The postnatal period is the time from delivery of baby till the first 42 days. Risks of maternal and newborn deaths are greatest during the first 24 to 48 hours after birth. Therefore, Providing Postnatal Care (PNC) to recently delivered mothers is quite essential during this period [1]. The most critical period for both mother and newborn baby in terms of their survival is the time around the childbirth and the immediate postpartum period where more than half of the maternal and newborn deaths occur [2,3]. Postnatal care is one of the recommended interventions to reduce the maternal and newborn deaths during postpartum period [4,5]. Women delivering in a health facility should remain for observation for the first-24-hour period, and those who deliver at home need close observation as well, preferably by a Skilled Birth Attendant (SBA) [2]. According to the Ministry of Health and Population, Nepal, a woman should have at least four Antenatal Care (ANC) visits and three PNC visits by heath workers whether delivered at home or at health facility: first PNC visit within 24 hours, second and third PNC visits on the third and seventh day respectively [2,6]. Ministry of Health and Population, Nepal provides maternal and child health (included ANC, delivery and PNC) care from the network of its health system extended up to the community level. District Hospitals, primary health care centers, health/sub-health posts are the key service providing institutions at district and peripheral level in Nepalese health care system.

In developing countries like Nepal and India, PNC is often neglected as compared to other components of maternal health care [7]. Promoting ANC and SBA at birth is not enough for improving maternal and child health. Promoting universal access to recommended PNC services has significant potentials in contributing to sustained reduction in maternal and neonatal mortality [8].

Nepal has Maternal Mortality Ratio (MMR) of 281/100,000 livebirths [9]; this is a very high figure as compared to developed countries. On average, the MMR in developing countries is 240 per 100,000 live-births; whereas, it is far less, (16/100,000 live births) in developed countries [10].

Nepal Maternal Mortality and Morbidity Study 2009 explained that there was a very clear evidence of the low priority placed on PNC, both by women and service providers; the health care was sought only if complication arises [11]. Lack of awareness among women and communities, no provision of information by providers and lack of services were the main reasons for not seeking postnatal care [11]. The same study revealed that 61% of deaths occurred in the ante-partum and postpartum (48 hours to 42 days) periods, suggesting that current policies and interventions need refocusing to address these periods adequately.

As there is poor utilization of PNC services by mothers in Nepal [9,11,12], updated knowledge on the social and health related determinants is essential for program managers and researchers to suggest, design, justify and evaluate the programs to increase utilization of PNC service. Very limited has been explored about the determinants of utilization of postnatal services in Nepal [13]. Therefore, this study aimed to (i) report proportion of utilization of any postnatal visits, early postantal visits and PNC service from health workers and (ii) examine factors associated with these PNC service.

Study design and sampling

A cross sectional study was conducted in Dumara Village Development Committee (VDC) of Kapilvastu district among women with children aged 6 weeks to 23 months. Dumara VDC is located at 6 Kilometer in the east from Kapilvastu district headquarters. Kapilvastu district is located at 313 Kilometers in the west from capital city of Nepal. In Nepal, a district is the key local government unit and VDCs are the lowest administrative structures. According to topographyy, Kapilvastu is a remote Terai (flat and low lying geographic areas of Nepal) district in western region of Nepal having the majority of Terai caste groups. Moreover, the study place, Dumara VDC, is located just at 6 Kilometer-distance from the district head-quarter; the situation of this VDC could be generalized as the ‘at least’ scenario for many other far-off VDCs from the district headquarter.

Data were collected between January and February 2012. The study VDC had the total population of 6246 and total under-2-year’s population of 278 according to the district health office annual report 2011. From the immunization record and with the help of FCHVs, we made a list with a total of 233 mothers having children aged 6 weeks to 23 months; if there were two or more mothers in a single family, a woman having the youngest child in the age group of 6 weeks to 23 months was interviewed. Finally, we could interview 223 women (that is 96% of the total eligible women) from the VDCs.

