Women's position within the household as a determinant of maternal health care use in Nepal.

Context: Although gender inequality is often cited as a barrier to improving maternal health in Nepal, little attention has been directed at understanding how sociocultural factors may influence the use of health care. In particular, how a woman's position within her household may affect the receipt of health care deserves further investigation.

Methods: Data on ever-married women aged 15-49 from the 2001 Nepal Demographic and Health Survey were analyzed to explore three dimensions of women's position within their household-decision making, employment and influence over earnings, and spousal discussion of family planning. Logistic regression models assessed the relationship of these variables to receipt of skilled antenatal and delivery care.

Results: Few women reported participation in household decision making, and even fewer had any control over their own earnings. However, more than half reported discussing family planning with their husbands, and there were significant differences among subgroups in these indicators of women's position. Though associations were not consistent across all indicators, spousal discussion of family planning was linked to an increased likelihood of receiving skilled antenatal and delivery care (odds ratios, 1.4 and 1.3, respectively). Women's secondary education was also strongly associated with the greater use of health care (5.1-5.6).

Conclusions: Gender inequality constrains women's access to skilled health care in Nepal. Interventions to improve communication and strengthen women's influence deserve continued support. The strong association of women's education with health care use highlights the need for efforts to increase girls' schooling and alter perceptions of the value of skilled maternal health care.