(PDF) Too Far to Walk: Maternal Mortality in Context

Sm. Sci. Med. Vol. 38. No. 8, 1091-1110, 1994

pp.

Copyright Q 1994 Elsevier Science Ltd

0277-9536194 $6.00 + 0.00

TOO FAR TO WALK: MATERNAL MORTALITY IN

CONTEXT

SEREEN THADDEUS’ and DEBORAH MAINE*

‘The Center for Communication Programs, Johns Hopkins University, I I1 Market Place, Suite 310,

Baltimore, MD 21202-4024, U.S.A. and rCenter for Population and Family Health, Columbia University,

60 Haven Avenue, New York, NY 10032, U.S.A.

Abstract-The Prevention of Maternal Mortality Program is a collaborative effort of Columbia

University’s Center for Population and Family Health and multidisciplinary teams of researchers from

Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned

with preventing maternal deaths. This review, which presents findings from a broad body of research, is

part of that activity.

While there are numerous factors that contribute to maternal mortality, we focus on those that affect

the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment

is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected

by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2)

delay arrival at a health facility; and (3) delay the provision of adequate care.

The literature clearly indicates that while distance and cost are major obstacles in the decision to seek

care, the relationships are not simple. There is evidence that people often consider the quality of care more

important than cost. These three factors--distance, cost and quality-alone do not give a full understand-

ing of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors,

such as severity. Differential use of health services is also shaped by such variables as gender and

socioeconomic status.

Patients who make a timely decision to seek care can still experience delay, because the accessibility

of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric

emergency may find the closest facility equipped only for basic treatments and education, and she may

have no way to reach a regional center where resources exist.

Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages

of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanage-

ment, become documentable contributors to maternal deaths.

Findings from the literature review are discussed in light of their implications for programs. Options

for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an

emphasis on strategies to mobilize and adapt existing resources.

Ke.r words-maternal mortality, obstetric complication, developing countries, health services utilization

INTRODUCTlON the key objective, not because death adversely affects

Every year about 500,000 women worldwide die children and other family members, but because the

due to complications associated with pregnancy and women are intrinsically valuable.

childbirth [l, p. 11. Unfortunately, maternal aspects Within SMI, there are proposals for a variety of

of Maternal Child Health have all too often been interventions. These include programs aimed at im-

relegated to secondary priority within the child sur- proving the health status of women who become

viva1 revolution (21. However, emerging information pregnant, at improving women’s access to health

and concern with this high rate of maternal mortality services during pregnancy and at improving the qual-

precipitated the foundation of the Safe Motherhood ity of medical care available to women who experi-

Initiative (SMI) and the Prevention of Maternal ence complications during pregnancy and delivery.

Mortality Program (PMM) in 1987. There are several similarities between the problems

The Safe Motherhood Initiative (SMI) was for- experienced by health planners and promoters within

mally launched at a conference held in Nairobi, SMI and those experienced by other health initiat-

Kenya. It calls for concerted action at the local, ives, including issues of distribution, utilization and

national and international levels to reduce the high quality of services. PMM thought it worthwhile to see

rates of maternal mortality and improve women’s what findings from research in related fields might be

health in the developing world [3]. SMI differs from applicable to the challenges faced by SMI. The PMM

Program is a collaborative effort of Columbia Uni-

other health initiatives in that it focuses on the

well-being of women as an end in itself. The preven- versity’s Center for Population and Family Health

tion of death of pregnant women is considered to be (CPFH) and multidisciplinary teams of African

researchers in Nigeria, Ghana and Sierra Leone.

1091

1092 SEKEEY THADDEUS and DEBORAH MAINE

Sponsored by the Carnegie Corporation of New

York and the John D. and Catherine T. MacArthur

Foundation, this partnership seeks to strengthen the

capabilities of African institutions in developing,

implementing and evaluating preventive programs.

Furthermore, an essential component of our program

is to disseminate information useful to researchers.

program planners and policy makers concerned with

preventing maternal deaths. This review is part of

that activity.

We conducted a multidisciplinary literature review

to gather information that can guide programmatic

effort in the prevention of maternal mortality.* In

reviewing a broader body of literature than that

dealing strictly with maternal mortality. we are view-

ing maternal mortality as an instance of a generic

problem. Our aim in doing so is to derive insights

from a broader body of research and experience.

notably in the social sciences, that can be applied in

SMI. The articles we selected cover the developing

world. with an emphasis on Africa.

We are not claiming to consider all possible factors

that may contribute to maternal deaths. For example,

we are not dealing here with background factors such

as nutriti0n.t The focus of our review is the interval

between the onset of an obstetric complication and its

outcome. The reason is that even among well-nour-

ished, well-educated women who reccivc prenatal

care, a sizable proportion develop serious compli-

cations during delivery. While there is still a lively

debate within SMI about the relative importance of

various kinds of interventions. there can be no doubt

that the interval we have chosen to concentrate on is

crucial to reducing maternal deaths [4].

This paper first presents a conceptual framework&

the three phases of delays-which identifies obstacles

to the provision and utilization of high quality, timely

obstetric care. We then present the lindings of our

literature review as they relate to these three phases

of delay. Potential applications of the findings and

*We produced short abstracts of the studies reviewed,

entering them in a computerized database. This database

is available to anyone interested in using it. modifying it,

or adding to it. Interested persons nil1 need to have

PROCITE. the bibliographic software used to enter.

edit. and retrieve abstracts. For more information, con-

tact Ana Pagan at the following address: Center for

Population and Family Health, Columbia University

School of Public Health. 60 Haven Avenue. New York.

