This study analyzed the determinants of institutional delivery in Nepal using the most recent MICS 2019. The odds of Nepalese women giving birth in health institutions with respect to their socio-economic and demographic characteristics was measured. Further, the wealth-related inequality in institutional delivery was calculated along with a decomposition analysis to find out the key determinants that explain the inequality. The study found that age of women, parity, four or more ANC visit, education status of women, area of residence, sex of household head, religious belief, province, and wealth index quintile were significant determinants for the institutional delivery. The institutional delivery was disproportionately higher among women belonging to wealthy households. The decomposition of the concentration index showed that the wealth-related inequality was explained mostly by household wealth, education status of women, urban residence, and ANC visits.
The odds of institutional delivery increased with the increase in age of women. The women above age 30 years were more than two times more likely to have institutional delivery compared to that of age below 15–19 years. This finding corroborates previous study that analyzed first-order births in 34 countries of sub-Saharan Africa and found that older age at birth was associated with significantly higher odds of facility-based delivery (34). Finding from this study aligns well also with the study from Bangladesh (35). However, the non-significant association was obtained in analysis from Pakistan and Ethiopia (3, 36). Further research are needed to investigate this intercountry variance. The likelihood of institutional delivery decreased with an increase in parity. This result support finding from similar studies conducted in developing countries that have shown that experienced mothers were less likely to opt for facility-based delivery (3, 7). One possible explanation for the low uptake of institutional delivery among high parity women is that women with birth history may develop confidence from the knowledge and experience acquired from earlier pregnancies and therefore are less motivated to opt for services from health facilities (7). The odds of institutional delivery was twice in women who have completed four or more ANC visits. Positive association between the antenatal visits and facility-based delivery was found in previous studies conducted in Kenya, Ethiopia, Nepal, Bangladesh, Pakistan (3, 4, 6, 35, 37). The counselling on birth preparedness received from health workers during the antenatal visits could be the reason.
The women with higher education were significantly more likely to deliver in health institution compared to women without formal education. Similar findings were obtained from studies conducted in other developing countries, establishing education as a significant determinant of facility-based delivery (3, 14, 15, 36, 38, 39). This association could be attributed to the fact that educated women are more likely to have a better understanding of risks associated with childbirth and benefits of using skilled healthcare compared to uneducated women. This evidence implies that inequality in institutional delivery could be reduced with appropriate intervention targeted to educate women. To reduce the barriers in uptake of maternal health services, GoN of Nepal has been implementing Birth Preparedness Package (BPP) through health workers and Female Community Health Volunteers (FCHVs) in the community since the early 2000s as part of the safe motherhood program (40). BPP educates pregnant women, their families, and communities to plan for normal pregnancy, delivery, and postnatal period and creates demand for healthcare through inter-personal communication using specially designed cards and flipcharts. So, more focused outreach education and awareness campaigns are key to further reduce the inequality in use of maternal healthcare services between educated and uneducated mothers.
The women from urban area were nearly two times more likely to opt for institutional delivery compared to the ones from rural counterparts. The findings from this study corroborate those of prior studies, where it was shown that urban residence of mother was associated with an increase in the use of institutional delivery (3, 15, 17, 36, 41). In general, women from urban area have better access to healthcare system due to better transport, well-equipped hospitals and less distance between residence and health facility (15, 17). Studies based in rural settings of Nepal have identified access to birthing facilities, perception regarding the quality of healthcare, lack of transportation, poor infrastructure and equipment at birthing centres as key barriers to access facility-based delivery services (42–44).
Women from Province 2 were significantly less likely to deliver in health institutions compared to women from Province 1. Province 2 is terai (plain northeast belt) of Nepal and generally falls behind other provinces in terms of public health coverage indicators (20) and health infrastructure. As per the evidence from nationally representative surveys it had the lowest percentage of facilities providing normal vaginal delivery (45) and lowest mean general health service readiness score (46). It observed the lowest annual change in Human Development Index (HDI) since 1996 and had one of the third lowest HDI of 0.485 (national average = 0.522) in 2011 (47). Focused measures that address the unique socio-economic positioning are urgent to bring maternal health indicators of Province 2 at par with the national average.
Institutional delivery increased monotonically in moving from women in poorest wealth quintile to richest wealth quintile. Analysis of concentration curve and concentration index revealed a pro-rich inequity in institutional delivery. The result from this study is consistent with findings from similar studies where it was shown that better socio-economic condition of mothers was associated with an increase in the use of maternal healthcare services (7, 14–18, 39, 48, 49). Women belonging to higher socio-economic group have a better chance to visit health facility and when required, make payment for the expenses related to travel and medical care (15, 48). Various studies indicate the potential reasons for disproportionally lower coverage of maternal health services among women from lower socio-economic group: direct and indirect cost related to healthcare including travel expenses and opportunity cost; perceived quality of care in public facilities; perceived importance of seeking formal healthcare during pregnancy and childbirth. This indicates that the efforts of government since the 1990s to address barriers posed by Nepalese, mainly the poor households, through various supply and demand-side financing are still insufficient. However, as observed in earlier analysis conducted using four rounds of Nepal Demographic and Health Survey (NDHS: 2001, 2006, 2011, 2016), the socio-economic inequality concerning institutional delivery between the socio-economic groups measured by relative CIX has, on average, narrowed over this period (20). The relative CIX obtained from these four rounds of NDHS were 0.56, 0.48, 0.35 and 0.19, respectively (20). The analysis presented in this paper using the data from MICS 2019 has shown that the relative CIX for institutional delivery has further narrowed down to 0.097. So, the investment made by GoN looks working, but it should be more focused on benefiting the lower socio-economic group (in contrast to the current blanket approach with more emphasis on national targets), to further reduce the inequality gap. The decomposition analysis found that household wealth status contributes significantly towards the inequality in institutional delivery (53.2%), followed by women’s education (17.02%.), urban residence (8.64%) and ANC visit (6.84%). This implies that the future policies and strategies need to be pro-poor, pro-rural and that needs to focus more on educating women and families for increased ANC uptake. The result of decomposition analysis presented in this paper is consistent with similar studies from developing countries (15, 17, 18, 50).
Few variables that did not demonstrate a significant association with institutional delivery in this study showed statistically significant association in studies conducted in other settings. Unlike Pulok et al. (7), Ketemaw et al. (36) this study found no statistically significant association between media exposure and institutional delivery. Similarly, unlike Atake (15), Pulok et al. (7) and Obiyan and Kumar (51), this study found no statistically significant association between education status of the household head (usually male/husband in Nepalese context) and institutional delivery. More studies might be required to ascertain these association.
Strength of this study
This study has used the most recent nationally representative household survey conducted in 2019. Rigorous statistical methods to calculate the odds of enrollment controlling for relevant socio-economic and demographic variables were employed. Further, this study offers the composite measure of inequality using standard techniques. The decomposition analysis was conducted to identify determinants that explain the inequality in the use of institutional delivery in Nepal.
Limitation of this study
First, the list of determinants of institutional delivery included in this study is not an exhaustive one. The potential determinants such as employment status of women, distance to the nearest institution with the birthing facility, cost (direct or indirect) associated with institutional delivery, understanding of the importance of safe delivery could not be included in this analysis due to the unavailability of such data in this round of MICS. Second, since this study is cross-sectional, it could not establish any causal relationship between the variables under study and institutional delivery. Notwithstanding, this study has elicited empirical evidence on socio-economic inequality and its predictors regarding institutional delivery which have policy relevance to countries with similar socio-economic context to Nepal.