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Utilization of Maternal Health Care Services in the Department of Matagalpa, Nicaragua

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Utilization of Maternal Health Care Services in the Department of Matagalpa, Nicaragua Investigación original / Original research Utilization of maternal health care services in the department of Matagalpa, Nicaragua 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 Caribbean 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 Managua. 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 Waslala, 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-
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