Factors that promote or hinder maternal health service provision by female community health volunteers in rural Nepal.

Abstract

Female Community Health Volunteers (FCHVs) provide basic Maternal Health Services (MHSs) to pregnant women and mothers in their communities. Their contribution to maternal health has been praised, as Nepal managed to reduce its maternal mortality by more than two-thirds and met the Millennium Development Goal 5. However, little published evidence is available on FCHVs’ views and the factors that promote or hinder their services. This thesis explores the role of FCHVs in MHS provision in two regions (the hill and Terai ) of Nepal, from the perspectives of health workers, service users, and FCHVs themselves. A qualitative approach was adopted using semi-structured interviews, focus group discussions (FGDs) and field notes. Interviews were conducted with 20 FCHVs, 11 health workers and 26 women in villages from the two study regions. In addition, four FGDs were held with 19 FCHVs and field notes were taken throughout the data collection. Data were analysed using thematic analysis. Findings indicate that FCHVs play an important role in MHS provision in the hill villages where there is limited access to professional healthcare. The FCHVs detected pregnancies, referred them for health check-ups, accompanied them for deliveries and assisted in child-births. They also distributed medicines and informed women on the availability of safe abortion services. In both regions, the FCHVs raised health awareness among pregnant women/mothers casually or through organised meetings. In the hill villages, they used interesting casual approaches to share maternal health information, for example, singing folk songs with health messages in them or visiting new mothers with nutritious food hampers. Such services were beneficial to the women in the remote villages, who otherwise would not have received any healthcare. The FCHVs also shared maternal health messages through regularly organised mothers' group meetings. Unfortunately, these meetings were also used for monetary discussions, which left a little time for discussion on health topics. Such activity combined with the lack of FCHVs’ education often proved to be counterproductive on their service provision. They have a desire to volunteer, as they saw their service as social responsibility, felt empowered and enjoyed community recognition. However, a lack of financial and non-financial incentives was the key hindrance for them followed by perceived community misconceptions regarding their voluntary status. The FCHVs’ illiteracy and older age also affected their services. Finally, various health systems related factors also hindered their services: a lack of access to medical supplies, inadequate training and supervision. In general, volunteers in the terai region were less supported than those in the hill region. In addition, a perceived lack of respect by some health workers towards volunteers and a lack of coordination between government health centres and NGOs were noted. Overall, the study found that most interviewees perceived FCHVs as a valuable resource in improving the maternal health of the poor women. In some remote hill villages, they are the only MHS providers. Therefore, their contribution to MHS needs to be recognised and respected by both the health workers and the communities. It is important that FCHVs are provided with context specific support - incentives, access to supplies and supportive supervision - to enable them to deliver services more productively and to ensure that these services flourish in the future.