In 2017, the global maternal mortality ratio was 211 per 100,000 live births.1 Less developed countries bear a disproportionate burden of maternal mortality, with an estimated maternal mortality ratio of 415 maternal deaths per 100,000 live births, up to 60 times greater than some of their more developed counterparts.2 Since 2000, South Asia has achieved the greatest percentage reduction in maternal mortality from 395 to 163 maternal deaths per 100,000 live births, an improvement of 59%.3 However, maternal deaths in this region still account for 20% of maternal deaths globally.2
In 2015, the United Nations set a target to reduce the global maternal mortality ratio to 70 per 100,000 live births by 2030 to achieve the third Sustainable Development Goal: Ensure healthy lives and promote well-being for all at all ages.4 At the current pace, this target is expected to be missed by over one million lives.2 This unfortunate trajectory calls for the identification and implementation of best practices for improving maternal health.
Institutional delivery, or giving birth in a medical facility with a skilled birth attendant, is an essential practice for reducing maternal mortality.5,6 Childbirth requires continuous skilled care and attention, but 15% of pregnancies and deliveries result in complications or unanticipated events requiring emergency care from health professionals.7,8 Seventy-five percent of all maternal deaths can be attributed to five complications: hemorrhage, infection, pre-eclampsia or eclampsia, obstructed labor, and unsafe abortion, each of which is largely preventable or treatable.9 Giving birth in a medical facility offers women the opportunity, resources, and support to manage complications that could save her or her child’s life. In medical facilities, maternal mortality can be avoided more easily than in home settings through simple procedures such as injecting oxytocics to reduce the risk of bleeding, practicing safe hygiene to reduce the risk of infection, and detecting high blood pressure before the onset of serious eclampsia symptoms, among many others.9 Skilled attendance during pregnancy and delivery can reduce maternal mortality by 16-33%, made possible by training of doctors, nurses and midwives and making available essential drugs; and equipment to ensure the safety of medical procedures.10
Institutional Delivery in Nepal
Nepal has made remarkable improvements in its maternal mortality ratio over the past two decades, declining from 539 maternal deaths per 100,000 live births in 1996 to 259 maternal deaths per 100,000 live births in 2016.2 Today, Nepal has a maternal mortality rate of 186 maternal deaths per 100,000 live births; however, it still has the second-highest maternal mortality ratio in South Asia after Afghanistan.1 One explanation for its high rate of maternal deaths is its low rate of institutional delivery. In Nepal, institutional delivery is practiced by only 54% of women who give birth.11 By comparison, the global and regional rates are 81% and 76%, respectively12. Still, the country has increased its institutional delivery rate by 22% since 2011.11 The government intends to continue this progress and has set a target to achieve a 90% institutional delivery rate by 2030.11
Nepal still must make significant progress to meet its institutional delivery goals. To do so, the Ministry of Health and Population offers new and expecting mothers the Safe Motherhood Programme.13 The Safe Motherhood Programme offers three key services, including birth preparedness packages for early detection and prompt treatment of complications; the Rural Ultrasound Programme, which brings portable ultrasound devices to remote areas for screenings; and the Aama Programme, which eliminates all childbirth-related fees and offers cash incentives for delivering in a medical facility and completing four antenatal care (ANC) visits. The use of these services, however, is still quite limited. Although close to 100% of pregnant women attend their first ANC visit, only 50% attend the recommended four ANC checkups.11 To increase availability and accessibility of institutional delivery at the local level, the government expanded the number of local health centers with birthing centers and skilled birth attendants, essential logistics to carry out normal deliveries, and referral systems for cases with complications. By 2018, over 2,000 health posts and 188 Primary Health Care Centers were providing institutional delivery services.11 Nonetheless, with rates of institutional delivery still low, other factors must be addressed to make a significant change.
Substantial inequities exist in the profile of Nepali women who give birth institutionally, as compared to those who do not. Data indicate that women’s demographic backgrounds play a large role in their birthing care.2,15,16 For example, 85% of women who have received higher education participate in institutional delivery compared to 61% with basic education and 37% with no education.2,16 Additionally, nearly all women in the wealthiest quartile (92%) give birth in health facilities compared to 36% in the poorest quintile.2,16,17 Discrepancies also exist geographically between provinces. While some provinces have institutional delivery rates of up to 75%, others are as low as 35%.11 A woman's ethnicity and age may also influence her likelihood of participating in institutional delivery. For instance, 69% of Brahmin/Chhetri caste members, which make up the more privileged castes, deliver in health facilities compared to 44% of other caste members.2,16 Likely because of educational differences, younger women are also more likely to have an institutional delivery, with rates of 66% among women 20 or younger compared to 48% among women ages 30-49.2,15,16
Prior research also depicts a strong correlation between ANC visits and institutional delivery in Nepal.2,15,16,17 For instance, approximately 75% of women who complete four ANC visits will have an institutional delivery, a 5.5 times greater likelihood than women who do not complete any ANC visits.2,15 ANC visits offer opportunities for pregnant women to communicate with health workers about the benefits of delivering in a medical facility and having a skilled birth attendant present during delivery, as well as discuss the risks of potential pregnancy- and birth-related complications in home settings.2,16
Others’ attitudes and behaviors – particularly those of husbands’ – could also influence the likelihood that a woman has an institutional delivery. Marital relationships and family dynamics are known to be contributing factors to institutional versus home delivery. Various studies point to the importance of female autonomy and husband support.18,19,20,21 For instance, Morrison et al.20 found that some women in Makwanpur, Nepal have less decision-making power in their marital relationships and feel pressure to prioritize the needs and beliefs of their family members over their own, creating a fear of speaking up for institutional delivery. This finding was echoed by Onta et al.,21 who noted how the woman’s role in her family could prevent her from delivering in a health facility. Their study also demonstrated the weight of husband support in institutional delivery. In some cases, women relied on their husband’s time and resources to provide them with medical care and transportation to health facilities. When that support was lacking, women were more likely to deliver at home.21
Influence of Descriptive Norms on Institutional Delivery
The behaviors of other women in the community (or at least the perceptions of others’ behaviors) can also influence a woman’s decision to deliver in an institution. Descriptive norms are an individual’s perceptions of the prevalence of certain behaviors in their social midst.22 Social scientists have long applied the concept of social norms to explain human behavior,23,24,25 with the understanding that descriptive norms can motivate particular behaviors when activated.22 Numerous researchers have established connections between descriptive norms and health behaviors in past studies,26,27 including but not limited to alcohol use,28,29 water conservation,30 exercise and nutrition,31,32 and speeding while driving.33
Prior research has explored social norms regarding institutional less thoroughly, but some evidence points to a potential impact. Two qualitative studies in Nepal have revealed a pattern of decision-making based on descriptive norms. For example, Shah et al.19 reported that some women choose to have home births because other women in their family and social networks had safe home deliveries in the past. Findings from Morrison et al.’s20 study conveyed a similar notion, revealing that some women perceived institutional delivery as “unusual” in their communities and were, therefore, more likely to have a home birth. Norms-related literature in African contexts may also indicate relevance in Nepal. A study based in Ghana demonstrated that a woman’s belief that community norms do not support institutional delivery was highly predictive of her actual behavior.34 Evidence from another study in Uganda further supported this finding, exhibiting that when women believe that most other women give birth at home, they perceive it as “normal” and “safe” and practice it themselves.35
This study has two main hypotheses: 1) The number of ANC visits a woman completed during her last pregnancy will be positively associated with institutional delivery for that pregnancy. 2) Descriptive norms related to institutional delivery will be positively associated with participation in institutional delivery, controlling for other known drivers.