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Original Article

Utilization of Maternal and Child Health Services in

Western Rural Nepal: A Cross-sectional
Community-based Study
Vishnu Khanal1, *Ramjee Bhandari2, Mandira Adhikari3, Rajendra Karkee4, Chandni Joshi5
MPH Candidate, School of Public Health, Curtin University, Bentley, 5MPH Candidate, School of Public Health and Community Medicine,
1

The University of South Wales, Sydney, Australia, 2MPH Candidate, Institute of Medicine, Kathmandu, 3Population Services International,
Nawalparasi, 4School of Public Health, BP Koirala Institute of Health Sciences, Dharan, Nepal

Abstract
Background: Considering the commitment and investment of Nepal to reduce maternal and child mortality,
understanding service utilization and factors associated with a child and maternal health services is important.
Objectives: This study was examined the factors associated with utilization of maternal and child health services in
Kapilvastu District of Nepal. Materials and Methods: A cross-sectional study was conducted in 2010 by interviewing
190 mothers having children of aged 12-23 months using the standardized questionnaire. Results: Immunization
status (97.4%) and vitamin A supplementation (98.4%) was high. However, initiation of breastfeeding within an hour
of birth was low (45.3%) and 63.2% had practiced exclusive breastfeeding. Majority (69.5%) of respondents delivered
their child at home and 39.5% sought assistance from health workers. The mothers who did not have any education,
mothers from Dalit/Janjati and the Terai origin were less likely to deliver at the health facility and to seek the assistance
of health workers during childbirth. Conclusion: The immunization program coverage was high, whereas maternal
health service utilization remained poor. Interventions that focus on mothers from Dalit/Janjati group and with lower
education are likely to increase utilization of maternal health services.

Keywords: Antenatal care, Breastfeeding, Cross sectional survey, Delivery services, Immunization, Vitamin A

Introduction hepatitis B, hemophilus influenza B (Pentavalent), polio

Child and Maternal Health Services are prioritized
programs in the health system of Nepal. The Ministry
of Health and Population (MoHP) started an expanded
program on immunization in 1979. 1,2 Routine
immunization program in Nepal includes Bacille
Calmette Guerin (BCG), diphtheria, pertussis, tetanus,
*Corresponding Author: Mr. Ramjee Bhandari,
MPH Candidate, Maharajgunj Medical Campus,
Institute of Medicine, Kathmandu, Nepal.
E-mail: bhandariramjee@gmail.com
Access this article online
Quick Response Code:
Website: www.ijph.in
DOI: 10.4103/0019-557X.128162
and measles. National multiyear immunization plan has
targeted to ensure the coverage of all of these vaccines
to 90% in each district.3 Current service delivery status
of the immunization program shows an increasing trend
in immunization coverage.3,4
There is high (281/100,000 live births) maternal mortality
in Nepal.5 MoHP has initiated various programs to increase
service utilization and to reduce maternal mortality.
Besides these, low social status of women, poverty,
ethnic and cultural beliefs over sorcery and traditional
healers, low priority of women’s health in family, low
female education and low health literacy are the main
determinants of under-utilization of health services and
of poor health status of women and children.6,7 However,
the exploration of such factors has been infrequent in
rural of part of Nepal.