Participants and procedures

The mothers of young children aged 6 weeks to 23 months were the participants for this study. Female Community Health Volunteers (FCHVs) and local health facility registers on immunization were used to trace these mothers. As the immunization (DPT: Diptheria, Pertusis, Tetanus, tetravalent vaccine given to a child after 6 weeks after birth) coverage of the VDC was 97% for the year preceding the survey [14,15] we assumed that >97% of households were covered in our study. Women who were not at their home at the time of interview were excluded from the survey if enumerators were not able to meet them in two follow up visits.

Ethical review for the study was approved from institute of Medicine, Maharajgunj Nursing Campus.The research proposal was also approved from District Health Office, Kapilvastu and informed consent was sought from each of the study participants before commencing the interview, during data collection in the field.

Interview questionnaires

Structured interview questionnaires were used as a tool for this study. Questionnaires were adopted from USAID KPC Survey module 2000-Plus and Nepal Demographic Health Survey, 2006. Necessary modifications were made to suit to the local context. The questionnaires were translated into Nepali language, pre-tested in Rupandehi district. After pre-test, modifications were made on layout, coding and language errors. Four auxiliary nurse midwives were mobilized to collect the data from the field after two days of orientation on the tools in District Health Office, Kapilvastu. The questionnaire consisted of information about socio-demographic characteristics of the respondents, utilization of antenatal, intra-natal and postnatal services.

Definition of variable

Three outcome variables were examined in this study: postnatal care (PNC); early PNC and PNC from health workers. PNC refers to any postnatal care service that was provided to mothers within 6 weeks of childbirth. Early PNC care refers to utilization of postnatal care within first 24-hours. We derived this outcome variable because first 24-hours is the critical time for recently delivered mothers. PNC from health workers refers to any postnatal service which were provided by doctors/nurses/auxillary midwives/health assistants/community medical auxillaries/ maternal and child health workers.

The indepedent variables included in the study were sociodemographic characteristics (age, ethnicity, literacy, occupation, number of children), utilization of antenatal services (number of antenatal check up visit, iron intake during pregnancy, danger signs experienced during pregnancy) and intra-natal services (place of delivery, danger signs experienced during delivery) were the independent variable of this study.

We categorized ethnicity according to the ethnic categories as used by Health Management Information System under Department of Health Service: (i) dalit (ii) disadvantaged janjatis (iii) disavantaged non-dalit Terai caste groups (iv) religious minorities (v) relatively advantaged janjatis [16]. The occupation was categorized as: (i) housewife/agriculture workers (ii) service holders (iii) business, (iv) labor worker. The place of delivery was previously categorized as: (i) home (ii) government health facility (iii) private hospital and nursing home; for our further analysis, we further categorized it as (i) health facility delivery and (ii) home delivery. The ANC and PNC provider was first categorized into: (i) doctor (ii) nurse, including auxiliary nursing midwife/ health assistants/ maternal and child health workers (iii) traditional birth attendants (iv) female community health volunteers (FCHVs) (v) Others (self, mother in law, neighbor etc). Later for our further analysis, we categorized it as health workers (doctor/nurse/ nurse/auxiallary nursing midwife/maternal health workers/ health assistants) and others (FCHVs/family memebers) [17,18]. Likewise, the delivery attendant was first categorized as: (i) doctor, (ii) nurse, (iii) traditional birth attendants, (iv) relatives/friends, (v) FCHVs, (vi) none and (vii) others. For our further analysis, we re-categorized it into (i) delivery by health workers and (ii) delivery by others [18,19]. The danger signs during pregnancy included (i) vaginal bleeding (ii) difficulty in breathing (iii) fever (iv) severe abdominal pain (v) severe headache (vi) foul smelling discharge from vagina (vii) Eclampsia (viii) no movement of foetus (ix) cloudy liqued discharge from vagina. The danger signs during delivery included: (i) eclampsia (ii) high fever (iii) severe bleeding per vagina (iv) difficult breathing (v)retained placenta (vi) severe headache (vii) blurring of vision (viii) prolonged labor.

