Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
BMC Public Health
Published in: BMC Public Health 1/2021

01-12-2021 | Care | Research article

Trends in national and subnational wealth related inequalities in use of maternal health care services in Nepal: an analysis using demographic and health surveys (2001–2016)

Authors: Vishnu Prasad Sapkota, Umesh Prasad Bhusal, Kiran Acharya

Published in: BMC Public Health | Issue 1/2021

Login to get access

Abstract

Background

Maternal health affects the lives of many women and children globally every year and it is one of the high priority programs of the Government of Nepal (GoN). Different evidence articulate that the equity gap in accessing and using maternal health services at national level is decreasing over 2001–2016. This study aimed to assess whether the equity gap in using maternal health services is also decreasing at subnational level over this period given the geography of Nepal has already been identified as one of the predictors of accessibility and utilization of maternal health services.

Methods

The study used wealth index scores for each household and calculated the concentration curves and indexes in their relative formulation, with no corrections. Concentration curve was used to identify whether socioeconomic inequality in maternity services exists and whether it was more pronounced at one point in time than another or in one province than another. The changes between 2001 and 2016 were also disaggregated across the provinces. Test of significance of changes in Concentration Index was performed by calculating pooled standard errors. We used R software for statistical analysis.

Results

The study observed a progressive and statistically significant decrease in concentration index for at least four antenatal care (ANC) visit and institutional delivery at national level over 2001–2016. The changes were not statistically significant for Cesarean Section delivery. Regarding inequality in four-ANC all provinces except Karnali showed significant decreases at least between 2011 and 2016. Similarly, all provinces, except Karnali, showed a statistically significant decrease in concentration index for institutional delivery between 2011 and 2016.

