Background: Institutional delivery is associated with reduced maternal mortality rates and is a key goal in Nepal. There is wide variation in the utilisation of institutional delivery, and a range of factors affect the decision on where to give birth. This study aims to explore facilitators and barriers to utilisation of institutional delivery in two geographically diverse districts in the federal context of Nepal. Methodology: In-depth individual interviews were conducted with 74 purposively selected participants in both districts, which included mothers who delivered at home or in birthing centres, their mothers-in-law and husbands, skilled birth attendants and policymakers/influencers at Local, Provincial and Federal levels. Also, 10 Focus Group Discussions were conducted with female community health volunteers and health facility operations management Committee members. Data analysis was done using “Levesque’s conceptual framework on healthcare access” using framework analysis. Results: Key facilitators in both districts include trust; supportive mothers-in-law; availability of ambulances and 24-hour delivery services; and perceived quality of services. In the Hill district, major facilitators demonstrated the successful implementation of decentralised leadership for local needs-based planning, including free ambulance and health insurance for the very poor, free delivery, and additional cash and transport incentives. New knowledge identified very supportive mothers-in-law, and a willingness of mothers to walk for institutional delivery despite remoteness and geographical terrain in the Hill district. However, barriers that contributed to underutilisation of institutional delivery in the Terai district include socio-cultural and religious and health system-related barriers such as a lack of mothers’ autonomy, fear of caesarean section and obstetric violence, and no free delivery. Whereas barriers in the Hill district include short labour pain, extreme remoteness that requires a half-day walk and a lack of young people to carry stretchers contributing to home delivery. Conclusions: Increasing utilisation of institutional delivery likely requires multiple strategies which differ across districts. This includes empowering women addressing context-specific socio-cultural and religious barriers and strengthening health system with provision of free quality and respectful care. Similarly, good governance, coordination and monitoring need to be strengthened.
| Date of Award | 27 Feb 2026 |
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| Original language | English |
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| Supervisor | Padam Simkhada (Main Supervisor) & Jackie Malone (Co-Supervisor) |
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