Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal

The Impact of Introducing Midwives and also Mentoring on the Quality of Sexual, Reproductive, Maternal, Newborn, and Adolescent Health Services in Low- and Middle-Income Countries: An Integrative Review Protocol

INTRODUCTION

Midwives have the potential to significantly contribute to health-delivery systems by providing sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH) care. However, scant research finds barriers to understanding what midwives need to realize their full potential. There are gaps in the definition of a midwife and an understanding of effective means to support the implementation of midwifery care. Mentorship has been found to support systems and healthcare providers to improve care availability and quality.

OBJECTIVES

We describe the methodology of an integrative review that aims to generate evidence of the impact of introducing midwives and also on-site facility mentoring to better understand facilitators and barriers to implementation of the quality and availability of SRMNAH services in low- and middle-income countries (LMICs).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be used to carry out the integrative review. Four electronic bibliographic databases, PubMed MEDLINE, EMBASE, Scopus, and CINAHL, will be used to identify eligible studies. All types of qualitative or quantitative studies will be considered. Eligible studies will be screened according to Population, Intervention, Comparison, and Outcome (PICO) inclusion criteria, and data will be extracted against a predetermined format. The aspects of health system strengthening in providing improved SRMNCH care will be examined in this review to generate evidence on how midwives and mentorship can improve routine care and health outcomes using the World Health Organization's Six Building Blocks approach. The quality of the articles will be thematically analyzed in four areas: coherence and integrity, appropriateness for answering the question, relevance and focus, and overall assessment using the Gough weight-of-evidence framework.

EXPECTED RESULTS

The literature review will consider assessing both upstream health systems regulators and downstream effectors for implementing midwifery interventions. Within this building block framework, this research will report on the outcomes and experiences of introducing midwives and the effectiveness of mentoring midwives and other staff in midwives' roles in improving care quality and health outcomes.

High coverage but low quality of maternal and newborn health services in the coverage cascade: who is benefitted and left behind in accessing better quality health services in Nepal?

BACKGROUND

Antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital to improve the health of mothers and newborns. Despite improved access to these routine maternal and newborn health (MNH) services in Nepal, little is known about the cascade of health service coverage, particularly contact coverage, intervention-specific coverage, and quality-adjusted coverage of MNH services. This study examined the cascade of MNH services coverage, as well as social determinants associated with uptake of quality MNH services in Nepal.

METHODS

We conducted a secondary analysis of data derived from the Nepal Demographic and Health Survey (NDHS) 2016, taking 1978 women aged 15-49 years who had a live birth in the 2 years preceding the survey. Three outcome variables were (i) four or more (4⁺) ANC visits, (ii) institutional delivery, and (iii) first PNC visit for mothers and newborns within 48 h of childbirth. We applied a cascade of health services coverage, including contact coverage, intervention-specific and quality-adjusted coverage, using a list of specific intervention components for each outcome variable. Several social determinants of health were included as independent variables to identify determinants of uptake of quality MNH services. We generated a quality score for each outcome variable and dichotomised the scores into two categories of "poor" and "optimal" quality, considering > 0.8 as a cut-off point. Binomial logistic regression was conducted and odds ratios (OR) were reported with 95% confidence intervals (CIs) at the significance level of p < 0.05 (two-tailed).

RESULTS

Contact coverage was higher than intervention-specific coverage and quality-adjusted coverage across all MNH services. Women with advantaged ethnicities or who had access to bank accounts had higher odds of receiving optimal quality MNH services, while women who speak the Maithili language and who had high birth order (≥ 4) had lower odds of receiving optimal quality ANC services. Women who received better quality ANC services had higher odds of receiving optimal quality institutional delivery. Women received poor quality PNC services if they were from remote provinces, had higher birth order and perceived problems when not having access to female providers.

CONCLUSIONS

Women experiencing ethnic and social disadvantages, and from remote provinces received poor quality MNH services. The quality-adjusted coverage can be estimated using household survey data, such as demographic and health surveys, especially in countries with limited routine data. Policies and programs should focus on increasing quality of MNH services and targeting disadvantaged populations and those living in remote areas. Ensuring access to female health providers and improving the quality of earlier maternity visits could improve the quality of health care during the pregnancy-delivery-postnatal period.

Health facility delivery among women of reproductive age in Nigeria: Does age at first birth matter?

BACKGROUND

High maternal mortality ratio in sub-Saharan Africa (SSA) has been linked to inadequate medical care for pregnant women due to limited health facility delivery utilization. Thus, this study, examined the association between age at first childbirth and health facility delivery among women of reproductive age in Nigeria.

