Health system barriers influencing perinatal survival in mountain villages of Nepal: implications for future policies and practices

Abstract

BackgroundThis paper aims to examine the health care contexts shaping perinatal survival in remote mountain villages of Nepal. Health care is provided through health services to a primary health care level—comprising district hospital, village health facilities and community-based health services. The paper discusses the implications for future policies and practice to improve health access and outcomes related to perinatal health. The study was conducted in two remote mountain villages in one of the most remote and disadvantaged mountain districts of Nepal. The district is reported to rank as the country’s lowest on the Human Development Index and to have the worst child survival rates. The two villages provided a diversity of socio-cultural and health service contexts within a highly disadvantaged region.MethodsThe study findings are based on a qualitative study of 42 interviews with women and their families who had experienced perinatal deaths. These interviews were supplemented with 20 interviews with health service providers, female health volunteers, local stakeholders, traditional healers and other support staff. The data were analysed by employing an inductive thematic analysis technique.ResultsThree key themes emerged from the study related to health care delivery contexts: (1) Primary health care approach: low focus on engagement and empowerment; (2) Quality of care: poor acceptance, feeling unsafe and uncomfortable in health facilities; and (3) Health governance: failures in delivering health services during pregnancy and childbirth.ConclusionsThe continuing high perinatal mortality rates in the mountains of Nepal are not being addressed due to declining standards in the primary health care approach, health providers’ professional misbehaviour, local health governance failures, and the lack of cultural acceptance of formalised care by the local communities. In order to further accelerate perinatal survival in the region, policy makers and programme implementers need to immediately address these contextual factors at local health service delivery points.Electronic supplementary materialThe online version of this article (10.1186/s41043-018-0148-y) contains supplementary material, which is available to authorized users.

Religio-cultural factors contributing to perinatal mortality and morbidity in mountain villages of Nepal: Implications for future healthcare provision

“…Based on these crude data, it is estimated that the study villages have a current neonatal mortality rate of 44 per 1,000 livebirths–similar to the official estimation of 46 per 1,000 as reported in the 2011 Nepal Demographic and Health Survey. This field visit also revealed an extended perinatal mortality rate of 63 per 1,000 births if stillbirths and all neonatal deaths until 28 days after birth are included in the calculation [ 54 ]. These estimates are based on the reported number of perinatal deaths for the previous four years.…”

“…The present study suggests that the invisibility of perinatal death in this study’s remote mountain villages is reinforced by the fatalistic attitude towards perinatal deaths, not only in the community but also in the local health system. The sum total of deaths reported by participating women from the study villages provided a larger number of deaths than the sum total of the perinatal deaths reported by the District Health Office for the last four years across the 24 villages in the district [ 54 ]. This underreporting seems likely due to the low social significance accorded to perinatal deaths.…”

“…This paper is extracted from the findings of a larger PhD project [ 54 ] of the first author, a qualitative study utilising social constructionism and critical theoretical approaches to examine the socio-cultural and healthcare contexts of poor perinatal survival in remote Nepal. The authors are thankful to all the women and families and health service providers who participated in the study.…”

Successes, Challenges and Opportunities Towards Universal Health Coverage for Maternal and Child Health in South East Asian Countries: A Systematic Review

“…Among studies included in the review, a majority was from India (n=30, 48 %) . There were 11 studies from Nepal (42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52) , 10 from Bangladesh (53)(54)(55)(56)(57)(58)(59)(60)(61)(62) , six from Indonesia (63)(64)(65)(66)(67)(68) and two from Timor-Leste 69,70 . From Bhutan 71 , Thailand 72 , and Myanmar 73 one from each was identi ed.…”

“…Poor governance in birthing centers 45 , lack of support from hospital administration 51 and less priority given on primary health care 50 are the barriers identi ed in Nepal for good quality delivery and postpartum care. In Indonesia, decentralization of the health sector which created confusion regarding roles and responsibilities as well as complex administration process were identi ed as important factors which impede the quality care 64,65 .…”