This study has found that utilisation of postnatal care has increased between 2006 to 2011 from 26.5%
 to 43.2%. Nevertheless, utilisation of postnatal care and immediate postnatal care among Nepalese mothers remains low. Community factors (place of residence and ecological region), socio-demographic factors (wealth status, religion, education, maternal occupation) and proximate factors (the use of recommended ANC service, place of delivery, skilled attendance during delivery) were significantly associated with the utilisation of postnatal care. A possible explanation for the low attendance to postnatal care in Nepal, could be cultural practice which prevents recently delivered mothers and newborns to be touched by any one or leave the house until the 12th day after delivery
. Such cultural practices have been reported in Bangladesh and India previously
[30, 31] and have been associated with non-utilisation of postnatal care
At the community level, the quality of care may also be preventing women from attending postnatal care. In Nepal, despite a focus on community-based services through primary health care outreach clinics, these clinics have been reported to function at a limited capacity
[32, 33], where lowly trained village health workers who have only a few months of training, and do not have a high school level qualification are often found running such clinics
. The major focus of their job is child immunisation. As result, they are rarely provided with postnatal care training. While these clinics can generally reach vast number of women, the clinics are usually conducted in public places such as schools, waiting areas of community centres, and temples; and thus lack adequate space for privacy. This lack of privacy, technical competency of the health workers, and lack of equipment may be the reason for the low utilisation of postnatal care by mothers.
One of the encouraging findings of this study is the effect of ANC attendance on postnatal care attendance. This study found that the mothers who attended four or more ANC visits as recommended by the WHO
 and the National guidelines of Nepal
, were more likely to attend postnatal care. ANC attendance and adequate counselling of mothers has been previously reported to be associated with postnatal care attendance
Place of delivery was significantly associated with attending immediate postnatal care. Women who deliver in a health facility, receive medical care from skilled attendants. Subsequently, mothers should receive postnatal care from skilled attendants within 24 hours after birth, before being discharged from the place of delivery, as per the Nepal postnatal guidelines
. Interestingly, this was not fully true for one in ten mothers in this study. Missing the opportunities to provide essential postnatal care in facility deliveries unnecessarily puts the lives of mothers and infants at risk. Future research needs to explore why such opportunities to provide postnatal care to mothers who deliver in health facilities and deliveries attended by skilled attendant are missed.
Mothers from urban areas and mothers from Terai areas were more likely to attend postnatal within 42 days after delivery and immediate postnatal care. This finding can be explained by the fact that in the mountainous and rural areas of Nepal there has less access to public services, such as roads, transport and health services. As a result, urban and Terai residents are likely to have more access to transportation and healthcare services
. A higher physical accessibility has been previously found to increase maternal health service utilisation in Nepal
 and Ghana
. This finding suggests there is a need to provide postnatal care through alternative means.
The finding that mothers with higher education were more likely to attend postnatal care can be explained by the notion that mothers with higher levels of education are more likely to be informed about health risks, demand and gain access to healthcare
. Likewise, mothers who are involved in paid employment are more likely to be economically independent and consequently have access to services, and utilise the services when they need or as recommended by their health workers
. Previous studies by Simkhada et al.
, Neupane et al.
 and Salam et al.
 also support the notion that attainment of education, and having a paid job empowers mothers to utilise maternal health services.
With regard to employment sector, agriculture is a very significant contributor to Nepal’s economy, with almost three in four households involved in agricultural activities, primarily as subsistence agriculture
. It is reasonable to assume that households who entirely depend on agriculture may be unable to attend postnatal care due to time away from work affecting their food production and income. Opening hours of health facilities (usually operating between 10.00 am-3.00 pm or only on certain days) may discourage women from seeking care. This conflicting time schedule may provide an explanation for the decreased likelihood of postnatal care attendance among mothers reporting agricultural occupation.
The current study also supported the common finding that mothers from rich households are more likely to attend postnatal care and immediate postnatal care. This finding can be explained by the availability of funds to spend on hospital for deliveries and obtain subsequent services such as postnatal care. Likewise, mothers from higher socioeconomic households are also more likely to be aware of the benefits of obtaining postnatal care through different media such as television, and newspapers than their counterparts from low socioeconomic groups. This finding is similar to the findings from the India and Nepal where mothers from higher socioeconomic group attend postnatal services
[12, 13, 34, 40, 41].
Public health implication
This study highlights the need to increase the availability and accessibility of health facilities during pregnancy, delivery and postnatal periods, as utilisation of ANC and delivery services increased the likelihood of postnatal care utilisation. Results from this study point to a combination of community and facility-based interventions as feasible measures to reach poor, rural, and less educated mothers including all mothers of the community
. To increase service use, it is necessary to invest in the existing networks of community health workers who run out-reach clinics in order to strengthen their capacity to provide quality maternity care with the necessary knowledge, skills and equipment. Such initiatives will ensure the most disadvantaged groups and those who cannot travel to health facilities due to long hours of work in the agricultural sector and those who live in remote hard-to-reach areas receive the necessary maternity care.
This study found that a significant proportion of the mothers who delivered in health facility or were attended by a skilled personal during delivery did not receive postnatal care. An incentive program to cover the transportation cost of mothers and incentive for health workers has been found successful in increasing the use of institutional deliveries
[9, 32]. A supply-side scheme, which rewards health workers for each postnatal woman they see, could be an option to ensure that all women who deliver in a health facility receive postnatal care.
Approximately 85% of mothers in Nepal attend at least one ANC visits, while the proportion of mothers attending four or more ANC visits drops to 50%
. This is a critical figure and, it suggests that health professionals should take advantage of the first ANC visit to highlight the potential risks of giving birth at home and not attending postnatal care. Further, as results suggest, encouraging mothers to attend the recommended four or more ANC visits will have a positive effect of postnatal care uptake. Providing education to husbands during antenatal period
, and increasing awareness about attending the recommended four ANC visits
 can have a positive effect in increasing institutional deliveries and postnatal care. At the community level, involvement of community leaders including religious leaders in health programs may be helpful in increasing the utilisation of postnatal care during the seclusion period when the mother and infant are confined to the isolation within their own house
. While it is encouraging to see the current implementation of community-based newborn programs focusing on the provision of home-based care to provide optimum care for newborn
, future pilot studies may evaluate the effect and feasibility of a similar approach to increase the use of postnatal care.
Strengths and limitations
The current study has a number of strengths. We used a national survey data, and relatively large sample size with a high response rate (95%)
. The demographic and health surveys are internationally validated and nationally adapted surveys. Therefore, the current findings are generalisable to the entire country. Our analysis accounted for study design and sampling procedure, which is more likely to yield accurate estimates
. This study has also provided updated knowledge on factors associated with the utilisation of postnatal care. In addition, this is the first study to report the prevalence and determinants of immediate postnatal care in Nepal. Nevertheless, the current study has several limitations. Cross-sectional nature of NDHS limits the capacity to draw any causal inferences. Also, as the survey asked the information retrospectively, this may have yielded some recall bias. Nevertheless, this bias is not considered problematic since this study included only women giving birth within five years preceding the survey.