Utilization of maternal health services among mothers with children under two years in Arjundhara municipality, Jhapa, Nepal

INTRODUCTION

The Government of Nepal prioritizes maternal and neonatal health through the National Safe Motherhood Program. Key initiatives include the National Neonatal Health Strategy (2004) for neonatal care, the Skilled Birth Attendant (SBA) policy (2006) to ensure skilled personnel at births, and the Birth Preparedness Package (2008-2009) for timely delivery care. The Maternity Incentive Scheme (2005) encourages facility-based maternity care. In 2016, Nepal endorsed the Every Newborn Action Plan, aiming to eliminate preventable newborn and stillbirth deaths while ensuring the well-being of mothers and children.¹ While incentives like Nepal’s maternity allowance program aim to improve service utilization, challenges remain in reaching marginalized groups.² Maternal health services, including antenatal care (ANC), delivery, and postnatal care (PNC), are essential for preventing maternal deaths and complications.³ Despite global efforts, maternal mortality remains high, particularly in low- and middle-income countries, where access to quality healthcare can significantly reduce risks.⁴

The World Health Organization (WHO) recommends at least four ANC visits to detect and manage pregnancy-related complications.⁵ However, disparities in healthcare access contribute to high maternal mortality, especially in sub-Saharan Africa, where MMR is 15 times higher than in developed regions.⁶ Understanding individual and contextual factors influencing health-seeking behavior is crucial for improving maternal health outcomes4. Addressing barriers through evidence-based interventions and strengthening health systems can enhance maternal healthcare services and reduce mortality.⁷ Each year, about 16 million adolescent women (15-19 years) give birth, with nearly 95% of these pregnancies occurring in low- and middle-income countries. Adolescent pregnancy poses serious health risks, including preterm birth, delivery complications, unsafe abortion, and obstetric fistula.⁸ Globally, around 800 women die daily from preventable pregnancy and childbirth-related causes, with 287,000 maternal deaths recorded in 2010.⁶ Access to quality maternal health services, including prenatal, delivery, and postpartum care, can prevent most maternal deaths.²

The WHO reports 400 maternal deaths per 100,000 live births, while natural mortality without interventions is estimated between 1,000 and 1,500 per 100,000. Global health initiatives have significantly reduced maternal mortality to a quarter of natural levels.⁹ In Nepal, the 2016 NDHS reported a maternal mortality rate of 239 per 100,000, with 83.6% of pregnant women receiving skilled prenatal care. Koshi province had high service utilization, with 82.7% receiving prenatal care and 62.2% institutional deliveries.¹

The 2019 NMICS showed that 94.3% of pregnant women in Nepal received at least one ANC visit, with 77.8% attending four visits. Postnatal care was received three times as per government policy by 69.4% of women, with 76.6% in Koshi province.¹⁰ The 2022 NDHS reported that 94% of women received ANC from skilled providers, and 81% attended at least four ANC visits. Additionally, 96% took iron supplements during pregnancy.¹¹ Ensuring access to skilled maternal healthcare remains crucial in reducing maternal morbidity and mortality.

METHODS

Study method

A quantitative cross-sectional research method was chosen, and numerical data were collected through structured surveys and observations. This approach enabled the analysis of relationships between variables and provided insights into population characteristics based on sample data.

Study design

An analytical cross-sectional study design was employed to assess the association between an exposure variable and an outcome at a single point in time.

Study area

The study was conducted in Arjundhara Municipality, Jhapa, Koshi Province, Nepal.

Study duration

The study was conducted from January 2023 to July 2023.

Study population

The study population was mothers with children under two years old.

Inclusion criteria

Mothers of children under two, residing in Arjundhara Municipality were included.

Exclusion criteria

Mothers unable or unwilling to respond or mentally unfit for participation were excluded.

Sample size

A sample size of 237 was calculated using standard formulas, considering a prevalence rate of 78.8% and an error margin of 5%.

Sampling frame and technique

The sampling frame was obtained from local sources, including birthing centers and health volunteers. A Simple Random Sampling method ensured equal selection probability for all participants.

Study variables

Dependent variable was maternal health care services utilization (ANC and PNC). Independent variables were age, education, family income, occupation, healthcare access, and provider behavior.

Data collection

Data was collected via a semi-structured questionnaire through face-to-face interviews, utilizing Kobo software after obtaining informed consent.

Data processing and analysis

Data was processed manually and with statistical package for the social sciences (SPSS) 23, ensuring accuracy through coding, cleaning, and tabulation for statistical analysis.

