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Too Far to Walk: Maternal Mortality in

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Article in Social Science & Medicine · April 1994

DOI: 10.1016/0277-9536(94)90226-7 · Source: RePEc

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 Sm. Sci. Med. Vol. 38. No. 8, pp. 1091-1110, 1994
Copyright Q 1994 Elsevier Science Ltd
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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

children and other family members, but because the
Every year about 500,000 women worldwide die women are intrinsically valuable.
due to complications associated with pregnancy and Within SMI, there are proposals for a variety of
childbirth [l, p. 11. Unfortunately, maternal aspects interventions. These include programs aimed at im-
of Maternal Child Health have all too often been proving the health status of women who become
relegated to secondary priority within the child sur- pregnant, at improving women’s access to health
viva1 revolution (21. However, emerging information services during pregnancy and at improving the qual-
and concern with this high rate of maternal mortality ity of medical care available to women who experi-
precipitated the foundation of the Safe Motherhood ence complications during pregnancy and delivery.
Initiative (SMI) and the Prevention of Maternal There are several similarities between the problems
Mortality Program (PMM) in 1987. experienced by health planners and promoters within
The Safe Motherhood Initiative (SMI) was for- SMI and those experienced by other health initiat-
mally launched at a conference held in Nairobi, ives, including issues of distribution, utilization and
Kenya. It calls for concerted action at the local, quality of services. PMM thought it worthwhile to see
national and international levels to reduce the high what findings from research in related fields might be
rates of maternal mortality and improve women’s applicable to the challenges faced by SMI. The PMM
health in the developing world [3]. SMI differs from Program is a collaborative effort of Columbia Uni-
other health initiatives in that it focuses on the versity’s Center for Population and Family Health
well-being of women as an end in itself. The preven- (CPFH) and multidisciplinary teams of African
tion of death of pregnant women is considered to be researchers in Nigeria, Ghana and Sierra Leone.

1091
1092 SEKEEY THADDEUS and DEBORAH MAINE

Sponsored by the Carnegie Corporation of New directions the PMM program has taken are then
York and the John D. and Catherine T. MacArthur discussed. The review points to an approach which
Foundation, this partnership seeks to strengthen the prioritizes practical, measurable interventions de-
capabilities of African institutions in developing, signed to improve the availability and accessibility of
implementing and evaluating preventive programs. services. which should in turn mitigate factors which
Furthermore, an essential component of our program impede the decision to seek these services.
is to disseminate information useful to researchers.
program planners and policy makers concerned with THE CONCEPTUAL FRAMEWORK: THE THREE PHASES
preventing maternal deaths. This review is part of OF DELAY

that activity.
We conducted a multidisciplinary literature review We know from the clinical literature that about
to gather information that can guide programmatic 75% of maternal deaths result from direct obstetric
effort in the prevention of maternal mortality.* In causes, such as hemorrhage, obstructed labor. infec-
reviewing a broader body of literature than that tion, toxemia and unsafe abortion [5]. We also know
dealing strictly with maternal mortality. we are view- from this same literature that a majority of these
ing maternal mortality as an instance of a generic deaths could have been prevented with timely medical
problem. Our aim in doing so is to derive insights treatment. Delay, therefore, emerges as the pertinent
from a broader body of research and experience. factor contributing to maternal deaths. Hospital-
notably in the social sciences, that can be applied in based investigators of maternal mortality have long
SMI. The articles we selected cover the developing bemoaned patients’ delay in coming for care. How-
world. with an emphasis on Africa. ever, to blame the patient for the delay would be
We are not claiming to consider all possible factors simplistic. We view delay as having three phases:
that may contribute to maternal deaths. For example, Phase I dela)
we are not dealing here with background factors such
as nutriti0n.t The focus of our review is the interval Delay in deciding to seek care on the part of’ the
between the onset of an obstetric complication and its individual, the family, or both. Examples of factors
outcome. The reason is that even among well-nour- that shape the decision to seek care include the actors
ished, well-educated women who reccivc prenatal involved in decision-making (individual. spouse, rela-
care, a sizable proportion develop serious compli- tive, family); the status of women; illness character-
cations during delivery. While there is still a lively istics; distance from the health facility; financial and
debate within SMI about the relative importance of opportunity costs; previous experience with the
various kinds of interventions. there can be no doubt health care system; and perceived quality of care.1
that the interval we have chosen to concentrate on is Phase II delu?
crucial to reducing maternal deaths [4].
This paper first presents a conceptual framework& De&y in reaching un udeyuate health care fircilit~..
the three phases of delays-which identifies obstacles Examples include physical accessibility factors. such
to the provision and utilization of high quality, timely as distribution of facilities, travel time from home to
obstetric care. We then present the lindings of our facility. availability and cost of transportation and
literature review as they relate to these three phases condition of roads.
of delay. Potential applications of the findings and

*We produced short abstracts of the studies reviewed, Delay in receining adequate care (tt the jticilit>,.
entering them in a computerized database. This database Relevant Factors include adequacy of the referral
is available to anyone interested in using it. modifying it,
system; shortages of supplies, equipment, and trained
or adding to it. Interested persons nil1 need to have
PROCITE. the bibliographic software used to enter. personnel; and competence of available personnel.
edit. and retrieve abstracts. For more information, con- Although some proportion of maternal mortality is
tact Ana Pagan at the following address: Center for a result of all three phases of delay, any one phase can
Population and Family Health, Columbia University prove fatal. ‘Phase’ here connotes placement in a
School of Public Health. 60 Haven Avenue. New York.
NY 10032. U.S.A. temporal order. from the onset of complications to
tReaders mterested in the literature on thcx background treatment. While there does exist complex interplay
factors are referred to the excellent review by J. Leslie between phases, one type of delay is not linked
and G. Rao Guptn. L’///izclrio,~ (I/ Forn~/ Scrrimv jiw inextricably with another. Anticipating concerns that
Moiernul Nurritiot~ mrl Hrulth Cure irr t/w Third U’orld.
a universal model such as this loses sight of the
International Center for Research on Women. Washing-
ton. DC. 1989. specific pathways exhibited in different places, we will
IExcept where otherwise noted. our discusslon of the de- simply note that maternal death in areas where
cision to seek care and the utilization of health care distances to health facilities are large and services
services focuses exclusively on modern medical care. poor are comparable to maternal deaths in New York
since the major complications we arc concerned with are
not treatable at the traditional health care Icvel. There- City, where a woman may live next door to a high
fore. when we talk about seeking care. we mean modern technology hospital but still die because of poverty
medical care. and its attendant impact on the decision to seek care.
 Maternal mortality in context 1093

The model as presented is universal insofar as both Phase I Delay: Decision to Seek Care
of these cases fit the framework.
The factors that affect the decision to seek care are
often those discussed as ‘barriers’ or ‘constraints’ to
FINDINGS
the utilization of services in the literature on health
Our findings are presented chronologically: care seeking behavior. Numerous researchers have
prospective patients begin their health-care-seeking observed that increasing the availability of services
process with the decision to seek care, then they try (for instance, by building more facilities or expanding
to reach a health facility where they can receive care. health programs) does not always increase the use of
Figure 1 is a schematic representation of how the services. This finding has stimulated research into
various factors discussed affect the interval between factors that might account for the underutilization of
onset of illness (specifically, an obstetric compli- services.
cation) and its outcome. Our review indicates that the barriers most

Phase I:
Socioeconomic/
Cultural Deciding to Seek,
Care

Accessibility Phase II:

Identifying and
Facilities Reaching Medical
Facility

Phase III:

Quality of Care Receiving Adequate

and Appropriate
Treatment

Fig. I. The three delays model.

