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Women’s access and utilization of health care services from pre-natal period through parturition in the Monteverde Zone

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Material Information

Title:
Women’s access and utilization of health care services from pre-natal period through parturition in the Monteverde Zone
Translated Title:
Acceso al servicio de atención prenatal para las mujeres de la Zona de Monteverde hasta el momento del parto ( )
Physical Description:
Book
Language:
English
Creator:
D’Epiro, JoHanna
Publication Date:
Frequency:
normalized irregular

Subjects

Subjects / Keywords:
Childbirth--Costa Rica--Puntarenas--Monteverde Zone
Parturition--Costa Rica--Puntarenas--Monteverde Zone
Prenatal care--Costa Rica--Puntarenas--Monteverde Zone
Pregnant women--Costa Rica--Puntarenas--Monteverde Zone
Medical Care--Costa Rica--Puntarenas--Monteverde Zone
Community Health 2002
Health Care
Genre:
Books/Reports/Directories
Books/Reports/Directories

Notes

Summary:
Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community.
Summary:
Retrospectivo, estudio exploratorio del acceso y uso de los servicios de atenció de la salud para mujeres embarazadas en la comunidad de Monteverde.
Abstract:
The purpose of this analysis is to conduct a retrospective, exploratory study of access and utilization of health care services from the prenatal period through parturition in the Monteverde Community. Initial interviews indicated that although universal health care is available to all women in the Monteverde zone through the CAJA, many women were not satisfied with the services they received and still others chose private physicians for care. A quantitative survey tool was utilized to assess the satisfaction of women with clinic services. In-depth semi-structured qualitative interviews were also conducted. The research group focused on women of childbearing age. Women were questioned about clinic utilization, satisfaction with services, and suggestions for improvements. The results of our study show that, overall, 67% of women are satisfied with women's health services at the clinic. Women also reported their largest concern with the clinic is the quality of care and the experience of the doctors. Of those surveyed, 47% either disagreed or strongly disagreed that they were satisfied with the doctors at the clinic. The study also highlighted the need for additional services such as a birthing center, a laboratory, specialty services, and H1V/A1DS testing. While limitations to the current study exist, the findings warrant further investigation into the access and utilization of services at the Clínica Monteverde.
Language:
EN

Record Information

Source Institution:
University of South Florida Library
Holding Location:
University of South Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
usfldc doi - M38-00015
usfldc handle - m38.15
System ID:
SFS0000209:00001


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Retrospective, exploratory study of access and utilization of health care services for pregnant women in the Monteverde Community.
Retrospectivo, estudio exploratorio del acceso y uso de los servicios de atenci de la salud para mujeres embarazadas en la comunidad de Monteverde.
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The purpose of this analysis is to conduct a retrospective, exploratory study of access and utilization of health care services from the prenatal period through parturition in the Monteverde Community. Initial interviews indicated that although universal health care is available to all women in the Monteverde zone through the CAJA, many women were not satisfied with the services they received and still others chose private physicians for care. A quantitative survey tool was utilized to assess the satisfaction of women with clinic services. In-depth semi-structured qualitative interviews were also conducted. The research group focused on women of childbearing age. Women were questioned about clinic utilization, satisfaction with services, and suggestions for improvements. The results of our study show that, overall, 67% of women are satisfied with women's health services at the clinic. Women also reported their largest concern with the clinic is the quality of care and the experience of the doctors. Of those surveyed, 47% either disagreed or strongly disagreed that they were satisfied with the doctors at the clinic. The study also highlighted the need for additional services such as a birthing center, a laboratory, specialty services, and H1V/A1DS testing. While limitations to the current study exist, the findings warrant further investigation into the access and utilization of services at the Clnica Monteverde.
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Parturition--Costa Rica--Puntarenas--Monteverde Zone
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Wilke, Jaime
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Utilization of Health Care Services from Pre natal Period through Parturition in the Monteverde Zone Aaron Lampkin Loralee Trocio Jaime Wilke Globalization and Health Monteverde Institute June 23 to August 4th, 2002

