Nearly every minute a woman dies in pregnancy or childbirth. In 2005, an estimated 536,000 women died due to complications developed during pregnancy and childbirth (1) and 10 million more suffered debilitating illnesses and lifelong disabilities (2). Seventy-five percent of maternal deaths occur during childbirth and the post-partum period (3).The vast majority of maternal deaths are avoidable when women have access to vital health care before, during and after child (4). Risks of mortality for women and their babies are highest at the time of birth (5).
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Sixty-two percent of births in the developing world are attended by skilled health workers – including midwives as well as doctors and nurses with midwifery skills – up from less than half in 1990(6). Coverage, however, remains low in Southern Asia (40 percent) and sub-Saharan Africa (47 percent) – the two regions with the greatest number of maternal deaths (7).The number of maternal deaths is highest in countries where women are least likely to have skilled attendance at delivery (8) .Worldwide, 62 percent of births are attended by a skilled health worker. Almost all births in developed countries are attended (8). In less developed countries, the figure is 57 per cent (8). In least developed countries it falls only to only 34 percent. An estimated 35 per cent of pregnant women in developing countries do not have contact with health personnel prior to giving birth (8).
“The safe motherhood means increasing the circumstances within which a women is enable to choose whether she becomes pregnant, and if she does, ensuring that she receives care for prevention and treatment of pregnancy complications. Further, she has access to a trained birth assistance and if she needs also to emergency obstetric care and care after birth to prevent death or disability from complication of pregnancy and child birth.”(9)
In Nepal, more than 80 percent (10) of women give birth at home without the presence of a health professional that is trained to recognize and manage complications. While the country has made progress in reducing maternal deaths, the maternal mortality ratio remains high at 281 per 100,000 live births (10).There are concerns that further reductions in mortality will be hampered by the slow progress made in increasing coverage of skilled birth attendance in 2005, the Government of Nepal introduced an innovative financing scheme, known as the Safe Delivery Incentive Programme (SDIP), as part of its strategy to increase the use of maternity services. The SDIP provides cash to women who deliver in a health facility and an incentive to health workers for attending deliveries. Across the developing world, there is increasing interest in whether such financing policies work to reduce barriers that women face when seeking health care at childbirth care at child birth. The SDIP comprises several financial benefits to women and health workers. It consists of conditional cash transfers (CCT) to women who deliver in a health facility; an incentive to health workers for each delivery they attend; and free delivery care for eligible women. The SDIP is one of the first CCT programmes to be implemented at scale in a low-income country. It is managed by the Ministry of Health which provides funds to districts and regional hospitals. There have been several challenges to implementation especially relating to the management of funds and promotion of the programme at the community level (11).
The Aama Karyakram was launched in January 2009, combining maternity incentives with free delivery care at all government health facilities and certain approved community/ NGO and private institutions (12). The new programme has benefited from the learning of the previous Safe Delivery Incentives Programme (SDIP), reflected in better management procedures. Under the Aama Program (Aama means mother in Nepali), all deliveries are performed for free in public health institutions recognized by the Ministry of Health as owning a valid birthing centre. In practice, birthing centers are to be found in PHC, DH and big hospitals Antenatal care consultations and post natal consultations are free, as well as family planning devices. On the other hand, laboratory examinations, including pregnancy test, are charged for. However, patients asking for private rooms are not allowed to benefit from free delivery. The women receive a transportation incentive when they discharge from the health facility. The amount of the incentive varies with the location of the health facility that performed the delivery: Rs.500 in the valley (called « terai » in Nepal), Rs.1,000 in the hills, Rs.1,500 in the mountain (12).
The present study will analyse the situation of ASK utilization in Dhanusa district in Nepal . The district has various caste, ethnic and religious groups following various rituals and cultures. This will have different perception and mindset on the place chosen for the delivery along with pregnancy outcome. Thus the present study will analyse the situation of the free delivery scheme and factors influencing utilisation of the scheme by the women and hindering to the utilisation in the utilisatin of scheme. It will further make us aware that the scheme is heading in right direction. It will access achievements as well as loopholes in the scheme so as to provide policy level recommendation.
