title: Factors affecting institutional delivery in rural Chitwan district of Nepal: a community-based cross-sectional study.
abstract: BACKGROUND
  Health facility delivery is considered a critical strategy to improve maternal health. The Government of Nepal is promoting institutional delivery through different incentive programmes and the establishment of birthing centres. This study aimed to identify the socio-demographic, socio-cultural, and health service-related factors influencing institutional delivery uptake in rural areas of Chitwan district, where high rates of institutional deliveries co-exist with a significant proportion of home deliveries.
  
  
  METHODS
  This community-based cross-sectional study was conducted in six rural Village Development Committees of Chitwan district, which are characterised by relatively low institutional delivery rates and the availability of birthing centres. The study area represents both hilly and plain areas of Chitwan. A total of 673 mothers who had given birth during a one-year-period were interviewed using a structured questionnaire. Univariate and multivariable logistic regression analysis using stepwise backward elimination was performed to identify key factors affecting institutional delivery.
  
  
  RESULTS
  Adjusting for all other factors in the final model, advantaged caste/ethnicity [aOR: 1.98; 95% CI: 1.15-3.42], support for institutional delivery by the husband [aOR: 19.85; 95% CI: 8.53-46.21], the decision on place of delivery taken jointly by women and family members [aOR: 5.43; 95% CI: 2.91-10.16] or by family members alone [aOR: 4.61; 95% CI: 2.56-8.28], birth preparations [aOR: 1.75; 95% CI: 1.04-2.92], complications during the most recent pregnancy/delivery [aOR: 2.88; 95% CI: 1.67-4.98], a perception that skilled health workers are always available [aOR: 2.70; 95% CI: 1.20-6.07] and a birthing facility located within one hour's travelling distance [aOR: 2.15; 95% CI: 1.26-3.69] significantly increased the likelihood of institutional delivery. On the other hand, not knowing about the adequacy of physical facilities significantly decreased the likelihood of institutional delivery [aOR: 0.14; 95% CI: 0.05-0.41].
  
  
  CONCLUSIONS
  With multiple incentives present, the decision to deliver in a health facility is affected by a complex interplay of socio-demographic, socio-cultural, and health service-related factors. Family decision-making roles and a husband's support for institutional delivery exert a particularly strong influence on the place of delivery, and this should be emphasized in the health policy as well as development and implementation of maternal health programmes in Nepal.
authors.affiliation: Center for International Health, Ludwig-Maximilians-University, Munich, Germany. rajani_shah89@yahoo.com.
authors.forename: Rajani
authors.initials: R
authors.lastname: Shah
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians- University, Munich, Germany. rehfuess@ibe.med.uni-muenchen.de.
authors.forename: Eva A
authors.initials: EA
authors.lastname: Rehfuess
authors.affiliation: Nepal Public Health Foundation, Kathmandu, Nepal. maskeymk8@gmail.com.
authors.forename: Mahesh K
authors.initials: MK
authors.lastname: Maskey
authors.affiliation: Pneumologische Praxis München-Pasing, Munich, Germany. rainald.fischer@gmail.com.
authors.forename: Rainald
authors.initials: R
authors.lastname: Fischer
authors.affiliation: Population Studies Center, University of Michigan, Ann Arbor, USA. prembh@umich.edu.
authors.forename: Prem B
authors.initials: PB
authors.lastname: Bhandari
authors.affiliation: Department of Gynaecology and Obstetrics, Ludwig-Maximilians-University, Munich, Germany. Maria.Delius@med.uni-muenchen.de.
authors.forename: Maria
authors.initials: M
authors.lastname: Delius
mesh_terms: D000293:Adolescent; D000328:Adult; D016550:Birthing Centers / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D003466:Cultural Characteristics; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006700:Home Childbirth / Q000706:statistics & numerical data*; D006801:Humans; D007231:Infant, Newborn; D020380:Needs Assessment; D009390:Nepal / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000523:psychology; D011247:Pregnancy; D011295:Prenatal Care / Q000379:methods / Q000523:psychology / Q000706:statistics & numerical data; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D014505:Urban Population / Q000706:statistics & numerical data