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Abstract The purpose of this analysis is to conduct a retrospective, exploratory study of access and utilization of health care services from the prenatal period through parturition in the Monteverde Community. Initial interviews indicated that although universal health care is available to all women in the Monteverde zone through the CAJA, many women were not satisfied with the services they received and still others chose private physicians for care. A quantitative survey tool was utilize d to assess the satisfaction of women with clinic services. In depth semi structured qualitative interviews were also conducted. The research group focused on women of childbearing age. Women were questioned about clinic utilization, satisfaction with serv ices, and suggestions for improvements. The results of our study show that, overall, 67% of women are satisfied with women's health services at the clinic. Women also reported their largest concern with the clinic is the quality of care and the experience of the doctors. Of those surveyed, 47% either disagreed or strongly disagreed that they were satisfied with the doctors at the clinic. The study also highlighted the need for additional services such as a birthing center, a laboratory, specialty services, and H1V/A1DS testing. While limitations to the current study exist, the findings warrant further investigation into the access and utilization of services at the Cl nica Monteverde. Personal Biography of the Team The research team consisted of four members from various research backgrounds. JoHanna D'Epiro is currently physician's assistant with a strong interest in birth outcomes. Aaron Lampkin is an undergraduate at the State University of New York at Buffalo majoring in Physical Anthropology. Loralee Trocio is finishing a graduate program at the George Washington University, School of Public Health and Health Services in Washington, D.C. Her focus lies within international health program development. Jaime Wilke is a Doctoral Stu dent from the University Of South Florida College Of Public Health with a concentration in Community and Family Health and Humanitarian Aid. Each member of the team had a prior interest in aspects related to access and utilization of health services, women's health and reproductive health. It felt appropriate for the members to address the topic at hand, especially considering prior efforts made by former Monteverde students to assess adolescent pregnancy and the community's request to learn more about utilization of clinic services. Introduction One of the highest priorities in Public Health has traditionally been the health of pregnant women and their children. For a healthy society, it is necessary to ensure the best possible start to life. Infant mortality, an indicator of health in a society, is greatly affected by maternal health and by the care a woman receives from the prenatal period through parturition. This care is impacted by access to care, u tilization of services and the quality of services received. This study is the result of preliminary research that indicated dissatisfaction with services provided to expectant mothers by the Cl nica Monteverde. Preliminary research generated questions regarding the ability of the clinic to meet the needs of women from the prenatal period through parturition in the Monteverde Zone. The goal of this analysis is to conduct an exploratory study of access and utilization of health care services fro m the prenatal period through parturition in the Monteverde Zone. Historical and Social Context Traditionally, women all over the world tend to be the victims of less access to health care services,

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significantly more than men. Women are more apt to have l ess decision making power when it comes to their own health, typically a result of socioeconomic status, poor living conditions, and gender differences. Access to health care has a direct effect on all aspects of their lives, including the health of their children and family. The chances of decreased health statuses in children correlate to their mother/caretaker's access to health services (Schnbeider, 2000). It is imperative that health authorities, including the government, advocate f or more health care access for women, services that reach beyond women into the population at large. Costa Rica is the wealthiest country of Central America, with a population of over 4 million residents. The no army policy has resulted in more resources g oing towards social issues, including health care and education. In 1996, 9.8% of the GNP was spent on the health care system (Pan American Health Organization [PAHO], 2000), which explains an increase in health and education statistics over the past years. This proportion of the GNP surpasses many Central American countries. The countries dedication to health care is apparent in Costa Rica's health outcomes. The under 5 mortality rate is estimated at 13.9 per 100,000 in 1999 (PAHO, 2000 ). The maternal mortality rate of 1999 was 19.1 per 100,000 (PAHO, 2000). In 1993, 75% of women began prenatal check ups during the first trimester. (PAHO, 2000). In the same year, 97% of deliveries were in hospitals (PAHO, 2000). Although these rates are high, they do not necessarily reflect the quality of services surrounding prenatal care in Costa Rica. While the Costa Rica's health status stands well compared to its neighbors, 13.3 per 1,000 live births result in death, with a neonatal mortality rate of 8.5 per 1,000. (PAHO, 2000). Disorders originating in the prenatal period were the leading cause of death in children under one, with a rate of 6.5 per 1,000 (PAHO, 2000). There are issues of quality and equality in regards to the access of health care for women, especially during the prenatal period. According to the Central Intelligence Agency, 20.6% lived below the poverty line in 1999. Eighty percent of poor households are located in rural areas (PAHO, 1995). Universally, poor people in rural areas are the ones that tend to lack financial resources for quality health services and access to this care. Unfo rtunately, these pockets in the population are often overlooked and do not have enough political support to create access to health care. Costa Rica's CAJA Costarricense de Seguro Social ideally provides universal health care to all people within its borders. It has developed many health facilities all over the country, including health centers, 29 hospitals, and over 250 clinics. The facilities provide specialty care including gynecology, surgeries, dermatology and allergists (Guirre, 2002). All of these services are available to all of the Costa Rican population, but access is not evenly distributed, particularly in more remote areas. There is, however, continuing development t o reach more remote areas throughout the country. The Monteverde Zone, geographically, includes communities found about 15 km around Monteverde. It is estimated that over 4,000 people reside in the zone. This includes Santa Elena, Cerro Pl ano and Monteverde, which is within the province of Puntarenas. The Puntarenas Region has a population of approximately 7,000 people. The Cl nica Monteverde, located in Monteverde, is the only facility implemented by CAJA. Services provided include: genera l medicine, pharmacy, dentistry, pre and post natal care, child health care and social services (Monteverde Institute, 2002).

