67
Journal of Public Health and Development Vol. 13 No. 3 September-December 2015
ORIGINAL ARTICLE
Factors associated with post-natal care utilization among mothers in MaldivesSheeza Ibrahim1, Sariyamon Tiraphat2 and Seoah Hong2
1 M.P.H.M., ASEAN institute for health development, Mahidol University, Thailand2 Ph.D., ASEAN institute for health development, Mahidol University, Thailand
Corresponding author: Sariyamon Tiraphat Email: [email protected] Received: 4 December 2015 Revised: 3 February 2016 Accepted 10 February 2016Available online: February 2016
Abstract
IbrahimS,TiraphatS andHongS.A.Factors associatedwithPost-natalCareUtilization amongmothers inMaldivesJPubHealthDev.2015; 13(3):67-80
Post Natal Care (PNC) is an important service formother and newborn during the vulnerable period. Properpostnatalfollowupwouldhelptopreventmanymaternalandfetaldeaths.Itcanidentifythedangersignsoflifethreateningformothers and babies.According toWHO, globally PNCutilization is quite low, especially in developing countries.InMaldives,which is a unique archipelago of 1192 islands, the information about the prevalence of PNC and factorsassociatedwithPNChas been limited.This cross sectional studywas conducted to determine the prevalenceof postnatalcareutilization and factors associatedwithPNCamongmothers inMaldives islands. This researchwas a community based cross-sectional studyundertaken in three different communitieswith primary,secondaryand tertiaryhospitals inMaldives.Thedatawerecollectedfromasampleof253mothersdrawnfromthestudypopulationusingconvenientsampling techniqueduringMay3rd to25thMay2015.Self-administeredquestionnaire,basedon the factors fromAndersen’s health and utilizationmodel including predisposing, enabling, and need factors, also theDonabedianmodel of healthcare quality,was given to collect the data.Our outcomevariable focused on postnatal careutilizationthatcategorizedaswhethertheycompletepostnatalvisitwithin6weeksafterchildbirthornot.Fordataanalysis,Chi-square test andmultiple logistic regressionwere applied to evaluate factors associatedwithPNC. The study revealed that the prevalence of PNC utilizationwas 34%. The results ofmultiple logistic regressionindicatedthatcostoftransportation,healthinsurancescheme,andmentalhealthproblemwerethesignificantpredictorsforPNCutilization.MotherswhoperceivedthatcostoftransportationisexpensivehadmorechanceofgettingPNCutilization1.98 times (95%C.I:1.05 –3.76) compared to those perceived that the cost is low.Motherwho thought that the nationalhealth insurance scheme is very good hadmore chance of PNCutilizationwith 2.9 times (95%C.I: 1.21-7.03).Motherexperiencedmental health problem increasedmore chanceof completingPNCwith 2.0 times (95%C.I.: 1.07-4.05). Thestudyindicatedthattheprevalenceofpostnatalcareutilizationwasverylow.Therefore,strengtheningtheprovisionofhealth insurance scheme isvery important toenhance theaccessibility forhealthcare service.Formotherswithmentalhealth problem, individual counseling is recommended.Regarding cost of transportation, the establishment of affordablepublic transportationwouldbe a supportive factor for better utilization of health services.
Keywords: postnatal careutilization, primaryhospital, secondaryhospital, tertiary hospital,Maldives
68
วารสารสาธารณสุขและการพัฒนา ปีที่ 13 ฉบับที่ 3 กันยายน-ธันวาคม 2558
ปัจจัยที่มีควำมสัมพันธ์กับกำรรับบริกำรที่คลินิกหลังคลอด ในหมู่เกำะ มัลดีฟส์ชีซ่า อิบราฮิม1 ศริยามน ติรพัฒน์2 และโซอะ หงส์2
