Significant disparities in reproductive, maternal, newborn, and child health (RMNCH) outcomes and intervention coverage exist between the Mountains and other ecoregions of Nepal. Delivery of essential health services to remote mountainous areas is challenging and access is a known barrier to utilization. However, the contribution of demand-side barriers is poorly understood. Consequently, policies and programs cannot strategically target constraints to increase coverage. This systematic review identifies demand-side barriers to utilization of RMNCH services in the Mountain districts of Nepal. Research was drawn from MEDLINE, Web of Science, Scopus, Google Scholar, Eldis, and unpublished literature. Beyond inaccessibility, utilization is undermined by costs of care-seeking, traditional attitudes and practices, low status of women, limited health knowledge, dissatisfaction with service quality, and low and inequitable care by community health workers. The intensity and repercussions of these barriers are of greater magnitude in the Mountains where delayed care-seeking combines with long distances for critical health consequences.
NguyenKMorganAJimenez-SotoEMorganC. Developing an Investment Case for Financing Equitable Progress Towards MDGs 4 and 5 in the Asia Pacific Region: Equity Report for Nepal. Brisbane, Australia: School of Population Health, The University of Queensland; 2011.
2.
NguyenKHMorganAMorganCJimenez-SotoEHodgeA. How does progress towards the MDG 4 affect inequalities between different sub-populations? Evidence from Nepal. J Epidemiol Community Health. 2013;67:311-319.
3.
United Nations Nepal Information Platform. Ecological zone map of Nepal. http://un.org.np/node/10018. Accessed January 2012.
4.
Ministry of Health and Population Nepal, New ERA, Macro International Inc. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population Nepal; 2012.
5.
Department of Health Services Nepal. Department of Health Services Annual Report 2067/68 (2010/11). Kathmandu, Nepal: Government of Nepal, Ministry of Health and Population, Department of Health Services; 2011.
6.
Ministry of Health and Population Nepal. Nepal Health Sector Programme—Implementation Plan 2—2010-2015. Kathmandu, Nepal: Government of Nepal; 2010.
7.
BaralYLyonesKSkinnerJvan TeijlingenE. Maternal health services utilisation in Nepal: progress in the new millennium?Health Sci J. 2012;6:618-633.
8.
BhusalCLSinghSPBcRK. Effectiveness and efficiency of Aama Surakshya Karyakram in terms of barriers in accessing maternal health services in Nepal. J Nepal Health Res Counc. 2011;9:129-137.
9.
BorghiJEnsorTNeupaneBDTiwariS. Financial implications of skilled attendance at delivery in Nepal. Trop Med Int Health. 2006;11:228-237.
10.
NewERA. Survey on Coverage and Compliance of Chlorhexidine (Kawach) Use and Other Components of Community-Based Program in Banke, Jumla and Bajhang Districts. Kathmandu, Nepal: NewERA, Nepal Family Health Program II; 2011.
11.
ThomasDMesserschmidtLMersserschmidtDDevkotaB. Increasing Access to Essential Obstetric Care: A Review of Progress and Process. Kathmandu, Nepal: DFID, Options, Family Health Division of Nepal Ministry of Health; 2004.
PetersDGargABloomGWalkerDBriegerWRahmanM. Poverty and access to health care in developing countries. Ann N Y Acad Sci. 2008;1136:161-171.
14.
PenchanskyRThomasJ. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19:127-140.
15.
O’DonnellO. Access to health care in developing countries: breaking down demand side barriers. Cad Saúde Pública. 2007;23:2820-2834.
16.
JacobsBIrPBigdeliMAnnearPVan DammeW. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan. 2012;27:288-300.
17.
GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490-1494.
18.
MorrisonJJacobyCGhimireSOyloeP. What affects clean delivery kit utilization at birth in Nepal? A qualitative study [published online September 14, 2012]. Asia Pac J Public Health. doi:10.1177/1010539512458950.
19.
Nepal Public Health Foundation. Overcoming Barriers to Scaling Skilled Birth Attendants Utilization in Improving Maternal, Newborn and Child Health in Nepal. Kathmandu, Nepal: Nepal Public Health Foundation; 2012.
20.
NewERA. Barriers and Enabling Factors Influencing the Use of a Skilled Birth Attendant Among Marginalized Populations in the Mid-Western Region of Nepal. Kathmandu, Nepal: NewERA, Nepal Family Health Program II; 2007.
21.
NewERA. Survey on Coverage and Compliance of Chlorhexidine in Banke, Jumla and Bajhang Districts. Kathmandu, Nepal: NewERA, Nepal Family Health Program II; 2011.
22.
Powell-JacksonT. The experiences of districts in implementing a national incentive programme to promote safe delivery in Nepal. BMC Health Serv Res. 2009;9(1):97.
