Abstract
Earlier studies claim inadequate knowledge and understanding of maternal health care service among women and families account for low demand and utilization of these services. This study explores maternal service utilization in Lao PDR by interviewing women, families, health service providers, and community members in Xiengkhuang province. In general, women’s attitude and acceptance of maternal health care were positive, with many expressing appreciation and need for maternal health services. Nevertheless, utilization of maternal health services remained poor largely due to dissatisfaction with services: inaccessibility, irregular services, fund shortage, poor facilities, and problems dealing with male health service providers. It appears that utilization of maternal health care services in Lao PDR is as much a health system concern as it is a user preference issue. This article advocates a “back to basics” approach for reviewing maternal health care infrastructure systems in developing countries to improve community health services and utilization.
Keywords
Introduction
The Lao People’s Democratic Republic (Lao PDR) is a land-linked country in Southeast Asia with a population of 6.5 million people divided into 49 ethnic groups. Almost 70% of the population reside in rural areas and 21% live in areas with no paved roads. Laos’ health service delivery system includes 7 central hospitals, 4 regional hospitals, 12 provincial hospitals, 131 district hospitals, 905 health centers, and a village health volunteer (VHV) network. 1
In 2012, the government started a Health Sector Reform, which is a roadmap for achieving universal health coverage by 2025. In line with the Millennium Development Goals 4 and 5, maternal and child health is the core and the entry point for this reform. Although maternal mortality ratio has dropped from 830 (1995) to 220 (2013), 2 the figure is still considered very high. Studies show maternal mortality could be reduced if more deliveries were assisted by skilled birth attendants at health facilities. 3 However, facility-based delivery rate in Lao is low while home delivery rate is high. 4 The National Reproductive Health Survey in 2007 found that only 18.5% of births were attended by health workers, the lowest rate in Southeast Asia. 5 Although urban residents made up only 6.2% of Lao population, 68% attended births took place in urban areas compared to a mere 11% in rural areas. In rural regions, deliveries mainly took place at home and were assisted by family members (63.4%) and traditional birth attendants (TBA) (12%).
The literature review reveals an unchallenged underlying assumption that inadequate knowledge and poor understanding of maternal health care service benefits by women and their families pose a major deterrent leading to low demand for these services.6-11 Women from rural areas and particularly from areas with dominant religious convictions had very strong misgivings about modern health practices.12,13 Women in rural areas were not given much decision making power and relied on their husbands, mothers, or the elderly—especially elderly mothers-in-law 11 whose decisions were influenced by traditional superstitions or religious beliefs. 14
Recent studies on maternal and child health issues in Lao PDR15,16 do not yield adequate empirical evidence about maternal service seeking behaviors of Lao women. This study aims to fill this research gap with a qualitative study conducted on 117 participants comprising interviews with 36 individuals and 17 focus groups to look into factors influencing maternal service utilization of Lao women.
Methods
This study was conducted from February to April of 2012 in purposively selected villages in the Xiengkhouang province. Xiengkhuang represents poor provinces in Lao PDR with many places that do not have paved roads. Its population of 249 817 comprises 3 main ethnic groups: Lao, Hmong, and Thai. There are 8 districts and 581 villages with 1 provincial hospital, 8 district hospitals, 53 health centers, and 609 VHVs. 17
Six villages in 2 districts (Phoukoud and Khoun) were selected via theoretical sampling. 18 Villages had various ethnic minority groups located in geographically advantaged and nonadvantaged areas. Semistructured interviews were conducted for both in-depth individual interviews and focused-group interviews. 19 A typical characteristic of Lao people is shyness or inhibition to speak to strangers. Hence the study used focus group interviews to bring participants together to create a trusting and relaxed setting where Lao women were encouraged to share views amongst themselves and with the research team. 20
To capture the factors that affect utilization of maternal health care services by the Lao women, 3 categories were identified: husband groups (n = 30), mother-in-law groups (n = 26), and young mothers groups (n = 25). For follow-up interviews, additional young mothers (n = 14), health care providers (n = 12), women’s union leaders (n = 4), and village head (n = 6) were approached individually (Tables 1 and 2).