1 M.P.H.M., ASEAN institute for health development, Mahidol University, Thailand2 Ph.D., ASEAN institute for health development, Mahidol University, Thailand
บทคัดย่อ
ชีซ่าอิบราฮิม ศริยามนติรพัฒน์ และโซอะหงส์ปัจจัยที่มีความสัมพันธ์กับการรับบริการที่คลินิกหลังคลอด ในหมู่เกาะมัลดีฟส์
ว.สาธารณสุขและการพัฒนา.2558;13(3):67-80
การรับบริการที่คลินิกหลังคลอดเป็นสิ่งที่ส�าคัญอย่างยิ่งส�าหรับมารดาและทารกแรกเกิด การรับการบริการหลังคลอดที่เหมาะสมจะช่วยป้องกันการเสียชีวิตของทารกและมารดา โดยการตรวจหลังคลอดจะสามารถระบุสัญญาณอันตรายที่เกิดขึ้นกับมารดาและทารกแรกเกิดซึ่งจะช่วยป้องกันการเสียชีวิตของทารกและมารดาได้อย่างมีนัยส�าคัญองค์การอนามัยโลกระบุว่าการรับบริการที่คลินิกหลังคลอดของประชากรทั่วโลกมีจ�านวนค่อนข้างต�่าโดยเฉพาะอย่างยิ่งประชากรในประเทศก�าลังพัฒนาส�าหรับประเทศมัลดีฟส์ข้อมูลเกี่ยวกับความชุกของการรับบริการที่คลินิกหลังคลอดและปัจจัยที่เกี่ยวข้องกับการรับบริการที่คลินิกหลงัคลอดยงัคงจ�ากดัการศกึษาครัง้นี้มวีตัถปุระสงค์เพือ่ศกึษาความชกุของการรบับรกิารทีค่ลนิกิหลงัคลอดและปัจจยัทีเ่กีย่วข้องกับการรับบริการที่คลินิกหลังคลอดของมารดา ในหมู่เกาะมัลดีฟส์ การศึกษานี้เป็นการเก็บข้อมูลแบบภาคตัดขวางโดยเก็บข้อมูลจากโรงพยาบาลระดับปฐมภูมิทุติยภูมิและตติยภูมิในประเทศมัลดีฟส์การสุ่มตัวอย่างแบบตามความสะดวกมีจ�านวนกลุ่มตัวอย่างทั้งหมด 253คนด�าเนินการระหว่าง 3-25พฤษภาคม2015การเกบ็ข้อมลูโดยใช้แบบสอบถามซึง่ใช้ทฤษฎขีองAndersen’shealthandutilizationmodelซึง่ประกอบด้วยตวัแปรpredisposing,enabling, และ need ร่วมกับ theDonabedianmodel of healthcare qualityมีตัวแปรผลคือภายในช่วง 6สัปดาห์หลังจากการคลอดบุตรมารดามารับบริการที่คลินิกหลังคลอดครบ3ครั้งหรือไม่ วิเคราะห์ข้อมูลโดยใช้การทดสอบไคสแควร์ และการวิเคราะห์ถดถอยโลจิสติกพหุคูณ การศึกษาพบว่าความชุกของการรับบริการที่คลินิกหลังคลอดคิดเป็นร้อยละ34 ผลการวิเคราะห์ถดถอยโลจิสติกพหุคูณพบว่าปัจจัยที่มีผลต่อการรับบริการที่คลินิกหลังคลอดประกอบด้วยค่าใช้จ่ายในการเดินทางเพื่อไปรับบริการ โครงการประกันสขุภาพและมารดาทีป่ระสบปัญหาสขุภาพจติโดยพบว่ามารดาทีต่ระหนกัว่าค่าใช้จ่ายในการเดนิทางมรีาคาสงูกว่ามโีอกาสทีไ่ปรบับริการจากคลินิกหลังคลอดสูงกว่า 1.98 เท่า (95%CI : 1.05-3.76 )มารดาที่ตระหนักว่าโครงการประกันสุขภาพแห่งชาติเป็นสิ่งที่มีประโยชน์มีแนวโน้มที่จะรับบริการจากคลินิกหลังคลอดสูงกว่า2.9เท่า(95%CI:1.21-7.03)ปัญหาสุขภาพจิตของมารดาหลังคลอดสามารถเพิ่มโอกาสที่มารดาจะใช้บริการจากคลินิกหลังคลอด2.0 เท่า (95%CI : 1.07-4.05) ผลการศกึษาแสดงให้เหน็ว่าความชกุของการรบับรกิารทีค่ลนิกิหลงัคลอดอยูใ่นระดบัต�า่ดงันัน้การปรบัปรงุโครงการประกนัสุขภาพเพื่อเพิ่มการเข้าถึงการให้บริการด้านการดูแลสุขภาพเป็นสิ่งส�าคัญส�าหรับมารดาหลังคลอดที่มีปัญหาสุขภาพจิตการให้ค�าปรึกษาส่วนบุคคลเป็นสิ่งที่ควรค�านึงถึง ในประเด็นเรื่องการเดินทาง เนื่องจากมัลดีฟส์เป็นประเทศที่ล้อมรอบด้วยหมู่เกาะจ�านวนมากค่าใช้จ่ายในการเดินทางจะเป็นปัจจัยส�าคัญในการเข้าถึงการบริการด้านสุขภาพดังนั้นการพัฒนาระบบขนส่งมวลชนสาธารณะที่เหมาะสมจะสามารถส่งเสริมการเข้าถึงการบริการด้านสุขภาพของประชากร
ค�าส�าคัญ: การรับบริการที่คลินิกหลังคลอด โรงพยาบาลระดับปฐมภูมิ โรงพยาบาลระดับทุติยภูมิ โรงพยาบาลระดับตติยภูมิ หมู่เกาะมัลดีฟส์
69
Journal of Public Health and Development Vol. 13 No. 3 September-December 2015
Introduction Among 130million newborn babies, fourmil-
lions are dyingwithin the first fourweeks of life,
withonethirdofallneonataldeathsoccurredin the
firstweek.1Although99%ofneonataldeathsarise
in low andmiddle-income countries, little progress
in reducing such deaths in the past 10-15 years of
thesecountrieswasmade.Withthisreason,focusing
on newborn care to reduce new born death in
developing country is very challenging.
