Why do women deliver in facilities, or not?

A key strategy promoted by international organizations to reduce maternal mortality is skilled birth attendance. This should be a provider trained in the essential elements of delivery care, typically a midwife, who could deliver at home or in an institution. In recognition that this skilled provider on her own can often do little if complications arise, the next extension of the strategy is to promote institutional delivery, either in a health centre with beds, or in a hospital, district or tertiary.1 In this issue of the WHO South-East Asia Journal of Public Health, a literature review by Rajendra Karkee and colleagues explores why maternity services in Nepal are underutilized, despite good overall availability of facilities.2 Their review highlights that various interventions aimed at increasing use of maternity services have been only partially successful. The main factors common to the reasons for underuse of maternity facilities were: social, distance, cost, and perceived quality of care.