BMJ Open. Secondary Subject Heading: Obstetrics and gynaecology, Health services research. Keywords: PUBLIC HEALTH, Maternal Health, Adolescent health

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1 BMJ Open Determinants of institutional delivery among young married women in Nepal: Evidence from the Nepal Demographic and Health Survey, 0 Journal: BMJ Open Manuscript ID bmjopen-0-0 Article Type: Research Date Submitted by the Author: -Apr-0 Complete List of Authors: SHAHABUDDIN, ASM; Instituut voor Tropische Geneeskunde, Public Health; Vrije Universiteit Amsterdam, Earth and Life Sciences De Brouwere, Vincent; Instituut voor Tropische Geneeskunde, Public Health Adhikari, Ramesh; Tribhuvan University, Geography and Population Department Delamou, Alexandre ; Centre national de formation et de recherche en santé rurale de Maferinyah, Forécariah, Guinea Bardají, Azucena; Universitat de Barcelona, Barcelona, Spain, ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic Delvaux, Thérèse; Instituut voor Tropische Geneeskunde, Public Health <b>primary Subject Heading</b>: Public health Secondary Subject Heading: Obstetrics and gynaecology, Health services research Keywords: PUBLIC HEALTH, Maternal Health, Adolescent health BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

2 Page of BMJ Open Title: Determinants of institutional delivery among young married women in Nepal: Evidence from the Nepal Demographic and Health Survey, 0 evidence from the National Demographic and Health Survey in 0 Corresponding author: ASM Shahabuddin, MPH, AMPHM,, Woman and Child Health Research Centre, Department of Public Health, Institute of Tropical Medicine, Nationalestraat, 000 Antwerp, Belgium. shahab@itg.be; Phone : + Co-authors: Vincent De Brouwere, MD, MPH, PhD Affiliation: Ramesh Adhikari, MSc, PhD Alexandre Delamou MD, MPH, MSc, Azucena Bardají, MD, PhD Thérèse Delvaux, MD, MPH, PhD VDBrouwere@itg.be rameshipsr@gmail.com adelamou@gmail.com abardaji@clinic.ub.es TDelvaux@itg.be Woman and Child Health Research Centre, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University Amsterdam, the Netherlands Geography and Population Department, Tribhuvan University, Mahendra Ratna Campus (TU), Kathmandu, Nepal Centre national de formation et de recherche en santé rurale de Maferinyah, Forécariah, Guinea Keywords: Determinants; Institutional delivery; Young women; Nepal Word count:, BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

3 BMJ Open Page of Abstract Objectives: To identify the determinants of institutional delivery among young married women in Nepal. Design: Demographic and Health Survey (DHS) data sets were analyzed for this study. Bivariate and multivariate analyses were performed using a subset of ever married young women. Outcome measures: Institutional delivery Results: Rate of institutional delivery among young married women was % which is higher than the national average (%) among the women of reproductive age. Young women who had more than four antenatal care visits were three times more likely to deliver in a health institution compared to those women who had no antenatal care visit (OR:.0; % CI:.0-.). Probability of delivering in an institution was % higher among urban young women than those young women who lived in rural area. Young women who had secondary or above secondary level education were. times more likely to go for institutional delivery than those young women who had no formal education (OR:.; % CI:.-.). Lower use of health institution for delivery was also observed among poor young women. Results showed that rich young women were. times more likely to deliver their child in an institution compared to poor young women (OR:.0; % CI:.-.). In addition to these, age of young women, religion, ethnicity, and ecological zone were other determinants that affect the use of institutional delivery. Conclusions: Poor and less educated women residing in rural areas, those who belong to Janajati ethnicity and live in mountain region, and young women with at least one child are less likely to opt for institutional delivery in Nepal. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

