Understanding the Situation
Women do not practice healthy MNC behaviors or use health system services for several reasons, including social and cultural factors. Thaddeus and Maine (1994) explain the three delays[i] that contribute to maternal death:
- Delays in seeking care may be caused by failure to recognize signs of complications, failure to perceive the severity of illness, cost considerations, previous negative experiences with the health care system, and transportation difficulties.
- Delays in reaching care may be created by the distance from a woman’s home to a facility or provider, the condition of roads, and a lack of emergency transportation.
- Delays in receiving care may result from a lack of health care personnel, poor skills of health care providers, unprofessional attitudes of providers, and shortages of supplies and basic equipment.
The first step in developing MNC interventions is to understand the situation. A situation analysis allows for an assessment of MNC knowledge, attitudes, and practices, as well as barriers and enabling factors that influence use of MNC services and adoption of healthy behaviors. It is important to understand what is happening at both the community and facility levels and what links exist between the two.
By identifying specific barriers or enabling factors, a project can better develop an effective social and behavior change (SBC) strategy and can target its interventions strategically. In a situation analysis, secondary data sources may include national surveys, health facility registers, and reporting forms. Primary data sources may include small-sample household surveys, focus group discussions, in-depth interviews, and health center exit surveys. Generally a mixture of qualitative and quantitative data is most informative. Following is a list of potential resources:
- Knowledge, Practice, and Coverage (KPC) Survey: Small-sample household survey that enables understanding of the MNC situation in a project area before and after implementation.
- Demographic and Health Surveys (DHS): Country-wide household surveys that cover many MNC issues, with indicators often disaggregated by region, age, and rural or urban.
- Barrier Analysis: A rapid assessment tool for identifying behavioral determinants associated with a particular behavior.
- Rapid Health Facility Assessment (R-HFA): An instrument for measuring a small set of key indicators to give “a balanced scorecard” for MNCH services at the primary health care level (including an optional module for use with CHWs for community outreach services) and identify key bottlenecks to quality service delivery.
For instance, a woman’s ability to seek prompt care requires that an emergency plan is in place and that the woman, family, and others attending the birth can recognize danger signs. Many factors influence the decision to seek care, including the ability of those attending the birth to understand and recognize danger signs, who the decision-maker is, traditional beliefs, traditional birthing practices, transportation costs and availability, perception of and actual quality of care at health facilities, fees and incidental costs, and availability of drugs and other supplies.
To improve the ability to seek prompt care for complications, programs must identify the barriers and address them at the household, community, and facility levels. ANC visits, home visits, and women’s group meetings all offer opportunities to educate and counsel women (and others). Reducing cultural or religious barriers also can improve access. Programs must also identify the cadre of health workers who could do home visits (e.g., for postnatal care) and deliver the community intervention package in various settings? What basic training is required for CHWs? What are considerations for CHW supervision? What targets and indicators on CHWs coverage are needed for M&E?
In addition to effective links between households and health facilities, it is essential to coordinate efforts among national and district governments, local and international NGOs, bilateral and multilateral donor agencies, and the private sector. A number of elements in the health system need to be assessed and likely strengthened in parallel with other program activities. Following is a list of examples:
- Training of facility-based health staff, including providers, managers, data analysts, and laboratory technicians
- Methods for monitoring and supervising health workers and improving clinical practice to assure delivery of quality services based on desired standards of practice
- Logistics systems to provide adequate supplies of essential drugs and other MNC supplies
- M&E systems to assess program performance
- District planning and management capacity
Key Resources for Understanding the Situation:
- John Snow, Inc., 1998. Assessing Safe Motherhood in the Community: A Guide to Formative Research
- Food for the Hungry, 2010. Barrier Analysis Facilitator’s Guide
- MCHIP, 2014. Knowledge, Practice, Coverage Survey Tool
- O’Donnell O, Access to Health Care in Developing Countries: Breaking Down Demand Side Barriers. Cad. Saúde Pública [online]. 2007; 23(12):2820-2834.
- Mercurio B, Resolving the Public Health Crisis in the Developing World: Problems and Barriers of Access to Essential Medicines, Northwestern Journal of International Human Rights 2007; 5(1).
[i] Thaddeus S and Maine D. Too far to walk: Maternal mortality in context. Social Science and Medicine 1994;38:1091.