NY 10032. U.S.A.

tReaders mterested in the literature on thcx background

factors are referred to the excellent review by J. Leslie

and G. Rao Guptn. L’///izclrio,~ (I/ Forn~/ Scrrimv jiw

Moiernul Nurritiot~ mrl Hrulth Cure irr t/w Third U’orld.

International Center for Research on Women. Washing-

ton. DC. 1989.

IExcept where otherwise noted. our discusslon of the de-

cision to seek care and the utilization of health care

services focuses exclusively on modern medical care.

since the major complications we arc concerned with are

not treatable at the traditional health care Icvel. There-

fore. when we talk about seeking care. we mean modern

medical care.

directions the PMM program has taken are then

discussed. The review points to an approach which

prioritizes practical, measurable interventions de-

signed to improve the availability and accessibility of

services. which should in turn mitigate factors which

impede the decision to seek these services.

THE CONCEPTUAL FRAMEWORK: THE THREE PHASES

OF DELAY

We know from the clinical literature that about

75% of maternal deaths result from direct obstetric

causes, such as hemorrhage, obstructed labor. infec-

tion, toxemia and unsafe abortion [5]. We also know

from this same literature that a majority of these

deaths could have been prevented with timely medical

treatment. Delay, therefore, emerges as the pertinent

factor contributing to maternal deaths. Hospital-

based investigators of maternal mortality have long

bemoaned patients’ delay in coming for care. How-

ever, to blame the patient for the delay would be

simplistic. We view delay as having three phases:

Phase I dela)

Delay in deciding to seek care on the part of’ the

individual, the family, or both. Examples of factors

that shape the decision to seek care include the actors

involved in decision-making (individual. spouse, rela-

tive, family); the status of women; illness character-

istics; distance from the health facility; financial and

opportunity costs; previous experience with the

health care system; and perceived quality of care.1

Phase II delu?

De&y in reaching un udeyuate health care fircilit~..

Examples include physical accessibility factors. such

as distribution of facilities, travel time from home to

facility. availability and cost of transportation and

condition of roads.

Delay in receining adequate care (tt the jticilit>,.

Relevant Factors include adequacy of the referral

system; shortages of supplies, equipment, and trained

personnel; and competence of available personnel.

Although some proportion of maternal mortality is

a result of all three phases of delay, any one phase can

prove fatal. ‘Phase’ here connotes placement in a

temporal order. from the onset of complications to

treatment. While there does exist complex interplay

between phases, one type of delay is not linked

inextricably with another. Anticipating concerns that

a universal model such as this loses sight of the

specific pathways exhibited in different places, we will

simply note that maternal death in areas where

distances to health facilities are large and services

poor are comparable to maternal deaths in New York

City, where a woman may live next door to a high

technology hospital but still die because of poverty

and its attendant impact on the decision to seek care.

Maternal mortality in context 1093

The model as presented is universal insofar as both

of these cases fit the framework.

FINDINGS

Our findings are presented chronologically:

prospective patients begin their health-care-seeking

process with the decision to seek care, then they try

to reach a health facility where they can receive care.

Figure 1 is a schematic representation of how the

various factors discussed affect the interval between

onset of illness (specifically, an obstetric compli-

cation) and its outcome.

Socioeconomic/

Cultural

Accessibility

Facilities

Quality of Care

Phase I Delay: Decision to Seek Care

The factors that affect the decision to seek care are

often those discussed as ‘barriers’ or ‘constraints’ to

the utilization of services in the literature on health

care seeking behavior. Numerous researchers have

observed that increasing the availability of services

(for instance, by building more facilities or expanding

health programs) does not always increase the use of

services. This finding has stimulated research into

factors that might account for the underutilization of

services.

Our review indicates that the barriers most

Phase I:

Deciding to Seek,

Care

Phase II:

Identifying and

Reaching Medical

Facility

Phase III:

Receiving Adequate

and Appropriate

Treatment

Fig. I. The three delays model.

1094 SEREEN THADDEUS and DEBORAH MAINE

commonly studied and discussed are distance, cost,

quality of care and sociocultural factors. In what

follows, we present findings concerning the influence

of each of these factors on the decision to seek care.

We also present our assessment of the relationships

among these factors and the hierarchy of their influ-

ence on the decision to seek care.

Distance

The distance separating potential patients from the

nearest health facility has been shown to be an

important barrier to seeking health care, particularly

in rural areas [6-IO]. Distance exerts a dual influence:

long distances can be an actual obstacle to reaching

a health facility, and they can be a disincentive to

even trying to seek care. In addition, the effect of

distance becomes stronger when combined with lack

of transportation and poor roads. Potential patients

who have to walk or ride a mule over rugged terrain

will take longer to reach a facility. Distance will

therefore be a greater obstacle for them, and act

as a greater disincentive to efforts to seek care, than

for those who can travel by motorized vehicles on

relatively good roads.

Distance as a disincentive to seeking care plays an

important role in Phase I delay. However, the two

influences-disincentive and actual obstacle-are re-

lated and often difficult to disentangle. Thus, some of

the findings presented below are conjectural.

The impact of distance as a consideration in the

utilization of health services has been assessed in a

variety of ways, including community-based inter-

views and analysis of facility records [l 11. In one

series of interviews in Oyo State, Nigeria, respondents

explained that they had not sought care because the

facility was too far or, alternatively, that their choice

of facility was made as a function of distance [12].

