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H. Bashour,¹ A. Abdulsalam,² W. Al-Faisal¹ and S. Cheikha²

نماذج ومحددات الرعاية التوليدية في دمشق - سورية

هيام بشور، أسماء عبد السلام، وليد الفيصل، صلاح شيخة

الخلاصـة: صُمِّمَتْ هذه الدراسة الوصفية لوصف نماذج ومحدِّدات الرعاية التوليدية التي تقدَّم للسيدات في دمشق. وقد جمعت المعطيات من 39 سجلاً للولادات في محافظتين كبيرتين، وضمت 500 أماً أنجَبْنَ أطفالاً أصحاء. وأجرى الباحثون مقابلات مع الأمهات في بيوتهن مستخدمين استبياناً مسبق التصميم جزئياً. وقد أظهر التحليل المتعدد المتغيِّرات لمحدِّدات تكرار استخدام الرعاية السابقة للولادة أن المتغيرَين التالين يعتد بهما إحصائياً؛ ألا وهما السكنى في المدينة وزيارة مرفق الرعاية السابقة للولادة في الأثلوث الأول من الحمل. أما المتغيرات التي يُعْتَدُّ بها إحصائياً للزيارة الباكرة التي تقوم بها الأم لمرفق الرعاية السابقة للولادة فهي المستوى التعليمي لدى الأم، والحمل الأول، وعدد الزيارات لمرفق الرعاية السابقة للولادة. كما يرتبط سن الشباب (العمر أقل من عشرين عاماً) بالزيارة الباكرة وتوقيتها في أول زيارة لمرفق الرعاية السابقة للولادة.

ABSTRACT: This descriptive study was designed to describe the patterns and determinants of maternity care among Syrian women living in Damascus. All 39 birth registers in 2 large provinces were used to recruit 500 mothers of healthy newborns. Mothers were interviewed in their homes using a semistructured questionnaire. Multivariate analysis of the determinants of the frequency of use of antenatal care showed the following variables were significant: urban residence and visit to antenatal care in the 1st trimester. The significant variables for an early visit to antenatal care were the woman’s level of education; being pregnant with the 1st baby; and number of visits to antenatal care. Being young (age < 20 years) also correlated with early timing of the 1st antenatal visit.

Caractéristiques et déterminants des soins de maternité à Damas

RÉSUMÉ: Cette étude descriptive avait pour but d’exposer les caractéristiques et les déterminants des soins de maternité chez des femmes syriennes vivant à Damas. L’ensemble des 39 registres des naissances de deux grandes provinces ont été utilisés pour recruter 500 mères de nouveau-nés en bonne santé. Celles-ci ont été interrogées à leur domicile sur la base d’un questionnaire semi-structuré. L’analyse multivariée des déterminants de la fréquence d’utilisation des soins prénatals a montré que les variables suivantes étaient significatives : résidence en milieu urbain et visite prénatale au cours du premier trimestre. Les variables significatives influençant une visite prénatale précoce étaient le niveau d’instruction de la femme, le fait qu’il s’agissait d’une première grossesse et le nombre de visites prénatales. La jeunesse (âge < 20 ans) était également corrélée à une date précoce de première visite prénatale

¹Department of Family and Community Medicine;
²Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Damascus, Damascus, Syrian Arab Republic (Correspondence to H. Bashour: This e-mail address is being protected from spambots. You need JavaScript enabled to view it )
Received: 23/08/05; accepted: 23/02/06
EMHJ, 2008, 14(3):595-604 

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Introduction

There is general consensus that the use of maternal health care services reduces maternal and child mortality and improves the reproductive health of women. The essence of maternity care is that it should be provided at all phases: pregnancy, birth and postpartum. This care is essential for both high- and low-risk pregnancies.

Over the past 2 decades, the Syrian Arab Republic has made remarkable progress in improving health outcomes among its population, particularly for children and pregnant women. From 1993 to 1999, the infant mortality rate dropped by 48% (from 34.6/1000 live births to 18/1000 live births), and the maternal mortality ratio dropped by 50% from 1990 to 2001 (from 143/100 000 live births to 65.4/100 000 live births) [1,2]. Although there have been no studies that explain the mortality decline, improvements in socioeconomic status, health services and individual factors may have been responsible.

Although considerable efforts have been made to improve maternity care in the country, government and professional priorities have dominated care, rather than the women’s needs. Women’s access to information, and their choice and involvement in decision-making are neglected. Maternity care is very much fragmented, and maternity practices deviate from evidence-based best practice [3,4].

Access to health services, traditional beliefs and cultural practices, individual qualities and health-care-seeking behaviour, as well as other factors, all contribute to the use of maternal health care. Several studies have been carried out to identify and understand the use of maternal health care services, especially in developing countries, where the services are underutilized [5–10]. As expected, there is no universal explanation that applies to all places and times; the determinants of utilization of maternal health care services are not the same across socioeconomic and cultural contexts.

