Maternal Mortality, a views from the right to health
Executive Summary
MATERNAL MORTALITY
A VIEW FROM THE RIGHT TO HEALTH IN
HONDURAS
RESEARCH ON MATERNAL MORTALITY IN THE DEPARTMENTS OF LEMPIRA, LA PAZ AND INTIBUCA,
2010 – 2011
CARE HONDURAS- HOGASA PROJECT
- Justification and Background
Background. Honduras has one of the highest rates of Maternal Mortality due to hemorrhage, high blood pressure and sepsis. Deaths are due to low coverage of institutional deliveries and the poor quality of services. In a great proportionthey are deaths that happen in the community, associated to socio-economic factors, gender and violence and to access to health services. Facing this problem the model of health management requires that each health unit reports maternal deaths, but there is limited qualitative research of the event, with few opportunities to socialize the information obtained.
Justification.Despite the importance of the goal achieved by decreasing the mortality rate, this is still unsatisfactory; therefore, it is necessary to change from a methodology approach that supports the quantitative method as the only alternative toscientific knowledge building. In this sense, the present research seeks to capture specific characteristics and the meaning of human actions, within a process of socio-cultural construction, whose understanding is key to access a relevant and valid human knowledge, in the event of the maternal death.
The general objective is aimed at sensitizing families for the solution to problems connected with pregnancy and decrease maternal mortality, facilitating initiatives that promote citizen participation, the linkage and partnership as mechanisms to generate effective responses and the specific to research maternal mortality in the communities covered by HOGASA Project, changing from quantitative analysis.
Referencial Theory Framework. Qualitative research tries to identify the deep nature of realities, their dynamic structure, the one that gives a complete reason for their behavior and manifestations. Indeed, every reality, and human realities even more, have many faces and we capture only, in a given moment, some of them; example, our current medicine is still basically biologic, it tends to ignore the non-biologic etiologyof many illnesses and their corresponding therapeutic, equally non-biologic. Additionally, as a rule or habit, scientific orientation tends to demand to quantify the object of the study and we can fall into the mistake of quantifying quantitative results to assure its “scientific validity”.
The enjoyment of the greater degree of health is one of the fundamental rights of every human being. (WHO Constitution). The amount of health should be considered as a citizen right since the Nation has the duty to guaranty the provision of quality services to the population (2009 Conceptual, political and strategic framework of the reform to the health sector). The right to health covers four elements:Availability, Accessibility, Acceptability and Quality and imposes various obligations on the Government, the duties to: Respect, Protect and Fulfill obligations.
Quality has two big dimensions:Technical quality, whichencompasses elements such as security, effectiveness, usefulness of the actions for health, as well as the timely, effective and safe care and the quality as perceived by users, that takes into account material, psychological, administrative and ethic conditions in which these actions take place(Conceptual, policy and strategic framework of the 2009 reform of the health sector 2009).
RAMNI Strategy, is the required reference framework,the instrument to align and harmonize any national resource or from the cooperation aimed at maternal and infant health. It considers that health cannot be conceived aside from political, economic and social circumstances which our society goes through and the need to strengthen the process of social production of health which these conditions demand.
IFC Strategy, individual, family and community have a strong information, education, social participation inter-sector coordination component to strengthen the development of personal attitudes that enable to recognize problems, analyze them and actively participate in the search and application of actions to solve them, provide follow-up to these actions and timely evaluate their results. Their objectives aim at increasing woman’s participation and her environment in activities geared towards reduction of maternal and infant mortality.
Methodology. It is qualitative and uses the method of research-action, since it is of interest to know reality from a rights view, but also it is desired to participate in its solution.With an ample participation in all phases of the process and as qualitative research it does not pretend to high generalization in its conclusions, but instead it desires to offer results and suggestions to make changes at various levels.
Geographic Área. HOGASA - CARE Project, with the technical, legal and financial support of the Ministry of Health since 2007, has operated in 17 municipalities of La Paz, Lempira and Intibucá, to assure effective participation processes among various social actors, thus is was identified as an ideal space to conduct the research.
Universe and sample: Although the sample includes the total of registered maternal deaths, it is reduced in the selection of informants in its numeric extension using as selection criteria the operational capacity in the collection and analysis, the understanding of the event avoiding “saturation of categories”,organizing a group of relatives of dead women and another of women whose pregnancy process was a successful one.
Measuring instrument and Techniques: The semi-structured interview was used as an instrument for data collection, with closed questions followed by open questions.