1094 SEREENTHADDEUS and DEBORAH MAINE

commonly studied and discussed are distance, cost, total distances travelled by cases and controls were
quality of care and sociocultural factors. In what similar. However, the mean distance travelled on
follows, we present findings concerning the influence unpaved roads was 10 miles for cases, compared to
of each of these factors on the decision to seek care. 14 miles for controls. The author suggests that the
We also present our assessment of the relationships distance travelled on unpaved roads acted as a disin-
among these factors and the hierarchy of their influ- centive and delayed the caretakers’ decisions to seek
ence on the decision to seek care. care until complications of the initial disease devel-
oped [15]. In a Nigerian study, the percentage of
Distance
individuals seeking treatment within one week of
The distance separating potential patients from the illness onset declined as distance from the treatment
nearest health facility has been shown to be an facility increased [lo].
important barrier to seeking health care, particularly Some studies indicated that contrary to investi-
in rural areas [6-IO]. Distance exerts a dual influence: gators’ expectations, physical proximity does not
long distances can be an actual obstacle to reaching necessarily increase utilization [16]. As one study in
a health facility, and they can be a disincentive to Kenya’s Meru District illustrates, road improvements
even trying to seek care. In addition, the effect of significantly reduced travel distance and time to
distance becomes stronger when combined with lack health centers in the district, However, admission
of transportation and poor roads. Potential patients rates and patterns at the two mission hospitals most
who have to walk or ride a mule over rugged terrain affected by these changes did not show substantial
will take longer to reach a facility. Distance will improvement. According to the author, road im-
therefore be a greater obstacle for them, and act provements alone do not guarantee increased utiliz-
as a greater disincentive to efforts to seek care, than ation, as institutional barriers. such as the financial
for those who can travel by motorized vehicles on cost of treatment at the fee-charging mission hospi-
relatively good roads. tals, may limit the advantages of shorter distances
Distance as a disincentive to seeking care plays an V71.
important role in Phase I delay. However, the two The magnitude of the impact of distance on the
influences-disincentive and actual obstacle-are re- decision to seek care appears to be shaped by other
lated and often difficult to disentangle. Thus, some of factors as well, such as the severity of the condition
the findings presented below are conjectural. and the reputation of the provider. Stock’s data from
The impact of distance as a consideration in the Nigeria show an effect of distance on utilization, yet
utilization of health services has been assessed in a he stresses that there are differences in the size of the
variety of ways, including community-based inter- effect according to illness and the perceived effective-
views and analysis of facility records [l 11. In one ness of the health care provider. Tuberculosis. for
series of interviews in Oyo State, Nigeria, respondents instance, is an illness for which respondents con-
explained that they had not sought care because the sidered medical care essential. In such cases. the
facility was too far or, alternatively, that their choice nature of the illness and quality of care appeared to
of facility was made as a function of distance [12]. be more important than distance, and people did
In studies using records from health facilities, travel far to obtain care [IO].
findings often indicate that the highest proportion of These and other studies suggest that the impact of
users are located close to the facility-e.g. within a distance is shaped by other factors and that reasons
radius of five miles or kilometers-and that the for nonuse often lie in institutional accessibility fac-
proportion of users declines as the radius increases tors. such as the cost and quality of care. to which we
[6, 13, 141. now turn.
A third way in which the role of distance has been
Cost
assessed is by looking at the severity of the condition
in which patients arrive at the facility and relating it Another variable that receiyes considerable atten-
to how far they had to travel. The hypothesis is that tion in the literature is the financial cost of receiving
those patients who arrive at the facility in an ad- care, which includes transportation costs, physician
vanced stage of illness probably had to travel further and facility fees (when they exist), the cost of medi-
than those who reached the facility in a less advanced cations and other supplies, and opportunity costs.
stage of illness. This scenario highlights the role of Cost and distance often go hand in hand as consider-
distance as actual obstacle. However, some re- ations in the decision-making process. as longer
searchers extrapolate further, and propose that those distances entail higher transportation costs [ 181.
patients who had to travel further probably also The effect of cost of services on utilization is
waited until the illness became serious before deciding commonly assessed through interviews and surveys of
to seek care. Presumably they waited longer because users and nonusers in which respondents are asked to
distance was acting as a disincentive to seek care give reasons for their choice of actions when they are
earlier, thus delaying their decision [14]. For example, ill. If a large proportion of respondents give financial
a case-control study of bacterial meningitis among constraints as a major reason for not seeking care, or
Navajo children in New Mexico revealed that the for seeking one form of care rather than another, this
 Maternal mortality in context 1095

indicates that cost of services was an important factor medication are only some of the cost considerations
affecting utilization. Much to our surprise, the litera- facing individuals in their decision to seek care.
ture indicates that compared to other factors, the The other important component is the opportunity
financial cost of receiving care is often not a major cost of the time used to seek health services. Time
determinant of the decision to seek care [ 121. A survey spent getting to, waiting for and receiving health
conducted among a sample of 680 Ibo, Yoruba and services is time lost from other, more productive
Hausa people in Nigeria revealed five factors that activities, such as farming, fetching water and wood
influenced people’s decision to seek traditional or for fuel, herding, trading, cooking and so on. As
western medical care: Respondents ranked cost and women carry out a large majority of these tasks, the
distance fourth and fifth, respectively [19]. Kloos value of their time and the competing demands made
et al. reported that in Ethiopia, cost of services was on it are important to consider.
often a less important consideration in utilization In many parts of the developing world, prospective
than were the quality of services and perceived patients, especially women, do not travel alone to a
efficacy of the treatment [20]. health facility: They are accompanied by other adults
We found only a few studies that assessed the effect and by children who cannot be left at home alone
of changes in the fee structure on utilization levels because caretakers are not available. All these ad-
[2l]. Recent data from Nigeria show a drastic decline ditional people swell the cost of transport [27]. Often,
in hospital births, apparently as a result of the family members accompanying patients must incur
country’s deepening economic crisis. Researchers at the costs of staying in a town where the health
the Ahmadu Belle University Teaching Hospital services are offered. Furthermore, the availability of
(ABUTH) in Zaria found that obstetric admissions others to help with household chores, to look after
declined sharply between 1983 and 1985, the year that children or to accompany patients to the facility can
the government instituted fees for prenatal care and be a factor in the decision to seek care [l3].
delivery. Obstetric admissions to ABUTH decreased It should be stressed that the cost/benefit ratio of
further in 1988, when patients were required to pay using medical services may be viewed very differently
for some of the essential supplies. The researchers in emergency cases [24]. However, we did not find
note, however, that admissions for complicated ob- information on factors influencing decision-making
stetric cases increased during the 1983-1988 period, under emergency conditions.
suggesting that the increased price did not deter
utilization by women with obstetric complications. Quality of care
Further examination of hospital records indicated Quality of care is an important consideration in the
that the incidence of maternal deaths in the hospital decision to seek care. Our review found that where
increased by 56% between 1985 and 1988, whereas it potential patients have access to more than one
had remained stable between 1983 and 1985. Hospital facility, their perception of the quality of care offered
staff believe that this rise in maternal deaths may at these facilities often takes precedence over con-
be associated with increasing costs that act to delay cerns about distance [28]. Annis found that in the
the decision to use the hospital until the woman’s Guatemalan highlands, government health posts
condition is critical [22]. seemed to be conveniently located, yet that proximity
Unfortunately, we did not find any studies that did not guarantee utilization, probably because the
compared actual fees charged by various providers facilities were understaffed and underequipped and
and then related the fees to income levels and to thus unable to provide quality care. Detailed on-site
utilization. In fact, a few studies suggest that govern- inspection of 83% of the operating health posts
ment facilities may be underutilized precisely because showed that more than half were understaffed, under-
they are free [23,24]. equipped, or both. Annis thus stressed that “the
More generally, the literature simply does not current low utilization of Ministry facilities reflects
provide systematic evidence that cost of services is a poor quality of services-and certainly not physical
major barrier to seeking care in the developing world. access nor mysterious ‘cultural barriers’ ” [l6, p. 5221.
These findings seem to contradict anecdotal reports The role that quality of care plays in the decision
from developing countries such as those mentioned to seek care is related to people’s own assessment of
above. Perhaps other study designs are needed to service delivery, which largely depends on their own
fully explore the circumstances in which the cost of experiences with the health system and those of
services poses a major and a definitive barrier to care. 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 SEREENTHADDEUS and DEBORAH MAINF

