Investigación original / Original research

Utilization of maternal health care services in the department of ,

Lindsey Ann Lubbock 1 and Rob B. Stephenson 1

Suggested citation Lubbock LA, Stephenson RB. Utilization of maternal health care services in the department of Mata- galpa, Nicaragua. Rev Panam Salud Publica. 2008;24(2):75–84.

ABSTRACT Objectives. To better understand the individual and community factors and perceptions that influence women’s health care–seeking behaviors during pregnancy in order to increase women’s utilization of maternal health services. Methods. This study investigates the logistical and sociocultural barriers influencing women’s utilization of maternal health services through 37 semi-structured in-depth inter- views with women from the department of Matagalpa, Nicaragua. Results. Results reveal that delays in seeking health care during pregnancy are influenced not only by poor access to care and economic barriers but also by individual and community knowledge and acceptance of maternal health services. Partner support, previous maternal health care experiences, and the degree of communication with other women and health work- ers affect women’s decisions to seek care. Conclusions. Evidence suggests that in order to improve maternal health outcomes in this region, interventions must be targeted at a hierarchy of levels: individual, household, and community.

Key words Maternal mortality, maternal health services, Nicaragua.

The United Nations estimates that tributing to maternal mortality in vention through education and ser- 529 000 women die each year from Nicaragua include lack of access to vices; developing secondary preven- complications during pregnancy and services, high fertility, domestic vio- tion through early detection and treat- childbirth (1) and approximately lence, complications of unsafe abor- ment of conditions; and advancing 22 000 maternal deaths occur annually tions, a large young reproductive age tertiary prevention through treatment in the Latin America and population, and hypertension (3–5). of conditions to reduce case fatality region (2). In Nicaragua, the second In recent decades, many strategies (7). While many strategies have at- poorest country in Latin America and have been implemented in an attempt tempted to address some of the eco- the Caribbean, the maternal mortality to improve maternal health outcomes nomic, social, and physical factors and ratio has reached as high as 230 mater- around the world. Programs aimed at barriers contributing to poor maternal nal deaths per 100 000 live births in re- reducing the three delays in seeking health outcomes, women’s utilization cent years (1). Common factors con- care2 include: improving primary pre- of maternal health services is often in- fluenced by perceived sociocultural, economic, and health system factors 1 Rollins School of Public Health, Emory University, 2 As outlined by Thaddeus and Maine (6), the three operating at the community, house- Hubert Department of Global Health, Atlanta, delays in receiving appropriate health care in- hold, and individual level as well as Georgia, United States of America. Send corre- clude: the delay in the decision to seek care, the spondence and reprint requests to: Lindsey Ann delay in arriving at a health facility, and the delay within the larger social and political Lubbock, e-mail: [email protected] in the provision of adequate care at the facility. environments (8–11). Addressing

