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Utilization of Health Care Services From The Pre Natal Period Through Parturition In The Monteverde Zone Phase II Aaron Lampkin Loralee Trocio Jaime Wilke Globalization and Health Monteverde Institute June 23 to August 4, 2002
Abstract II Following the initial exploratory study entitled Women's Access and Utilization of Health Care Services from Pre natal Period through Parturition in the Monteverde, Zone this phase of research focused on two areas which had been targeted for follow' up. Using semi structur ed interviews and reassessing th e original data, the topics of standard of care during pregnancy and birth histories were examined. This included a brief historical review of obstetric care and medical transportation from The Monteverde area. Three medical personnel and four additional women who had children within the last 12 years were interviewed for a total of 17 interviews. Many women (50%, n =36) chose to have their care with private providers. H owever, all the women in our study delivered their children in public hospitals provided by the CAJA. The results of the study showed that like their predecessors, women from Monteverde often choose to wait near the hospital before their delivery (57%) ra ther than risking having to make the difficult trip to the closest hospital during labor. The average wait ti me before delivery was 10.86 day s among seven women for whom this data was available. The choice of hospital was made for three primary reasons: proximity of the facility, family or friends nearby and because of the hospital's reputation. Births occur frequently in transit as the local ambulance service reported that one worker alone had 14 deliveries over 17 time. Des pite these hardships, the majority (88%) of reported birth weights in our study was healthy and the district of Puntarenas has an infant mortality rate consistent with the rest of Costa Rica. Biography of Researcher Jo Hanna Friend D'Epiro is a Masters of Public Health student at the School of Medicine and Public Health at the Ohio State University. She ha s also been a practicing Physician Assistant since 1981 and has an interest in Women's and Immigrant Health. Introduction Historical Precedent Since the advent of the community of Monteverde in 1951, women have had to overcome the geographical and economic barriers to receive prenatal care and delivery of their babies "down the mountain". In Monteverde, which is District 10 of the County (Canton) of Puntarenas in the Province of Puntarenas, during the first ten years, nineteen babies were born to Monteverde families. (Guindon, 2001) Six of these women opted to deliver in the hospital in San Jose which sometimes required a two week wait near the ho spital. Fifty years later, women still wait near the hospital for their time of delivery because the drive to the closest hospital is approximately two hours away. Statistical Background Infant mortality is a salient marker of national health. Among Central American countries, Costa Rica ranks first as having the best infant mortality rate. (March of Dimes, 1996) The infant mortality rate has dramatically declined in Costa Rica from 19.1/1,000 in 1980 to 10.21/1,000 in the year 2,000. (The same year the province of Puntarenas 11.76/1,000. Therefore, of the 8,1 59 births during 2,000 in Puntarenas approximately 83 babies died within the first year of life. (Ministe rio de Salud 2000) UNICEF reports that the rate of prenatal coverage in 1999 was 69.6%. According to the Anlisis de Sit uacin de Salud, 2001, from the CAJA, there were 63 births through the Clnica de Monteve rde during 2001. One infant death was recorded. In the same time period during 2,000 there were 50 births recorded and no deaths. In Costa Rica, deaths of infants were fairly evenly distributed. Approximately 29% at less than 24 hours, 22% less than one week, 17% less than one month and 30% from 1 month to 1 1 months. The fact that almost 1/3 of infant deaths occur within 24 hours of birth has very important implications for a community two hours from the close st hospital. From 1990 2,000, many more neonates (7366) died than newborn infants (4001). Infant deaths related to respiratory problems are highest in the country in Puntarenas (1.1/1,000) and Guanacaste at (1.3/1,000)
Distribution of Deaths of Children less than 1 Year by Place of Death Memoria Annual 2000 from the Costa Rica Health Ministry Place 2000 Total 704 (7.1%) Home 50 (2.4%) During transportation 17 (2.4%) Clinic 8 (1.1%) Public Hospital 625 (88.8%) Private Hospital 2 (0.3%) Unknown 2 (0.3%) Most (31.7%) These are national hospitals and it is probable that these hospitals provide tertiary care and therefore hospitalize some of the sickest children in the country. (Ministerio de Salud, 2000). Maternal mortality in Costa Rica has also declined dram atically in the last ten years from a risk of dying of 1 in 420 in 1990, to 1 in 820 in 1995. In com parison, in 1995, the risk of a mother's dying during child birth was 1:80 in Honduras and 1 in 3500 in the United States. (UNICE F, 1995 ) R esearch Methods The second phase of the study was both a qualitative and quantitative analysis of utilization of health care in the last trimester of pregnancy through delivery in the Monteve rde community. This particular topic was requested through community forums. The study used both a case study approach as well as quantitative data analysis from a survey tool used in the first part of the study. The Rapid Assessment Procedure (RAP) that heavily relies upon qualitative interviews was