Factors associated with Post-natal Care Utilization among...

67

Journal of Public Health and Development Vol. 13 No. 3 September-December 2015

ORIGINAL ARTICLE

Factors associated with post-natal care utilization among mothers in MaldivesSheeza Ibrahim1, Sariyamon Tiraphat2 and Seoah Hong2

1 M.P.H.M., ASEAN institute for health development, Mahidol University, Thailand2 Ph.D., ASEAN institute for health development, Mahidol University, Thailand

Corresponding author: Sariyamon Tiraphat Email: [email protected] Received: 4 December 2015 Revised: 3 February 2016 Accepted 10 February 2016Available online: February 2016

Abstract

IbrahimS,TiraphatS andHongS.A.Factors associatedwithPost-natalCareUtilization amongmothers inMaldivesJPubHealthDev.2015; 13(3):67-80

Post Natal Care (PNC) is an important service formother and newborn during the vulnerable period. Properpostnatalfollowupwouldhelptopreventmanymaternalandfetaldeaths.Itcanidentifythedangersignsoflifethreateningformothers and babies.According toWHO, globally PNCutilization is quite low, especially in developing countries.InMaldives,which is a unique archipelago of 1192 islands, the information about the prevalence of PNC and factorsassociatedwithPNChas been limited.This cross sectional studywas conducted to determine the prevalenceof postnatalcareutilization and factors associatedwithPNCamongmothers inMaldives islands. This researchwas a community based cross-sectional studyundertaken in three different communitieswith primary,secondaryand tertiaryhospitals inMaldives.Thedatawerecollectedfromasampleof253mothersdrawnfromthestudypopulationusingconvenientsampling techniqueduringMay3rd to25thMay2015.Self-administeredquestionnaire,basedon the factors fromAndersen’s health and utilizationmodel including predisposing, enabling, and need factors, also theDonabedianmodel of healthcare quality,was given to collect the data.Our outcomevariable focused on postnatal careutilizationthatcategorizedaswhethertheycompletepostnatalvisitwithin6weeksafterchildbirthornot.Fordataanalysis,Chi-square test andmultiple logistic regressionwere applied to evaluate factors associatedwithPNC. The study revealed that the prevalence of PNC utilizationwas 34%. The results ofmultiple logistic regressionindicatedthatcostoftransportation,healthinsurancescheme,andmentalhealthproblemwerethesignificantpredictorsforPNCutilization.MotherswhoperceivedthatcostoftransportationisexpensivehadmorechanceofgettingPNCutilization1.98 times (95%C.I:1.05 –3.76) compared to those perceived that the cost is low.Motherwho thought that the nationalhealth insurance scheme is very good hadmore chance of PNCutilizationwith 2.9 times (95%C.I: 1.21-7.03).Motherexperiencedmental health problem increasedmore chanceof completingPNCwith 2.0 times (95%C.I.: 1.07-4.05). Thestudyindicatedthattheprevalenceofpostnatalcareutilizationwasverylow.Therefore,strengtheningtheprovisionofhealth insurance scheme isvery important toenhance theaccessibility forhealthcare service.Formotherswithmentalhealth problem, individual counseling is recommended.Regarding cost of transportation, the establishment of affordablepublic transportationwouldbe a supportive factor for better utilization of health services.

Keywords: postnatal careutilization, primaryhospital, secondaryhospital, tertiary hospital,Maldives

68

วารสารสาธารณสุขและการพัฒนา ปีที่ 13 ฉบับที่ 3 กันยายน-ธันวาคม 2558

ปัจจัยที่มีควำมสัมพันธ์กับกำรรับบริกำรที่คลินิกหลังคลอด ในหมู่เกำะ มัลดีฟส์ชีซ่า อิบราฮิม1 ศริยามน ติรพัฒน์2 และโซอะ หงส์2

1 M.P.H.M., ASEAN institute for health development, Mahidol University, Thailand2 Ph.D., ASEAN institute for health development, Mahidol University, Thailand

บทคัดย่อ

ชีซ่าอิบราฮิม ศริยามนติรพัฒน์ และโซอะหงส์ปัจจัยที่มีความสัมพันธ์กับการรับบริการที่คลินิกหลังคลอด ในหมู่เกาะมัลดีฟส์