Postnatal care is a primary step to savemother
and newborns life.2 Postnatal care provides all
essential routine care for newbones, and extra care
forbabieswith special conditions suchas lowbirth
weightorprematurebabies.Postnatalcareisthetime
to identify thedangersignsandsymptomsforearly
referrals and clinicalmanagement. In this regard,
postnatalcareutilizationisareassuringprotectionto
decreasematernal and neonatalmortality and other
neonatalcomplication. Inmanycountries,Antenatal
Care(ANC)coverage isveryhigh,whereasPostna-
talCareCoverage (PNC) is lesser3.WHOdefined4,5
postnatalperiodas thefirst sixweeksafterdelivery
composed of three visit. First visitwill be on the
3rddaybetween48–72hoursofbaby’slife,second
visitwill between7- 14days and the last visitwill
on the sixthweeks of delivery5. Proper followup
canpreventthenewbornandmotherfromdeathsand
other infectious disease.
Maldives is a very small country composed of
341,256 total population6with 173,172male and
168,084 female.Maldives has a unique archipelago
of 1192 islands; only 194 islands are inhabited7.
Because islands are being clustered in the Indian
Ocean,Maldives government initiatesmaternal and
child health care at each level. The government
classifiedthehospitalasthirteenatollhospital(primary
level),sixregionalhospital(secondarylevel),and188
healthcentersatsubdistrictlevel.Additionally,there
isonegovernmenthospital andoneprivatehospital
in the capital island ofMaldives (MaleCity)with
tertiary care facilities.
InMaldives,maternalmortality rate is 13 per
1000 live births.Womenwhohad 4 ormoreANC
visitswas 85%.Amongmotherswho delivered in
the health facility, 46%had receivedpostnatal care
within4hours,and21%ofmothersreceivedpostna-
talcareafter2daysofdelivery8. Researchstudyin
Maldivesabout thefactorsassociatedwithpostnatal
care utilization are limited. Factors associatedwith
postnatalcareutilizationamongthemothersarestill
questionableandneedtoexplore.Therefore,thisstudy
aims to determine the prevalence of postnatal care
and examine the factors associatedwith postnatal
care utilization amongmothers living inMaldives
islands.
Methods Thisstudywasacommunitybasedcross-sectional
research conducted amongmothers living in three
differentlevelofhospitalintheislandsofMaldives.
We chose to collect data toward southern part of
Maldives because the population are the original
Maldivianpeople.Aftercalculationsamplesizefrom
67%of estimated population of PNCutilization in
Maldives thatwas stated inMaldives demographic
health survey 2009, our study took account of 253
mothers from the southern part of the country. For
morereadilyaccessibletoresearcher,aconvenience
samplingbyaskingmotherswhocametoreceivethe
70
วารสารสาธารณสุขและการพัฒนา ปีที่ 13 ฉบับที่ 3 กันยายน-ธันวาคม 2558
growthmonitoring and vaccination from the target
clinicswereselectedduringMay3rdto25thMay2015.
Primaryhospital,Gn.Fuvahmulak;secondaryhospital,
Addu atoll; and tertiary hospital, capitalMalewere
includedinthestudy.Thestudyareaswereselected
basedonthetransportroutforthecosteffectiveness
of the study.
Datawereobtained frommotherswith6month
to two-year-old childwho came to register growth
monitoring service from the particular hospital
duringtheworkinghours.Astructuredquestionnaire
wasgiventotherespondentsfortakinghometofill.
Respondentswere given 2-4 days’ time in order to
completethequestionnaire.BasedontheAnderson’s
behavioralmodel of health care utilization together
with Donabedian’s model of quality care, the
predictorsinthisstudyincludedpredisposingfactors,
enablingfactors,needfactors,andperceivedquality
ofcare factors.Under thepredisposing factors; age,
education, occupation, type of family, knowledge,
and distance to hospital and cost of transportwere
included. Enabling factors include the birth place,
numberofchildren,hospitalhours,incomeandhealth
insurance.Asneed factors, after birth complication,
breastfeeding difficulty, sickness of baby, health
education, perceivedmental health problem such
as depression and anxiety duringPNCperiod, and
lifethreateningexperienceafterbirthwereincluded.