not lies in institutional factors, such as the procedures fear them include surgical operations such as
performed, staff attitudes and long waiting times. cesarean sections [35] and episiotomies [36].
These factors will act as inhibitors of future utiliz- Finally, how the prospective patient expects to be
ation, thus affecting the decision to seek care [30]. treated by providers and staff at the health care
Furthermore, modern medical facilities have a facility is an important dimension of the patient’s
culture of their own, which often clashes with the assessment of the quality of care. If the facility has a
culture of potential users [30]. The lack of emotional reputation for unfriendly staff, rude service providers
support and privacy in the hospital setting, compared and humiliating treatment, the prospective patient
with the home, and disruption of household respon- may delay the decision to seek care until the serious-
sibilities as a result of hospital confinement are some ness of her condition necessitates overcoming all
of the complaints which contribute to women’s barriers [24, 30, 3 I, 37, 381.
dissatisfaction with maternity services [23, 311. Leslie and Rao Gupta identify corruption as
Although a focus on cultural barriers to seeking another important dimension of staff attitudes [39].
modern obstetrical care may inappropriately de- Where ‘little presents’ help to get medicines and
emphasize institutional inadequacies and economic supplies, corruption may indeed delay the decision to
considerations, several studies have shown that seek care by increasing patient dissatisfaction and, of
beliefs associated with traditional birth practices course, by swelling the costs of seeking care [24].
act as disincentives to seeking such care. For example, We have sketched some of the interactions between
Sargent’s ethnographic studies of the Bariba in distance, cost and quality of services as they appear
Benin suggest that where infanticide is still practised, from our review of the literature on utilization of
modern medical culture comes into conflict with services. A fuller understanding of the decision to
beliefs. creating barriers. Traditional Bariba belief seek care needs to take into account other factors
holds that witches may be identified at birth, and an related to the illness itself.
entire cosmology provides a rationale for infanticide.
Although the values and beliefs of that society Illness ,factors
are in flux. and witches are increasingly ‘managed’
The literature clearly shows that health-care-seek-
through less drastic procedures, infanticide
ing behavior is strongly influenced by the character-
persists.
istics of the illness as perceived by individuals. To
In Pehunko (Benin), extrinsic factors such as distance, time, begin with, prospective health care users must recog-
and lack of support services rendered cosmopolitan support
nize that an abnormal condition exists. The perceived
services unavailable to most women. But even where cosmo-
politan practitioners were available to attend home deliver- severit?, and the perceived etiolog~~ of the disorder
ies. this alternative was viewed with suspicion for fear that then shape the decision to seek care. The studies we
witch detection and management might be obstructed. reviewed describe one or more of these illness factors
Moreover, the rural ideal was solitary delivery in which a without necessarily drawing conclusions about their
woman demonstrated her courage and stoicism, enhanced
role in the health-care-seeking process.
her prestige, and had the flexibility to keep or reject the child
[32. p. 2061. Recognition. Before deciding to seek treatment,
people need to recognize that they have a condition
While Sargent’s most recent and far-reaching ma- requiring specialized attention 1401.
terial acknowledges the saliency of time, distance,
A recent survey conducted m six of Senegal‘s IO regions
cost and government policy factors, and that “modifi- indicated that women In these regions lack basic Infor-
cations in medical and religious beliefs and practices mation on signs and symptoms of obstetric complications.
occur in conjunction with hospital use,” [32, p. 231, One-quarter of the women interviewed could not name a
she maintains that belief is central to the decision- single complication. Only 13 percent recognized fever, and
IO percent prepartum hemorrhage. as important danger
making process [ibid.]. Our review suggests that be-
signals. Some women even said that fever. dizziness and
liefs. as they relate to the etiology of illness and pallor were signs of a normal pregnancy [41].
maternal complications, also play some part in the Although pregnancy is considered a normal life event
decision whether to seek modern obstetrical care. among respondents [to a qualitative survey in Jamaica]. a
childbirth was perceived as potentially dangerous to the
However. these beliefs play less and less of a role as
majority of the women interviewed. However. most women
societies change through urbanization and increasing were f~tmiliar with only the common symptomatic com-
recognition of the efficacy of modern medical treat- plaints of pregnancy. and less than IOO;, of women could
ment. identify any specific risks or danger of pregnancy or birth
[31].
In addition to the above examples of what may be
seen as general hospital policy, there are those pro- Recognition of illness is defined by the patient’s
cedures specific to childbirth that women dislike or view of reality. not by the health professional’s
fear [33]. Women may feel uncomfortable having to medical criteria. with which it may or may not
expose their genitals in the hospital ward [23]. or they coincide [42,43]. Moreover. individuals’ assessment
may intensely, dislike the positions favored by hospi- of a health condition can be influenced by the preva-
tals for delivery [34]. Other specific hospital pro- lence of the condition. In a classic study in medical
cedures that inhibit utilization because women may sociology, Zola emphasized that in populations
 Maternal mortality in context 1097

where a particular condition is widespread, it is The perception of a condition as normal or minor

perceived as normal, natural, inevitable “and thus to interacts with cost and distance in the decision to seek
be ignored as being of no consequence” [44, p. 6151. care. Just as certain conditions (such as pregnancy)
In addition, the perception of a condition as in- are perceived as ‘natural’ and therefore not requiring
evitable is often accompanied by the perception that medical care, conditions that are perceived as minor
it is not amenable to treatment, that nothing can be also do not justify the expenses of money, time and
done to manage it [20]. travel effort often involved in medical care [lo, 201.
Pregnancy and childbirth are ubiquitous events. Cosminsky and Scrimshaw report that residents on
Although acknowledged as potentially risky, preg- the Guatemalan plantation that they studied tended
nancy and delivery are commonly considered natural, to use low-cost remedies to treat minor conditions
normal work for women. In other words, they are and then move to more expensive resources if the
often not seen as illnesses for which medical expenses illness progressed [59].
are justified and a hospital room booked [23, 36,451. It is important to note that we did not find any
Furthermore, just as pregnancy is considered a nor- studies showing that illness severity was not an
mal event, death during labor and delivery may important factor or that it played a lesser role than
sometimes be considered ‘normal ’ or inevitable. Such other variables as a consideration in the decision to
fatalistic views can lead to the perception that the seek care. This is in contrast with the findings of
condition is not amenable to treatment, and can thus studies examining the role of distance, cost and beliefs
act as effective barriers to a timely decision to seek about illness causation, all of which reveal much
care. The recognition of a health condition can also variation in the importance of these factors.
be shaped by sociocultural prescriptions and in- The aforementioned studies indicate that the per-
terpretations. Among the Bariba of Benin, for ceived severity of the condition may well be an
example, labor that lasts up to a day is considered overriding factor in the decision to seek appropriate
normal and thus is not recognized as dangerous care. Furthermore, there is an interaction between
[33,46]. severity of illness and other factors involved in the
In parts of Africa, prolonged obstructed labor is decision. Specifically, there is a reluctance to incur
taken to be a sign of the woman’s infidelity costs when the disorder is perceived as non-threaten-
[45,4749]. Obstructed labor is thus interpreted as ing or self-limiting. However, the perception of these
punishment for adultery and not recognized as a expenses as a barrier seems to decrease dramatically
medical problem. It is believed that the woman must when the disorder is perceived as serious, debilitating
‘confess her sins’ so that the delivery will progress or life-threatening, and the perceived benefits of
smoothly, thus precluding the decision to seek medi- seeking care seem to outweigh the constraints. As
cal care for the complication. perceived severity increases, utilization of services
Finally, mention should be made of situations in increases and the impact of distance and cost in
which a health problem is recognized, but care is not decision-making decreases.
sought because of the fear of social or legal sanctions. It should be noted that most of the studies we
Those suffering from a condition they view as shame- reviewed assume that the decision to seek care is
ful or stigmatizing may recognize its seriousness, yet a process that occurs in stages. While this may
the fear of punishment and ostracism can prevent be the case for conditions with a slow onset, it is
them from seeking appropriate care. For example, unclear what happens in medical emergencies (e.g.
venereal diseases are often denied, unreported and postpartum hemorrhage).
untreated [20]. Vesicovaginal fistulae and compli- Etiology. Once the decision to seek care is justified
cations resulting from unsafe induced abortion often by the perceived severity of the illness, a key factor
remain unreported, therefore untreated, because of in determining the type of care (self, traditional,
ostracism and shame in the former and the fear of modern or a combination of the three) that will be
sociolegal sanctions in the latter [34,50-531. Certainly sought is the cause to which the illness is attributed
in the case of an unwanted pregnancy, the condition by patients and their families.
and the need for care are both recognized. However, Our review indicates that while beliefs about illness
fear, shame and desperation can act as powerful causation do sometimes play a role in the decision to
barriers and lead to disastrous consequences as seek medical care, this role is not as important as it
women seek illicit and unsafe abortion, attempt to might have been a few decades ago, when the efficacy
self-abort and, in extreme cases, commit suicide of medical care was less well accepted in the develop-
[5457]. ing world [27]. Furthermore, while traditional medi-
Severit),. In addition to recognition of a health cine is still relatively more available than modern
condition, the perceived severity of an illness is a very medical care in rural areas, there is ample evidence
important factor in the decision to seek care. Utiliz- from most parts of the developing world that the
ation of services appears to be influenced by the trend is toward utilization of both systems for treat-
recognition of symptoms and the assessment that the ment of most conditions.
symptoms are serious enough to justify medical care Medical anthropologists and sociologists, such as
[l8, 42, 581. Cosminsky and Scrimshaw [59], Foster [27]. Lasker
1098 SEREEN THADDEUS and DEBORAH MAINE

