Henry Perry MD PhD MPH Karin Rivas Eng MSc Ira Stollak MA MPH Casas Maternas in the Rural Highlands of Guatemala: A Case Study of Their Introduction, Utilization and Equity of Utilization by Indigenous Population Henry Perry MD PhD MPH Karin Rivas Eng MSc Ira Stollak MA MPH Guatemala, March 2015

Content Introduction Purpose of the research Methodology Results and Discussion Conclusions

INTRODUCTION

The maternal mortality among indigenous women in Guatemala is one of the highest in Latin America and is twice that of non-indigenous women (163 vs. 77) This evident inequality represents a long history of marginalization and discrimination among indigenous women who lack access to health care; in the department of Huehuetenango, for example, only 20% deliver in health facilities. To reduce maternal and child mortality, Curamericas-Guatemala has implemented the Casas Maternas

RESEARCH PURPOSE

Examine whether the Casa Materna has contributed to increasing institutional deliveries in the 32 communities in the municipality of San Sebastián Coatán, What factors have influenced the women in these communities to use or not use the Casas Maternas? Has the Casa Materna improved equity regarding institutional deliveries in the region of study?

METHODOLOGY

Study setting

Study design

Mixed methods study KPC survey In-depth interviews Group interviews Women who delivered in the study area between April 2013 and March 2014 (n=275) were interviewed. Focus group discussions and in-depth interviews were conducted in a purposive but representative sample in the study area. Women who delivered, Comadronas, and community leaders were interviewed.

Data collection KPC survey was done in September 2014 by a team of 12 trained bilingual Chuj women. Of the 321 women identified from the vital events registration system, 46 had moved out of the area, could not be located, or refused to be interviewed, 275 were interviewed.

In depth interviews and group interviews were conducted during 4 weeks, September/October 2014. Women for in depth interviews were purposely selected reviewing the Curamericas-Guatemala data base. For each community were selected 4 women two who has used the Casa Materna and 2 who has not used the Casa Materna. We select them by age (the youngest, the oldest), number of births, etc. In order to have a good sample (Varied kind of participants). 19 in-depth interviews and 5 group interview

Data analysis

In-depth interviews and group interviews were audio-recorded and independently transcribed and translated into Spanish, with the transcriptions reviewed by two field supervisors before analysis. The qualitative data were manually reviewed and inductively grouped and coded into categories. This process in referred to as descriptive content analysis, which involves identifying themes among the responses and locating the specific responses with these themes. The coding and interpretation were then checked collaboratively, and found to be consistent. The quantitative and qualitative data were integrated at the interpretation stage and triangulated for congruence and complementarity

Equity indicators of coverage Level of education Level of poverty Epi Info 7.1, Stata 13 Equity indicators of coverage Level of education Level of poverty Distance to the nearest Casa Materna For the equity analyses, frequency distributions of the number of years of education of the mother and the distance of the mother’s community from the nearest Casa Materna were utilized to establish terciles. The distribution of the mother’s family’s PCA asset score was used to develop quintiles.

Decision about birth place Theme Description   Decision about birth place Comments about how the location of birth was selected. Sub-codes: • Influence of others on delivery location • Cultural traditions • Previous birth experiences • Perception of distance (transportation) • The influence of costs on birth location Birth experience Comments related to the actual experience of giving birth. • Opinions about the care received at home or at a facility Recommendations Comments about suggestions for labor and delivery services. • Suggestions for improvements to the health services

Ethical Clearance

RESULTS

Coverage, poverty indicator

Coverage, distance indicator

Decision about birth place Theme Sub-themes Barriers and Facilitators Decision about birth place Influence of others about birth place decision Barrier: Many people involved in the decision Facilitator: Comadrona role Barrier: Husband role Cultural traditions Barrier: Traditions that support delivery at home Previous experiences Facilitator/Barrier: effect of previous experience about the birth place. Distance perception Barrier: The Casa Materna is perceived as far place Facilitator: the Casa Materna is perceived as near place Delivery cost perception Barrier: the perception of the Casa Materna is expensive. Facilitator: Casa Materna is perceived as a cheap place

DISCUSSION

The Casa Materna approach to strengthening maternity care as developed by Curamericas shows promise for increasing 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.

Conclusions The research results indicate that the influence of Comadronas and community leaders strongly influences the use of the Casa Materna in the partner communities, and women receiving high quality services in them. Keeping high quality services homes is vital to the Casas Maternas success.