In studies using records from health facilities,

findings often indicate that the highest proportion of

users are located close to the facility-e.g. within a

radius of five miles or kilometers-and that the

proportion of users declines as the radius increases

[6, 13, 141.

A third way in which the role of distance has been

assessed is by looking at the severity of the condition

in which patients arrive at the facility and relating it

to how far they had to travel. The hypothesis is that

those patients who arrive at the facility in an ad-

vanced stage of illness probably had to travel further

than those who reached the facility in a less advanced

stage of illness. This scenario highlights the role of

distance as actual obstacle. However, some re-

searchers extrapolate further, and propose that those

patients who had to travel further probably also

waited until the illness became serious before deciding

to seek care. Presumably they waited longer because

distance was acting as a disincentive to seek care

earlier, thus delaying their decision [14]. For example,

a case-control study of bacterial meningitis among

Navajo children in New Mexico revealed that the

total distances travelled by cases and controls were

similar. However, the mean distance travelled on

unpaved roads was 10 miles for cases, compared to

14 miles for controls. The author suggests that the

distance travelled on unpaved roads acted as a disin-

centive and delayed the caretakers’ decisions to seek

care until complications of the initial disease devel-

oped [15]. In a Nigerian study, the percentage of

individuals seeking treatment within one week of

illness onset declined as distance from the treatment

facility increased [lo].

Some studies indicated that contrary to investi-

gators’ expectations, physical proximity does not

necessarily increase utilization [16]. As one study in

Kenya’s Meru District illustrates, road improvements

significantly reduced travel distance and time to

health centers in the district, However, admission

rates and patterns at the two mission hospitals most

affected by these changes did not show substantial

improvement. According to the author, road im-

provements alone do not guarantee increased utiliz-

ation, as institutional barriers. such as the financial

cost of treatment at the fee-charging mission hospi-

tals, may limit the advantages of shorter distances

V71.

The magnitude of the impact of distance on the

decision to seek care appears to be shaped by other

factors as well, such as the severity of the condition

and the reputation of the provider. Stock’s data from

Nigeria show an effect of distance on utilization, yet

he stresses that there are differences in the size of the

effect according to illness and the perceived effective-

ness of the health care provider. Tuberculosis. for

instance, is an illness for which respondents con-

sidered medical care essential. In such cases. the

nature of the illness and quality of care appeared to

be more important than distance, and people did

travel far to obtain care [IO].

These and other studies suggest that the impact of

distance is shaped by other factors and that reasons

for nonuse often lie in institutional accessibility fac-

tors. such as the cost and quality of care. to which we

now turn.

Cost

Another variable that receiyes considerable atten-

tion in the literature is the financial cost of receiving

care, which includes transportation costs, physician

and facility fees (when they exist), the cost of medi-

cations and other supplies, and opportunity costs.

Cost and distance often go hand in hand as consider-

ations in the decision-making process. as longer

distances entail higher transportation costs [ 181.

The effect of cost of services on utilization is

commonly assessed through interviews and surveys of

users and nonusers in which respondents are asked to

give reasons for their choice of actions when they are

ill. If a large proportion of respondents give financial

constraints as a major reason for not seeking care, or

for seeking one form of care rather than another, this

Maternal mortality in context 1095

indicates that cost of services was an important factor

affecting utilization. Much to our surprise, the litera-

ture indicates that compared to other factors, the

financial cost of receiving care is often not a major

determinant of the decision to seek care [ 121. A survey

conducted among a sample of 680 Ibo, Yoruba and

Hausa people in Nigeria revealed five factors that

influenced people’s decision to seek traditional or

western medical care: Respondents ranked cost and

distance fourth and fifth, respectively [19]. Kloos

et al. reported that in Ethiopia, cost of services was

often a less important consideration in utilization

than were the quality of services and perceived

efficacy of the treatment [20].

medication are only some of the cost considerations

facing individuals in their decision to seek care.

The other important component is the opportunity

cost of the time used to seek health services. Time

spent getting to, waiting for and receiving health

services is time lost from other, more productive

activities, such as farming, fetching water and wood

for fuel, herding, trading, cooking and so on. As

women carry out a large majority of these tasks, the

value of their time and the competing demands made

on it are important to consider.

We found only a few studies that assessed the effect

of changes in the fee structure on utilization levels

[2l]. Recent data from Nigeria show a drastic decline

in hospital births, apparently as a result of the

country’s deepening economic crisis. Researchers at

the Ahmadu Belle University Teaching Hospital

(ABUTH) in Zaria found that obstetric admissions

declined sharply between 1983 and 1985, the year that

the government instituted fees for prenatal care and

delivery. Obstetric admissions to ABUTH decreased

further in 1988, when patients were required to pay

for some of the essential supplies. The researchers

note, however, that admissions for complicated ob-

stetric cases increased during the 1983-1988 period,

suggesting that the increased price did not deter

utilization by women with obstetric complications.

Further examination of hospital records indicated

that the incidence of maternal deaths in the hospital

increased by 56% between 1985 and 1988, whereas it

had remained stable between 1983 and 1985. Hospital

staff believe that this rise in maternal deaths may

be associated with increasing costs that act to delay

the decision to use the hospital until the woman’s

condition is critical [22].

In many parts of the developing world, prospective

patients, especially women, do not travel alone to a

health facility: They are accompanied by other adults

and by children who cannot be left at home alone

because caretakers are not available. All these ad-

ditional people swell the cost of transport [27]. Often,

family members accompanying patients must incur

the costs of staying in a town where the health

services are offered. Furthermore, the availability of

others to help with household chores, to look after

children or to accompany patients to the facility can

be a factor in the decision to seek care [l3].