4 Page of BMJ Open Strengths and limitations of the study One of the strengths of this study is the use of nationally representative survey (Nepal Demographic and Health Survey). Therefore, findings can be generalized at national or regional levels of Nepal. One limitation is about the study design which does not confirm causal relationship between dependent and independent variables. Moreover, this study did not explain any programmatic and socio-cultural factors of the determinants of institutional delivery as Nepal demographic and health survey Nepal did not collect data related to these factors. Introduction Over the past years, global maternal mortality ratio (MMR) fell by nearly % from an estimated maternal deaths per 00,000 livebirths in 0 to an MMR of in 0 []. Despite the significant reduction in maternal deaths, still every day about 0 women die during pregnancy and childbirth. The majority (%) of these deaths occur in developing countries []. After sub-saharan Africa, countries in Southern Asia (including Nepal) carry the highest burden of global maternal deaths. Several studies showed that compared to adult women, young women (aged - years) including adolescent (aged 0- years) girls are at higher risk of pregnancy, delivery complications, and even death []. Preterm delivery, systemic infection, low birthweight, perinatal death, and maternal death are common among young women particularly among adolescents [ ]. An important strategy in decreasing maternal mortality is to utilize adequate, quality, maternal health services in a timely manner. Delivery complications and death can be averted by hospital or institutional assisted delivery with the assistance of skilled care providers within an enabling environment, and by effective referral systems [ ]. The government of Nepal has been implementing a free delivery policy since 00 providing incentives to women who choose to deliver in a designated health facility []. However, the country remains as one of the countries in Southern Asia with a high MMR ( per 00,000 live births) [,0]. Underutilization of maternal health services is one of the reasons for such high number of maternal deaths in Nepal []. Most recently a nationwide survey BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

5 BMJ Open Page of showed that about in 0 pregnant women received antenatal care from skilled providers while only % of childbirths occurred in health institutions [0]. Several studies have been conducted in Nepal documenting the determinants of institutional delivery among women of reproductive age between - years. Results showed that several socio-demographic, economic, and cultural factors played a role in determining whether to use skilled birth attendants and institutional delivery. Women s education, ethnicity, area of residence, women s autonomy, women s involvement in a community group, wealth index, poor infrastructure, and lack of services appeared as the major factors that affect utilization of institutional delivery in Nepal. [,, 0]. As most of these studies provide evidence pertaining to all women of reproductive ages, there is a need for broader data at a national level and for specific age groups, such as youth (aged - years). However, little is known about the factors that affect young Nepali women in utilizing skilled maternal health services, especially factors that affect their decisions for having an institutional delivery. As the survey (Nepal demographic and health survey) did not collect pregnancy or delivery related information from unmarred women, this study aimed only to identify the determinants of institutional delivery among young married women in Nepal. Methods Source of data We analyzed the Nepal Demographic and Health Survey (NDHS) 0 data set for this study. NDHS is a nationally representative survey which aimed to provide reliable and current data on fertility, family planning, child health and its nutritional status, use of maternal health services, domestic violence, and HIV/AIDS related information. NDHS was conducted under the guidance of the Population Division of the Ministry of Health and Population, Nepal. Sample size A total of, women of reproductive age completed interviews in NDHS 0. Of those,, women had given at least one live birth in the five years preceding the survey. Given our study objective, our analysis was based on the, ever married young women (- years) who had given at least one birth in the last five years preceding the NDHS 0. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

6 Page of BMJ Open Variables Dependent variable We used place of delivery as a dependent variable. We categorized this variable into two categories: home delivery (when childbirth took place at home), and institutional delivery (when childbirth took place at hospital or at primary health care center or at health post or at sub-health post). Independent variables The dependent variables included in this study were: age, ethnicity, education of the women, religion, ecological zone, place of residence, wealth index, parity, sex of the household head, women s involvement in a community group, number of antenatal care (ANC) visits for the most recent live birth, and women s autonomy in household decisions. The variable women s autonomy in household decisions was categorized based on whether a young woman participated in decision making in the areas of: () her own health care, () making major household purchases, and () visits to her family and relatives. The category no decision meant that none of the three decisions were taken by the woman, moderate autonomy indicated that a woman participated in making at least or decisions in the three mentioned areas, and higher autonomy reflected that a woman participated in decision making in all the three areas. Data analysis Bivariate analysis (Pearson s chi-squared) was done to assess the relationship between the dependent and independent variables. A binary logistic regression analysis was carried out to determine the adjusted effect of each factor on the dependent variable (place of delivery). Multicollinearity was checked before logistic regression. The results of the logistic regression analysis were presented by odds ratios (OR) with % confidence intervals (CI). All statistical analyses were performed using SPSS. for Windows. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