Rev Panam Salud Publica/Pan Am J Public Health 24(2), 2008 75 Original research Lubbock and Stephenson • Utilization of maternal health services in Nicaragua health system factors and socioeco- and morbidity, the Nicaraguan Min- assume responsibility for the family’s nomic barriers is imperative for in- istry of Health has implemented the well-being and encourage specific creasing women’s overall utilization Women’s Comprehensive Care (Aten- health decisions and behaviors (28). of health services. Reducing maternal ción Integral a La Mujer) program (4). Women’s low status in society re- mortality through increased service Specific program interventions in- lative to the status of men contributes utilization, in turn, requires more clude emphasizing prenatal attention, to maternal mortality (29). The role of effective public health interventions clean and safe deliveries, family plan- men or partners in the decision-making built on a clear understanding of ning, and essential obstetric care (4). process regarding women’s prenatal women’s perceptions of maternal care While this program encourages wom- and delivery care has been noted as a services within their cultural context. en’s utilization of maternal health ser- factor influencing women’s health Although previous studies have ex- vices, women continue to face many care–seeking behaviors (9, 16, 24, 30). amined factors contributing to poor social, economic, and health system Women’s husbands’ or mothers-in- maternal health outcomes and access barriers when deciding whether or not law’s belief that maternal services are to care in some regions in Nicaragua, to seek antenatal and delivery care inappropriate or irrelevant has been a gap persists in understanding wom- (9–11, 16–19). Studies have examined shown to influence women’s percep- en’s perceptions of barriers limiting women’s individual perceptions influ- tions and utilization of care (31). their utilization of maternal health encing their utilization of prenatal care This qualitative research study aims services in the department of Mata- and delivery services in a wide range to explore the perceptions and factors galpa. This study examines the com- of socioeconomic and cultural contexts that influence women’s decisions to plex interaction of socioeconomic and around the world (9, 11, 16–20). While seek maternal health care in rural and cultural factors influencing women’s a woman’s perceived value of care semirural municipalities within the utilization of maternal health services often influences her decision to seek department of Matagalpa, Nicaragua.3 in the department of Matagalpa, care, the value she places on receiving Examining how delays in seeking and Nicaragua. prenatal care may differ from the receiving care are augmented by indi- Nicaragua has experienced some value she ascribes to delivery care (21). vidual and community attitudes and success in reducing maternal mortal- Perceptions of quality of care—includ- perceptions toward maternal health ity, but maternal deaths remain high ing promptness of care, competence of care is necessary to improve the health in some regions. A recent Nicaraguan health workers, desire for privacy, of pregnant women in this region and Ministry of Health report states that perceived availability of equipment, to provide the information needed for overall maternal mortality has disempowerment, abusive behavior, more effective targeting of public dropped by 46% over the past 15 and friendliness of staff—often influ- health interventions aimed at reducing years. It should be noted, however, ence women’s decisions to seek mater- maternal mortality. that over the past decade the mortality nal health care (9, 11, 22, 23). Women’s rate has only dropped by 22% (4). Ma- fear of doctors, medical examinations, ternal mortality ratios in Nicaragua and health procedures such as ce- MATERIALS AND METHODS range from 71.8 maternal deaths per sarean sections may influence their de- 100 000 live births (12) to 121 (13) and cision to seek care and the type of The department of Matagalpa is situ- 230 (1, 14). In the department of Mata- provider they use (16, 17, 24). Religion, ated in north-central Nicaragua, which galpa, approximately 19% of women spirituality, and traditional beliefs is located 120 km from the capital city surveyed did not receive any prenatal have also contributed to women’s per- of . Approximately 31% of care during their pregnancy for their ceptions and utilization of prenatal Nicaragua’s population (383 776) re- most recent child born, and 31.2% of and delivery care services (24–27). In sides in this region, with 68% of the those who had received prenatal care addition, while a woman’s knowledge population living in rural areas (15). attended less than four prenatal visits regarding pregnancy and delivery According to representatives from (15). While nearly 63% of children in risks is an important factor contribut- CARE Nicaragua, the department of the department of Matagalpa were de- ing to her decision to seek care (6), it Matagalpa has one regional hospital; livered in a health facility in the five may not change her reproductive 14 health centers (two of which have years prior to the 2001 survey, 37% of health behaviors due to conflicting pri- beds); and 126 health clinics (Erasmo deliveries still occurred in the home orities (16). For example, despite a (15). In a county with a very young high level of awareness of the poten- 3 For the purpose of the study, the municipality of population, one in three women that tial risks, a woman may choose to use , which is politically assigned to the de- partment of RAAN (Región Autónoma del Atlántico die of maternal causes in the depart- traditional methods rather than take Norte), was included in the department of Mata- ment of Matagalpa is an adolescent advantage of institutional maternal galpa. According to CARE Nicaragua representa- tives, Waslala, due to its geographic accessibility, under 20 years of age (4). services due to the influence of cul- receives health, education, and additional social In an attempt to improve maternal tural mores. In Latin America, women service programs through the department of Mata- galpa (Erasmo Jarquín, PhLic, and Daisy Navarro, health, increase safe deliveries, and re- take advantage of the knowledge of MD, CARE Matagalpa, personal communication, duce infant and maternal mortality extended family members, who often 29 January 2007).

76 Rev Panam Salud Publica/Pan Am J Public Health 24(2), 2008 Lubbock and Stephenson • Utilization of maternal health services in Nicaragua Original research

