Safe Delivery Incentive Programme Research Articles

Financial incentives and delivery care: Evidence from the Safe Delivery Incentive Program in Nepal.

This paper examines the effects of the Safe Delivery Incentive Program in Nepal, a cash transfer program that reduced the costs of childbirth in healthcare facilities. Women giving birth for the first, second, or third time (below-cutoff) became eligible in 2005, and women giving birth for the fourth time or more (above-cutoff) became eligible two years later. Using a difference-in-differences design, I find that below-cutoff women in high Human Development Index (HDI) districts increased facility delivery by 8.8 percentage points. Despite larger cost reductions, below-cutoff women in low HDI districts did not increase facility delivery but increased home delivery with skilled personnel by 4.8 percentage points. The program had no impact on above-cutoff women, who become eligible 2years into the program. I suggest that pre-existing barriers such as poor infrastructure of roads and facilities, customs, liquidity constraints, and lack of program awareness limited the program's effectiveness.

Inequality in Institutional Delivery of Recent Birth among Married Women in Nepal: A Trend Analysis

The huge discrepancy in health statistics between developed and developing countries occur in the area of maternal mortality, with developing countries contributing most of the figures. This study assesses the trend of institutional delivery of recent birth and compares the inequalities with associated factors that affect institutional delivery in Nepal. The data for this study were obtained from three sequential Nepal Demographic and Health Surveys [NDHS] of 2006, 2011, and 2016. The association between institutional delivery and the explanatory variables was assessed via bivariate analysis (Chi-square test) and multivariate analysis (binary logistic regression). The utilization of health service during delivery stepped up from 21% in 2006 to 62% in 2016. Although the proportion of delivery in health facility increased among poorest over the period of 10 years, the disparity between richest and poorest still persisted from 2006 to 2016 and the association was highly significant in all the surveys. Although government of Nepal has launched the maternity incentive scheme through safe delivery incentive program in 2005, poor women are still deprived from utilizing the service. Poorest and poorer women were 78 per cent (aOR=0.22, 95% CI 0.17-0.27) and 71 Per cent (aOR=0.23, 95%CI 0.23-0.35) respectively less likely to have institutional delivery than the richest women after controlling the other socio-demographic and culture factors. Furthermore, this study has found that education, place of residence, women’s autonomy, religion, number of ANC visits, exposure to newspaper and TV were significant predicators for place of delivery. Although there has been three-fold increment in utilization of health services during delivery over the period of 10 years, the discrepancy between rich and poor, educated and uneducated and urban and rural area is highly evident. Overall, the present study highlights the necessity of interventions to promote institutional delivery with greater focus on poor, uneducated, and rural women

Investigation of technical quality of antenatal and perinatal services in a nationally representative sample of health facilities in Nepal

BackgroundAccess to routine antenatal and perinatal services is improved in the last two decades in Nepal. However, gaps remain in coverage and quality of care delivered from the health facilities. This study investigated the delivery of technical quality antenatal and perinatal services from health facilities and their associated determinants in Nepal.MethodsData for this study were derived from the Nepal Health Facility Survey 2015. The World Health Organization's Service Availability and Readiness Assessment framework was adopted to assess the technical quality of antenatal and perinatal services of health facilities. Outcome variables included technical quality scores of i) 269 facilities providing antenatal services and ii) 109 facilities providing childbirth and postnatal care services (perinatal care). Technical quality scores of health facilities were estimated adapting recommended antenatal and perinatal interventions. Independent variables included locations and types of health facilities and their management functions (e.g., supervision). We conducted a linear regression analysis to identify the determinants of better technical quality of health services in health facilities. Beta coefficients were exponentiated into odds ratios (ORs) and reported with 95% confidence intervals (CIs). The significance level was set at p-value < 0.05.ResultsThe mean score of the technical quality of health facilities for each outcome variable (antenatal and perinatal services) was 0.55 (out of 1.00). Compared to province one, facilities of Madhesh province had 4% lower odds (adjusted OR = 0.96; 95%CI: 0.92, 0.99) of providing better quality antenatal services, while health facilities of Gandaki province had higher odds of providing better quality antenatal services (aOR = 1.05; 95% CI: 1.01, 1.10). Private facilities had higher odds (aOR = 1.13; 95% CI: 1.03, 1.23) of providing better quality perinatal services compared to public facilities.ConclusionsPrivate facilities provide better quality antenatal and perinatal health services than public facilities, while health facilities of Madhesh province provide poor quality perinatal services. Health system needs to implement tailored strategies, including recruiting health workers, supervision and onsite coaching and access to necessary equipment and medicine in the facilities of Madhesh province. Health system inputs (trained human resources, equipment and supplies) are needed in the public facilities. Extending the safe delivery incentive programme to the privately managed facilities could also improve access to better quality health services in Nepal.