7 BMJ Open Page of Results Results showed that among all the young women who had given birth at least once within the last five years preceding the survey, 0% of them was aged between 0- years. About onethird of the young women did not have any formal education. About % of them were Hindu and more than 0% were living in rural areas. Almost % of the young women fell into the poorest socio-economic category and % of them received at least ANC. Forty three percent of the women did not have any household decision making autonomy (Table ). Table : Background characteristics of ever married young women who had at least one birth in the five-year preceding the survey, NDHS 0 Demographic and socio-economic characteristics Frequency (n) Age groups - years years 0.0 Ethnicity Brahmin/Chhetri.0 Janajati. Dalit 0. Other. Education level of women No education. Primary. Secondary or above. Religion Hindu 0. Buddhist. Muslim.0 Kirat/Christian. Ecological zone Mountain.0 Hill 0. Terai. Place of residence Urban. Rural. Wealth index Poor 0. Middle 0. Rich. Parity Percentage (%) BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

8 Page of BMJ Open One. Two 0 0. Three 0.0 Four or more.0 Sex of household head Male.0 Female.0 Involvement in community group Not involved in any community group. Involvement in community group. Number of ANC visits for the most recent live birth Less than visits.0 or more visits.0 Decision on own health care Without involvement of respondent 0.0 Involvement of respondent 0.0 Decision on making large household purchases Without involvement of respondent 0. Involvement of respondent 0. Decision on visits to family or relatives Without involvement of respondent 0. Involvement of respondent. Women's autonomy in household decision No autonomy 0. Moderate autonomy (involved in - issues). High autonomy (involved in all issues). Total 00.0 About % of the total young women chose an institutional delivery for their recent childbirth. Young women who were between - years of age had more institutional deliveries than those aged 0- years (% vs. %). Other socio-demographic variables which appear to be associated to the place of delivery include: ethnicity, level of education, religion, ethnicity, religion, place of residence, wealth index, parity, number of ANC visits, and women s autonomy in household decisions. Young women who were poor, not firstorder pregnant, received less than ANC, had a lower level of education, lived in rural areas, and those from the mountain region had the lowest number of institutional deliveries (Table ). BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

9 BMJ Open Page of Table : Background characteristics of married young women who had at least one live birth in the five-year preceding the survey by place of delivery for the most recent live birth, NDHS 0 Demographic and socio-economic characteristics Home (%) Institutional delivery (%) n Age in -year groups *** Ethnicity *** Brahmin/Chhetri.. Janajati.. Dalit.. 0 Other.. Education level of women *** No education 0.. Primary.. Secondary or above. 0. Religion * Hindu.. 0 Buddhist.. Muslim.0.0 Kirat/Christian.. Ecological zone *** Mountain.. Hill Terai.. Place of residence *** Urban.. Rural.. Wealth index *** Poor 0.. Middle.. 0 Rich.. Parity*** One.. Two Three.0.0 Four or more.. Sex of household head Male.0.0 Female.0.0 Involvement in community group Not involved in any community group.. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

10 Page of BMJ Open Involvement in community group.. Number of ANC visits for the most recent live birth*** Less than visits.0.0 or more visits.0.0 Decision on own health care *** Without involvement of respondent.. Involvement of respondent.. Decision on making large household purchases Without involvement of respondent.. 0 Involvement of respondent.. 0 Decision on visits to family or relatives Without involvement of respondent.. 0 Involvement of respondent.. Women's autonomy in household decision ** No autonomy.. 0 Moderate autonomy (involved in - issues).. High autonomy (involved in all issues).. Total.. Note: ***=p<0.00,**=p<0.0 and *=p<0.0 Table : Institutional delivery and place of delivery stratified by wealth index (n=) Home Institutional Total Wealth Index Place of residence n % n % n % Poor Urban.. 00 Rural.. 00 Middle Urban Rural.. 00 Rich Urban.. 00 Rural.. 00 Total.. 00 Table shows that the institutional delivery rates were higher among rich young women despite their place of residence. Institutional delivery rate (.%) was higher among rural rich young women compared to rural poor or middle class young women (.% and.%). BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

11 BMJ Open Page 0 of Table : Adjusted odds ratios (aor) from multivariable logistic regression assessing the likelihood among young women having institutional delivery within the past five years preceding the survey by selected socio- demographic and economic predictors Institutional delivery Demographic and socio-economic characteristics OR % CI Age group -.0* Ethnicity Brahmin/Chhetri.000 Janajati 0.* Dalit Other Education level of women No education.000 Primary Secondary or above.**.-. Religion Hindu.000 Buddhist Muslim.0*.0-. Kirat/Christian Ecological zone Mountain.000 Hill Terai.*.0-. Place of residence Urban.000 Rural 0.*** Wealth index Poor.000 Middle.**.-. Rich.0***.-. Parity One.000 Two 0.*** Three 0.0*** Four or more Sex of household head 0 BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