It should be stressed that the cost/benefit ratio of

using medical services may be viewed very differently

in emergency cases [24]. However, we did not find

information on factors influencing decision-making

under emergency conditions.

Quality of care

Unfortunately, we did not find any studies that

compared actual fees charged by various providers

and then related the fees to income levels and to

utilization. In fact, a few studies suggest that govern-

ment facilities may be underutilized precisely because

they are free [23,24].

More generally, the literature simply does not

provide systematic evidence that cost of services is a

major barrier to seeking care in the developing world.

These findings seem to contradict anecdotal reports

from developing countries such as those mentioned

above. Perhaps other study designs are needed to

fully explore the circumstances in which the cost of

services poses a major and a definitive barrier to care.

Quality of care is an important consideration in the

decision to seek care. Our review found that where

potential patients have access to more than one

facility, their perception of the quality of care offered

at these facilities often takes precedence over con-

cerns about distance [28]. Annis found that in the

Guatemalan highlands, government health posts

seemed to be conveniently located, yet that proximity

did not guarantee utilization, probably because the

facilities were understaffed and underequipped and

thus unable to provide quality care. Detailed on-site

inspection of 83% of the operating health posts

showed that more than half were understaffed, under-

equipped, or both. Annis thus stressed that “the

current low utilization of Ministry facilities reflects

poor quality of services-and certainly not physical

access nor mysterious ‘cultural barriers’ ” [l6, p. 5221.

The role that quality of care plays in the decision

to seek care is related to people’s own assessment of

service delivery, which largely depends on their own

experiences with the health system and those of

people they know.

In addition to fees for services, there is evidence in The two mechanisms through which quality of care

the literature that the cost of medications is often very affects the decision to seek care are satisfaction or

high [24,25]. The cost of medicines is most likely to dissatisfaction with the outcome (e.g. effectiveness of

affect compliance with prescribed treatment. How- the treatment and remedies prescribed), and satisfac-

ever, to the extent that the cost of drugs figures in the tion or dissatisfaction with the service received (e.g.

decision to seek care, it can be expected to delay or staff attitudes, hospital procedures, availability of

discourage that decision. The financial cost of health supplies, efficiency) [IO, 19,291. When patients are

services in the form of provider fees and the price of dissatisfied with services, the reason more often than

1096 SEREEN THADDEUS and DEBORAH MAINF

not lies in institutional factors, such as the procedures

performed, staff attitudes and long waiting times.

These factors will act as inhibitors of future utiliz-

ation, thus affecting the decision to seek care [30].

Furthermore, modern medical facilities have a

culture of their own, which often clashes with the

culture of potential users [30]. The lack of emotional

support and privacy in the hospital setting, compared

with the home, and disruption of household respon-

sibilities as a result of hospital confinement are some

of the complaints which contribute to women’s

dissatisfaction with maternity services [23, 311.

Although a focus on cultural barriers to seeking

modern obstetrical care may inappropriately de-

emphasize institutional inadequacies and economic

considerations, several studies have shown that

beliefs associated with traditional birth practices

act as disincentives to seeking such care. For example,

Sargent’s ethnographic studies of the Bariba in

Benin suggest that where infanticide is still practised,

modern medical culture comes into conflict with

beliefs. creating barriers. Traditional Bariba belief

holds that witches may be identified at birth, and an

entire cosmology provides a rationale for infanticide.

Although the values and beliefs of that society

are in flux. and witches are increasingly ‘managed’

through less drastic procedures, infanticide

persists.

In Pehunko (Benin), extrinsic factors such as distance, time,

and lack of support services rendered cosmopolitan support

services unavailable to most women. But even where cosmo-

politan practitioners were available to attend home deliver-

ies. this alternative was viewed with suspicion for fear that

witch detection and management might be obstructed.

Moreover, the rural ideal was solitary delivery in which a

woman demonstrated her courage and stoicism, enhanced

her prestige, and had the flexibility to keep or reject the child

[32. p. 2061.

While Sargent’s most recent and far-reaching ma-

terial acknowledges the saliency of time, distance,

cost and government policy factors, and that “modifi-

cations in medical and religious beliefs and practices

occur in conjunction with hospital use,” [32, p. 231,

she maintains that belief is central to the decision-

making process [ibid.]. Our review suggests that be-

liefs. as they relate to the etiology of illness and

maternal complications, also play some part in the

decision whether to seek modern obstetrical care.

However. these beliefs play less and less of a role as

societies change through urbanization and increasing

recognition of the efficacy of modern medical treat-

ment.

In addition to the above examples of what may be

seen as general hospital policy, there are those pro-

cedures specific to childbirth that women dislike or

fear [33]. Women may feel uncomfortable having to

expose their genitals in the hospital ward [23]. or they

may intensely, dislike the positions favored by hospi-

tals for delivery [34]. Other specific hospital pro-

cedures that inhibit utilization because women may

fear them include surgical operations such as

cesarean sections [35] and episiotomies [36].

Finally, how the prospective patient expects to be

treated by providers and staff at the health care

facility is an important dimension of the patient’s

assessment of the quality of care. If the facility has a

reputation for unfriendly staff, rude service providers

and humiliating treatment, the prospective patient

may delay the decision to seek care until the serious-

ness of her condition necessitates overcoming all

barriers [24, 30, 3 I, 37, 381.

Leslie and Rao Gupta identify corruption as

another important dimension of staff attitudes [39].