Determinants of skilled birth attendants in Nepal: a case of Surkhet district

Background: Safe delivery incentive program was introduced to increase the skilled attendants at births. The program provided childbirth by skilled birth attendants as well as incentives to skilled birth attendants ‘cash’ to women giving birth in a health facility in addition to incentives to health provider for each delivery attended, either at home or the facility. Due to its implementation and administrative delays, the program was reformed and implemented as a ‘safer mother program’ popularly known as “aama-suraksha-karyakram” since January 2009.Methods: The study was conducted in Surkhet district of Nepal. Surkhet is a hilly district and is head-quarter of mid-western development region of Nepal. There is one hospital, 5 PHCCs, 9 HPs and 38 SHPs serving 288,527 people in the district. The delivery by trained health worker (HW) in the district is 31.8% in 2005/06 which has increased about two times for two years. Surkhet is one of the districts monitoring the process indicators for safe motherhood programme in Nepal. Birth preparedness package programme has been implementing in the district from this year. The study population were the mothers within the age group of 15 to 49 years in Surkhet district. The sampling frame of the study was the mothers who had delivered the baby within 12 months preceding the survey.Results: About one third mothers, having 0-5 poverty score, utilised delivery assisted by HWs, while about three fourth of them having more than 5 score utilised HWs as delivery assistant. Higher educated mothers utilised HWs as delivery assistant more than that of higher educated husband. Among higher educated mothers, about 85% utilised delivery assisted by HWs, while it was about 75% for higher educated husband. Occupation of mother was also significantly associated with utilisation of delivery by HWs. Mother having office work utilised about 5 times higher HWs than others as their delivery assistant. The distance to health facility was significantly associated with utilisation of delivery attendant (p value &lt;0.001). The mothers with less travelling time to reach health facility were more likely to utilise HWs as delivery attendant. About three fourth mothers who needed less than half an hour utilised delivery assisted by HWs. There was equal proportion of mothers who needed 30-59 minutes to reach the nearest health facility. In the other hand, about 73% of mothers who needed one hour or more to reach health facility utilised others as delivery assistant. Perceived quality of service to nearby health facility by mothers was also significantly associated with utilisation of HWs as delivery attendant (p value &lt;0.05). About two third of mothers perceiving good quality of service at local health facility utilised HWs as delivery attendant while, it was only 44% among mothers perceiving poor quality of services.Conclusions: There should be adequate planning and preparation at all levels of health facilities; implementing a new program should not adversely affect another existing service delivery system. For the optional implementation, hospital organogram should be revised; and physical facilities and the low-risk birthing-centers with referral linkages should be expanded.