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Research Methods The study was a qualitative analysis of access and utilization of health care services from the prenatal period through parturition in the Monteverde community. The design of the study followed a case study approach, consisting of in depth interviewing. Th e decision to follow a case study design reflects the nature of the groups being studied and the desire to identify access, utilization, and satisfaction of women with health care services provided by the Cl nica de Monteverde. A quantitative survey tool w as also created to provide additional information regarding the satisfaction of women with services. Participants The target population for the study included women of childbearing ages within the Monteverde Zone. The sampling frame consisted of women who received care at the Clnica Monteverde during the prenatal period through parturition. Due to time constraints, convenience sampling was used to obtain the sample for the interview portion of this study. Spe cifically, each team member approached two women, known to have a child and receive care at the Clnica Monteverde. An interview was then arranged, and if necessary, the help of a translator. Convenience sampling was also used to reach women with the survey tool. The research team approached women at variou s sites in Santa Elena, Cerro Pl ano, and the Monteverde Institute area. Nine women participated in the in depth interview phase of the study and 21 women were selected t o participate in the survey phase of the study. Measures of Instrumentation Variables of interest were measured through semi structured in depth interviews and a survey (See Appendix la). For the survey phase, the questions were open ended in an effort to avoid influencing participant responses. The interviewer asked questions regarding the prenatal and postnatal care, as well as satisfaction with th at c are The interviews were designed to assess the overall utilization, access and satisfaction of care provided to women in the Monteverde community during pregnancy. The survey tool (See Appendix 1 b) utilized a Likert scale to measure satisfaction with service s provided by the Cln ica Montev erde. Data Collection Procedures Participants for the study were recruited using a convenience sampling of women within the Monteverde community. The researcher team recruited 9 women for in depth semi structured interviews and 21 women for the satisfaction survey. Each survey took approx imately 10 minutes to complete. Each interview was approximately one hour in length. Notes were taken and transcribed for analysis. Interviews were arranged at the convenience of the participant and where necessary, the availability of a translator. The re search team asked follow up questions to the initial prompts and used probing questions to elicit information related to the research topic. Demographic information on age, number of children, education, and job was also collected. The participant was info rmed that demographic information was needed for statistical purposes only and is useful in gaining an understanding of additional correlations that may exist between services and satisfaction. Analysis Analysis of Interviews Interviews were transcribed an d checked for accuracy. Analysis of transcribed interviews was conducted. Transcripts from each participant were analyzed and each response was segmented to allow