Description of Health Worker Participants.
Description of Community Participants.
Abbreviations: IDI, individual interview; FGI, focus group interview.
“Near” indicates less than 1 hour’s walk to the nearest health facility and “Far” indicates more than 1 hour’s walk to the nearest health facility.
The study received institutional review board approval from the University of Health Sciences in Lao PDR. Voluntary participants were informed of the study’s purpose; informed consent and content recording permission were obtained verbally prior to each interview.
Data were collected by a team which includes 11 Lao interviewers trained to conduct real-time interviews. One of the interviewing team was a note-taker tasked with recording verbal data, including information gleaned from nonverbal behaviors. 21 Interviews were conducted through interpreters if interviewees could not speak Lao. Transcriptions were inputted into a computer word-processing program in Lao based on playback recordings and observation notes. The transcriptions were translated into English under the supervision of a researcher fluent in both languages.
Data analysis was done through five analytical stages, including familiarization, thematic framework identification, indexing, charting, mapping, and interpretation.22,23 A content summary form for each interview was developed during familiarization. Guided by the study framework of Peters et al 7 on “assessing access to health services,” the researchers identified emerging themes. The 4 themes were acceptability (user’s attitude and expectations), geographic accessibility (service location, user’s location), availability (health workers, drugs, and equipment), and financial accessibility (costs and price of services). Key phrases were coded and categorized using common category analysis 23 while indexed texts were transcribed for analysis. Relationships between themes and subthemes were explored by the researchers to arrive at conclusions and implications.
Findings
Low Utilization of Maternal Services
Our interview showed that one third of interviewed women (12 out of 39 women, or 30.7%) received antenatal care at health facilities. In addition, 9 out of 39 women (23%) delivered at health facilities at least once. Although most women agreed postnatal care was important, only 1 participant (2.5%) reported having visited the hospital for check-up after delivery. Perspectives on accessibility and quality of maternal health services are presented in Table 3.
Perspectives on Accessibility and Quality of Maternal Health Services.
Acceptability
Traditionally, many women in Lao PDR had to deliver babies in the forest on their own. Some women delivered at home with the help of families while others were assisted by TBAs. However, our interviewees showed a strong preference for delivery at health center facilities with the assistance of health staff and medical equipment to ensure easier and safer deliveries.
I want to deliver at the hospital because if something bad happens the doctor can help me. If some difficulties occur during delivery at home, I could die and my parents just look at it. (Hmong female, 25 years old). Delivery at home or in the forest is not safe because there is no one to assist the woman. (Hmong female, 30 years old)
Participants said they appreciated the support of TBA during delivery. However, TBA assistance was not always accorded medical recognition, especially in complicate cases and emergency deliveries. This reaction was apparent even among Hmong villagers who were seen as being more traditionally conservative than other communities.
TBA has no medicine and equipment and they did not study medicine. In case of difficult deliveries, they could not assist (Hmong male, 27 years old). I saw many women die when delivering with TBA (Hmong female elderly, 45 years old) My husband asked me to have a check in the nearest health center when I was pregnant with my last child. He told me to deliver at health center to avoid complications (Hmong female, 23 years old)
Service providers also perceived attitude changes and higher acceptance of modern maternal care within the community. Findings show the community as a whole—not only the women but also their husbands, female elders, and village authorities—increasingly recognized the critical role of modern maternal practice.
The villagers trust health staff more than TBA, which gives them more confidence in using health services. People believe that health staff are more skillful and knowledgeable (staff of Health Department of Xiengkhouang province) Now my daughter-in-law is pregnant and I want her to deliver at the hospital so that doctor can help her. If she could not push the baby, doctor can give some injection and doctor can do caesarean (Lao female, 60 years old)
Maternal care was included in regular village meetings’ agenda to disseminate knowledge in the community. VHV and health staff from health centers attended village meetings to introduce maternal health services and discuss health related issues. It would appear that community’s knowledge and acceptance of maternal health issues improved as a result of these interactions.