Kapilvastu District has been categorized as having fewer

problems in the immunization program but this district still

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28 Khanal, et al.: Utilization of Maternal and Child Health Services
had a higher percentage of BCG versus measles dropout
rate (9.7% in 2007/2008, 11.3% in 2008/2009 and 10.99%
in 2010/2011) in three consecutive fiscal years since
2007/2008.3,4,8 As of 2008/2009, the utilization of antenatal
care (ANC) services (53.26% for four ANC), assistance
of deliveries by health workers (31.14%) and institutional
deliveries were low in the district. It is essential to find the
determinants of such service utilization to design, justify
and implement the health programs to increase maternal
and child survival. Therefore, the aim of this study was to
examine the utilization pattern of maternal and child health
services and the factors associated with it in Kapilvastu
District of Western Nepal.
Materials and Methods
The study was conducted in Kapilvastu District of the
western region of Nepal. This district has 77 government
health facilities and one District Health Office (DHO) to
implement the public health programs. Total population
of the district in 2011 was 570,612 with an annual
population growth rate of 1.69%.9 As of 2011, total
births attended by skilled birth attendants (SBA) were
14.9%.8 Village Development Committee (VDC) is
the lowest administrative authority in Nepal. 10 VDCs
were included in this study where District Development
Committee (DDC) had implemented the community-
based social mobilization program (DACAW) with
technical assistance of UNICEF. Therefore, the local
government authorities prioritized these areas to monitor
the health service utilization.
This cross-sectional study was conducted based on the
lot quality assurance survey (LQAS) method as guided
by the World Health Organization (WHO) and related
studies.10,11 Based on the WHO LQAS guide, 19 household
from each strata (VDCs) was obtained, which yielded a
total of 190 samples from 10 VDCs.10 Mothers who had
children aged 12-23 months were included in the study.
The list of the household was obtained from the respective
VDC office. Where there were more than one children
of the age 12-23 months, information of the youngest
child was obtained. Mothers were excluded from the
study if enumerators could not meet them at their houses
in two attempts. Questionnaires were adapted from the
WHO’s guide on LQAS and UNICEF’s generic health
questionnaire10,12 and some of the questions were adopted
from previously carried out survey by CARE Nepal in Doti
and Dadeldhura Districts of Nepal (unpublished source).
The English questionnaires were translated into Nepali
Indian Journal of Public Health, Volume 58, Issue 1, January-March, 2014
and back translated into English and were revised if there
were any inconsistencies. The questionnaire was pretested
in 30 households of the suburbs of district headquarter
and modification of the questionnaire was carried out
accordingly. Data collection was conducted by using a
structured questionnaire in Nepali language.
Statistical analysis
First association of independent variables with outcome
variables was explored using univariate statistics and then
further analyzed by multiple logistic regression. Level
of statistical significance was set at P-0.05. Statistical
Package for Social Sciences (SPSS 17.0.2, release March,
2009) was used for data analysis. We recoded some of the
outcome variables into dichotomous variables: Initiation
of breastfeeding (within 1 h [early initiation] or after 1 h
of birth); exclusive breastfeeding (for 6 months or not for
6 months); and place of delivery (health facility or home).
We categorized ethnicity into three groups; Hill origin
(Brahmins, Chhetri and Thakuri), Terai origin (Madhesi,
Tharu and Muslim), Dalit, Janjati and others (including
Hill and Terai).13 Involvement in community organization
was categorized based on the reported involvements in
the mother’s group, forest consumers group, community
organizations (run by DDC with technical and financial
assistance from UNICEF).13 For assistance during delivery
health workers referred to doctor, nurse, health assistant,
auxiliary nurse midwife, auxiliary health worker or maternal
and child health worker.14,15 Ethical approval was obtained
from Nepal Health Research Council before data collection.
Verbal informed consent was taken before each interview.
Results
Background information of the respondents
A total of 190 mothers were interviewed. The mean age
of the mothers was 27.2 years (standard deviations = 5.7).
Nearly ½ (47.9%) of the respondents were illiterate. More
than ½ (57.4 %) were people of Terai origin [Table 1].
Utilization of child and maternal health services
Immunization coverage was consistently high for all the
antigens (more than 97%). Nearly 98% of the children
were given vitamin A capsule within last 6 months. The
practice of ever breastfeeding was 95.8 % among the
respondents. However, initiation of breastfeeding within
1 h of birth was only 45.3%. Less than two-thirds (63.2%)
of the mothers had exclusively breastfed their babies for
6 months [Table 1].
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Khanal, et al.: Utilization of Maternal and Child Health Services 29

