PurposeOverall health status indicators have improved significantly over the past three decades in Indonesia. However, the country’s maternal mortality ratio remains high with a stark inequality by region. Fewer studies have explored access inequity in maternal health care service over time using multiple inequality markers. In this study, we analyzed Indonesian Demographic and Health Survey (DHS) data to explore trends and inequities in use of any antenatal care (ANC), four or more ANC (ANC4+), institutional birth, and cesarean section (c-section) birth in Indonesia during 1986–2012 to inform policy for future strategies ending preventable maternal deaths.MethodsIndonesian DHS data from 1991, 1994, 1997, 2002/3, 2007, and 2012 surveys were downloaded, merged, and analyzed. Inequity was measured in terms of variation in use by asset quintile, parental education, urban–rural location, religion, and region. Trends in use inequities were assessed plotting changes in rich:poor ratio, rich:poor difference, and concentration indices over period based on asset quintiles. Sociodemographic determinants for service use were explored using multivariable logistic regression analysis.FindingsBetween 1986 and 2012, institutional birth rate increased from 22% to 73% and c-section rate from 2% to 16%. Private sector was increasingly contributing in maternal health. There were significant access inequities by asset quintile, parental education, area of residence, and geographical region. The richest women were 5.45 times (95% CI: 4.75–6.25) more likely to give birth in a health facility and 2.83 times (95% CI: 2.23–3.60) more likely to give birth by c-section than their poorest counterparts. Urban women were 3 times more likely to use institutional birth and 1.45 times more likely to give birth by c-section than rural women. Use of all services was higher in Java and Bali than in other regions. Access inequity was narrowing over time for use of ANC and institutional birth but not for c-section birth.ConclusionOngoing pro-poor health-financing strategies should be strengthened with introduction of innovative ways to monitor access, equity, and quality of care in maternal health.

Background: Family planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on communitybased PPFP services by improving FCHV's knowledge through orientation on PPFP. Methods: We conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data. Results: In total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate postpartum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling. Conclusion: The orientation improved the FCHV's knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV's role in improving community-based PPFP services.

BackgroundPelvic organ prolapse (POP) is a common gynecological condition that can affect quality of life (QOL) in women. In Nepal, the prevalence of POP is high, but many affected women are still deprived of treatment. Vaginal hysterectomy with pelvic floor repair is one of the common treatment options for advanced POP. However, QOL outcomes after surgery have not been reported in low-income countries. Thus, we aimed to examine changes in QOL among Nepalese women with POP after such surgery.MethodsThis longitudinal study was conducted in the selected central and peripheral hospitals in Nepal where vaginal hysterectomy was being performed free of cost for POP. A baseline study first measured the QOL domains (physical, psychological, social relationships and environment) among 252 women with advanced POP. Follow-up data was then collected at six weeks and three months after surgery. Among the 177 women that were available at six weeks post-surgery, 166 participated in the follow-up study at three months post-surgery. To evaluate QOL at baseline, 142 women with no history of POP were included as a comparison group.ResultsThe mean scores across QOL domains improved from baseline to 3 months after surgery. The baseline score for the physical domain increased from 11.2 to 12.8 at six weeks and 13.5 at three months post-surgery (p < 0.001); the psychological domain score increased from 11.6 to 13.1 at six weeks and 13.8 at three months post-surgery (p < 0.001); the social relationships domain score increased from 13.6 to 14.4 at six weeks and 15.0 at three months post-surgery (p < 0.001); and the environmental domain score increased from 12.9 to 13.9 at six weeks and 14.0 at three months post-surgery (p < 0.001).ConclusionQOL progressively improved among women undergoing surgery for POP. Such surgical services need to be scaled up for treatment of advanced POP in low-income countries.

Background The use of post-partum family planning (PPFP) methods such as post-partum intrauterine device (PPIUD) in general remains low despite its benefits for the women. The reasons or factors affecting the uptake and continuation of such PPFP methods in developing countries such as Nepal remains unclear. This qualitative research aims to explore the factors affecting PPIUD uptake and continuation related behaviors among post-partum mothers within 6 weeks of childbirth in Nepal. Methods This qualitative study was conducted through 43 in-depth interviews among post-partum mothers who delivered in 3 selected hospitals in Nepal. Data were analyzed through content analysis using the theory of planned behavior (TPB) as the theoretical framework. Results The themes and categories were structured around the three major components of the TPB on attitude, subjective norms, and behavioral control. Majority of the women in this study, irrespective of their behavioral outcome expressed a positive attitude towards PPIUD use. However, the women who expressed an unfavorable attitude towards PPIUD influenced their behavior to not choose or discontinue PPIUD. Subjective norms such as the family, peer, and societal influences against PPIUD negatively affected the women’s intention and behavior related to PPIUD. Whereas, the positive influence of the health providers positively affected their behavior. Regarding the behavior control, women who had their own control over decisions tended to use PPIUD. However, external factors such as their husband’s preference or medical conditions also played a prominent role in preventing many to use PPIUD despite their positive intentions. Conclusion As suggested in TPB, this study shows that multiple factors that are interlinked affected the behaviors related to uptake and continuation of PPIUD. The attitude helped in s`haping intention but did not always lead to the behavioral outcome of PPIUD uptake and continuation. Subjective norms had a strong influence on both intention and behavior. Behavior control belief also had an important role in the outcome with respect to PPIUD uptake and continuation. Thus, a more layered, multidimensional and interlinked intervention is necessary to bring positive behavior changes related to PPIUD. Electronic supplementary material The online version of this article (10.1186/s12884-019-2310-y) contains supplementary material, which is available to authorized users.

BackgroundMedical education can play important role in cultivating the willingness among the medical students to work in underprivileged areas after their graduation. Experiential learning through early exposure to primary health care centers could help students better understand the opportunities and challenges of such settings. However, the information on the real experiences and reflections of medical students on the rural primary health care settings from low-income countries like Nepal are still limited. The aim of this study is to demonstrate the learning process of the medical students through their reflective writings based on Kolb’s theory of experiential learning.MethodsThe students wrote their experiences, observations and reflections on the experiential learning from the primary health care centers on individual logbook as part of their community posting assignments. We analyzed the data of 50 logbooks through content analysis using Kolb’s experiential learning cycle as a theoretical framework.ResultsThe students’ reflections are structured around the four main learning stages of Kolb’s experiential learning theory. Each learning stage consisted of different categories. The first stage consisted of concrete experiences on rural health and learning by doing. The second stage included their reflective observations on primary versus tertiary care, application of theoretical knowledge and role of supervisors. In the third stage, the students developed and refined their concepts on self-development, understanding reality, compassion and sense of responsibility. The final stage, active experimentation, included their immediate future plans, suggestions to improve curriculum, plans after becoming a doctor and suggestions to improve policies.ConclusionThis study provided important insights on different stages of experiential learning of medical students on primary health care in low resource rural settings. Reflective writing of experiential learning could be an important step to address the gaps in medical education for resource constraint settings like that of Nepal and other low-income countries.