METHODS

The study used the most recent secondary dataset from Nigeria's Demographic and Health Survey (NDHS) conducted in 2018. Only women aged15-49 were considered for the study (N = 34,193). Bi-variate and multivariable logistic regression models were used to examine the association between age at first birth and place of delivery. The results were presented as crude odds ratios and adjusted odds ratios (aOR) with corresponding 95% confidence intervals (CIs). Statistical significance was set at p<0.05.

RESULTS

The results showed that the prevalence of health facility deliveries was 41% in Nigeria. Women who had their first birth below age 20 [aOR = 0.82; 95%(CI = 0.74-0.90)] were less likely to give birth at health facilities compared to those who had their first birth at age 20 and above.

CONCLUSION

Our findings suggest the need to design interventions that will encourage women of reproductive age in Nigeria who are younger than 20 years to give birth in health facilities to avoid the risks of maternal complications associated with home delivery. Such interventions should include male involvement in antenatal care visits and the education of both partners and young women on the importance of health facility delivery.

Who are dying and why? A case series study of maternal deaths in Nepal

OBJECTIVES

To identify delays and associated factors for maternal deaths in Nepal.

DESIGN

A cross-sectional case series study of maternal deaths. An integrated verbal and social autopsy tool was used to collect quantitative and qualitative information regarding three delays. We recorded death accounts and conducted social autopsy by means of community Focus Group Discussions for each maternal death; and analysed data by framework analysis.

SETTING

Sixty-two maternal deaths in six districts in three provinces of Nepal.

RESULTS

Nearly half of the deceased women (45.2%) were primiparous and one-third had no formal education. About 40% were from Terai/Madhesi and 30.6% from lower caste. The most common place of death was private hospitals (41.9%), followed by public hospitals (29.1%). Nearly three-fourth cases were referred to higher health facilities and median time (IQR) of stay at the lower health facility was 120 (60-180) hours. Nearly half of deaths (43.5%) were attributable to more than one delay while first and third delay each contributed equally (25.8%). Lack of perceived need; perceived cost and low status; traditional beliefs and practices; physically inaccessible facilities and lack of service readiness and quality care were important factors in maternal deaths.

CONCLUSIONS

The first and third delays were the equal contributors of maternal deaths. Interventions related to birth preparedness, economic support and family planning need to be focused on poor and marginalised communities. Community management of quick transportation, early diagnosis of pregnancy risks, accommodation facilities near the referral hospitals and dedicated skilled manpower with adequate medicines, equipment and blood supplies in referral hospitals are needed for further reduction of maternal deaths in Nepal.

Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants

Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal’s transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal’s maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal

INTRODUCTION

Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings.

METHODS

This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys.

RESULTS

The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014).

CONCLUSION

BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility.

Ready to deliver maternal and newborn care? Health providers' perceptions of their work context in rural Mozambique

Background: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

Objectives: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

Methods: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach’s α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

Results: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

Conclusions: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants’ responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

The quality of skilled birth attendants in Nepal: High aspirations and ground realities

BACKGROUND

While Nepal's maternal mortality ratio (MMR) has improved overall, the proportion of maternal deaths occurring in health facilities and attended to by skilled birth attendants (SBAs), has nearly doubled over 12 years. Although there are numerous socioeconomic, environmental and other factors at play, one possible explanation for this discrepancy between utilization of skilled maternal care services and birth outcomes lies in the quality of care being provided by SBAs. The objective of this study is to determine how competent SBAs are after training, across multiple settings and facility types in Nepal.

METHODS

We used a quantitative cross-sectional analysis to evaluate a sample of 511 SBAs, all female, from 276 sub-health posts (SHP), health posts (HP), primary healthcare centers (PHC), and district and regional hospitals in the mountain, hill, and terai districts of Nepal. Any SBA actively employed by one of these health facilities was included. SBAs who had received less than three months of training were excluded. Outcomes were measured using SBAs' scores on a standardized knowledge assessment, clinical skills assessment, and monthly delivery volume, particularly as it compared with the WHO's recommendation for minimum monthly volume to maintain competence.

RESULTS

SBAs on average exhibit a deficiency of both knowledge and clinical skills, failing to meet even the 80-percent standard that is required to pass training (knowledge: 75%, standard deviation 12%; clinical skills: 48%, standard deviation 15%). Moreover, SBAs are conducting very few deliveries, with only 7 percent (38/511) meeting the minimal volume recommended to maintain competence by the WHO, and a substantial fraction (70/511, 14%) performing an average of no monthly deliveries at all.