an appropriate methodology given th e time frame of the research. Key providers of care were interviewed and their information was compared to community perception of care during pregnancy. The information gathering among child bearing women was confined to those who had delivered a baby within the last 12 years and focused on the process of transition between outpatient care and delivery. Personal contacts limited to the narrow social circle of the students provided our convenience sample. This personal contact facilitated information gathering in a private subject area. Because the community is so small, confidentiality was difficult to maintain especially among prominent community members and women with uni que birth histories. The consistent results obtained both among interview participants and surveys demonstrated the effectiveness of the RAP method in conducting research in exploratory studies. Women love to talk about the significant experience of childb irth and the warmth of the participants in this exchange was gratifying. The patience and openness of the health care professionals was also refreshing. Participants The target population for this phase of the study was confined to women from the Monteverde area who had given birth within the last 12 years and key providers of health care within the area. Because of time constraints, convenience sampling was used to obtain candidates for the interviews. Health care professionals were contacted as a result of their recommendations as important providers of care from other community members. Interviews were arranged, and language assistance was provided as needed with the use of a translator. I n the initial phase of the study, the research team approached w omen at various sites in Santa Elena, Cerro Pl ano, and the Monteve rde Institute area. Fourteen women participated in the in depth interviews and 22 women were selected to participate in the survey phase of the study. Measures of Instrumentation Variables of interest were measured through semi structured in depth interviews and a focused survey in the initial phase of the study. The data from the open ended interviews and the surveys was re ex amined and selected information about the choice of private versus clinic care, birth weights reflecting outcomes, choice of hospital and the reasons for this choice was elicited. In depth interviews with health care p roviders regarding their past and current practice procedures and personal experiences were conducted. Information from further open ended interviews was gathered. The thrust
of this information gathering was to elicit information on the standards of care and practices of women du ring Data Collection Procedures Participants for the study were recruited using a convenience sampling of women within the Monteverde community. The researcher team recruited 14 women and 3 health care professionals for in depth semi structured interviews and 22 women for the survey. Each survey took approximately 10 minutes to complete. Interviews varied in time from 15 minutes to 1 hours. Notes were taken and trans cribed for analysis. Interviews were arranged at the conve nience of the participant and w ere necessary, the availability of a translator. The research 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, ownership of a car (reflecting economic status), and job was collected. Each participant was informed 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 Interviews were transcribed and checked for accuracy. Comparison for common themes was performed and quantitative data such as demographic information, birth weights, site of delivery, and site of care during pregnancy was collected from the interviews. This same data was culled from the interviews. The results were tabulated and quantified. Findings Past Care As alluded to earlier in the paper, from the 1950s onward, obstetric care was rendered to the community by a series of lay health workers and midwives. (Guindon, 2001) One account in the "Monteverde Jubilee Family Album", tells of members of the community sending for manuals to assist them in this endeavor. However, during the 1970s, this situation stabilized when an obstetric nurse who had trained in Puerto Rico largely provided prenatal and general care to the community. The demand for care was so great that the day after she arrived, people were waiting for her. She quickly earned the reputation as providing sound care for a variety of problems and many women desired her services at delivery. This nurse encour aged everyone t o go to the hospital, but safely delivered many who were unable or unwilling to go to the hospital, both in their homes and in her home. Her thinking was that the women had never had bad experiences to understand they have to be in a hospital." The only woman she considered g ood candidates for home delivery were those who had previously delivered a healthy baby in an uncomplicated delivery. However, because the women were so anxious for this nurse to deliver their children, they would often wait until they were in labor to call her or show up at her home. Supplies were purchased through local stores and a pharmacy in San Jose. However, the nurse had to clean her own surgical instruments and heated a sheet in her oven to take to the homes. Disposable plastic syringes replaced the glass syringes that occasionally broke on horseback. Conditions f or deliveries were often crude. Individuals within the community often had no electricity, telephones or running water. As earlier in the century, horseback was often the only available