Evaluation of a health promotion intervention associated with birthing centres in rural Nepal.

INTRODUCTION: Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings.
METHODS: This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys.
RESULTS: The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014).
CONCLUSION: BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility.

Introduction

Proven interventions such as skilled birth attendance provided through a continuum of care that links households and communities with health systems, could prevent thousands of maternal and neonatal deaths in the world [1]. Skilled birth attendance requires the presence of a skilled attendant along with enabling environment including adequate supplies, equipment and infrastructure plus an efficient and effective communication and referral system [2]. Skilled birth attendants (SBAs) are competent maternal and newborn health professionals who are educated, trained and regulated to national and international standards [3]. The proportion of births attended by skilled health personnel are part of indicator 3.1.2 of the Sustainable Development Goals (SDGs) [4]. Measuring and monitoring of SBA remains a challenge because of the wide variety of definitions used. One study found uncertainty and diversity of reported qualifications and competency of SBAs between low- and middle- income countries and a need for improved coverage measurement and monitoring of SBAs [5]. Although there are many deaths caused by complications of pregnancy [6], evidence shows that the majority of women in low income countries, including Nepal, still give birth at home or in community settings without SBAs and in the absence of facility-based services [1, 7, 8]. In Nepal, one woman dies every eight hours due to complications in childbirth and 38 newborns die every day largely from preventable causes [9].

Nepal has seen a significant drop in its maternal mortality ratio as a result of an increase in the number of facility births and women being assisted by a SBA [10], however the remote and rural nature of the country means that many women still give birth at home without trained support. The solution may be the promotion of birthing centres (BCs) located closer to where women live.

Birthing Centres are a component of health system at local level designed to provide care for women experiencing a natural vaginal birth without complications. BCs provide a midwifery-led model of care where SBAs provide maternity services in a community or hospital setting normally to healthy women with uncomplicated or low risk pregnancies [11]. In Nepal, essential obstetric care (EOC) services are available at three levels of care: i) basic obstetric care available at Health Posts (HPs) including stabilising patients with obstetric first aid, making an appropriate referral and arranging transport; ii) basic emergency, obstetric and neonatal care (BEmONC) available at Primary Health Care Centres (PHCCs) to prevent and treat haemorrhage, treat puerperal sepsis, eclampsia, infection and manage prolonged labour; and iii) comprehensive emergency obstetrics and neonatal care (CEmONC) available at hospitals (central, provincial and district) to manage all the above plus caesarean section, anesthesia and blood transfusion [12]. In Nepal, a BC is usually established in rural areas at HPs and PHCCs and the number of BCs reported in the year prior to this study (2015/16) was 1,755 [13]. With a cadre of adequately trained SBAs in BCs it has been possible to provide basic essential obstetric care services in an effective way [14].

In most BCs, Auxiliary Nurse Midwives (ANMs) provide much of the primary care maternity services in Nepal. ANMs have 18 months of pre-service training in nursing and midwifery after ten years of schooling. They are trained to assist normal births, identify complications (and refer women to more specialist care) and offer health promotion. They are mostly deployed in BCs in rural Nepal where there is a lack of proper health facilities [15] but some are also deployed in urban hospitals.

BCs in Nepal are often bypassed in the hope of getting better quality services offered by hospitals [16, 17]. In this context, the role of BCs in providing good quality maternity services has often been overlooked in the case of Nepal [18]. Since BCs in Nepal are mostly present in rural areas, it is important that it provides quality services in order to increase its utilisation. Community-based health promotion interventions, which mobilise the community through facilitated participatory learning to improve access to, and use of, skilled care during pregnancy, childbirth and after birth, are highly recommended [19, 20]. Previous research in rural Nepal found that women’s groups, based on participatory learning and action, led to improved maternal and newborn survival [21]. Thus, an intervention supporting BCs and providing community-based health promotion messages to community women [18] would appear to be an appropriate mechanism to improve maternity care.

Improving maternal health and outcomes requires a complex intervention. Increasing only the number of SBAs at BCs would not increase the uptake of services available at BCs; other enabling factors such as effective training, appropriate infrastructure, on-going professional development for staff, sufficient supplies and equipment, support from community health workers and effective referral mechanism are equally important [22]. This paper evaluated the effects of an intervention consisting of supporting BCs and community-based health promotion programme on increasing access and utilisation of perinatal care facilities in community settings.

Materials and methods

The study area consisted of four village development committees (VDCs) in Nawalparasi district in southern Nepal that included two BCs where an intervention was conducted. A VDC used to be the smallest administrative unit at local level, but was dissolved in March 2017, just after conducting this survey [23]. The intervention, that was conducted by a local non-governmental organisation (NGO) during 2014–16, involved supporting two BCs and conducting a health promotion programme with local women in four VDCs. These two BCs started functioning in the year 2015 and 2016. The support included refurbishing the health facilities’ infrastructure, providing equipment required for normal delivery, training all the ANMs at these two BCs and appointing two local ANMs as health promoters. An additional fund equivalent to US $50 was also provided monthly to the BCs for purchasing necessary instruments and materials. The health promotion programme consisted of training local health promoters, who then trained Female Health Community Volunteers (FCHVs). Prior to this intervention, no specific health promotion intervention existed apart from the basic health promotion role that all FCHVs have. The health promoters conducted meetings with mothers-in-laws as a strategy for creating demand for utilisation of the BCs [24]. For example, in 2016, there were 157 mothers-in-law meetings and 334 women’s group meetings. The health promoters and FCHVs also met mother groups on a monthly basis and discussed various issues related to women’s health through a curriculum covering content on ANC/PNC, baby feeding, sanitation and hygiene. The classes were informal and participatory and lasted one to two hours [24].

A longitudinal (repeated cross-sectional) study was conducted over a period of five years. The pre-intervention survey was conducted in the year 2012, the intervention was carried out in 2014–2016 by the local NGO and we conducted a post-intervention survey in 2017 as part of this study. The data from pre-intervention survey were received from the NGO which conducted this survey. Being a repeated cross-sectional longitudinal study, the subjects were largely different from each other on each sampling occasion, although the area of study was the same [25]. The effects of the intervention were measured in this study.