Statistical analysis

The utilization of postnatal care is reported in proportion. Chisquare test was used to examine the association of socio-demographic and health related independent varaibles. The significant variables were further examined by using logistic regression. We performed multilevel regression analysis. In first model, we entered socio-demographic variables which were significant in chi square test. In second model, we added health related variables except for place of delivery, assistance during delivery and danger signs during delivery as these three independent varaibles were likely to have the strongest bearing on utilization of PNC service. In the final model, we included the place of delivery, assistance during delivery and danger signs during delivery if they were significant in chi square test. The summary of these models are provided at the end of respective tables; a p-value<0.05 was considered statistically significant. Statististical Package for Social Sciences (release 19) was used for data analysis.

Characteristics of respondents

The socio-demographic information of mothers (N=223) who had participated in the study is reported in Table 1. The majority (80.9%) were from 20-35 years age group. Slightly less than three quarters were from Hindu religion (71.3%) and were illiterate (74%). More than half (57%) of the mothers were from nuclear family. Slightly more than two quarters (56.5%) were from disadvantaged janjatis followed by (27.4%) disadvantaged non-dalit Terai caste groups. In response to ANC utilization, 70%, (n=156) mothers had attended ANC visit. Only 36.8% completed four ANC visit followed by one quarter (33%) of mothers for 1-3 times visit. Majority of the mothers (73%) had received ANC services from health workers. More than half (64.1%) of the pregnant mothers had taken iron tablet during pregnancy. The majority (88.8%) of the respondents did not experience any danger signs during pregnancy period. Eight out of ten mothers had delivered their youngest child at home. Similar proportion of mothers (81.2%) sought assistance of health workers during their childbirth. Only 8.1% of the mothers experienced some danger signs during delivery.

Table 1: Background variables.

Utilization of postnatal services

Of the 223 participants, 25.1% (n=56) attended any PNC, 13.5% (n=30) attended early PNC and 19.3% (n=43) sought PNC service from health workers.

Factors associated with utilization of postnatal services, early postnatal service and postnatal service from health workers

Factors associated with utilization of Postnatal Care (PNC): The socio-demographic variables were not significant in chi square test therefore these were not included in the regression model, we built two models for examining the association of independent variables with postnatal care (any visit) (Table 2). In model 1: number of ANC visit, iron consumption and danger sign during ANC were entered into the model. In model 2, we further added the place of delivery, delivery assistance and experienc of danger signs during pregnancy. Iron consumption during pregnancy, place of delivery and experience of danger signs during pregnancy were significantly associated with the use of PNC. The mothers who consumed iron during pregnancy [OR 6.548; 95% CI (1.932-22.190)], who delivered in health facility [OR 78.641; 95% CI (23.296-265.476)], and who experienced danger signs during pregnancy [OR 5.499; 95% CI (1.113-27.169)] were more likely to attend PNC services (Table 3).

Table 2: Factors associated with attending PNC, early ANC and ANC with health workers.

Table 3: Determinants of Attending Postnatal care-Adjusted Odds Ratio.

Factors associated with utilization of early PNC services: The independent variables significant in Chi square test and in unadjusted logistic regression, were then entered into multiple logistic regression analysis. Model 1 included education; model 2 included all variable of model 1 and ANC provider, number of ANC visit, iron consumption; and finally model 3 included all variables of model 2; and place of delivery, delivery assistance. In model 3, place of delivery and education had the strongest effect on early utilization of PNC services. For other variables, model 2 is explained to understand the effect of other variable without having the model being confounded by the effect of the place of delivery. In model 2, number of ANC visit, ANC provider and Iron consumption during ANC visit were the significant factors associated with attending early PNC visits. The mothers who attended four or more ANC visits [OR 3.964; 95% CI (1.063-14.780)]; assisted delivey by health workers [OR 10.281; 95% CI (1.297-81.522)]; consumed iron during pregnancy [OR 3.660; 95% CI (1.185-11.300)]; who attended secondary and above education [OR 3.921; 95% CI (0.574-28.129)] were more likely to utilize PNC services earlier than their counterparts. The mothers who delivered at health facility [OR 78.213;95% CI (19.063-320.909)] were more likely to have attended early PNC services (Table 4).