[24] and Young [ 181 reject the view that beliefs about delay can occur through staff errors and misdiagno-
illness causation generally lead to decisions not to sis.
seek medical care. They argue that people are empir- In addition to identifying the major factors gener-
ical and pragmatic, as opposed to ‘unscientific,’ or ally shaping the decision to seek care, our review
‘irrational,’ that they base their health care decisions indicates that these constraints often apply unequally
on an assessment of available and accessible re- to women. Consider the example of distance. We
sources. have discussed how overcoming this barrier largely
The important lesson from anthropological studies depends on mobility: Individuals with access to mo-
of health beliefs is that a narrow focus on ‘cultural torized vehicles are more mobile than those with
barriers’ obscures the role that institutional inade- access only to bicycles or donkeys, who are in turn
quacies and economic considerations play in the more mobile than those who can rely only on their
decision to seek care. Nonetheless, variation across feet. Yet among the strict Muslim communities of
cultural groups and across health conditions remains northeastern Nigeria, women are not allowed to ride
great, and beliefs about illness causation do some- bicycles or donkeys. Although these means may be
times affect the decision to seek medical care. As we physically present in the community. they are effec-
noted earlier, the belief that obstructed labor is tively unavailable to women [IO].
caused by a woman’s infidelity is widely held-for Women’s status also interacts with the cost of
example, in Sierra Leone, Liberia. Ghana and treatment in the decision to seek care. The litcraturc
Zimbabwe. It should serve as an important reminder on the preference for male children provides evidence
of the types of factors that need to be identified by that the consideration of cost in the decision to seek
research and addressed by programs. It also illus- care is applied unequally to males and females [26].
trates that at the heart of many factors that limit Witness for example the impact of son preference on
access to care is the status of the women in the access to health services, a phenomenon best docu-
society. mented for Asia, specifically India and Bangladesh,
and to a lesser extent, for the Middle East [63] and
Africa [38. 641.
Women’s status is composed of the educational.
In Bangladesh, as elsewhere, private physicians’ fees arc
cultural, economic, legal and political position of much higher than those of other providers. Parents con-
women in a given society. While women’s status sulted private physicians three times as often for their sons
generally underlies and shapes women’s access to as for their daughters. Moreover, the purchase of drugs
health services, there are specific ways in which it prescribed by physicians was about three times as frequent
when the prescription was for a boy as when it was for a girl
directly affects and delays the decision to seek care.
WI.
In this section, we focus on how women’s access to
health services is limited by constraints on their Especially where resources are scarce. parents’
autonomy. health care seeking behavior and expenditures often
In countries as diverse as Nigeria, Ethiopia, reveal a preferred investment in their sons’ health.
Tunisia, India and Korea, studies show that women Even where health care services and transportation
do not decide on their own to seek care: the decision were both free of charge, such as in Matlab.
belongs to a spouse or to senior members of the Bangladesh, parents still used the services far more
family [IO, 20, 23.41. 60-621. Furthermore. women’s frequently for injured or ill boys than for girls [66].
mobility is limited in certain areas because they need It is evident that the low value placed on females
permission to travel. Often this permission must be adversely affects their utilization of health services.
granted by the spouse or the mother-in-law [IO]. However, this link has been generally overlooked. As
Where women‘s mobility is severely restricted be- Royston and Armstrong have recently pointed out.
cause of such cultural prescriptions, efforts to seek “sex discrimination as a contributory factor to ma-
timely care may be thwarted. According to Harrison. ternal mortality has been largely ignored, [and] has
in Zaria, Nigeria, “no matter how obvious the need been hidden within the general issue of poverty and
for hospital management becomes for the girl who underdevelopment which is assumed to put evcry-
develops obstructed labor, permission to leave home one. at an equal disadvantage in health terms” [67.
for hospital can usually be given only by the husband; pp. 45-461. Stemming from the low status of women.
if he happens to be away from home. those present reluctance to allocate resources or assign importance
are often unwilling to accept such responsibility” [34, to female health inhibits the decision to seek modern
p. 3851. In Ethiopia. women tend to use those primary medical care when complications associated with
care facilities within walking distance from their pregnancy and childbirth arise.
homes. because of “cultural restrictions placed on In many parts of the developing world. women
[their] travel outside the community” [20, p. 10131. consider childbearing as their only means of gaining
For a woman with obstetric complications, access status. Thus, women often find themselves in a
limited to the nearby primary care centers is not of paradoxical situation: high fertility is their main
much help. These facilities are usually not equipped channel to improving their status. but it increases
to deal with obstetric complications, and further their risk of maternal death. Even in some societies
 Maternal mortality in context 1099

where women are financially independent, they derive away were of higher economic status and more
pride and prestige chiefly from their roles as mothers commonly owned cars or motorcycles than did those
[68]. Sargent’s study of the Bariba of Benin illustrates living closer to the clinic [7].
yet another way in which pregnancy and childbirth
Educational status
confer status on women.
To the Bariba, birth represents a rare opportunity for a
Education is measured by the number of years of
woman to demonstrate courage and bring honor to both her formal schooling. In developing countries, men gen-
family and that of her husband by stoic demeanor during erally have higher educational levels than women.
labor and delivery. The woman who manages to deliver Our review reveals two major findings with respect to
without calling for assistance until the child is born is
the role of formal education in the decision to utilize
especially esteemed [33, p. 2911.
health services: (I) that its role is not clear-cut; and
In such situations, a woman’s efforts to gain esteem (2) that the mechanisms through which education
and enhance her status have direct implications for may play a role are not well understood.
the recognition of complications and delays in the Most of the studies reviewed show that utilization
decision to seek care if they do develop. of medical services increases with increasing levels of
None of the studies reviewed examines utilization education. The positive association repeatedly docu-
of services by women who are financially indepen- mented is that between mother’s education and use of
dent, who are autonomous in their decision-making child health services and child survival technologies
and who derive status and prestige from roles other [76-781. The presence of a positive association be-
than motherhood alone. Furthermore, the role of tween educational level and use of adult health
women’s informal power is rarely addressed. Re- services is not as consistent [75]. However, survey
search in such contexts is much needed. It might results from Ethiopia, Jordan and the Philippines
mitigate some of the gloominess described above. indicate a significant positive association between
The potential contribution of such research can be use of prenatal care services and level of womens’
gleaned from preliminary results of focus-group re- education [56, 58, 781.
search conducted in Enugu, Nigeria. Women partici- The mechanisms through which education might
pating in the focus groups argued that although their affect the decision to use health services are not well
husbands are the overall decision-makers, the women understood. It has been hypothesized that education
are financially independent. Access to cash, they affects individuals by introducing them to a new
stated, was the most important factor in the decision ‘modern’ culture [77]; that increasing levels of edu-
to seek care. This means that in case of a medical cation increase knowledge and awareness by shaping
problem, the women do not need to wait for their thought patterns-for example, by acting as “medi-
husbands, as they have ready access to cash and are cation against fatalism” [76]; and that education
able to pay for the expenses incurred [69]. increases access to information. A related hypothesis
is that education increases self-confidence and
Economic status imparts respect and influence [76].
The literature describes statistical associations be- There is evidence in the literature that higher levels
tween economic status and the utilization of services. of education may not guarantee higher levels of
However, the mechanisms through which this associ- health services utilization [I I, 24,42,43]. Some stud-
ation operates are not specified. Possibilities include: ies suggest that with increasing education, individuals
(1) income constraints; and (2) characteristics of the depend more on self-care and self-prescribed medi-
health care facilities serving the poor that may dis- cation and postpone the visit to a facility until after
courage use [20, 70, 711. What is clear, however, is these methods fail to produce a cure. However, it may
that morbidity and mortality rates are higher among also be that the better educated are generally health-
groups of low economic status [20,52,56,72-741. ier, thus requiring less care than the less educated.
Most of the studies reviewed indicate that econ- Although there are not many studies that show a
omic status affects the use of health services. In negative relationship between education and utiliz-
general, these studies find that utilization increases as ation of health services, they are important, because
economic status increases [9, 12,751. In studies by they illustrate that the explanation of differential
Kwast et al. in Addis Ababa, Ethiopia, economic utilization cannot be reduced to one variable. In
status was measured by income, house ownership and addition to their education, literate and illiterate
occupation. The lowest rates of prenatal clinic attend- individuals alike rely on their past experience of
ance and the highest rates of home delivery were health services as a source of information. Further-
found among women from the lowest economic more, focusing on education as a main factor in poor
status groups [56, 731. Data from Iraq show that utilization levels in effect lets the health system ‘off
consultation rates for all health facilities rose from 67 the hook.’ It obscures the fact that there are often
per 100 illness episodes for low-income households to institutional factors that deter utilization and it
103 for those in the high income bracket [l3]. In ignores the potential effect of outreach activities.
Calabar, Nigeria, distance did not deter patients from The experience of declining infant mortality inde-
using the family health clinic: Patients living further pendent of education in countries such as Cuba,
II00 SEREENTHADUEUSand DEBORAHMAINE