23.
MorganAPrasaiYJimenez-SotoEDettrickZFirthS. Nepal: Developing an Investment Case for Financing Equitable Progress Towards MDGs 4 and 5 in the Asia Pacific Region (Scale-up report). Brisbane, Australia: Nossal Institute for Global Health, University of Queensland, NewERA, UNICEF Nepal; 2011.
24.
BhattaraiBGhimireABaralBKShresthaADhunganaY. Anaesthesia and perioperative care in remote health camps: patients’ concerns. JNMA J Nepal Med Assoc. 2010;49:195-198.
25.
BhurtyalAPoudyalAKMaskeyMKAdhikariDSharmaDRBhurtyalK. Changes in utilisation of health services after removal of user fees: observations in rural Nepal. J Epidemiol Community Health. 2011;65:A177.
26.
ChhetryDBUpretiSRDangalGSubediPKKhanalMN. Impact evaluation of uterine prolapse surgery in Nepalese women. J Nepal Health Res Counc. 2012;10:167-171.
27.
DavisW. Voices From the Mountain: Oral Testimonies From Nepal. London, England: Panos Institute; 2003.
28.
FurutaMSalwayS. Women’s position within the household as a determinant of maternal health care use in Nepal. Int Fam Plan Perspect. 2006;32:17-27.
29.
HeydonS. Mountains and medicines: history and medicines use in rural Nepal. South Med Rev. 2011;4(1):4-8.
30.
ManandharM. Ethnographic Perspectives on Obstetric Health Issues in Nepal: A Literature Review. Kathmandu, Nepal: DFID; 2000.
31.
PandeySLamaGLeeH. Effect of women’s empowerment on their utilization of health services: a case of Nepal. Int Social Work. 2012;55:554-573.
32.
PokhrelSSnowRDongHHidayatBFlessaSSauerbornR. Gender role and child health care utilization in Nepal. Health Policy. 2005;74:100-109.
33.
SharmaKR. Malnutrition in children aged 6-59 months in Mugu district. J Nepal Health Res Counc. 2012;10:156-159.
34.
ThapaS. Challenges to improving maternal health in rural Nepal. Lancet. 1996;347:1244-1246.
35.
ThapaNChongsuvivatwongVGeaterAFUlsteinM. High-risk childbirth practices in remote Nepal and their determinants. Women Health. 2000;31(4):83-97.
36.
WitterSKhadkaSNathHTiwariS. The national free delivery policy in Nepal: early evidence of its effects on health facilities. Health Policy Plan. 2011;26(suppl 2):ii84-ii91.
37.
Powell-JacksonTNeupaneBDTiwaiSMorrisonJ. Evaluation of the Safe Delivery Incentive Programme—Final Report of the Evaluation. Kathmandu, Nepal: SSMP Nepal; 2008.
38.
BarzgarMASheikhMRBileMK. Female health workers boost primary care. World Health Forum. 1997;18:202-210.
39.
HuberDSaeediNSamadiAK. Achieving success with family planning in rural Afghanistan. Bull World Health Organ. 2010;88:227-231.
40.
PrataNGessessewACartwrightAFraserA. Provision of injectable contraceptives in Ethiopia through community-based reproductive health agents. Bull World Health Organ. 2011;89:556-564.
41.
DickersonTCrookstonBSimonsenSEShengXSamenANkoyF. Pregnancy and Village Outreach Tibet: a descriptive report of a community- and home-based maternal-newborn outreach program in rural Tibet. J Perinat Neonatal Nurs. 2010;24:113-127.
42.
NatoliLRenzahoAMNRinaudoT. Reducing harmful traditional practices in Adjibar, Ethiopia: lessons learned from the Adjibar Safe Motherhood Project. Contemp Nurse. 2008;29:110-119.
43.
ErulkarASMuthengiE. Evaluation of Berhane Hewan: a program to delay child marriage in rural Ethiopia. Int Perspect Sex Reprod Health. 2009;35:6-14.
44.
O’RourkeKHoward-GrabmanLSeoaneG. Impact of community organization of women on perinatal outcomes in rural Bolivia. Rev Panam Salud Publica. 1998;3:9-14.
45.
PerreiraKMBaileyPEde BocalettiEHurtadoERecinosdeVillagranSMatuteJ. Increasing awareness of danger signs in pregnancy through community- and clinic-based education in Guatemala. Matern Child Health J. 2002;6:19-28.
46.
KwastBE. Building a community-based maternity program. Int J Gynecol Obstet. 1995;48(suppl.):S67-S82.
47.
de HaanO. From patient to client. Patient Educ Couns. 2010;81:442-447.