mode of transportation to reach many homes even at this late date. This hard work was provided free of charge for approximately nine years. Occasionally familie s were so appreciative of the care they would give her goods in barter. One particularly funny gift was that of a pig t hat would only eat cooked food and later jumped a fence that had been specifically prepared for it. With the help of an appreciative fam ily, this special individual was instrumental in starting the first clinic here in Monteverde. Although the specific number of deliveries was not recorded, she reported universally good birth outcomes among her deliveries. Present Care In order to address important issues raised by women in the initial study, an administrator from the Santa E lena clinic was interviewed. Specifically, women voiced concern about the inexperience of the attending physicians at the clinic, the turn around times for laboratory work, the fact that women do not have pelvic exams
during pregnancy that no ultrasounds are ordered during pregnancy and the lack of specialty physicians. In response, the administrator explained CAJA protocol largely dictates care th roughout the country in normal pregnancies. That is, the CAJA dictates a ''standard of care" which guides the health workers in planning which tests will be ordered, how often the patient is seen and what to do if there is a problem. In a normal pregnancy the CAJA protocol may include confirmation of the pregnancy by a E BAIS worker in the house. The EBAIS worker would also take a medical history and encourage the person to enter care within the first trimester. The first visit at the clinic would include a complete panel of blood work. According to the administrator, the turn around time for lab work is about one week and is followed during regular visits to make sure it is complete. She stated that laboratory results took about one week and was unaware of any problem with this. If the history and abdominal exam is normal, the general doctor follows the patients throughout their pregnancy. Pelvic exams are not performed routinely in an otherwise normal pregnancy. Ultrasounds are not ordered routinely but if the patient takes her own initiative and obtains a study, they use the informat ion. Likewise, amniocenteses are done only for high risk pregnancies. Sta. Elena clinic has an OB/Gyn twice monthly. This person follows the high risk pregnancies. Women are given their record and are reliable about bringing it to the hospital. Birth plans are discussed throughout the pregnancy and the administrator agreed that the choice of hospital is often made according to whether family or friends live nearby. Patients are encouraged to wait near the hospital at about 37 weeks. h school. Medical school is six years followed by a two year in hospital supervised internship. During their clinical rotations, they spend 6 months on gynecology and are required to do 50 vaginal deliveries and assist with 25 cesarean s. Then individuals are required to serve two years in the CAJA. This represents the time period they would serve at the Monteverde clinic. After this time the doctor may complete a residency program. The clinic is equipped for emergency deliveries. There have been four deliveries at the clinic within the last three years. Three of the four had not planned to deliver their babies at the clinic. One woman planned to deliver at home and could not be persuaded to deliver at the hospital. Personnel at the clinic felt the clinic birth would be preferable to the women's house. Obviously t he birthing facility is not like the hospital in that it has no capacity to perform an operative delivery, no nursery or neonatal unit and limited emergency capabilities. This makes the need for excellent transportation to the hospital imperative. Medical Transportation For this community of about 4,000 with 50,000 visitors, there are two ambulance services. One service is run out of the clinic. The Red Cross has two ambulances and is an important provider of emergency transportation for the community. They are called frequently when the clinic is closed and they work closely with the clinic. The Red Cross service works largely by volunteer help. Their driver, a level one E MT, like most rural ambulance drivers in Costa Rica, usually drives alone. "I don't like it, but it is routine in Costa Rica." No advanced life support is available through the Red Cross service. The only circumstance for allowing for more people in the ambulance is when the patient is unstable. In that circumstance, the driver may help a doctor or nurse who attends the patient. The bumpy two hour ride to hospital, th e area's closest, Monseor Sanabria in Puntarenas is the only hospital alternative for transportation from the Red Cross ambulance service. The Red Cross is an important service for the community when the clinic is closed during the evenings and on weekends. Over seventeen years of experience in driving the ambulance, this worker has delivered 14 babies. The babies this worker has delivered have included three high risk pregnancies. The worker commented that Costa Rican women are "tranquila" about childbirth and often wait to call at the onset of labor. In contrast, women from Nicaragua are more afraid, are more likely to have had no prenatal care and do not call out during labor. The worker reported they get frequent calls for pregnancy related problems and transportation to the hospital during labor. One woman in our interviews reported delivering her baby in the ambulance. "(She ) went to the clinic urned to the clinic when she still wasn't feeling well. They put her in the ambulance to Puntare nas where she delivered the baby There wa s a doctor there have any supplies or anything Just a blanket to put the baby in. The doctor was totally unprep ared for