Table 1: Characteristics and child and maternal health related were then entered into multiple regression models, only
information of the participants (N = 190)
ethnicity remained statistically significant determinants
Variables Categories Number (%)
[Table 4]. It was found that mothers who are from Hilly
Background information
Education level No education 91 (47.9)
ethnic group were more likely (adjusted odds ratio [aOR]:
School level 76 (40.0) 6.192; 95% confidence interval [CI]: [2.329-16.466])
(primary and secondary) to initiate breastfeeding within 1 h of childbirth when
Higher secondary or above 23 (12.1)
compared with the mothers from Dalit/Janjati groups
Ethnicity Hilly origin 48 (25.3)
(Brahmin, Chetri, Thakuri) [Table 4]. None of the independent variables in the
Terai origin 109 (57.4) study were significantly associated with exclusive
(Madhesi, Tharu, Muslim) breastfeeding [Table 2].
Dalit Janjati and others 33 (17.3)
Involvement in community Yes 64 (34.4)
Maternal health
organization (n=186)© No 122 (65.5)
Child health services
Education, ethnicity and attending antenatal visits were
Immunization BCG 188 (98.9) associated with the place of delivery in the univariate
DPT III 187 (98.4) analysis [Table 3]. When these significant variables
Measles 186 (97.9) were entered into multiple regression model, only
Vitamin A in last 6 month Yes 187 (98.4) education and ethnicity of mother remained statistically
Ever done breastfeeding Yes 182 (95.8)
Time of initiation of Within 1 h 86 (45.3)
significant [Table 4]. The mothers who had higher
breastfeeding After 1 h 85 (44.7) education (aOR: 7.510; 95% CI: [2.161-12.101])
Do not know 19 (10) and who had secondary education (aOR: 3.391; 95%
Exclusive breastfeeding <6 months 32 (16.8) CI: [1.421-8.093]) were more likely to delivery their
6 months 120 (63.2) child at the health facility than the mothers who did not
>7 months 38 (20)
have any education. When compared to the mothers of
Maternal health
Antenatal visit (n=189)© No visit at all 14 (7.4) Hilly origin, the mothers from Dalit/Janjati (aOR: 0.381;
1-3 visits 111 (58.7) 95% CI: [0.133-1.087]) and Terai origin mothers (aOR:
≥4 visits 64 (33.9) 0.228; 95% CI: [0.093-0.557]) were less likely to delivery
Place of delivery Home 132 (69.5) at the health facility.
Health facility 57 (30.0)
Others 1 (0.5)
Education of mothers, ethnicity and involvement in
Assistance during delivery Health workers 75 (39.5)
Health volunteers 65 (34.2) community organization were significantly associated
Others 50 (26.3) with availing assistance of health workers in the univariate
(family members, neighbor) analysis [Table 3]. When these significant variables were
Post-partum vitamin A Yes 143 (75.3)
consumption
subjected to multivariable analysis, only education of
©
Number of observation in each category may differ from total sample due to missing
mothers and ethnicity remained statistically significant
information, BCG - Bacille calmette guerin, DPT - Diphtheria pertussis tetanus [Table 4]. The mothers who had higher education
(aOR: 6.507; 95% CI: [1.887-22.445]) and had secondary
One-third (33.9%, n = 189) of the pregnant mothers had level education (aOR: 2.522; 95% CI: [1.202-5.292]) as
four or more ANC visits. Home was the place of delivery compared to mothers with no education. The mothers
in 7 out of 10 (69.5%) cases. Only 39.5 % women had who were from Dalit/Janjati group (aOR: 0.549; 95%
their last delivery assisted by health workers. A quarter CI: [0.200-1.513]) and Terai origin group (aOR: 0.283;
(26.3%) of mothers relied on their family members 95% CI: [0.118-0.675]) were less likely to seek assistance
during their deliveries [Table 1]. of health workers during delivery when compared to the
mothers from Hill origin.
Factors associated with maternal and child health
service utilization and practices Discussion
Child health
Education status of mothers, ethnicity, place of delivery Maternal and child health services are one of the major
and assistance during delivery were associated with health programs delivered in Nepal. Adequate utilization
the initiation of breastfeeding within 1 h of birth in of those services is essential to reduce the high burden
the univariate analysis [Table 2]. When these variables of mortality and morbidity.