Where ‘little presents’ help to get medicines and

supplies, corruption may indeed delay the decision to

seek care by increasing patient dissatisfaction and, of

course, by swelling the costs of seeking care [24].

We have sketched some of the interactions between

distance, cost and quality of services as they appear

from our review of the literature on utilization of

services. A fuller understanding of the decision to

seek care needs to take into account other factors

related to the illness itself.

Illness ,factors

The literature clearly shows that health-care-seek-

ing behavior is strongly influenced by the character-

istics of the illness as perceived by individuals. To

begin with, prospective health care users must recog-

nize that an abnormal condition exists. The perceived

severit?, and the perceived etiolog~~ of the disorder

then shape the decision to seek care. The studies we

reviewed describe one or more of these illness factors

without necessarily drawing conclusions about their

role in the health-care-seeking process.

Recognition. Before deciding to seek treatment,

people need to recognize that they have a condition

requiring specialized attention 1401.

A recent survey conducted m six of Senegal‘s IO regions

indicated that women In these regions lack basic Infor-

mation on signs and symptoms of obstetric complications.

One-quarter of the women interviewed could not name a

single complication. Only 13 percent recognized fever, and

IO percent prepartum hemorrhage. as important danger

signals. Some women even said that fever. dizziness and

pallor were signs of a normal pregnancy [41].

Although pregnancy is considered a normal life event

among respondents [to a qualitative survey in Jamaica]. a

childbirth was perceived as potentially dangerous to the

majority of the women interviewed. However. most women

were f~tmiliar with only the common symptomatic com-

plaints of pregnancy. and less than IOO;, of women could

identify any specific risks or danger of pregnancy or birth

[31].

Recognition of illness is defined by the patient’s

view of reality. not by the health professional’s

medical criteria. with which it may or may not

coincide [42,43]. Moreover. individuals’ assessment

of a health condition can be influenced by the preva-

lence of the condition. In a classic study in medical

sociology, Zola emphasized that in populations

Maternal mortality in context 1097

where a particular condition is widespread, it is

perceived as normal, natural, inevitable “and thus to

be ignored as being of no consequence” [44, p. 6151.

In addition, the perception of a condition as in-

evitable is often accompanied by the perception that

it is not amenable to treatment, that nothing can be

done to manage it [20].

Pregnancy and childbirth are ubiquitous events.

Although acknowledged as potentially risky, preg-

nancy and delivery are commonly considered natural,

normal work for women. In other words, they are

often not seen as illnesses for which medical expenses

are justified and a hospital room booked [23, 36,451.

Furthermore, just as pregnancy is considered a nor-

mal event, death during labor and delivery may

sometimes be considered ‘normal ’ or inevitable. Such

fatalistic views can lead to the perception that the

condition is not amenable to treatment, and can thus

act as effective barriers to a timely decision to seek

care. The recognition of a health condition can also

be shaped by sociocultural prescriptions and in-

terpretations. Among the Bariba of Benin, for

example, labor that lasts up to a day is considered

normal and thus is not recognized as dangerous

[33,46].

In parts of Africa, prolonged obstructed labor is

taken to be a sign of the woman’s infidelity

[45,4749]. Obstructed labor is thus interpreted as

punishment for adultery and not recognized as a

medical problem. It is believed that the woman must

‘confess her sins’ so that the delivery will progress

smoothly, thus precluding the decision to seek medi-

cal care for the complication.

Finally, mention should be made of situations in

which a health problem is recognized, but care is not

sought because of the fear of social or legal sanctions.

Those suffering from a condition they view as shame-

ful or stigmatizing may recognize its seriousness, yet

the fear of punishment and ostracism can prevent

them from seeking appropriate care. For example,

venereal diseases are often denied, unreported and

untreated [20]. Vesicovaginal fistulae and compli-

cations resulting from unsafe induced abortion often

remain unreported, therefore untreated, because of

ostracism and shame in the former and the fear of

sociolegal sanctions in the latter [34,50-531. Certainly

in the case of an unwanted pregnancy, the condition

and the need for care are both recognized. However,

fear, shame and desperation can act as powerful

barriers and lead to disastrous consequences as

women seek illicit and unsafe abortion, attempt to

self-abort and, in extreme cases, commit suicide

[5457].

Severit),. In addition to recognition of a health

condition, the perceived severity of an illness is a very

important factor in the decision to seek care. Utiliz-

ation of services appears to be influenced by the

recognition of symptoms and the assessment that the

symptoms are serious enough to justify medical care

[l8, 42, 581.

The perception of a condition as normal or minor

interacts with cost and distance in the decision to seek

care. Just as certain conditions (such as pregnancy)

are perceived as ‘natural’ and therefore not requiring

medical care, conditions that are perceived as minor

also do not justify the expenses of money, time and

travel effort often involved in medical care [lo, 201.

Cosminsky and Scrimshaw report that residents on

the Guatemalan plantation that they studied tended

to use low-cost remedies to treat minor conditions

and then move to more expensive resources if the

illness progressed [59].

It is important to note that we did not find any

studies showing that illness severity was not an

important factor or that it played a lesser role than

other variables as a consideration in the decision to

seek care. This is in contrast with the findings of

studies examining the role of distance, cost and beliefs

about illness causation, all of which reveal much

variation in the importance of these factors.

