential person were analyzed by multivariate logistic regression model. The agreement was analyzed using kappa statistic. RESULTS: Among teens and young adults and their husband and mother-in-law, the woman's husband was perceived as the most influential person. Among adults, the most influential person for ANC was the woman herself but for delivery care was the woman's husband. A woman of adult age, having a non-indigenous ethnicity or who was not referred was more likely to perceive herself as the most influential person in the decision to utilize delivery care. A fair to poor level of agreement was found on the perception of the most influential person for ANC and delivery care utilization. CONCLUSIONS: Both women and their husbands influenced the decision to utilize ANC and delivery care but husbands were more influential, especially in teens and young adults. Thus, husband's involvement is crucial as a strategy to improve maternal health care utilization in Nepal.

Effects of abortion legalization in Nepal, 2001-2010.

BACKGROUND: Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion. METHODS: We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001-2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001-2003), early implementation (2004-2006), and later implementation (2007-2010). RESULTS: 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75). CONCLUSION: Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women's health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

Change in willingness to pay for normal delivery and caesarean section during pregnancy and after delivery in Kathmandu.

SUMMARY OBJECTIVES: To determine the change in willingness to pay (WTP) measured at pregnancy and at postpartum before and after knowing hospital costs among women who gave birth by normal delivery (NL) and caesarean section (CS) and to identify factors affecting the change in WTP. METHODS: A prospective study was conducted from May to August 2009 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. WTP for total costs was measured by double-bound dichotomous contingent valuation and an open-ended technique. The trend of WTP over time was tested using longitudinal analysis. Associated factors to the positive or negative change in WTP were analysed by logistic regression. RESULTS: Of 438 pregnant women followed up both at pregnancy and postpartum, two-thirds were willing to pay for services at the initial bid of the double-bound method by $60-$85 for NL and $110-$170 for CS. There were no significant differences in the median WTP measured during pregnancy between NL and CS. The WTP of both groups changed significantly over time (P < 0.001). Caesarean section, perception of good care, information provided on delivery costs and discussion with family about cost were significantly associated with changes from pregnancy to the postpartum period. CONCLUSIONS: In low-income countries such as Nepal, where out-of-pocket health care expenditures are common, women perceived the health benefit of delivery care in hospital, especially for emergency CS. Their WTP had changed substantially after delivery, and awareness of the associated factors is essential for further policy and planning to improve the services and utilization.

Maternal mortality over the last decade: a changing pattern of death due to alarming rise in hepatitis in the latter five-year period.

AIMS: To study the causes of maternal mortality in two consecutive five year periods over a decade (1997-2001/2002-2006) in a university hospital. METHOD: A maternal mortality over 10 years (1997-2006) was analyzed prospectively from the Obstetrics/Gynecology Department of Tribhuvan University Teaching Hospital. RESULTS: The maternal mortality ratio of 267.5/100 000 live births was affected by 83 (41 [49.3%] direct, 36 [43.3%] indirect and six [7.2%] non-obstetric) maternal deaths in 31,021 live births. Direct cause was led by infections (n=23, 27.7%): 15 septic abortions (two [2.4%] spontaneous and 13 [15.6%] induced; seven of these occurred in 1997-2001); along with seven (8.6%) cases of puerperal sepsis; a case of antenatal septic shock; and a case of hemolysis, elevated liver enzyme levels, and low platelet count syndrome. There were eight (9.8%) cases of obstetric hemorrhage (six post-partum hemorrhage; two abortions); eclampsia (n=2); severe pregnancy-induced hypertension with hemolysis, elevated liver enzyme levels, and low platelet count syndrome (n=1); and cesarean complications included one from anesthesia and another surgical, which was included under post-partum hemorrhage. There were two cases of pulmonary embolism and four unexplainable deaths. Indirect causes included infective hepatitis (n=19, 22.8%) (13 of these occurred in the more recent 5-year period [2002-2006]), followed by heart disease (n=6), tuberculosis (n=5, 6%), anemia (n=3, 3.6%) and a case each of meningitis, chronic renal failure and diarrhea. Six non-obstetric deaths occurred: one from a road traffic accident; and five due to suicidal (n=1) and accidental (n=4) burns. CONCLUSION: Maternal mortality over a period of a decade in an institutional setting exhibited induced septic abortion as the main cause of maternal death during the first five years of the study period (1997-2001). In the second five years of the study period (2002-2006) an alarming rise in infective hepatitis became the main cause of maternal death.

Effect of education and pill count on hemoglobin status during prenatal care in Nepalese women: a randomized controlled trial.