the birth of the child. Luckily there were no t any complications and the baby was born fine. It could have turned out badly Another woman recalled calling the ambulance service when she was in labor and none of the ambulances were available. She had to arrange her own transportation to the hospital. Experiences of Women Among the 36 women who responded to our interviews and surveys, the average age was 31.7 with a range of 21 to 51. The youngest child's age ranged from 1 month to 11 years. Sev eral women reported an overall good experience during pregnancy ("excelente", "a nice period a happy surprise"). Eighteen of the twenty women who answered the question entered prenatal care in the first trimester. A few problems were reported, namely nausea and vomiting, asthma and bleeding during pregnancy. Site of Care During Pregnancy Total reported 35 Monteve rde Clinic 29 Private 18 Both 12 Many women that were interviewed (8 of 14) had an ultrasound during pregnancy. They had to take their own initiative to get the ultrasound by going outside the community to have the study and pay for it out of pocket. One woman said "the ultrasound was expensive, she had a hard time getting the money together, but she thinks the expense was reasonable." Another interviewee said that it cost about $10,000 colones. This sometimes would involv e a two hour bus ride for the appointments. All of the women in our study delivered their care in CAJA hospitals. Although Monse or Sanabria is the designated hospital for the district, many women used other sites for their care such as San Ramon, hospitals in San Jose and Heredia. The women reported that they chose their hospitals for three main reasons: the proximity of the facility, family or friends lives nearby and because the hospital is part of the CAJA system. Women often waited near the hospital from 2270 to 4540 grams with an average of 3197.44 gram s. Only three of the 25 recorded birth weights fell below the 2500 gram cut point for low birth weights. Interestingly, two of the three of these low birth weight babies were born to women who entered care late in pregnancy. Discussion The provision of health care for women during pregnancy in the Monteverde community has progressed. The community itself, with the help of the Costa Rican government, has brought an Obstetrician/Gynecologist twice monthly to the CAJA clinic. The clinic committee recently conducted a survey about some of the concerns mentioned in the study and plans to report this to the medi cal staff. Statistics reflect this progress in that the infant mortality rate has declined almost 50% within the past ten years within the country and this district's rate is commensurate with that data. However, as evidenced by the fact that many women seek private care outside the clinic, there is still room for improvement. Infant mortality rates do not tell the whole story. It is remarkable that in the crudest conditions for delivery, historical accounts recall these births with fondness and a woman that provided this care within the community 30 years ago is still held in high esteem. Why were the women "satisfied" in what would seem to b e extremely harsh conditions? Although the Monteve rde clinic uses the CAJA standard of care, the women's expectations are not being met. The specific clinical tasks that they receive from outside sources namely pelvic exams, ultrasounds and rapid turnaround times for laboratory work are part of the unmet expectations. As mentioned in the goals from the first phase of the study, learning more from the community about what women expect during care would probably help the clinic meet these expectations. Explaining what is going to happen during the course of their prenatal care might also enhance the experience of the women. Education during pregnancy has been shown to be one of the most important components of
care. The issue of physician experience is a difficult one. If the Obstetrician/Gynecologist could rotate through the care of normal patients in a few visits, and the clinic physicians could co manage the high risk patients, this could answer this dilemma. It would also create a greater atmosphere of accountability and learning for the more junior physicians. It is important for the pregnant women to feel they have expert advice at their disposal all the time. Medical transportation is critical for the community of Monteverde. Considering the swell of the population related to tourist trade, it is important to assess whether the current service is adequate f or the needs of the community. No advance life support is currently available during the long ride to the closest hospital. This is especially important to mother and baby given the large number (~ 30%) who die within 24 hours of delivery and who die during transportation (2.4%). Although the practice of driving the patient alone to the hospital is common in rural Costa Rica, common sense would dictate that this could be improved upon. Because of the nature of funding sources for the Red Cross, the community will again need to support this effort in order to see change implemented. (Int'l Fed. Red Cross, 2002) The closest hospital for delivery remains a bumpy two hour ride away. According to last year's Globalization, Nutrition and Health report, a birthing center at the new clinic is not likely because it would require