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for the extraction of themes and a comparison of participants. A comparison across interview texts was conducted to determine common themes. Context units were also used to compare the number of times certain themes occur across the set of interview texts. The interview texts were used to develop a codebook. An initial code list was developed and then open coding was used to identify more codes. Codes were applied to responses and the results analyzed. Common themes, beliefs, and values will be determined. Analysis of Satisfaction Survey Data collected through the satisfaction survey were tabulated and the results quantified. Bivariate statistics were used to determine levels of satisfaction of clinic care and services, frequency of usage, and hospitals of delivery. Findings Interviews In depth interviews were conducted with 9 women from the Monteverde zone. The interview tool was utilized to ensure consistency among interviews. Through the use of this tool, a number of common themes were discovered. It is to be emphasized that many part icipants expressed satisfaction with different aspects of the clinic However, this research project attempts to expose areas of improvement of women 's access and utilization of Cl nica Monteverde's health services from the prenatal period through parturition. Five main themes were consistently mentioned by all nine interview participants. The themes were: 1. Health Professional Services 2. Waiting Time 3. Access to Health Services 4. The Need for More Services 5. Prenatal and Postnatal Services Health Professional Services The majority of the women felt there were many issues involving physicians when it came to assessing their satisfaction with Cl nica Monteverde. Among those interviewed, there was a general consensus that they could never develop a rapport with a physician because there was a constant influx of new doctors at the clinic. It was reported that the physicians are "young and fresh out of medical school." Many of the women believed t hat because the doctors were young and new to the field, they did not have extensive experience to treat patients. The women sited incidences of inappropriate medications given to patients and serious misdiagnoses, which threatened the life not only of the mother but also the unborn baby. Participants noticed inconsistent quality of care in their experiences and the need for more doctors. Some women felt that if there were more doctors, they would not be overwhelmed with many patients and could afford to give more individual attention, hence enhance the quality of services. The following is a story told by one of the participants. Such traumatic stories were consistent throughout the interviews. The women interviewed felt that this story highlighted the in experience of the doctors at the clinic and the results of such inexperience.

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Sample testimony: A woman went to the doctor because she didn't feel the baby moving and she was worried. The doctor told her that the baby was sleeping. Even when she insisted t hat s omething was wrong, he told her that there was nothing to worry about and sent her home. Later, the baby was a stillborn. She knew something was wrong but was undermined by the doctor. The participants reported a general sense of satisfaction with the nurses at the clinic. The nurses were perceived to pay attention to the patients and were sympathetic to their needs. It was also mentioned that the women appreciate the house visits done by nurses for chil d immunizations and blood pressure measurements. Many of the participants cited that the nurses were a helpful and important part of their healthcare services and helped to enhance the quality health services. There was, however, mention of some dissatisfaction by interviewees with the staff at the clinic. They reported an image of inefficiency. Ho wever, it was cited by the ma jority of that participants that better health care services were provided if the patients knew someone at the clinic. It is important to note ,that this was mentioned as fact by both women who did know someone who worked at th e clinic, and therefore felt the received better care, as well as those who did not know someone at the clinic, and felt they witnessed unfair treatment Waiting t ime All of the interviewees made points related to the waiting time. It was emphasized by all of the participants that they had to wait, one way or another, for health services. They all felt that this wait time was far too long. Frustration, anger and lack of trust seem to result from the long waits that seem to be experienced by everyone. Factors that may play a role in the wait include inefficient staff, not enough doctors, or non convenient access to the health service desired. Sample testimony: One woman had a hard time getting time off of work to see a doctor. She made an appointment with the clinic, only to wait from 8am to 2pm. At 2pm she was finally told that the doctor could not see her and she would have to rearrange another time to come in. She was frustrated because not only did she lose a whole day's pay, she still was not able to see a doctor and had to come back again. She claimed that only in private clinics are appointments truly met on time, but you have to pay for this private service. This story highlights a problem faced by many women in the Monteverde community. The cl inic serves areas such as San L uis, which is currently cut off due to road closures. Patients from this area have to leave up to 2 hours befor e a scheduled appointment, only to wait. Women continually cited that appointment times are not adhered to and wait times usually take up the entire day. This makes attending regular appointments extremely difficult, especially for women who are working, r aising a family, and on limited income, and creates a barrier to accessing health care. Access to Health Services Women reported the hours of the clinic were inconvenient, especially in emergency situations. Women also cited that they had to pay for after hour services. As a result of this, the women interviewed claimed

