Transcript The Guatemala Case - ATMCH - Association of Teachers of

Why Do Women Choose To
Deliver At Home And Not In
A Hospital?
The Guatemala Case Study
Fannie Fonseca-Becker, DrPH, MPH
Irina Zablotska, MD, MPH, PhD candidate
Johns Hopkins University Bloomberg SPH
Center for Communication Programs
JOHNS HOPKINS
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BACKGROUND
• Each year worldwide, almost 600,000 maternal deaths
occur due to complications of pregnancy and childbirth
• 90% occur in developing countries
• Safe 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
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BACKGROUND
• Rate of maternal deaths still remains high in
many developing countries
• Majority 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
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Conceptual framework of determinants of the place
of delivery
BACKGROUND
VARIABLES
MEDIATING
OUTCOME
Cognitive factors
Knowledge
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
Fonseca-Becker & Zablotska,
2002
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
PLACE OF DELIVERY
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
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Guatemala: a Setting for Theory Testing
• maternal 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 services
• main delivery providers - TBAs
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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
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Methods
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 union
• Departments Quiche, Solola and San Marcos
• stratified random sample
• Information on 1008 females is used in this analysis
MEASUREMENT 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
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Methods
• OUTCOME:
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 doctor
• INDEPENDENT VARIABLES / PREDICTORS:
Background variables, cognitive and environmental
variables and indices
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JOHNS HOPKINS
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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
utilization
• Only 30% of rural women think that
doctors or nurses can help them with
problems in delivery vs. 67% of urban
women
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Conclusions
• Wealthier women are more likely to use
formal health services for delivery
• women with more children are less likely
to deliver in hospitals
• past prenatal care increases probability
of woman’s delivery in health services
• knowing where to go is an important
predictor of delivery service utilization
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Conclusions
Believes and attitudes play important role in defining
woman’s delivery in formal health services:
• belief in institutional delivery increases chances of
delivery in the hospitals
• Positive attitudes towards health services and health
professionals are associated with institutional delivery
HOWEVER
• Positive attitudes towards traditional birth attendants
play negative role and are inversely associated with
delivery in health services
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