1. Why Do Women Choose To Deliver At Home And Not In A Hospital? The Guatemala Case Study Fannie Fonseca-Becker, DrPH, MPH Irina Zablotska, MD, MPH, PhD candidate Johns Hopkins University Bloomberg SPH Center for Communication Programs

2. BACKGROUND Each year worldwide, almost 600,000 maternal deaths occur due to complications of pregnancy and childbirthEach year worldwide, almost 600,000 maternal deaths occur due to complications of pregnancy and childbirth 90% occur in developing countries90% occur in developing countries Safe Motherhood InitiativeSafe Motherhood Initiative - launched in 1987 - designed to address the consequences of poor maternal health in developing countries - goal: to reduce maternal mortality by half by 2000 - it focused mainly on correcting institutional deficiencies

3. BACKGROUND Rate of maternal deaths still remains high in many developing countriesRate of maternal deaths still remains high in many developing countries Majority of maternal deaths happens outside of the formal health care systemMajority of maternal deaths happens outside of the formal health care system Main reasons of maternal deaths:Main reasons of maternal deaths: - delays in decision-making to seek health services - delays in decision-making to seek health services - delays in reaching services and - delays in reaching services and - delays in obtaining services in time - delays in obtaining services in time

4. Conceptual framework of determinants of the place of delivery of delivery

5. Guatemala: a Setting for Theory Testing maternal mortality ratio:maternal mortality ratio: - 190 maternal deaths per 100,000 live births - the second highest in South America (MNH country profile sheet) more than 60% of rural indigenous populationmore than 60% of rural indigenous population 80% of indigenous women do not reach formal health sector and deliver at home80% of indigenous women do not reach formal health sector and deliver at home only 22.7% of all pregnant women in Guatemala had their last birth in formal health servicesonly 22.7% of all pregnant women in Guatemala had their last birth in formal health services main delivery providers - TBAsmain delivery providers - TBAs

6. MotherCare Project & Maternal/Neonatal Health (MNH) Program in Guatemala MotherCare Project & Maternal/Neonatal Health (MNH) Program in Guatemala MotherCare ProjectMotherCare Project - started in 1990 - focused on provider training, behavior change interventions, community mobilization, and program monitoring systems to promote the survival of mothers and children Maternal and Neonatal Health (MNH) ProgramMaternal and Neonatal Health (MNH) Program - succeeded the MotherCare Project in 1998 - a collaborative partnership of JHPIEGO, the Center for Development and Population Activities (CEDPA), Johns Hopkins University Center for Communication Programs (JHU/CCP), and Program for Appropriate Technology in Health (PATH) - funded by a cooperative agreement between the United States Agency for International Development (USAID) and the JHPIEGO Corporation - goal: to increase the adoption of healthy practices and use of services to improve the health of mothers and newborns

7. Study Population: Spring 2001: baseline household survey of women 15-49 years of age who had a child in the past 5 years and men older than 15 years of age in unionSpring 2001: baseline household survey of women 15-49 years of age who had a child in the past 5 years and men older than 15 years of age in union Departments Quiche, Solola and San MarcosDepartments Quiche, Solola and San Marcos stratified random samplestratified random sample Information on 1008 females is used in this analysisInformation on 1008 females is used in this analysis MEASUREMENT INSTRUMENT: standard household survey, to assess:standard household survey, to assess: (1) knowledge, attitudes, practices and advocacy regarding birth (2) knowledge, perception and behavior regarding care of the mother and the neonate (3) family, and community birth preparedness (4) relations between families, traditional birth attendants and community leaders, (5) perceptions about family and community attitudes towards the health care system. Methods

8. Methods OUTCOME:OUTCOME: The use of formal health sector for most recent birth was defined as delivery in one of the following: 1) public hospital, health center or other public health institution/services; 1) public hospital, health center or other public health institution/services; 2) hospital within the structure of social security system; or 2) hospital within the structure of social security system; or 3) private clinic/hospital, and delivery attended by a private doctor 3) private clinic/hospital, and delivery attended by a private doctor INDEPENDENT VARIABLES / PREDICTORS:INDEPENDENT VARIABLES / PREDICTORS: Background variables, cognitive and environmental variables and indices

11. Conclusions This study observed increase in prenatal care and institutional delivery in Guatemala in comparison with DHS data (1998-1999). However big differences still exist between rural and urban women in service utilizationThis study observed increase in prenatal care and institutional delivery in Guatemala in comparison with DHS data (1998-1999). However big differences still exist between rural and urban women in service utilization Only 30% of rural women think that doctors or nurses can help them with problems in delivery vs. 67% of urban womenOnly 30% of rural women think that doctors or nurses can help them with problems in delivery vs. 67% of urban women

12. Conclusions Wealthier women are more likely to use formal health services for deliveryWealthier women are more likely to use formal health services for delivery women with more children are less likely to deliver in hospitalswomen with more children are less likely to deliver in hospitals past prenatal care increases probability of woman’s delivery in health servicespast prenatal care increases probability of woman’s delivery in health services knowing where to go is an important predictor of delivery service utilizationknowing where to go is an important predictor of delivery service utilization

13. Believes and attitudes play important role in defining woman’s delivery in formal health services: belief in institutional delivery increases chances of delivery in the hospitalsbelief in institutional delivery increases chances of delivery in the hospitals Positive attitudes towards health services and health professionals are associated with institutional delivery HOWEVERPositive attitudes towards health services and health professionals are associated with institutional delivery HOWEVER Positive attitudes towards traditional birth attendants play negative role and are inversely associated with delivery in health servicesPositive attitudes towards traditional birth attendants play negative role and are inversely associated with delivery in health services Conclusions