Conclusion

Despite appreciable progress at national level, the study found that the progress in reducing equity gap in use of maternal health services is not uniform across seven provinces. Tailored investment to address barriers in utilization of maternal health services across provinces is urgent to make further progress in achieving equitable distribution in use of maternal health services. There is an opportunity now that the country is federalized, and provincial governments can make a need-based improvement by addressing specific barriers.
Literature
1.
Bongaarts J. WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Trends in Maternal Mortality: 1990 to 2015 Geneva: World Health Organization, 2015. Population and Development Review. 2016;42(4):726.
2.
Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN maternal mortality estimation inter-agency group. Lancet. 2016;387(10017):462–74.PubMedCrossRef
3.
Jolivet RR, Moran AC, O’Connor M, Chou D, Bhardwaj N, Newby H, et al. Ending preventable maternal mortality: phase II of a multi-step process to develop a monitoring framework, 2016–2030. BMC pregnancy and childbirth. 2018;18(1):258.PubMedPubMedCentralCrossRef
4.
Campbell OM, Calvert C, Testa A, Strehlow M, Benova L, Keyes E, et al. The scale, scope, coverage, and capability of childbirth care. Lancet. 2016;388(10056):2193–208.PubMedCrossRef
5.
Ceschia A, Horton R. Maternal health: time for a radical reappraisal. Lancet. 2016;388(10056):2064–6.PubMedCrossRef
6.
Freedman LP. Implementation and aspiration gaps: whose view counts? Lancet (London, England). 2016;388(10056):2068–9.CrossRef
7.
Graham W, Woodd S, Byass P, Filippi V, Gon G, Virgo S, et al. Diversity and divergence: the dynamic burden of poor maternal health. Lancet. 2016;388(10056):2164–75.PubMedCrossRef
8.
Koblinsky M, Moyer CA, Calvert C, Campbell J, Campbell OM, Feigl AB, et al. Quality maternity care for every woman, everywhere: a call to action. Lancet. 2016;388(10057):2307–20.PubMedCrossRef
9.
Kruk ME, Kujawski S, Moyer CA, Adanu RM, Afsana K, Cohen J, et al. Next generation maternal health: external shocks and health-system innovations. Lancet. 2016;388(10057):2296–306.PubMedPubMedCentralCrossRef
10.
Government of Nepal NPC, Nepal UNCTo. Nepal Millenium Development Goals: Progress Report 2013. 2013.
11.
Mehata S, Paudel YR, Dariang M, Aryal KK, Lal BK, Khanal MN, et al. Trends and inequalities in use of maternal health care services in Nepal: strategy in the search for improvements. Biomed Res Int. 2017;2017.
12.
Ministry of Health. MOH/Nepal, New ERA/Nepal, ICF. Nepal Demographic and Health Survey 2016. Kathmandu, Nepal: MOH/Nepal, New ERA, and ICF; 2017.
13.
14.
15.
National Planning Commission. Nepal: Sustainable development goals, status and roadmap 2016-2030. Kathmandu: Government of Nepal National Planning Commission. p. 2017.
16.
Bhatt H, Tiwari S, Ensor T, Ghimire DR, Gavidia T. Contribution of Nepal’s free delivery care policies in improving utilisation of maternal health services. Int J Health Policy Manag. 2018;7(7):645.PubMedPubMedCentralCrossRef
17.
Ensor T, Bhatt H, Tiwari S. Incentivizing universal safe delivery in Nepal: 10 years of experience. Health Policy Plan. 2017;32(8):1185–92.PubMedCrossRef
18.
19.
Ministry of Health. Nepal health sector program-implementation plan (NHSP-IP) 2004–9. 2004.
20.
Ministry of Health Population. Nepal Health Sector Programme-2 Implementation Plan 2010–2015, vol. 2010. Nepal: Government of Nepal Kathmandu.
21.
Pradhan PM. A critical review of National Health Policy-1991. Nepal Health Research Council; 2009.
22.
23.
Corsi DJ, Neuman M, Finlay JE, Subramanian S. Demographic and health surveys: a profile. Int J Epidemiol. 2012;41(6):1602–13.PubMedCrossRef
24.
Secretariate CA. Nepal’s constitution, 2015 (2072 BS). Singhadurbar, Kathmandu: Constitutional Assembly Secretariate; 2015.
25.
Acharya K, Paudel YR, Dharel D. The trend of full vaccination coverage in infants and inequalities by wealth quintile and maternal education: analysis from four recent demographic and health surveys in Nepal. BMC Public Health. 2019;19(1):1673.PubMedPubMedCentralCrossRef
26.
Johnson K, Bradley S. Trends in economic differentials in population and health outcomes. Further analysis of the 2006 Nepal Demographic and Health Survey; 2006.
27.
Collin SM, Anwar I, Ronsmans C. A decade of inequality in maternity care: antenatal care, professional attendance at delivery, and caesarean section in Bangladesh (1991–2004). Int J Equity Health. 2007;6(1):9.PubMedPubMedCentralCrossRef
28.
Rutstein S, Johnson K. The DHS wealth index. DHS comparative reports no. 6. 2004. Calverton: ORC Macro; 2017.
29.
Rutstein SO, Staveteig S. Making the demographic and health surveys wealth index comparable. DHS methodological reports. Rockville, MD: ICF International; 2014.
30.
O'donnell O, Van Doorslaer E, Wagstaff A, Lindelow M. Analyzing health equity using household survey data: a guide to techniques and their implementation: the World Bank; 2007.CrossRef
31.
Kakwani N, Wagstaff A, Van Doorslaer E. Socioeconomic inequalities in health: measurement, computation, and statistical inference. J Econ. 1997;77(1):87–103.CrossRef
32.
33.
Team RC. R: a language and environment for statistical computing; 2013.
34.
35.
Wickham H. ggplot2: elegant graphics for data analysis: Springer; 2016.
36.
37.
Rath AD, Basnett I, Cole M, Subedi HN, Thomas D, Murray SF. Improving emergency obstetric care in a context of very high maternal mortality: the Nepal safer motherhood project 1997–2004. Reproductive Health Matters. 2007;15(30):72–80.PubMedCrossRef
38.
Murray SF, Hunter BM, Bisht R, Ensor T, Bick D. Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low-and middle-income countries: a systematic review. BMC pregnancy and childbirth. 2014;14(1):30.PubMedPubMedCentralCrossRef
39.
Powell-Jackson T, Mazumdar S, Mills A. Financial incentives in health: new evidence from India's Janani Suraksha Yojana. J Health Econ. 2015;43:154–69.PubMedCrossRef
40.