Population-based multi-stage sampling (Fig 1) of women of reproductive age and having a child below 24 months of age was undertaken for both pre-intervention and post-intervention survey. Being a household survey, the eligible participants from each household of 29 selected wards of four VDCs who agreed to take part were approached by trained enumerators and a structured validated questionnaire [26] was completed. In order to get a spread on poorer and slightly better off wards as well as those closer to the BCs and those further away, 29 out of 36 wards were included in the study (Fig 1). The questionnaire used for the pre-intervention survey was adapted from the Nepal Demographic and Health Survey, the Water and Sanitation Survey and wider literature. For the post-intervention survey, the questionnaire was modified slightly based on experience of conducting the pre-intervention survey and removing some unnecessary questions related to socio-demographic characteristics.

Fig 1

Population-based multistage sampling.

The pre-intervention survey was conducted by a local NGO. This primary data from pre-intervention survey was made available to the first author who conducted a secondary analysis [27]. Post-intervention data were collected and a trainee, an undergraduate public health student, helped enter the data. All eight female data enumerators had a degree level qualification in a health subject. They received training (two days) from the first author.

A ten percent of sample was cross checked by the first author identifying a small number of discrepancies in data entry and these were corrected by the first author who then used this to supervise the trainee for future data entry. The pre- and post-intervention surveys were compared to identify any changes that might have occurred due to the intervention and also to determine the factors affecting place of birth. The outcome variables of the intervention were birth at BCs (primary outcome), number of ANC, women’s decision making about place of birth and satisfaction with childbirth services (secondary outcome). The primary outcome changed to various places of birth–home, primary care and tertiary care facilities because the descriptive findings of survey (pre-intervention) showed the data related to place of birth consisted of three categories. Descriptive analysis, cross-tabulation (chi-square), and multinomial regression analysis were conducted. To establish the strength of association between variables and where the association lies exactly, cross tabulation of the intervention with other significant variables was conducted. For the multinomial regression analysis both the pre- and post-intervention surveys were combined and the effect of each variable on birthplace was measured.

Ethical approval for this study was granted by University Research Ethics Committee (UREC) at Bournemouth University (Reference 8710) and Nepal Health Research Council (NHRC). In addition, informed consent was taken from the participants, either in written or verbal form. The consent process was clearly described in Nepali and was also explained verbally to all participants by the trained enumerators. Those participants who were able to read and write provided their consent by signing the participant information sheet and those who were not able to read and write provided their consent in verbal form. Verbal consent was witnessed and documented by the trained enumerators. Participants were made aware that taking part in the survey was voluntary and that information they provided would remain anonymous. The data were stored in a password-protected computer.

Results

Among 704 women approached for the post-intervention survey, one did not take part in the survey and four were removed after data cleaning due to insufficient information, leaving a total of 699 (Fig 2).

Fig 2

Data analysis flow chart.

Table 1 presents the socio-demographic characteristics of the pre- and post-intervention study samples. The single largest group of women belonged to the 20–24 age group in both surveys, with slightly younger women represented in the post-intervention survey. The samples were similar for caste, religion and age at marriage for both surveys. The pre-intervention sample had a higher proportion of women who were illiterate (66.3%) compared to the post-intervention sample, where a higher proportion of women had achieved primary level education (54.5%). A higher proportion of women reported their husband’s occupation as a farmer in the pre-intervention sample (60.5%), whereas in the post-intervention sample a higher proportion reported their husband’s occupation as an unskilled labourer or others (46.4%). Looking at this comparative data from pre- and post-intervention survey, it is evident that these two sets of data are comparable but not the same. Some variables have improved from pre- to post-intervention survey such as literacy of women, with more women being educated to primary level education in post-intervention (54.5%) than pre-intervention survey (27.4%). While other variables changed slightly, the percentage of women aged 20–24 changed considerably from 38.8% to 46.8% (Table 1).

Table 1

Socio-demographic characteristics.

Characteristics	Pre-intervention N (%)	Post-intervention N (%)
Age of women during study	420	699
15–19	46 (11.0)	28 (4.0)
20–24	163 (38.8)	327 (46.8)
25–29	148 (35.2)	226 (32.3)
30 and above	63 (15.0)	118 (16.9)
Caste	420	699
Disadvantaged	380 (90.5)	649 (92.8)
Advantaged	40 (9.5)	50 (7.2)
Religion	420	699
Hindu	351 (83.6)	587 (84.0)
Muslim and others	69 (16.4)	112 (16.0)
Education	407	699
Illiterate	270 (66.3)	205 (29.3)
Primary	112 (27.5)	381 (54.5)
Secondary and above	25 (6.1)	113 (16.2)
Husband’s occupation	420	699
Farmer	254 (60.5)	234 (33.4)
Skilled labour and Teacher	101 (24.0)	141 (20.2)
Unskilled labour and Other	65 (15.5)	324 (46.4)
Age at marriage	420	699
Below 15	89 (21.2)	124 (17.7)
15–19	226 (53.8)	374 (53.5)
20 and above	105 (25.0)	201 (28.8)
Total people living in house	420	685
Less than 5	54 (12.9)	172 (25.1)
5–9	217 (51.7)	313 (45.7)
10–14	111 (26.4)	159 (23.2)
15–19	30 (7.1)	32 (4.7)
20 and above	8 (1.9)	9 (1.3)
Total number of children	415	699
Less than 3	364 (87.7)	623 (89.1)
3 and above	51 (12.3)	76 (10.9)

Most of the women in the pre-intervention sample gave birth at home (58.8%), but this proportion decreased in the post-intervention sample (29.3%) (Table 2). Similarly, women who gave birth at BCs increased significantly (from 2.4% to 28.3%). This was reflected in an increased proportion of births with skilled health professionals (increase from 53.7% to 70.5%). Women reported greater involvement in the decision about the birthplace, post-intervention (57.4%) and the number experiencing the optimal number of ANC visits (four and above) increased to 80.3% post-intervention.

Table 2

Health services, obstetric and maternal characteristics of respondents.