ว.สาธารณสุขและการพัฒนา.2558;13(3):67-80

การรับบริการที่คลินิกหลังคลอดเป็นสิ่งที่ส�าคัญอย่างยิ่งส�าหรับมารดาและทารกแรกเกิด การรับการบริการหลังคลอดที่เหมาะสมจะช่วยป้องกันการเสียชีวิตของทารกและมารดา โดยการตรวจหลังคลอดจะสามารถระบุสัญญาณอันตรายที่เกิดขึ้นกับมารดาและทารกแรกเกิดซึ่งจะช่วยป้องกันการเสียชีวิตของทารกและมารดาได้อย่างมีนัยส�าคัญองค์การอนามัยโลกระบุว่าการรับบริการที่คลินิกหลังคลอดของประชากรทั่วโลกมีจ�านวนค่อนข้างต�่าโดยเฉพาะอย่างยิ่งประชากรในประเทศก�าลังพัฒนาส�าหรับประเทศมัลดีฟส์ข้อมูลเกี่ยวกับความชุกของการรับบริการที่คลินิกหลังคลอดและปัจจัยที่เกี่ยวข้องกับการรับบริการที่คลินิกหลงัคลอดยงัคงจ�ากดัการศกึษาครัง้นี้มวีตัถปุระสงค์เพือ่ศกึษาความชกุของการรบับรกิารทีค่ลนิกิหลงัคลอดและปัจจยัทีเ่กีย่วข้องกับการรับบริการที่คลินิกหลังคลอดของมารดา ในหมู่เกาะมัลดีฟส์ การศึกษานี้เป็นการเก็บข้อมูลแบบภาคตัดขวางโดยเก็บข้อมูลจากโรงพยาบาลระดับปฐมภูมิทุติยภูมิและตติยภูมิในประเทศมัลดีฟส์การสุ่มตัวอย่างแบบตามความสะดวกมีจ�านวนกลุ่มตัวอย่างทั้งหมด 253คนด�าเนินการระหว่าง 3-25พฤษภาคม2015การเกบ็ข้อมลูโดยใช้แบบสอบถามซึง่ใช้ทฤษฎขีองAndersen’shealthandutilizationmodelซึง่ประกอบด้วยตวัแปรpredisposing,enabling, และ need ร่วมกับ theDonabedianmodel of healthcare qualityมีตัวแปรผลคือภายในช่วง 6สัปดาห์หลังจากการคลอดบุตรมารดามารับบริการที่คลินิกหลังคลอดครบ3ครั้งหรือไม่ วิเคราะห์ข้อมูลโดยใช้การทดสอบไคสแควร์ และการวิเคราะห์ถดถอยโลจิสติกพหุคูณ การศึกษาพบว่าความชุกของการรับบริการที่คลินิกหลังคลอดคิดเป็นร้อยละ34 ผลการวิเคราะห์ถดถอยโลจิสติกพหุคูณพบว่าปัจจัยที่มีผลต่อการรับบริการที่คลินิกหลังคลอดประกอบด้วยค่าใช้จ่ายในการเดินทางเพื่อไปรับบริการ โครงการประกันสขุภาพและมารดาทีป่ระสบปัญหาสขุภาพจติโดยพบว่ามารดาทีต่ระหนกัว่าค่าใช้จ่ายในการเดนิทางมรีาคาสงูกว่ามโีอกาสทีไ่ปรบับริการจากคลินิกหลังคลอดสูงกว่า 1.98 เท่า (95%CI : 1.05-3.76 )มารดาที่ตระหนักว่าโครงการประกันสุขภาพแห่งชาติเป็นสิ่งที่มีประโยชน์มีแนวโน้มที่จะรับบริการจากคลินิกหลังคลอดสูงกว่า2.9เท่า(95%CI:1.21-7.03)ปัญหาสุขภาพจิตของมารดาหลังคลอดสามารถเพิ่มโอกาสที่มารดาจะใช้บริการจากคลินิกหลังคลอด2.0 เท่า (95%CI : 1.07-4.05) ผลการศกึษาแสดงให้เหน็ว่าความชกุของการรบับรกิารทีค่ลนิกิหลงัคลอดอยูใ่นระดบัต�า่ดงันัน้การปรบัปรงุโครงการประกนัสุขภาพเพื่อเพิ่มการเข้าถึงการให้บริการด้านการดูแลสุขภาพเป็นสิ่งส�าคัญส�าหรับมารดาหลังคลอดที่มีปัญหาสุขภาพจิตการให้ค�าปรึกษาส่วนบุคคลเป็นสิ่งที่ควรค�านึงถึง ในประเด็นเรื่องการเดินทาง เนื่องจากมัลดีฟส์เป็นประเทศที่ล้อมรอบด้วยหมู่เกาะจ�านวนมากค่าใช้จ่ายในการเดินทางจะเป็นปัจจัยส�าคัญในการเข้าถึงการบริการด้านสุขภาพดังนั้นการพัฒนาระบบขนส่งมวลชนสาธารณะที่เหมาะสมจะสามารถส่งเสริมการเข้าถึงการบริการด้านสุขภาพของประชากร

