Why are there low institutional delivery rates in the Gambia? Women’s opinion.

Abstract

Rationale for the Study: The Gambia, a small and poor Country in West Africa. Health is one of the key pillars in the agenda of the Gambia government. Spending has been increased from 13.6% in 2001 to 4.95% in 2003. Public health expenditure also increases steadily to 3.2% in 2003. Expenditure on health per capita US$8 is only spent by the Government. Access to health facilities is good, with over 85% of the population living within 3 kilometres of a primary health care or outreach health post and 97% of the population within 5 kilometres. Despite the high Antenatal Care coverage of 96%, only few deliveries take place in the health facilities. Skilled attendant at deliveries is estimated at 44%. The majority of the deliveries take place at home attended by TBAs or a relative. Cost of Antenatal services is extremely low and it’s paid once during registration for the entire visit. Women with normal deliveries pay D12.50 (US$0.45) and D25.00 (US$ 0.90) respectively. Those with Caesarean Section (CS) pay D50.00 (US$1.79). After delivery, they attend infant welfare clinic immediately after the naming ceremony. It is the same distance and they know the facilities well. However, the women do not use the institutions for delivery. Institutional delivery is very low, estimated at 30.4%. Objectives of the study: 1. To identify and describe the socio- demographic factors associated with not utilising health facility for delivery. 2. To identify and describe the economic factors associated with the low institutional deliveries. 3. To describe health services related factors contributing to the low utilization of health facility for deliveries. 4. To identify and describe cultural factors (if any) that act as a barrier to health facility deliveries. 5. To put forward recommendation for improved care and increased utilization of health institutions for delivery care and improved maternal health outcomes.

Materials and Methods: A cross sectional design was used. Individual in-depth interview using a semi structured interview guide and a focus group discussion were used to collect information on women who have just delivered and have come to the clinic for registration of their infants for infant welfare clinic; immunization and growth monitoring in 2 of the health divisions WD (urban) and NBW ( rural) in the Gambia. The women with live births were randomly selected from the MCH clinics, interviewed and followed back in the community for a focus group discussion.

Results: A total of 391 women were interviewed in the quantitative study and 36 women participated in the focus group discussions. Four focus groups was performed; 2 in each division. The study revealed that cultural factors, attitude of health care providers, previous experiences with the health system, long waiting time, negligence of health care workers, alternative delivery services, transport and cost of receiving services and expectations are factors that influenced their utilization of health facilities for delivery. The individual in-depth interview revealed that place of delivery for first pregnancy in NBW was health facility 60% and home 40.6% and WD place of delivery for first pregnancy was health facility 88% and home 13%. Those who delivered in health facility during their first pregnancy, (N296) in both divisions, only 24% delivered at home during their index pregnancy and 40% delivered in health facility. In NBW 80% did not receive any information on place of delivery. Of those who received information, 45% delivered at home and 55% delivered in HF. In WD, 42% received information and 60% did not receive information. Of those who received information, 18% delivered at home and 82% delivered in HF. The prominent danger signs that are the major causes of maternal death are not known. Bleeding before and after delivery which are very severe and are major causes of maternal death is only known by 14(4.4%) and 3(1.0%) respectively in both divisions.

Conclusions: Cultural factors and health services factors which include staff attitude and lack of maternal education during ANC attendance were the most frequently identified contributing factors to the low Uterlisation of health institutions for delivery in this study.