12 Page of BMJ Open Male.000 Female Involvement in community group Not involved in any community group.000 Involvement in community group Number of ANC visits for the most recent live birth Less than visits.000 or more visits.0***.0-.0 Women's autonomy in household decision No autonomy.000 Moderate autonomy (involved in - issues) High autonomy (involved in all issues) Note: ***=p<0.00,**=p<0.0 and *=p<0.0 The multivariate analysis (Table ) showed that age had a significant effect on the use of institutional delivery among young women. After controlling the other socio-demographic variables, women aged between - years had resulted significantly higher institutional delivery compared to young women aged 0- years (OR:.; % CI:.00-.). Probability of institutional delivery was about 0% higher among young women belonging to the Brahmin/Chhetri ethnic group compared to women belonging to the Janajati ethnic group. Young women who had a secondary or above level of education were. times more likely to go for an institutional delivery than those young women who had no formal education (OR:.; % CI:.-.). Muslim young women were. times more likely to deliver at the institution compared to Hindu young women. In terms of their place of residence, the probability of delivering a child in an institution was about % higher among urban young women compared to that of those living in rural areas. Young women from the Terai region were. times more likely to choose an institutional delivery than the young women of the Mountain region (OR:.; % CI:.0-.). Young women belonging to the richest wealth category were. times more likely to deliver their child in the institution compared to young women belonging to the poor socioeconomic index (OR:.0; % CI:.-.). Young women who were pregnant for the first time (parity-one) were more likely to choose an institutional delivery than those who had given birth previously. Regarding the use of antenatal care, young women who had received four or more ANC were about times more likely to choose an institutional delivery BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

13 BMJ Open Page of compared to young women who had not received at least four ANC (OR::0; % CI:.0-.0). Discussion Although institutional delivery rates (%) were higher among young women compared to the national average (%), there were disparities among young women in selecting a health institution for delivery. Institutional delivery was found to be influenced by several factors among young women. After controlling several socio-demographic factors, the use of antenatal care appeared to be strongly associated with institutional delivery among young married women in Nepal. In addition, age, ethnicity, level of education, religion, place of residence, wealth index, and parity also appeared as other potential determinants of institutional delivery. Consistent with the results of other studies conducted among women of reproductive age including young women, this study showed that the use of antenatal care had a positive association with institutional delivery [,, ]. Adequate use of antenatal care is likely to: make pregnant women more aware about possible complications, and adding the three delays and safe delivery practices which ultimately encourage them to seek institutional delivery [, ]. However, quality of counseling practices in ANC has been shown to be poor in many settings and counselling in ANC is not very effective in increasing institutional delivery [0]. Literature showed that adolescents are less likely to seek skilled maternal health services including institutional delivery compared to adults and young adults [ ]. Inconsistent with the findings of other studies, this study revealed that in Nepal, adolescents (aged - years) were more likely to seek institutional delivery compared to older young women (0- years). Another study (n= women) conducted in Kaski district in Nepal showed that the woman s age was not significantly associated with place of delivery []. One possible reason for the increased use of institutional delivery by adolescent girls (aged - years) could be that they were more aware about the consequences of adolescent pregnancy because of the ongoing campaigns and projects about decreasing adolescent pregnancy and improving maternal health of adolescent girls in Nepal []. On the other hand, it could be due to the fact that adolescent girls might typically be referred to deliver at the health institution as they are at higher risk of delivery complications compared to adult women [,]. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