ค�าส�าคัญ: การรับบริการที่คลินิกหลังคลอด โรงพยาบาลระดับปฐมภูมิ โรงพยาบาลระดับทุติยภูมิ โรงพยาบาลระดับตติยภูมิ หมู่เกาะมัลดีฟส์

69


Introduction Among 130million newborn babies, fourmil-

lions are dyingwithin the first fourweeks of life,

withonethirdofallneonataldeathsoccurredin the

firstweek.1Although99%ofneonataldeathsarise

in low andmiddle-income countries, little progress

in reducing such deaths in the past 10-15 years of

thesecountrieswasmade.Withthisreason,focusing

on newborn care to reduce new born death in

developing country is very challenging.

Postnatal care is a primary step to savemother

and newborns life.2 Postnatal care provides all

essential routine care for newbones, and extra care

forbabieswith special conditions suchas lowbirth

weightorprematurebabies.Postnatalcareisthetime

to identify thedangersignsandsymptomsforearly

referrals and clinicalmanagement. In this regard,

postnatalcareutilizationisareassuringprotectionto

decreasematernal and neonatalmortality and other

neonatalcomplication. Inmanycountries,Antenatal

Care(ANC)coverage isveryhigh,whereasPostna-

talCareCoverage (PNC) is lesser3.WHOdefined4,5

postnatalperiodas thefirst sixweeksafterdelivery

composed of three visit. First visitwill be on the

3rddaybetween48–72hoursofbaby’slife,second

visitwill between7- 14days and the last visitwill

on the sixthweeks of delivery5. Proper followup

canpreventthenewbornandmotherfromdeathsand

other infectious disease.

Maldives is a very small country composed of

341,256 total population6with 173,172male and

168,084 female.Maldives has a unique archipelago

of 1192 islands; only 194 islands are inhabited7.

Because islands are being clustered in the Indian

Ocean,Maldives government initiatesmaternal and

child health care at each level. The government

classifiedthehospitalasthirteenatollhospital(primary

level),sixregionalhospital(secondarylevel),and188

healthcentersatsubdistrictlevel.Additionally,there

isonegovernmenthospital andoneprivatehospital

in the capital island ofMaldives (MaleCity)with

tertiary care facilities.

InMaldives,maternalmortality rate is 13 per

1000 live births.Womenwhohad 4 ormoreANC

visitswas 85%.Amongmotherswho delivered in

the health facility, 46%had receivedpostnatal care

within4hours,and21%ofmothersreceivedpostna-

talcareafter2daysofdelivery8. Researchstudyin

Maldivesabout thefactorsassociatedwithpostnatal

care utilization are limited. Factors associatedwith

postnatalcareutilizationamongthemothersarestill

questionableandneedtoexplore.Therefore,thisstudy

aims to determine the prevalence of postnatal care

and examine the factors associatedwith postnatal

care utilization amongmothers living inMaldives

islands.

Methods Thisstudywasacommunitybasedcross-sectional

research conducted amongmothers living in three

differentlevelofhospitalintheislandsofMaldives.

We chose to collect data toward southern part of

Maldives because the population are the original

Maldivianpeople.Aftercalculationsamplesizefrom

67%of estimated population of PNCutilization in

Maldives thatwas stated inMaldives demographic

health survey 2009, our study took account of 253

mothers from the southern part of the country. For

morereadilyaccessibletoresearcher,aconvenience

samplingbyaskingmotherswhocametoreceivethe

70


growthmonitoring and vaccination from the target

clinicswereselectedduringMay3rdto25thMay2015.

Primaryhospital,Gn.Fuvahmulak;secondaryhospital,

Addu atoll; and tertiary hospital, capitalMalewere

includedinthestudy.Thestudyareaswereselected

basedonthetransportroutforthecosteffectiveness

of the study.

Datawereobtained frommotherswith6month

to two-year-old childwho came to register growth

monitoring service from the particular hospital

duringtheworkinghours.Astructuredquestionnaire

wasgiventotherespondentsfortakinghometofill.