Characteristics	Pre-intervention (N, %)	Post-intervention (N, %)
Birthplace	420	699
Home	247 (58.8)	205 (29.3)
Birthing centre	10 (2.4)	198 (28.3)
Primary care facilities	39 (9.3)	88 (12.6)
Tertiary health centre	124 (29.5)	208 (29.8)
Decision maker for birthplace	420	699
Woman	72 (17.1)	102 (14.6)
Husband	177 (42.1)	86 (12.3)
Woman and family members	13 (3.1)	401 (57.4)
Family members/others	158 (37.6)	110 (15.7)
Birth attendant	417	699
Skilled health professionals	224 (53.7)	493 (70.5)
Unskilled people and others	193 (46.3)	206 (29.5)
Received financial assistance for childbirth	413	693
Yes	105 (25.4)	370 (53.4)
Total number of pregnancies (gravida)	418	699
1–3	342 (81.8)	586 (83.8)
4 and above	76 (18.2)	113 (16.2)
Frequency of antenatal check-up	373	699
Less than 4	140 (37.5)	138 (19.7)
4 and above	233 (62.5)	561 (80.3)

Several factors were significantly associated with the change between pre- and post-intervention surveys. These included: woman’s age, woman’s education, husband’s education, iron tablets taken during pregnancy, tetanus toxoid (TT) vaccine received during pregnancy, money received for childbirth, birthplace, decision maker for birthplace, person assisting birth, number of ANC visits and knowledge if abortion is legal. Only these variables were entered in the multinomial regression analysis. The variables women’s education, birthplace, decision maker for birthplace and satisfaction with childbirth services had a strong association with intervention (S1 Table).

Table 3 presents the adjusted multinomial regression analysis results for factors affecting choice of birthplace. Generally, controlling for all other variables, the likelihood of giving birth at a facility (either primary care facilities such as BCs or tertiary care facilities like hospitals) increased post-intervention (Table 3). The likelihood was only statistically significant for the primary care facilities (OR 5.60, p-value <0.001).

Table 3

Adjusted multinomial logistic regression of factors affecting place of delivery.

Variables	Primary care facility vs home		Hospitals/tertiary vs home
	OR (95% CI)	p value	OR (95% CI)	p value
Intervention (Ref Pre)
Post	5.60(3.34,9.38)	<0.001	1.56 (0.98,2.47)	0.060
Decision maker for birthplace (Ref Family members/others)
Women	0.16(0.08,0.29)	<0.001	0.16(0.08,0.30)	<0.001
Husband	3.17 (1.87,5.37)	<0.001	2.80(1.75,4.47)	<0.001
Women & family members	1.76 (1.08,2.85)	0.023	1.78 (1.10,2.88)	0.020
Frequency of ANC visit (Ref 4 and above)
Less than 4 (1–3)	0.39 (0.26,0.60)	<0.001	0.63 (0.43,0.91)	0.014
Age (years) (Ref 30 and above)
15–19	2.72 (1.20,6.17)	0.016	3.02(1.42,6.44)	0.004
20–24	1.64 (1.01,2.68)	0.045	2.28(1.40,3.70)	0.001
25–29	1.27 (0.76,2.10)	0.355	1.25 (0.75,2.10)	0.394
Education (Ref Secondary and above)
Illiterate	0.79(0.43, 1.43)	0.438	0.66 (0.36,1.20)	0.169
Primary	0.49 (0.28,0.87)	0.014	0.58 (0.33,1.03)	0.063
Husband’s occupation (Ref Skilled labourer & teacher)
Farmer	0.86 (0.57,1.27)	0.447	0.77 (0.52,1.15)	0.196
Unskilled labourer/others	0.86 (0.54,1.38)	0.530	1.11 (0.70,1.74)	0.665
Knowledge if abortion is legal (Ref No)
Don’t know	0.61(0.37,0.99)	0.046	0.90 (0.55, 1.49)	0.683
Yes	0.72 (0.42, 1.22)	0.217	0.96 (0.56, 1.64)	0.867
Money received for childbirth (Ref No)
Don’t know	0.92 (0.07, 11.039)	0.947	1.66 (0.16, 17.14)	0.672
Yes	0.46 (0.32, 0.66)	<0.001	0.48 (0.34, 0.68)	<0.001

Women whose husbands or family members were the decision makers had an increased likelihood of having a facility birth. However, women were significantly less likely to give birth at either primary care facilities (OR 0.16, p-value <0.001) or hospitals/tertiary care facilities (OR 0.16, p-value <0.001) if they alone were responsible for deciding on the birthplace.

Respondents who reported a less than optimal number of ANC visits (one to three) compared to the recommended (four and over) had a significantly lower likelihood of giving birth at either primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.021).

Generally, the likelihood of a facility birth decreased with the age of the respondent. The likelihood of health facility birth was significantly higher for age group 15–19 (OR 2.72, p-value 0.016 for primary care facilities and OR 3.02, p-value 0.004 for hospitals/tertiary care facilities), which declined but remained significant for age group 20–24.

Women’s education also affected the birthplace. Women who had only attended primary level education were half as likely to give birth at primary care facilities (OR 0.49, p-value 0.014), compared to those with ‘secondary level education and above’. Although there was a difference in relation to tertiary level care (hospital), this was not statistically significant.

Women were less likely to give birth at health facilities even when they received money for childbirth compared to those who did not receive money. The results were significant for both primary care facilities (OR 0.46, p-value <0.001) and hospitals/tertiary care facilities (OR 0.48, p-value <0.001).

Discussion

Health promotion interventions designed to increase access and utilisation of perinatal care facilities have been recommended by Smith et al. [20]. This paper reports an intervention that increased the births at BCs and decreased home births. The intervention also had an influence on women’s autonomy and the use of perinatal care facilities at BCs. The results indicate that if women were included in the decision making about place of birth, they were more likely to give birth at health facilities. Women’s level of education had an influence on determining where they would give birth and if they would use perinatal care facilities available at health facilities. Having four ANC visits was also reported as important factor in choosing health facilities for childbirth.

Increased birth at birthing centres

This study demonstrates that an intervention promoting BCs has the potential to increase the proportion of women birthing in a health facility and decrease the proportion of home births. The increase in BCs births exceeded the national average of 27% 2016, the latter decreased from 29% in 2015[10].

Skilled care during pregnancy and childbirth can be achieved by safe and clean delivery at birth and care of the newborn at birth [28]. Giving birth at health facilities not only prevents/treats pregnancy related complications but also helps in reducing maternal and neonatal mortality [29, 30]. Thus, in low-income countries such as Nepal, it is preferable to reduce home births in the absence of a SBA and increase institutional births where a SBA will be in attendance. Encouraging BC birth is the best way to secure improved SBA attendance in rural communities. This is also the policy of the Government of Nepal which launched free institutional delivery care in 2009 [31]. In addition, the government’s policy of upgrading BCs and strengthening the competency of health staff may be helpful in increasing institutional delivery rates [32]. This study also shows that an intervention of supporting BCs has effectively decreased the number of home births without a SBA and increased the number of births at these BCs.