14 Page of BMJ Open This study showed that young women from Brahmin/Chhetri ethnicity had a higher tendency to choose delivery at the health institution compared to young women who belong to Janajati ethnicity. This variation in the use of institutional delivery can be explained by the higher socio-economic status of the people of Brahmin/Chhetri ethnicity than those of Janajati ethnicity []. However, it should be noted that a study conducted in Nepal showed that ethnicity was not associated with place of delivery []. Consistent with the findings of other studies in Nepal and countries in Southern Asia, this study also showed that education is one of the most important factors which influence the use of institutions for childbirths [,,,, 0]. Women with higher education (often wealthier) have more knowledge about maternal health and are more aware of the use of skilled maternal health services including institutional delivery [,]. In addition, women with higher education have greater decision-making autonomy about their health and wellbeing [0]. This study showed that young women from the Mountain region were less likely to choose an institutional delivery compared to the women in Terai region. It could possibly be due to the poor access and availability of quality health services in the Mountain region of Nepal. However, another study showed that region of residence does not have any association with institutional delivery []. Variation in sample size among studies might yield the differences in results. Studies showed that the place of residence showed a significant association to institutional delivery among women of reproductive age including young women, which was also identified in other studies [,,,0]. Women residing in rural areas are less likely to choose institutional deliveries than those women residing in urban areas. Increased rates of institutional deliveries in urban settings could be a result of easier accessibility and availability of medical facilities for maternal and child health care compared with that of rural settings. Similar to the findings of other studies, this study also found a strong positive association between wealth index and use of institutional delivery [,,,,,]. Despite their place of residence (rural/urban), rich young women were always in a position to receive better health services such as institutional delivery. Although the government of Nepal has been subsidizing the cost of institutional delivery, still, young women who were belonging to a poor wealth index were less likely to choose institutional delivery compared to young women with higher wealth indexes. It could be because of hidden costs (e.g. medicines, transport) BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

15 BMJ Open Page of involved in having an institutional delivery or other cultural barriers that may exist among poorer women. Finally, this study found that parity is one of the strongest predictors of institutional delivery among young women, which is consistent with the results of other studies among women of reproductive age in general [,,0]. Women who are first-time pregnant were more likely to choose an institutional delivery than those with second or higher parity. Young women in their first parity might be more careful or anxious about childbirth due to their inexperience regarding pregnancy and delivery. Because of the several ongoing campaigns and projects in Nepal, young women might be more aware of the risk of complication in adolescent pregnancy. Therefore, if the first pregnancy occurs during adolescence, it might influence young women to seek institutional delivery. Besides, if a previous home delivery resulted without complication, then the woman might again prefer a home delivery for subsequent pregnancies. Conclusions Inequality exists in the utilization of institutional delivery among young married women in Nepal. Young women aged between 0- years (older young women), poor, less educated, and living in rural areas had a lower tendency to deliver in a health institution. Use of antenatal care was found to be crucial as it positively influenced the use of institutional delivery. In addition, the use of institutional delivery remained low amongst young women with higher parity (>parity), belonging to Janajati ethnicity, and residing in the Mountain region. All these factors need to be taken into account when developing health programs attempting to increase rates of institutional delivery among young women in Nepal. Acknowledgements The authors would like to acknowledge the European Commission and the Department of Economy, Science and Innovation of Flemish Government, Belgium for funding. In addition, the authors wish to thank Robert Suarez for editing the manuscript. Besides, authors are thankful to The Demographic and Health Surveys (DHS) Program for providing the data. Contributors AS, TD, RA and VDB are responsible for the design and planning of the study. RA and AS participated in extraction, analysis and interpretation of the data. AS drafted the article, on which all authors made important suggestions. TD, AD, AB, RA and VDB revised the article BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

16 Page of BMJ Open for important intellectual content. All authors revised and approved the final version of the article for publication. Details of ethics approval This study was except from review by the ethics committee as publicly available data was used and no identifying participant information was obtained. With the permission of MEASURE DHS, we downloaded the Demographic and Health Survey (DHS) data sets of Nepal from the website of MEASURE ( Funding This study, part of a PhD research, was funded by the European Commission and the Department of Economy, Science and Innovation of Flemish Government, Belgium. Competing interests The authors declare they have no competing interests. Data sharing statement Nepal Demographic and Health Survey 0 data (secondary data) were used for this study. These data are public and freely available to anyone from MEASURE DHS, on request. The website for MEASURE DHS is References WHO, UNICEF, World Bank G, et al. Trends in Maternal Mortality : 0 to 0. 0;:. doi:isbn 0 World Health Organization. Maternal mortality: Fact sheet. Geneva: 0. Beydoun H, Itani M, Tamim H, et al. Impact of maternal age on preterm delivery and low birthweight: a hospital-based collaborative study of nulliparous Lebanese women in Greater Beirut. J Perinatol 00;:. doi:0.0/sj.jp.0 Althabe F, Moore JL, Gibbons L, et al. Adverse maternal and perinatal outcomes in adolescent pregnancies: The Global Network s Maternal Newborn Health Registry study. Reprod Health 0;:S. doi:0./---s-s Ganchimeg T, Ota E, Morisaki N, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG An Int J Obstet Gynaecol 0;:0. doi:0./-0.0 Dahal RK. Factors Influencing the Choice of Place of Delivery among Women in Eastern Rural Nepal. Int J Matern Child Heal 0;:0. doi:0./ijmch Assarag B, Dujardin B, Delamou A, et al. Determinants of maternal near-miss in BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