Respondentswere given 2-4 days’ time in order to

completethequestionnaire.BasedontheAnderson’s

behavioralmodel of health care utilization together

with Donabedian’s model of quality care, the

predictorsinthisstudyincludedpredisposingfactors,

enablingfactors,needfactors,andperceivedquality

ofcare factors.Under thepredisposing factors; age,

education, occupation, type of family, knowledge,

and distance to hospital and cost of transportwere

included. Enabling factors include the birth place,

numberofchildren,hospitalhours,incomeandhealth

insurance.Asneed factors, after birth complication,

breastfeeding difficulty, sickness of baby, health

education, perceivedmental health problem such

as depression and anxiety duringPNCperiod, and

lifethreateningexperienceafterbirthwereincluded.

Perceived quality of care consists of counselling,

effectivenessofdoctorstreatment,andopinionabout

the first postnatal care quality. Themain outcome

variable focused on postnatal care utilization that

categorizedaswhethertheycomplete3postnatalvisit

within 6weeks after child birth or not.

For the reliability, a pilot studywas conducted

among 30motherswith 6month to two-year-old

child living in one part of the capital named “Hul-

humale”.This isanartificially reclaimed island that

take20minutesbyengineDhoni(seavessel) to the

capitalMale and later declared as a part of capital

city.TheresultwasmeasuredusingCronbachalpha

test;gettingCronbachcoefficient0.616. This study

was approvedby the experts committee atMahidol

UniversitytogetherwithNationalResearchCommittee

(NRC) atMinistry ofHealth,Maldives.

Data were analyzed by SPSS version 21.

Descriptive statisticswere applied to describe the

basic features of the data.Univariate analysiswere

usedtofindtheassociationbetweentheindependent

variable and dependent variable. Finallymultiple

logistic regressionwere used to predict the factors

associatedwith thePNCutilization.

Results As shown in table 1, themajority (83.4%) of

the subjectwere less than30years of age,whereas

respondentsabove30yearswere16.6%.Withregards

of education, over2/3 (79.4%)of the subjectswere

belowthelevelofcollege,while20.6%ofrespondents

reported as college and above.Over 2/3 (70%) of

spouseeducationwashigherthansecondaryeducation,

while30%of the respondents spousehadeducation

less than primary level.More than half (55.3%) of

therespondentswerelivinginasinglefamily,while

44.7%of themwere living in an extended family.

In termsofoccupation,majority (73.1%)of the

motherswereunemployed.Amongthespouse,71.9%

wereworkingasgovernmentofficers,professionaland

others. 28.1%of themwereworking in the tourism

71


industryanddoingtheirownbusiness.Withregards

ofknowledge,86.6%ofrespondentsknowthereason

why they need to do followup for PNC.Similarly

81%ofthesubjectwereawareofthefollowupdate

forPNC.Nearlyhalf(48.2%)oftherespondentslive

farfromhospital.Majority(66.8%)oftherespondent

stated that the transport cost is not expensive.

Table 1 Distributionof respondents bypredisposing factors

Predisposing Factors n= 253 Frequency Percentage

Age 30yrs or less than 211 83.4

Above30yrs 42 16.6

(Median=30years;QD=4;Min=17;Max=49)

Mother’s education Lower than college 201 79.4

College and above 52 20.6

Husband's education Less thanprimary 76 30

Higher than secondary 177 70

Type of family Extended family 113 44.7

Single family 140 55.3

Mom occupation No job 185 73.1

In Job 68 26.9

Husbands occupation Business& tourism 71 28.1

Others, government officers

&professional

182 71.9

Know the Importance of PNC Yes 219 86.6

No 34 13.4

Know PNC timing Yes 205 81

No 48 19

House is far from hospital Yes 122 48.2

No 131 51.8

Transportation Expensive 84 33.2

Not expensive 169 66.8

72


AsTable2,nearlyhalf(49.4%)oftherespondents

agreed that the health insurance schemewas good.

In termsof family income,overhalf (54.5%)of the

respondents, their familyget income less thanMRF

10,000permonth.26.9%oftherespondents’family

had incomebetweenMRF10,000 to 15,000,while

18.6%of respondents’ family getmore thanMRF

15,000permonthrespectively.Amongtherespond-

ents,71.9%ofthemwerehavingonetotwochildren,

while 28.1%were having3 ormore children.Over

half (51.4%)of the respondents had delivered their

lastchildattertiarylevelhospital,whereas48.6%of

themhad delivered in secondary and primary level

hospital.Regardinghospitalhours,90.1%agreedthat

the present hours of hospitalwas convenient.