Jarquín, PhLic, and Daisy Navarro, poses of the study and provided verbal ceptual codes that evolved from the MD, CARE Matagalpa, personal com- informed consent. text and were used in this analysis munication, 29 January, 2007). The interviews were conducted in were related to barriers to accessing Women in Nicaragua live in a soci- Spanish using a pre-designed in- care, gender roles, perceptions of ety where machismo and conservative terview guide pretested for cultural health care, support, and the health religious ideology prevail (32). Such appropriateness and clarity. The inter- care system. ideology has limited women’s repro- view guide consisted of 31 multifac- ductive health choices and empow- eted open-ended questions covering a ered men to make the decisions re- range of issues related to maternal RESULTS garding sex and reproductive health4 mortality, prenatal care activities, (33). Reproductive health indicators community and familial support, Use of prenatal care and delivery for the department of Matagalpa are knowledge of pregnancy danger signs, services more worrisome than the average in- and access to care. The interview dicators for the country overall (15). In guide included specific questions re- Table 1 presents the patterns of ma- this region, approximately 19% of garding the mother’s maternal health ternal health care use among the women do not receive any prenatal care and delivery care experiences women interviewed. The self-reported care, and only 63% of births are deliv- (e.g., “Where did you give birth to age of participants ranged from 18–40, ered in a health facility (15). The total your child, and who was present dur- with a mean age of 26 years. The mean fertility rate in the region is 3.5, com- ing the birth?”, and “Who accompa- number of children per woman inter- pared to the national fertility rate of nied you to the birth?”) and broader viewed was 3.3.5 The overwhelming 3.2 (15). This qualitative investigation questions related to community and majority of women interviewed (31 of women’s maternal health care– individual beliefs about maternal out of 37, or 84%) reported seeking seeking behaviors and perceptions health (e.g., “Does a method exist in prenatal care at health facilities. The was conducted at rural and semirural your community for transporting a mean total number of prenatal care health posts and health centers located woman who has a pregnancy or birth visits among participants was 5. While in communities within the three mu- emergency?”, “Is it important to seek 31 women reported accessing prenatal nicipalities of Matagalpa, La Dalia, care during pregnancy?”, and “Do care services, only 19 (61%) of those and Waslala. others in your community think it is women delivered in health facilities. Qualitative data for this study was important to seek care during preg- All 10 of the women who stayed in a collected using an analytic induction nancy?”). The interviewer used prob- casa materna (maternity house) deliv- approach. In-depth interviews with ing and question-rephrasing tech- ered in a hospital or health center. All mothers 18 years of age or older were niques to clarify questions and obtain five of the women who reported hav- conducted between June and August details from the mothers. Participants ing a parity of one reported delivering 2006. Potential interview subjects were were not required to answer all of in a health facility. However, only six recruited using non-random snowball the questions. Interviews were tape- (67%) of the nine biparous women re- sampling of women waiting to receive recorded, and field notes served as a ported delivering their second child in health services at seven health clinics backup method of retrieving data. In- a health facility. Only five (33%) of the or centers in the three municipalities. terviews were conducted until a satu- 15 women who reported a birth order Sample selection criteria included non- ration point was reached when no new of three or greater delivered in a health pregnant women, women who had at information or insight into women’s facility. All of the six women who did least one child under the age of 3, and health-seeking behaviors and percep- not attend any prenatal visits deliv- non-health workers (i.e. those who tions was obtained. In total, 37 inter- ered at home. were not traditional birth attendants, views with mothers were conducted. health brigadistas [community health Interview field notes were written in volunteers], nurses, or physicians). Re- Spanish by the researcher throughout Logistical barriers to seeking care ferrals from community health volun- the tape-recorded interviews. Prelimi- teers were used to reach mothers who nary analysis was conducted through- While the services are theoretically lived near the health posts. All of the out the data collection process, allow- free, indirect costs such as financing women who volunteered to participate ing for early recognition of themes. All travel to and from the clinic, leaving received an explanation of the pur- interviews were transcribed into Span- work to seek care, and paying for pre- ish and subsequently analyzed the- scribed medicines were reported as 4 Mann E. Familialism in Nicaragua: reproductive matically using MAX Qualitative Data considerable barriers to accessing care and sexual policy regimes, 1979–2002. Paper pre- Analysis 2 (MAXqda2) (VERBI Soft- and treatment. Women also cited their pared for the International Sociological Associa- tion’s Research Committee on Poverty, Social Wel- ware, Berlin, Germany, 2004). Each in- need to prioritize spending money on fare and Social Policy (RC19) Annual Conference. terview was coded using unique the- September 8–10, Northwestern University, Chi- cago, 2005. Available from: http://www.north matic in-vivo codes systematically 5 Mean calculated from 29 of the 37 respondents western.edu/rc19/Mann.pdf. applied throughout the text. The con- who reported their total number of children.

Rev Panam Salud Publica/Pan Am J Public Health 24(2), 2008 77 Original research Lubbock and Stephenson • Utilization of maternal health services in Nicaragua

TABLE 1. Antenatal care utilization and place of delivery (department of Matagalpa, Nicaragua, 2006)

Received Reported Number prenatal number Use of Location Age of of care at of casa Place of of interview mother children facility visits materna last delivery

La Dalia 18 1 Yes 4 Yes Health facility La Dalia 18 1 Yes 4 Yes Health facility La Dalia 19 1 Yes 9 No Health facility La Dalia 19 1 Yes 9 Yes Health facility La Dalia 21 . . .a Yes 9 No Home La Dalia 22 2 Yes 3 No Home La Dalia 22 . . .a Yes 4 No Home La Dalia 23 2 Yes 6 No Health facility La Dalia 26 1+b No 0 No Home La Dalia 26 . . .a Yes 4 No Health facility La Dalia 28 . . .a Yes 4 No Health facility La Dalia 29 2 Yes 8 No Health facility La Dalia 29 4 Yes 4 No Health facility La Dalia 30 5 No 0 No Home La Dalia 30 3 Yes 9 Yes Health facility La Dalia 32 3 Yes 6 No Health facility La Dalia 34 7 No 0 No Home La Dalia 40 7 Yes 2 No Home Matagalpa 19 2 Yes 4 Yes Health facility Matagalpa 20 1 Yes 9 No Health facility Matagalpa 24 . . .a Yes 9 No Home Matagalpa 25 2 Yes 4 Yes Health facility Matagalpa 27 . . .a Yes 4 No Home Matagalpa 28 6 Yes 7 No Home Matagalpa 29 2 Yes 5 Yes Health facility Waslala 20 3 Yes 2 No Home Waslala 21 2 Yes 4 Yes Health facility Waslala 22 3 No 0 No Home Waslala 22 6 Yes 9 No Home Waslala 23 3 No 0 No Home Waslala 23 2 Yes 4 No Home Waslala 23 2 Yes 9 No Home Waslala 25 3 Yes 4 Yes Health facility Waslala 28 4 No 0 No Home Waslala 35 8 Yes 4 No Home Waslala 36 7 Yes 5 No Health facility Waslala 39 1+b Yes 9 Yes Health facility