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that many people wait until the next day for health care services, despite their dire need to see a doctor. The Cl nica Monteverde does not have birthing facilities. Therefore, all participants reported the birth of their children elsewhere. Most of these births o ccurred outside the Monteverde Z one. The women traveled to Puntarenas or San Jose, which involved a minimum of 2 hours commute, highlighting the need for more services, as well as a birthing unit/neonatal unit at the clinic to avoid the long distances traveled Need for Additional Services Many women felt there was a need for more doctors. Some women tended to think that if more physicians were available, waiting time would decrease, the quality of health care services would improve, and more attention could be spent on each patient. Comment s justified the lack of quality was due to the extreme patient load physicians endured each day. Women also reported a need for a laboratory in the clinic. Some women go to the clinic for yearly check ups, including a pap smear, which aren't conducted by gynecologists. Others, however, did not rely on the clinic for gy necological services, citing both the need for a laboratory and the nature of the exam. The women interviewed believed that a laboratory could produce results from tests in a timely manner. Currently, women have been known to wait 3 5 months for test results. There was also a perceived need for more specialists including an additional dentist and gynecologist. Women re ported that they depended on private clinics for tests and ultrasounds during their pregnancy. Most women travel to the hospital for childbirth via the Red Cross ambulance or they choose to stay with family in cities with hospitals, Puntarenas, San Ramon or San Jose. Some of the women interviewed had negative experiences with the Puntarenas hospital and would ideally prefer to go to a San Jose hospital. However, the official procedure in Monteverde is to go to the clinic, where an ambulance will be called to take the patient to Puntarenas. Prenatal & Postnatal Services It was also repeatedly cited that women are utiliz ing the prenatal and postnatal services offered by Cl nica Monteverde. The check ups include: nutrition education, abdomen measurements and exams, and encouragement of breast feeding. Two of the interviewees cited that there were no pelvic exams at clinic, possibly due to a lack of a gynecologist. Others emphatically stated that they only went to the clinic for noninvasive procedures but utilized private physicians for all invasive exams. Postnatal care was utilized for the following services: removal of stitches, after birth check ups, and immunizations for babies. Satisfaction Survey A survey was conducted to test the satisfaction of women, of child bearing age, with the services provided by Cl nica Monteverde. Twenty five women were contacted and asked about their experiences with the Clinic. Of those women, 21 filled the survey out to completion and the results were quantified. The mean age of women contacts was 32.4 years, with ages ranging between 21 and 53. The women had an average of 2.4 children, with ages ranging from one month to 31 years. Women w ere asked to record the birth weight of their youngest child. Of the women, 15 responded. The mean birth weight for youngest child in this group was 3153.2 grams, a healthy birth weight, consistent with the birthing standards of

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Costa Rica. Questions regarding clinic usage, frequency of use, and start of care were also asked. Of the women surveyed, 18 had prenatal care at the clinic, 3 did not (See Table 1). As mentioned before, prenatal care is essential to the health and wellbeing of a child. In the population surveyed all of the women sought some sort of prenatal care. Women were also questioned about the frequency of prenatal care and their start date. Thirteen of the women responded to the question, 4 w omen did not respond and 4 others had data that was not usable. Although variation existed in the frequency of care, the vast majority of women received care monthly. The majority of women also began care in the first trimester, 30% began care within the first month, 15% within the 2 nd month, and 38% in the third month. It is important to note that two women did not begin care until the 7 th and 8 lh month of pregnancy. These women were correlated with the lowest birth weights of their children (See Chart 3). For impr oved outcomes, it is imperative to start care early in the pregnancy. According to our survey, most women in the Monteverde Zone are aware of the need to start health care early in their pregnancy. This is comparable with the prenatal care reported by Costa Rica, a country in which 75% of women receive prenatal care. In the satisfaction survey, women also report utilizing postnatal care at the clinic. Of those surveyed, 81% reported having postnatal care at the clinic (See Chart 2). It is important, however, to note that when questioned about what they perceived to be postnatal services, the women responded that services included predominately services to their children, including vaccinations. The women were then asked to use a scale to rate services at the clinic. Responses included Strongly Agree, Agree, Disagree, Strongly Disagree, and not applicable. The women were asked about their level of satisfaction with the women's services at the Cl nica Monteverde Of the women surveyed, the majority 67% stated that they agreed or strongly agreed th at they were satisfied with services provided by the clinic (See Chart 4). Women were also asked about their satisfaction with services provided during their last pregnancy. Seventy six percent of the women that responded said that they were satisfied with the services, while 20% disagreed or strongly disagreed with the statement. There was also a 5% non response rate (See Chart 5). The research team feels that it is important to reach the 20% of the women that are not satisfied with prenatal services. Prenatal services are vital to the health and wellbeing of a child When asked about their satisfaction with services following pregnancy, 24% strongly agreed that they were satisfied with services, 52% agreed that they were satisfied. However, 24% disagreed that they were satisfied with services (See Chart 6). Based o n the results of our interviews and with written comments on the survey tool, the women were, overall, generally satisfied with the postnatal services at the clinic, but again, it is important to note that these postnatal services do not include traditional postnatal care. Women were asked to respond to their beliefs regarding preparation by the clinic for childbirth. Of the women that responded, 10% strongly agreed t hat the clinic prepared them for childbirth, 43% agreed that the clinic prepared them for childbirth, 24% disagreed, and there was a 10% non response rat e (See Chart 7). Many women provided comments and insight on this statement. Many felt that there was a need for additional services, including birthing classes, ultrasound facilities, and other means of preparation.