Perceived quality of care consists of counselling,
effectivenessofdoctorstreatment,andopinionabout
the first postnatal care quality. Themain outcome
variable focused on postnatal care utilization that
categorizedaswhethertheycomplete3postnatalvisit
within 6weeks after child birth or not.
For the reliability, a pilot studywas conducted
among 30motherswith 6month to two-year-old
child living in one part of the capital named “Hul-
humale”.This isanartificially reclaimed island that
take20minutesbyengineDhoni(seavessel) to the
capitalMale and later declared as a part of capital
city.TheresultwasmeasuredusingCronbachalpha
test;gettingCronbachcoefficient0.616. This study
was approvedby the experts committee atMahidol
UniversitytogetherwithNationalResearchCommittee
(NRC) atMinistry ofHealth,Maldives.
Data were analyzed by SPSS version 21.
Descriptive statisticswere applied to describe the
basic features of the data.Univariate analysiswere
usedtofindtheassociationbetweentheindependent
variable and dependent variable. Finallymultiple
logistic regressionwere used to predict the factors
associatedwith thePNCutilization.
Results As shown in table 1, themajority (83.4%) of
the subjectwere less than30years of age,whereas
respondentsabove30yearswere16.6%.Withregards
of education, over2/3 (79.4%)of the subjectswere
belowthelevelofcollege,while20.6%ofrespondents
reported as college and above.Over 2/3 (70%) of
spouseeducationwashigherthansecondaryeducation,
while30%of the respondents spousehadeducation
less than primary level.More than half (55.3%) of
therespondentswerelivinginasinglefamily,while
44.7%of themwere living in an extended family.
In termsofoccupation,majority (73.1%)of the
motherswereunemployed.Amongthespouse,71.9%
wereworkingasgovernmentofficers,professionaland
others. 28.1%of themwereworking in the tourism
71
Journal of Public Health and Development Vol. 13 No. 3 September-December 2015
industryanddoingtheirownbusiness.Withregards
ofknowledge,86.6%ofrespondentsknowthereason
why they need to do followup for PNC.Similarly
81%ofthesubjectwereawareofthefollowupdate
forPNC.Nearlyhalf(48.2%)oftherespondentslive
farfromhospital.Majority(66.8%)oftherespondent
stated that the transport cost is not expensive.
Table 1 Distributionof respondents bypredisposing factors
Predisposing Factors n= 253 Frequency Percentage
Age 30yrs or less than 211 83.4
Above30yrs 42 16.6
(Median=30years;QD=4;Min=17;Max=49)
Mother’s education Lower than college 201 79.4
College and above 52 20.6
Husband's education Less thanprimary 76 30
Higher than secondary 177 70
Type of family Extended family 113 44.7
Single family 140 55.3
Mom occupation No job 185 73.1
In Job 68 26.9
Husbands occupation Business& tourism 71 28.1
Others, government officers
&professional
182 71.9
Know the Importance of PNC Yes 219 86.6
No 34 13.4
Know PNC timing Yes 205 81
No 48 19
House is far from hospital Yes 122 48.2
No 131 51.8
Transportation Expensive 84 33.2
Not expensive 169 66.8
72
วารสารสาธารณสุขและการพัฒนา ปีที่ 13 ฉบับที่ 3 กันยายน-ธันวาคม 2558
AsTable2,nearlyhalf(49.4%)oftherespondents
agreed that the health insurance schemewas good.
In termsof family income,overhalf (54.5%)of the
respondents, their familyget income less thanMRF
10,000permonth.26.9%oftherespondents’family
had incomebetweenMRF10,000 to 15,000,while
18.6%of respondents’ family getmore thanMRF
15,000permonthrespectively.Amongtherespond-
ents,71.9%ofthemwerehavingonetotwochildren,
while 28.1%were having3 ormore children.Over
half (51.4%)of the respondents had delivered their
lastchildattertiarylevelhospital,whereas48.6%of
themhad delivered in secondary and primary level
hospital.Regardinghospitalhours,90.1%agreedthat
the present hours of hospitalwas convenient.