Health promotion intervention

The change in birthplace from home to health facilities in this study can be explained as the effect of health promotion programme conducted by local health promotors targeting local women as part of the intervention. The intervention took into account the diverse/changing needs of local communities and the best use of existing resources [33]. Review studies have shown community-based intervention packages reduce morbidity for women, mortality and morbidity for babies and improves care-related outcomes and the health of mothers, neonates and children, particularly in low and middle-income countries [34, 35]. One study also highlighted the value of integrating maternal and newborn care in community settings through a range of interventions which could be effectively delivered through community health workers and health promoters [34]. A review concluded community-based interventions could be an important component of a comprehensive approach to accelerating improvements in maternal health and reducing preventable maternal deaths by 2030 [36].

It is important that health promotional interventions are targeted at women, their husbands and family members, since the results of this study show that a majority of the decisions related to childbirth and maternity care is taken by husbands and family members especially the mother-in-law. In the Nepalese context, women have less control over decisions related to birth processes; for example, in going for ANC visits [37]. Therefore, it is important that midwives work in partnership with mothers and families, especially mothers-in-law, thus facilitating decisions about the care they need [38].

The results also highlighted drastic increase in financial assistance received for childbirth through the ‘Aama programme’ (a kind of financial incentive scheme specifically for women who gives birth at health facilities) [13] pre and post intervention. The rapid increase in percentages here might be attributed to health promoters’ role in promoting the ‘Aama Programme’ during the meetings conducted with women’s group and mothers’ groups. However, more research is required on this as the results of regression analysis demonstrated less likelihood of giving birth in health facilities when women received financial assistance compared to when women did not receive any assistance.

Women’s autonomy

Women autonomy was seen as an important factor that determined the uptake of health facilities (the BCs). Determinants of women’s autonomy, such as making the decision around birthplace, were important factors affecting choice of birthplace. The results of multinomial regression analysis showed that when women solely decided about their birthplace, they were less likely to attend a health facility for childbirth. The reason behind this could be that these women many not have anyone else to depend upon such as their mother-in-law or if their husband is a migrant worker. Another reason could be that they belong to lower socio-economic strata and did not feel they had the resource for a facility birth. The “Aama programme” provides certain amount but would not cover all of the costs. Conversely, when women were included in decision, but were not the sole decision-makers about where to give birth, they were more likely to have a facility birth. Research has shown that although women want to choose their birthplace based on safety and other grounds [39], for many women the decision to give birth at a health facility is not their own but involves their family as well as the community [40]. The women sometimes find that their right to choose their birthplace is compromised because of cultural and traditional practices [41]. A study in rural Nepal also established that the decision for uptake of the institutional birth services was influenced more by family members or family members and women and not by women alone [42]. Similarly, husbands’ control over decision making regarding the birthplace was found in Tanzania [43] and Bangladesh [44].

The results of this study identified the need for involving women in the decision-making process including choosing their place of childbirth. Involving women in the decisions on maternal healthcare, including choosing the birthplace, ensures that women are empowered and can exercise their rights over reproductive healthcare. The findings suggest there is a need for further work focusing on educating mothers about the importance of giving birth at health facilities along with educating husbands and other family members. This should include the importance of involving women in decision making regarding their healthcare and specifically about where to give birth.

Women’s literacy level

The education level of women determined if they utilised the birth services at BCs. A study in Ethiopia found that women’s educational level affected the birthplace, but not that of their husbands [45]; however, this contrasted to the study in rural Nepal where the educational status of women had no effect on deciding the birthplace [42].

Importance of having optimum ANC visits

The results of multinomial regression analysis showed a decreased likelihood of giving birth at primary care facilities and hospitals/tertiary care facilities if the women had less than four ANC visits with reference to ‘four and above ANC visits’. The results thus depict the importance of having four or more ANC visits, which indicates that women are generally more concerned about their babies’ wellbeing in addition to encouraging women to attend health facilities for giving birth. Studies in Nepal have highlighted the importance of education, socio-economic and socio-cultural status on the uptake of ANC. This pointed to the presence of cultural barriers for Terai women to attending the ANC visits [46]. Additionally, decision making power related to ANC visits was less for women in Terai region compared to those living in mountains and hilly regions [47]. The literature suggests that people living in the mountains and inner Terai (Nawalparasi lies in inner Terai) regions are an absolute minority and belong to most marginalised groups [47]. Furthermore, one study found that improving the quality of ANC visits will have a positive and motivating effect on women utilising institutional delivery services [48]. A study in Nepal has shown that FCHVs play a pivotal role in improving antenatal care [49] and this will also be the case in this study specifically due to involvement of health promoters who worked together with FCHVs. Similar to the above-mentioned studies, the population of this study consisted mainly of women belonging to disadvantaged castes in the Terai, with low levels of education and decision-making power. These women are dependent on either their husbands or other family members for decisions related to household and health related matters.

Conclusion

BCs have the potential to increase the proportion of women who have access to a skilled birth attendant. The uptake of BC care is a complex issue, but this study has shown that the role of health promoters is important in rural Nepal.

Association of intervention with other variables.

(DOCX)

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13 Mar 2020

PONE-D-19-33046

A study of birthing centres and maternity users in southern Nepal

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: General Comments:

This article addresses a very pertinent issue in the field of maternal and child health in Nepal—birthing centers. Birthing centers have been developed and heavily promoted over the last decade by the Ministry of Health and Population of Nepal. Some function very well and have high delivery volumes but many are underutilized. The authors show that an intervention aimed at improving the birthing center and promoting it in the community through FCHVs and health promoters is associated with an increase in uptake in facility births.

The overall study is sound with a pre and post intervention component and multinomial regression analysis of predictors of place of delivery. However, one topic which I would like the authors to explore further is the issue of the “Aama program” which gave financial incentives to mothers for health facility delivery. The pre and post intervention Table 2 shows a large increase in percentage of mothers receiving financial assistance for childbirth. (I am presuming this is from the government’s Aama program). However, in the multinomial regression, this variable is not appropriately explored—the “money received for childbirth reference category is “Don’t know”. I believe either “yes” or “no” should have been used.

Specific Comments

Line 75: Should be “healthy women”

Line 109-111: “This paper reports a study which…” Very vague—please lay out the specific objectives of your study here.

Line 116-123: Although you provide some level of detail regarding the intervention, I wanted more detail. For example, how much financial support was given to each birthing center? Was this strictly through the NGO or through the government? Regarding the health promotion program—is it not part of the FCHVs role to educate mothers about ANC/PNC, sanitation, etc. What exactly did your program do? How many mother-in-law meetings were conducted?