1.2 Research Question
What are the factors influencing the utilization of the Aama Surakshya Karyakram in Janakpur Zonal Hospital?
To identify the factors related to the utilization of the Aama Surakshya Karyakram in rural area and in the hospital setting.
1) To examine the relation between the socio demographic characteristics of women accessing a utilization of Aama Surakshya Karyakram (Free Delivery Incentive Programme).
2) To explore the perception of the clients on Aama Surakshya Karyakram (Free Delivery Incentive Programme).
3) To identify factors hindering the utilisation of Aama Surakshya Karyakram from women who opted for home deliveries.
1. There are relationships between socio economic factors ( e.g Maternal age , occupation, income, residence, education, occupation) and ASK utilization
2. There are relationships between enabling factors and ASK utilization
3. There are relationships between source of information and ASK utilization
1.5 Variables of the Study
Pre Disposing Factors
Socio Demographic Factors
(Age, occupation, income, residence, education, occupation, ethnicity, religion)
Convenience of Transport
Satisfaction on services
Source of Information
(Health personnel, friends, family members, media)
Free Delivery Incentive Scheme
1.6 Operational Defination
Free Delivery Incentive Scheme/ Aama Surakshya Karyakram refers to the scheme of the government where the institution gets as per for the unit of normal delivery, CEOC and BEOC. The clients gets travel incentives for having utilized hospital services.
Mother’s education refers to highest level of education that mother attained by the respondent.
The transportation cost refers to the cost that cost the new mothers get as an incentive for delivering in the hospital.
Attitude towards ASK
This refers to how health providers treat women (e.g. sympathetically, rudely, patiently etc) during delivery in the health facilities.
Knowledge about ASK
This refers to the awareness about the facilities that is provided under the ASK.
Age of the women refers to her age from her last birthday.
A pregnant woman refers to women who are tested positive in their urine for pregnancy and are going to give birth to a child.
Occupation of the new mothers refers to the work they do during from 9 AM to 5PM (e.g house wife, teachers, farmers, service holders etc).
Source of Income
Source of income refers to the income /earnings of the family members of the new mothers.
The residence refers to the place where the new mothers were living on a permanent temporary basis before coming for institution for delivery.
Distance refers to the time taken to reach to the hospital from the place of residence.
Convenience of Transport
Convenience of transport refers to the availability of transport to reach to the hospital from the place of residence.
Support from Husband and Family
Support from husband and family refers to the support received by mothers in terms of information, encouragement, advice, money and taking women for ANC visits.
Satisfaction on services
Satisfaction of Services refers to the Perception of the respondent towards ventilation, waiting time, service area, manner and skills of the health personnel.
Source of Information
Source of Information refers to the information about the free delivery incentive scheme that respondents got weather from or Health personnel, friends or family member etc.
Utilisation of Aama Surakshya Karyakram
It refers to the utilisation of Janakpur Zonal Hospital for the delivery of the newborn.
Utilisation of Aama Surakshya Programme1.7 Conceptual Framework
Socio Economic Factors ( Maternal age , occupation, income, residence, education, occupation, religion, ethnicity)
Knowledge about ASK
Attitude about ASK
Knowledge of Aama Karyakram
Convenience of Transport
Satisfaction on services
Support from husband and famiy
Source of Information
( Health personnel, friends, family members, media)
Support from husband
Usefulness of the Study
1.8 Usefulness of the Study
This study will have benefit in different level including those who participating the study:
A ) Benefit to pregnant women in Nepal: Enrich the basic understanding of Aama Programme in delivering safe motherhood service. This study will be helpful to the people to develop a sense of awareness towards the importance of safe motherhood and the role of Aama Programme to better the health outcome.
B) The results of the study will be helpful for policy makers of the government and non-governmental agencies to have information for planning the safe motherhood program. .