a pediatrician and an obstetrician/gynecologist. The CAJA bases its assessment for this possibility on need and population. The conventional wisdom and that advised by the clinic, is that women should wait near the hospital prior to delivery. This inconvenient practice is probably the best alternative for expectant mothers. However, in the event of an emergent problem during pregnancy, medical transportation again remains critical. Recommendations Obstetric Care The Monteverde clinic could consider having the Obstetrician/Gynecologist who already comes to the clinic see all patients at least twice during their pregnancy and having the clinic physicians co manage high risk patients Suggest that clinic staff explain the plan of care at the onset of prenatal care. This would include information about what lab tests will be ordered, discussing pelvic exams, explaining that ultrasounds are not done routinely in healthy pregnancies. Continue to consistently educate women about the importance of arriving at the hospital before childbirth. This could include showing women some of the statistics mentioned in this report. Clear birth plans including choice of transportation to the hospital and which hospital the woman plans to deliver should be included in this discussion. Emergency Care that Red Cross offer courses here in Monteverde to upgrade the skills of the existing personnel serving with the ambulance services. Encourage the community to financially support the Red Cross service here in Monteverde to provide every available option to stabilize patients in the field. studies to examine the capacity for emergency care in the community for both pregnancy and other health related problems. Other Investigate the possibility of unmet health care needs of Nicaraguans in the area. clinic expand hours by offering extended weekday hours, evening and/or a Saturday session at the clinic
References Anlisis de Situacin de Salud 2001, EBA1S No 9, Monteve rde, rea de Salud 3, Regin Pacifico Central, CAJA Costarriccnse dc Seguro Social Anlisis de Situacin de S alud 2000, EBALS No 9, Monteve rde, rea de Salud 3, Regin Pacifico Centra l, CAJA Costarrice nse de Seguro Social Guindon L. Moss M, Rockwell, et al, 2001. "Monteverde Jubilee Family Album" Monteve rde, Puntarenas. Costa Rica: Asociacin de Amigos de Monteve rde International Federation of Red Cross and Red Crescent Societies 2002. Where We Work, Costa Rica, [electronic version] Retrieved July 2002 from htt p://www.ifrc.org/where/country/cn6.asp?countryid=51 March of Dimes. International Co mparisons of Infant Mortality Rates, 7996 [electronic version]. Retrieved July 2002 from http://www.modimes.org/HealthLibrary344_1369.htmo Minist erio de Salud, Costa Rica. Me moria An ual 2000 Comisin Nacional para la Prevencin de la Mor t alidad Infantil [electronic versin ] Retrieved July 2002 from http:// www.n et salud.sa. cr / Munoz M. Scrimshaw N, 1995. "The Nutrition and Health Transition of Democratic Costa Rica", Boston, MA USA: International Foundation for Developing Countries UNICEF Antenatal Care Coverage Maternal Mortality, 1995 [electronic version ] .Retrieved July 2002 from http://wvvw.child info.org/eddb/antenatal/database/ht m
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El acceso de la mujer y la utilizacin de los servicios de salud desde el perodo prenatal a travs del parto en la zona de Monteverde fase II.
Womens access and utilization of health care services from the pre-natal period through parturition in the Monteverde Zone phase II.
Follow up study of access and utilization of health care services for pregnant women in the Monteverde Community.
Estudio de seguimiento de acceso y utilizacin de los servicios de salud para mujeres embarazadas en la comunidad de Monteverde.
Following the initial exploratory study entitled Women's Access and Utilization of Health Care Services from Pre-natal Period through Parturition in the Monteverde, Zone, this phase of research focused on two areas which had been targeted for follow' up. Using semi-structured interviews and reassessing the original data, the topics of standard of care during pregnancy and birth histories were examined. This included a brief historical review of obstetric care and medical transportation from The Monteverde area. Three medical personnel and four additional women who had children within the last 12 years were interviewed for a total of 17 interviews. Many women (50%, n =36) chose to have their care with private providers. However, all the women in our study delivered their children in public hospitals provided by the CAJA. The results of the study showed that like their predecessors, women from Monteverde often choose to wait near the hospital before their delivery (57%) rather than risking having to make the difficult trip to the closest hospital during labor. The average wait time before delivery was 10.86 days among seven women for whom this data was available. The choice of hospital was made for three primary reasons: proximity of the facility, family or friends nearby and because of the hospital's reputation. Births occur frequently in transit as the local ambulance service reported that one worker alone had 14 deliveries over 17 years time. Despite these hardships, the majority (88%) of reported birth weights in our study was healthy and the district of Puntarenas has an infant mortality rate consistent with the rest of Costa Rica.
Parturition--Costa Rica--Puntarenas--Monteverde Zone
Childbirth--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
Scanned by Monteverde Institute
t Community Health