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 Phase II delays are very common. particularly in
strong national investments in education nor achieve- rural areas. yet they are not systematically docu-
ment of a high literacy rate appeared to have any mented in the literature. Rather. researchers have
effect on that country’s high mortality rate. Bullough typically focused on the individual and institutional
has pointed out that countries with high under-five characteristics that inhibit the timely use of services.
mortality rates spend about three to five times as The perspective that users and providers are the only
much on education as on health. He further notes actors in the health-care-seeking process prevails
that Paraguay and Tanzania are examples of throughout the literature. By focusing exclusively on
countries that “manage to combine high literacy rates the two poles of the health-care-seeking process, this
with high maternal mortality rates: adult female pcrspectivc fails to take into account all that happens
literacy 85 percent and 80 percent. maternal mortality on the way to the health care facility.
rate 469 and 370/100 000 live births” [80, p. I 1191. Phase II delays have important programmatic im-
In its purest form, the decision to seek medical care plications. For instance, it is of little use to identify
is a behavioral response to a perceived need created high-risk pregnant women who should deliver in the
by an illness. The complexity of the real world. hospital and to raise the community’s awareness of
however, introduces variability and constraints into risk factors if the women are unable to reach the
this process. It is therefore simplistic to relate people’s hospital, as in the Kenyan example cited above.
underutilization of services to their ignorance, illiter- Gathering data on delays that face patients who are
acy, poverty, laziness or superstition. Rather, under- trying to reach a facility is thus an important research
utilization is often related to people’s knowledge, effort that can serve to guide programmatic interven-
based on previous experience, that facilities are far tions.
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 There is a general shortage of medical care insti-
other words. the actual accessibility of services is tutions in the developing world. In addition. existing
often at the heart of the matter (Fig. 2). facilities are more often than not concentrated in and
around urban areas. Governments plan to have rural
Phme II Delq: Reuching u Medid Fucilitl areas served by a network of regional and district
hospitals in large towns, primary health centers,
The accessibility of services plays a dual role in the
health posts and dispensaries. In many cases. how-
health-care-seeking process. On the one hand, it
ever. this network does not function as planned. All
influences people’s decision-making, as outlined
studies reviewed indicate that inhabitants of urban
under the rubric of Phase I Delays. On the other
areas have better access to health facilities than do
hand, it determines the time spent in reaching a
rural inhabitants [20,24]. In the Syrian Arab Repub-
facility after the decision to seek care has been made.
lic, 30% of all government and 19% of all private
This latter effect we term Phase II Delay.
hospital beds are concentrated in Damascus. the
Interviews with pregnant women in rural Kenya indicated capital city. Also. 65% of the nation’s health centers
that 47 percent of the women intended to deliver in a are located in urban capitals of governorates. Health
hospital, 40 percent intended to deliver at home and 13
care providers are also in short supply and unevenly
percent had not yet decided at the time of the interview. Of
those who had decided to deliver in a hospital, only 36 distributed. Of the country’s 221 obstetricians. 78
percent actually did so. The rest had not changed their (35%) practice in the capital city. In contrast, only
minds-they were simply not able to reach the hospital [S I]. nine obstetricians practice in the rural areas. and four
The data further indicate that 84 percent of the women in
of them are located in Damascus governorate. This
the sample had received prenatal care; that the majority of
the women and their relatives could recognize risk factors; means that there are only five obstetricians in the
and that women who experienced difficulties with previous country’s remaining I3 governorates [82].
deliveries were significantly more inclined to plan for a A concern for equitable distribution seems to
hospital delivery than were those who had a history of have guided the allocation of health resources in a
uncomplicated deliveries. Yet a sizable proportion of
few countries. According to Cardoso, the Cuban
women could not act on their informed decision because
they lived far from the hospital, which they could reach only Ministry of Health has paid particular attention to
by walking or by waiting for a passing lorry [8 I]. the rural areas in establishing a network of hospital
 Maternal mortality in context

Factors Affecting
Utilization and Outcome

‘,‘.~Pil& 1,; ‘.

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 Travel distances

population. Existing hospitals were enlarged
and new hospitals were built in the rural areas [83]. The uneven distribution of facilities has impli-
Unfortunately, the Cuban model does not appear cations for travel distances between women and even
to be widespread. Of course, Cuba is a relatively small the closest facility, let alone a specialist referral
country, a factor which probably facilitates the im- hospital. The issue of access is therefore an acute
plementation of such policies. Still, there are many problem for rural inhabitants in most developing
small countries where distribution of resources is countries. Examples of actual travel distances cited in
much less equitable. the literature gives an idea of the magnitude of the
1102 SEREENTHAVVEIJSand DEBORAHMAINE,

problem [I 1,23, 521: People from a rural farming seeking care are sometimes counted as deaths at home.
community in Mexico had to travel 30 km to reach the Of all studies reviewed, the literature on maternal
nearest medical facility [84]; in Ethiopia, rural mortality proved to be the richest source of data on
patients had to walk between I5 and I8 km to the deaths occurring on the way to seeking care [76.91, 921
nearest town where Land Rover service was available (Fig. 3).
to transport them to the nearest medical facility [20]. A 1984 investigation of maternal mortality in 2X7 Chinese
Travel distance can be measured as a straight line cities, districts and counties revealed that I5 percent of all
between two points+.g. the house and the hospital. recorded maternal deaths occurred on the way to the
But people often cannot follow a straight line to reach hospital. They were all in rural areas [93].
In Addis Ababa, I3 percent of maternal deaths recorded
a facility. The nature of the terrain and the condition of
over a two-year period occurred on the way to the hospital
the roads often dictate that distances will be longer ]941.
[69, 851.