a Number of children was not obtained in these interviews. b Women reported having more than one child but did not specify an exact number of children.

food and school-related expenditures “It was difficult because . . . sometimes Women’s intentions to utilize prena- for children and other family members you save the [money] but with other older tal and delivery care were often im- as an economic barrier to service uti- children in classes [you must borrow peded by their inability to cover the lization. Women’s perceptions of the money for school fees], and after [pay- cost of transportation, especially in an cost of delivery care services, includ- ing for the maternal services], you have emergency. Emergency transportation ing the cost of using a partera (tradi- to save to return this money.” 32-year-old options cited by women included: pay- tional birth attendant) and staying at mother, La Dalia ing a neighbor with a car; paying for the casa materna, contributed to their gas for the community ambulance; decisions to seek delivery care. “They told me that I would [have to] and calling on community members or pay and afterward they told me that I did the emergency transportation brigade “Yes, it is the most difficult—the not have to pay [and] that it would be (which often resulted in transport by money—because I was alone. I did not relaxing there [at the casa materna]. hammock to the nearest health facility have anyone to lend it to me.” 26-year-old Then I said, ‘No, it is better if I go home.’ ” or to an available vehicle). The burden mother, La Dalia 28-year-old mother, Matagalpa of accessing transportation was magni-

78 Rev Panam Salud Publica/Pan Am J Public Health 24(2), 2008 Lubbock and Stephenson • Utilization of maternal health services in Nicaragua Original research fied by the challenge of traveling long “I was working but during the nine vices. Women’s perception that facil- distances alone along inadequate roads months of pregnancy I did not continue ity-based care provides a safe environ- and/or in poor weather conditions. working . . . my husband was working far ment for receiving care evolved from away so he sent me the money.” 22-year- the quality of care they received and “If someone does not have money or old mother, La Dalia their delivery outcomes with previous means [of transportation], she has to pregnancies. Many women who expe- die in the home because here there is no “As always my mother accompanies me rienced complications with previous one that will give it to you. We have to because I am always not well. I leave . . . births or low parity had an increased carry you or take you if there is a vehicle.” my husband [with the house] and the fear and awareness of the risks in- 28-year-old mother, Waslala kids and he cares for them.” 28-year-old volved in failing to seek care and thus mother, La Dalia sought care to avoid complications. “There is an ambulance here but there is no gas, and if you do not have [money] for “More than any of the support, the gas you have to hold out here or die . . . Value of health care greatest support of all is the support of those who don’t have 200 córdobas can the hospital because of the safe delivery.” not be transported. [Women must] look Women’s knowledge and accep- 29-year-old mother, Matagalpa for how to borrow [money].” 32-year-old tance of the importance of maternal mother, La Dalia health care and healthy pregnancy “There are [some] parteras who are practices are shaped by previous expe- prepared [to care for women] in the home, “When it is wintertime the roads be- riences as well as formal and informal but not all, so sometimes I am afraid. Not come bad . . . and so some [women] do not communication within the community all parteras are well prepared.” 32-year- go. Also, the centers are [often] closed and and households. Many women who old mother, La Dalia sometimes women can not [find] someone utilized maternal health services be- to accompany [them] on the roads . . . and lieved it was important as a means of “I decided [to use the services] be- bad people [are on the roads], and for this reducing the risks of complications cause—[in case of an] emergency. Be- sometimes [women] do not go. Sometimes and ensuring the health of the unborn cause if I needed an IV solution or blood or the buses are dangerous.” 25-year-old child. Women—often those who deliv- if the baby was born sick there is also a doc- mother, Matagalpa ered healthy babies—praised the qual- tor. Because if someone is born sick then ity of care and attention they received they have to stay there.... If something Familial support allowed women to during pregnancy and delivery, not- occurred in the home it is not as if it were overcome logistical barriers associated ing the importance of receiving vita- in the hospital.” 19-year-old mother, with seeking care. A woman’s use of mins, vaccinations, and examinations Matagalpa services was facilitated by her hus- during pregnancy and the benefits of band’s financial contribution and such care in regard to the healthy de- “When a mother dies it is because she recognition of the importance of ma- livery of the new baby. did not attend her prenatal visits at the ternal health care. Women frequently health centers. With my first son, he died mentioned how husbands participated “In the health center they give you vita- because I started having pains in the home in securing monetary resources in mins. They check you to see if the baby is and they took me out of here and sent me preparation for the costs associated well, how it is coming along. For this rea- to the hospital in [community X]. They with transportation and care. In- son I go to the health center—to see how told me that the baby was born sick, and formed and engaged husbands indi- I am and the baby.” 23-year-old mother, three days after he was born, he died in the rectly supported women’s utilization Waslala hospital in [community X].... Yes, I of services by bearing the burden of went to all of my visits . . . and to deliver, caring for their homes and children “More than anything they always cared I went 15 days before to the maternity while women were seeking care. Fi- for me in the place that they sent me for the house.” 21-year-old mother, Waslala nancial preparation and support at the birth. I was attended to very well. They familial level permitted women, espe- accompanied me and the baby was born cially those experiencing a first- or healthy.” 20-year-old mother, Matagalpa Communication second-order birth, to access delivery services, including staying at the casa Many women stated that their materna to ensure the availability of Security of health facilities knowledge of pregnancy and delivery emergency transportation. practices came from health workers, Health facility–based care increased prior experience, or other more experi- “Saving. [Selling] animals, staple foods, women’s sense of security and safety, enced women in the community, espe- corn, beans to always have money for the which contributed to their perception cially their mothers and mothers-in- moment when you go to the hospital.” of the value of institutional care and law. Open communication with one’s 29-year-old mother, Matagalpa encouraged further utilization of ser- husband about the importance of seek-