Quality control

Quality assurance included pre-testing tools on a similar population, orienting enumerators, and routine consultations with supervisors to maintain data reliability and validity.

Validity and reliability

The research emphasized validity through a comprehensive literature review, a standardized questionnaire, and rigorous tool testing. Consistent supervision, pre-testing, and translation for accuracy enhanced reliability.

RESULTS

Socio-demographic characteristics of the respondents

Table 1 shows the socio-demographic characteristics of respondents show that out of 237 total participants, more than three-fourths (78.5%) had been married for over 20 years. The average age of respondents with a current child was 28.62 years, and the child's average age was 10.62 months. Nearly all respondents were married (97%). Nearly half (46.4%) identified as Brahmin/Chettri, while 2.5% were Muslim. The majority (80.6%) of respondents identified as Hindus, followed by 0.4% who practiced Kirat. Two-thirds (67.9%) of respondents lived in nuclear families, and 76.4% had family sizes of fewer than five members. Most (86.1%) of the respondents had fewer than two children. Almost half (46.8%) of participants made the decision to seek maternal health services independently. More than half (56.5%) of the household heads were husbands.

Socio-economic characteristics of the respondents

Table 2 represent the socioeconomic status of the 237 respondents is described. Nearly half (44.3%) of the respondent husbands had completed their +2 level, followed by 1.7% who had completed primary education. Similarly, less than half (42.6%) of mothers had completed their +2 level, with 2.1% having no formal education.

More than half (55.2%) of respondent husbands are employed, followed by 5.2% who work in agriculture as a primary occupation. Likewise, nearly half (42.6%) of mothers are housewives, with 4.6% engaged in agriculture. Nearly half (46.0%) of family monthly incomes fall between 10000-44999, followed by 10.1% between 90000-150000.

Maternal health services utilization of the respondents

Table 3 data illustrate respondents' use of maternal health services. Almost all participants utilized these services during antenatal and postnatal periods. The majority (87.8%) received ANC services as recommended, with nearly three-fourths (70.9%) attending more than four ANC visits, while 12.2% attended fewer than four. About 62.9% preferred government health facilities for ANC checkups, compared to 37.1% who chose private hospitals.

For delivery, approximately two-thirds (66.7%) visited private hospitals, and 1.7% delivered at home. Less than a quarter (21.5%) completed all PNC checkups as per protocol; the majority (78.5%) visited fewer than three times, with 99.6% only completing the first PNC visit, and 36.7% attending the 7-day checkup. Over half (57.8%) conducted PNC at private hospitals, followed by 41.7% at government facilities. Family support influenced 97% of respondents to use maternal health services, and 60.8% cited positive prior experiences.

About 75.5% faced challenges, mainly inadequate health facilities (78.8%) and transportation issues (46.9%). To enhance service quality, 35% suggested increasing service availability, and 17.7% recommended mobilizing FCHV. Most (89%) felt cost was a barrier.

To improve utilization, 93.7% advocated for better access, and 29.1% suggested providing incentives. Around 66.2% felt highly satisfied with the services received, while 1.3% found them ineffective. Nearly all (98.7%) had access to health facilities within 30 minutes.

Relationship between ANC services utilization and socio-demographic variables

Table 4 shows no statistically significant association between ANC services received as per protocol and socio-demographic factors such as age at marriage or childbirth, child’s age, marital status, ethnicity, religion, parents’ education or occupation, income, family type or size, decision-making, and household head. Most mothers were married, Hindu, from both Brahmin/Chettri and indigenous groups, and lived in nuclear families with male heads of household. Parents generally had an education below secondary level, and occupations varied between business, job-holding, and housework.

Relationship between PNC services utilization and socio-demographic variables

Table 5 indicates that most socio-demographic characteristics, including age at marriage or childbirth, marital status, ethnicity, religion, parents’ education, occupation, family type, family size, total childbirths, decision-making, and household head, were not significantly associated with receiving PNC services as per protocol. However, household income showed a significant association, with a higher proportion of mothers receiving protocol-based PNC services in families earning between 50,000–150,000 NPR compared to those earning less. Most participants were married, Hindu, from both Brahmin/Chettri and indigenous groups, and lived in nuclear families with male heads of household.

Relationship between ANC and maternal health service utilization

Table 6 shows no statistically significant association between receiving ANC services as per protocol and type of health facility visited, challenges faced, suggestions for improvement, measures taken to increase utilization, service quality, accessibility, incentives, or perceived effectiveness. Most women visited government facilities, faced some challenges (mainly transportation issues and long waiting times), and suggested service extension, FCHV mobilization, better availability, and awareness programs. The majority perceived the services as effective, accessible, and of good quality, with awareness programs being the most common measure to improve utilization.