Transportution Phase III Delay: RrceitQng Adequate Treatment

In addition to travel distance, the scarcity of trans- Today. Mary, the lady who helps us in the house, came late
portation in developing countries is also a harsh reality to work, I told her off for being late and asked why. She said
that one of her townswomen had died in the hospital
[24, 881. In Tanzania, a woman with placenta previa while giving birth to a baby. This was her fifth delivery. She
“died only 20 miles from the Consultant Referral was not from a far off village but from Sokoto city itself. She
Hospital because the Land Rover assigned to her had not gone too late to hospital but rather gone on
medical center was being used by an unauthorized time. By the ttme they found a vehicle to go to hospital,
by the time they struggled to get her an admission card. by
person at the time, and she bled to death at the
the time she was admitted, by the time her file was made up,
roadside waiting for a taxi” [89, p. 1041. by the time the midwife was called, by the time the midwife
As a result, inhabitants of rural areas commonly finished eating, by the time the midwife came, by the time
have to walk or improvize means of transportation to the husband went and bought some gloves, by the time the
reach a health care facility [72, 901. For example, “In a gloves were brought to the hospital, by the time the midwife
was called, by the time the midwife came. by the time the
remote area of Bangladesh, seriously ill patients were midwife examined the woman, by the time the bleeding
often carried to the clinic on a chair because there were started, by the time the doctor was called. by the time
no vehicles available to transport them” [ 141. the doctor could be found, by the time the ambulance went
The patient’s condition can, of course, deteriorate to find the doctor. by the time the doctor came. by the time
the husband went out to buy drugs, IV set. drip and bottle
with increasing delays in reaching a treatment facility,
of ether, by the time the husband went round to look for
making the condition more difficult to treat once the blood bags all round town, by the time the husband found
facility is reached-that is, if the patient is still alive one and by the time the husband begged the pharmacist to
upon arrival. reduce the prices since he had already spent all his money
on the swabs, dressings, drugs and fluids, by the time the
Deaths on the way to the hospital haematologist was called. by the time the haematologist
came and took blood from the poor tired husband, by
Not all individuals who decide to seek care at a the time the day and night nurses changed duty, by the time
medical facility arrive there in time to be treated: some the day and night doctors changed duty, by the time the
die while trying to get there. Deaths on the way to midwife came again, by the time the doctor was called, by
the time the doctor could be found, by the time the doctor
seeking care may result from the joint effect of Phase I
came, by the time the t’s had been properly crossed and all
and Phase II delays: There might have been a delay in the i’s dotted and the husband signed the consent form, the
the decision to seek care, which was further aggravated woman died. Today the husband wanted to sell the drugs
by the long distances and/or the unavailability of and other things they never used to be able to carry the body
transportation. But it is entirely possible that the of his wife back to their village but he could never trace [the
body] again in the hospital [95].
decision to seek care was timely, yet the poor distri-
bution of facilities and the resulting distances separ- This excerpt from a letter sent to us by a colleague
ating people from services accounted for the delay and provides a vivid illustration of Phase III delays~--those
therefore caused the death. that occur at treatment facilities. Delays in the delivery
In addition. it must be specified that reaching a of care are symptomatic of the inadequate care that
health facility does not necessarily mean the end of the results from shortages of staff, essential equipment,
health-care-seeking journey. If the nearest facility is a supplies, drugs and blood as well as inadequate man-
peripheral health center not equipped to treat the agement. Late or wrong diagnosis and incorrect action
condition or even to administer essential first aid, by the staff are other factors that contribute to delays
seriously ill patients will have to go on to another, in the timely provision of needed care. All these
better equipped institution. By the time the patient deficiencies in the quality of the care provided at health
reaches an adequate health facility, the delays will have facilities are frequently mentioned in the literature.
further increased the risk of a death en route. In addition to identifying the diagnoses in cases of
Data on such deaths are scarce. Hospital-based maternal death, some hospital-based studies deter-
studies are not helpful, since they include only deaths mine whether or not the deaths were avoidable. They
that occur in the institution. Community-based re- generally find that while a small number of maternal
search is more relevant, but deaths on the way to deaths are unavoidable. the large majority are either
 Maternal mortality in context 1103

entirely or probably preventable. For example, 98% cedures. According to a technical working group
of institutional deaths studied in Tanzania [87]; 94% formed by the World Health Organization in 1986,
of maternal deaths studied in Cah, Colombia [96]; these deficiencies “represent a failure on the part of
88% of those studied in Vietnam [97]; and 80% of the health services to seize the last chance to save a
those studied in Jamaica [98] and in Lusaka, Zambia woman” [99, p. 21. This technical working group also
[88], were judged preventable by the respective inves- identified seven obstetric functions that are essential
tigators. at the first referral level to save the life of emergency
Insufficient and unqualified staff, clinical misman- obstetric patients. Accordingly, district and subdis-
agement of patients, unavailability of blood, short- trict hospitals should be able to perform cesarean
ages of essential drugs and missing supplies and sections, administer anesthetics and blood transfu-
equipment limit individuals’ access to lifesaving pro- sions, perform vacuum extraction, carry out suction

Fig. 3. Phase II delay, detail.

I104 SEKEENTHAUDEUS and DEBOKAH MAINE

curettage for incomplete abortion, insert intrauterine hospital study. Most of these would have been pre-
devices and perform tubal ligation or vasectomy. The vented with a course of antibiotics [lO6].
capacity to perform these essential obstetric functions In brief, the vast body of literature documenting
provides a guideline against which to evaluate the medical and nursing staff shortages, failures in the
quality of care described in the following findings. clinical management of complications and shortages
in essential supplies indicates that the quality of care
Ill-staged ,facilities in many institutions is inadequate. These studies
Insufficient numbers of medical and nursing per- show that blaming the patient for seeking care late
sonnel at a facility necessarily lead to delays in obscures the fact that the health care system often
patients’ receiving the care they need. This shortage fails the patient (Fig. 4).
is often not only a matter of staff numbers, it is
also a matter of competence. In other words, there DISCUSSION
is a shortage of trained, qualified personnel
[57, 87.98, 1001. In a study of maternal mortality at In the preceding sections of this paper. we have
the University Teaching Hospital (UTH) in Lusaka, presented findings from a great variety of studies to
Zambia. “the most worrying finding [was] that an help us elaborate some of the factors that may
avoidable hospital factor was present in 52 percent of contribute to delay in preventing deaths among
cases” [88. p. 771. Hospital factors identified included women with obstetric complications. We now piece
poor intrapartum assessment, failure to correct ane- together these various factors to examine the larger
mia, missed diagnosis of ruptured ectopic pregnancy picture.
and unavailability of the anesthetist. The investi- Obtaining medical care for women with obstetric
gators argue that all these factors could be “reduced complications begins with the recognition of danger
or eliminated” [ibid.]. Numerous other studies report signs, Access to such information and understanding
similar cases of clinical mismanagement from Colom- of the gravity of symptoms, such as bleeding or
bia [96], Kenya [IO I], Malawi [ 1021, Vietnam [97], and prolonged labor, help a woman and her family to
Zambia [88, p. 771. seek timely treatment. Even when women and their
families recognize danger signals and understand the
need for medical care, they are also aware that there
A lack of equipment and supplies plagues health is not much the medical facility can do for her when
facilities in most regions of the developing world. there is no trained doctor or nurse-midwife, when
There is little question that this situation is due in blood shortages are regular and when equipment is
part to the very real issue of limited resources. But it frequently broken. People do not bother to seek care
is often perpetuated by poor management and organ- when they know that they probably will not be cured,
ization of the available resources. Difficulty obtaining that they are even likely to die in the hospital.
blood for transfusion assumes paramount import- Unfortunately, and despite the efforts of many dedi-
ance in the management of several major obstetric cated and hardworking health providers, this is the
complications and is often identified as an avoidable state of affairs in many facilities in the developing
factor delaying the provision of adequate care world. Under such circumstances, people’s decisions
[56, 103, 1041. For example, blood shortages were not to use the health facilities available to them make
implicated in 35% of hospital maternal deaths in sense.
rural Tanzania [89]. 39% in Malawi [102], and 36% The process of obtaining medical care unfolds
in Vietnam [97]. At Korle-Bu Teaching Hospital in within the confines of the health care system. In
Ghana, prepartum hemorrhage was an indication for defining the components of this system, it is import-
9% of the cesarean sections performed in 1971. The ant to speak not only of the providers, but also of the
investigators argue, however, that patients who might users as part of that system. As with any system,
be treated conservatively if blood were available are changes introduced into one component can effect
sectioned as the quickest way of stopping the bleed- changes in other components. Thus, the objective
ing. They maintain that the situation would improve obstacles encountered in Phases II and III feed back
considerably if the maternity unit had its own blood into the subjective decision-making of Phase I, link-
bank [I OS]. ing the user of health services and the provider of
Inadequate supplies of essential drugs. such as these services into the same system.
antibiotics and ergometrine, are other avoidable To apply what has been learned in this literature
factors that contribute to phase 3 delays. Such short- review, one can begin with a brief discussion of
ages occur at all levels of the health system program strategies. The factors identified as con-
[16. 26, 56, 87,971. In Ilorin University’s Teaching tributing to delay were the following: distance, cost,
Hospital in Nigeria, some patients were without any quality of care, illness characteristics, women’s status,
antibiotics until the third day after a cesarean section, economic status and educational status. As Fig. I
because their relatives were not able to buy the drugs showed, these factors all influence a woman and her
immediately and they were not in stock at the hospi- family in their home as they decide whether to seek
tal pharmacy. Sepsis caused 82% of the deaths in this medical care for her. Interventions designed to affect
 Maternal mortality in context 1105

Phase 1:
Socioecunamicl
Cultural
Factors . @xid.ingi tp.Se,&:~.
Care

Phase II:

AccesstbiMy of
idarrtifying and
Fad ities
Reaching Medicat
Facility

...... ............. .........................

