Inequality in institutional delivery of the recent birth among married women in Nepal: a trend analysis

Background The huge discrepancy in health statistics between developed and developing countries occur in the area of maternal mortality, with developing countries contributing most of the gures. Nepal has higher maternal mortality ratio than its South Asian neighbors.This study assesses the trend of institutional delivery of recent birth and compared the inequalities with associated factors that affect institutional delivery in Nepal. Methods The data for this study was obtained from three sequential Nepal Demographic and Health Surveys [NDHS] of 2006, 2011, and 2016. The information was collected from mothers having a child within last ve years preceding the survey years.The total number of such mothers was 4066, 4148, and 3998 respectively in the survey of 2006, 2011, and 2016.The association between institutional delivery and the explanatory variables was assessed via bivariate analysis (chi-square test) and multivariate analysis (binary logistic regression). Results

income countries, more than nine out of ten births are attended by skilled health care professionals. In contrast, less than half of all births in many low income and lower-middle-income countries are assisted by such skilled health personnel 4, 5,6 . Study shows that high-quality, obstetric and neonatal care during delivery is one of the major priorities to reduce illness and death in mothers and newborns. 7 The maternal mortality ratio of Nepal is 258 per 100,000 live births, which is higher than other South Asian countries like Sri Lanka, India, Bhutan, Bangladesh etc. It is of paramount importance to receive antenatal care (ANC) on speci ed months as per national protocol, deliver at health facilities or being assisted by skilled birth attendants (SBA) at health institutions and at home, and to receive postnatal care (PNC) to prevent maternal and newborn deaths. 8,9,10 There has only been mediocre progress in the efforts of Ministry of Health and Population (MoHP) of Nepal to promote safer pregnancy and childbirth, in increasing the proportion of four ANC visits, institutional delivery, and PNC. 11,12 . Government of Nepal has launched the maternity incentive scheme through safe delivery incentive program in 2005.
Government of Nepal removed user fees from all types of delivery in public health facilities nationwide and renamed the program 'Aama' targeted at increasing institutional delivery by minimizing nancial barriers women face in accessing services so as to improve maternal health outcomes. 10 However, only less than three out of ve (57%) of all birth in the 5 years preceding the survey were delivered in health facilities. 9 The underlying cause of low institutional delivery needs further investigation and exploration in order to better understand and appropriately address through reproductive health programs.It is essential to develop the effective strategies and implement the program for the increase of institutional delivery. After the Nepal's national agship programs (Aama) since 2005 which have been promoting safe motherhood through initiatives such as providing free delivery care and transportation incentive schemes to women delivering in a health facility, we hypothesized that there is not inequality between poorest and richest in utilization of institutional delivery services in Nepal. The ndings of this study aim to guide reproductive health program planners and policy makers to understand various factors in uencing institutional delivery and to assist in implementation of the reproductive health program which will increase institutional delivery as well as reduce the risk of maternal and newborn morbidity and mortality.

Methods
The data for this study was obtained from three sequential Nepal Demographic and Health Surveys IBM SPSS Statistics version 20 was used to analyze the data. Three level of analyses were made. In univariate analysis simply frequencies and percentage were calculated. Bivariate analysis showed the association between independent and dependent variables using chi-square test as per the survey years separately. However, in multivariate analysis, we pooled all data from NDHS 2006, 2011 and 2016. Binary logistic regression model was used to predict the adjusted effects of covariates on utilization of health service during delivery. Before the multivariate analysis, multicollinearity between the variables was assessed. We found age and number of children born were highly correlated. So we removed age from the logistic model. We put wealth status in Model I and added other socio-demographic variables were in Model II. We presented adjusted odds ratios [aOR] with reference categories at 95 percent con dence interval [95% CI].

Background characteristics
The total number of women aged 15-49 years who had a live birth in the ve years preceding the survey wealth quintiles in all surveys. More than a third of all women had no autonomy (36%) and moderate autonomy (34%). Similarly, in regards to exposure to mass media, three-fourth (75%) of all women had no exposure to newspaper, nearly two-fths each had high exposure to radio (39%) and television (38%).
( Table 1 is  In the similar manner, signi cantly higher proportion of women who were currently working had their most recent birth in health facility in all the surveys. Number of ANC visits completed was highly statistically signi cant with place of delivery in all three surveys. 43% of women who had four or more ANC visits had their most recent delivery in health facility in the survey of 2006, which increased to 74% in 2016. Exposure to mass media (newspaper, radio and TV) was also directly proportional to delivery in health facility as signi cantly higher proportions of women who had high exposure to mass media had their delivery in health facility than those with low exposure in all three surveys.
( Table 2 is about here)