Overhalf(67.2%)oftherespondentsreceivehealth

educationforfollowup.Withregardsofcomplication

during pregnancy, 81% ofmothers reported as no

complication.Motherswhohad experiencedbreast-

feedingdifficultieswere20.9%.Nearlyhalf(41.5%)

oftherespondents’babyhadfallsickduringthefirst

6monthsoftheirage.Intermsofmentalhealthsuch

asdepressionandanxiety,28.1%ofrespondentshad

gone through depression after delivery. 75.8% of

respondentshadreceivedcounsellingforPNC.With

regardsofqualityandeffectivenessofdoctors treat-

ment,overhalf (75.9%)ofrespondentswereagreed

it is effective. 44.3%of respondents stated that the

quality offirst neonatal careweregood (table 2).

73


Table 2 Distributionof respondents by enabling, need andperceivedquality of care factors

Factors n= 253 Frequency Percentage

Opinion for Health Insurance scheme

Family income/month

Number of children

Place of last child birth

Hospital opening hours

Health education from nurse

Complication in pregnancy

Life threatening experience

Breast feeding difficulty

Baby had sickness

Had depression

Counselling for PNC

Dr’s treatment is effective

Quality of first neonatal care

VerygoodGoodNotGoodMRF10,000-15,000MRF>15,000MRF<10,0002or less3ormorePrimary& secondaryhospitalTertiaryhospitalNot convenientConvenientYesNoYesNoYesNoYesNoYesNoYesNoYesNoAgreeDisagreeVerygoodGoodNotGood

401258813868471827112313025228170834820515240532001051487118219261192619611245

15.849.434.854.526.918.671.928.148.651.49.990.167.232.819815.194.920.979.141.558.528.171.975.924.175.924.137.944.317.8

Table3explained theassociationbetweenPNC

utilizationandpredisposingfactors.Theresultrevealed

that there is a statistically significant association

withPNCutilizationandinformationaboutthePNC

followup date (P= 0.036).Motherswho know the

informationaboutthefollow-updatewere2.2times

morelikelytoutilizethePNCservice.Amongother

predisposing factors,we found that age, education

occupation,typeoffamily,distancetohospitalandthe

costoftransportdoesn’tshowstatisticallysignificant

withPNCutilization.

74


Table 3 Associationbetweenpredisposing factors andutilization ofPNC

Predisposing Factors

Utilization of PNC

n Complete% Incomplete%Crude OR (95% CI)

P-value

Age>30<31Mothers educationLower than collegeCollege and aboveHusbands educationLess thanprimaryHigher than secondaryFamily typeExtendedFamilySingle familyMothers Occupational statusNo JobIn JobHusbands OccupationBusiness& tourismOthers (Government officer, professionals)Know the importance of PNCYesNoKnow the PNC follow up dateYesNoHouse is far from the hospitalYesNoOpinion about the cost of transportExpensiveModerately good

21142

20152

76177

113140

18568

71182

21934

20548

122131

84169

33.635.7

33.834.6

34.233.9

36.332.1

34.632.4

29.635.7

35.623.5

37.120.8

33.634.4

40.530.8

66.464.3

66.265.4

65.866.1

63.767.9

65.467.6

70.464.3

64.476.5

62.979.2

66.465.6

59.569.2

11.10(0.55-2.19)

11.04(0.55-1.97)

1.01(0.58-1.79)1

1.20(0.71-2.03)1

1.11(0.61-1.99)1

11.32(0.73-2.39)

1.79(0.78-4.16)1

2.23(1.06-4.75)1

11.03(0.61-1.74)

1.53(0.89-2.64)1

.796

0.915

0.962

0.490

0.739

0.355

0.171

0.036

0.901

0.126

75


Table4explained theassociationbetweenPNC

utilizationwith enabling factors, need factors and

perceived quality factors. The result indicated that

thereisastatisticallysignificantassociationbetween

PNC utilizationwith family income (P= 0.026).

Motherswho have family incomebetween 10,000-

15,000MRFare1.98timesmore likely tousePNC

service comparing tomotherswith family income

morethanwhohavefamilyincomelessthan10,000

MRF.However, number of children, place of last

childbirth,hospitalhours,healtheducation,complica-

tionduringpregnancy and after birth, breastfeeding

difficulties,babiesandmothers’health,andqualityof

firstneonatalcaredoesn’tshowstatisticallysignificant

associationwithPNCutilization.

Table 4 Associationbetween enabling, need, andperceivedquality factors andutilization ofPNC.