Line 185-187: “While other variables changed slightly such as age of marriage for women remained higher for age group 20-24 in both pre- and post-intervention survey although the percentage changed from 38.8% to 46.8%.

-This is not a complete sentence.

-I also don’t see the numbers 38.8% and 46.8% in the Tables.

Line 197 (Table 2): I think it’s quite interesting that the “Received financial assistance for childbirth” was so different pre and post intervention (25.4% to 53.4%). I wonder how much of the increase in BC births was due to this financial assistance program (“Aama program”) versus your intervention.

Table 3 comments:

-Please fix formatting for “Decision maker for birthplace” section: the numbers should be moved up a row”

-For the “knowledge if abortion is legal” variable, why did you use “Don’t know” as the reference category? Why not either “Yes or No”?

-For the “Money received for childbirth” variable, why did you use “Don’t know” as the reference. I don’t think this makes sense. Your pre and post intervention Table 2 clearly shows a huge jump in this variable. I think that if you used either the “yes” or “no” category as the reference, you would have very significant results. It might change your whole Table 3.

-I am curious about why you used the “Time baby first washed” variable. Why is this important?

Line 282: as part of “the” intervention

Line 289: “A” review study concluded..

Line 293: show that “a” majority of

Line 294: “the” mother-in-law

Women’s autonomy section

Lines 299-313:

I’m not sure that I understand your argument about women’s autonomy. I feel that your numerical results are the opposite of your argument. You state, “The results of multinomial regression analysis showed that when women solely decided about their birthplace, they were less likely to attend a health facility for childbirth.” In a later paragraph you state, “Involving women in the decisions related to their maternal healthcare including choosing the birthplace ensures that women are empowered and can exercise their rights over reproductive healthcare.” These seem polar opposite arguments to me. It seems that if only the woman chooses, she chooses not to deliver at a health facility. Am I misunderstanding something?

I wonder if one way to explain the discrepancy in the results is to surmise that when only the woman is solely involved in the decision, she may not have anyone else to depend upon (perhaps, there is no mother-in-law, perhaps husband is a migrant worker, etc). I wonder if these women were also of lower socioeconomic strata and did not feel they had the resources for a facility birth—the Aama program gives them a certain amount but would not cover all of the costs.

Reviewer #2: This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings. The study is well written, however, I have a few concerns:

Minor revisions

1) In line 58, sentence with ‘Measuring SBA rates’ is not clear.

2) Abbreviations: “BC” in line 72 should instead be in line 70 where birthing centre is written for the first time. In line 121, ANC and PNC have been written first time but with abbreviations.

3) Line 77 mentions that basic obstetric care are available from ‘Sub health posts (SHPs)’. SHPs have been upgraded to Health Posts (HPs). Please remove SHP from subsequent content as well.

4) Hospitals are no longer categorized as regional and zonal. Hence, in line 82 revise the category of current hospitals correctly.

5) Lines 88-93. ‘ANMs providing care especially at BCs’ is confusing because ANMs work also in other Health Posts that are not birthing centres, as well as in hospitals which you have mentioned in last sentence. So, ‘In most of the BCs ANMs are service providers’ would be more appropriate.

6) Line 119. Who were ‘health promoters’?

7) Figure 1. How many wards from each village development committee were selected and what was the basis for? Explanation of the figure is required.

8) Line 149. Which data were analysed as ‘secondary data’?

9) In Table 2, variable ‘Birth Attendant’ would be better than ‘Skilled Birth Attendant’.

10) Your analysis and results would be more clear if ‘outcome variables’ of the intervention are clearly mentioned (the characteristics in table 2 seem to be the ones) and assessed for statistical significant difference in the outcome variables between pre and post intervention, as well as their strength of association with intervention. And then another table with contributing factors to place of birth would be sufficient.

11) The manuscript should be read thoroughly and corrected for few errors in English writing before submitting revised version.

Reviewer #3: Title

Revise the title to reflect the aim of the study—the evaluation of the intervention as stated in the manuscript. I would say ‘Impact of …………..interventions in improving maternity services in rural Nepal’.

Abstract

BCs are supposed to provide care for women without complications. However, this is not the case, more importantly in the rural areas. Women often present late, and therefore mostly with a complication. An Skilled Birth Attendant is supposed to manage most of the Basic Emergency Obstetric Complications.

Introduction

As this is an evaluation study of BC, I would start the introduction section with paragraph third. The introduction as of now is a bit general and does not clearly demonstrate a review of prior interventions to support birthing centres, gaps in those interventions and the need for doing this particular study.

Materials and Methods

I would again emphasize to clearly describe the interventions carried out in the two birthing centres and 4 catchment VDCs focussing on:

o When did the two health facilities (the BCs as mentioned now) started functioning (or perhaps named/announced) as birthing centres?

o What specific interventions did we do in addition to existing care/support in the selected BCs?

o What kind of prior health promotion interventions existed before?

o What did we do in the 4 communities?

o Did we hire additional staffs, SBAs? Community health workers?

o Any new trainings? Supplies?

o When did the intervention start? How did we monitor the intervention adherence/fidelity?

o What were primary outcomes of interest?

o What were other/secondary outcomes of interest?

Please briefly describe the qualification of the enumerators including their gender, number

Figure 1. mention the total wards, number of wards selected randomly

Did you know the list of households selected in each ward? It would be great to mention what is the proportion of the approached household (704) of the total households in the ward?

Please mention briefly about what you found after cross checking 10% sample.

You approached 704 for the post-intervention survey. How many did you approach in pre-intervention survey? Table 1 shows 420 included in Analysis? How such a huge difference in size of the participants for pre and post intervention survey?

Who approached these women? How did you recruit them?

Authors nowhere talk about consents form participants and ethical approval for this study. This is very important and I want to clearly know whether this study was ethically approved. Please mention it.

Results

Table 2. where do you demonstrate the impact of the birthing centre support intervention as aimed in this study? How do you justify that the intervention worked?

Why did you also include hospital when the focus was to see the impact of BC intervention?

Discussion

You stated ‘’ This paper reports an intervention that increased the births at BCs and decreased home births. The intervention also had an influence on women’s autonomy and the use of perinatal care facilities at BCs.” I would again like to know the intervention—what exactly was done in the 2 BCs and 4 villages?.

How do you discuss the contribution of already exiting network of female community health volunteers, mothers groups, the voucher programme (monetary incentives to motivate women to come for antenatal and childbirth)?

