Factors influencing inequitable access to maternal health services in Morang district, Nepal

Main Article Content

Rakchya Amatya
Mathuros Tipayamongkholgul
Nawarat Suwannapong
Siriwan Tangjitgamol


This study aimed to compare accessibility to maternal health services between rural and urban areas, and identify socio-economic factors related to four facets of accessibility in Morang District, Nepal. A comparative cross-sectional study was conducted in Rangeli (urban) and Kanepokhari (rural) areas of Morang among 600 women aged 15 to 49 years with at least one child aged under 2 years using a semi-structured questionnaire. Four facets of accessibility to maternal health services, i.e., geographical, financial, cultural and functional accessibility were measured using WHO’s primary health care framework.  Frequency and percentage were used to describe domains of accessibility and multiple logistic regression analysis was used to identify related factors.  A p-value less than 0.05 was considered statistically significant. Among the four facets of accessibility, financial accessibility was 50% less among rural women than that of urban women (p<0.001). Poor women revealed less accessibility to all facets up to 6 times compared with others. Similarly, low autonomous women who were homemakers had less accessibility to all facets up to 5 times compared with others. Essential maternal health services should be available at all times with a particular focus on regions with poor socio-economic conditions. Further, essential health information and key messages should be evenly disseminated to improve equitable access to maternal health services.

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Amatya R, Tipayamongkholgul M, Suwannapong N, Tangjitgamol S. Factors influencing inequitable access to maternal health services in Morang district, Nepal. J Public Hlth Dev [Internet]. 2021 May 16 [cited 2024 Apr. 24];19(2):1-13. Available from: https://he01.tci-thaijo.org/index.php/AIHD-MU/article/view/245072
Original Articles


World Health Organization. WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization [Internet]. 2013. Available from: https://www. who.int/maternal_child_adolescent/documents/postnatal-care-recommendations/en/

World Health Organization. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization [Internet]. 2019. Available from: https://www. who.int/reproductivehealth/publications/maternal-mortality-2000-2017/en/

Hart RH, Belsey MA, Tarimo E, World Health Organization. Integrating maternal and child health services with primary health care : practical considerations / R. H. Hart, M. A. Belsey, E. Tarimo. Geneva: World Health Organization [Internet]. 1990. Available from: https://apps.who.int/ iris/handle/10665/39618

Tsawe M, Susuman AS. Determinants of access to and use of maternal health care services in the Eastern Cape, South Africa: a quantitative and qualitative investigation. BMC Res Notes. 2014;7(1):723. doi: 10.1186/1756-0500-7-723

Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Ann N Y Acad Sci. 2008; 1136:161-71. doi:10.1196/annals.1425. 011

Baral YR, Lyons K, Skinner J, van Teijlingen ER. Maternal health services utilisation in Nepal: progress in the new millennium? Health Sci J. 2012;6(4): 618-33. Available from: https://www. hsj.gr/medicine/maternal-health-services-utilisation-in-nepal-progress-in-the-new-millennium.php?aid=3154

Ministry of Health and Population. Nepal Demographic and Health Survey 2016. Kathmandu, Nepal: Ministry of Health and Population, Government of Nepal [Internet]. 2017. Available from: https://www.mohp.gov.np/eng/publications/nepal-demographic-health-survey

Ashworth HC, Roux TL, Buggy CJ. Healthcare accessibility in the rural plains (terai) of Nepal: physical factors and associated attitudes of the local population. Int. Health. 2019;11(6): 528-35. doi: 10.1093/inthealth/ihz008

Government of Nepal. Nepal Living Standards Survey 2010/11. Kathmandu, Nepal: Central Bureau of Statistics, National Planning Commission [Internet]. 2011. Available from: https://cbs.gov.np/nepal-living-standard-survey-2010-11/

World Health Organization. Report of the International Conference on Primary Health Care, Alma Ata, 6-12 September. Geneva, Switzerland 1978. Available from: https://apps.who.int/ iris/handle/10665/39228

Ministry of Health and Population. Inequalities in maternal health service utilisation in Nepal: An analysis of routine and survey data. Kathmandu, Nepal: Ministry of Health and Population, Government of Nepal 2018.

Mehata S, Paudel YR, Dariang M, Aryal KK, Lal BK, Khanal MN, et al. Trends and Inequalities in Use of Maternal Health Care Services in Nepal: Strategy in the Search for Improvements. Biomed Res Int. 2017;2017:5079234. doi: 10.1155/ 2017/5079234.

Ministry of Health and Population. Nepal Health Sector Strategy 2015-2020. Kathmandu, Nepal: Government of Nepal, Ministry of Health and Population 2015.

Nepal Law Commission. Local Government Operation Act. Kathmandu, Nepal: Nepal Law Commission 2017. (In Nepali)

Lemeshow S, Hosmer DW, Klar J, Lwanga SK, World Health Organization. Adequacy of sample size in health studies. Chichester: John Wiley & Sons [Internet]. 1990. Available from: https://apps.who.int/ iris/handle/10665/41607

District Public Health Office. District Health Report of Morang. Morang, Nepal: District Public Health Office, Department of Health Services, Ministry of Health and Population, Government of Nepal 2017/2018. (In Nepali)

Ministry of Health and Population. National Health Policy 2071. Kathmandu, Nepal: Ministry of Health and Population, Government of Nepal 2014.

