Exploring inequalities in access to and use of maternal health services in South Africa

Abstract

BackgroundSouth Africa’s maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country’s Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, “patient-oriented” barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services.MethodsA mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers.ResultsAccess to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care.ConclusionsTo move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these “patient-oriented” barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.

‘I am all alone’: factors influencing the provision of termination of pregnancy services in two South African provinces

“…However, maternal mortality in South Africa remains unacceptably high at an estimated 155 per 100,000 live births in 2013 [10]. Difficulties in access to safe TOP services add to HIV and obstetric causes of maternal mortality [11]. The factors that have influenced access to TOP services include: negative attitudes towards TOP services and the staff who provide TOP services; poor infrastructure; staff shortages and lack of support programmes for the few health care providers in existing TOP services [12,13].…”

Giving Birth in a Foreign Land: Exploring the Maternal Healthcare Experiences of Zimbabwean Migrant Women Living in Johannesburg, South Africa

“…Whilst South Africa lacks verifiable means of counting maternal deaths, estimates of overall maternal mortality (MMR) for 2007/2008 have ranged from 310 or more per 100,000 live births and most of these are caused by indirect causes (Burton 2013;Silal et al 2012). Although MMR dropped significantly to 197 per 100,000 births in 2011, primarily as a result of extensive provision of antiretroviral drugs (ARVs) to pregnant women (Dorrington et al 2014), this remains unacceptably high for a middle-income country such as South Africa.…”

“…The initiative of the first democratically elected government in South Africa was to remove user fees for all pregnant and lactating women and children under 6 years of age at public healthcare facilities (Silal et al 2012). Additionally, the South African national constitution section 27 ((2) and (3)) makes provision for universal access to healthcare regardless of nationality.…”

Barriers and Strategies to Prevent HIV/AIDS among Pacific Countries: A Systematic Review Study

“…Another reason would be that services provided in the urban hospitals vary from health services available in rural health centres due to hospitals being more advanced than rural health centres [31]. As further discussed by Silal et al, (2012) [32], in Africa, lack of transportation, long hours of travel and remote areas do not have good access to health services compared to urban centres. Cost of medications could be another possible factor, only allowing people with high economic status to have access to good health services [11].…”