Rev Panam Salud Publica/Pan Am J Public Health 24(2), 2008 79 Original research Lubbock and Stephenson • Utilization of maternal health services in Nicaragua ing care also facilitated a woman’s uti- delivering at home like other women in experiences receiving care—including lization of services. It was evident that their families. These women often only lack of attendance, excessive waiting the women who used the casa materna experienced minor (if any) complica- times, lack of agency regarding one’s had received information from health tions during labor and delivery. Wom- health, and embarrassing physical workers or community members re- en’s persistent disdain and distrust for examinations—discouraged women garding the services offered and the health care workers, including parteras, from seeking care at health facilities. A purpose of the casa materna. Women strengthened their desire to rely on fa- few women who experienced compli- who acknowledged their fears of com- miliar, traditional forms of care. While cations and had to deliver via cesarean plications and risks related to poor a majority of people in Nicaragua section believed returning to the health maternal and infant outcomes often maintain strong religious conviction, facility for a future delivery would communicated their feelings and re- women often attributed health care– result in the same outcome. Complica- ceived encouragement to seek care to seeking behaviors and both positive tions that resulted after having re- avoid complications. A few women re- and negative outcomes of past experi- ceived care from a partera have de- ported their desire to begin family ences to fate. Women’s strong fatalistic terred women from seeking future care planning to minimize the risk of com- beliefs were used to justify failure to at facilities or from parteras. plications due to birth spacing and seek care and reflected a sense of lim- high parity. ited control over health outcomes. “She had to go, the poor woman, and she spent all day here and left at four in the af- “When one does not know [one] asks “I did not want to go to the hospital be- ternoon from here and arrived at home at the parteras and the people, the older cause I am used to delivering in the home.” eight at night and then said she would not women. Some ask the older women who 23-year-old mother, Waslala go back because she says that no one at- have had an abundance of children.” tends to you in the [health] center and it 29-year-old mother, Matagalpa “. . . There was [a partera] but she was is too full and there are not sufficient doc- old, and I do not like her because she is a tors so it is not easy.... She decided to “My mother told me that we were going Sandinista. Sometimes . . . there is [no] stay in her house and if she were to die to the hospital because the second [preg- partera.” 35-year-old mother, Waslala she would be there.” 40-year-old mother, nancy] I was very sick, so I went. I tell La Dalia you that you can be very weak and also the “Afterward, when the doctor checked on birth can cause you to hemorrhage and you me, I told him that I did not want to go “The first months I did not come be- can die.” 28-year-old mother, La Dalia [home] because I still felt bad, but [then] cause when I arrived at five months or four I left because the people [at the hospital] months I began my visits, but the doctor “Every month my husband told me, are very bad and because they didn’t have did not attend to me because he did not be- ‘Today go to your [prenatal] visit. You time for me the following day.” 28-year- lieve that I was pregnant and I went to have to go because it is important because old mother, Matagalpa [community X] and had an exam and you do not want to go to the hospital,’ he afterward he did my visits [exams].” says, ‘but it is important to go to your “. . . If you do not have money, you de- 25-year-old mother, Matagalpa [prenatal] visits because someone tells you liver alone. It is the will of God.” 22-year- how you are [doing].’ He never told me old mother, La Dalia “[The health provider] told me, ‘I am not to go.” 28-year-old mother, Matagalpa not going to send you [to the casa ma- terna] because you have a lot of time left. “Where we live, a woman works there. Previous experiences No; go to your house’.... I left from the She said that a pregnant woman that goes center at 12 and arrived at [my] house to the casa materna goes to the health Women’s past experiences with and he was born at three in the morning.” center. I went to the casa materna be- poor-quality care or unclear informa- 30-year-old mother, La Dalia cause there it is much faster to get a tion in health facilities influenced fu- woman [to the health center] and it does ture behaviors. Poor communication “I didn’t look for a partera because with not take much time. Then I went with this or miscommunication with health pro- the first birth that was attended by the son that I have now.” 30-year-old mother, fessionals also contributed to wom- partera they did a cesarean section and be- La Dalia en’s misperceptions and lack of under- cause of this I remained scared to trust the standing regarding healthy behaviors partera.” 34-year-old mother, La Dalia and potential complications, as re- Traditional practices vealed in the interviews. Reported mis- diagnoses or unclear communication Shared information Many of the women who did not from health workers and other women seek prenatal or delivery care stated in the community have led to delayed Women’s decisions to seek care that they were not accustomed to using antenatal care visits and home deliver- were affected by prevailing rumors of prenatal care and were familiar with ies. Uncomfortable or negative past other women’s adverse experiences,