2.1 Situation of Pregnancy and Delivery Globally Nationaly and Regionally
It is estimated 211 million pregnancies that occur every year globally; about 46 million end in induced abortion, of which only approximately 60% are carried out under safe conditions (19). Pregnancy and childbirth and their consequences are still the leading causes of death, disease and disability among women of reproductive age in developing countries (19).It is estimated that 150 million women get pregnant globally every year (20). Every day, 1500 women die from pregnancy- or childbirth-related complications. In 2005, there were an estimated 536 000 maternal deaths worldwide. Most of these deaths occurred in developing countries, and most were avoidable (21). Improving maternal health is one of the eight Millennium Development Goals adopted by the international community at the United Nations. Women die from a wide range of complications in pregnancy, childbirth or the postpartum period. Most of these complications develop because of their pregnant status and some because pregnancy aggravated an existing disease. The four major killers are: severe bleeding (mostly bleeding postpartum), infections (also mostly soon after delivery), hypertensive disorders in pregnancy (eclampsia) and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Globally, about 80% of maternal deaths are due to these causes. Among the indirect causes (20%) of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anemia and HIV(22).
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2.2 The Aama Karyakram (ASK)
Nepal’s Interim Constitution 2007 has enshrined the concept of health for all as the fundamental right of the Nepalese people and established the right of the citizens to essential health care services free of charge and the right of every women to a good standard reproductive health. ( Annual Report) The vision of providing free delivery was spelled out in the budget speech of Fiscal Year 2065/66 (2008/2009). The program was launched on 14th January 2009 (Magh 1, 2065) (12) .The ASK is combining maternity incentives with free delivery care at all government health facilities and certain approved community/ NGO and private institutions. The new programme has benefited from the learning of the previous Safe Delivery Incentives Programme (SDIP), reflected in better management procedures. Already there are indications of its potential to significantly increase facility deliveries and provision of 24-hour services at peripheral level (5).
ASK has two components
Free Institutional Delivery Care ( launched in Jan 2009)
Safe Delivery Incentive Programme (SIDP) this is a cash incentive scheme launched in 2005.( annual report )
The SIDP has been supported by the DFID to the government of Nepal which provided direct cash handout to the women who delivered at the health institution ( Annual report). Simila/rly with SSMP/Options, DFID also supported government to provide free institutional delivery care.
ASK provides following facility
Incentive to Women:
Cash payment after the delivery at the facility in the following pattern
NRs. 1500 (USD 20) in the mountain areas, NRs. 1,000 (USD 13) in hill areas and NRs.500 in the teari area.( Annual Report)
Payment to the Health Facility for the provision of free care in the following manner:
Normal Delivery at Health Facility with 25 and more beds NRs. 1500 (USD 20), Health Facility with less than 25 beds NRs. 1000 ( USD 13), Complication (BEOC) NRs.3000 (USD 40) C Section (CEOC) NRs. 7000 (USD 93). It also covers all the cost of all the required drugs, supplies, instruments and small incentive to health worker NRs. 300(USD 4). The a forth mentioned claim is to be done by the hospital and not by individual health workers.( Annual Report)
Incentive to Health Worker for Home Delivery: This is a temporary provision originally in SIDP and is slowly phasing out to emphasize the importance of facility deliveries. The payment has been reduced from NRs 300 to NRs. 200. ( Annual Report)
2.3 Policy leading up to ASK
After the world nations agreed to attain the goal of ‘Health For All’ (HFA) by the year 2000 AD through primary health care approach, Nepal also stepped ahead to extend and strengthen the integrated approach to meet the national goals.
The National Health Policy was adopted in 1991 (FY 2048 BS) to bring about improvement in the health conditions of the people of Nepal with emphasis on (i) preventive health services (ii) promotive health services (iii) curative health services (iv) basic primary health services with one health post each in the entire 205 electoral constituencies to be converted into primary health care centre (v) Ayurvedic and other traditional health services (vi) community participation (vii) human resources for health development (viii) resource mobilization (ix) decentralization and regionalization (x) drug supply, and (xi) health research. (14).
The second long-term health plan (1997-2017) aims at improving health status of the people, particularly those whose health needs are often not met; the most vulnerable groups, women and children, the rural population, the poor, the under-privileged and the marginalized. It emphasizes on assuring equitable access by extending quality essential health care services with full community participation and gender sensitivity by technically competent and socially responsible health personnel throughout the country (14).
