Birth preparedness and skilled attendance at birth in Nepal: Implications for achieving millennium development goal 5

Abstract

Objective

to assess birth preparedness in expectant mothers and to evaluate its association with skilled attendance at birth in central Nepal.

Design

a community-based prospective cohort study using structured questionnaires.

Setting

Kaski district of Nepal.

Participants

a total of 701 pregnant women of more than 5 months gestation were recruited and interviewed, followed by a second interview within 45 days of delivery.

Measurements

outcome was skilled attendance at birth. Birth preparedness was measured by five indicators: identification of delivery place, identification of transport, identification of blood donor, money saving and antenatal care check-up.

Findings

level of birth preparedness was high with 65% of the women reported preparing for at least 4 of the 5 arrangements. It appears that the more arrangements made, the more likely were the women to have skilled attendance at birth (OR=1.51, p<0.001). For those pregnant women who intended to save money, identified a delivery place or identified a potential blood donor, their likelihood of actual delivery at a health facility increased by two to three fold. However, making arrangements for transportation and antenatal care check-up were not significantly associated with skilled attendance at birth.

Conclusions

intention to deliver in a health-care facility as measured by birth preparedness indicators was associated with actual skilled attendance at birth. Birth preparedness packages could increase the proportion of skilled attendance at birth in the pathway of meeting the Millennium Development Goal 5.

Introduction

Maternal mortality remains a major issue for health systems despite the progress made in reducing the maternal mortality ratio in many countries (Hogan et al., 2010). The key strategy incorporated in safe motherhood programmes for achieving the Millennium Development Goal 5 of Maternal Health is to ensure all deliveries take place in the presence of skilled birth attendants (Cambell and Graham, 2006, Starrs, 2006). To become a skilled birth attendant, a health worker must undertake accredited training and education to gain midwifery skills that are essential to manage a normal delivery, to recognise and manage obstetric complications, or refer those complications in time if needed (World Health Organisation, 2004). The adoption of this strategy has enabled the reduction of maternal mortality in several countries such as Malaysia and Sri Lanka (De Brouwere et al., 1998, Koblinsky et al., 1999, Pathmanathan et al., 2003). Moreover, the ‘Three Delay Framework’ has been widely used to explain obstacles to health-care facilities resulting in maternal death (Thaddeus and Maine, 1994): delay in decision to seek care, delay in reaching a health-care facility, and delay in receiving treatment for obstetric complications. They arise due to a variety of reasons including lack of money, distance, quality of service, inadequate community and family awareness, and insufficient knowledge about maternal and newborn health issues.

The elements of birth preparedness have been promoted by international agencies as part of their maternal mortality reduction strategies. Birth preparedness and complications readiness (BP/CR) is the process of planning for normal birth and anticipating the actions needed in case of an emergency. It is the initial prerequisite step to seek skilled birth attendance, and indicates the perceived need of a skilled birth attendant for delivery. BP/CR assists women to seek and reach midwifery care during pregnancy and childbirth, especially when they experience obstetric complications or are far away from a health facility. It can reduce the first and second types of delay in obtaining obstetrical care (Stanton, 2004). BP/CR components at the individual level include knowing danger signs of pregnancy, childbirth and post partum, identifying a health facility and skilled birth attendant, attending a health facility for an antenatal check-up, arranging transport, saving money, and identifying a potential blood donor (JHPIEGO, 2004b).

Nepal has made a substantial progress in reducing maternal mortality and is likely to achieve the Millennium Development Goal 5 (Hussein et al., 2011, World Health Organisation, 2012). Community mobilisation strategies that utilised counselling have made a positive impact on maternal and child health in Nepal (Manandhar et al., 2004, Morrison et al., 2005, Morrison et al., 2010). The BP/CR framework was first adopted in the government's ‘SUMATA’ programme in 2002. This programme encouraged families to care for women during pregnancy, to share their work, and to prepare for birth (JHPIEGO, 2004a, Sood et al., 2004). Birth preparedness packages were then introduced at a number of districts in partnership with several non-government organisations. Community health workers, including maternal and child health workers, village health workers and community volunteers, were trained in counselling techniques and use of the birth preparedness tools (flip-charts and key chains) to communicate the BP/CR messages. Female community health volunteers identified and counselled expectant mothers in their locality, whereas facility-based health workers dealt with pregnant women during antenatal check-ups (McPherson et al., 2006, McPherson et al., 2010). BP/CR has now been incorporated into the national safe motherhood programme of Nepal and implemented throughout the district health system. The district health facilities as well as female community health volunteers use pictorial charts that depict preparation activities and danger signs.

The government of Nepal implemented the ‘safer mother programme’ in January, 2009. This programme provides monetary incentives to women who have attended the recommended four antenatal care visits and delivered at designated birth facilities. It also provides free delivery services at such facilities and encourages women to deliver under skilled attendance, preferably at designated birth centres (Ministry of Health and Population, 2009). Staff nurses and auxiliary midwives with additional training on midwifery skills are qualified as skilled birth attendants in Nepal, and can lead the maternity and delivery care in birth centres. In-service skilled birth training has been provided to midwives since 2006 (Ministry of Health and Population, 2006).

BP/CR is acclaimed as ‘a process indicator in the pathway to maternal survival and a demand-creation intervention that promotes key messages and behaviour change via inter-personal communication through community health volunteers’ (JHPIEGO, 2004a). Although BP/CR has been widely accepted, its effectiveness as a means of increasing the use of skilled birth attendants remains uncertain (Miller et al., 2003, Maine, 2007, Solnes et al., 2013). Studies have been undertaken to measure change in birth preparedness level after educational intervention, rather than measuring the increase in skilled attendance at birth (Sood et al., 2004). Therefore, the aim of this study was to assess birth preparedness level in expectant mothers and to evaluate its association with skilled attendance at birth in a central hills district of Nepal.