80 Rev Panam Salud Publica/Pan Am J Public Health 24(2), 2008 Lubbock and Stephenson • Utilization of maternal health services in Nicaragua Original research negative perceptions, and shared “Since I live alone working, out of ne- tal visits. . . . The husbands do not allow misconceptions that remained uncor- cessity working in the kitchen, my bosses them to go. They say to them that they have rected by health workers or other for- did not allow me to leave so I went on to care for the other [children in the mal sources of information. A wom- being pregnant and did not leave until I household].” 25-year-old mother, Waslala an’s fear of receiving vaccinations, delivered.... My bosses were demanding being touched or examined by health and did not allow me to leave.” 28-year- “There are women whose men left them workers, and taking unsafe trans- old mother, Waslala who have to go to work with this big portation to reach a health facility pre- belly. . . . In my community a woman vented some women from attending “When the husband tells her that she died . . . she was out working in the coffee prenatal visits. Women reported that can not go . . . no, no, the woman can fields but she had a man. But what hap- their fear of delivering in health facili- not go. Then she has to stay and bear it.” pened was that he was not the father of her ties is related to the shared perceptions 25-year-old mother, Waslala child she was about to have and during the that delivering in a health facility entire pregnancy she was in the coffee causes illness or guarantees a cesarean “Sometimes because they are jealous. . . . fields and the child was born dead because section delivery. Jealousy perhaps because of not wanting she often wore a corset and she ignored her the doctor to look at her or because he does tummy when lifting the baskets.” 21-year- “It troubles me because many women not want [the doctor] to see her vagina.” old mother, La Dalia tell me that they were touching the tummy, 25-year-old mother, Waslala they were lifting the dress, and [because of] fear of the vaccinations, because I have “When men hit us it is when we are DISCUSSION been terrified of vaccinations . . . since I with another man, right. Thus, we have to [started family] planning, because look at respect them and keep only one husband, This study examined the logistical my age. I have never been at a boarding because there are husbands that do not like and perceived barriers women con- [inpatient] hospital.” 34-year-old mother, when their wives speak to other men be- front when accessing maternal health La Dalia cause there are husbands that get jealous, services within the cultural context of right. They may think ‘my woman is be- Matagalpa, Nicaragua. The study has “Not in the hospital, because they give traying me’; [when] he hits me [I] think identified a range of logistical barriers you milk, and milk is bad. They give you that he is imagining things.” 22-year-old to seeking care that have also been fatty ingredients, and fatty ingredients are mother, La Dalia shown to be important in other coun- bad.... Cancerous tumors and vaginal tries and cultural contexts (9, 11, 16, cancers come from the fat.” 22-year-old Women were discouraged from ac- 20). The findings indicate that finan- mother, La Dalia cessing services because they feared cial obstacles, especially in relation to straying from their role as the caretaker transportation, time constraints, and “Sometimes it scares me because they by leaving their children, animals, and availability of health care staff and ser- say that the hospital can cause a woman to homes unattended in order to commit a vices influence women’s utilization of swell. They tell me this and it scares me so substantial amount of time to seeking prenatal and delivery services. While I did not go to the hospital.” 40-year-old care. Community expectations of a previous studies in Matagalpa have mother, La Dalia mother to act as the caregiver were rein- addressed logistical barriers, specifi- forced by the husband’s demand for her cally at the health facility level, no to remain at home. As a result of study has previously addressed the Gender and power issues society’s acceptance of the husbands’ underlying social and cultural percep- dominant role within the family, many tions influencing women’s utilization Women’s lack of autonomy and mo- women attributed poor maternal out- of services in this region (34). bility in the study region is illustrated comes to the husbands’ control over Women who perceive prenatal and by their need to receive permission women’s health care utilization. delivery care to be relevant overcome from their bosses or partners to seek Women also mentioned that the degree the logistical barriers with the support care. Women working and living in ha- of support a man provides throughout a of family members, most notably their ciendas (farms) or working outside of woman’s pregnancy and delivery may husbands and mothers or mothers- their own agricultural land or home vary depending on whether or not the in-law. Various factors facilitate wom- reported having to receive permission new baby is his own biological child. en’s utilization of institutional-based from bosses or managers to seek pre- maternal health services, including natal care. Women reported that men “I did not leave because I felt sorry to establishing financial savings, most expressed jealousy if their wives were leave the other children alone.” 22-year- often with the support of their hus- examined by a health practitioner and, old mother, Waslala bands; timely preparation for delivery, as a result, women were not permitted including staying at the casa materna; to seek care or chose not to in order to “Sometimes she dies because the hus- and arranging for a family member or avoid potential violence or conflict. band does not allow her to go to her prena- friend to accompany them, or to care

