title: Determinants of institutional birth among women in rural Nepal: a mixed-methods cross-sectional study.
abstract: Encouraging institutional birth is an important component of reducing maternal mortality in low-resource settings. This study aims to identify and understand the determinants of persistently low institutional birth in rural Nepal, with the goal of informing future interventions to reduce high rates of maternal mortality.
  
  
  
  Postpartum women giving birth in the catchment area population of a district-level hospital in the Far-Western Development Region of Nepal were invited to complete a cross-sectional survey in 2012 about their recent birth experience. Quantitative and qualitative methods were used to determine the institutional birth rate, social and demographic predictors of institutional birth, and barriers to institutional birth.
  
  
  
  The institutional birth rate for the hospital's catchment area population was calculated to be 0.30 (54 home births, 23 facility births). Institutional birth was more likely as age decreased (ORs in the range of 0.20-0.28) and as income increased (ORs in the range of 1.38-1.45). Institutional birth among women who owned land was less likely (OR = 0.82 [0.71, 0.92]). Ninety percent of participants in the institutional birth group identified safety and good care as the most important factors determining location of birth, whereas 60 % of participants in the home birth group reported distance from hospital as a key determinant of location of birth. Qualitative analysis elucidated the importance of social support, financial resources, birth planning, awareness of services, perception of safety, and referral capacity in achieving an institutional birth.
  
  
  
  Age, income, and land ownership, but not patient preference, were key predictors of institutional birth. Most women believed that birth at the hospital was safer regardless of where they gave birth. Future interventions to increase rates of institutional birth should address structural barriers including differences in socioeconomic status, social support, transportation resources, and birth preparedness.
authors: Bayalpata Hospital, Possible, Sanfebagar-10, Achham, Nepal. sheela@possiblehealth.org.|Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA. sheela@possiblehealth.org.|Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA. sheela@possiblehealth.org.|Department of Medicine, Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA. sheela@possiblehealth.org.
authors: Sheela
authors: S
authors: Maru
authors: Bellevue Hospital Center, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA.
authors: Sindhya
authors: S
authors: Rajeev
authors: City of Berkeley, Berkeley, CA, USA.
authors: Richa
authors: R
authors: Pokhrel
authors: Faculty of Health and Life Sciences, Department of Biological and Life Sciences, Oxford Brookes University, Oxford, United Kingdom.
authors: Agya
authors: A
authors: Poudyal
authors: Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA.|Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA.
authors: Pooja
authors: P
authors: Mehta
authors: Bayalpata Hospital, Possible, Sanfebagar-10, Achham, Nepal.
authors: Deepak
authors: D
authors: Bista
authors: Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA.|Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA.
authors: Lynn
authors: L
authors: Borgatta
authors: Bayalpata Hospital, Possible, Sanfebagar-10, Achham, Nepal.|Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.|Department of Medicine, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.|Department of Medicine, Harvard Medical School, Boston, MA, USA.
authors: Duncan
authors: D
authors: Maru
mesh_terms: D000328:Adult; D000367:Age Factors; D002391:Catchment Area, Health / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D036861:Delivery, Obstetric / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006700:Home Childbirth / Q000706:statistics & numerical data*; D006801:Humans; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D009390:Nepal; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D055815:Young Adult
keywords: Global health; Implementation research; Institutional birth rate; Maternal mortality; Nepal; Skilled birth attendants; Women’s health