Overhalf(67.2%)oftherespondentsreceivehealth
educationforfollowup.Withregardsofcomplication
during pregnancy, 81% ofmothers reported as no
complication.Motherswhohad experiencedbreast-
feedingdifficultieswere20.9%.Nearlyhalf(41.5%)
oftherespondents’babyhadfallsickduringthefirst
6monthsoftheirage.Intermsofmentalhealthsuch
asdepressionandanxiety,28.1%ofrespondentshad
gone through depression after delivery. 75.8% of
respondentshadreceivedcounsellingforPNC.With
regardsofqualityandeffectivenessofdoctors treat-
ment,overhalf (75.9%)ofrespondentswereagreed
it is effective. 44.3%of respondents stated that the
quality offirst neonatal careweregood (table 2).
73
Journal of Public Health and Development Vol. 13 No. 3 September-December 2015
Table 2 Distributionof respondents by enabling, need andperceivedquality of care factors
Factors n= 253 Frequency Percentage
Opinion for Health Insurance scheme
Family income/month
Number of children
Place of last child birth
Hospital opening hours
Health education from nurse
Complication in pregnancy
Life threatening experience
Breast feeding difficulty
Baby had sickness
Had depression
Counselling for PNC
Dr’s treatment is effective
Quality of first neonatal care
VerygoodGoodNotGoodMRF10,000-15,000MRF>15,000MRF<10,0002or less3ormorePrimary& secondaryhospitalTertiaryhospitalNot convenientConvenientYesNoYesNoYesNoYesNoYesNoYesNoYesNoAgreeDisagreeVerygoodGoodNotGood
401258813868471827112313025228170834820515240532001051487118219261192619611245
15.849.434.854.526.918.671.928.148.651.49.990.167.232.819815.194.920.979.141.558.528.171.975.924.175.924.137.944.317.8
Table3explained theassociationbetweenPNC
utilizationandpredisposingfactors.Theresultrevealed
that there is a statistically significant association
withPNCutilizationandinformationaboutthePNC
followup date (P= 0.036).Motherswho know the
informationaboutthefollow-updatewere2.2times
morelikelytoutilizethePNCservice.Amongother
predisposing factors,we found that age, education
occupation,typeoffamily,distancetohospitalandthe
costoftransportdoesn’tshowstatisticallysignificant
withPNCutilization.
74
วารสารสาธารณสุขและการพัฒนา ปีที่ 13 ฉบับที่ 3 กันยายน-ธันวาคม 2558
Table 3 Associationbetweenpredisposing factors andutilization ofPNC
Predisposing Factors
Utilization of PNC
n Complete% Incomplete%Crude OR (95% CI)
P-value
Age>30<31Mothers educationLower than collegeCollege and aboveHusbands educationLess thanprimaryHigher than secondaryFamily typeExtendedFamilySingle familyMothers Occupational statusNo JobIn JobHusbands OccupationBusiness& tourismOthers (Government officer, professionals)Know the importance of PNCYesNoKnow the PNC follow up dateYesNoHouse is far from the hospitalYesNoOpinion about the cost of transportExpensiveModerately good
21142
20152
76177
113140
18568
71182
21934
20548
122131
84169
33.635.7
33.834.6
34.233.9
36.332.1
34.632.4
29.635.7
35.623.5
37.120.8
33.634.4
40.530.8
66.464.3
66.265.4
65.866.1
63.767.9
65.467.6
70.464.3
64.476.5
62.979.2
66.465.6
59.569.2
11.10(0.55-2.19)
11.04(0.55-1.97)
1.01(0.58-1.79)1
1.20(0.71-2.03)1
1.11(0.61-1.99)1
11.32(0.73-2.39)
1.79(0.78-4.16)1
2.23(1.06-4.75)1
11.03(0.61-1.74)
1.53(0.89-2.64)1
.796
0.915
0.962
0.490
0.739
0.355
0.171
0.036
0.901
0.126
75
Journal of Public Health and Development Vol. 13 No. 3 September-December 2015
Table4explained theassociationbetweenPNC
utilizationwith enabling factors, need factors and
perceived quality factors. The result indicated that
thereisastatisticallysignificantassociationbetween
PNC utilizationwith family income (P= 0.026).
Motherswho have family incomebetween 10,000-
15,000MRFare1.98timesmore likely tousePNC
service comparing tomotherswith family income
morethanwhohavefamilyincomelessthan10,000
MRF.However, number of children, place of last
childbirth,hospitalhours,healtheducation,complica-
tionduringpregnancy and after birth, breastfeeding
difficulties,babiesandmothers’health,andqualityof
firstneonatalcaredoesn’tshowstatisticallysignificant
associationwithPNCutilization.
Table 4 Associationbetween enabling, need, andperceivedquality factors andutilization ofPNC.