Rev Panam Salud Publica/Pan Am J Public Health 24(2), 2008 81 Original research Lubbock and Stephenson • Utilization of maternal health services in Nicaragua for their other children. However, enhanced through positive personal notion of motherhood and serving the women’s utilization of prenatal care experiences; an established sense of se- family leaves them economically de- does not necessarily translate to use of curity in health facilities; shared posi- pendent on men. This dependence institutional delivery care. While it ap- tive experiences; and direct, compre- grants men the authority, both in the pears that parity may affect a woman’s hensive communication with health workplace and in the home, to dictate use of delivery services, the themes workers. The disconnect between uti- women’s mobility and autonomy in ac- identified in the study did not clearly lization of prenatal care and delivery cessing maternal health care services. vary by women’s age or parity. It is services may be attributed to women’s A husband’s perception of the rele- possible that low-parity women face collective comfort with receiving pre- vance of accessing maternal health ser- fewer opportunity costs in relation to natal care at well-known rural health vices is an important factor influencing caring for additional children when clinics versus their apprehension at re- a woman’s health care–seeking behav- seeking delivery services. Some wom- ceiving delivery services at the larger ior. While a previous study in Nicara- en’s intentions to seek delivery care and better equipped yet unfamiliar gua revealed that men believe they may be thwarted by their failure to ac- health centers. have the right to decide when a cess or pay for emergency transporta- Women’s utilization of prenatal and woman should have children, further tion or their inability to travel due to delivery services is influenced by com- research regarding husbands’ percep- extremely rapid labor. However, these munal and individual perceptions re- tions and interpersonal communica- barriers do not completely explain the garding maternal care. This study re- tion regarding maternal health care is discrepancy between the use of pre- veals the shared cultural belief that a necessary for understanding women’s natal services and the use of delivery woman’s role is to be the caretaker of health care–seeking behaviors (33). services. The data show that a range of her children. Women’s acceptance of The study results should be consid- sociocultural factors may explain this their prescribed gender role as the pas- ered within the scope of the limita- disconnect between women’s utiliza- sive caretaker of the family heightens tions. Interviews were only conducted tion of prenatal and delivery services. the perceived opportunity costs of with mothers seeking care for their Logistical barriers, which are a seeking care. For women, prenatal child at a health clinic, thus the results product of the political and economic care is considered necessary primarily are not necessarily representative of environment, are easier to surmount to ensure the health of a child rather women who never seek care at health than the intergenerational cultural in- than to protect one’s own health. facilities. An additional limitation of fluences in this region. Women’s uti- There is a disconnect in how women this study is the effect of a three- lization of services is affected by the view prenatal and delivery care in re- month-long health workers’ strike five varying degree to which they receive lation to the health and security of months prior to beginning the research information about health care through their child, which may result in the dif- on prenatal and delivery care practices. formal and informal sources, includ- ference in their utilization of antenatal In addition, as with all research involv- ing other women in the community, and delivery services. Further research ing self-reported interview responses, health workers, and partners. Further- is warranted to examine the external there was a potential for recall bias, more, the level of encouragement and and internal construction of this care- particularly in reporting number of promotion of healthy maternal health taker role and the degree to which it prenatal visits. Furthermore, women care–seeking behaviors provided by extends to the unborn child. Better un- who were accompanied by their hus- those information resources influences derstanding of how the expectations of bands to the health facilities on the a woman’s ability to overcome the cul- other women, and husbands, influ- days of the interviews may have been tural barriers to seeking care. ence women’s perceptions of their du- hesitant to disclose details about their In the study setting, cohesive wom- ties as a caretaker may shed light on relationships with their husbands. As a en’s networks within families and women’s use of institutional delivery result, gender power dynamics at the communities link women and dissem- services and its influence on neonatal household level, which may not have inate their knowledge and experi- survival and overall child health. been completely understood, may ences. The data reveal that women’s Nicaragua is a country in which have affected the study outcome. disclosure of past experiences, tradi- machismo is manifested within the po- tional practices, and prevailing fears litical, social, and cultural environment and misconceptions influence their at- and may be exhibited in the behaviors CONCLUSION titudes toward prenatal and delivery of individual men (33). According to care as well as their utilization of ser- Sternberg (33), machismo is a domi- This study highlights the logistical vices. Women often rely on the knowl- nant, dynamic component of a value and sociocultural barriers impeding edge and advice of older, more experi- system that justifies the subordination women’s utilization of maternal health enced authority figures within their of women and governs the relation- services in Matagalpa, Nicaragua. En- network to direct their health care– ships among men in which women hanced health care infrastructure and seeking behaviors. Women’s percep- are considered “a form of currency.” human resource capacity would im- tions of prenatal and delivery care is Women’s acceptance of an idealized prove overall access to services and