Multivariate analysis
The predictors of institutional delivery among women aged 15-49 years were investigated through multivariate logistic regression analysis.At rst, while calculating unadjusted odds ratio, wealth status was a signi cant predictor of institutional delivery in which poorest were 92 percent (OR=0.075, 95% CI=0.065-0.086) times less likely to deliver their recent child in health facility than the richest.
Although attenuated, wealth status still remained signi cant predictor of institutional delivery after adjusting all other variables where poorest were almost 78 percent (aOR=0.218, CI=0.174-0.272) less likely to practice institutional delivery than richest. Adjusted odd's ratio was calculated for all other remaining variables. Time period was another signi cant predictor of institutional delivery as women in the survey of 2016 and 2011 were almost 6 and 3 times respectively more likely to deliver their child in health facility than in the year 2006. Similarly, women married at an age of 21 and above were signi cantly more likely to have institutional delivery than women married at an age of less than 15 years. Number of children was also signi cant predictor of institutional delivery in which women having two or more children were signi cantly less likely to deliver their child in health facility. In regards to ethnicity, women who belonged to Janajati(aOR=0.732, CI=0.641-0.837) and other castes (aOR=0.749, CI=0.636-0.881) were less likely to practice institutional delivery.
Secondary level education had signi cant positive impact on institutional delivery as women having secondary and above education were more likely to deliver their child in health facility than women having no education. Compared to Hindu women, Muslim women were more likely to practice institutional delivery although this was only marginally signi cant (aOR=1.291, CI=1.043-1.599).
Likewise, women living in rural areas and currently working women were signi cantly less likely to deliver their most recent child in health facility. Women with moderate and high autonomy were also signi cantly more likely to deliver their child in health facility than women with no autonomy. Number of ANC visits was also a signi cant predictor of institutional delivery in whichwomen completing four or more ANC visits (aOR=2.739, CI=2.472-3.035) were nearly three times more likely to practice institutional delivery than their counterparts. Similarly, exposure to mass media like newspaper and television had signi cant positive in uence on institutional delivery. (Table 3 is about here) Discussion: Only less than two-thirds (62%) women in our country delivered their recent child in health facility in 2016.
The proportion of institutional delivery in our country matches with that of various African countries as shown by different studies. In studies conducted in Ethiopia 13 , Kenya 14 , Zambia 15 and Sub-Saharan Africa 16 , the proportion of institutional delivery was 60.5%, 61%, 62.2% and 57% respectively.
Our study illustrates the positive in uence of education on institutional delivery. In multivariate logistic regression analysis, educated women were signi cantly more likely to practice institutional delivery than uneducated women. This nding is consistent with the studies conducted in Ethiopia 13,17,19 , India 18 and also Nepal 20 . This could be because less educated mothers were less aware about the importance of safe delivery and complications of child birth.So, the impact of education on health care seeking behavior of women is evident from different studies.
Our study also showed that wealth status is signi cant predicator of institutional delivery both with and without controlling other variables. The result are similar with the study conducted in Bangladesh 21 Gambila 22 , Southwest Ethiopia 23 ,and Mozambique 24 . The nding is also consistent with other studies Pakistan 25 , Eastern Nepal 26 and other different low income countries [27][28][29][30] .Despite of the Nepal's national agship programs (Aama) since 2005 which promoting safe motherhood through initiatives such as providing free delivery care and transportation incentive schemes to women delivering in a health facility, it is discouraging that poor women are less likely to deliver their recent child in the health facilities.
Our study also highlights the importance of completing four or more ANC visits for greater utilization of institutional delivery aswomen completing four or more ANC visits were nearly three times more likely to deliver in health facility. This nding is in-line with the ndings of studies conducted inChitwan 20 and Kavrepalanchowk 31 districts of Nepal and also in Ethiopia 32 and Sudan 33 .Other different studies 25, 34,35 ,36 also showed that improving ANC practices can help increase institutional delivery. This can be justi ed by the fact that women are women are also counseled for institutional delivery in their ANC check-up as birth-preparedness is also a component of ANC.Similarly, women having more number of children were also less likely to practice institutional delivery in our study which is in accordance with the ndings of studies in Bangladesh 37,38 , and Nepal 26 . Institutional delivery also signi cantly increased with increase in autonomy among women through our analysis which is also further supported by other studies in Ethiopia 39 and also Nepal 40,41 .From our ndings, women living in rural area were less likely to deliver in health facilities than urban area which matches to the ndings of another study in African country 42 . Variations according to regions within the nation has also been demonstrated in different other studies in African nations 27, 43-46 .

Conclusion:
There has been three-fold increment in utilization of health services during delivery over the period of 10 years; from 21% in 2006 to 62% in 2016. But nearly two-fths women did not deliver in health facility which is an evidence that there's still a lot of space for improvement. The discrepancy between rich and poor, educated and uneducated and those living in urban and rural area is still evident in 2016 which is also statistically signi cant. Apart from this, age at marriage, caste, women's autonomy and exposure to mass media were also signi cant predictors of practice of institutional delivery. Likewise, completion of four or more ANC visits also had signi cant positive impact on increasing institutional delivery.
Overall, our study highlights the necessity of interventions to promote institutional delivery with greater focus on poor, uneducated, and women in rural area. Furthermore, attempts to encourage women to practice four or more ANC visits can be a powerful strategy to increase institutional delivery. Note *** Significant in chi-square test at p<0.001; **=p<0.01 and *=p<0.05 Note * significant at p<0.05, ** P<0.01, ***P<0.001, ref= reference category Figure 1 Institutional delivery of recent birth by wealth status