title: Impact of the roll out of comprehensive emergency obstetric care on institutional birth rate in rural Nepal.
abstract: Increasing institutional births rates and improving access to comprehensive emergency obstetric care are central strategies for reducing maternal and neonatal deaths globally. While some studies show women consider service availability when determining where to deliver, the dynamics of how and why institutional birth rates change as comprehensive emergency obstetric care availability increases are unclear.
  
  
  
  In this pre-post intervention study, we surveyed two exhaustive samples of postpartum women before and after comprehensive emergency obstetric care implementation at a hospital in rural Nepal. We developed a logistic regression model of institutional birth factors through manual backward selection of all significant covariates within and across periods. Qualitatively, we analyzed birth stories through immersion crystallization.
  
  
  
  Institutional birth rates increased after comprehensive emergency obstetric care implementation (from 30 to 77%, OR 7.7) at both hospital (OR 2.5) and low-level facilities (OR 4.6, p < 0.01 for all). The logistic regression indicated that comprehensive emergency obstetric care availability (OR 5.6), belief that the hospital is the safest birth location (OR 44.8), safety prioritization in decision-making (OR 7.7), and higher income (OR 1.1) predict institutional birth (p ≤ 0.01 for all). Qualitative analysis revealed comprehensive emergency obstetric care awareness, increased social expectation for institutional birth, and birth planning as important factors.
  
  
  
  Comprehensive emergency obstetric care expansion appears to have generated significant demand for institutional births through increased safety perceptions and birth planning. Increasing comprehensive emergency obstetric care availability increases birth safety, but it may also be a mechanism for increasing the institutional birth rate in areas of under-utilization.
authors.affiliation: Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.|Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA.|Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA.|Department Medicine, Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Sheela
authors.initials: S
authors.lastname: Maru
authors.affiliation: Contra Costa Regional Medical Center, Contra Costa Family Medicine Residency, Martinez, CA, USA.
authors.forename: Alex Harsha
authors.initials: AH
authors.lastname: Bangura
authors.affiliation: 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.forename: Pooja
authors.initials: P
authors.lastname: Mehta
authors.affiliation: Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.
authors.forename: Deepak
authors.initials: D
authors.lastname: Bista
authors.affiliation: 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.forename: Lynn
authors.initials: L
authors.lastname: Borgatta
authors.affiliation: United Nations Population Fund, Kathmandu, Nepal.
authors.forename: Sami
authors.initials: S
authors.lastname: Pande
authors.affiliation: Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal.|Department of Anthropology, University of Washington, Seattle, WA, USA.|Department of Global Health, University of Washington, Seattle, WA, USA.|Henry M. Jackson School of International Studies, University of Washington, Seattle, WA, USA.
authors.forename: David
authors.initials: D
authors.lastname: Citrin
authors.affiliation: Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
authors.forename: Sumesh
authors.initials: S
authors.lastname: Khanal
authors.affiliation: Faculty of Health and Applied Science, University of West England, Bristol, UK.|Public Health Perspective Nepal, Department of Research and Training, Pokhara, Nepal.
authors.forename: Amrit
authors.initials: A
authors.lastname: Banstola
authors.affiliation: Possible, Bayalpata Hospital, Sanfebagar-10, Achham, Nepal. duncan@possiblehealth.org.|Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, USA. duncan@possiblehealth.org.|Boston Children's Hospital, Department of Medicine, Division of General Pediatrics, Boston, MA, USA. duncan@possiblehealth.org.|Departments of Medicine and Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. duncan@possiblehealth.org.
authors.forename: Duncan
authors.initials: D
authors.lastname: Maru
mesh_terms: D000328:Adult; D001723:Birth Rate; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D009390:Nepal; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D036301:Qualitative Research; D019035:Rural Health Services / Q000706:statistics & numerical data; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors
keywords: Global health; Implementation research; Institutional birth rate; Maternal mortality; Nepal