................
........ ..... ... ...................
.... ................................
.................
................. “““”
...........................
.................................... .......

........ ..................
... .... .......... ... ....

............................................. ........
:::::.~.harb:ci~re~~.~r~~~~;~;
.....................................................
. ..I.. .....................
......... ............
......................
.....................
................ .... ...................
... ............ ............................
......... ...... ........................ .,
.....................................................
:.:.~:.:~ij~~~~~~.:~~~~~~:.:.:.:.:.:.:.:.:.:.:.:.:.:.: .................... ............... ........
.......................... .................
..................................................... ... ............ ................ ........
..... , ........ a ........... ....... ........................
:.:.:.:.:.~.:i~Bi~~~t:~i~:~~~~:~~~;~,,*n:.~~, .........................................
......................................................

Fig. 4. Phase III delay, detail.

these factors, however, must operate at quite different of maternal deaths. Some of these are discussed
levels. below.
Consider, for example, distance and cost. Both
these factors affect people’s decisions to seek care; Distance
there is, however, relatively little that individuals or The physical distance between people and medical
families can do to influence these factors. Rather, in care in developing countries is a problem that will
order to make systematic and widespread changes in take a substantial amount of time, money and politi-
these factors, the government must take steps to cal will to solve. However, there are several compara-
improve the distribution and financing of medical tively inexpensive measures that could reduce
care. Even so, there are some actions that can be maternal deaths by reducing travel distance to health
started on a smaller scale and may help reduce the toll services. Simply expressed, either pregnant women
I106 S~KEENTHAWEUS and DEBORAH MAINE

have to move closer to the services, or the services portion of the deliveries. While there may be other
have to move closer to the women. benefits to such training (e.g. reducing the incidence
The first option has been implemented in the form of tetanus among newborn infants), it does not
of maternity waiting homes. which provide modest address the problem of major obstetric compli-
accommodation close to the hospital for pregnant cations, many of which cannot be predicted. For
women who live far away. These women can live in most major complications. there is little that 21 TBA
the home during the last few weeks of their preg- can do in the way of treatment, although existing
nancy. then be transferred at the onset of labor or any training programs would do well to include more on
complication to the nearby local hospital for delivery. first aid measures.
A number of countries such as Cuba [lO7]. Colom-
Quditv of cure
bia. Uganda and Zaire are experimenting with ma-
tcrnity waiting homes. Unfortunately. there are no Some of the program options for improving quality
studies to date that evaluate the impact of maternity of care have already been mentioned, for instance.
waiting homes on deaths among women from compli- upgrading peripheral facilities to provide obstetric
cations. Such programmatic research is much needed. first aid and even treatment. But thcrc are also actions
While maternity waiting homes will be practical that can be taken to improve the services in large
and useful in xomc situations. they are not the hospitals. For example. in a major teaching hospital
solution to the uneven distribution of obstetric care in Nigeria, the obstetric operating thcatre has been
in developing countries. To deal with this problem, a closed for more than a year because the anesthesia
number of programs are being planned in which equipment needs repair. Consequently. women who
community members will be helped to prcparc for the need emergency obstetric surgery have to wait until
eventuality of obstetric emergencies either by setting they can be operated on in the hospital’s all-purpose
aside funds to pay for public transport or by arrang- theatre. Reducing Phase III Delay in this case does
ing with ownc~-s to make their vehicles available in not require equipping a whole operating room. it just
cmergcncies.* requires repairing the available equipment.
The second option ~that of moving the services- As noted in our review. lack of essential supplies is
was endorsed by a WHO Working Group on the a common problem in developing countries. Usually.
Organization of Maternal Health Care. which this is part of much wider economic problems. inbolv-
stressed that “programmes should be guided by the ing devalued currencies, reduced purchasing power.
axiom that all scrviccs should be provided at the most poor balance of trade and stringent structural adjust-
peripheral level of the health system at which this can ment policies. Such issues are, for the most part.
bc done effectively” [YY. p. Y]. beyond the scope of health programs. Even within
It is not reasonable to propose that definitive these difficult conditions, however, there is often
treatment of obstetric complications (such as ce- something that can be done to reduce their impact. In
sarcan section) bc made available at all health facili- an African country. PMM staff have observed a
tics. Even so. man) women’s lives would probably be ‘people’s store’ set up in the courtyard of a large
saved if health centers in rural areas were at least able clinic. This store operates on a revolving fund started
to provide first aid to women with complications. In with clinic money. It sells items that are out of stock
three isolated Gambian villages. the single most in the clinic pharmacy (which depends on the govern-
important factor contributing to mortality declines mcnt’s central store for supplies). The people’s store
“has apparently been the on-the-spot. 24-hr avail- buys its supplies from merchants in the town at
ability of a physician or qualified midwnifc” at the wholesale prices. Thus, the people’s store saves
clinic [ 108 p. 9121.In addition. free transportation to patients and their families both time and money.
and from the chmc was provided. and the clinic There are many other options for improving qual-
physician or midwjife assisted at home deliveries. ity of care in health facilities. including training
According to the authors, transfer to a hospital in programs and expanding roles for nurses and mid-
casts of major difficulties could be achieved within wives. The few mentioned above are intended only to
3 hr. No pregnancy-related deaths have been illustrate that relatively simple innovations arc poss-
recorded in the project arca since 1975. This is in ible even under very difficult economic conditions.
contrast to statistics from a nearby non-project vil-
lage where. in IYXI X3. there were 24.2 maternal
C‘o.rt
deaths per 1000 women of childbearing age. This is one of the most difficult factors for which
One of the common suggestions for extending the to propose program options at any level. In the past
coverage of maternity care services is to train tra- decade, household incomes and purchasing power
ditional birth attendants (TBAs). since there are have been declining in many countries along with
many societies where they still conduct a large pro- government spending in general and for health care
in particular. In addition, importing drugs and
supplies requires hard currency, which many
*These programs have been plnnncd in the context of the
PMM collaboration with teams of African researchers. countries must allocate instead to servicing their
Implementation began in 1991. debts with foreign banks.
 Maternal mortality in context 1107