Factors
Utilization of PNC
n Complete% Incomplete%Crude OR (95% CI)
P-value
Opinion for Health Insurance schemeVeryGoodGoodGoodFamily Income/monthMRF10,000-15,000MRF>15,000MRF<10,000Place of Last child birthPrimary& secondaryTertiaryExperienced mental health problemYesNo
4012588
6847138
123130
71182
47.532.829.5
45.629.829.7
30.137.7
42.330.8
52.567.270.5
54.470.270.3
69.962.3
57.769.2
2.16 (0.99-4.67)1.16 (0.65-2.10)1
1.98 (1.09-3.62)1.00 (0.49-2.07)1
11.41 (.83-2.37)
1.65 (0.93-2.90)1
0.0510.615
0.0260.992
0.202
0.085
Table 5 shows the result ofmultiple logistic
regressions,controlledforotherfactorsofpredisposing,
enabling, need and quality of care. Significant pre-
dictorsforPNCutilizationincludeopinionaboutthe
costoftransport,healthinsurancescheme,andexpe-
riencedmentalhealthproblem.Motherwhoperceived
that cost of transportationwas expensive hasmore
chance of gettingPNCutilization 1.98 times (95%
C.I:1.050–3.755)comparedto thoseperceivedthat
the costwas low.Mother’s opinion for the national
health insurance schemewith very good hasmore
chanceofPNCutilization2.9times(95%C.I:1.21-
7.03).Experiencedmental health problem increases
thechanceofcompletingPNCwith2.0 times (95%
C.I.: 1.07-4.05)more.
76
วารสารสาธารณสุขและการพัฒนา ปีที่ 13 ฉบับที่ 3 กันยายน-ธันวาคม 2558
Table 5 Multiple logistic regression for factors associatedwithPNCutilization
Variables Utilization of PNC
Adj. OR 95% C.I P-value
Opinion for transport cost
Opinion for health insurance scheme
Family income
per month
Place of last child birth
Experience mental health problem
Expensive
Not expensive
Very. good
Good
Not good
MRF10,000-15,000
MRF>15,000
MRF<10,000
Primary & secondary
hospital
Tertiaryhospital
Yes
No
1.99
1
2.92
1.20
1
1.82
0.93
1
1
1.18
2.09
1
1.05–3.76
1.21– 7.03
0.61-2.38
0.88-3.75
0.39-2.24
0.60-2.32
1.07-4.05
0.035
0.017
0.106
0.640
0.030
Table6indicatedtheproportionofPNCutilization
and significant predictors by three different level
hospital.Theresultsindicatedthatthehighestpercent-
ageofPNCutilizationwasfoundinsecondarylevel
hospital, and the lowest in primary level hospital.
Regarding opinion for transportation cost, although
mothersreportedthetransportationwasnotexpensive,
theywere less likely to complete PNCutilization.
However,mothersinthesecondaryandtertiarylevel
hospitalsweremorelikelytocompletePNCutilization
thanmothers inprimary levelhospital, even though
the transportation is expensive. In terms of health
insurance,mothersintertiaryandsecondaryhospital
whoreportedthehealthinsurancewasverygoodwill
bemorelikelytocompletePNCutilization.Regards
tomental health problem,mothers experienced in
mentalproblemwillbe less likely tocompletePNC
service exceptmothers in secondary level hospital.
77
Journal of Public Health and Development Vol. 13 No. 3 September-December 2015
Table 6 ProportionofPNCutilization and significant predictors by three different level of hospitals
Factors Primary Secondary Tertiary
Complete Incomplete Complete Incomplete Complete Incomplete
PNCutilization
Opinion for Transport cost
Expensive
Inexpensive
Opinion for Health Insurance
Scheme
VeryGood
Good
NotGood
Experienced mental health problem
Yes
No
27.4
27.3
27.5
20.0
36.4
20.0
45.5
24.2
72.6
72.7
72.5
80.0
63.6
80.0
54.5
75.8
40.7
44.7
38.3
58.8
27.8
46.4
52.4
36.7
59.3
55.3
61.7
41.2
72.2
53.6
47.6
63.3
33.3
46.4
28.2
53.8
33.9
23.3
35.9
31.7
66.7
53.6
71.8
46.2
66.1
76.7
64.1
68.3
Discussion Post-natalcare(PNC)hasbeenadvocatedasthe
bestway to preventmaternal and newborn deaths.