Factors

Utilization of PNC

n Complete% Incomplete%Crude OR (95% CI)

P-value

Opinion for Health Insurance schemeVeryGoodGoodGoodFamily Income/monthMRF10,000-15,000MRF>15,000MRF<10,000Place of Last child birthPrimary& secondaryTertiaryExperienced mental health problemYesNo

4012588

6847138

123130

71182

47.532.829.5

45.629.829.7

30.137.7

42.330.8

52.567.270.5

54.470.270.3

69.962.3

57.769.2

2.16 (0.99-4.67)1.16 (0.65-2.10)1

1.98 (1.09-3.62)1.00 (0.49-2.07)1

11.41 (.83-2.37)

1.65 (0.93-2.90)1

0.0510.615

0.0260.992

0.202

0.085

Table 5 shows the result ofmultiple logistic

regressions,controlledforotherfactorsofpredisposing,

enabling, need and quality of care. Significant pre-

dictorsforPNCutilizationincludeopinionaboutthe

costoftransport,healthinsurancescheme,andexpe-

riencedmentalhealthproblem.Motherwhoperceived

that cost of transportationwas expensive hasmore

chance of gettingPNCutilization 1.98 times (95%

C.I:1.050–3.755)comparedto thoseperceivedthat

the costwas low.Mother’s opinion for the national

health insurance schemewith very good hasmore

chanceofPNCutilization2.9times(95%C.I:1.21-

7.03).Experiencedmental health problem increases

thechanceofcompletingPNCwith2.0 times (95%

C.I.: 1.07-4.05)more.

76


Table 5 Multiple logistic regression for factors associatedwithPNCutilization

Variables Utilization of PNC

Adj. OR 95% C.I P-value

Opinion for transport cost

Opinion for health insurance scheme

Family income

per month

Place of last child birth

Experience mental health problem

Expensive

Not expensive

Very. good

Good

Not good

MRF10,000-15,000

MRF>15,000

MRF<10,000

Primary & secondary

hospital

Tertiaryhospital

Yes

No

1.99

1

2.92

1.20

1

1.82

0.93

1

1

1.18

2.09

1

1.05–3.76

1.21– 7.03

0.61-2.38

0.88-3.75

0.39-2.24

0.60-2.32

1.07-4.05

0.035

0.017

0.106

0.640

0.030

Table6indicatedtheproportionofPNCutilization

and significant predictors by three different level

hospital.Theresultsindicatedthatthehighestpercent-

ageofPNCutilizationwasfoundinsecondarylevel

hospital, and the lowest in primary level hospital.

Regarding opinion for transportation cost, although

mothersreportedthetransportationwasnotexpensive,

theywere less likely to complete PNCutilization.

However,mothersinthesecondaryandtertiarylevel

hospitalsweremorelikelytocompletePNCutilization

thanmothers inprimary levelhospital, even though

the transportation is expensive. In terms of health

insurance,mothersintertiaryandsecondaryhospital

whoreportedthehealthinsurancewasverygoodwill

bemorelikelytocompletePNCutilization.Regards

tomental health problem,mothers experienced in

mentalproblemwillbe less likely tocompletePNC

service exceptmothers in secondary level hospital.

77


Table 6 ProportionofPNCutilization and significant predictors by three different level of hospitals

Factors Primary Secondary Tertiary

Complete Incomplete Complete Incomplete Complete Incomplete

PNCutilization

Opinion for Transport cost

Expensive

Inexpensive

Opinion for Health Insurance

Scheme

VeryGood

Good

NotGood

Experienced mental health problem

Yes

No

27.4

27.3

27.5

20.0

36.4

20.0

45.5

24.2

72.6

72.7

72.5

80.0

63.6

80.0

54.5

75.8

40.7

44.7

38.3

58.8

27.8

46.4

52.4

36.7

59.3

55.3

61.7

41.2

72.2

53.6

47.6

63.3

33.3

46.4

28.2

53.8

33.9

23.3

35.9

31.7

66.7

53.6

71.8

46.2

66.1

76.7

64.1

68.3

Discussion Post-natalcare(PNC)hasbeenadvocatedasthe

bestway to preventmaternal and newborn deaths.

However, PNCutilization inmany countries is still

very low.This study aims to determine the factors

associatedwith PNCutilization amongmothers in

Maldives islands.We found that cost of transporta-

tion, health insurance scheme, experiencedmental

health problemwere significantly associatedwith

PNC utilization.Maldives has established country

healthinsuranceschemetowardstheachievementof

universalhealthcoverage5toprovidetheaccessibility

tohealth service.Health insurance schemeprovides

financial assurance to the public. It’s a challenge in

manycountriestoimprovepeople’shealth,especially

for the poor. Therefore, better health insurance

schemewouldhighly impactutilizationofpostnatal

careservices.Thisstudyindicatedthatifpeoplehave

positivethinkingabouthealthinsurancescheme,they

aremore likely to havePNCutilization (OR=2.92,

95%C.I.:1.21-7.03).