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18 Page of BMJ Open ;:. Chakraborty N, Islam MA, Chowdhury RI, et al. Determinants of the use of maternal health services in rural Bangladesh. Heal Promot Int 00;:. Feyissa TR, Genemo GA. Determinants of institutional delivery among childbearing age women in Western Ethiopia, 0: Unmatched case control study. PLoS One 0;:. doi:0./journal.pone.00 Gitimu A, Herr C, Oruko H, et al. Determinants of use of skilled birth attendant at delivery in Makueni, Kenya: a cross sectional study. BMC Pregnancy Childbirth 0;:. doi:0./s-0-0- Mostafa Kamal SM. Preference for institutional delivery and caesarean sections in Bangladesh. J Heal Popul Nutr 0;: 0. Mosiur R. Deliveries among adolescent mothers in rural Bangladesh: who provides assistance? World Health Popul 00;:. &AN=00 0 Duysburgh E, Zhang WH, Ye M, et al. Quality of antenatal and childbirth care in selected rural health facilities in Burkina Faso, Ghana and Tanzania: Similar finding. Trop Med Int Heal 0;:. doi:0./tmi.0 Godha D, Hotchkiss DR, Gage a J. Association between child marriage and reproductive health outcomes and service utilization: a multi-country study from South Asia. J Adolesc Health 0;:. doi:0.0/j.jadohealth [doi] Kamal SMM. Preference for institutional delivery and caesarean sections in Bangladesh. J Health Popul Nutr 0;: 0. trez&rendertype=abstract Shahabuddin ASM, Delvaux T, Abouchadi S, et al. Utilization of maternal health services among adolescent women in Bangladesh: A scoping review of the literature. Trop Med Int Heal 0;0:. doi:0./tmi.0 Mobilizing married youth in Nepal to improve reproductive health: The Reproductive Health for Married Adolescent Couples Project, Nepal, Evaluation and Research Report. New York: : EngenderHealth/The ACQUIRE Project Conde-Agudelo A, Belizán JM, Lammers C. Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study. Am J Obstet Gynecol 00;:. doi:0.0/j.ajog Nove A, Matthews Z, Neal S, et al. Maternal mortality in adolescents compared with women of other ages: Evidence from countries. Lancet Glob Heal 0;:. doi:0.0/s-0x()0- Lynn B, Dahal DR, Govindasamy P. Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 00 Nepal Demographic and Health Survey. 00. Wagle RR, Sabroe S, Nielsen BB. Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: an observation study from Nepal. BMC Pregnancy Childbirth 00;:. doi:0./--- Bolam a., Manandhar DS, Shrestha P, et al. Factors affecting home delivery in the Kathmandu Valley, Nepal. Health Policy Plan. ;:. doi:0.0/heapol/.. 0 Singh PK, Rai RK, Alagarajan M, et al. Determinants of maternity care services utilization among married adolescents in rural India. PLoS One 0;:e. doi:0./journal.pone.00 Rakesh A, Amardeep T. Effect of maternal education on choice of location for BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

19 BMJ Open Page of delivery among Indian women. Natl Med J India 0;:. &AN=0 Karkee R, H Lee A, Khanal V. Need factors for utilisation of institutional delivery services in Nepal: an analysis from Nepal Demographic and Health Survey, 0. BMJ Open 0;. Singh A, Kumar A, Pranjali P. Utilization of maternal healthcare among adolescent mothers in urban India: evidence from DLHS-. PeerJ 0;:e. doi:0./peerj. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