Prevalence of Antenatal Care Practice among Marginalized Community of Nepal

Background: The government of Nepal aims to improve the health of mothers and newborns by providing quality safe motherhood services. Increasing access and utilization of antenatal care (ANC) services are the first steps towards improving maternal and neonatal health outcomes, particularly those of the marginalized communities.Objective: The aim of this study is to assess the prevalence and factors associated with the antenatal care visits among the marginalized community of Nepal.Methods: A mixed-method study was conducted among 202 reproductive aged females of marginalized community in Nepal having childbirth during the last 2 years. Pre-tested semi-structured questionnaires and key informant interview guidelines were used for the collection of data. Bivariate and multiple regression analysis were carried out to find out the factors associated with the antenatal care visits. For qualitative data, thematic analysis was done. Results: More than half (56.9%) of the participants had completed four or more antenatal care visits. Mothers with primary level of education were 2.7 times more likely to complete four or more ANC visits (AOR: 2.7, CI: 1.09-7.07). Age at marriage (AOR: 2.3, CI: 1.08-5.22), women who took decisions alone for their health (AOR: 2.9, CI: 1.22-6.96),exposure to FCHV (AOR:2.5, CI: 1.1-5.9), knowledge about safe delivery incentive program (AOR: 3.6, CI: 1.46-9.0) and perception of “good quality” ANC service(AOR:7.5, CI: 3.3-17.1)were significantly associated with the number of ANC visits. Conclusion: The overall utilization of antenatal health services was low. So, there is a need of different community based maternal health programs especially targeting the marginalized females.

Free delivery care and supply-side incentives in Nepal’s poorest districts: the effect on prenatal care and neonatal tetanus vaccinations

ABSTRACT In July 2005, Nepal introduced the ‘Safe Delivery Incentive Programme’, which included free delivery care and supply-side incentives for women in the poorest districts. Using a difference-in-differences model and microdata from the Demographic and Health Surveys, we find the policy increased the probability of prenatal care and neonatal tetanus vaccinations, offsetting disparities between women in the poorest districts and rest of Nepal. Moreover, it was associated with a change in the source of prenatal care, from ‘other’ providers to nurses/midwives. Finally, we find that health investment decisions are interconnected across pregnancy stages; free delivery and supply-side incentives affected prenatal care.

Conditional cash transfer policies in maternal health service utilization in Nepal: Analysis of safe delivery incentive program (Aama Surakshya Karyakram) using Kingdon's multiple streams framework.

Various factors limit access to and utilization of health services even when provided at subsidized cost. This results in poor utilization of services that contributes to further economic impoverishment and health care disparity. Many countries are experimenting with various approaches to tackle the poor utilization of health care services including demand-side financing policy. This paper explains the policymaking process during the formulation of safe delivery incentive program, a conditional cash transfer program in Nepal using Kindgon's multiple streams framework. Analysis of earlier policies and programs around safe motherhood concludes that high transportation cost was a major cause for poor utilization of institutional obstetric care, despite being provided at free of cost. Health was recognized as fundamental constitutional right in 2007. This assured societal support and political commitments for protecting health constitutionally. Furthermore, there was commitment from external development partners (EDPs) for investment in maternal health. Together, these problem, policy, and politics opened Kingdon's "windows of opportunity" for formulation of conditional cash transfer policy. This paper presents evolution of Aama Surakshya Karyakram and uses Kingdon's multiple streams framework to explain how problem, policy, and politics streams converged together to allow this program to be introduced in Nepal.

Women's knowledge about the conditional cash incentive program and its association with institutional delivery in Nepal.

Background and purposeHome deliveries increase the risk of maternal and child mortality. To increase institutional deliveries, South Asian countries have introduced various forms of Conditional Cash Transfer (CCT) schemes that offer women cash if they come to deliver at a health facility. In 2005, Nepal introduced its Safe Delivery Incentive Programme (SDIP)—a cash incentive program nationwide to boost the rate of institutional delivery and care from health professionals at childbirth. This study asks the following research questions: How informed were Nepalese women about the cash incentive program? Does knowledge about the cash incentive program correlate with institutional delivery?MethodsData to answer these questions come from the 2011 Nepal Demographic and Health Survey (NDHS). This is a nationally representative data collected from 12,674 women between 15 and 49 years of age, of which 4,036 had given births in the past five years. Multiple logistic regression was employed to predict if knowledge about the cash incentive program increased the odds of institutional delivery controlling for sociodemographic and geographic factors.ResultsApproximately 90% of the women knew about the SDIP. About 42% of the women who knew about the SDIP and 13% of the women who did not know about the SDIP had their most recent delivery at a health institution. The odds of institutional delivery increased nearly three-fold (OR = 2.70; CI: 1.59–4.59) among women who knew about the SDIP compared to women who did not know about the SDIP. Other factors that predicted institutional delivery included education, wealth, urban status, first birth, the number of antenatal care visits, and exposure to news media.ConclusionThis study shows that there is a correlation between women’s knowledge about the SDIP and increased institutional delivery. Nepal’s health and social work professionals should inform all women of reproductive age about the program so that they can make more informed delivery decisions.

