Evaluation of midwifery care: results from a survey in rural Guatemala
Introduction
Of the nearly 600,000 women who die each year due to pregnancy-related causes, over 99 percent live in developing countries (WHO & UNICEF, 1996). An additional 50 million women in developing countries experience a pregnancy-related complication each year (NRC, 1997). These numbers reflect huge disparities in maternal morbidity and mortality between developing and industrialized countries, with rates in the former countries reaching values 100 times as large as those in the latter (Walsh, Feifer, Measham, & Gertler, 1993).
About half of births in the developing world are attended by a person with no professional training (WHO, 1997). Moreover, midwives or traditional birth attendants1 (TBAs) are frequently the primary or sole providers of maternal health care (Levitt & Minden, 1995). Obstetrical care is neither affordable nor accessible to the vast majority of women in these countries. Thus, it is not surprising that governments and international agencies attempting to reduce international disparities in maternal mortality and morbidity have focused many of their efforts on TBAs.
In the early 1970s, the World Health Organization began to promote the training and incorporation of TBAs into formal health care systems to serve as extensions of government-sponsored maternal and child health services (Alma-Ata, 1978; Du Gas, Mangay-Maglacas, Pizurki, & Simon, 1979; Leedam, 1985). More recently, the Safe Motherhood Initiative was developed in response to the persistence of high rates of maternal mortality and morbidity in the developing world and the concentration of biomedical health services in major urban areas. The underlying premise of this initiative has been that most infant and maternal deaths and disabilities are preventable through high quality care, detection and efficient referral for complications, and effective access to the essential elements of obstetric care if needed (Mahler, 1987; Safe Motherhood IAG, 2000). Although nearly 30 years have passed since the WHO first recommended the incorporation of midwives into the maternal health care system, our knowledge of the extent to which the quality and accessibility of services in poor countries have improved is extremely limited in many developing countries.
In this paper, we examine the content of pregnancy-related care in Guatemala, one of the poorest countries in Latin America and one characterized by some of the highest maternal and infant mortality rates in the region. The most recent estimates indicate a maternal mortality rate of 190 per 100,000 live births and an infant mortality rate of 43 per 1000 (World Bank, 1999). The government of Guatemala has had formal association with midwives for decades, having introduced licensing arrangements for midwives as early as 1935 and having initiated training programs in 1955, although little action was taken for several decades. In the 1980s, the Guatemalan Ministry of Health adopted WHO recommendations toward the formal recognition of midwives and their incorporation into the national health care system (Acevedo & Hurtado, 1997; Du Gas et al., 1979; Leedam, 1985), and, by the late 1980s, about 70 percent of the approximately 20,000 midwives in Guatemala had received training (Putney & Smith, 1989). On the other hand, there is widespread criticism of these training programs, and utilization of biomedical services for pregnancy care remains low relative to other Latin American countries (INE, MSPAS, USAID, UNICEF, & DHS, 1996; WHO, 2001).
Apart from several small-scale evaluation studies,2 there is little information on the efficacy of the midwife training program. Studies in other parts of the developing world have provided mixed results regarding the success of such training programs (Piper, 1997). Whereas some studies find that training has an impact on knowledge, practices, or referrals (Akpala, 1994; Islam & Malik, 2001; Kumar, Thakur, & Aggarwal, 2000), others find little or no effect (Lynch & Derveeuw, 1994; Smith et al., 2000). Moreover, even when training appears to influence practices, researchers seldom are able to identify a positive effect on maternal outcomes (Goodburn, Chowdhury, Gazi, Marshall, & Graham, 2000; Smith et al., 2000).
More generally, there is a dearth of research on the quality of the pregnancy-related care that midwives (or other providers) offer in Guatemala. This limitation reflects a general lack of knowledge about the quality of prenatal care in both the developing and the industrialized world. Most studies of the adequacy of prenatal care are based on measures of the timing and frequency of visits to providers, not on the content of services, although there is no evidence that the amount of care is a major determinant of birth outcomes (Petitti, Hiatt, Chin, & Croughan-Minihane, 1991; Stringer, 1998). The scarcity of research in this area probably results in large part from the absence of uniform criteria with which to assess such care. Guidelines regarding care and practices during pregnancy are often not consistent across countries, even among more developed countries, and frequently reflect “expert opinion” or published standards rather than scientific evidence (Enkin, Keirse, Renfrew, & Neilson, 1995; Haertsch, Campbell, & Sanson-Fisher, 1999; Rooks, 1999). The few studies that have examined content of care are limited not only by the lack of standard evaluation criteria, but also by the inappropriateness of most of these criteria for developing countries where the majority of births occur at home, attended by a midwife with little biomedical training.