Others

Authors mention two NGOs providing technical support, and also describe an NGO involved in delivering the intervention. Please clearly mention as disclaimer whether this was a funded study?

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Reviewer #1: No

Reviewer #2: Yes: Rajani Shah Malla

Reviewer #3: No

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15 Apr 2020

Reviewer 1

Article addresses pertinent issue in the field of maternal and child health in Nepal—birthing centers. … Authors show that an intervention aimed at improving the birthing center and promoting it in the community through FCHVs and health promoters is associated with an increase in uptake in facility births. Thank you

The overall study is sound with a pre and post intervention component and multinomial regression analysis of predictors of place of delivery. … I would like authors to explore further is the issue of the “Aama program” which gave financial incentives to mothers for health facility delivery. The pre and post intervention Table 2 shows a large increase in % mothers receiving financial assistance for birth. (I presume this is from government’s Aama program). However, in multinomial regression, this variable is not appropriately explored—the “money received for childbirth reference category is “Don’t know”. I believe either “yes” or “no” should have been used. We have provided details on “Aama Program” in Discussion. See lines 296-301.

We understand that the reference category could have been ‘yes’ or ‘no’ but since the reference category was always chosen the last category for convenience reason, we did not anticipate this could have made a lot of difference in the results. Rather we viewed that changing reference category might only change how results were interpreted. For example, if ‘no’ was selected as reference category then it would be interpreted compared to those who received financial assistance (Table 2).

Line 75: Should be “healthy women” This is changed now

Line 109-111: “This paper reports a study which…” Very vague—please lay out the specific objectives of your study here. Line 110-113 now changed to “This paper evaluated the effects of an intervention consisting of supporting BCs and community-based health promotion programme on increasing access and utilisation of perinatal care facilities in community settings.”

Line 116-123: Although you provide some detail regarding the intervention, I wanted more, e.g. how much financial support was given to each BC? Was this strictly through the NGO or through the government? Regarding the health promotion program—is it not part of the FCHVs role to educate mothers about ANC/PNC, sanitation, etc. What exactly did your program do? How many mother-in-law meetings …d? We have provided additional details about the intervention and mentioned that the intervention and pre-intervention survey was carried out by a local NGO. We conducted post-intervention survey and received the pre-intervention survey data from the NGO (lines 119-137).

Line 185-187: “While other variables changed slightly such as age of marriage for women remained higher for age group 20-24 in both pre- and post-intervention survey although the percentage changed from 38.8% to 46.8%.

-This is not a complete sentence. Line 206-208.

This sentence has been changed to “While other variables changed slightly, the percentage of women aged 20-24 changed considerably from 38.8% to 46.8%.

I also don’t see the numbers 38.8% and 46.8% in the Tables These are in Table 1, age group of women during pre-intervention (38.8%) and post-intervention (46.8%). This has been clarified in the text (line 208).

Line 197 (Table 2): I think it’s quite interesting that the “Received financial assistance for childbirth” was so different pre and post intervention (25.4% to 53.4%). I wonder how much of increase in BC births was due to this financial assistance (“Aama program”) versus your intervention Financial incentive was from “Aama program” and not from our intervention. These figures show the percentage change that reported the receiving of financial incentive pre and post intervention. Added few sentences about this in the Discussion section (see lines 296- 301).

Table 3 fix formatting for “Decision maker for birthplace” section: numbers should be moved up a row” Thank you we have done this in clean copy

For the “knowledge if abortion is legal” variable, why did you use “Don’t know” as the reference category? Why not either “Yes or No”? The ‘don’t know’ was used as reference category for convenience reason as it was the last category. Also, the number who didn’t know that abortion was legal was quite high.

For the “Money received for childbirth” variable, why did you use “Don’t know” as the reference. I don’t think this makes sense. Your pre and post intervention Table 2 clearly shows a huge jump in this variable. I think that if you used either the “yes” or “no” category as the reference, you would have very significant results. It might change your whole Table 3. Again ‘don’t know’ was used as reference category for convenience reason since this was the last category. There were no natural reference categories and we did not anticipate that changing reference categories might make lot of difference to the results. Rather we viewed that changing reference category might only change how results are interpreted.

I am curious about why you used the “Time baby first washed” variable. Why is this important? We understand removing this variable from the table will reduce confusion, therefore we have done this.

Line 282: as part of “the” intervention

Line 289: “A” review study concluded.

Line 293: show that “a” majority of

Line 294: “the” mother-in-law Thank you we have changed these now.

Women’s autonomy section Lines 299-313:

I’m not sure I understand your argument about women’s autonomy. I feel that your numerical results are the opposite of your argument. You state, “The results of multinomial regression analysis showed that when women solely decided about their birthplace, they were less likely to attend a health facility for childbirth.” In a later paragraph you state, “Involving women in the decisions related to ……..their rights over reproductive healthcare.” These seem polar opposite arguments….. if only the woman chooses, she chooses not to deliver at a health facility. Am I misunderstanding?

One way to explain the discrepancy in results is to surmise that when only woman is solely involved in decision, she may not have anyone else to depend upon (perhaps, there is no mother-in-law, perhaps husband is a migrant worker, etc). I wonder if women were also of lower socioeconomic strata and felt they had no resources for a facility birth—the Aama program gives them a certain amount but would not cover all of the costs. Thank you, as you noted, when women solely decided about their birthplace, they were less likely to attend a health facility for childbirth, could mean that when they decide by themselves they choose not to deliver at health facility.

We also agree with your comments that these women might not have any support or maybe of low socioeconomic status. In addition, we also mention that such women need further education and awareness about importance of giving birth at a health facility along with husbands and other family members. This has been added to the discussion (line 307-311).

Reviewer 2

In line 58, sentence with ‘Measuring SBA rates’ is not clear. Changed this to “Measuring and monitoring of SBA remains a challenge because of the wide variety of definitions used.” (line 59).

Abbreviations: “BC” in line 72 should instead be in line 70 where birthing centre is written for the first time. In line 121, ANC and PNC have been written first time but with abbreviations. Thank you, corrected this.

Line 77 mentions that basic obstetric care … from ‘Sub health posts (SHPs)’. SHPs have been upgraded to Health Posts (HPs). Please remove SHP from subsequent content as well. Thank you, we have done this.

Hospitals are no longer categorized as regional and zonal. Hence, in line 82 revise the category of current hospitals correctly. We have mentioned as “central, provincial and district” (line 83).