Cost and Consequences of Integrated Public Health Campaign in Baglung District, Nepal

Correction: On 17th May 2020 the third author's name was changed from 'Chiranjibi' to 'Chiranjivi'&#x0D; Budget allocated, especially for new pilot program should yield better health effects than the regular ones. The government of Nepal launched Integrated Public Health Campaign (IPHC), a new type of intervention to make rural and vulnerable communities more aware about basic level health care services and increase their utilization. This paper examines the cost of the campaign and its outcomes in terms of providing awareness, utilization of maternal health services and improving health indicators. The study followed a comparative quasi experimental design, study unit being the household and the campaign. Case and Control village development committees (VDCs) were selected from the same territory and matched based on the criteria of IPHC and other socio-demographic &amp; health services characteristics. Cost calculation was based on direct method whereas the effectiveness was measured by analyzing the output of campaign between case and control VDC. The total cost of the campaign was NRs. 18, 00,000 with per household cost NRs. 585.93 and per capita cost NRs. 123.11. The awareness level of Free Health Services (FHS), Primary Health Care-Out Reach Centre and Safe Delivery Incentive Program (SDIP) was found to be 3.3, 2.65 and 1.95 times more in people of Case VDC than those of Control VDC. Moreover, there was no significant association between implementation of campaign with different practices of maternal health viz. Antenatal Care visit, delivery, SDIP and post natal care visit. The campaign was found effective in improving the status of OPD visit, measles, TT2+, growth monitoring of children and vitamin A supplementation to postpartum mothers. The campaign was effective in limited aspects. In case of its continuation, revision is necessary with the introduction of newer and better approaches.&#x0D; Economic Journal of Development Issues Vol. 23&amp;24 No. 1-2, (2017) Combined Issue, Page : 113-122

The Safe Delivery Incentive Program in Nepal: towards women's empowerment

Background: Providing equal opportunities for the newborn to survive requires a comprehensive approach. One of the approaches to provide equal opportunities for the new born is by promoting birth at the institutions. Nepal faces its unique challenges for meeting the public health goals. While some of the most common barriers toward safe delivery are related to access, cultural practices, lack of healthcare human resource, and inadequate healthcare financing. The government of Nepal in 2005 has initiated an incentive scheme, for the women to deliver at the health facility and to the provider for each delivery attended. Objective: To assess the perspectives of the beneficiaries of Safe Delivery Incentive Program on the domains of benefits, difficulties, use of the cash incentive, and any recommended changes in the program. Materials and Methods: This study utilizes a qualitative methodology by the use of in-depth interviews to learn about the perception of women about the scheme. Thirty in-depth interviews were conducted with the beneficiaries in randomly selected three wards in Khandbari Municipality. Manual qualitative data analysis was carried out using open coding and axial coding techniques according to Grounded Theory approach to derive a conceptual framework eliciting the perceptions. Result: Beneficiaries in this study perceive this program as beneficial but not adequate to address the economic burden of childbirth to poor families and to those who are living in the distant health facilities. They find difficulty in availing the scheme in terms of delay in getting money and lack of proper information about the program. Decision-making was mainly by husband and pattern of utilization hugely deviated from the intended purpose (i.e., transportation). They also suggest providing the incentive beforehand and relaxing the clause of ANC as a part of the incentive. Empowerment, both financial and awareness based, emerged as a dominant theme that the women perceived as a benefit of the program. Conclusion: The findings of the study mention cash transfer mechanism in the program has significantly empowered women. This model for women’s empowerment in developing countries should be explored in greater depth.

