Dear maternal health researchers in Nepal!

Nepal baby

Dear research team at the Centre for Midwifery, Maternal & Perinatal Health, Faculty of Health and Social Science, Bournemouth University, Dorset, UK;

You have just published research in BMC Pregnancy and Childbirth about barriers to accessing birthing services in Nepal. It is a really interesting read and represents problems that are encountered across the world.

We invite you to consider the evidence from a family perspective. We think this might lead to new conclusions for improving attendance by pregnant women at health clinics.

Three of the barriers you have described could perhaps be seen differently from a family inclusive perspective.

Busy at home in Nepal

You find that mothers are too busy at home to come to the birthing service. But is the problem actually that they are not getting enough help at home from others while they are pregnant?

An Indian study showed that working with expectant fathers led to them being more likely to assist with household work (up from 27% to 42%) and more likely to take their wives to clinics (Sinha 2008).

Other research suggests a lot of variation depending on the family arrangements and the status of the woman in the family. But we think there is enough evidence to merit exploring this in Nepal.

No money to travel

You find that mothers don’t have enough money to travel to the birthing service. But is the problem actually that the people who control the money in the family do not understand the importance of her attending and so are not making the right decisions about money? We know from research that when family members are engaged, women access birthing facilities more.

A review conducted by Bohren et al. (2014) showed the important roles that family members, especially elder women and husbands, play as facilitators or inhibitors of institutional delivery in low and middle-income countries.

In a study conducted in rural Nigeria, the husband’s denial accounted for 17% of women’s failure to attend antenatal care (Adamu & Salihu, 2002). The reasons for the husbands’ denial included: lack of knowledge about the importance of antenatal care, fear of women’s exposure to strange ideas at the health institutions and concerns about incurring financial costs and fear that their wives may be unfaithful.

In a study in Nepal, 13% of women reported that their mothers-in-law refused to allow them to deliver in a health facility (Shrestha et al 2012).

Feeling unsafe at health facility

You find that women do not feel safe and at home in clinics. This is actually a world-wide phenomenon, created last century when birth was taken out of the home and placed in a foreign medical environment. Women reacted by bringing members of their family with them, usually the father of the baby, but not always. The best thing a maternity setting can do to make women feel secure is to allow them to be present with people they love and trust.

A study in Nepal found that having family members around is important to mothers and is one reason they do not want to go into a health facility (Morrison et al 2014).

“At home we can move around as we like and hold onto anything we like but in hospital they make us stay on the bed and they do what they like. If I deliver at home my family members hold and support me and that makes it easier for me to have the baby.”

Similarly, in interviews with women in a Tanzanian community, Pfeiffer and Mwaipopo (2013) found that many women preferred to give birth in a private environment with the help of someone they know and trust in their community, even after being advised by health staff against such practices.

We hope these suggestions are useful in your work to improve maternity care in Nepal!


Adamu YM & Salihu HM (2002), Barriers to the use of antenatal and obstetric care services in rural Kano, Nigeria, Journal of Obstetrics & Gynaecology 22

Borhan MA et al. (2014), Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis, Reproductive Health 11

Morrison J et al. (2014), Exploring the first delay: a qualitative study of home deliveries in Makwanpur district Nepal, BMC Pregnancy & Health 14

Pfeiffer C & Mwaipopo R (2013), Delivering at home or in a health facility? hHealth-seeking behaviour of women and the role of traditional birth attendants in Tanzania, BMC Pregnancy & Health 13

Sinha D (2008), Empowering communities to make pregnancy safer: an intervention in rural Andhra Pradesh. New Delhi: Population Council

Shrestha SK et al. (2012), Changing trends on the place of delivery: why do Nepali women give birth at home? Reproductive Health 9

Photo: meghla_akashe_pori_:).  Creative Commons.

1 comments On Dear maternal health researchers in Nepal!

  • Many thanks for your comprehensive response and invitation to consider the evidence
    from a family perspective; you make a number of interesting and useful points
    which are very much welcomed.

    During the process of analysing the research results we noted a number of key themes and
    some have been presented in our paper Staff perspectives of barriers to women
    accessing birthing services in Nepal: a qualitative study
    using Thaddeus and Maine’s (1994) three Phases of Delay model. The paper that
    we are currently working on discusses gender as a theme which cuts across all Phases
    of Delay and a family inclusive perspective features in the discussion section.

    Best wishes, Lesley

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