Table 4: Determinants of Early Utilization of PNC Services-Adjusted Odds Ratio.

Factors associated with seeking PNC from Health Workers: In model 1, we included education; model two, variable in model one and number of ANC visit, ANC provider, iron consumption during pregnancy, experience of any danger signs during pregnancy and model three included all variables from model two and experience of any danger signs during delivery. Experience of danger signs during delivery was found to be strongly associated with seeking PNC services from health workers. Mothers who were affected by the danger signs during delivery were 17.427 folds more likely [OR 17.427; 95% (CI 4.099-74.088)] to get PNC utilization from health workers. The mothers who had completed secondary or higher education [OR 6.106; 95% CI (1.457-25.587)]; had attended four or more ANC services [OR 3.694; 95% CI (1.139-11.978)] or 1-3 ANC visits [OR 2.824; 95% CI (0.840- 9.498)]; who had assisted ANC services by health workers [OR 8.539; 95% CI (1.677-43.482)]; who had taken iron supplementation during pregnancy [OR 5.398; 95% CI (1.475-19.459)] were more likely than their counterparts to be provided PNC by health workers (Table 5).

Table 5: Determinants of Seeking PNC from Health Workers.

In order to detect and save the life of mother and newborn from life threatening complications like primary and secondary postpartum hemorrhage, severe - preeclampsia, infection, injuries, hypothermia; and to ensure the healthy outcome for both mother and baby, PNC is one of the very essential components of maternal and newborn care [2,8,13,20-22]. Also, the mental and social problem can emerge during postpartum period which can further complicate the health of mother as well as newborn [23]. Of all the components of maternal and child care, PNC and early newborn care are neglected interventions; women in Nepal and India access maternal health services more consistently during pregnancy than during delivery or after childbirth [2,7].

The proportion of women utilizing PNC services is low in comparison with those utilizing ANC and delivery services in Nepal; Nepal Demographic and Health Survey 2011 indentified 58% ANC, 35% health facility delivery and 45% PNC [24]. Several studies have described the factors affecting low health facility delivery [18,19,25,26]. However, factors associated with the low use of PNC has not been reported frequently. Therefore, this study aimed to identify the determinants of PNC among the Nepalese mothers who had children aged 6 weeks to 23 months. This study found that a quarter of mothers attended PNC service and 13.5% attended early PNC services. This finding is very low given that Nepal has put much efforts in increased utilization of maternal health services since its committement to Millennium Development Goals. Despite the fact that overall national average on utilization of antenatal services has increased significantly over the past decade, achievement in rural community has remained still low as pointed by our study [24]. Use of PNC services has remained a challenge as the majority of deliveries occured at home. In this context, when mothers do not reach health facilities for their child birth, the chance in availing services for PNC is lower. In Nepalese societies, there is a culture of segregration of mother and the newborn for around 12 days after deliveries [14]. During this period, mother and newborn are not allowed to be touched by other people; and they are not allowed to go outside home, are often kept in isolated area inside the house. As they are restricted to home during these periods, the utilization of PNC service remains a major challenge, thus reducing chances of contacts with health service providers. On the other hand, there is no government mechanism in Nepal which supports home visits of health workers for PNC. In the rural communities, the families can not afford private sector health workers to avail PNC.