Pattern of Institutional delivery in Dadeldhura district of Nepal: A cross-sectional study

Background: Maternal mortality ratio of Nepal is one of the highest (380/100000 live births) among the South East Asian countries, where majority of the births take place at home without the assistance of skilled attendant. Latest estimates revealed that only 36.0% births were attended by skilled attendants in Nepal. Objective: To examine the pattern of institutional deliveries among the mothers in Dadeldhura District of Nepal. Materials and Methods: A community-based cross-sectional quantitative study was conducted in Dadeldhura district during October 2012 to March 2013 among 516 mothers who delivered within last 1 year. In addition, 3 years records of District Health Office, Dadeldhura were reviewed. Data were collected by trained enumerators through face to face interview using structured interview schedule. Data were analyzed by SPSS (17.0 versions). Percentage, mean, median, standard deviation, and range were calculated. Results: Mean age of the participants was 24.76 ± 3.77 years. The combined proportion of Dalit and Chhetri was 82.8%. About 17.6% participants were illiterates and 81.6% agriculture workers. About 95% had done one time antenatal care (ANC) visit, while only 64.8% had four time ANC visits during index pregnancy. Majority (82.2%) had received ANC services from primary level health facilities. Almost 77.3% had institutional delivery; among them 59.6% delivered at primary level health facilities. About two-third went to facility on foot, where 45.4% accessed delivery care from a health facility with an approximate distance of >5 km. Almost 55.0% had knowledge of at least one complication occurring during delivery and 74.0% were known about the safe delivery incentive program. Conclusions: Institutional delivery rate was good (77.3%) as against national average (37.0%). Majority (59.6%) had delivery at primary level health facilities. Three quarters were known about Safe Delivery Incentive Programme. Strengthening the capacity of primary level health care facilities in terms of skilled attendants and materials to cater the growing acceptance of local level health facility is recommended to scale up safe delivery practices.

Safe Delivery Care: Policy, Practice and Gaps in Nepal

Delivery care is regarded as safe when it is attended by a skilled birth attendant either at health facility or home. Childbirth practices differ from place to place and are determined by availability and accessibility of health services. After National Health Policy (1991), Nepal has focused on safe motherhood policies and programmes. Maternal mortality ratio decreased nearly fourfold between the years 1990 to 2011. The country is likely to achieve the Millennium Development Goal (MDG) 5. However, indicators of the MDG 5: skilled care at birth and institutional delivery rates are very far from the targets. From the initial findings of limited studies, safe delivery incentive programme has been successful for increasing the skilled care at birth and institutional delivery and reducing the maternal mortality twofold between the years 1990 to 2011. In spite of numerous efforts there is a wide difference in the utilization of skilled care at birth among the women by area of residence, ecological regions, wealth quintiles, education status, age and parity of women, caste ethnicity and so forth. This difference indicates that current policies and programmes are not enough for addressing the low utilization of safe delivery care throughout the country.

Domicile or Hospice? Choices for the Site of Delivery

Background: Besides expert attention, it is essential that mothers deliver their babies in a suitable location so as to lessen the risk of complications that may be problematic to mother and child. Since then and even now the place of delivery and its determinants have been on the research agenda. Objective: To explore the linkage between socio-demographic variables and place of delivery and to look at the reasons for delivering at home. Methodology: This cross-sectional study applies systematic random sampling method. Semi-structured questionnaire was used to collected information and analyzed by SPSS-16.0. Results were obtained by frequency distribution and cross-tabulation of the variables. Chi-square test was also performed. Results: Result shows that 34% delivered their baby at institute and 66% at home. Trend of home delivery slowly goes up higher with their age. Most women (73%), having higher educational level had practiced institutional delivery. The preference for delivery place was influenced by husband occupation, ANC visit and household income; lower the income higher the percentage of home delivery (80%). More than 72% delivery was conducted by non-health personal. Conclusion: Although the government of Nepal has initiated new strategies, through safe delivery incentive programme, to promote hospital delivery this is not followed substantially even in the semi-urban area. In order to bring about behavioral changes and to improve the situation of maternal morbidity and mortality socio-demographic and socio-cultural factors needs to be addressed in public health intervention programs.

