Factors Affecting the Use of Midwifery Services in Remote Nepal

Tens of thousands of mothers and hundreds of thousands of newborns die each year or have birth injuries. Families living in remote mountainous areas of Nepal are geographically marginalized, and women often deliver without skilled assistance. Human resources are few and often not trained to the level that international professional organizations recommend. Although the government has established birthing centers in communities in eastern Nepal’s remote, mountainous region of lower Solukhumbu, they are not fully utilized. This study of birthing in a remote area of Nepal examined factors associated with access to skilled birth attendants from both a health systems perspective and from the perspectives of mothers and community members. A concurrent, embedded, mixed methods study investigated mothers’, maternity staff and community members’ experiences with birth through semi-structured interviews. The skills of attending nurses, and the enabling factors such as infrastructure, equipment, and supplies in three levels of maternity facilities were examined through two surveys. Participant observation and field notes were additional methods used. Distance and cost were barriers for many women and lack of birth preparedness contributed to delays in reaching a facility if problems occurred. Although communities believed that health facilities save lives, some women preferred home births, citing institutional barriers arising from outdated and unnecessary obstetrical practices, and lack of choices for women. A shortage of skilled human resources and lack of adequate life-saving supplies and medications were found. Lack of infrastructure resulted in difficulty providing care and referrals. Skilled birth attendants were found to have gaps in life-saving skills. Infrastructure and supplies were inadequate in birthing centers. Improvements in quality of care to maintain cultural safety within birthing institutions require respect for women’s preferences, including birth companions and spiritual healers when requested. Frequent focussed midwifery skills refreshers are needed to improve ability to provide skilled and respectful care. Implementing a fully trained midwifery cohort in rural areas would be a longer term goal.