Study On Needs And Accessibility Of Maternal Health Care Among Childbearing-age Women In Rural Areas, Anhui Province

Objectives This study aims to describe the maternal health care needs and knowledge, attitude, practices (KAP) of childbearing-age women in rural area of A and B county of Anhui province and to analyze the association between maternal health care knowledge, attitude and practices. It also will identify the main factors influencing maternal health care needs and KAP among these women of reproductive age in rural area. This study aims to understand the current situation of accessibility of maternal health care service, identify the main problems in provision of maternal health services in rural area of Anhui province, and study the effective measures to improve the accessibility of maternal health care in rural area.Methods Using a stratified randomized cluster-sampling method, 1 789 childbearing-age women were selected for a questionnaire survey from townships of 2 counties in Anhui province. Only women who had delivered live babies during the period 1 January 2005 to 31 December 2006 were selected. According to their own wills, all participants completed face to face self-adapted questionnaires by centralization and household. The content of the questionnaires included social demography characteristics, perceived needs for maternal health care, and maternal health care knowledge, attitude, practices. Descriptive analysis was to analyze the demographic characteristics, perceived needs for maternal health care and maternal health care knowledge, attitude, practices were analyzed descriptively. BCG method was used to examine the association between knowledge, attitude and practices of 5 or more times prenatal examinations. Theχ2-test determined the maternal health care knowledge score classification of low, middle and high. And the independent variables which were the factors related to the maternal health care knowledge score classification by usingχ2-test model related to the dependent variable which was maternal health care knowledge score classification were analyzed by using multinomial logistic regression model. The dependent variables which were four maternal health care attitude related to the independent variables which were demographic variables and maternal health care knowledge score classification were analyzed by using non-conditional multivariate logistic regression model. The dependent variables which were four maternal health care practices such as doing prenatal checkup, asking doctors questions actively, buying maternal health care data, changing habit about partiality for a particular kind of food related to the independent variables which were demographic variables, maternal health care knowledge score classification and the attitude to 5 or more times prenatal examinations were analyzed by using non-conditional multivariate logistic regression model. The independent variables which were the score classification of maternal health care knowledge and service Needs related to the dependent variables which were demographic variables were analyzed by using multinomial logistic regression model.By using both qualitative and quantitative methods, the situation of maternal health care service was investigated. In the quantitative study, 1 789 childbearing-age women in rural areas completed a questionnaire about the maternal health education and services they had received. This data were analyzed by descriptive analysis. In the qualitative study, individual interviews were conducted with 8 leaders from maternal health care and other departments. Focus group discussions were held with administrators of township hospitals, township doctors and nurses, village doctors and family planning workers. A total of 60 people were included in the focus group discussions. Topic guides were used to explore providers and policy makers'perceptions of the current situation and development of maternal health care services and factors influencing these services by semi-structured interviews outline. Results This study found that women identified the most important areas for maternal health care knowledge as:knowledge and skills of caring for the baby (92.6%), maternal health care in postnatal period and breast-feeding (91.6%) and nutrition (90.6%). The best approaches for pregnant women to obtain knowledge were in turn: advice from health professionals (91.3%), leaflets (85.7%) and television programmes and other media (81.3%). 22.0% of rural women expressed that they did not need postpartum visits, and 13.8% of women thought that the current content of prenatal check-up was adequate. 81.5% of women gave correct answers to more than half of the maternal health care questions. The study findings on attitude towards the maternal health care included: 74% of women thought that it was necessary to have prenatal examinations; 71.5% of women thought that they should have at least 5 prenatal examinations even if they had no problems; 90.3% of women would choose hospital delivery though themselves and their children were healthy; and 81.6% of women wanted health professionals to visit their homes to do postpartum care. The survey found that the prenatal examination rate, rate of prenatal examination in the first three months of pregnancy, 5 or more prenatal examinations rate, and percentage of hospitalized delivery were 96.9, 50.3%, 56.4%, 99.8% respectively. 65.8% of women said they would first consult the doctor for advice whilst 26.1% of women would ask their relatives and friends. 