AIM: To determine the effect of an education program and/or pill count on the change in hemoglobin levels and the prevalence of anemia in pregnant women. METHODS: A randomized, factorial design controlled trial was conducted at the Tribhuvan University Teaching Hospital, Nepal. A total of 320 eligible pregnant women receiving prenatal care were randomized into four groups (control, education, pill count and education with pill count) by block randomization with allocation concealment. All recruited women received conventional routine prenatal care with a daily dose of 60 mg iron supplementation. In addition, the education group received an education program. Pill counting was done for the pill count group at their routine prenatal visits. The education with pill count group received both the education program plus pill counting. Baseline hemoglobin at the recruitment phase and follow-up hemoglobin after three months of recruitment were measured. Changes in hemoglobin levels and anemia prevalence were analyzed and compared between groups. RESULTS: The education only and education with pill count groups had significantly higher hemoglobin changes (0.23 and 0.26 g/dL, respectively) than the control group (P < 0.01). Anemia was reduced by 59% in the education group and by 65% in the education with pill count group, compared to the control group (P < 0.05). Pill count alone significantly improved neither the hemoglobin level nor anemia prevalence compared to the control group. CONCLUSION: An education program along with routine iron supplementation can improve hemoglobin levels and reduce anemia prevalence in pregnant women. Pill count as a measure of compliance has no additional effect on improving hemoglobin status.

Mifepristone plus vaginal misoprostol vs vaginal misoprostol alone for medical abortion in gestation 63 days or less in Nepalese women: a quasi-randomized controlled trial.

AIM: To compare the efficacy of mifepristone and vaginal misoprostol with misoprostol alone for pregnancy termination up to 63 days. METHOD: This exploratory study was conducted in the Department of Obstetrics and Gynecology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal as a part of a thesis study for a period of one year from April 2005-2006. After confirming a pregnancy < or =63 days gestation by transvaginal ultrasound, an equal number of women (50) were randomized into (i) group A, women who received 200 mg oral mifepristone (RU 486) on day 1 and vaginal misoprostol 800 microg on day 3; and (ii) group B, women who received vaginal misoprostol (800 microg) on day 1 and 3 (total dose 1600 microg). The primary study outcome measure was complete abortion without surgical intervention making comparisons between these two groups in terms of complete abortion rate, need for manual vacuum aspiration for incomplete abortion and pregnancy continuation after reconfirming the diagnosis on transvaginal ultrasound, besides comparing the side effects/complications. RESULTS: Fewer side effects and a more complete abortion rate (94%) was observed in group A (mifepristone and vaginal misoprostol) in comparison to vaginal misoprostol alone (total dose 1600 microg) giving a complete abortion rate of 86% along with a significant hematocrit drop on follow-up day 10 (P = 0.03) besides having increased duration of bleeding (P = 0.017). CONCLUSION: Mifepristone oral (200 mg) followed by vaginal misoprostol (800 microg) on day 3 provides a better success rate (94%) with fewer complications than vaginal misoprostol 800 microg used on days 1 and 3 for medical abortion of pregnancies up to 63 days.

Induced septic abortion: a major factor in maternal mortality and morbidity.

BACKGROUND: Septic abortion is an infection of the uterus and its appendages following any abortion especially, illegally performed induced abortions. It is characterized by a rise of temperature to at least 100.4 degrees F, associated offensive or purulent vaginal discharge and lower abdominal pain and tenderness. AIM: To study maternal mortality and morbidity in induced septic abortions. METHODS: Induced septic abortions were analyzed between April 1992 and September 1999 in TU Teaching hospital. Morbidity indicators were surgery other than curettage, prolonged hospitalization and permanent damage. RESULTS: In 92 cases of induced septic abortions, comprising 6% of total abortions; nine deaths occurred because of disseminated intravascular coagulation, acute renal failure and adult respiratory distress syndrome. Vaginal, intraperitoneal and gum bleeding; epistaxis and malaena resulted in severe anemia (Hb < 6 gm/L) in 11 cases. Wound debridement and skin graft cured two cases of necrotizing fasciitis. One of four conservatively managed tubo-ovarian masses spontaneously drained rectally. In 15 cases laparotomy for pus drainage, salpingectomy, salpingo-oophorectomy, hysterotomy/uterine rent repair was conducted, along with four bowel surgeries and six hysterectomies were performed. Post-operative complications included burst abdomen (one case) and reopened pyoperitoneum, which resulted fecal fistula in three cases, one of these patients died. CONCLUSION: : Induced abortion was proven to be a major detrimental factor for maternal mortality. Morbidity was four times higher than mortality to the extent that patients suffered hemiplegia and forced barrenness.