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30 Khanal, et al.: Utilization of Maternal and Child Health Services

Table 2: Factor associated with initiation of breastfeeding within 1 h of birth and providing exclusive breastfeeding
Factors Initiation of breastfeeding P value Exclusive breastfeeding P value
Within 1 h of After 1 h of birth 6 months < or >6 months
birth (n = 86) (%) (n = 104) (%) (n = 120) (%) (n = 70) (%)
Education of mother
No school 30 (33.0) 61 (67.0) 0.004** 52 (57.1) 39 (42.9) 0.099
Primary and secondary 42 (55.3) 34 (44.7) 55 (72.4) 21 (27.6)
Higher secondary and above 14 (60.9) 9 (39.1) 13 (56.5) 10 (43.5)
Ethnicity
Hill origin 35 (72.9) 13 (27.1) <0.001** 36 (75.0) 12 (25.0) 0.086
Terai origin 41 (37.6) 68 (62.4) 62 (56.9) 47 (43.1)
Dalit, Janjati and others 10 (30.3) 23 (69.7) 22 (66.7) 11 (33.3)
Place of delivery
Health facility 33 (57.9) 24 (42.1) 0.022** 40 (70.2) 17 (29.8) 0.189
Home 53 (39.8) 80 (60.2) 80 (60.2) 53 (39.8)
Assistance during delivery
Health workers 41 (54.7) 34 (45.3) 0.035** 47 (62.7) 28 (37.3) 0.910
Others 45 (39.1) 70 (60.9) 73 (63.5) 42 (36.5)
**Statistically significant

Table 3: Factor associated with place of delivery and assistance during delivery
Factors Place of delivery P value Assistance during delivery P value
Health facility Home Health workers Others
(n = 57) (%) (n = 133) (%) (n = 75) (%) (n = 115) (%)
Education of mother
No school 10 (11.0) 81 (89.0) 0.001** 19 (20.9) 72 (79.1) 0.001**
Primary and secondary 31 (40.8) 45 (59.2) 38 (50.0) 38 (50.0)
Higher secondary and above 16 (69.6) 7 (30.4) 18 (78.3) 5 (21.7)
Ethnicity
Hill origin 31 (64.6) 17 (35.4) 0.001** 34 (70.8) 14 (29.2) 0.001**
Terai origin 17 (15.6) 92 (84.4) 27 (24.8) 82 (75.2)
Dalit, Janjati and others 9 (27.3) 24 (72.7) 14 (42.4) 19 (57.6)
ANC visit
No ANC visit 0 (0.0) 14 (100.0) 0.001** 1 (7.1) 13 (92.9) 0.001**
1-3 ANC visits 25 (22.5) 86 (77.5) 37 (33.3) 74 (66.7)
≥ 4 visits 32 (50.0) 32 (50.0) 37 (57.8) 27 (42.2)
Involvement in community organizations (n=186)
Yes 23 (35.9) 41 (64.1) 0.209 34 (53.1) 30 (46.9) 0.007**
No 33 (27.0) 89 (73.0) 40 (32.8) 82 (67.2)
**Statistically significant, ANC - Antenatal care

Child health has preferred breastfeeding. Breastfeeding practice

The current finding of a high status of immunization is similar
to findings from the Nepal Demographic and Health Survey
(NDHS) of 2011 and regular reporting from DHOs.8,16 These
findings indicate that immunization is one of the most valued
and highly monitored and effective programs in the health
system of Nepal. Immunization programs are carried out
by continuous supply of vaccines, increased awareness
level, trained community health volunteers and with social
mobilization through community action process.3 Moreover,
the easy terrain of the study district is supportive.
Breastfeeding was associated with child’s healthy
development and survival.17 Nepalese society traditionally
(95.3%) in the current study was similar to the findings
of NDHS 2011.16 The WHO recommends breastfeeding
as early as possible after birth, preferably within an hour
of delivery.18 The early initiation of breastfeeding helps to
establish successful breastfeeding; improve health of the
children; increase their survival; and increase emotional
bond between mother and child.17 Early initiation of
breastfeeding was low (45.3%, n = 190) in this study.
The reasons behind such delay may be the practice of
early bathing (within 1st h of birth and then only keeping
into breast milk) and providing other woman’s milk to
the new born in the study area. The mothers from Terai
caste groups and Dalit/Janjati groups were less likely to

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Khanal, et al.: Utilization of Maternal and Child Health Services 31