The aforementioned studies indicate that the per-

ceived severity of the condition may well be an

overriding factor in the decision to seek appropriate

care. Furthermore, there is an interaction between

severity of illness and other factors involved in the

decision. Specifically, there is a reluctance to incur

costs when the disorder is perceived as non-threaten-

ing or self-limiting. However, the perception of these

expenses as a barrier seems to decrease dramatically

when the disorder is perceived as serious, debilitating

or life-threatening, and the perceived benefits of

seeking care seem to outweigh the constraints. As

perceived severity increases, utilization of services

increases and the impact of distance and cost in

decision-making decreases.

It should be noted that most of the studies we

reviewed assume that the decision to seek care is

a process that occurs in stages. While this may

be the case for conditions with a slow onset, it is

unclear what happens in medical emergencies (e.g.

postpartum hemorrhage).

Etiology. Once the decision to seek care is justified

by the perceived severity of the illness, a key factor

in determining the type of care (self, traditional,

modern or a combination of the three) that will be

sought is the cause to which the illness is attributed

by patients and their families.

Our review indicates that while beliefs about illness

causation do sometimes play a role in the decision to

seek medical care, this role is not as important as it

might have been a few decades ago, when the efficacy

of medical care was less well accepted in the develop-

ing world [27]. Furthermore, while traditional medi-

cine is still relatively more available than modern

medical care in rural areas, there is ample evidence

from most parts of the developing world that the

trend is toward utilization of both systems for treat-

ment of most conditions.

Medical anthropologists and sociologists, such as

Cosminsky and Scrimshaw [59], Foster [27]. Lasker

1098 SEREEN THADDEUS and DEBORAH MAINE

[24] and Young [ 181 reject the view that beliefs about

illness causation generally lead to decisions not to

seek medical care. They argue that people are empir-

ical and pragmatic, as opposed to ‘unscientific,’ or

‘irrational,’ that they base their health care decisions

on an assessment of available and accessible re-

sources.

The important lesson from anthropological studies

of health beliefs is that a narrow focus on ‘cultural

barriers’ obscures the role that institutional inade-

quacies and economic considerations play in the

decision to seek care. Nonetheless, variation across

cultural groups and across health conditions remains

great, and beliefs about illness causation do some-

times affect the decision to seek medical care. As we

noted earlier, the belief that obstructed labor is

caused by a woman’s infidelity is widely held-for

example, in Sierra Leone, Liberia. Ghana and

Zimbabwe. It should serve as an important reminder

of the types of factors that need to be identified by

research and addressed by programs. It also illus-

trates that at the heart of many factors that limit

access to care is the status of the women in the

society.

Women’s status is composed of the educational.

cultural, economic, legal and political position of

women in a given society. While women’s status

generally underlies and shapes women’s access to

health services, there are specific ways in which it

directly affects and delays the decision to seek care.

In this section, we focus on how women’s access to

health services is limited by constraints on their

autonomy.

In countries as diverse as Nigeria, Ethiopia,

Tunisia, India and Korea, studies show that women

do not decide on their own to seek care: the decision

belongs to a spouse or to senior members of the

family [IO, 20, 23.41. 60-621. Furthermore. women’s

mobility is limited in certain areas because they need

permission to travel. Often this permission must be

granted by the spouse or the mother-in-law [IO].

Where women‘s mobility is severely restricted be-

cause of such cultural prescriptions, efforts to seek

timely care may be thwarted. According to Harrison.

in Zaria, Nigeria, “no matter how obvious the need

for hospital management becomes for the girl who

develops obstructed labor, permission to leave home

for hospital can usually be given only by the husband;

if he happens to be away from home. those present

are often unwilling to accept such responsibility” [34,

p. 3851. In Ethiopia. women tend to use those primary

care facilities within walking distance from their

homes. because of “cultural restrictions placed on

[their] travel outside the community” [20, p. 10131.

For a woman with obstetric complications, access

limited to the nearby primary care centers is not of

much help. These facilities are usually not equipped

to deal with obstetric complications, and further

delay can occur through staff errors and misdiagno-

sis.

In addition to identifying the major factors gener-

ally shaping the decision to seek care, our review

indicates that these constraints often apply unequally

to women. Consider the example of distance. We

have discussed how overcoming this barrier largely

depends on mobility: Individuals with access to mo-

torized vehicles are more mobile than those with

access only to bicycles or donkeys, who are in turn

more mobile than those who can rely only on their

feet. Yet among the strict Muslim communities of

northeastern Nigeria, women are not allowed to ride

bicycles or donkeys. Although these means may be

physically present in the community. they are effec-

tively unavailable to women [IO].

Women’s status also interacts with the cost of

treatment in the decision to seek care. The litcraturc

on the preference for male children provides evidence

that the consideration of cost in the decision to seek

care is applied unequally to males and females [26].

Witness for example the impact of son preference on

access to health services, a phenomenon best docu-

mented for Asia, specifically India and Bangladesh,

and to a lesser extent, for the Middle East [63] and

Africa [38. 641.

In Bangladesh, as elsewhere, private physicians’ fees arc

much higher than those of other providers. Parents con-

sulted private physicians three times as often for their sons

as for their daughters. Moreover, the purchase of drugs

prescribed by physicians was about three times as frequent

when the prescription was for a boy as when it was for a girl

WI.

Especially where resources are scarce. parents’

health care seeking behavior and expenditures often

reveal a preferred investment in their sons’ health.

Even where health care services and transportation

were both free of charge, such as in Matlab.

Bangladesh, parents still used the services far more

frequently for injured or ill boys than for girls [66].

It is evident that the low value placed on females

adversely affects their utilization of health services.

However, this link has been generally overlooked. As

Royston and Armstrong have recently pointed out.