Likeour study, a study in Indonesia6 compared

the utilization rate ofmaternal health care between

the people registered under the health coverage

schemeandnon-registeredpeople.Theresultshows

thattheserviceutilizationwassignificantlyimproved

(OR=1.84, 95%C.I.:1.18-2.89) among the people

registered under the health coverage scheme. In

ordertoimprovehealthservicesaccessofpopulation,

many countries has established health care financ-

78


ing strategies. Sub-SaharaAfrica countries are the

countries that established community based health

insurance scheme to bring good impacts for health

careespeciallyformaternalhealth.Previousresearch

fromWestAfrica7alsoindicatedthatmembershipin

communitybasedhealthinsuranceschemepositively

usematernal health services.

MentalhealthproblemoverPNCperiodisanother

problem among postnatalmothers.Actually, it is

the most common psychiatric condition among

childbearingagewomenspeciallyduringthepost-natal

period8-12.Inthisstudy,28.1%ofrespondentmothers

experiencedmentalhealthproblemoverPNCperiod.

Our study indicated thatmotherswho experienced

mental health problem over PNC periodwere 2.0

timesmorelikelytoutilizetheservice.Theprevalence

ofmotherswho experiencedmental health problem

overPNCperiod,especiallypostpartumdepressionin

developedcountriesisapproximately1310-15%,while

the prevalence in low andmiddle income countries

about 40%.The resultsmaybe influencedwith the

characteristics of the study population. Regarding

theutilizationofhealthservice,somepreviousstudy

disclosedthatmotherswithdepressivesymptomshave

morefrequentcontactwithhealthcareprofessionals14-17

A study to investigate the influence of depressive

symptomsonutilizationofhealthservices18revealed

thatdepressivesymptomsarehighlyassociatedwith

health service utilizationwith over 50%of utilizers

havingfirstmonth postpartumdepression.

Additionally, our study supported that cost of

transportation significantly associatedwithpostnatal

care utilization. Respondent who reported that

transport costwas expensivewere 1.9 times (95%

C.I.:1.05-3.76)morelikelytoutilizethePNCservice.

Thisresultmayduetothelivingstandardthatvaryby

income.OurresultsindicatedthatutilizationofPNC

was higher amongmothers living in the secondary

and the tertiary level of health facility, andmost of

therespondentsindicatedthetransportationcostwas

expensivewerefromthebothlevelhospitalsthatare

thecityandurbanareas.Itispossiblethatthemothers

fromthesecondaryandthetertiarylevelhospitalshave

touse transportation inorder to travel tohavePNC

services even the transportation is expensive.Tran-

sportation impactshealth through theaccessibility19,

therefore facilitation transport among patients is a

goodpolicytoincreasehealthcareutilization.Astudy

to find the barriers and facilitator related to use of

postnatalcareservice20 supported that transportation

wasastrongpersonalbarriertoimpedetheutilization

ofPNC service.

Recommendation Our study indicated that the prevalence of

postnatal care utilizationwas very small. Cost of

transportation, health insurance scheme, andmental

health problemwere the factors effecting the PNC

utilization.Therefore,strengtheningtheprovisionof

health insurance scheme is very important strategy

to enhance the accessibility for health care service.

Formotherswith depressive symptoms, individual

counselling should be recommended.Additionally,

morefrequentandclosecontactwithmotherswould

behelpful to improvemotherandchildhealth.This

couldbemorepossiblebypromotinghomevisiting

programs by healthworkers.Another point is cost

of transportation. BecauseMaldives is a country

clustered intomany islands, transport costswould

beveryinfluential.Forthisreason,establishmentof

79


affordablepublictransportationwouldbeasupportive

factor for increasing health services utilization.

Additionally, trainingcommunityvolunteers regard-

ingpostnatal homevisiting to reduce transportation

barrierwill be a goodoption.

References 1. Lawn JE,CousensS,Zupan J,TeamLNSS. 4

million neonatal deaths:when?Where?Why?

TheLancet.2005;365(9462):891-900.

2. NationalBureauofStatisticsMoFTM,Rep. of

Maldives. Preliminary Results - Revised. 04

March2015.