Relationship between PNC and maternal health service utilization

Table 7 shows that there is no significant link between receiving PNC services as per protocol and factors like the type of health facility, challenges encountered, cost barriers, suggestions for improvement, awareness activities, service quality, accessibility, incentives, or perceived effectiveness. Most mothers used private facilities, faced challenges mainly related to transportation and long waiting times, and recommended extending services, mobilizing FCHVs, enhancing availability, and raising awareness. Most respondents considered the services effective, accessible, and of good quality, with awareness programs being the most common recommendation for improvement.

*Multiple responses

*Fisher’s exact test

*Fisher’s exact test

*Fisher’s exact test

*Fisher’s exact test

DISCUSSION

The study explores factors influencing the use and satisfaction levels of maternal healthcare services among mothers of children under two years in Arjundhara Municipality, Jhapa. An analytical cross-sectional study was conducted with 237 respondents from diverse backgrounds, including age, education, occupation, religion, and ethnicity. All 237 respondents (100%) had at least one ANC visit, with 87.8% completing ANC as per protocol. Among them, 70.9% had more than four visits, while 12.2% had fewer than four. More than one-third (62.9%) received ANC at government health facilities. The study found a higher ANC compliance rate than the national average (81%) and Province 1 (78.8%) as reported by NDHS 2022.¹¹

A study in Eastern Nepal reported that 69% had ANC visits, while 13% had none.² In Ethiopia, 57% had no ANC visits, while 19.1% had four or more visits.⁶ Bivariate analysis showed no significant association between ANC utilization and factors like maternal age, marital status, ethnicity, education, occupation, and family income. Institutional delivery was reported by 98.3% of respondents, exceeding the national average (79%) and Province 1 (81.5%) according to New ERA 2022.¹¹ Postnatal care (PNC) was received by 99.6% at least once, but compliance with all recommended PNC visits was low. The first PNC visit within 24 hours was completed by 99.6%, the second (at 3 days) by 59.5%, and the third (at 7 days) by 36.7%. The decline in PNC visits aligns with findings from NDHS 2022, where national (70.2%) and Province 1 (77.3%) rates were higher.¹¹ Similarly, in Ethiopia, PNC utilization was higher among urban women (33.5%) compared to rural women (5%).⁶ Maternal health is a government priority, with incentives for ANC visits, institutional deliveries, and transportation costs (NPR 1,000 for Terai, 2,000 for Hills, and 3,000 for Mountains). An additional NPR 800 is provided for completing four ANC visits.

The government also trains ANMs, staff nurses, and medical officers to ensure skilled birth attendance and emergency obstetric care. Infrastructure development, referral systems, and public awareness campaigns further strengthen maternal health services. These efforts aim to improve maternal health outcomes and reduce maternal mortality in Nepal.¹²

CONCLUSION

The study provides valuable insights into the socio-demographic and economic factors affecting maternal health service use among 237 respondents. Most respondents were in long-term marriages, with an average maternal age of 28.62 years. Brahmin/Chettri (46.4%) was the predominant ethnicity, and the majority (80.6%) identified as Hindus. Nuclear families were common (67.9%), and most had fewer than five members (76.4%). Education levels varied, with 42.6% of mothers and 44.3% of their husbands completing their +2 level. Employment was higher among husbands (55.2%), while 42.6% of mothers were housewives. Family income varied widely, with 46.0% earning between 10,000–44,999 NPR per month.

Maternal health service utilization was high, with 87.8% receiving ANC as per protocol, though only 21.5% completed postnatal care (PNC) checkups. Government health facilities were preferred for ANC (62.9%), while private hospitals were favored for deliveries (66.7%) and PNC (57.8%). Family support (97%) and prior positive experiences (60.8%) were key factors influencing service use. Challenges included inadequate health facilities (78.8%) and transportation barriers (46.9%). Cost was a major concern (89%), leading some to delay care (57%) or borrow money (69.9%). Despite these barriers, 66.2% found services highly effective, and 98.7% had a health facility within 30 minutes. Suggestions to improve service utilization included enhancing accessibility (93.7%) and providing incentives (29.1%).

ACKNOWLEDGEMENTS

Authors would like to thank all the respondents at Little Buddha College of Health Science, who helped during data collection and the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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