Since the way in which maternity care is provided is influenced by policies, availability and quality of services, and, most importantly, the health-care-seeking behaviours of the women, the current study aimed to describe the patterns of maternity care among Syrian women and to study its determinants. We hoped to contribute to the body of research on the use of maternal health services, and to articulate the policy implications of the findings.

Methods

Study design and data collection

All 39 birth registers in 2 large provinces in the country were used to recruit women for this descriptive study: 4 from Damascus, the capital city, and 35 from Rural Damascus (which is not in fact rural). A total of 500 mothers of healthy newborns (< 90 days old) were identified from those registers. Non-probability sampling (quota sampling) was used to select women. The quota sample was stratified by register and the number of births in each register during the previous year. Random selection of women from the birth register was then used to meet the target sample size.

Houses in the relevant areas were traced using phone numbers and/or moukhtars (civil registrars at the smallest administrative unit). Women were approached and their verbal informed consent was obtained; none refused to participate. Interviews were carried out by trained young female social scientists, to avoid any potential bias if medical personnel interviewed the women.

The interviews were based on a predesigned and pretested semistructured questionnaire that collected data on the sociodemographic characteristics of the women; their obstetric history; and on their use of care during the 3 stages of pregnancy and childbirth, namely antepartum, intrapartum and postpartum. Other data were also collected on the practices women experienced during their delivery, and also on their preferences about the place of delivery and birth attendant (reported elsewhere). The questionnaire was piloted on 20 women not included in the study, and necessary modifications were made.

Statistical analysis

The questionnaires returning from the field were coded, and data were entered into a personal computer. The data were cleaned and checked using range checks and validity checks. Analysis was done using the statistical package SPSS for Windows, version 10 [11]. Missing values were allowed for in the analysis.

Frequencies were calculated from the univariate analysis. Four selected dichotomous dependent variables were then constructed to indicate major relevant items of maternal care. They were as follows:

If the woman received antenatal care, whether she had at least 4 visits or fewer than 4. This cut-off point was used in accordance with the 1994 World Health Organization recommendation [12].

If the woman received antenatal care, whether the 1st visit was during the 1st trimester or later during the pregnancy.

Place of delivery, whether at home or a health facility.

Care provider who attended the delivery, whether a midwife or doctor, apart from the place of delivery.

Bivariate analysis was used to describe the relationships between different variables of interest and the dependent variables. To study the determinants of maternal care use, a multivariate analysis was carried out and a logistic regression model estimated the likelihood. Multivariate analysis included only variables that showed a significant relationship with the outcomes of interest, as demonstrated by the bivariate analysis.

Results

Characteristics of the women

Table 1 presents the background characteristics of the women. Socioeconomic variables showed that 12.0% were highly educated and only 8.4% were working. Only 18.2% were primiparous, and 36.2% has a history of medical or obstetric problems during her last pregnancy.

Patterns of maternal health care

Tables 2 - 3 - 4 show the patterns of care as reported by women during their most recent experience of pregnancy and delivery that resulted in a live birth. Only 3.6% (18/500) of the women reported no use of antenatal care services. Of those, 14 women said that their pregnancy was normal and thus there was no need for them to visit the antenatal service. The mean number of ultrasound scans taken during pregnancy was 5.5 (standard deviation 3.2). Nearly 80% of those women who had an ultrasound said that it was done on request of the care provider, and only 15% requested the ultrasound themselves.

The majority of women had a normal delivery and gave birth at hospital. The rate of caesarean section was 13.6%. Midwives attended 91.0% of home deliveries. A quarter of those who paid for the delivery admitted that the payment was expensive for them.

The mean length of stay at hospital after a normal delivery was 7.4 hours, 28.5 hours for caesarean sections. Only 8.6% of women reported that a postpartum visit was scheduled for them; however, this proportion increased to over 25% among women who had problems after delivery.

Determinants of maternal health care use

Tables 5 and 6  show the results from the bivariate analysis. Results from multivariate logistic regression analysis showed that the main determinants of having delivery at a heath facility were the woman’s level of education (OR = 2.04; 95% CI: 1.25–3.34); having a medical problem during the last pregnancy (OR = 1.7; 95% CI: 1.01–2.75); and, as expected, use of antenatal care (having 4+ antenatal care visits during pregnancy) (OR = 2.2; 95% CI: 1.3–3.7). The 2nd model estimated the likelihood of being attended at birth by a doctor rather than a midwife. The significant variables in the model were: having a medical problem during the last pregnancy (OR = 1.57; 95% CI: 1.01–2.5); and the use of antenatal care, as previously defined (OR = 1.93; 95% CI: 1.2–3.2).