We get together once a month to discuss about the work in the village and talk about mother and child health related issues. We encourage women to deliver at health center. (member of women union of Song village, 50-year-old female) Then the village leader gathered all women and other villagers to the meeting. They provided some health education to the villagers and informed them where they could seek health care. If the villagers did not understand, I was asked to explain to them again (Hmong male, 32 years old, VHV)
Geographic Accessibility
Geographic accessibility is a major barrier in maternal health care access for this region. Although new roads had been built, those living in disadvantaged areas faced challenging travel conditions especially in rainy seasons. For many, deliveries with complications or early arrivals, lacking a system of timely, convenient and safe access to health facilities meant needless maternal deaths.
There was no difficulty in the hot season but it was difficult in the rainy season because the road was muddy and slippery (Thai female, 30 years old). I have 5 children and I delivered (all of them) at home because I was poor and I could not go to hospital. For the last child, the labor pains occurred at night and nobody brought me to the hospital. Transportation was not available and my brother was also away from home. If my younger brother was at home, I might have delivered at the hospital because he had a car (Hmong female, 45 years old).
Several participants pointed out that the referral system between health centers and hospitals was not efficient or even functionally working.
We went to health center for delivery but they referred us to the hospital. Because it is very far and expensive to get to the hospital we went back home and delivered there. (Hmong female, 22 years old).
Financial Accessibility
Financial constraint and service cost were definite barriers to accessing maternal care. In addition to service costs, if a wife leaves home to receive antenatal or postnatal care, there was no one to take care of the family or tend to the fields.
I think that for poor families, mothers should not return to hospital to check-up after delivery if they look healthy because it would waste the money. I delivered at home because I was poor and I could not go to hospital (Thai female, 36 years old) During my pregnancy I did not go to hospital because I had no money. If the delivery is free, I definitely will go to hospital because I want to care for my health. Hospital is good if you have money (Lao female, 36 years old)
Service Availability
Staff Absenteeism
Health staff absenteeism was high at health centers as not enough health staff were assigned and staff also had to provide outreach services.
The health center is near my house but there were no health staff because they all had gone to a wedding party. But illness cannot wait. Therefore, next time we went directly to district hospital to save time. Health workers do not work at weekend even. (Lao male, 30 years old)
Staff Skill or Confidence
Participants described the skillfulness of health workers as low at health centers, average at district hospitals, and good at provincial hospitals. Nonetheless, they believed medical workers were better than TBA for solving complications in deliveries. Some health workers, however, admitted that they lack confidence when assisting in delivery, especially cases with complications.
There was no delivery at the Nanang health center because the staff could not assist delivery. Health staff have limited knowledge and skills on obstetric care. At Keosad health center, health staff could not provide delivery services because they did not practice. (staff of Health Department of Xiengkhouang province) We are not knowledgeable enough to provide the service and we are afraid that we would do wrong. We could provide assistance to normal deliveries, however, for high risk pregnancies we could not assist them. (Phalouang health center staff)
Staff Attitude
In most cases, participants reacted positively to health staff’s attitude. However, some reported being humiliated and expressed no intention of future utilization or recommending health services to others. Most interviewees experienced long waiting times and slow responsiveness of health workers. Several interviewees felt these problems originated from ethnic discrimination with preferences toward those with personal networks, and speedier responses for those offering informal payments.
Mostly, medical doctors do not take care of us because we are Hmong. When we came for health services they never asked us anything and ignored us. They never treat Lao people that way. They were very rude to us. So I do not want to go there again. (Hmong female, 39 years old) It is said that delivery at provincial hospital is difficult and sometimes the health staff are very slow. If we want them to perform quickly and nicely we need to pay them extra money. (Lao male, 29 years old)
Male Dominance of Health Staff
Some health centers did not have female staff. Many women, especially minority women said they were uncomfortable exposing sensitive body parts to male health staff. More importantly, husbands did not want their wives to expose their bodies to other men.