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Women were asked if they were satisfied with the doctors at the clinic. Fourteen percent strongly agreed that they were satisfied with the doctors and 38 % agreed. However, of those questioned, 33% disagreed and 14% strongly disagreed to being satisfied with the doctors at the clinic. Although a slight majority of women were satisfied with the doctors at the clinic, 47% of women were not satisfied with the doctors at the clinic (See Chart 8). It is important to note that the greatest levels of dissatisfaction related with services provided by the Cl nica Monteverde related to the services of the doctors. These findings were consistent with comments from the in depth interview. Throughout the study, women cited concerns with the experience of doctors, as well as the availability and quality of services. Women were then asked if they were satisfied with the support staff, including nurses, techs, etc. at the clinic. Of those that responded, 10% strongly agreed and 57% agreed that they were satisfied with the support staff. However, 24% disagreed and 5% strongly disagreed to being satisfied with the support staff at the clinic. There was a 5% non response rate (See Chart 9). This high level of disagreement regarding satisfaction with support staff was consistent with comments regarding the efficacy of support staff, as discussed in the interview section. The final portion of the survey asked the participants what they liked most about the clinic (See Table I). The most common responses included the building/accommodations, services provided, and attention, particularly as provided by the nurses. Participants were also asked what they liked least about the clinic (See Table 2). Common responses included the wai t time, poor services, and staff issues. Participants were asked what additional services the clinic could provide to better meet their needs (See Table 3). There were a host of responses, many of which related to more specially care. Responses also included the need for laboratory services, a birthing center, and HIV testing. There were also requests for more experienced doctors, better attention, a better referral service, and "Quality not quantity." When asked what other changes they would suggest, respondents cited better service from the staff, more specially services, more experienced doctors, 24 hour services, and the ability to perform exams daily. Discussion/ Interpretation of Findings Based on our research, we ha ve concluded that the Monteverde Clinic is not meeting the complete needs of the community. While many of the services provided by the clinic are utiliz ed by the community and are important in maintaining overall health, there are important services that are not being provided. In addition, there is concern over some of the services already in place, as well as issues with accessibility of the clinic for many residents of the community. This study focused on the quality and accessibility of services provided by the Cl nica Monteve rde from the prenatal period through parturition in the Monteverde z one. We found that t he majority of those surveyed received b oth prenatal and postnatal, 86% and 81% respectively. However, experiences differed by participant. Most women in the community received some type of prenatal care monthly but services such as ultrasounds were not accessible through the Cl nica Monteverde and only those who used private doctors, or went to the larger hospitals were able to receive this service. The majority of women responded favorably to services offered by the clinic during the prenatal phase through parturition. However, concerns were present and there was an apparent discrepancy between interviews and written comments and positive ratings of services. The highest level of disagreement was in regards to satisfaction with doctors at the clinic. Forty seven percent of women disagreed or