In addition to essential health care, specialist services are also to be extended gradually on a cost-effective basis. The targets to be achieved by the second long- term health plan (SLTHP) by the end of the plan period of 1997-2017, are as follows:
1. IMR will be reduced to 34.4 per thousand live births from its present level;
2. Under 5 mortality rate to be reduced to 62.5/1000 live births from its present level;
3. TFR to be reduced to 3.05 from its present level;
4. Increase life expectancy to 68.7 from its present level;
5. To reduce CBR to 26.6 per thousand population from the its present level;
6. To reduce CDR to 6 per thousand population from its present level.
7. To reduce maternal mortality ratio to 250 per 100,000 births from the its present level;
8. To increase CPR to 58.2 percent of its present level.
9. To reduce percentage of new born < 2,500 gm to 12 and
10.To provide essential health care services at district level to 90 percent of the population living within 30 minutes of travel time.
The Infant Mortality Rate has declined in Nepal from 140 per thousand live births in 1976, 64 per thousand live births in 2001 to 48 per thousand live births (10). It is proposed to reduce IMR to 34.4 per thousand live births by 2017 (SLTHP 1997-2017). Under-5 Mortality: The Under-five 5 mortality came down from 118 in 1997, 91 in 2001 to 61 per thousand live births (10).Maternal Mortality has come down from 539 per 100,000 live births in 1997 to 281 per 100,000 live births in 2006 and is proposed to be reduced to 250 per 100,000 live births by 2017 (10).
The Interim Constitution of Nepal of 2007 stated, for the first time, that: ‘Every citizen shall have the right to get basic health service free of cost from the State as provided for in the law’. This makes “health for all” a fundamental human right and given this commitment, the Ministry of Health and Population has implemented a policy aimed at providing free health services.This has been progressively rolled out since December 2007 (13). As a result of the commitment of the Government to Free Health Care, Free Delivery Incentive Programme stared in Nepal since January 2009 which provides incentives to women who choose to deliver in the Government Health Facility and the Policy is commonly known as the Aama Srakshya Karyakram.
2.4 Access to health Care in Nepal
Access to health services in Nepal is limited due to remote mountainous areas, poor infrastructure, lack of sufficient and qualified health personnel, and socio-cultural and language barriers especially among excluded groups. The conflict had a serious impact on health-services delivery. Women’s lack of access to health care, information and education contributed to high levels of female mortality and morbidity. Nepal has a high rate of adolescent pregnancies and roughly 20% (15) of adolescent girls are pregnant or are mothers with at least one child. About half of them do not receive adequate obstetric care. 19%(15) of maternal deaths occur among this age group.
Many other health and social issues are related to adolescent pregnancies and early marriages. A widespread adherence to traditional gender roles and some harmful cultural beliefs and practices prevent girls and women from making decisions about their reproductive lives and exercising their reproductive rights, effectively limiting the reproductive health care they receive. Due to early child bearing, the educational and employment opportunities of women are greatly reduced. While the number of in-school and out-of-school education programmes that incorporate basic reproductive health issues as part of overall life skills and HIV peer education are increasing, current coverage remains limited. Adolescent sexual and reproductive health (ASRH) issues have not yet been incorporated into the basic health-service delivery packages. There is also limited capacity amongst teachers and health providers to provide necessary youth-friendly information, services and counseling. Nearly all Nepalese women and men know at least one method of contraception and there is marked increase in the use of contraceptives. Nevertheless, there is a considerable scope for increased use of family planning (FP).
