title: Barriers to using skilled birth attendants' services in mid- and far-western Nepal: a cross-sectional study.
abstract: BACKGROUND
  Skilled birth attendants (SBAs) provide important interventions that improve maternal and neonatal health and reduce maternal and neonatal mortality. However, utilization and coverage of services by SBAs remain poor, especially in rural and remote areas of Nepal. This study examined the characteristics associated with utilization of SBA services in mid- and far-western Nepal.
  
  
  METHODS
  This cross-sectional study examined three rural and remote districts of mid- and far-western Nepal (i.e., Kanchanpur, Dailekh and Bajhang), representing three ecological zones (southern plains [Tarai], hill and mountain, respectively) with low utilization of services by SBAs. Enumerators assisted a total of 2,481 women. All respondents had delivered a baby within the past 12 months. We used bivariate and multivariate analyses to assess the association between antenatal and delivery care visits and the women's background characteristics.
  
  
  RESULTS
  Fifty-seven percent of study participants had completed at least four antenatal care visits and 48% delivered their babies with the assistance of SBAs. Knowing the danger signs of pregnancy and delivery (e.g., premature labor, prolonged labor, breech delivery, postpartum hemorrhage, severe headache) associated positively with four or more antenatal care visits (OR = 1.71; 95% CI: 1.41-2.07). Living less than 30 min from a health facility associated positively with increased use of both antenatal care (OR = 1.44; 95% CI: 1.18-1.77) and delivery services (OR = 1.25; CI: 1.03-1.52). Four or more antenatal care visits was a determining factor for the utilization of SBAs.
  
  
  CONCLUSIONS
  Less than half of the women in our study delivered babies with the aid of SBAs, indicating a need to increase utilization of such services in rural and remote areas of Nepal. Distance from health facilities and inadequate transportation pose major barriers to the utilization of SBAs. Providing women with transportation funds before they go to a facility for delivery and managing transportation options will increase service utilization. Moreover, SBA utilization associates positively with women's knowledge of pregnancy danger signs, wealth quintile, and completed antenatal care visits. Nepal's health system must develop strategies that generate demand for SBAs and also reduce financial, geographic and cultural barriers to such services.
authors.affiliation: Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden. bishnu.p.choulagai@gu.se.
authors.forename: Bishnu
authors.initials: B
authors.lastname: Choulagai
authors.forename: Sharad
authors.initials: S
authors.lastname: Onta
authors.forename: Narayan
authors.initials: N
authors.lastname: Subedi
authors.forename: Suresh
authors.initials: S
authors.lastname: Mehata
authors.forename: Gajananda P
authors.initials: GP
authors.lastname: Bhandari
authors.forename: Amod
authors.initials: A
authors.lastname: Poudyal
authors.forename: Binjwala
authors.initials: B
authors.lastname: Shrestha
authors.forename: Matthews
authors.initials: M
authors.lastname: Mathai
authors.forename: Max
authors.initials: M
authors.lastname: Petzold
authors.forename: Alexandra
authors.initials: A
authors.lastname: Krettek
mesh_terms: D000293:Adolescent; D000328:Adult; D000704:Analysis of Variance; D003430:Cross-Sectional Studies; D004522:Educational Status; D005260:Female; D006297:Health Services Accessibility / Q000592:standards*; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008880:Midwifery / Q000706:statistics & numerical data*; D009390:Nepal; D011247:Pregnancy; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D055815:Young Adult