57.6% of women did not buy any books, magazines or discs on maternal health care. 32.7% of women did not change their dietary habits. The result of the BCG analysis showed that the number of people inⅢquadrant who adopted the correct practices was least, and the people inⅠquadrant who adopted the correct practices were greatest. This is in keeping with the natural relationship between knowledge, attitude and practices. Analysis using the multinomial logistic regression model showed that the middle and high levels of maternal health care knowledge were with significant difference compared to the low level among childbearing-age women with different nationality and culture degree. Husbands who went out of their home area for work and higher education level of the women were protective factors of the score of middle and high level of maternal health care needs which were higher than the low level. The non-conditional multivariate logistic regression model showed that the four maternal health care attitude measures were all affected by maternal health care knowledge. Women with higher education level were more likely to have a positive attitude to prenatal examination, 5 or more prenatal examinations, and more postpartum visits. Histories of induced abortion, abortion drug before the last childbirth, and poor outcome in previous pregnancies (including spontaneous abortion, fetal death, stillbirth and infant death) were protective factors for prenatal examination and postpartum visit. Positive attitude to having 5 or more prenatal examinations was higher amongst women who had one child and whose husbands had higher education level. Positive attitude to hospital delivery was higher amongst women with Han nationality than women of minority nationalities. The four health care practices were lower among women with lower education level women with no history of poor outcome in previous pregnancies (including spontaneous abortion, fetal death, stillbirth and infant death), and women with negative attitudes to 5 or more prenatal examinations. Lower education level, minority nationality, and having more than one child were risk factors for the two practices: having 5 or more prenatal examinations and buying materials about maternal health care. Women who assessed their economic status as low, were less likely to actively consult the doctor for advice than women who assessed their economic status as average, good and high economic. Husbands who went out of their home area for work was a protective factor for women buying material on maternal health care.With regard to maternal health care services, prenatal examination, hospital delivery, postpartum visit and health education were all carried out in the township hospitals. However the quantity and quality of these services did not reach the national requirements. All maternal health care service providers (68/68) thought that the proportion of prenatal examinations of at least 5 was low, and in some townships the proportion was as low as 10%. 70% high risk pregnant women did not have prenatal examinations according to the national requirements. Although two thirds of the village doctors interviewed wanted to do prenatal health care, as most village doctors were male it was difficult for them to provide this service. At present, pregnant women went to village doctors for examination. The survey showed that 53.6% of women had caesarean sections, of which, 44.5% were decided by the doctors. However interviews with doctors and nurses of township hospitals interviewed revealed that 80% pregnant women chose the type of delivery themselves. In the township hospitals, the postpartum visits were seldom carried out. Only 2.5 % of women received more than 2 postpartum visits. In some hospitals, no postpartum visits were done. Carrying out postpartum visits was hampered by a number of factors including: lack of personnel and limited funds in the township hospitals, not knowing where women stayed following delivery and transport problems.The study revealed the following findings about health education: 46.5% of women did not know about breastfeeding; 39.5% of women did not know about eating certain foods to prevent birth defects; and 33.9% of women did not know about avoiding contact with pesticides during pregnancy. Most administrators, doctors and nurses in township hospitals who were interviewed (36/42) thought that the maternal health care VCDs and DVDs were the most effective mode of health education for farmers. The second most effect way was giving leaflets. One advantage for village family planning workers to provide health education was that they could do during their talks with pregnant women.This study showed the following key findings on the quality of maternal health care services. Women evaluated their satisfaction with medical treatment and attitudes of staff during prenatal examination as average (74.5%) and not bad (53.8%). Satisfaction with medical treatment and attitudes of staff during hospital delivery was graded as average (61.1%) and good (45.5%). 81.8% women were satisfied with the health care services provided by village doctors. In recent years, the accessibility of maternal health care services in township hospitals and village clinics has improved through measures such as greater government awareness, increased allocation of funds, more training of staff, increased education and changes in management. However there are still many obstacles in providing maternal health care services. Funds allocated to maternal health are inadequate. In township hospitals the funding for maternal health care services is mainly income generated from clinical work. Central and common township hospitals do not receive equal funding. In township hospitals and village clinics skilled maternal health care personnel are lacking. The education level of most doctors was technical secondary school, and less than 20% had qualification from junior college. Opportunities for further training were few. The doctors mastered limited maternal health care knowledge because they were pluralists of maternal health care work. Obstetric doctors did not want to become maternal health care workers as they"valued clinical work but looked down on health care". In rural areas, women were not aware of the importance of health care, existing health education was ineffective, and the means of health education was not popular. So the health education in rural areas should be strengthened. The maternal health care network was not complete. At the county and township levels the maternal health care services existed, but at the village level, these services did not exist.Conclusions Health education should focus on rural pregnant women with low education level and poor economic status. It is necessary to study and establish effective health education programmes and materials. In rural areas there have been some achievements made by the maternal health care services. However there are some problems which hinder the use and effectiveness of the services. We should develop new approaches to maternal care which take into consideration local conditions, and explore new ways so that township hospitals work with village clinics to provide maternal care services.