A severe problem encountered by numbers of Nepalese women is uterine prolapse, a medical term for the maternal illness where the pelvic organ, the uterus, the rectum or the bladder protrudes into the vagina. In severe cases the uterus falls out of the vagina. Although the problem is common worldwide, it strikes women in Nepal at a young age, and is rarely treated. Its prevalence among women in reproductive age exceeds 10 percent and is as high as 24 percent among women between the age of 45 and 49 years old (15). According to a population based survey carried out by UNFPA/World Health Organization and the Institute of Medicine Tribhuvan University in 2006 all together more than 600,000 women are found having uterine prolapse and of them nearly 200,000 are in immediate need of surgery (15). Uterine prolapse is related to poverty and associated factors of discrimination against women, the denial of their human and reproductive rights, unequal gender relationships, and as a consequence of sexual and gender based violence and low level of maternity care. Ill treatment by mothers-in-law and husbands during pregnancy, chronic under-nutrition, early marriage and pregnancy, repeated pregnancy, difficulties during child birth, lack of skilled birth attendance, heavy manual work and sexual relationships just after child birth increase the prevalence of uterine prolapse.
2.5 Situation of Pregnancy and Delivery in Nepal
In 2005/06 total pregnancies in Nepal was 862,811(16), in 2006/07 total pregnancies was 812,674 (16), in 2007/08 total pregnancy was 805,000 (16) and in 2009 total pregnancies was 10,07130 (16). In Nepal number of women who received incentive in 2005/2006 was 34,347, in 2006/07 it was 74,511 similarly it was 100,251 women received incentive in the year 2007/08 (16). However the women who received incentive after the initiation of ASK increased up to 172,879.With the initiation ASK, the percentage women who delivered in institution by Traditional Birth Attendant and received incentive increased from 67.5% to 89% (16). Similarly,51.2 % of women delivered in institution by Traditional Birth Attendance and received free care (16). The total ANC coverage in Nepal increased by 51.8% to 55.9% in between 2007/08 to 2009/10 (16).
2.6 Dhanusa District its culture and Situation of Pregnancy in Dhanusa District
Janakpur is located in the Terai, alluvial, forested and marshy terrain at the base of the Himalaya mountain range. The major rivers surrounding Janakpur are Dudhmati, Jalad, Rato, Balan and Kamala. Janakpur is famous for its temples and the numerous ponds which carry significant religious importance, but are now extremely polluted. Now, the people are becoming conscious and trying to preserve the 52 gandas, i.e, 208 ponds as a sacred place. Earlier, people used to bring the water from those ponds for cooking purposes when there were no hand-pumps and no electricity.
One can see all the six seasons in Janakpur. Basant ritu (Spring-February/March), Grisma ritu (Summer- April/May/June), Barsha ritu (Rainy – July/August), Sharad ritu (Autumn- September/October), Hemanta ritu (Autumn-winter: November/December), Shishir ritu (Winter: December/January). The best time to visit Janakpur is from September to March. The foreigner should visit Janakpur during deepawali (Laxmi pooja or Tihar in nepali or deewali in hindi). This festival lies in the month of Kartik amavashya (No moon’s day in between 15 October to 15 November) of every year. One should consult the Nepali people before planning. After six days of Deepawali, the chhath festival (worship of God Sun) is celebrated. Janakpur is famous for both festivals and one can have the opportunity of this beautiful festival only in Janakpurdham in Nepal and not in any other places either in Nepal or in India. This would be the lifetime memory for a foreigner.
The delivery conducted by SBA at home was 1926 and at institutio was 7509 (Annual report, DoHs 2009). The delivery conducted by health workers comprised of 9694 home deliveries and 240 institutional delivery(Annual report, DoHs 2009).The ANC first visit in 2008/09 was 21,254 and ANC 4 visit was 12,250 amongst the total 29154 deliveries.
2.7 Precede Proceed Model:
The PRECEDE-PROCEED model (18) provides a comprehensive structure for assessing health and quality-of-life needs and for designing, implementing, and evaluating health promotion and other public health programs to meet those needs. PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) outlines a diagnostic planning process to assist in the development of targeted and focused public health programs. PROCEED (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) guides the implementation and evaluation of the programs designed using PRECEDE.
PRECEDE consists of five steps or phases (see Figure 1). Phase one involves determining the quality of life or social problems and needs of a given population. Phase two consists of identifying the health determinants of these problems and needs. Phase three involves analyzing the behavioral and environmental determinants of the health problems. In phase four, the factors that predispose to, reinforce, and enable the behaviors and lifestyles are identified. Phase five involves ascertaining which health promotion, health education and/or policy-related interventions would best be suited to encouraging the desired changes in the behaviors or environments and in the factors that support those behaviors and environments.