Lines 88-93. ‘ANMs providing care especially at BCs’ is confusing as ANMs work also in other Health Posts that are not BCs, as well as in hospitals as you have mentioned in last sentence. So, ‘In most of the BCs ANMs are service providers’ would be more appropriate. We have added this sentence “In most of the BCs, Auxiliary Nurse Midwives (ANMs) provide much of the primary care maternity services in Nepal.” (line 89).

Line 119. Who were ‘health promoters’? The health promoters were employed by the NGO and trained to provide health promotion program in their local community. Now mentioned in the text as “The health promotion programme consisted of training local health promoters employed by the NGO, who then trained Female Health Community Volunteers (FCHVs).” (see lines 126-128).

Figure 1. How many wards from each village development committee were selected and what was the basis for? Explanation of the figure is required. We added: “In order to get a spread on poorer and slightly better off wards as well as those closer to the BCs and those further away 29 out of 36 wards were visited.” (lines 150-52).

Line 149. Which data were analysed as ‘secondary data’? The secondary data were the pre-intervention survey data made available by the NGO. The pre-intervention survey was conducted by the NGO as is mentioned in line 158-160.

In Table 2, variable ‘Birth Attendant’ would be better than ‘Skilled Birth Attendant’. Thank you, we have changed this.

Your analysis and results would be more clear if ‘outcome variables’ of the intervention are clearly mentioned (the characteristics in table 2 seem to be the ones) and assessed for statistical significant difference in the outcome variables between pre and post intervention, as well as their strength of association with intervention. And then another table with contributing factors to place of birth would be sufficient. The outcome variables of the intervention are birth at BCs (primary outcome), number of ANC, women’s decision making about place of birth and satisfaction with childbirth services (secondary outcome) (see lines 169-172). Additional analysis such as association of intervention with other variables was undertaken and their strength of association is shown in S1 Table. It is supplementary, if editor/reviewers prefer it can go in main text.

The manuscript should be corrected for few errors in English writing before resubmitting. The manuscript has been proof-read and errors corrected

Reviewer 2

Revise the title to reflect the aim of the study—the evaluation of the intervention as stated in the manuscript. I would say ‘Impact of …………..interventions in improving maternity services in rural Nepal’. Thank you for suggestion. We evaluated an intervention but did not carry it out, therefore we changed the title to: “Evaluation of a health promotion intervention associated with birthing centres in rural Nepal”

Abstract

BCs are supposed to provide care for women without complications. However, this is not the case, more importantly in the rural areas. Women often present late, and therefore mostly with a complication. An Skilled Birth Attendant is supposed to manage most of the Basic Emergency Obstetric Complications. Thank you, in our experience women often present late but that does not mean they have complications. Those women who have complications are referred to higher level health facilities. Since most women even in rural areas of Nepal go for at least one ANC, the ANMs are aware of complications and if there is complication, the ANMs always refer these women to hospital as they do not want to take risk.

Introduction

As this is an evaluation study of BC, I would start the introduction section with paragraph third. The introduction as of now is a bit general and does not clearly demonstrate a review of prior interventions to support birthing centres, gaps in those interventions and the need for doing this particular study. Thank you for your comments. We understand that this is evaluation study, but we also need to set the scene for a general audience. So, we feel it is important to start with a general introduction about SBA, moving to maternity care provision in Nepal. We do have a paragraph related to interventions but since this is not an intervention study but evaluation study, we thought this can go in the third paragraph.

Materials and Methods

I would emphasize to clearly describe the interventions carried out in the two BCs and 4 catchment VDCs focussing on:

When did the two health facilities (BCs mentioned now) started functioning (or perhaps named/announced) as BCs? We have mentioned 2015 and 2016. (line 122)

What specific interventions did we do in addition to existing care/support in the selected BCs? Health promotion and supporting BCs (added to line 122-137)

What kind of prior health promotion interventions existed before? None except the health promotion role of FCHVs (sentence added to line 130-131.)

What did we do in the 4 communities? We have mentioned this in Materials and Methods: “the health promoters conducted meetings with mothers-in-laws as a strategy for creating demand for utilisation of the BCs [24]. For example, in 2016, there were 157 mothers-in-law meetings and 334 women’s group meetings. The health promoters and FCHVs met mother groups on a monthly basis and discussed various issues related to women’s health through a curriculum covering content on ANC/PNC, baby feeding, sanitation and hygiene.” (lines 131-137)

Did we hire additional staffs, SBAs? Community health workers? Yes, the NGO hired additional staff also called as health promoters who were trained by the NGO for their role. Added to line 127.

Any new trainings? Supplies? We have mentioned “The support included refurbishing the health facilities infrastructure, providing equipment required for normal delivery, and training all the ANMs at these two BCs and appointing two local health promoters” (lines 122-128)

When did the intervention start? How did we monitor the intervention adherence/fidelity? We added: “The intervention, that was conducted by a local non-governmental organisation (NGO) during 2014-16, involved supporting two BCs and conducting a health promotion programme with local women.” (lines 119-120).

What were primary outcomes of interest?

What were other/secondary outcomes of interest? Primary outcome originally was birth at BCs and secondary outcome included number of ANC, women’s decision making about place of birth and satisfaction with childbirth services. Primary outcome changed to place of birth consisting of various categories i.e. home, primary care facilities including BCs and tertiary care facilities. This became clear when we tried to conduct chi square and regression analysis as descriptive findings of survey analysis showed that data related to place of birth consisted of three categories as mentioned above (see line 169-174).

Please briefly describe the qualification of the enumerators including their gender, number Post-intervention data were collected by eight female data enumerators having at least a degree level qualification in a health subject who were trained for two days by the first author. This has been added to lines 162-164.

Figure 1. mention the total wards, number of wards selected randomly

Now added: “In order to get a spread on poorer and slightly better off wards as well as those closer to the BCs and those further away 29 out of 36 wards were visited.” (lines 150-152.

Did you know the list of households selected in each ward? It would be great to mention what is the proportion of the approached household (704) of the total households in the ward? Since this was a household survey, we approached all eligible participants from each household of selected wards of 4 VDCs and whoever agreed to take part was recruited. Very few refused to take part and response rate is more than 99% (One refused to take part in post-intervention survey) (Figure 2).

Please mention briefly about what you found after cross checking 10% sample. The main aim of cross checking 10% sample was to check completeness of data entry. The cross checking identified a small number of discrepancies in data entry and these were corrected by the first author who then used this to supervise the trainee for future data entry. This has been added to lines 165-167.