However, PNCutilization inmany countries is still
very low.This study aims to determine the factors
associatedwith PNCutilization amongmothers in
Maldives islands.We found that cost of transporta-
tion, health insurance scheme, experiencedmental
health problemwere significantly associatedwith
PNC utilization.Maldives has established country
healthinsuranceschemetowardstheachievementof
universalhealthcoverage5toprovidetheaccessibility
tohealth service.Health insurance schemeprovides
financial assurance to the public. It’s a challenge in
manycountriestoimprovepeople’shealth,especially
for the poor. Therefore, better health insurance
schemewouldhighly impactutilizationofpostnatal
careservices.Thisstudyindicatedthatifpeoplehave
positivethinkingabouthealthinsurancescheme,they
aremore likely to havePNCutilization (OR=2.92,
95%C.I.:1.21-7.03).
Likeour study, a study in Indonesia6 compared
the utilization rate ofmaternal health care between
the people registered under the health coverage
schemeandnon-registeredpeople.Theresultshows
thattheserviceutilizationwassignificantlyimproved
(OR=1.84, 95%C.I.:1.18-2.89) among the people
registered under the health coverage scheme. In
ordertoimprovehealthservicesaccessofpopulation,
many countries has established health care financ-
78
วารสารสาธารณสุขและการพัฒนา ปีที่ 13 ฉบับที่ 3 กันยายน-ธันวาคม 2558
ing strategies. Sub-SaharaAfrica countries are the
countries that established community based health
insurance scheme to bring good impacts for health
careespeciallyformaternalhealth.Previousresearch
fromWestAfrica7alsoindicatedthatmembershipin
communitybasedhealthinsuranceschemepositively
usematernal health services.
MentalhealthproblemoverPNCperiodisanother
problem among postnatalmothers.Actually, it is
the most common psychiatric condition among
childbearingagewomenspeciallyduringthepost-natal
period8-12.Inthisstudy,28.1%ofrespondentmothers
experiencedmentalhealthproblemoverPNCperiod.
Our study indicated thatmotherswho experienced
mental health problem over PNC periodwere 2.0
timesmorelikelytoutilizetheservice.Theprevalence
ofmotherswho experiencedmental health problem
overPNCperiod,especiallypostpartumdepressionin
developedcountriesisapproximately1310-15%,while
the prevalence in low andmiddle income countries
about 40%.The resultsmaybe influencedwith the
characteristics of the study population. Regarding
theutilizationofhealthservice,somepreviousstudy
disclosedthatmotherswithdepressivesymptomshave
morefrequentcontactwithhealthcareprofessionals14-17
A study to investigate the influence of depressive
symptomsonutilizationofhealthservices18revealed
thatdepressivesymptomsarehighlyassociatedwith
health service utilizationwith over 50%of utilizers
havingfirstmonth postpartumdepression.
Additionally, our study supported that cost of
transportation significantly associatedwithpostnatal
care utilization. Respondent who reported that
transport costwas expensivewere 1.9 times (95%
C.I.:1.05-3.76)morelikelytoutilizethePNCservice.
Thisresultmayduetothelivingstandardthatvaryby
income.OurresultsindicatedthatutilizationofPNC
was higher amongmothers living in the secondary
and the tertiary level of health facility, andmost of
therespondentsindicatedthetransportationcostwas
expensivewerefromthebothlevelhospitalsthatare
thecityandurbanareas.Itispossiblethatthemothers
fromthesecondaryandthetertiarylevelhospitalshave
touse transportation inorder to travel tohavePNC
services even the transportation is expensive.Tran-
sportation impactshealth through theaccessibility19,
therefore facilitation transport among patients is a
goodpolicytoincreasehealthcareutilization.Astudy
to find the barriers and facilitator related to use of
postnatalcareservice20 supported that transportation
wasastrongpersonalbarriertoimpedetheutilization
ofPNC service.
Recommendation Our study indicated that the prevalence of
postnatal care utilizationwas very small. Cost of
transportation, health insurance scheme, andmental
health problemwere the factors effecting the PNC
utilization.Therefore,strengtheningtheprovisionof
health insurance scheme is very important strategy
to enhance the accessibility for health care service.
Formotherswith depressive symptoms, individual
counselling should be recommended.Additionally,
morefrequentandclosecontactwithmotherswould
behelpful to improvemotherandchildhealth.This
couldbemorepossiblebypromotinghomevisiting
programs by healthworkers.Another point is cost
of transportation. BecauseMaldives is a country
clustered intomany islands, transport costswould
beveryinfluential.Forthisreason,establishmentof
79
Journal of Public Health and Development Vol. 13 No. 3 September-December 2015
affordablepublictransportationwouldbeasupportive
factor for increasing health services utilization.
Additionally, trainingcommunityvolunteers regard-
ingpostnatal homevisiting to reduce transportation
barrierwill be a goodoption.
References 1. Lawn JE,CousensS,Zupan J,TeamLNSS. 4
million neonatal deaths:when?Where?Why?
TheLancet.2005;365(9462):891-900.