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strongly disagreed to being satisfied with the doctors at the clinic. This theme was supported by the in depth interviews. According to the women interviewed and surveyed, there are concerns over the experience of the doctors at the clinic and their ability to provide quality health care. This was a common concern among all interviewees and survey participants. There were also concerns over the amiability of the staff, their education, and the quality of service they provided. It is also important to note that although 76% of women reported that they were satisfied with postnatal services, these services were often associated with the care of the child as well as the mother in this community. Many also reported the use of a pri vate doctor instead of the clinic, for both birthing and pediatric care. The frequent or preferred use of private physicians when it can be afforded may indicate a lack of quality service available to those who use the public services. The lack of birthing facilities is also a major area of concern for women in the Monteverde zone. Although the study focused on women of childbearing age, the interviews and comments from the survey highlighted the need for more specialty services. A major criticism was the lack of specialty services provided. Some of the most common services the community would like to see include a radiology unit, pediatrician, a birthing unit, and ultrasounds services. Other services people would like to see include p odiatry, gynecology, HI V/AIDS testing, ophthalmology, and psychiatry services. Many of the services can be accessed b y the community, but it is often a timely process that includes travel to hospitals which are located hours away. Some people simply have trouble leaving for this amount of time or lack the funding and resources to make this trip possible. Members of the Monteverde zone expressed concern over some services provided by the clinic. All of the women interviewed discussed the long wait times at the clinic and the inefficiency of services. One of the most frequent complaints was the inadequacy of laboratory services. Women told stories of waiting months for labs to get results, or not getting results back at all. Often times, the child was born before the lab results were returned. The lack of adequate laboratory services also overlaps with emergency care. Without proper access to laboratory assessments, it is very difficult to handle emergency situations. These emergency laboratories are especially important in the western biome dical system, a system by which Costa Rica has developed their healthcare. Limitations While the research team made every effort to conduct a research project with sound design and implementation, a number of limitations existed. The greatest limitation faced was the time constraints placed on the teams. For a sound study, it is important to have a representative sample. However, based on time limitations, a convenience sample had to be utilized for this study. Therefore, we are unable to say that this survey is represe ntative of the entire Monteverde Community. Time limitations also played a role in the quantity of participants in the study. A total of 9 interviews and 21 surveys were conducted. A larger sample size is needed to ensure appropriate representation. Another limitation (need by the research team was the language barrier. None of the team members are fluent Spanish speakers. Therefore, a translator had to be present for most interviews. This leads to the possibility of losing valuable information in the translation and creates an additional barrier to already difficult questions. In other cases, the participant spoke E nglish. However, for all of the women, Spanish is not their first language and questioning was often difficult.

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Recommendations Ultimately, our study found that a large portion of the community is very concerned with the quality of health services they receive, and the problems of accessing maternal healthcare in the Monteverde community. In order to better assess these problems and to improve the overall satisfaction of the community, more work will need to be. This is only a short list of suggestions those future studies may be able undertake. A study including interviews w ith the clinic staff assessing their concerns and suggestions regarding future improvements in service and direction of the clinic. This would provide recognition of the limitations the clinic staff has, and also another voice towards the improvement of the clinic. We feel that having community members and medical practitioners working together will only help to improve the quality and satisfaction of care. More research information including survey and interview data is needed. In order to belter evaluate the problems with the clinic, and to prioritize the problems that need changing most, it is essential that more information be collected. Due to the small amount of data was collected and size of the area in which we collected it from, many concerns may have been missed. Therefore, it is vital to obtain more information, in order to decide what the major concerns of the entire community Obtain further informati on on the standards in prenatal/ postnatal care. We were unable to determine what the community felt were the "normal" practices surrounding prenatal/postnatal care. It is also important to examine the recommendations for care provi ded by the medi cal staff at the clinic. This will offer possible explanations regarding clinic utilization, and sat isfaction with care. A study comparing quality and sat isfaction provided by public and private doctors. This is extremely important in assessing the discrepancy in care between socio economic classes, and the ability of public healthcare to meet the needs of the community. Preliminary research indicates that those who can afford private healthcare do. It is important lo examine the reasons why. Further research on the birth outcomes of this community. Due to the absence of a birthing facility in the Monteverde community, the hospital in Puntarenas provides the closest service. It is important to assess how well the clinic in Santa Elena is handling emergency births, and if the three hour drive between these areas are having an effect on birth outcomes. References activities and structure. June 23, 2002. Pan American Health Organization [PAHO]. (2000). Summary from Health in the Americas: Health Situation Analysis and Trends Summary [electronic version]. Retrieved July 17, 2002 from http://www.paho.org/English/SHA/prflcor.htm PAHO. (1995). Country Health Profile: Costa Rica. Retrieved June 8, 1995 from http://165.158.1.110/english/sha/prflcor.html Schneider, M. (2000). Introduction to Public Health. Gaithersburg: Aspen Publishers.