When we modelled the variables as to predict the determinants of the frequency of use of antenatal care, the following variables were significant: urban residence (OR = 1.73; 95% CI: 1.1–2.8); and early visit to antenatal care (in the 1st trimester) (OR = 9.1; 95% CI: 5.3–15.8). It should be noted that we excluded from this analysis the 18 women who did not have any antenatal care.

As for the determinants of timing, the 1st antenatal visit in the 1st trimester of pregnancy showed that the significant variables in the model were the woman’s level of education (OR = 1.93; 95% CI: 1.1–3.4); being pregnant with the 1st baby (OR = 6.3; 95% CI: 1.4–28.8); and also the number of visits to antenatal care (OR = 9.0; 95% CI: 5.3–16.7). Being young (age < 20 years) also correlated with early timing of the 1st antenatal visit (OR = 2.9; 95% CI: 1.1–7.7).

Discussion

This study examined the maternal health care use among 500 women in Damascus and Rural Damascus provinces and the main determinants of that use. Our results do not represent women throughout the country since we only targeted women in the capital and its surroundings. The women in our study had a higher proportion of deliveries at health care facilities and were more frequently attended by doctors at birth, as compared to the national figures [1]. This is due to fact that we covered a better served area of the country. However, we do not think that this will bias our findings since the main aim of our study was to investigate the determinants of maternal health care use; this is a factor of the availability of the health services as well as the health-care-seeking behaviour of women.

Our results showed that women who had received more than 6 years education at school were more likely to have their births at a health facility and to have better use of antenatal services in terms of numbers of visits and also the timing of the 1st visit. In their study of the use of maternal health services in Jordan, Obermeyer and Potter found that higher levels of education were associated with greater use of antenatal care, while larger numbers of children in the household and rural residence were associated with less use of antenatal care [8]. Urban residence was also associated with the use of antenatal care in our study. In India, Bhatia and Cleland confirmed the association between socioeconomic factors, including maternal education, and the use of maternal health services [7]. Educated women are considered to have greater awareness of the existence of maternal health care services and the benefits of using such services. They are likely to enjoy more autonomy within and outside the household and the skills acquired from schooling enable women to communicate with health professionals and be more demanding about health care services.

This study showed that having a medical or obstetric problem in the last pregnancy increased the likelihood of having a delivery at a health facility and being attended at delivery by an obstetrician, after controlling for other confounders. This finding is very important, since it implies that the women’s experience can explain a change in their behaviour. Magadi et al. argued that the variations in the use of maternal health services can be present at the level of the individual woman, depending on the circumstances of the pregnancy [6]. However, in normal circumstances, there is an expectation that health-seeking behaviour will be homogenous at the individual level.

Important findings from this study include the extensive use of private health services. This is a critical issue that needs further attention at the country level. The importance of working with as well as supervising the private sector was recently stressed [13]; however, when thinking about this issue one should also think of the disproportionate number of health care facilitates between urban and rural areas. The absence of continuity of care from pregnancy through the postnatal period was also evident. Studies of continuity of care demonstrate the beneficial effects of such continuity [14]. Our results also indicated some deviation from the best-evidence practice where, for example, the services did not allow companionship at labour and delivery, and also when extensive use of ultrasound was noted. Enkin et al. classified the physiological and psychosocial support at labour and delivery as a proven beneficial form of care, and they did not recommend having routine and frequent ultrasounds during pregnancy [15].

Another interesting finding is that the use of antenatal care explained the place of delivery and the person attending the delivery as seen from the tables. One can argue that antenatal care encourages women to seek delivery assistance by doctors and also to have the birth at a health facility. It is well known that regular antenatal care is important for identifying women at increased risk of adverse pregnancy outcomes and for establishing good relations between the women and their health care providers [12]. Assistance during delivery is an important component in reproductive health care services. Although assistance during delivery is associated with the place of delivery, those variables were treated separately in our study. Midwives attended births at hospitals and homes.

The results provide a basis for a number of policy implications. First, education was found to have an important impact on the use of maternal care, suggesting that improving maternal education should have an impact on the use of maternal care services. Secondly, the use of antenatal care services needs to be encouraged, and an evidence-based antenatal package should be given to all pregnant women. The findings suggest that maternal care programmes at the country level should be reviewed and revisited.

Acknowledgements

This study was supported by the contribution of the American University of Beirut award (Regional Changing Childbirth Research Program at the Faculty of Health Sciences, supported by Wellcome Trust Grant). We thank colleagues at the FHS/AUB, especially Dr Hala Tamim, for their support, and all colleagues and friends who shared their comments with us.

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