82 Rev Panam Salud Publica/Pan Am J Public Health 24(2), 2008 Lubbock and Stephenson • Utilization of maternal health services in Nicaragua Original research would likely increase service utiliza- workers to address women’s questions and counseling, and encourage repeat tion. As demonstrated in this study, and misconceptions regarding care use of services. better understanding of community and delivery. Discussions about preg- This study highlights how men’s fi- and individual perceptions about pre- nancy and postpartum danger signs, nancial power and women’s accep- natal care, the quality of services, and adequate nutrition during pregnancy, tance of their passive gender role limits women’s health needs may improve delivery care services, casa materna uti- women’s agency in their own health the efficacy of public health interven- lization, and postpartum care could in- care. To maximize community under- tions and contribute to increased uti- form women about appropriate care standing and acceptance of maternal lization and effectiveness of maternal and the types of services available health services, public health interven- health services. Women’s ability to while initiating a dialogue about con- tions must target men, who often con- convene and communicate is a power- cerns women may have regarding trol women’s health-seeking practices. ful force that—if better understood by these issues. Alleviating misconcep- As the inclusion of men in maternal researchers—could be used as a tool tions and fears and reducing the gap in health programs has proven controver- for public health interventions. Future maternal health knowledge during sial, more research and comprehensive public health research should there- prenatal care may contribute to an in- monitoring and evaluation of programs fore target women’s networks and the crease in the utilization of delivery ser- involving men are needed to ascertain information being communicated via vices. Communication with women the male influence on women’s utiliza- those interpersonal relationships. about their expectations and percep- tion of maternal health services. Investigating women’s concerns re- tions of health facility deliveries, along garding quality of care and lack of with other issues, could improve com- Acknowledgements. Funding for communication between health work- munity awareness of the importance this research was provided through ers and patients may improve services of delivery services in regard to the The O. C. Hubert Charitable Trust and and increase consumer confidence. health of their unborn children. Prena- the Global Field Experiences Program The high level of utilization of prenatal tal care visits should also be used to at the Rollins School of Public Health, care services provides an opportunity educate women on how to avoid logis- Emory University. The authors wish to to improve the content and effective- tical barriers at the time of delivery. thank CARE and Annie Rivera, Mer- ness of prenatal care while encourag- Human resources at rural health facil- cedes Eritzia, and Erlinda Ruiz from ing healthy maternal care practices, in- ities, which are often understaffed, Nicaragua for their support in con- cluding delivering in health facilities. could be supplemented by trained ducting this research. The authors are Incorporating prenatal and delivery local community health workers to re- grateful to the many Nicaraguan education and counseling into stan- duce the workload of physicians or women who candidly shared their dard prenatal visits will allow health nurses, introduce effective education personal experiences.

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RESUMEN Objetivos. Mejorar el conocimiento sobre las percepciones y los factores personales y comunitarios que influyen en la búsqueda de atención médica durante el embarazo, con vistas a aumentar la utilización de los servicios de salud materna. Utilización de los servicios Métodos. Mediante 37 entrevistas semiestructuradas en profundidad aplicadas de salud materna en a mujeres del departamento de Matagalpa, Nicaragua, se investigaron las barreras el departamento de logísticas y socioculturales que influyen en la utilización de los servicios de salud materna. Matagalpa, Nicaragua Resultados. Los resultados muestran que sobre la demora en la búsqueda de aten- ción sanitaria durante el embarazo influyeron no solo el escaso acceso y las barreas económicas, sino también el conocimiento individual y comunitario sobre los servi- cios de salud materna y su grado de aceptación. El apoyo de la pareja, el haber reci- bido atención médica durante embarazos previos y el grado de comunicación con otras mujeres y trabajadores sanitarios influyeron en la decisión de las embarazadas de buscar atención. Conclusiones. Los datos indican que para mejorar la salud materna en esta región, las intervenciones se deben dirigir a diversos niveles: el individuo, el hogar y la comunidad.

Palabras clave Mortalidad materna, servicios de salud materna, Nicaragua.

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