20 Page of BMJ Open STROBE 00 (v) Statement Checklist of items that should be included in reports of cross-sectional studies Title of the study: Determinants of institutional delivery among young married women in Nepal: Evidence from the Nepal Demographic and Health Survey, 0 Section/Topic Item # Recommendation Reported on page # Title and abstract (a) Indicate the study s design with a commonly used term in the title or the abstract Introduction (b) Provide in the abstract an informative and balanced summary of what was done and what was found Background/rationale Explain the scientific background and rationale for the investigation being reported - Objectives State specific objectives, including any prespecified hypotheses - Methods Study design Present key elements of study design early in the paper Setting Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection Participants (a) Give the eligibility criteria, and the sources and methods of selection of participants Variables Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if Data sources/ measurement applicable * For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group Bias Describe any efforts to address potential sources of bias Study size 0 Explain how the study size was arrived at - Quantitative variables Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why Statistical methods (a) Describe all statistical methods, including those used to control for confounding on 0 December 0 by guest. Protected by copyright. (b) Describe any methods used to examine subgroups and interactions BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from -

21 BMJ Open Page 0 of Results Participants Descriptive data (c) Explain how missing data were addressed (d) If applicable, describe analytical methods taking account of sampling strategy Not applicable (e) Describe any sensitivity analyses Not applicable * (a) Report numbers of individuals at each stage of study eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed (b) Give reasons for non-participation at each stage (c) Consider use of a flow diagram Not applicable * (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential - confounders (b) Indicate number of participants with missing data for each variable of interest - Outcome data * Report numbers of outcome events or summary measures - Main results (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, % confidence 0- interval). Make clear which confounders were adjusted for and why they were included (b) Report category boundaries when continuous variables were categorized Not applicable (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Not applicable Other analyses Report other analyses done eg analyses of subgroups and interactions, and sensitivity analyses Not applicable Discussion Key results Summarise key results with reference to study objectives Limitations Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias Interpretation 0 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from - similar studies, and other relevant evidence Generalisability Discuss the generalisability (external validity) of the study results - Other information Funding Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based *Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

22 Page of BMJ Open Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at Annals of Internal Medicine at and Epidemiology at Information on the STROBE Initiative is available at BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

23 BMJ Open Determinants of institutional delivery among young married women in Nepal: Evidence from the Nepal Demographic and Health Survey, 0 Journal: BMJ Open Manuscript ID bmjopen-0-0.r Article Type: Research Date Submitted by the Author: -Jul-0 Complete List of Authors: SHAHABUDDIN, ASM; Instituut voor Tropische Geneeskunde, Public Health; Vrije Universiteit Amsterdam, Earth and Life Sciences De Brouwere, Vincent; Instituut voor Tropische Geneeskunde, Public Health Adhikari, Ramesh; Tribhuvan University, Geography and Population Department Delamou, Alexandre ; Centre national de formation et de recherche en santé rurale de Maferinyah, Forécariah, Guinea Bardají, Azucena; Universitat de Barcelona, Barcelona, Spain, ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic Delvaux, Thérèse; Instituut voor Tropische Geneeskunde, Public Health <b>primary Subject Heading</b>: Public health Secondary Subject Heading: Obstetrics and gynaecology, Health services research Keywords: PUBLIC HEALTH, Maternal Health, Adolescent health BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

24 Page of BMJ Open Title: Determinants of institutional delivery among young married women in Nepal: Evidence from the Nepal Demographic and Health Survey, 0 Corresponding author: ASM Shahabuddin, MPH, AMPHM,, Woman and Child Health Research Centre, Department of Public Health, Institute of Tropical Medicine, Nationalestraat, 000 Antwerp, Belgium. shahab@itg.be; Phone: + Co-authors: Vincent De Brouwere, MD, MPH, PhD Affiliation: Ramesh Adhikari, MSc, PhD Alexandre Delamou MD, MPH, MSc, Azucena Bardají, MD, PhD Thérèse Delvaux, MD, MPH, PhD VDBrouwere@itg.be rameshipsr@gmail.com adelamou@gmail.com abardaji@clinic.ub.es TDelvaux@itg.be Woman and Child Health Research Centre, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University Amsterdam, the Netherlands Geography and Population Department, Tribhuvan University, Mahendra Ratna Campus (TU), Kathmandu, Nepal Centre national de formation et de recherche en santé rurale de Maferinyah, Forécariah, Guinea Keywords: Determinants; Institutional delivery; Young women; Nepal Word count:, BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