“sex discrimination as a contributory factor to ma-

ternal mortality has been largely ignored, [and] has

been hidden within the general issue of poverty and

underdevelopment which is assumed to put evcry-

one. at an equal disadvantage in health terms” [67.

pp. 45-461. Stemming from the low status of women.

reluctance to allocate resources or assign importance

to female health inhibits the decision to seek modern

medical care when complications associated with

pregnancy and childbirth arise.

In many parts of the developing world. women

consider childbearing as their only means of gaining

status. Thus, women often find themselves in a

paradoxical situation: high fertility is their main

channel to improving their status. but it increases

their risk of maternal death. Even in some societies

Maternal mortality in context 1099

where women are financially independent, they derive

pride and prestige chiefly from their roles as mothers

[68]. Sargent’s study of the Bariba of Benin illustrates

yet another way in which pregnancy and childbirth

confer status on women.

To the Bariba, birth represents a rare opportunity for a

woman to demonstrate courage and bring honor to both her

family and that of her husband by stoic demeanor during

labor and delivery. The woman who manages to deliver

without calling for assistance until the child is born is

especially esteemed [33, p. 2911.

In such situations, a woman’s efforts to gain esteem

and enhance her status have direct implications for

the recognition of complications and delays in the

decision to seek care if they do develop.

None of the studies reviewed examines utilization

of services by women who are financially indepen-

dent, who are autonomous in their decision-making

and who derive status and prestige from roles other

than motherhood alone. Furthermore, the role of

women’s informal power is rarely addressed. Re-

search in such contexts is much needed. It might

mitigate some of the gloominess described above.

The potential contribution of such research can be

gleaned from preliminary results of focus-group re-

search conducted in Enugu, Nigeria. Women partici-

pating in the focus groups argued that although their

husbands are the overall decision-makers, the women

are financially independent. Access to cash, they

stated, was the most important factor in the decision

to seek care. This means that in case of a medical

problem, the women do not need to wait for their

husbands, as they have ready access to cash and are

able to pay for the expenses incurred [69].

Economic status

The literature describes statistical associations be-

tween economic status and the utilization of services.

However, the mechanisms through which this associ-

ation operates are not specified. Possibilities include:

(1) income constraints; and (2) characteristics of the

health care facilities serving the poor that may dis-

courage use [20, 70, 711. What is clear, however, is

that morbidity and mortality rates are higher among

groups of low economic status [20,52,56,72-741.

Most of the studies reviewed indicate that econ-

omic status affects the use of health services. In

general, these studies find that utilization increases as

economic status increases [9, 12,751. In studies by

Kwast et al. in Addis Ababa, Ethiopia, economic

status was measured by income, house ownership and

occupation. The lowest rates of prenatal clinic attend-

ance and the highest rates of home delivery were

found among women from the lowest economic

status groups [56, 731. Data from Iraq show that

consultation rates for all health facilities rose from 67

per 100 illness episodes for low-income households to

103 for those in the high income bracket [l3]. In

Calabar, Nigeria, distance did not deter patients from

using the family health clinic: Patients living further

away were of higher economic status and more

commonly owned cars or motorcycles than did those

living closer to the clinic [7].

Educational status

Education is measured by the number of years of

formal schooling. In developing countries, men gen-

erally have higher educational levels than women.

Our review reveals two major findings with respect to

the role of formal education in the decision to utilize

health services: (I) that its role is not clear-cut; and

(2) that the mechanisms through which education

may play a role are not well understood.

Most of the studies reviewed show that utilization

of medical services increases with increasing levels of

education. The positive association repeatedly docu-

mented is that between mother’s education and use of

child health services and child survival technologies

[76-781. The presence of a positive association be-

tween educational level and use of adult health

services is not as consistent [75]. However, survey

results from Ethiopia, Jordan and the Philippines

indicate a significant positive association between

use of prenatal care services and level of womens’

education [56, 58, 781.

There is evidence in the literature that higher levels

of education may not guarantee higher levels of

health services utilization [I I, 24,42,43]. Some stud-

ies suggest that with increasing education, individuals

depend more on self-care and self-prescribed medi-

cation and postpone the visit to a facility until after

these methods fail to produce a cure. However, it may

also be that the better educated are generally health-

ier, thus requiring less care than the less educated.

The mechanisms through which education might

affect the decision to use health services are not well

understood. It has been hypothesized that education

affects individuals by introducing them to a new

‘modern’ culture [77]; that increasing levels of edu-

cation increase knowledge and awareness by shaping

thought patterns-for example, by acting as “medi-

cation against fatalism” [76]; and that education

increases access to information. A related hypothesis

is that education increases self-confidence and

imparts respect and influence [76].

Although there are not many studies that show a

negative relationship between education and utiliz-

ation of health services, they are important, because

they illustrate that the explanation of differential

utilization cannot be reduced to one variable. In

addition to their education, literate and illiterate

individuals alike rely on their past experience of

health services as a source of information. Further-

more, focusing on education as a main factor in poor

utilization levels in effect lets the health system ‘off

the hook.’ It obscures the fact that there are often

institutional factors that deter utilization and it

ignores the potential effect of outreach activities.

The experience of declining infant mortality inde-

pendent of education in countries such as Cuba,

II00 SEREEN THADUEUS and DEBORAH MAINE

China, Costa Rica and Sri Lanka illustrates what Here, distance and the unavailability of public

Cleland and van Ginneken call the “equalizing influ- transportation were not considerations that delayed

ence of health services” [78]. Declines in infant mor- the decision to seek care. They were actual obstacles

tality were sharp among offspring born to illiterate that prevented women from reaching the hospital.

mothers in China and to those with less than four Factors that create Phase II Delays include the

years of schooling in Costa Rica. Over time, accessi- location of health facilities, the travel distances that

bility and availability of medical services in these result from this distribution and the transportation

countries reportedly decreased differentials in infant means necessary to cover the distances. In other

and child mortality that had been associated with words, Phase II Delays result from the actual

levels of parental education. accessibility of health services.