Table 4: Factors associated with initiation of breastfeeding in 1 h of birth, place of delivery and assistance during delivery
Initiation of breastfeeding Place of delivery Assistance during delivery
Factors (1 h/after 1 h) (HF/Home) (health workers/others)
aOR (95% CI) aOR (95% CI) aOR (95% CI)
Education of mother P=0.299 P=0.003 P=0.005
No school 1.00 1.00 1.00
Primary and secondary 1.727 (0.858-3.477) 3.391 (1.421-8.093) 2.522 (1.202-5.292)
Higher secondary and above 1.270 (0.401-4.026) 7.510 (2.161-12.101) 6.507 (1.887-22.445)
Ethnicity P<0.001 P=0.005 P=0.014
Hill origin 6.192 (2.329-16.466) 1.00 1.00
Terai origin 1.387 (0.600-3.204) 0.228 (0.093-0.557) 0.283 (0.118-0.675)
Dalit, Janjati and others 1 0.381(0.133-1.087) 0.549 (0.200-1.513)
Place of delivery P=0.959 © ©
Home 1
Health facility 0.972 (0.335-2.825)
Assistance during delivery P=0.678 © ©
Others 1.158 (0.579-2.315)
Health workers 1.00
Involvement in community organizations (n=186) © © 0050=0.125
Yes 1
No 1.734 (0.861-3.495)
CI - Confidence interval, aOR-Adjusted odds ratio. Summary of regression models — Initiation of breastfeeding: Independent variables in initial model: Education,
ethnicity, place of delivery, assistance during delivery (−2 log likelihood ratio: 240.905; df = 2). Place of delivery: independent variables in model: Education, ethnicity,
(−log likelihood ratio: −2 log likelihood ratio: 183.234; df = 4). Assistance during delivery: Independent variables in model: Education, ethnicity and involvement in
community organizations (−2 log likelihood ratio: 207.793; df = 5). ©The independent variables were not in model. Attending antenatal visit were not included in the
regression analysis of place of delivery and assistance during delivery as the observation in cell contains zero/one

initiate breastfeeding within 1 h of childbirth. Ethnicity
has been a major determinant of child and other health
issues in Nepal as it is one of the factors determining
women’s status, access to education, economy and
services.19 In the Terai group and the Dalit groups, in
general, situation of women is lower and they do not
have decision making power. These two ethnic groups are
socially and economically marginalized groups in Nepal.
More than a half of the mothers had breastfed exclusively
their children for 6 months in this study and similar
findings have been reported by NDHS 2006 (65%) and
NDHS 2011 (71%).16 In rural Nepalese society, women
have high workload. Mothers have very less time to
continue exclusive breastfeeding. Further, in this study
area, there is also a culture of starting complementary
feeding (Pasni in Nepali) to boys when they complete 5
months of age and to girls when they complete 4 month
of age.20 This practice is a major hindering factor for
exclusive breastfeeding. Exclusive breastfeeding needs
constant support and education and a number of cultural
factors should be considered while educating the mothers.
In the study setting, mothers would be in contact with
health facilities for immunization of children only. As
only less than half of the mothers went for postnatal
visits, there was less chance of interaction between
health worker/midwives and mothers, which might be
another reason for such a low status of optimum exclusive
breastfeeding.6,21
Maternal health
The utilization of maternal health service is associated
with better birth outcomes. Inadequate ANC practice
reflects poor health seeking behavior with potential
adverse maternal and child health outcomes.11 In Nepal,
ANC clinics (in health facilities and in outreach clinics)
are the conventional platforms for educating pregnant
women. The WHO and MoHP recommend a minimum of
four timely ANC visits.3 In our study, the majority had at
least one visit and ⅓ (33.9%) had four ANC visits, more
than the finding from a previous study of Kathmandu
where 22% of women did not receive ANC.22 Delay in the
start of ANC visit, low perceived benefit of ANC visits,
low education status might explain such low uptake of
four ANC visit.23
Delivery assistance by health workers and institutional
delivery are in increasing trend over the last decade in
Nepal.24 Initiation of maternity incentive system (Aama
Surakshya Program) and abolition of user fee for these
services increased institutional delivery in Nepal by two
folds.24 Despite such efforts, our study showed that only
30.0% women delivered in the health facilities and only
39.5% received assistance from health workers. This

