Health inequities occur when health services are not accessible or utilized by certain groups of people, based on their gender, socio-economic status, ethnicity, geographic residence, or other characteristics. For example, a majority of native Mayan women in Guatemala do not receive the recommended maternity care, contributing to a maternal mortality rate more than double the national average. In order to improve equity disadvantaged groups need services and interventions that are designed to reduce inequities.
In 2011, Curamericas Guatemala launched the Casa Materna project to serve rural Mayan communities. The project established two Casas Maternas, or birthing centers, which provide skilled birth attendants and are planned and operated in collaboration with partner communities. The Casas provide culturally appropriate health services in the native language, and train mother peer-educators to educate women in the community. An initial evaluation of the project showed that access and use of maternal health services increased among communities served by the Casa Maternas. TRAction supported a case study to identify factors that influence the use of Casa Maternas in partner and non-partner communities. In addition, the study examined the project’s impact on equitable access to services among the most disadvantaged groups within the community.
Guatemala: San Sebastián Coatán, Huehuetenango Department
The aim of this case study was to identify factors that influence the use of Casas Maternas for delivery. TRAction and its research partners aimed to answer the following questions:
A mixed-methods design was used to identify factors influencing use of Casas Maternas for delivery, and to determine the impact of the program on equity. The research was carried out in the western highlands of the Department of Huehuetenango in the municipality of San Sebastián Coatán where isolated, difficult to access communities are located and inhabited by indigenous Mayan people.
A structured household questionnaire was administered to a total of 275 women who had given birth in the study area, representing 86% of all of those who had given birth during that period. Questions addressed socio-demographic characteristics, as well as information on the location of maternal and newborn health services received and opinions regarding the quality of care received.
A total of 22 in-depth interviews were also conducted from among this group of women. The interview questions probed how decisions were made on the place of birth, the birth experience, and recommendations for improving Casa Materna services. In addition, six group interviews were conducted with key informants.
In the partner communities (that are officially connected to and support a Casa Materna), 70% of the births took place in a health facility compared to 30% in the non-partner communities. In the partner communities, 78% of the facility deliveries occurred in a Casa Materna. There was no statistically significant difference in uptake of the Casa Materna by level of education of the mother. Household wealth showed a very weak effect on uptake. Distance from the Casa Materna did have a pronounced effect when the distance to the Casa Materna was four or more kilometres. Traditional birth attendants (comadronas) in the partner communities are strong advocates for utilization of the Casa Materna and play an important role in the decision regarding where the birth will take place.
The findings from this case study provide strong evidence of a high level of use of Casas Maternas in the study area. Working with communities to establish Casas Maternas that provide high-quality, culturally appropriate maternity care provides a promising approach to reducing maternal mortality. Casas Maternas also provide opportunities for comadronas to continue in their traditional role of supporting mothers at the time of childbirth. The success of Casas Maternas in the study area is likely due to a combination of factors, including the provision of high-quality and culturally-appropriate medical services, close proximity of these services, and the enthusiastic participation of comadronas.
If the Casas Maternas are to succeed for the longer term at scale, they must consistently provide high-quality, respectful and readily accessible maternity care in a clean and safe environment. Health workers will also need to recognize the essential role of community involvement in planning and building the Casas Maternas as well as the vital role that comadronas can play as cultural mediators and champions of facility delivery.
This case study identified the contextual factors surrounding birth decisions, and the extent to which Casa Maternas reach vulnerable populations. Curamericas Guatemala will apply the findings to future projects, and use the results to improve services provided at the Casas Maternas. The results will also be shared with the Guatemalan government and local research institutions to inform improvements to health services for rural indigenous populations. In addition, TRAction will synthesize the findings from this and four other equity studies to gain a global understanding of factors influencing access and utilization of facilities for delivery. Experience from this study and other TRAction projects will be used to develop training materials and other tools for conducting qualitative studies.