By contrast. there are instances where neither

strong national investments in education nor achieve-

ment of a high literacy rate appeared to have any

effect on that country’s high mortality rate. Bullough

has pointed out that countries with high under-five

mortality rates spend about three to five times as

much on education as on health. He further notes

that Paraguay and Tanzania are examples of

countries that “manage to combine high literacy rates

with high maternal mortality rates: adult female

literacy 85 percent and 80 percent. maternal mortality

rate 469 and 370/100 000 live births” [80, p. I 1191.

Phase II delays are very common. particularly in

rural areas. yet they are not systematically docu-

mented in the literature. Rather. researchers have

typically focused on the individual and institutional

characteristics that inhibit the timely use of services.

The perspective that users and providers are the only

actors in the health-care-seeking process prevails

throughout the literature. By focusing exclusively on

the two poles of the health-care-seeking process, this

pcrspectivc fails to take into account all that happens

on the way to the health care facility.

In its purest form, the decision to seek medical care

is a behavioral response to a perceived need created

by an illness. The complexity of the real world.

however, introduces variability and constraints into

this process. It is therefore simplistic to relate people’s

underutilization of services to their ignorance, illiter-

acy, poverty, laziness or superstition. Rather, under-

utilization is often related to people’s knowledge,

based on previous experience, that facilities are far

away and often difficult to reach, that they may be

closed, that needed drugs may be out of stock. and

that staff are often less than helpful and polite. In

other words. the actual accessibility of services is

often at the heart of the matter (Fig. 2).

Phase II delays have important programmatic im-

plications. For instance, it is of little use to identify

high-risk pregnant women who should deliver in the

hospital and to raise the community’s awareness of

risk factors if the women are unable to reach the

hospital, as in the Kenyan example cited above.

Gathering data on delays that face patients who are

trying to reach a facility is thus an important research

effort that can serve to guide programmatic interven-

tions.

Phme II Delq: Reuching u Medid Fucilitl

The accessibility of services plays a dual role in the

health-care-seeking process. On the one hand, it

influences people’s decision-making, as outlined

under the rubric of Phase I Delays. On the other

hand, it determines the time spent in reaching a

facility after the decision to seek care has been made.

This latter effect we term Phase II Delay.

Interviews with pregnant women in rural Kenya indicated

that 47 percent of the women intended to deliver in a

hospital, 40 percent intended to deliver at home and 13

percent had not yet decided at the time of the interview. Of

those who had decided to deliver in a hospital, only 36

percent actually did so. The rest had not changed their

minds-they were simply not able to reach the hospital [S I].

The data further indicate that 84 percent of the women in

the sample had received prenatal care; that the majority of

the women and their relatives could recognize risk factors;

and that women who experienced difficulties with previous

deliveries were significantly more inclined to plan for a

hospital delivery than were those who had a history of

uncomplicated deliveries. Yet a sizable proportion of

women could not act on their informed decision because

they lived far from the hospital, which they could reach only

by walking or by waiting for a passing lorry [8 I].

There is a general shortage of medical care insti-

tutions in the developing world. In addition. existing

facilities are more often than not concentrated in and

around urban areas. Governments plan to have rural

areas served by a network of regional and district

hospitals in large towns, primary health centers,

health posts and dispensaries. In many cases. how-

ever. this network does not function as planned. All

studies reviewed indicate that inhabitants of urban

areas have better access to health facilities than do

rural inhabitants [20,24]. In the Syrian Arab Repub-

lic, 30% of all government and 19% of all private

hospital beds are concentrated in Damascus. the

capital city. Also. 65% of the nation’s health centers

are located in urban capitals of governorates. Health

care providers are also in short supply and unevenly

distributed. Of the country’s 221 obstetricians. 78

(35%) practice in the capital city. In contrast, only

nine obstetricians practice in the rural areas. and four

of them are located in Damascus governorate. This

means that there are only five obstetricians in the

country’s remaining I3 governorates [82].

A concern for equitable distribution seems to

have guided the allocation of health resources in a

few countries. According to Cardoso, the Cuban

Ministry of Health has paid particular attention to

the rural areas in establishing a network of hospital

Maternal mortality in context

Factors Affecting

Utilization and Outcome

‘,‘.~Pil& 1,; ‘.

L

Phase II:

identifying and

Reaching Medical

Facility

Phase Ill:

Receikig .Adequate

and Appropriate

Treatment

Fig. 2. Phase I delay, detail.

facilities that would be accessible to the entire

population. Existing hospitals were enlarged

and new hospitals were built in the rural areas [83].

Unfortunately, the Cuban model does not appear

to be widespread. Of course, Cuba is a relatively small

country, a factor which probably facilitates the im-

plementation of such policies. Still, there are many

small countries where distribution of resources is

much less equitable.

Travel distances

The uneven distribution of facilities has impli-

cations for travel distances between women and even

the closest facility, let alone a specialist referral

hospital. The issue of access is therefore an acute

problem for rural inhabitants in most developing

countries. Examples of actual travel distances cited in

the literature gives an idea of the magnitude of the

1102 SEREEN THAVVEIJS and DEBORAH MAINE,

pr