Background
Methods
Study design and population
Sampling
Observation of women during labour and delivery
Exit interviews with post-partum women
HF inventory assessment
Interviews with the service providers attending labour and delivery
Data collection
Conceptual framework
Unit of analysis
Study variables
Outcome variable
Standards of care variables
Standards | Results | Indicators measured as availability of equipment or performance of a service |
---|---|---|
S1 Evidence-based practices (15) | Input (7) | (i) Health facility with at least one functioning unit of each of seven basic equipment and supplies for mothers: delivery pack, partograph, examination light, blood pressure apparatus, latex gloves, sterilization equipment, delivery bed |
(ii) Health facility with any delivery care guidelines | ||
(iii) Health facility with at least one provider trained on delivery care | ||
(iv) Health facility with five essential medicines for mothers: magnesium sulfate, uterotonics, antibiotics, intravenous solution, skin antiseptics | ||
(v) Health facility with two types of equipment for an assisted delivery: vacuum aspirator, manual vacuum extractor | ||
(vi) Health facility with three basic types of equipment for newborns: suction apparatus, bag and mask, infant weighing scale | ||
(vii) Health facility with five essential medicines for newborns: gentamycin, chlorhexidine, tetracycline, amoxicillin, ceftriaxone powder | ||
Output (8) | (i) Provider monitored the mother’s vital signs | |
(ii) Provider administered immediate postpartum uterotonic | ||
(iii) Provider dried, covered, and cleaned the newborn | ||
(iv) Provider delivered the newborn to the mother’s abdomen | ||
(v) Provider supported the initiation of early breastfeeding | ||
(vi) Provider checked newborn breathing and crying | ||
(vii) Provider helped mother to initiate skin-to-skin contact | ||
(viii) Provider counseled on postpartum family planning | ||
S2 Actionable health information systems (5) | Input (4) | (i) Health facility with Maternal and Newborn Health Service Register |
(ii) Health facility with Health Management Information System monthly reports | ||
(iii) Health facility that displayed health statistics | ||
(iv) Health facility with Quality Assurance Action Plans | ||
Output (1) | (i) Women who had a completed discharge slip | |
S3 Functional referral systems (2) | Input (2) | (i) Health facility with at least one unit of functioning ambulance or emergency transport |
(ii) Health facility with at least one type of communication equipment | ||
Output (0) | None | |
S4 Effective communication (6) | Input (3) | (i) Health facility with at least one unit of information materials on maternal care |
(ii) Health facility that received at least one external supervision from federal, provincial, or local authorities in the last 12-month-period before data collection | ||
(iii) Health facility which had a 24-hour on-call service | ||
Output (3) | (i) Women received postnatal counseling before discharge | |
(ii) Provider explained to women about the delivery procedures | ||
(iii) Provider completed a partograph | ||
S5 Respect and preservation of dignity (8) | Input (2) | (i) Health facility with physical environment that allows privacy |
(ii) Health facility with a system for collecting clients’ opinions | ||
Output (6) | (i) Woman did not experience use of physical force or abrasive behavior from the provider | |
(ii) Woman experienced caring and appropriate behavior from the provider | ||
(iii) Woman felt comfortable with visual and auditory privacy | ||
(iv) Woman did not experience discriminatory behavior from the provider | ||
(v) Woman was attended to by a provider when she called | ||
(vi) Woman was not scolded by any provider | ||
S6 Emotional support (3) | Input (1) | (i) Health facility with a maternity waiting room |
Output (2) | (i) Woman who was allowed a companion to join her when requested | |
(ii) Provider who provided emotional support and reassurance to the woman | ||
S7 Competent, motivated human resources (5) | Input (4) | (i) Provider received supervision in the last 12 months |
(ii) Health facility that implemented quality assurance activities routinely | ||
(iii) Provider reported having a written job description | ||
(iv) Provider reported opportunities for staff promotion | ||
Output (1) | (i) Provider who was experienced (worked more than 1 year) | |
S8 Essential physical resources (9) | Input (6) | (i) Health facility with regular source of electricity |
(ii) Health facility with basic water supply in maternity care areas | ||
(iii) Health facility with one functioning unit of the six-infection prevention and control equipment (surgical masks, waste receptacle, disinfectant, sterilization equipment, aprons/gowns, latex gloves) | ||
(iv) Health facility with health-care waste management system | ||