At our health center, there is only male staff. I do not want my wife to deliver at health center because I am afraid that the doctor would see the vagina of my wife. He lives in the same village with us so every time I see him I feel shy and ignominious. (Hmong male, 28 years old) In the past, there was a female staff at our center so people came for maternal services. However, since 2011, the utilization of services has declined because there has been no female staff, and instead there are only male staff. (Phalouang health center staff)
Physical Conditions
Generally, health centers were old buildings without restroom, clean water, or sometimes electricity. Some health centers provided no labor room and waiting room for pregnant women.
There was no electricity at some health centers (Khoun District hospital doctor) The relatives of patients have to carry water by themselves because there is no clean water (Phalouang health center staff) There is not enough equipment such as speculum and delivery kits, and sonic aid for fetal Doppler so we cannot provide some services (Khoun District hospital doctor)
Satisfaction With Private Practices
There were private clinics that provided pregnancy care, delivery, and postnatal care. Although the charges for services in clinics were more costly, some interviewees expressed preference to visit private clinics to reduce waiting time, experience better staff service, and receive higher quality health care with adequate medical equipment and medicine.
Most people in my village like to visit private clinic because it’s convenient. We can get the service immediately without having to wait for a long time and doctors talk to us nicely while health staff in hospital or health center sometimes ignore us and we do not understand each other (head of Nasy village, 35 years old)
Discussion
In previous studies, low level of comprehension on the importance of maternal services and social-cultural beliefs were claimed to be major deterrents for maternal health care access in Lao PDR. Earlier studies also reported that even when women understood the importance of modern obstetric care, their decisions in seeking health care was reported to be largely influenced by the negative attitudes of their husbands, the misconceptions of the elderly on modern maternal practices, and the community’s general superstitions. 24
Although some deterrents exist, this study found generally positive attitudes and acceptability of modern maternal practice among villagers in Xiengkuang province, Lao PDR. Positive attitudes toward modern maternal practice were evident among the women, the husbands, the elderly, and the village authorities. Such changes in community perceptions might be connected to current efforts of health education promotional programs and Lao government’s effort to promote Millennium Development Goals.
Nevertheless, this study concludes that while women’s attitude toward maternal health care has become more positive over the years, they regrettably do not actively seek health care services at health facilities. Our interviews with participants reveal reasons for this reluctance to use modern health care services. Main barriers identified are related to lack of ‘basics of service provision,’ namely, limited staff and availability, high cost, poor physical conditions, low satisfaction with health service quality, and male dominance of health staff. Consequently, financially better-off women utilize the private services because of higher perceived quality of care and easier access, which leads to deeper structural inequities in utilization of maternal care services. It would appear development in maternal health care services in Lao PDR is as much a health system concern as it is a user preference issue.
A limitation of this study is that qualitative data often make standardization and comparison difficult. For example, focus group interviews had the constraints of being given a limited selection of the participants, thus reducing the diversity or reliability of information provided. We recommend future studies consider a mixed methods design that would serve to address the research aims from both qualitative and quantitative data triangulation and substantiation.
Overall, our findings indicate that to reduce persistent under-utilization of maternal care services, the Lao government should consider a “back to basics” health infrastructure improvement, including a review of physical, human, and organizational infrastructures with a focus on provision of services with the needs of maternal women in mind. In addition, to achieve the universal access and utilization to maternal and child health services as suggested by post-2015 agenda, 25 future policy reform efforts should address systemic and structural imbalances and inequalities that are highly gendered such as subordinate roles of women in making health care decisions as well as sensitization of maternal health care by readdressing male dominance of health staff. As far as possible, a review and alignment of community health services provision for this region will serve to support improved acceptance and utilization of maternal health care services.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication: The study was funded by the WHO Lao PDR office and the Korea Foundation for International Health (KOFIH). Dr. Minah Kang also received financial support from the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2012S1A3A2033416).