Ethic considerations: The negotiation process included an explanation of the study before to requesting and obtaining their consentto participate, although because of risk to participants, the written consent was not requested, confidentiality was guaranteed and safeguard of data, and the feedback of results in collective meetings was planned.
Analysis plan. Data were divided in categories, with the purpose of having information that bases the design of solution strategies to constraints in the availability of material resources, human capacities and management systems that are necessary to offer quality care and avoid maternal deaths. An interrelation model between perceptions, processes and results was applied.
General Participant Profile.They are women, mainly young adults, with representation of older than 38 and less tan 18, married or in a cohabitation relationship, with a small representation of single women and one widow; their education levelis elementary school and almost half with incomplete elementary, they are catholic, large multiparous; with an scarce number of abortions.
PROBLEM PERCEPTION
Capacity levels on preventive measures/actions. Most of them mention that they do not know what is a delivery plan, they do not know that the transportation committee in coordination with the trained traditional midwife and that the community key actorsare aimed at identifying the most important measures to take in order to decrease risks at the moment of delivery and, as a consequence, women that died did not have this instrument.
It bears mentioning that almost all women were in prenatal care, thus making evident the dichotomy between clinic care and public health actions, generating the loss of opportunities to promote and obtain the implementation of a delivery plan, cross-cutting element in the IFC strategy.
Nevertheless, attending prenatal controls should be seen as an exercise of the right to received required care to their condition. Women perceive them as a mechanism to obtain security and to have protection measures vis-a-vis unexpected events and cesarean section, technically perceived by the personnel as a response to an obstetric emergency, for obvious reasons for those women interviewed, it is a complication.
Level of knowledge, delivery and puerperium
There is a clear perception that pregnancies and deliveries are differentiated in its importance as they respond to characteristics of each woman andher environment. They identify the reasons of these differences, the attitude of their partners and relatives; that is, the care and support they receive, as well as geographic access, but the most important role is assigned to the woman’s condition, her nutritional condition, the presence of illnesses, associated or not to the pregnancy process, anatomic problems, narrowness,and, to a lesser degree, advanced age and multiparity.
Less relevant are the differences with the role of the constructor of beliefs such as, when an eclipse occurs, attending a mourning site, wishing something and does not get it, as well as religious explanations or magic interpretations of the effects of medicines.
The most important source of information is the institutional and volunteer personnel, then the NGOs, and the personal search, although an important number of participants mentioned that that they have not received any information.
The perception of the problem that has to do with pregnancy is highly biologic with a tendency to consider the conditions of the mother as the most important source of danger signs, mainly the identification of the pain, such as headache, the swelling of feet and face, vaginal bleeding, high blood pressure and seizures. All these symptoms together are signs of toxemia of pregnancy, but they are identified separately and, frequently, the detection of the problem in pregnancy was made in the health unit.
Fever is the only sign associated to infectious processes and does not establish any link with pain or burning sensation while urinating or sore or blisters in the vaginal area (possible herpes) or symptoms of vaginal infection, itching, burning sensation and increase of vaginal discharges, possible due to constraints to talk openly about sexual organs and their infections.
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The inclusion of observations on sleeplessness and domestic accidents, as danger signs are important to take into account, since facing strong emotions and critical situations during pregnancy have a negative impacton the physical and psychic health. It bears mentioning that they do not identify teen pregnancy as a cause for concern.
Likely, the view on delivery in its general appreciation is of a biologic type, but the inclusion of a reference to domestic violence, she fell because her husband pushed her, provides the opportunity to transcend this limit and begin the reflection as a social and cultural event.
Unlike pregnancy and child delivery, the ignorance of symptoms or problems associated to puerperium, was more common among participants.
When asked about the perception their relatives have on the causes and conditions that resulted in death, the following can be grouped together: infection, negligence, risk, violence.
The great majority of mothers when the emergency happed they were with relatives, one pregnant women that was working in the presence of her employer she considered herself that she had someone with her, not so in the presence of health personnel, because the pregnant women that was in the hospital: “was alone”.
Reactions facing an emergency are framed within a positive attitude to look for a response, seeking the transportation to the health center; unfortunately, these kind of actions in most cases were unsuccessful.
The social support network to provide support, activated by the emergency situation was made in the first place by relatives (relatives, husband, midwife) and by a wide rangeof community members (social network) from the mayor, neighbors, teachers, the godmother and friends.