(v) Health facility with a toilet for female clients | ||
(vi) Health facility with a newborn corner | ||
Output (3) | (i) Women who reported access to drinking water | |
(ii) Women who reported access to a toilet | ||
(iii) Women who reported getting a maternity bed on time | ||
Total (53) | Input (29); Output (24) |
Contextual variables
Characteristics | Indicators |
---|---|
Women (6) | i) Age: less than 20 years, 20–34 years, and 35 or more years |
ii) Caste: advantaged which includes Brahmin/Chhetri, and disadvantaged which includes Terai castes, Dalits, Janajatis, and others. | |
iii) Education: ever went to school, never went to school | |
iv) The number of pregnancies: one, two, three or more | |
v) Experience of complications (during current pregnancy): yes, no | |
vi) Experience of stillbirths (during previous pregnancies): yes, no | |
Provider (2) | i) Type of provider: doctor, nurse, auxiliary nurse midwife |
ii) Sex of the provider assisting birth: female, male | |
Health facility (4) | i) Type of health facility: public hospital, other public health facility, private hospital |
ii) Health facility that implemented the Maternity Incentive Scheme: yes, no | |
iii) Type of site: emergency obstetric and neonatal care (EmONC), basic emergency obstetric and neonatal care (BEmONC), comprehensive emergency obstetric and neonatal care (CEmONC), other | |
iv) Distance to health facility: proximal (< 30 minutes’ walking distance from women’s place of residence), semi-proximal (30–60 minutes’ walking distance from women’s place of residence), distal (> 60 minutes’ walking distance) | |
Total (12) |
Statistical analysis
Sample characteristics
Standards of care for normal low-risk health facility deliveries (objective 1)
Standards of care, contextual factors, and women’s satisfaction with delivery services (objective 2)
Ethical approval
Results
Characteristics of women, service providers, and health facilities
Characteristics of women | Number | Percent |
---|---|---|
Age | ||
Less than 20 years | 25 | 7.8 |
20–34 years | 282 | 88.1 |
35 years and above | 13 | 4.1 |
Caste | ||
Advantaged | 78 | 24.4 |
Disadvantageda | 242 | 75.6 |
Education | ||
Ever went to school | 269 | 84.2 |
Never went to school | 51 | 15.8 |
Number of pregnanciesb | ||
One | 141 | 44.1 |
Two | 101 | 31.5 |
Three or more | 77 | 24.4 |
Experience of complications | 46 | 14.3 |
Experience of stillbirths | 23 | 7.1 |
Total women | 320 | 100.0 |
Characteristics of service providers and health facilities | Number | Percent |
---|---|---|
Type of provider | ||
Doctor | 22 | 6.9 |
Nurse | 180 | 56.2 |
Auxiliary Nurse Midwife | 118 | 36.9 |
Sex of the provider assisting the birth | ||
Female | 310 | 96.9 |
Male | 10 | 3.1 |
Type of health facility | ||
Public hospital | 228 | 71.3 |
Other public health facility | 24 | 7.3 |
Private hospital | 68 | 21.4 |
Implementation of Maternity Incentive Scheme | 269 | 83.9 |
Type of site | ||
Emergency obstetric and neonatal care (EmONC) | 25 | 7.7 |
Basic emergency obstetric and neonatal care (BEmONC) | 8 | 2.4 |
Comprehensive emergency obstetric and neonatal care (CEmONC) | 274 | 85.6 |
Other | 14 | 4.3 |
Distance to health facility | ||
Proximal, within 30 minutes’ walking distance | 206 | 64.4 |
Semi-proximal, 30–60 minutes’ walking distance | 114 | 35.6 |
Total women | 320 | 100.0 |
Standards of care of normal low-risk health facility deliveries (objective 1)
Standards of care, contextual factors, and women’s satisfaction with delivery services (objective 2)
Independent variables: deliveries meeting the following criteria at health facilities | Bivariate logistic regression | Multivariate logistic regression | ||||||
---|---|---|---|---|---|---|---|---|
OR | 95% CI for OR | p-value | AOR | 95% CI for AOR | p-value | |||
Lower | Upper | Lower | Upper | |||||
Contextual variables | ||||||||
Health facility that implemented the Maternity Incentive Scheme | 0.34 | 0.18 | 0.65 | 0.0010** | 0.27 | 0.13 | 0.55 | 0.0004* |
Standards of care variables | ||||||||
Health facility with any delivery care guidelines | 2.07 | 1.12 | 3.84 | 0.0210* | 1.97 | 0.98 | 3.96 | 0.0575 |
Health facility that displayed health statistics | 2.15 | 1.37 | 3.38 | 0.0010* | 3.16 | 1.87 | 5.33 | < 0.0001* |
Health facility with at least one unit of information materials on maternal care | 0.54 | 0.33 | 0.86 | 0.0100* | 0.57 | 0.33 | 0.97 | 0.0393* |
Health facility with a maternity waiting room | 0.36 | 0.16 | 0.82 | 0.0140* | 0.35 | 0.15 | 0.82 | 0.0156* |
Woman experienced caring and appropriate behavior from the provider | 2.67 | 1.19 | 5.99 | 0.0170* | 2.59 | 1.06 | 6.30 | 0.0359* |
Woman felt comfortable with visual and auditory privacy | 2.41 | 1.28 | 4.55 | 0.0070** | 2.13 | 1.04 | 4.38 | 0.0399* |
Woman was attended to by a provider when she called | 8.13 | 2.04 | 32.35 | 0.0030** | 5.29 | 1.18 | 23.64 | 0.0292* |