Social determinants of health affecting utilisation of routine maternity services in Nepal: a narrative review of the evidence

Abstract

Nepal has one of the highest maternal and neonatal mortality rates among low-and middleincome countries. Nepal's health system focuses on life-saving interventions provided during the antenatal to postpartum period. However, the inequality in the uptake of maternity services is of major concern. This study aimed to synthesise evidence from the literature regarding the social determinants of health on the use of maternity services in Nepal. We conducted a structured narrative review of studies published from 1994 to 2016. We searched five databases: PubMed; CINAHL; EMBASE; ProQuest and Global Index Medicus using search terms covering four domains: access and use; equity determinants; routine maternity services and Nepal. The findings of the studies were summarised using the World Health Organization's Social Determinants of Health framework. A total of 59 studies were reviewed. A range of socio-structural and intermediary-level determinants was identified, either as facilitating factors, or as barriers, to the uptake of maternity services. These determinants were higher socioeconomic status; education; privileged ethnicities such as Brahmins/Chhetris, people following the Hindu religion; accessible geography; access to transportation; family support; women's autonomy and empowerment; and a birth preparedness plan. Findings indicate the need for health and non-health sector interventions, including education linked to job opportunities; mainstreaming of marginalised communities in economic activities and provision of skilled providers, equipment and medicines. Interventions to improve maternal health should be viewed using a broad 'social determinants of health' framework.

Factors Influencing Birth Preparedness in Rapti Municipality of Chitwan, Nepal

“…Similarly, birth preparedness practice was found better among those with higher education than with lower education in Thailand, too [25]. Findings from a narrative review from Nepal advocated for the education linked with job opportunities in order to improve the health status of women [26].…”

“…Another study reveals that the reason for home delivery is an easy and convenient environment which is also influenced by different sociodemographic characteristics [31]. A published review stated that higher socioeconomic status, education, privileged ethnicities, Hindu people, having access to transport and health services, getting family support, able to decide themselves, empowered, and having a birth preparedness plan are the major determinants of maternal health [26]. Another study concluded that emphasis should be given to women without education, to improve accessibility and provide advice on birth preparedness and danger signs to reduce home delivery [32].…”

The Availability of Emergency Obstetric Care in Birthing Centres in Rural Nepal: A Cross-sectional Survey

“…A few HPs were performing assisted vaginal deliveries and manual removal of placenta, but PHCCs were not because of a lack of cases to perform these signal functions in the last three months in the PHCCs. The possible rationale for no cases in PHCCS might be due to shorter travel time or distance to the nearest referral/higher-level health facility (Khatri and Karkee 2018). The other reasons for unavailability of a case to perform signal functions may be the non-risk taking attitude of health workers.…”

Women’s Health Status in Nepal: Appraising Continuity and Change

“…The percentage of women with a postpartum check-up within 2 days after the delivery increased from 17% in 2001 to 57% in 2016. Khatri and Karkee (2018) found that limited means of transport, unequal access to health facilities, and lack of awareness, social exclusion, poor daily living conditions, and poor family support for care-seeking behaviour of health services are the core barriers to safe motherhood services.…”