Agha S. Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention. Int J Equity Health. 2011;10(1):57.PubMedPubMedCentralCrossRef
41.
Ir P, Horemans D, Souk N, Van Damme W. Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia. BMC pregnancy and childbirth. 2010;10(1):1.PubMedPubMedCentralCrossRef
42.
Upreti SR, Baral S, Lamichhane P, Khanal MN, Tiwari S, Tandan M, et al. Rapid assessment of the demand side financing schemes: Aama and 4ANC Programmes (the seventh rapid assessment), Ministry of Health and Population,Nepal Health Sector Support Programme and Health Research and Social Development Forum. Kathmandu; 2013.
43.
Hodge A, Byrne A, Morgan A, Jimenez-Soto E. Utilisation of health services and geography: deconstructing regional differences in barriers to facility-based delivery in Nepal. Matern Child Health J. 2015;19(3):566–77.PubMedCrossRef
44.
Hatt L, Nguyen H, Sloan N, Miner S, Magvanjav O, Sharma A, et al. Economic evaluation of demand-side financing (DSF) for maternal health in Bangladesh: Review, Analysis and Assessment of Issues Related to Health Care Financing and Health Economics in Bangladesh; 2010.
45.
Febriany V, Toyamah N, Sodo J, Budiyati S. Qualitative impact study for PNPM Generasi and PKH on the provision and the utilization of maternal and child health services and basic education Services in the Provinces of West Java and East Nusa Tenggara: SMERU research institute; 2011.
46.
Kashyap A. No tally of the anguish: accountability in maternal health Care in India: Human Rights Watch; 2009.
47.
Malini S, Tripathi R, Khattar P, Nair K, Tekhre Y, Dhar N, et al. A rapid appraisal on functioning of Janani Suraksha Yojana in South Orissa. Health Popul Perspect Issues. 2008;31:126–31.
48.
Rai SK, Dasgupta R, Das M, Singh S, Devi R, Arora N. Determinants of utilization of services under MMJSSA scheme in Jharkhand'Client Perspective': a qualitative study in a low performing state of India. Indian J Public Health. 2011;55(4):252.PubMedCrossRef
49.
Gupta A. Study of maternal health Care Services for the Rural Poor in Bihar reviewing two years of NRHM 2007. New Delhi: Centre for Health and Social Justice; 2007.
50.
Uttekar BP, Barge S, Khan W, Deshpande Y, Uttekar V, Sharma J, et al. Assessment of ASHA and Janani Suraksha Yojana in Rajasthan. Vadodara, Gujarat: Centre for Operations Research & Training; 2007.
51.
Hangmi P, Kuki J. In reaching the unreached: rapid assessment studies of health Programmes implementation in India. Role of JSY in institutional delivery a study in Churachandpur District. Manipur New Delhi: Nidhi Books; 2009.
52.
Krishna A, Ananthpur K. Reasons for seeking (and not seeking) institutional health care: a qualitative examination in 12 villages of Karnataka. Durham, NC: Working Paper, Sanford School of Public Policy, Duke University; 2011.
53.
Kumar D, Manisha DA. In reaching the unreached: rapid assessment studies of health Programmes implementation in India. Has Janani Suraksha Yojana stimulated institutional delivery; 2009.
54.
Uttekar B, Uttekar V, Chakrawar B, Sharma J, Shahane S. Assessment of Janani Suraksha Yojana in Uttar Pradesh. Vadodara, Gujarat: Centre for Operations Research & Training; 2008.
55.
Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Policy Plan. 2004;19(2):69–79.PubMedCrossRef
56.
Dhungel S. Provincial comparison of development status in Nepal: an analysis of human development trend for 1996 to 2026. J Management Dev Stud. 2018;28:53–68.CrossRef
57.
Pandey CL, Poudyal N, Khadka D. Resource mapping and indexing of Federal Provinces of Nepal: an analysis. Molung Educ Front. 2018;8:1–16.CrossRef
58.
Khanal V, Karkee R, Lee AH, Binns CW. Adverse obstetric symptoms and rural–urban difference in cesarean delivery in Rupandehi district, western Nepal: a cohort study. Reprod Health. 2016;13(1):17.PubMedPubMedCentralCrossRef
59.
Paudyal P, Gurung G, Baral J, Rana A. Changing trends in caesarean deliveries at a tertiary care Centra: a ten year appraisal. J Soc Surgeons Nepal. 2014;17(2):7–11.CrossRef
60.
Regmi K, Upreti S, Maureen DI, Subedi HN, Devi P, Kapil BD. A study on access to maternal, neonatal, and child health Services in Remote Areas of Nepal: consolidated report of findings. Kathmandu: Family Health Division and Nepal Health Sector Support Programme; 2013.
61.
Aryal KK, Dangol R, Gartoulla P, Subedi GR. Health services availability and readiness in seven provinces of Nepal. Rockville, Maryland: ICF; 2018.
62.
63.
Silva CHM, Laranjeira CLS. Use of the Robson classification system for the improvement and adequacy of the ways of delivery in maternities and hospitals. An opportunity to reduce unnecessary cesarean rates. Revista Brasileira de Ginecologia e Obstetrícia. 2018;40(7):377–8.PubMedCrossRef
Metadata
Title
Trends in national and subnational wealth related inequalities in use of maternal health care services in Nepal: an analysis using demographic and health surveys (2001–2016)
Authors
Vishnu Prasad Sapkota
Umesh Prasad Bhusal
Kiran Acharya
Publication date
01-12-2021
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2021
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-020-10066-z

Other articles of this Issue 1/2021

BMC Public Health 1/2021 Go to the issue

Research article

Impact of immediate initiation of antiretroviral therapy among men who have sex with men infected with HIV in Chengdu, southwest China: trends analysis, 2008–2018

Research article

Health system costs of rheumatic heart disease care in South Africa

Research article

Prevalence and socio-demographic correlates of tobacco and alcohol use in four sub-Saharan African countries: a cross-sectional study of middle-aged adults

Research

Perceptions of workplace heat exposure and adaption behaviors among Chinese construction workers in the context of climate change

Research article

Assessment of self-medication practices in the context of the COVID-19 outbreak in Togo

Research

The causal effect and impact of reproductive factors on breast cancer using super learner and targeted maximum likelihood estimation: a case-control study in Fars Province, Iran