PROCEED is composed of four additional phases. In phase six, the interventions identified in phase five are implemented. Phase seven entails process evaluation of those interventions. Phase eight involves evaluating the impact of the interventions on the factors supporting behavior, and on behavior itself. The ninth and last phase comprises outcome evaluation-that is, determining the ultimate effects of the interventions on the health and quality of life of the population.
In actual practice, PRECEDE and PROCEED function in a continuous cycle. Information gathered in PRECEDE guides the development of program goals and objectives in the implementation phase of PROCEED. This same information also provides the criteria against which the success of the program is measured in the evaluation phase of PROCEED. In turn, the data gathered in the implementation and evaluation phases of PROCEED clarify the relationships examined in PRECEDE between the health or quality-of-life outcomes, the behaviors and environments that influence them, and the factors that lead to the desired behavioral and environmental changes. These data also suggest how programs may be modified to more closely reach their goals and targets.
Among the contributions of the PRECEDE-PROCEED model is that it has encouraged and facilitated more systematic and comprehensive planning of public health programs. Sometimes practitioners and researchers attempt to address a specific health or quality-of-life issue in a particular group of people without knowing whether those people consider the issue to be important. Other times, they choose interventions they are comfortable using rather than searching for the most appropriate intervention for a particular population. Yet, what has worked for one group of people may not necessarily work for another, given how greatly people differ in their priorities, values, and behaviors. PRECEDE-PROCEED therefore begins by engaging the population of interest themselves in a process of identifying their most important health or quality-of-life issues. Then the model guides researchers and practitioners to determine what causes those issues-that is, what must precede them. This way, interventions can be designed based not on speculation but, rather, on a clear understanding of what factors influence the health and quality-of-life issues in that population. As well, the progression from phase to phase within PRECEDE allows the practitioner to establish priorities in each phase that help narrow the focus in each subsequent phase so as to arrive at a tightly defined subset of factors as targets for intervention. This is essential, since no single program could afford to address all the predisposing, enabling and reinforcing factors for all of the behaviors, lifestyles, and environments that influence all of the health and quality-of-life issues of interest.
Applications of the PRECEDE-PROCEED model in the public health field are myriad and varied. The model has been used to plan, design, implement, and/or evaluate programs for such diverse health and quality-of-life issues as breast, cervical, and prostate cancer screening; breast self-examination; cancer education; heart health; maternal and child health; injury prevention; weight control; increasing physical activity; tobacco control; alcohol and drug abuse; school-based nutrition; health education policy; and curriculum development and training for health care professionals
2.8: Models of Utilization:
Multiple forces determine how much health care people use, the types of health care they use, and the timing of that care identifies some, but certainly not all, major forces that affect trends in overall health care utilization over time. Some forces encourage more utilization; others deter it .
Factors that may decrease health services utilization (17)
Decreased supply (e.g., hospital closures,large numbers of physicians retiring)
Public health/sanitation advances (e.g.quality standards for food and water distribution)
Better understanding of the risk factors of diseases and prevention initiatives (e.g.,smoking prevention programs, cholesterol lowering drugs)
Discovery/implementation of treatments that cure or eliminate diseases
Consensus documents or guidelines that recommend decreases in utilization
Shifts to other sites of care may cause declines in utilization in the original sites: as technology allows shifts (e.g., ambulatory surgery) as alternative sites of care become
available (e.g., assisted living)
Payer pressures to reduce costs
Changes in practice patterns (e.g., encouraging self-care and healthy lifestyles; reduced length of hospital stay)
Changes in consumer preferences (e.g.,home birthing, more self-care, alternative
Factors that may increase health services utilization (17)
Increased supply (e.g., ambulatory surgery centers, assisted living residences)
Growing elderly population, more functional limitations associated
with aging, more illness associated with aging,more deaths among the increased
number of elderly (which is correlated with high utilization)
New procedures and technologies (e.g.,
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