Overall, this study found that educated mothers, mothers who already experienced problems during delivery, mothers who delivered in health facility, who had assisted delivery by health workers, and those mothers who received ANC services including iron intake were more likely to seek PNC services.

Education is a significant determinant of maternal and child health. Education is likely to empower an individual to gain access to health promotion message, information to obtain services and importance of available services. Likewise, educated individuals are likely to be able to process the health message. Education of mothers has been found significantly associated with increased uptake of maternal services in few other studies as well [19,26].

Utilization of ANC service and iron supplementation consumption has been found to positively influence PNC service utilization [12,27,28]. Iron supplementation for pregnant women is a part of ANC services in Nepal. A woman recieves iron/folate tablets free of cost when she receives ANC services. Attending ANC provides a pregnant women to obtain neccessary health information on possible preparation for childbirth, and also neccessity of further service utilization. A woman receives counseling along with ANC examinations. Part of the counseling also includes delivering at health faciltiy and utilization of PNC services. As a result, a pregnant woman may perceive that PNC service is important and is available in her place.

Health facility delivery and assistance of delivery by health workers are two factors which we expect that increase PNC service utilization; this has been found so by some other studies too [27,29-31]. When a woman delivers at health facility, it is ensured that health workers are available. As part of the maternity care at birthing centres and/or health centres, health workers assess the mother’s situation within few hours of childbirth. Therefore, the current finding is in line with the guidelines of maternal health services.

Danger sings during pregnancy is likely to increase the perceived susceptibilility and perceived severity. According to Health Belief Model, people are likely to be ready to take action when they perceive themselves at risk of some ill health [17,32]. In this study, the mothers who had experienced some danger signs were more likely to perceive themselves at the risk of maternal morbidity and mortality which in turn might have resulted in increased utilization of postnatal service.

Based on the current findings, some of the public health programs can be recommended. It highlights the need of girl’s education as utmost priority. Educating girls is not within the scope of public health sectors, however, health workers can educate mothers through counseling, mother’s group meeting, and mobilisation of FCHVs so that mothers are aware of the benefits and neccessity of PNC. There is a need to initiate home visit service by health workers (such as maternal health workers) so that the mothers are reached within the period when they are confined within home. As maternity incentive scheme in Nepal has been successful in increasing institutional delivery, intervention study may be useful to examine the effect of smilar initiative to increase the uptake of PNC services. Also, further re-enforcing the uptake of ANC and institutional delivery together with adequate counselling is essential to increase the uptake of PNC service.

This study has picked up a critical, yet neglected component of maternity care. We believe this has been brought out in a right time when the national as well as district health system should prioritize the re-enforcement of PNC including other quality care and facility site strengthening in maternal and newborn health.There are a number of limitations in our study. Though we included all the eligible mothers for our study, it was confined in only one VDC. Therefore, the current findings may not be entirely generalizable for whole district. However, we believe, our study has given insight to some of the major areas to be focused to increase the uptake of postnatal care. Qualitative studies involving mothers, mother in laws, husbands and health care providers could be of great insight to understand further about the socio-cultural domain including service site barriers affecting PNC service utilization in Nepal.

This study revealed that the uptake of post natal care service was very low. Educated mothers, mothers who attended ANC, who delivered at health facility and who had delivery assistance from health workers were more likely to utilise PNC services. Despite having maternity incentive scheme in place and a major focus on maternal health in Nepal, the current low upatake of PNC services suggest that the postpartum mothers are still at high risk of dying if any problem occurs duirng the postpartum period. Opportunity to educate mothers in nutrition, immunization, and family planning are also likely to be missed which are crucial for maternal and child health survival. Home visits of health workers could be effective approach to increase the uptake of PNC service. Initating incentive schemes for health workers or the mothers could be future direction for PNC focused intervetion studies in maternal health in Nepal.

The authors would like to thank all the participants of the study for their time and information and District Health Office, Kapilvastu for their cordial support during the study period.