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32 Khanal, et al.: Utilization of Maternal and Child Health Services
finding was similar to previous findings from other places
of Nepal.15,25 There can be many reasons behind low
proportion of deliveries in health facilities. One recent
study reported that although Aama Surakshya (maternity
incentive) program gives incentive for transportation
of pregnant mothers from home to health facilities for
childbirth, none of the mothers knew the cash was for
transportation cost.24
Educated mothers were more likely to deliver at the
health facility and seek assistance from health workers.
This finding is consistent with previous Nepalese study.6
Educated mothers are more likely to be empowered, have
paid job, have access to service, have decision making
power in regards to her health and also likely to have
more capacity to process and understand the message
provided by the health workers and other awareness
programs. Therefore, the mothers with lower education
status need further focus to increase the utilization of
maternity services.
Mothers who were from Terai origin and the Dalit/Janjaati
groups were less likely to deliver at a health facility and
seek assistance from health worker. In our study setting,
decision about the place of delivery is made by mothers-
in-law or the head of the household (usually male) who
are rarely counseled by the health professionals during
ANC visit of the pregnant women.25,26 There is still a
culture of veiling of the young women, restriction of
movement during pregnancy and restriction to make a
decision by women themselves especially in Muslim and
Madhesi ethnic groups. Such restriction on the pregnant
women has an adverse effect on service utilization.27
Though these were the points from the demand side, there
are a lot of other causes which hinder the utilization of
health service and institutional delivery in Kapilvastu.
During the survey period, only two birthing centers were
serving the entire district.28 The health workers, who
are trained, often fail to provide proper service due to
inadequate space and equipment. This study’s finding
that ethnicity based service utilization pattern in the
study area has a major implication for health planners.
In our study, both the Dalit/Janjati and the Terai origin
people were found to be utilizing the services lesser
than other communities. Therefore, these ethnic groups
need more focus. Our study has several limitations.
The missing values in some of the variables might have
influenced our analysis. The cross-sectional nature of
this study precludes us from drawing causal inference
Indian Journal of Public Health, Volume 58, Issue 1, January-March, 2014
from the findings. Due to low number of observations
in unimmunized population, we could not explore the
causes of not using immunization services. Some of
the variables have less number of observations and as a
result it was not possible to perform logistic regression
analysis. The study was related to a limited number of
variables within the service delivery process of health
services of Nepal and did not include a wider number
of independent socio-economic variables. Another major
caution should be taken while interpreting the result
from LQAS method is that the findings may lead to false
positive results.29 Despite these, the results presented in
the study gives an account of maternal and child health
services in the district.
Conclusion
This study found the high rate of utilization of immunization
and consumption of vitamin A supplementation among
children; lower proportion of mothers who initiated
breastfeeding within 1 h of childbirth; and lower rate
of institutional delivery and assistance of delivery by
health workers. Based on these findings, breastfeeding
promotion program, provision of 24-h birthing centers
with SBA, educational interventions to increase
awareness and demand of institutional delivery service
will help to improve maternal and child health. Further,
the Dalit/Janjati and illiterate mothers should be on focus
for interventions.
Acknowledgements
We would like to acknowledge the mothers for their time and
information, Health and Nutrition Section, UNICEF Nepal
and DHO Kapilvastu. We like to thank Dr. Sudhir Khanal,
Mr. Purushottam Acharya and Mr. Madhab Chandra Baral
of UNICEF; Mr. Dinesh Kumar Chapagain (Chief of DHO,
Kapilvastu), Mr. Diwakar Maharjan (Immunization Officer,
DHO) and Dr. John Fielder for their support. The views
expressed in this paper are solely of authors and does not
necessarily reflect the view of District Public Health Offices
or UNICEF.
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Cite this article as: Khanal V, Bhandari R, Adhikari M, Karkee R, Joshi C.
Utilization of maternal and child health services in western rural Nepal: A
cross-sectional community-based study. Indian J Public Health 2014;58:27-33.
Source of Support: Nil. Conflict of Interest: No.