CARE PROCESS
The analysis of this chapter is based on the understanding that pregnancy is not an exclusive responsibility of the woman andthat it should be perceived as an event that, aside from being biologic, it has socio-cultural characteristics and, therefore, from a rights view, it should be addressed with the participation, commitment and responsibility of various social actors that make the social fabric or the daily environment of pregnant women.
DESCRIPTION OF DELAYS IN THE CARE PROCESS
Delay in identifying the problem. Women are associated with the right to health by receiving immediate and specialized care, congruent with the urgency that demands her condition, according to its seriousness, timely, free and with confidentiality, in any part of the country, not only in the local health center.But stand outthe importance of receiving a dignified treatment while receiving health services: to be respected, without discrimination and to be told what she has and timely providing her with the required medicines.
The information received in the place was around her current situation and associated to the presence of complications or when her baby had died.Most frequently women were taught on baby care and danger signs of the baby. Guidance on follow up was focused on recommendations to attend the Health Center from seven to ten days after delivery and up to forty days afterwards.
Although women want to access citizenship, understood as an opportunity for active and full participation and to stop being occasional guests, a general ignorance is perceived on public policy favoring woman’s participation.
Delay in the decision to access a health service. In this sense, they interpret as decision making complying with her work of accessing care for them and their children. Upon deciding among apparently simple and daily options, such as choosing the family planning method, an important number of them does not choose any and their explanations means that they are not mentally aware or that they cannot make a decision because they are pregnant or in the last instancethat it is a decision is for her husband to make. This situation stresses the fact that the vast majority of women have very little power for decision making on their sexual and reproductive life.
Facing an obstetric emergency, they establish the existence of a wide range of actors to be consulted in order to make a decision, from local leaders to relatives but they recognize three as the main actors “Who makes the decision is the midwife, the husband and one self”; Facing a violation to her rights, the first option, is an informal one, accessing the community organization.
Delay in the mobilization towards the health services. Unfortunately, in the municipalities studied, the organization and operation of the transportation committee and the communication for Emergencies is incipient, although they express a great satisfaction with the operation of same. Therefore, for the majority, their options are to go walking, to be transported in a hammock, to the main road seeking transportation, which is usually under risky conditions.
Functional access expressed in the useless search for transportation or its consequence in an untimely manner, the dissatisfaction for not admitting her into the hospital or for referring her to another hospital.Geographic access due to roads that prevent the passing of vehicles in certain times of the year and, in an extreme case, the deliberated obstruction of a public road that was considered to be private and preventing the passage of people.Economic access due to the lack of money to pay for vehicle cost and the onerous charge imposed in order to remove a corpse from a center after her death.
Delay in receiving appropriate care. Accessibility. The vast majority received care in public units, hospital ranks in the first place, because of the complexity in the required response. In the second place the health center and the midwife, associated with the primary search of a response and to a similar situation to a public or private maternal and child clinic.
Availability.They do not remember if the places had medicines available, but in most cases delivery care was free. Although they do not exist in all municipalities, because Maternal Homes are linked to a hospital or to public maternal and child clinics, they know where the nearest Maternal Homesare located, inclusive those in Tegucigalpa andthat facilities consisted of beds and a place to prepare meals.
Aceptance.They mention that the culturally most-accepted services are those offered by the midwife and, as a previous step to be referred to the hospital, they provide care, revising the child’s position, they provide emotional support, they give them massage when they request it, and also, they give them advice. They trust them because they go with them to the health unit or, they send them with a reference and seek the transportation.
Quality. They grade in a similar manner the quality of care received in the health units andfrom the midwife and, in the case of the latter, they satisfaction is basedon the fact that they respond promptly when called and that they refer them if necessary, although there are mentions that have to do with maternal deaths or to fulfill their role without being authorized.They are afraid to go or to be sent to the Hospital because people say that they are not cared properly and that they are scolded and the techniques used in care services promote doubts, they are asked to exercise, when talking about the measure to promote walking to favor the process of cervical dilation.
Managing grief. Mother’s deaths invade the everyday reality with the children, her parents. It impacts in the short term decreasing boy’s or girls’ survival and in the long terms its effect can be as traumatic that it could last through the life. In many occasions, they were not able to express their pain, children and mainly the younger ones, but through the contributions various grief stages are identified, situations that they did not have or are still pending an institutional response to same.
Among the main consequences, they point out to family disintegration and its immediate effect the abandonment, the lack of understanding among relatives that have remained as responsible ones, the additional economic burden on a poor family, with its correlation that in many occasions ends with the child’s death.
Conclusions and Recommendations