Achieving Millennium Development Goals 4 and 5 in Nepal

The under 5 child mortality rate in Nepal is on track to achieve the target of 54 per 1000 live births by 2015 compared with 158 per 1000 live births in 1991. The maternal mortality rate also looks set to drop to its target of 134 per 100,000 live births by 2015 from 539 per 100,000 live births in 1991. A 3-year interim plan (2008-11) was established to provide free basic health care for all citizens and the safe delivery incentive programme has proved to help progression towards achieving Millennium Development Goals 4 and 5. The development of a policy targeting women, children and vulnerable populations in hard to reach places is a key feature. The principle of a primary healthcare approach is applied in the development and implementation of strategy plans and programmes. The focus is on ensuring that there are functioning facilities for essential obstetric care at health facilities and provision of trained personnel at delivery.

Financial incentives for maternal health evaluation of a national programme in Nepal

People often behave in ways that are not in their best long term interest. Financial incentives are increasingly being used by governments to persuade individuals to improve health-related behaviours. In developing countries, financial incentives have been shown to increase uptake of preventive health interventions, but it is not well understood whether financial incentives are effective when targeted towards more complex types of care or when implemented at scale in low-income countries. This thesis explores the impact of financial incentives on health seeking behaviour, in the context of the Safe Delivery Incentive Programme (SDIP) in Nepal. Launched nationwide in 2005, the SDIP seeks to encourage greater use of professional care at childbirth by providing cash to women after they give birth in a health facility, as well as an exemption from user fees for those residing in the least developed districts. The thesis develops a theoretical model of the programme's causal pathway and draws on consumer choice theory to derive a set of predictions. These are tested empirically using a variety of econometric methods applied to household data (from a secondary data source and a primary data source). The analysis comprises three main parts. First, it estimates the demand for maternity care using discrete choice models to understand the most important factors influencing a household's decision of where to give birth. By focusing on the role of price, this analysis serves as an ex-ante evaluation of the SDIP. Second, it investigates implementation of the SDIP. The analysis uses a number of key process indicators that emerge from the conceptual framework to explore what factors may have constrained the implementation process. Third, it estimates the impact of the SDIP on health seeking behaviour at childbirth in two areas of Nepal using propensity score matching and longitudinal methods of analysis. It finds that the programme had a modest impact on utilisation of women who had heard of the SDIP, but because programme uptake was low, it has led to only a small increase in skilled birth attendance across the entire population. Implications for financial incentive programmes and maternal health care in low- income countries are explored.

The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal

BackgroundNepal's Safe Delivery Incentive Programme (SDIP) was introduced nationwide in 2005 with the intention of increasing utilisation of professional care at childbirth. It provided cash to women giving birth in a health facility and an incentive to the health provider for each delivery attended, either at home or in the facility. We explored early implementation of the programme at the district-level to understand the factors that have contributed to its low uptake.MethodsWe conducted in ten study districts a series of key informant interviews and focus group discussions with staff from health facilities and the district health office and other stakeholders involved in implementation. Manual content analysis was used to categorise data under emerging themes.ResultsProblems at the central level imposed severe constraints on the ability of district-level actors to implement the programme. These included bureaucratic delays in the disbursement of funds, difficulties in communicating the policy, both to implementers and the wider public and the complexity of the programme's design. However, some district implementers were able to cope with these problems, providing reasons for why uptake of the programme varied considerably between districts. Actions appeared to be influenced by the pressure to meet local needs, as well individual perceptions and acceptance of the programme. The experience also sheds light on some of the adverse effects of the programme on the wider health system.ConclusionThe success of conditional cash transfer programmes in Latin America has led to a wave of enthusiasm for their adoption in other parts of the world. However, context matters and proponents of similar programmes in south Asia should give due attention to the challenges to implementation when capacity is weak and health services inadequate.