Trends and Inequalities in Use of Maternal Health Care Services in Nepal: Strategy in the Search for Improvements

BACKGROUND Nepal has made significant progress against the Millennium Development Goals for maternal and child health over the past two decades. However, disparities in use of maternal health services persist along geographic, economic, and sociocultural lines. METHODS Trends and inequalities in the use of maternal health services in Nepal between 1994 and 2011 were examined using four Nepal Demographic and Health Surveys (NDHS), nationally representative cross-sectional surveys conducted by interviewing women who gave birth 3-5 years prior to the survey. Sociodemographic disparities in maternal health service utilization were measured. Rate difference, rate ratios, and concentration index were calculated to measure income inequalities. FINDINGS The percentage of mothers that received four antenatal care (ANC) consultations increased from 9% to 54%, the institutional delivery rate increased from 6% to 47%, and the cesarean section (C-section) rate increased from 1% in 1994 to 6% in 2011. The ratio of the richest and the poorest quintile mothers for use of four ANC, institutional delivery, and C-section delivery were 5.08 (95% CI: 3.82-6.76), 9.00 (95% CI: 6.55-12.37), and 9.37 (95% CI: 4.22-20.83), respectively. However, inequality is reducing over time; for the use of four ANC services, the concentration index fell from 0.60 (95% CI: 0.56-0.64) in 1994-1996 to 0.31 (95% CI: 0.29-0.33) in 2009-2011. For institutional delivery, the concentration index fell from 0.65 (95% CI: 0.62-0.70) to 0.40 (95% CI: 0.38-0.40) between 1994-1996 and 2009-2011. For C-section deliveries, an increase in concentration index was observed, 0.64 (95% CI: 0.51-0.77); 0.76 (95% CI: 0.64-0.88); 0.77 (95% CI: 0.71-0.84); and 0.66 (95% CI: 0.60-0.72) in the periods 1994-1996, 1999-2001, 2004-2006, and 2009-2011, respectively. All sociodemographic variables were significant predictors of use of maternal health services, out of which maternal education was the most powerful. CONCLUSION To increase equitable use of maternal health services in Nepal there is a need to strengthen the health system to increase access to and utilization of services among poorer women, those with less education, and those living in remote areas. Beyond the health sector stronger efforts are needed to tackle the root causes of health inequality, reduce poverty, increase female education, eradicate caste/ethnicity based social discrimination, and invest in the development of remote areas.