2. NationalBureauofStatisticsMoFTM,Rep. of
Maldives. Preliminary Results - Revised. 04
March2015.
3. UNFPADoN. ICPDBeyond 2014 -Maldives
OperationalReview.2004.
4. Ministry ofHealth, gender section.Maldives
HealthProfile2014.March2014.
5. Moreno-SerraR,SmithPC.Doesprogresstowards
universal health coverage improve population
health?TheLancet.2012;380(9845):917-23.
6. KesumaZM,ChongsuvivatwongV.Utilizationof
theLocalGovernmentHealthInsuranceScheme
(JKA) forMaternal Health ServicesAmong
WomenLivinginUnderdevelopedAreasofAceh
Province,Indonesia.Asia-Pacificjournalofpublic
health /Asia-PacificAcademicConsortium for
PublicHealth.2015;27(3):348-59.
7. SmithKV,SulzbachS.Community-basedhealth
insuranceandaccesstomaternalhealthservices:
evidencefromthreeWestAfricancountries.So-
cialscience&medicine.2008;66(12):2460-73.
8. ParsonsCE,YoungKS,RochatTJ,Kringelbach
ML,SteinA.Postnataldepressionanditseffects
onchilddevelopment:areviewofevidencefrom
low-andmiddle-incomecountries.Britishmedical
bulletin.2012;101(1):57.
9. BlackMM,BaquiAH, ZamanK, ElArifeen
S, BlackRE.Maternal depressive symptoms
and infant growth in rural Bangladesh. The
Americanjournalofclinicalnutrition.2009Mar
1;89(3):951S-7S.
10. FisherJ,MelloMC,PatelV,RahmanA,TranT,
HoltonS,HolmesW.Prevalenceanddeterminants
ofcommonperinatalmentaldisordersinwomen
in low-and lower-middle-income countries: a
systematicreview.BulletinoftheWorldHealth
Organization.2012Feb;90(2):139-49.
11. StewartRC,BunnJ,VokhiwaM,UmarE,Kauye
F,FitzgeraldM,TomensonB,RahmanA,Creed
F. Commonmental disorder and associated
factors amongstwomenwith young infants in
ruralMalawi.Socialpsychiatryandpsychiatric
epidemiology.2010May1;45(5):551-9.
12. SawyerA,AyersS,SmithH.Pre-andpostnatal
psychologicalwellbeinginAfrica:asystematic
review.Journalofaffectivedisorders.2010Jun
30;123(1):17-29.
13. LobatoG,BrunnerMA,DiasMA,MoraesCL,
ReichenheimME.Higher rates of postpartum
depression amongwomen lacking care after
childbirth: clinical and epidemiological impor-
tance ofmissed postnatal visits. Archives of
women'smentalhealth.2012;15(2):145-6.
14. WebsterJ,PritchardMA,LinnaneJW,Roberts
JA,HinsonJK,StarrenburgSE.Postnataldepres-
sion:Useofhealthservicesandsatisfactionwith
health-careproviders.Journalofqualityinclinical
practice.2001Dec1;21(4):144-8.
80
วารสารสาธารณสุขและการพัฒนา ปีที่ 13 ฉบับที่ 3 กันยายน-ธันวาคม 2558
15. BoycePM, JohnstoneSJ,HickeyAR,Morris-
YatesAD,HarrisMG,StrachanT.Functioning
andwell-beingat24weekspostpartumofwomen
withpostnataldepression.ArchivesofWomen's
MentalHealth.2000Dec1;3(3):91-7.
16. Dennis CL, Ross LE. The clinical utility of
maternal self-reported personal and familial
psychiatrichistoryinidentifyingwomenatriskfor
postpartumdepression.Actaobstetriciaetgyneco-
logicaScandinavica.2006Jan1;85(10):1179-85.
17. MandlKD,TronickEZ,BrennanTA,AlpertHR,
HomerCJ. Infant health care use andmaternal
depression.Archivesofpediatrics&adolescent
medicine.1999Aug1;153(8):808-13.
18. DennisCL. Influenceofdepressivesymptoma-
tologyonmaternalhealthserviceutilizationand
general health. Archives of women'smental
health.2004;7(3):183-91.
19. BonifaceS,ScantleburyR,WatkinsS,Mindell
J.Healthimplicationsoftransport:Evidenceof
effectsoftransportonsocialinteractions.Journal
ofTransport&Health.2015.
20. HeamanMI, SwordW, Elliott L, Moffatt
M,HelewaME,MorrisH, et al.Barriers and
facilitators related to use of prenatal care by
inner-citywomen: perceptions of health care
providers. BMC pregnancy and childbirth.
2015;15(1):2.