Why Do Women Choose To Deliver At Home And Not In A Hospital?The Guatemala Case StudyFannie Fonseca-Becker, DrPH, MPH Irina Zablotska, MD, MPH, PhD candidate

Johns Hopkins University Bloomberg SPHCenter for Communication Programs

BACKGROUNDEach year worldwide, almost 600,000 maternal deaths occur due to complications of pregnancy and childbirth90% occur in developing countriesSafe Motherhood Initiative - launched in 1987- designed to address the consequences of poor maternal health in developing countries - goal: to reduce maternal mortality by half by 2000- it focused mainly on correcting institutional deficiencies

BACKGROUNDRate of maternal deaths still remains high in many developing countriesMajority of maternal deaths happens outside of the formal health care system Main reasons of maternal deaths: - delays in decision-making to seek health services - delays in reaching services and - delays in obtaining services in time

Conceptual framework of determinants of the place of delivery

BACKGROUNDMEDIATINGOUTCOME

VARIABLES

Demographic

Age

Marital Status

Parity

Ethnic group (language

as proxy)

Place of residence

Socio-Economic

Education

Income

Wealth Index

Other

Past prenatal care

Social support

Cognitive factors

Knowledge

Knows where to go for care

Knows danger symptoms

Perceived Response Efficacy

In institutional delivery

In mothers seeking outside care

In health care professionals for healthy

Delivery

Attitudes

Index of attitudes towards quality of care by health professional

Index of attitudes towards quality of care by traditional birth attendant

Index of attitudes toward quality of care

in health services

Community / Social Norms

Maternal decision making index

Perception of community norms index

Intends to deliver in health system

Environmental Factors

Index of constraints to access to care

Existence of health care system in the community

Use of mass media

PLACE OF DELIVERY

Fonseca-Becker & Zablotska, 2002

Guatemala: a Setting for Theory Testingmaternal mortality ratio: - 190 maternal deaths per 100,000 live births - the second highest in South America (MNH country profile sheet) more than 60% of rural indigenous population 80% of indigenous women do not reach formal health sector and deliver at home only 22.7% of all pregnant women in Guatemala had their last birth in formal health servicesmain delivery providers - TBAs

MotherCare Project & Maternal/Neonatal Health (MNH) Program in Guatemala MotherCare Project - started in 1990- focused on provider training, behavior change interventions, community mobilization, and program monitoring systems to promote the survival of mothers and children

Maternal and Neonatal Health (MNH) Program- succeeded the MotherCare Project in 1998- a collaborative partnership of JHPIEGO, the Center for Development and Population Activities (CEDPA), Johns Hopkins University Center for Communication Programs (JHU/CCP), and Program for Appropriate Technology in Health (PATH)- funded by a cooperative agreement between the United States Agency for International Development (USAID) and the JHPIEGO Corporation- goal: to increase the adoption of healthy practices and use of services to improve the health of mothers and newborns

Study Population:Spring 2001: baseline household survey of women 15-49 years of age who had a child in the past 5 years and men older than 15 years of age in unionDepartments Quiche, Solola and San Marcosstratified random sampleInformation on 1008 females is used in this analysisMEASUREMENT INSTRUMENT: standard household survey, to assess:(1) knowledge, attitudes, practices and advocacy regarding birth (2) knowledge, perception and behavior regarding care of the mother and the neonate (3) family, and community birth preparedness (4) relations between families, traditional birth attendants and community leaders, (5) perceptions about family and community attitudes towards the health care system. Methods

MethodsOUTCOME:The use of formal health sector for most recent birth was defined as delivery in one of the following: 1) public hospital, health center or other public health institution/services; 2) hospital within the structure of social security system; or 3) private clinic/hospital, and delivery attended by a private doctorINDEPENDENT VARIABLES / PREDICTORS:Background variables, cognitive and environmental variables and indices

Chart3

2221.7

55.334.2

33.522.7

MNH

DHS

Percentage

Figure 2. Women's contact with formal health services, reported by MNH study (2001) and DHS Guatemala (1998-1999).

figure 2

Data source

MNHDHS

Current contraceptive use2221.7

Prenatal care provided by doctor/nurse55.334.2

Last birth in health services33.522.7

figure 2

00

00

00

MNH

DHS

Percentage

Figure 2. Women's contact with formal health services, reported by MNH study (2001) and DHS Guatemala (1998-1999).

figure3

Who can help in case of problems with delivery. Perceptions of

Urban women, %Rural women, %

Nobody0.00.2

Doctor/nurse66.929.6

TBA29.965.6

Relatives3.24.5

Other people0.00.2

figure3

00.19

66.8829.61

29.9465.55

3.184.47

00.19

Urban women, %

Rural women, %

Urban

figure4

0.19

29.61

65.55

4.47

0.19

Rural women, %

Rural

% women delivered in health services among those who

NoYes

Don't know where to go33.239

Services too far32.840.2

No transportation32.740.2

Too expensive31.246.4

Nobody to take care of children and/or home33.136.4

Fear of being mistreated31.938.3

Services are not good32.738.2

Family doesn't allow32.441.4

Other3429.8

Figure 3. Women's perceptions of who can help them in case of problems during delivery

Rural

Nobody

Doctor/nurse

TBA

Relatives

Other people

0.19

29.61

65.55

4.47

0.19

_1098258162.doc

Urban

30%

3%

67%

Doctor/nurse

TBA

Relatives

Figure 3. Women's perceptions of type of person who can help them

in case of problems during delivery.

Rural

4%

30%

66%

_1098258975.doc

Urban

30%

3%

67%

Doctor/nurse

TBA

Relatives

Figure 3. Women's perceptions of type of person who can help them

in case of problems during delivery.

Rural

4%

30%

66%

_1098278973.doc

Urban

30%

3%

67%

Doctor/nurse

TBA

Relatives

Figure 3. Women's perceptions of type of person who can help them

in case of problems during delivery.

Rural

4%

30%

66%

_1098258583.doc

Urban

30%

3%

67%

Doctor/nurse

TBA

Relatives

Figure 3. Women's perceptions of type of person who can help them

in case of problems during delivery.

Rural

4%

30%

66%

_1098258068.doc

Urban

30%

3%

67%

Doctor/nurse

TBA

Relatives

Figure 3. Women's perceptions of type of person who can help them

in case of problems during delivery.

Rural

4%

30%

66%

Conclusions This study observed increase in prenatal care and institutional delivery in Guatemala in comparison with DHS data (1998-1999). However big differences still exist between rural and urban women in service utilizationOnly 30% of rural women think that doctors or nurses can help them with problems in delivery vs. 67% of urban women

Conclusions Wealthier women are more likely to use formal health services for deliverywomen with more children are less likely to deliver in hospitalspast prenatal care increases probability of womans delivery in health servicesknowing where to go is an important predictor of delivery service utilization

Believes and attitudes play important role in defining womans delivery in formal health services:belief in institutional delivery increases chances of delivery in the hospitalsPositive attitudes towards health services and health professionals are associated with institutional delivery HOWEVERPositive attitudes towards traditional birth attendants play negative role and are inversely associated with delivery in health services

Conclusions