Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal

Trop Med Int Health. 2014 Dec;19(12):1457-65. doi: 10.1111/tmi.12390. Epub 2014 Sep 24.


Objectives: In Nepal, where difficult geography and an under-resourced health system contribute to poor health care access, the government has increased the number of trained skilled birth attendants (SBAs) and posted them in newly constructed birthing centres attached to peripheral health facilities that are available to women 24 h a day. This study describes their views on their enabling environment.

Methods: Qualitative methods included semi-structured interviews with 22 SBAs within Palpa district, a hill district in the Western Region of Nepal; a focus group discussion with ten SBA trainees, and in-depth interviews with five key informants.

Results: Participants identified the essential components of an enabling environment as: relevant training; ongoing professional support; adequate infrastructure, equipment and drugs; and timely referral pathways. All SBAs who practised alone felt unable to manage obstetric complications because quality management of life-threatening complications requires the attention of more than one SBA.

Conclusions: Maternal health guidelines should account for the provision of an enabling environment in addition to the deployment of SBAs. In Nepal, referral systems require strengthening, and the policy of posting SBAs alone, in remote clinics, needs to be reconsidered to achieve the goal of reducing maternal deaths through timely management of obstetric complications.

Keywords: Nepal; Népal; accoucheuse qualifiée; agents de la santé; health services; health workers; investigación cualitativa; maternal health; partera capacitada; qualitative research; recherche qualitative; salud materna; santé maternelle; services de santé; servicios sanitarios; skilled birth attendant; trabajadores sanitarios.

MeSH terms

  • Adult
  • Attitude of Health Personnel*
  • Birthing Centers / standards*
  • Delivery, Obstetric / standards*
  • Female
  • Focus Groups
  • Health Services Accessibility*
  • Health Services Needs and Demand*
  • Humans
  • Interviews as Topic
  • Maternal Health Services / standards*
  • Maternal Welfare
  • Middle Aged
  • Midwifery*
  • Nepal
  • Obstetric Labor Complications / therapy
  • Pregnancy
  • Qualitative Research
  • Referral and Consultation
  • Young Adult