title: Perceptions of users and providers on barriers to utilizing skilled birth care in mid- and far-western Nepal: a qualitative study.
abstract: BACKGROUND
  Although skilled birth care contributes significantly to the prevention of maternal and newborn morbidity and mortality, utilization of such care is poor in mid- and far-western Nepal. This study explored the perceptions of service users and providers regarding barriers to skilled birth care.
  
  
  METHODS
  We conducted 24 focus group discussions, 12 each with service users and service providers from different health institutions in mid- and far-western Nepal. All discussions examined the perceptions and experiences of service users and providers regarding barriers to skilled birth care and explored possible solutions to overcoming such barriers.
  
  
  RESULTS
  Our results determined that major barriers to skilled birth care include inadequate knowledge of the importance of services offered by skilled birth attendants (SBAs), distance to health facilities, unavailability of transport services, and poor availability of SBAs. Other barriers included poor infrastructure, meager services, inadequate information about services/facilities, cultural practices and beliefs, and low prioritization of birth care. Moreover, the tradition of isolating women during and after childbirth decreased the likelihood that women would utilize delivery care services at health facilities.
  
  
  CONCLUSIONS
  Service users and providers perceived inadequate availability and accessibility of skilled birth care in remote areas of Nepal, and overall utilization of these services was poor. Therefore, training and recruiting locally available health workers, helping community groups establish transport mechanisms, upgrading physical facilities and services at health institutions, and increasing community awareness of the importance of skilled birth care will help bridge these gaps.
authors.affiliation: Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
authors.forename: Sharad
authors.initials: S
authors.lastname: Onta
authors.affiliation: Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal; Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; bishnu.p.choulagai@gu.se.
authors.forename: Bishnu
authors.initials: B
authors.lastname: Choulagai
authors.affiliation: Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal; Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
authors.forename: Binjwala
authors.initials: B
authors.lastname: Shrestha
authors.affiliation: Nepal Public Health Foundation, Kathmandu, Nepal.
authors.forename: Narayan
authors.initials: N
authors.lastname: Subedi
authors.affiliation: Nepal Public Health Foundation, Kathmandu, Nepal.
authors.forename: Gajananda P
authors.initials: GP
authors.lastname: Bhandari
authors.affiliation: Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Nordic School of Public Health NHV, Gothenburg, Sweden.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Krettek
mesh_terms: D001291:Attitude of Health Personnel; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel; D006297:Health Services Accessibility; D006801:Humans; D009390:Nepal; D011247:Pregnancy; D036301:Qualitative Research; D019035:Rural Health Services / Q000191:economics
keywords: Nepal; barrier; qualitative; skilled birth attendants; skilled birth care; utilization