Department of Health Services. Annual Report. Kathmandu, Nepal: Department of Health Services, Ministry of Health and Population, Government of Nepal 2017/2018 [Internet]. Available from: https:// dohs.gov.np/annual-report-2074-75/

Lama TP, Munos MK, Katz J, Khatry SK, LeClerq SC, Mullany LC. Assessment of facility and health worker readiness to provide quality antenatal, intrapartum and postpartum care in rural Southern Nepal. BMC Health Serv Res. 2020;20(1):16. doi: 10.1186/s12913-019-4871-x

Paudel SB, Upreti BR, Acharya G, Tandukar A, Harvey P. Health services and users’ perceptions of the state in Rolpa, Nepal. London, UK: Secure Livelihoods Research Consortium, Overseas Development Institute [Internet]. 2015. Available from: https://www.gov.uk/dfid-research-outputs/health-services-and-users-perceptions-of-the-state-in-rolpa-nepal-slrc-working-paper-36

Paudel R, Upadhyaya T, Pahari DP. People's perspective on access to health care services in a rural district of Nepal. J Nepal Med Assoc [Internet]. 2012;52(185):20-4. Available from: https://pubmed.ncbi.nlm.nih.gov/23279768/

Upreti B, Sharma S, Kc S, Richard M, Anita G, Babajanian B, et al. Livelihoods, basic services and social protection in Nepal. London, UK: Secure Livelihoods Research Consortium, Overseas Development Institute [Internet]. 2012. Available from: https://www.odi.org/ publications/6758-livelihoods-basic-services-and-social-protection-nepal

McCarthy DM, Waite KR, Curtis LM, Engel KG, Baker DW, Wolf MS. What did the doctor say? Health literacy and recall of medical instructions. Med Care. 2012;50(4):277-82. doi: 10.1097/MLR.0b013e318241e8e1

Okonofua FE, Ogu RN, Ntoimo LF, Gana M, Okike ON, Durodola A, et al. Where do delays occur when women receive antenatal care? A client flow multi-site study in four health facilities in Nigeria. Ghana Med J. 2018;52(1):8-14. doi: 10.4314/gmj.v52i1.3

Mehata S, Paudel YR, Dariang M, Aryal KK, Paudel S, Mehta R, et al. Factors determining satisfaction among facility-based maternity clients in Nepal. BMC Pregnancy Childbirth. 2017;17(1):319. doi: 10.1186/s12884-017-1532-0

Ghimire A, Samuels F. Understanding Intimate Partner Violence in Nepal: Prevalence, Drivers and Challenges. Overseas Development Institute [Internet]. 2017. Available from: http:// niser.com.np/site/publications/understanding_intimate_partner_violence_

Lamichhane P, Puri M, Tamang J, Dulal B. Women's Status and Violence against Young Married Women in Rural Nepal. BMC Womens Health. 2011;11(1):19. doi: 10.1186/1472-6874-11-19

Gautam S, Jeong H-S. The Role of women's autonomy and experience of intimate partner violence as a predictor of maternal healthcare service utilization in Nepal. Int J Environ Res Public Health 2019;16(5):895. doi: 10.3390/ijerph16050895

Agunwa CC, Obi IE, Ndu AC, Omotowo IB, Idoko CA, Umeobieri AK, et al. Determinants of patterns of maternal and child health service utilization in a rural community in south eastern Nigeria. BMC Health Serv Res. 2017;17(1):715. doi: 10.1186/s12913-017-2653-x

Gebrehiwot G, Medhanyie AA, Gidey G, Abrha K. Postnatal care utilization among urban women in northern Ethiopia: cross-sectional survey. BMC Womens Health. 2018;18(1):78. doi: 10.1186/s12905-018-0557-5

Tarekegn SM, Lieberman LS, Giedraitis V. Determinants of maternal health service utilization in Ethiopia: analysis of the 2011 Ethiopian Demographic and Health Survey. BMC Pregnancy Childbirth. 2014;14(1):161. doi: 10.1186/1471-2393-14-161

Adhikari R. Effect of Women’s autonomy on maternal health service utilization in Nepal: a cross sectional study. BMC Womens Health. 2016; 16(1):26. doi: 10.1186/s12905-016-0305-7

Chalise B, Chalise M, Bista B, Pandey AR, Thapa S. Correlates of continuum of maternal health services among Nepalese women: Evidence from Nepal Multiple Indicator Cluster Survey. PLoS One 2019;14(4):e0215613. doi: 10.1371/journal.pone.0215613

Khanal V, Adhikari M, Karkee R, Gavidia T. Factors associated with the utilisation of postnatal care services among the mothers of Nepal: analysis of Nepal Demographic and Health Survey 2011. BMC Womens Health. 2014;14(1):19. doi: 10.1186/1472-6874-14-19

Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. doi: 10.1186/ 1475-9276-10-59

Mpembeni RNM, Kakoko DCV, Aasen HS, Helland I. Realizing women´s right to maternal health: A study of awareness of rights and utilization of maternal health services among reproductive age women in two rural districts in Tanzania. PLoS One. 2019;14(5):e0216027. doi: 10.1371/ journal.pone.0216027