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Appendix 1a. In depth Interview Tool 1. Please tell me a little bit about yourself? 2. Please tell me a little about your experiences with the clinic here in Monteverde. 3. Do you have yearly gynecological exams at the clinic? a. Why/why not? b. What are some barriers? 4. How many children do you have? 5. How did you prepare for child care? 6. When you were pregnant, did you visit the clinic during your pregnancy a. For prenatal care? b. How many times? c. When did you begin care? (What trimester) d. If not did you get care elsewhere? i. For prenatal care? ii. How many times? 7. Did you have an ultrasound? 8. Were there any complications with your pregnancy? 9. Where did you actually give birth to your child? a. Please tel l me a little about your experiences there? b. Why did you choose to go there? c. How was your treatment at the hospital different from the clinic? d. How long did you stay? e. Did you have natural child birth or a Cesarean section? 10. Did you receive any postnatal treat ment? If so where? a. Please tell me a little about your postnatal experience. 11. In general, how do you feel about the services provided by the clinic? a. What are some services that you like? Why? b. 12. If you could change anything about the clinic what would it be? 13. Do you have anything that you would like to add? Demographics: Name Age Number of children, sex and age Income Education Race/ethnicity Appendix 1b Satisfaction Survey Cuantos aos tiene? Hasta que grado estudio? Cuantos nios tiene?

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Cuales son las edades de sus nios? Peso al nacer del nio menor? Antes de que su nio menor naciera, usted fue a la clnica para recibir servicios? Que tan frecuente? En que mes empez a ir? Despus de que el bebe naci, recibio servicios en la clnica? Cuando estaba embarazada alguna vez tuvo que buscar asistencia mdica en otra parte? Donde tuvo su ltimo nio? Porque escogi ese sitio? Usted tiene carro? Usted tiene horno microondas? Marque una respuesta para cada una de las preguntas: Estoy satisfecha con los servicios para mujeres en la clnica. a. Muy de acuerdo b. De acuerdo c. En desacuerdo d. Muy en desacuerdo e. No aplica Estoy satisfecha con el cuidado que la clnica me dio durante mi ltimo embarazo. a. Muy de acuerdo b. De acuerdo c. En desacuerdo d. Muy en desacuerdo e. No aplica Estoy satisfecha con el cuidado que la clnica me dio despus de que mi bebe naci. a. Muy de acuerdo b. De acuerdo c. En desacuerdo d. Muy en desacuerdo e. No aplica Creo que la clnica pr epara bien a las mujeres para el parto. a. Muy de acuerdo b. De acuerdo c. En desacuerdo d. Muy en desacuerdo e. No aplica

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Estoy satisfecha con los mdicos de la clnica. a. Muy de acuerdo b. De acuerdo c. En desacuerdo d. Muy en desacuerdo e. No aplica Estoy satisfecha con el personal de apoyo (enfermeras, techs, etc) de la clnica. a. Muy de acuerdo b. De acuerdo c. En desacuerdo d. Muy en desacuerdo e. No aplica Que es lo que ms le gusta de la clnica? Que es lo que menos le gusta de la clnica? Que servicios adicionales podra ofrecer la clnica para servirle mejor? Que otros cambios sugerira? Comentarios adicionales. Appendix 3 Tables Table 1. What do you like most about the clinic? The building/accommodations 10 Dental services 3 Attention to people 1 Provision of care 1 Quality of nurses 1 Kind and respectful doctors 1 Doctors in charge of nights and weekends 1 Not having to pay for services 1 Table 2. What do you like least about the clinic? Wait time 4 Poor service in general 4 Poor emergency services 2 Staff 2 Cleaning women are in the dental exam room during exam 2 Attention given to people 1 Bureaucracy in providing services 1 Difficulty in making appointments (Dental) 1

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Table 3. What additional services could the clinic offer to serve you better? Laboratory Service 6 Radiology Service 3 Birthing Center 2 Better Attention 2 More dental services 2 More experienced doctors 2 More timely appointments 2 Pediatrician 2 Ultrasound service 2 Better referral service 1 Gynecologist 1 HIV/AIDS testing 1 More specialty care 1 Ophthalmologist 1 Psychiatrist (especially for children) 1 Podiatrist 1 Quality not Quantity 1 24 hour service 1