CONCLUSIONS

Taken together, our findings suggest that while countries like Nepal have made important investments in SBA programs, these healthcare workers are failing to receive either effective training or sufficient practice to stay clinically competent and knowledgeable in the field. This could in part explain why institutional deliveries have generally failed to deliver better outcomes for pregnant women and their babies.

Social determinants of health affecting utilisation of routine maternity services in Nepal: a narrative review of the evidence

Nepal has one of the highest maternal and neonatal mortality rates among low- and middle-income countries. Nepal's health system focuses on life-saving interventions provided during the antenatal to postpartum period. However, the inequality in the uptake of maternity services is of major concern. This study aimed to synthesise evidence from the literature regarding the social determinants of health on the use of maternity services in Nepal. We conducted a structured narrative review of studies published from 1994 to 2016. We searched five databases: PubMed; CINAHL; EMBASE; ProQuest and Global Index Medicus using search terms covering four domains: access and use; equity determinants; routine maternity services and Nepal. The findings of the studies were summarised using the World Health Organization's Social Determinants of Health framework. A total of 59 studies were reviewed. A range of socio-structural and intermediary-level determinants was identified, either as facilitating factors, or as barriers, to the uptake of maternity services. These determinants were higher socioeconomic status; education; privileged ethnicities such as Brahmins/Chhetris, people following the Hindu religion; accessible geography; access to transportation; family support; women's autonomy and empowerment; and a birth preparedness plan. Findings indicate the need for health and non-health sector interventions, including education linked to job opportunities; mainstreaming of marginalised communities in economic activities and provision of skilled providers, equipment and medicines. Interventions to improve maternal health should be viewed using a broad 'social determinants of health' framework.

Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care.

OBJECTIVES

To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies.

SEARCH METHODS

Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016).

SELECTION CRITERIA

We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review.

MAIN RESULTS

We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America.Our synthesis pointed to a number of factors affecting SBAs' provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed.Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards.Skilled birth attendants' ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs' morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women's negative perceptions of the health system could make them reluctant to accept referral.We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants' motivation, their decision-making abilities, and the quality of care. Skilled birth attendants' workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers.

AUTHORS' CONCLUSIONS

Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

Barriers to utilization of childbirth services of a rural birthing center in Nepal: A qualitative study

Background

Maternal mortality and morbidity are public health problems in Nepal. In rural communities, many women give birth at home without the support of a skilled birth attendant, despite the existence of rural birthing centers. The aim of this study was to explore the barriers and provide pragmatic recommendations for better service delivery and use of rural birthing centers.

Methods

We conducted 26 in-depth interviews with service users and providers, and three focus group discussions with community key informants in a rural community of Rukum district. We used the Adithya Cattamanchi logic model as a guiding framework for data analysis.

Results

Irregular and poor quality services, inadequate human and capital resources, and poor governance were health system challenges which prevented service delivery. Contextual barriers including difficult geography, poor birth preparedness practices, harmful culture practices and traditions and low level of trust were also found to contribute to underutilization of the birthing center.

Conclusion

The rural birthing center was not providing quality services when women were in need, which meant women did not use the available services properly because of systematic and contextual barriers. Approaches such as awareness-raising activities, local resource mobilization, ensuring access to skilled providers and equipment and other long-term infrastructure development works could improve the quality and utilization of childbirth services in the rural birthing center. This has resonance for other centers in Nepal and similar countries.

Is the Job Satisfaction Survey a good tool to measure job satisfaction amongst health workers in Nepal? Results of a validation analysis

Background

Job satisfaction is an important predictor of an individual’s intention to leave the workplace. It is increasingly being used to consider the retention of health workers in low-income countries. However, the determinants of job satisfaction vary in different contexts, and it is important to use measurement methods that are contextually appropriate. We identified a measurement tool developed by Paul Spector, and used mixed methods to assess its validity and reliability in measuring job satisfaction among maternal and newborn health workers (MNHWs) in government facilities in rural Nepal.

Methods

We administered the tool to 137 MNHWs and collected qualitative data from 78 MNHWs, and district and central level stakeholders to explore definitions of job satisfaction and factors that affected it. We calculated a job satisfaction index for all MNHWs using quantitative data and tested for validity, reliability and sensitivity. We conducted qualitative content analysis and compared the job satisfaction indices with qualitative data.

Results

Results from the internal consistency tests offer encouraging evidence of the validity, reliability and sensitivity of the tool. Overall, the job satisfaction indices reflected the qualitative data. The tool was able to distinguish levels of job satisfaction among MNHWs. However, the work environment and promotion dimensions of the tool did not adequately reflect local conditions. Further, community fit was found to impact job satisfaction but was not captured by the tool. The relatively high incidence of missing responses may suggest that responding to some statements was perceived as risky.