25 BMJ Open Page of Abstract Objectives: To identify the determinants of institutional delivery among young married women in Nepal. Design: Nepal Demographic and Health Survey (NDHS) data sets 0 were analyzed. Bivariate and multivariate logistic regression analyses were performed using a subset of ever married young women (aged - years). Outcome measures: Institutional delivery Results: Rate of institutional delivery among young married women was % which is higher than the national average (%) among the women of reproductive age. Young women who had more than four antenatal care (ANC) visits were three times more likely to deliver in a health institution compared to those women who had no antenatal care visit (OR:.0; % CI:.0-.). The probability of delivering in an institution was % higher among young urban women than those young women who lived in rural areas. Young women who had secondary or above secondary level education were. times more likely to go for institutional delivery than those young women who had no formal education (OR:.; % CI:.-.). Lower use of health institution for delivery was also observed among poor young women. Results showed that wealthy young women were. times more likely to deliver their child in an institution compared to poor young women (OR:.0; % CI:.-.). Other factors such as the age of young women, religion, ethnicity, and ecological zone were also associated with the use of institutional delivery. Conclusions: Maternal health programs should be designed to encourage young women of receiving adequate (at least four) ANC. Moreover, health programs should target poor, less educated, rural, young women who reside in Mountain regions, belongs to Janajati ethnicity and young women with at least one child as they were less likely to opt for institutional delivery in Nepal. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

26 Page of BMJ Open Strengths and limitations of the study One of the strengths of this study is the use of latest nationally representative survey (Nepal Demographic and Health Survey 0). Therefore, findings can be generalized at national or regional levels of Nepal. One limitation is about the study design (cross-sectional) which does not confirm causal relationship between dependent and independent variables. Moreover, this study does not explain any programmatic and socio-cultural factors of the determinants of institutional delivery as Nepal Demographic and Health Survey Nepal did not collect data related to these factors. Recall bias, a potential limitation of DHS, could have limited the study findings. Introduction Over the past years, global maternal mortality ratio (MMR) fell by nearly % from an estimated maternal deaths per 00,000 livebirths in 0 to an MMR of in 0 []. Despite the significant reduction in maternal mortality, still every day about 0 women die during pregnancy and childbirth. The majority (%) of these deaths occurred in developing countries []. After sub-saharan Africa, countries in Southern Asia (including Nepal) carried the highest burden of global maternal mortality. Several studies showed that compared to adult women, young women (aged - years) including adolescent (aged 0- years) girls were at higher risk of pregnancy, delivery complications, and even death []. Preterm delivery, systemic infection, low birthweight, perinatal death, and maternal mortality were common among young women particularly among adolescents [ ]. An important strategy in decreasing maternal mortality is to utilize adequate, quality, maternal health services in a timely manner. Delivery complications and death can be averted by a hospital or institutional assisted delivery with the assistance of skilled care providers within an enabling environment, and by effective referral systems [ ]. The government of Nepal has been implementing a free delivery policy since 00 providing incentives to women who choose to deliver in a designated health facility []. However, the country remains as one of the countries in Southern Asia with a high MMR ( per 00,000 live births) [,0]. Underutilization of maternal health services is one of the reasons BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.

27 BMJ Open Page of for such high number of maternal deaths in Nepal []. Most recently a nationwide survey showed that about in 0 pregnant women received antenatal care from skilled providers while only % of childbirths occurred in health institutions [0]. Literature showed that several socio-demographic, economic, and cultural factors played a role in determining whether to use skilled birth attendants and institutional delivery among women in Nepal. Women s education, ethnicity, the area of residence, women s autonomy, women s involvement in a community group, wealth index, poor infrastructure, and lack of services appeared as the major factors that affect utilization of institutional delivery in Nepal. [,, 0]. However, all most all the studies considered all women of reproductive age (- years) as the study participants. So far, there has not been a study which explicitly focused on the young women s use of institutional delivery and factors influenced their utilization of maternal health services (i.e. institutional delivery). As most of existing studies conducted in Nepal provided evidence about all women of reproductive age, there was a need for broader data at a national level and for specific age groups, such as young women (aged - years). Therefore, in order to fulfill this gap, and an explicit understanding of the issue of institutional delivery among young women, this study aimed at identifying the determinants of institutional delivery among young women in Nepal. As the survey (Nepal Demographic and Health Survey) did not collect pregnancy or delivery related information from unmarred young women, so this study considered only married young women as the study participants. The findings of the study would be useful for health program managers and policy makers in policy generation and designing maternal health programs targeting young (including adolescent) women in Nepal. BMJ Open: first published as 0./bmjopen-0-0 on April 0. Downloaded from on 0 December 0 by guest. Protected by copyright.