At the same time, grass roots development contin- The PMM experience
ues in the face of these constraints. Farmer-run coop- Many of the practical applications of our con-
eratives already allow individuals to pool limited clusions from the literature review become apparent in
resources and negotiate a better deal in the market-
the above discussion. Indeed, several aspects of the
place. Similarly, a community group, such as a
PMM program take their cues from the conclusions we
women’s organization, could use the profits of an
suggest here. As mentioned earlier, the PMM program
income-generating activity toward the bulk purchase
works through a network of teams of researchers and
of generic drugs to stock a local clinic. Such a group
practitioners in Ghana, Nigeria and Sierra Leone. In
could cooperate with an area hospital toward the same
each country, solutions to problems associated with
end, making the drugs available to patients at cost. The
maternal mortality are different. As a part of their
need for creative experimentation and the involvement
operations research projects, teams first conducted
of interested nongovernmental organizations is great
situational analyses of health facilities and focus group
and may be the most fruitful direction at present.
research to determine barriers to utilization of services
and areas where the quality of these services may be
Economic educational and women‘s status
improved. The PMM Network’s activities to date have
Here again, extensive changes will require policy focused attention on hospitals (improving the avail-
changes at a very high level. Policies and measures to ability of drugs and supplies, improving hospital man-
improve women’s status, for instance, are being agement and quality of care), on secondary health
adopted at the global, national, and local level [109]. facilities (expanding and decentralizing provision of
The United Nations Convention on the Elimination of All emergency obstetric care, improving staffing and
Forms of Discrimination Against Women is, in effect, an skills), and finally on communities (improving emer-
international bill of rights for women. The convention was gency transportation, improving the availability of
adopted by the United Nations General Assembly in 1979
blood, providing first aid, and encouraging the early
and by early 1988, it had been ratified by 94 nations [I lo].
treatment of complications). The PMM project has
Lasting change lies in the structure of a society and adopted a strategy of meeting the community half-
change must occur at the top as well as at the grass way, feeling that it is counter-intuitive to educate and
roots. Thus, people in health programs must put motivate the community about seeking emergency
government proclamations into action, and even an- obstetric care until services and accessibility are
ticipate them, if necessary, to ensure that women’s adequate.
status becomes more than a topic at cabinet meetings. Although women experience delays beginning with
‘Your wife’s health is important; look after her’ was the the decision to seek care, the PMM approach starts at
theme for a community education program in northern the other end-with receiving care at the emergency
Nigeria. Men in the communities targeted were reminded of obstetric care facility. The schematic diagram in Fig. I
the importance of women’s health and the need for maternal
is helpful in pointing out our rationale; all the factors
care through posters and radio broadcasts. In addition,
separate discussion groups were held with men and women affecting utilization and outcome of Phase II and III
(most of whom are in purdah). Participants were told about Delays-distance, transport, roads, cost and quality of
activities to promote the role of women in development care-are crucial variables in the Phase I decision-
locally, nationally and globally. Women’s health needs were
making process.
also discussed and experiences and perceptions of home and
hospital delivery were exchanged [I 1 I]. Programs must recognize that even ‘low risk’
women develop obstetric complications, and that
provision of prenatal care, food and vitamin sup-
Illness characteristics plementation programs, and training of traditional
The literature reviewed indicated that people’s rec- birth attendants in safe. hygienic birthing practices
ognition of illness and their perception of its severity may be of limited efficacy. Additional locally relevant
are important influences on the decision to seek care. research should be conducted when designing more
From a program point of view, this is an encouraging community-based interventions, such as involving tra-
finding, because the recognition of danger signs during ditional birth attendants in the reduction of maternal
pregnancy, labor and delivery can be addressed mortality. Prenatal screening programs, whether these
through community-level programs. A Senegalese sur- involve traditional birth attendants or not, may not
vey revealed that women lacked information about bring the benefits they intend to bring. since their
obstetric complications. In response, the government epidemiologic sensitivity has traditionally been
of Senegal plans to provide community education on disappointingly low. Also, it is widely assumed that
pregnancy care and obstetric complications through traditional birth attendants are influential in encour-
women’s groups [4l]. In other countries, lack of infor- aging or discouraging patients and their families
mation may not be a problem. Women and their from seeking necessary obstetric care; clearly,
families could have enough knowledge to seek care in more research is needed in this regard. Certainly
a timely fashion. They may face other obstacles, such research and education efforts should be directed at
as distance, the cost of services and their inadequate decision-makers as they are identified-e.g. mothers-
quality. in-law, husbands, religious leaders, etc. The PMM
1108 SEREENTHADDEUSand DEBORAHMAINE

Network works with community leaders to encourage Inrerregional Meeiing, I I~-15 November. 1985.
Geneva, 1986.
their participation as educators, advisors and mobi-
6 Frederiksen H. S. cl crl. Epidemographic SuweiNance:
lizers. A Symposium. Monograph No. 13, Carolina Popu-
lation Center. UniversTty-of North Carolina. Chapel
Hill, 1970.
CONCLUSIONS
7 Freeman D. H. Jr et al. A categorical analysis of
contacts with the family health clinic. Calabar, Nige-
In conclusion, we believe that given large gaps in ria. Sot. Sci. Med. 17, 571, 1983.
the literature regarding factors affecting the utiliz- 8 Lennox C. E. Assessment of obstetric high risk factors
ation of health services, high priority should be given in a developing country. Tropical Doctor, July. 125.
to field-based research that can elaborate the factors 1984.
9 Roghmann K. J. and Zastowny T. R. Proximity as a
leading to delay in different settings by focusing
factor in the selection of health care providers: emer-
simultaneously on circumstances facing women in the gency room visits compared to obstetric admissions
community and in the health facility. We believe that and abortions. Sot. SKI. Med. 13, 61, 1979.
programs to reduce maternal deaths are more likely 10 Stock R. Distance and the utilization of health facili-
ties in rural Nigeria. Sot. SCI. Med. 17, 563, 1983.
to succeed if they are based on gathering data on
II Orubuloye I. 0. and Caldwell J. C. The impact of
these various components and then devising interven- public health services on mortality: a study of mor-
tions that will address them. tahty differentials in a rural area of Nigeria. Popul.
The next step is thus for people involved in the Safe Stud. 29, 259, 1975.
Motherhood Initiative to assess the situation in their 12 Egunjobi L. Factors influencing choice of hospitals: a
case study of the northern part of Oyo State. Nigeria.
respective regions and implement program options
Sot. Sci. Med. 17, 585, 1983.
based on their findings. We also urge people to 13 Habib 0. S. and Vaughan J. P. The determinants of
evaluate their interventions: only if programs are health services utilization in southern Iraq: a house-
systematically evaluated will we be able to say hold interview survey. Inr. J. Epidemiol. 15, 395, 1986.
whether they were effective in reducing delay. 14 Rahaman M. et ul. A diarrhea clinic in rural
Bangladesh: Influence of distance, age, and sex on
We hope that this article encourages a fresh per- attendance and diarrhea1 mortality. Am. J. Pub/. H//h
spective on the prevention of deaths among women 72, 1124. 1982.
with obstetric complications. I5 Williams R. Meningitis and unpaved roads. Sot,. &.I.
Med. 24, 109. 1987.
Acknowledgemenls-This monograph is the result of a team 16 Annis S. Physical access and utilization of health
effort, and the contribution of several individuals must be services in rural Guatemala. SOL.. Sci. Med. IS. 515.
acknowledged. Sharon Stash was the driving force behind 1981.
the literature review in its early stages. As graduate research 17 Airey T. The impact of road construction on hospital
assistants with the program, Sheryl McCurdy. Voahangi in-patient catchments in the Meru District of Kenya.
Ravao, Jack Kilcullen, Pamela Skripak. Laura Sanders and Sot. Sri. Med. 29, 95. 1989.
Schuyler Frautschi contributed their valuable skills at 18 Young J. C. Non-use of physicians: Methodological
various stages. approaches, policy implications. and the utility of
We greatly appreciate comments on various drafts of this decision models. Sot,. Ser. Med. 15, 499, 1981.
paper from Angela Kamara, Joe Wray. James Allman, 19 Nnadi E. E. and Kabat H. F. Choosing health care
Norman Weatherby and Allan Rosenfield of Columbia services in Nigeria: A developing nation. J. Trap. Med.
University and Annette Ramirez of Hunter College. Hyg. 87, 47, 1984.
We especially thank James McCarthy. director of CPFH. 20 Kloos H. et crl. Illness and health behavior m Addis
for the time he took to comment on and discuss several Ababa and rural central Ethiopia. Sot. Sci. Med. 25,
drafts. 1003. 1987.
We would also like to thank Ana Pagan for production 21 Yoder R. Are people willing and able to pay for health
assistance and Mary Lutton O’Connor for copy editing. services? Sot. .%I. Mrd. 29, 35. 1989.
Finally. we must express our immense gratitude to the 22 Ekwempu C. C. CI 01. Structural adjustment and health
Carnegie Corporation of New York for their financial in Africa. The Lower 336, 56 57, 1990.
support and for the inspiration provided by Drs 23 Auerbach L. S. Childbirth in Tunisia: Implication of a
Adetokunbo Lucas and Patricia Rosenfield. decision-making model. Sot. Sci. Med. 16, 1499. 1982.
24 Lasker J. N. Choosing among therapies: Illness behav-
ior in the Ivory Coast. Sot,. Sci. Med. 15, 157. 1981.
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