Conclusion

Our findings indicate that the adapted job satisfaction survey was able to measure job satisfaction in Nepal. However, it did not include key contextual factors affecting job satisfaction of MNHWs, and as such may have been less sensitive than a more inclusive measure. The findings suggest that this tool can be used in similar settings and populations, with the addition of statements reflecting the nature of the work environment and structure of the local health system. Qualitative data on job satisfaction should be collected before using the tool in a new context, to highlight any locally relevant dimensions of job satisfaction not already captured in the standard survey.

Implementing a culturally appropriate birthing policy: Ethnographic analysis of the experiences of skilled birth attendants in Peru

Policies about skilled birth attendants (SBA) need to account for cultural acceptability of care rendered by SBAs. Few studies have assessed these policies from the perspective of SBAs. I identify challenges and analyze the experiences of SBAs implementing a culturally appropriate birth care policy in Peru. I collected data during 15 months of ethnographic research: conducting semi-structured interviews and informal conversations with 5 SBAs in 2 villages and with health officials. I compared interview results with my observations of consultations and of labor and delivery. Weak institutional support, lack of training, negative perceptions of the policy inhibited implementation, as did detrimental effects on future personal and professional opportunities. SBAs in Peru face many challenges when trying to establish intercultural birth care. My recommendations include provision of focused training, promoting a more diverse workforce, and increasing community engagement.Journal of Public Health Policy advance online publication, 19 May 2016; doi:10.1057/jphp.2016.19.

Birthing Centers Staffed by Skilled Birth Attendants: Can They Be Effective … at Scale?

Peripheral-level birthing centers may be appropriate and effective in some circumstances if crucial systems requirements can be met. But promising models don’t necessarily scale well, so policy makers and program managers need to consider what requirements can and cannot be met feasibly at scale. Apparently successful components of the birthing center model, such as engagement of traditional birth attendants and use of frontline staff who speak the local language, appear conducive to use in other similar settings.

Casas Maternas in the Rural Highlands of Guatemala: A Mixed-Methods Case Study of the Introduction and Utilization of Birthing Facilities by an Indigenous Population

In an isolated mountainous area of Guatemala with high maternal mortality, an NGO-sponsored approach engaged communities to operate local, culturally appropriate birthing facilities and is achieving high and equitable utilization. Likely success factors:

Community engagement and ownership

Close location of facilities

Perceived high quality of services

Engagement of traditional birth attendants in the birthing process and as advocates for facility use

Background:

An international NGO, with financial and managerial support from “partner” communities, established Casas Maternas (birthing facilities) in 3 municipalities in the isolated northwestern highlands of the department of Huehuetenango in Guatemala—an area with high maternal mortality ratio (338 maternal deaths per 100,000 live births). Traditional birth attendants are encouraged to bring patients for delivery at the Casas Maternas, where trained staff are present and access to referral care is facilitated.

Methods:

We conducted a mixed-methods study in San Sebastian Coatán municipality to assess the contribution of 2 Casas Maternas to health facility deliveries among partner and non-partner communities, with particular emphasis on equity in access. We surveyed all women who delivered in the study area between April 2013 and March 2014, the first full year in which both Casas Maternas in the study area were operating. In addition, using purposive sampling, we conducted in-depth interviews with 22 women who delivered and 6 focus group discussions with 42 community leaders, traditional birth attendants, and Casas Maternas staff members. We analyzed the quantitative data using descriptive statstics and the qualitative data with descriptive content analysis.

Results:

Of the 321 women eligible for inclusion in the study, we surveyed 275 women (14.3% could not be located or refused to participate). Between April 2013 and March 2014, 70% of women living in partner communities delivered in a health facility (54% in a Casa Materna) compared with 30% of women living in non-partner communities (17% in a Casa Materna). There was no statistically significant difference in uptake of the Casa Materna by maternal education and only a weak effect by household wealth. In contrast, distance from the Casa Materna had a pronounced effect. Traditional birth attendants were strong advocates for utilization of the Casa Materna and played an important role in the decision regarding where the birth would take place. In addition, the program’s outreach component, in which peer volunteers visit homes to promote healthy behaviors and appropriate use of health facilities, was identified as a key factor in encouraging mothers to deliver in facilities.

Discussion:

The Casa Materna approach to strengthening maternity care as developed by Curamericas has potential to increase health facility utilization in isolated mountainous areas inhabited by an indigenous population where access to government services is limited and where maternal mortality is high. The approach shows promise for broader application in Guatemala and beyond.