3. UNFPADoN. ICPDBeyond 2014 -Maldives

OperationalReview.2004.

4. Ministry ofHealth, gender section.Maldives

HealthProfile2014.March2014.

5. Moreno-SerraR,SmithPC.Doesprogresstowards

universal health coverage improve population

health?TheLancet.2012;380(9845):917-23.

6. KesumaZM,ChongsuvivatwongV.Utilizationof

theLocalGovernmentHealthInsuranceScheme

(JKA) forMaternal Health ServicesAmong

WomenLivinginUnderdevelopedAreasofAceh

Province,Indonesia.Asia-Pacificjournalofpublic

health /Asia-PacificAcademicConsortium for

PublicHealth.2015;27(3):348-59.

7. SmithKV,SulzbachS.Community-basedhealth

insuranceandaccesstomaternalhealthservices:

evidencefromthreeWestAfricancountries.So-

cialscience&medicine.2008;66(12):2460-73.

8. ParsonsCE,YoungKS,RochatTJ,Kringelbach

ML,SteinA.Postnataldepressionanditseffects

onchilddevelopment:areviewofevidencefrom

low-andmiddle-incomecountries.Britishmedical

bulletin.2012;101(1):57.

9. BlackMM,BaquiAH, ZamanK, ElArifeen

S, BlackRE.Maternal depressive symptoms

and infant growth in rural Bangladesh. The

Americanjournalofclinicalnutrition.2009Mar

1;89(3):951S-7S.

10. FisherJ,MelloMC,PatelV,RahmanA,TranT,

HoltonS,HolmesW.Prevalenceanddeterminants

ofcommonperinatalmentaldisordersinwomen

in low-and lower-middle-income countries: a

systematicreview.BulletinoftheWorldHealth

Organization.2012Feb;90(2):139-49.

11. StewartRC,BunnJ,VokhiwaM,UmarE,Kauye

F,FitzgeraldM,TomensonB,RahmanA,Creed

F. Commonmental disorder and associated

factors amongstwomenwith young infants in

ruralMalawi.Socialpsychiatryandpsychiatric

epidemiology.2010May1;45(5):551-9.

12. SawyerA,AyersS,SmithH.Pre-andpostnatal

psychologicalwellbeinginAfrica:asystematic

review.Journalofaffectivedisorders.2010Jun

30;123(1):17-29.

13. LobatoG,BrunnerMA,DiasMA,MoraesCL,

ReichenheimME.Higher rates of postpartum

depression amongwomen lacking care after

childbirth: clinical and epidemiological impor-

tance ofmissed postnatal visits. Archives of

women'smentalhealth.2012;15(2):145-6.

14. WebsterJ,PritchardMA,LinnaneJW,Roberts

JA,HinsonJK,StarrenburgSE.Postnataldepres-

sion:Useofhealthservicesandsatisfactionwith

health-careproviders.Journalofqualityinclinical

practice.2001Dec1;21(4):144-8.

80


15. BoycePM, JohnstoneSJ,HickeyAR,Morris-

YatesAD,HarrisMG,StrachanT.Functioning

andwell-beingat24weekspostpartumofwomen

withpostnataldepression.ArchivesofWomen's

MentalHealth.2000Dec1;3(3):91-7.

16. Dennis CL, Ross LE. The clinical utility of

maternal self-reported personal and familial

psychiatrichistoryinidentifyingwomenatriskfor

postpartumdepression.Actaobstetriciaetgyneco-

logicaScandinavica.2006Jan1;85(10):1179-85.

17. MandlKD,TronickEZ,BrennanTA,AlpertHR,

HomerCJ. Infant health care use andmaternal

depression.Archivesofpediatrics&adolescent

medicine.1999Aug1;153(8):808-13.

18. DennisCL. Influenceofdepressivesymptoma-

tologyonmaternalhealthserviceutilizationand

general health. Archives of women'smental

health.2004;7(3):183-91.

19. BonifaceS,ScantleburyR,WatkinsS,Mindell

J.Healthimplicationsoftransport:Evidenceof

effectsoftransportonsocialinteractions.Journal

ofTransport&Health.2015.

20. HeamanMI, SwordW, Elliott L, Moffatt

M,HelewaME,MorrisH, et al.Barriers and

facilitators related to use of prenatal care by

inner-citywomen: perceptions of health care

providers. BMC pregnancy and childbirth.

2015;15(1):2.

Factors associated with Post-natal Care Utilization among...

Documents

Transcript of Factors associated with Post-natal Care Utilization among...