The objective of the present analysis is to use a large-scale sample survey—the 1995 Encuesta Guatemalteca de Salud Familiar (EGSF), or the Guatemalan Survey of Family Health—to examine four aspects of the integration of traditional and biomedical maternity care that are likely to reflect the quality of care received by Guatemalan women. This study complements an earlier study that used qualitative interviews collected as part of the same project to look at the relationship between traditional and biomedical maternity care (Acevedo & Hurtado, 1997). First, we examine the extent to which women combine traditional and biomedical care during pregnancy and the postpartum period. Second, we estimate the frequency with which midwives refer pregnant women to other types of providers and investigate whether a midwife's training status and other characteristics of the midwife and the community are associated with these referral practices. Third, we analyze the content of pregnancy-related care offered by midwives, with a focus on practices considered either beneficial or harmful according to current scientific evidence. Wherever possible, we compare these estimates with those obtained from ethnographic or small-scale studies in order to infer plausible changes over time in midwifery practice. In the fourth and final part of the analysis, we evaluate the effect of training programs on the quality of midwifery care.
In the next section of the paper, we briefly describe the social context, the nature of the health care system, and the content of midwife training programs in Guatemala. Subsequently, we discuss the detailed objectives of the analysis. Next, we describe the data collected as part of the EGSF, explore the availability of different providers who offer care during pregnancy and the characteristics of midwives, and discuss our analytical procedures. In the final two sections, we present the results and consider the implications of our findings.
Section snippets
Social context in Guatemala
Guatemala is one of the poorest countries in Latin America and one of the most stratified in the world, with the vast majority of the population living below the poverty line. A small elite controls much of the land and the economy and retains political power. A majority of the rural population does not have adequate access to such public services as water, sanitation, and electricity (Steele, 1994).
The population is divided into two ethnic groups of roughly equal size: the indigenous
The 1995 Guatemalan Survey of Family Health (EGSF)
The EGSF was designed to collect information on maternal and child health. In 1995, structured interviews were conducted with 2872 women aged 18–35 in 60 small, rural communities (i.e., between 200 and 10,000 inhabitants) by a staff of trained interviewers. Approximately 50 women were administered questionnaires in 15 communities in each of four departments of Guatemala. One department is primarily ladino (Jalapa), two are predominantly indigenous (Chimaltenango and Totonicapán), and one has a
Patterns of care
Table 4 presents distributions of care pertaining to pregnancy, delivery and the postpartum period. The data reveal that in almost all pregnancies (96 percent), women obtain some form of prenatal care. As suggested by earlier research, the midwife is the most frequently sought provider at all stages of a pregnancy and birth and most deliveries occur at home. In about 28 percent of pregnancies, women rely on both the midwife and a biomedical provider during pregnancy—most commonly a government
Discussion
This analysis has provided mixed findings regarding the efficacy of midwife training programs in Guatemala. About three-quarters of midwives in the sample attended formal training and presumably were encouraged to refer their clients for biomedical care. Nevertheless, most pregnant women did not see a biomedical provider at any point during pregnancy. Previous research offers numerous reasons for women's low utilization of biomedical care, even when they are given a referral by a midwife: fear
Acknowledgements
We gratefully acknowledge support for this project from NICHD (grants R01 HD27361, R01 HD31327, and P30 HD32030) and from USAID (#HRN-A-00-97-000018-00) through UNC-CH (5-56127). The findings, opinions, and recommendations expressed here are those of the authors and not necessarily those of UNC-CH or USAID. The Guatemalan Survey of Family Health (EGSF) was a joint undertaking among RAND, Princeton University, and the Instituto de Nutrición de Centro América y Panamá (INCAP), directed by Dr.
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