You approached 704 for the post-intervention survey. How many did you approach in pre-intervention survey? Table 1 shows 420 included in Analysis? How such a huge difference in size of the participants for pre and post intervention survey? As mentioned, pre-intervention survey was conducted by the NGO. For post-intervention survey, we approached 704, out of which one refused to take part and four removed after data cleaning leaving 699 entries. More participants were approached for post-intervention survey for more detailed sub-group analyses to ensure that sub-populations could be compared and linked to qualitative part of study not reported here (see Figure 2).

Who approached these women? How did you recruit them? Data enumerators approached women and if they agreed a structured questionnaire was completed by them (lines 149-150).

Authors nowhere talk about consents form participants and ethical approval for this study. …. Please mention it. Thank you for noting this, we have ethical approval. Now mentioned in materials and methods section (lines 180-186).

Results

Table 2. where do you demonstrate the impact of the birthing centre support intervention as aimed in this study? How do you justify that the intervention worked? Conducting adjusted regression allowed adjustment of all other factors so that the effects of certain variable are measured. This also ensures that the results obtained is not just a temporal trend but is likely the effect of intervention.

Why did you also include hospital when the focus was to see the impact of BC intervention? Primary outcome was originally birth at BCs but changed to place of birth consisting of three categories: home, primary care (incl. BCs) and tertiary care facilities. This became clear when we tried to conduct chi square and regression analysis as the descriptive findings of survey analysis showed that data related to place of birth consisted of three categories as mentioned above (see lines 169-174).

Discussion

You stated ‘’ This paper reports an intervention that increased the births at BCs and decreased home births. The intervention also had an influence on women’s autonomy and the use of perinatal care facilities at BCs.” I would again like to know the intervention—what exactly was done in the 2 BCs and 4 villages? We have provided description on intervention as “The intervention, that was conducted by a local non-governmental organisation (NGO) during 2014-16, involved supporting two BCs and conducting a health promotion programme with local women in four VDCs. These two BCs started functioning in the year 2015 and 2016. The support to BCs was provided in the form of refurbishing health facilities infrastructure, providing equipment required for normal delivery, recruiting two local ANMs for two years, training all the ANMs at these two BCs and appointing health promoters who were trained for their role. ……….. The health promoters and FCHVs also met mother groups on a monthly basis and discussed various issues related to women’s health through a curriculum covering content on ANC/PNC, baby feeding, sanitation and hygiene. The classes were informal and participatory, lasting about 1-2 hours [24].” (lines 119-137).

How do you discuss contribution of already existing network of FCHVs, mothers groups, voucher programme (monetary incentives to motivate women to come for ANC & birth)? We have mentioned about the contribution of FCHVs and Aama Programme in Discussion section (see lines 296-301, 307-311).

Others

Authors mention two NGOs providing technical support, and also describe an NGO involved in delivering the intervention. Please clearly mention as disclaimer whether this was a funded study? A local NGO conducted the intervention and provided technical support during post-intervention survey. This is a part of a PhD study at UK university with technical support from NGO but no financial support from the NGO. See also the Acknowledgments.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

28 Apr 2020

PONE-D-19-33046R1

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal

PLOS ONE

Dear Dr Mahato,

Thank you for submitting your revised manuscript to PLOS ONE. Most of the revisions are acceptable. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Abstract

- Please add numeric results to the results section

-Avoid stating “significantly more likely”. The post-intervention survey provided evidence that women were more likely to … than prior to the intervention.

In the tracked copy, P5. Line 73. Need to start a sentence with a word, not an abbreviation.

Table 3. This needs the number and percent for each response. Some of these are already in Table 1. However, important factors such as knowledge about abortion and money received for childbirth are not really clear. I agree with Reviewer 1 the reference for each of these needs to be “No”, rather than “Don’t know”. It is possible to rearrange the data in the statistical package to do this. I also don’t understand why the emphasis is placed on being “somewhat satisfied” or “highly dissatisfied” with childbirth – I would have thought the hope was that the intervention increased the proportion of women who were positive about the experience, rather than emphasising dissatisfaction.  I also presume the asterisks indicate the level of significance. These are not needed, as the reader can see this from the p=values – the reader also needs to focus on the width of the confidence intervals, which are more meaningful than a p-value.

The supplementary table was not available for view in this revision. Please provide it again.

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5 May 2020

Abstract

- Please add numeric results to the results section

Thank you for your comment, we have added numeric data to the results section of the abstract.

-Avoid stating “significantly more likely”. The post-intervention survey provided evidence that women were more likely to … than prior to the intervention.

Thank you for the suggestion. We have used following sentences in the results section of abstract “The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020). If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014)”

In the tracked copy, P5. Line 73. Need to start a sentence with a word, not an abbreviation.

We have done this.

Table 3. This needs the number and percent for each response. Some of these are already in Table 1. However, important factors such as knowledge about abortion and money received for childbirth are not really clear. I agree with Reviewer 1 the reference for each of these needs to be “No”, rather than “Don’t know”. It is possible to rearrange the data in the statistical package to do this. I also don’t understand why the emphasis is placed on being “somewhat satisfied” or “highly dissatisfied” with childbirth – I would have thought the hope was that the intervention increased the proportion of women who were positive about the experience, rather than emphasising dissatisfaction. I also presume the asterisks indicate the level of significance. These are not needed, as the reader can see this from the p=values – the reader also needs to focus on the width of the confidence intervals, which are more meaningful than a p-value.

Thank you for this important suggestion. As you have mentioned, we have not included the number and percent for each response in Table 3, since it is already mentioned in Table 1 and 2 and it would not be possible to include this Table 3 due to space constraints. Your comments about using ‘don’t know’ as reference category are valid, and we have rearranged the data in the SPSS for ‘knowledge about abortion’ and ‘money received for childbirth’. The reference category for these variables now are ‘No’ rather than ‘Don’t know’. We had to conduct the regression analysis again, therefore there is slight change in the figures in Table 3. The categories for ‘satisfaction with childbirth’ was based on the pre-intervention survey questionnaire and was not revised for the post-intervention survey. We understand that including this in the regression analysis does not clarify anything, so we chose not to include this in this analysis.

As per your suggestion we have removed the asterisk sign as the confidence interval does tell this.

The supplementary table was not available for view in this revision. Please provide it again.

We have provided this again.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

11 May 2020

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal

PONE-D-19-33046R2

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13 May 2020

PONE-D-19-33046R2

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal

Dear Dr. Mahato:

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