“One Foot in This World and One in the Next”: Barriers to Care for Rural Pregnant Women in Morocco

Abstract

Maternal health is an key item on the international agenda. Half of the world’s population can become pregnant; healthy pregnancies and healthy mothers are important not just to the wellbeing of women involved, but to the health of the child she is carrying, the health of her family, and the health of her community. Yet, out of all the Millennium Development Goals, MDG 5, to “reduce the maternal mortality ratio by three-­quarters” is the farthest from success. What can be done to meet this goal, if not by 2015, then in the post-­2015 global health agenda? Recent research suggests that the maternal care studies analyzing data at the national level are masking significant subpopulation differentials in outcomes. For instance, many middle‐income countries show general improvement in maternal care indicators, but upon closer analysis, rural, ‘hard to reach’ regions within the country lag far behind. There is a need for sub-­national analysis on barriers to maternal care, in order to achieve international goals but also to ensure equity. Morocco was chosen as a case study, because it is a middle-­income country with a large differential in maternal health between urban and rural milieus. It was hypothesized that rural women are not ignorant of the medical risks of pregnancy (due in part to successful Information, Education, and Communication campaigns organized by the Moroccan Ministry of Health); instead, more complicated barriers to care such as perceived quality of care and indirect costs inform a rural woman’s decision to utilize or not utilize antenatal care or skilled birth attendance. Methods were designed to address gaps in knowledge in the health barriers literature. A series of semi-­structured interviews were carried out with Moroccan practitioners and policy-­makers on barriers to care for rural women. Next, a logistic regression analysis was performed on 1992 and 2003­‐2004 Moroccan Demographic and Health Surveys datasets to identify determinants of care at the national level. Finally, a household survey based on the Health Belief Model was conducted in three field sites in the Atlas Mountains, and a logistic regression analysis performed. Main findings include: (1) A preponderance of ‘scare tactics’ that may be preventing women from seeking maternal care. The household survey regression showed that women who perceived themselves to be at high risk during pregnancy were less likely to seek care across a range of outcome measures; at the same time, well-­meaning practitioners often encouraged women to seek care by using frightening stories or exaggerating the risks faced in pregnancy. (2) The impact of the ‘perceived benefit’ construct and its relation to human resource scarcity. Lower ‘perceived benefit’ reported by women meant that they were much less likely to seek antenatal care; simultaneously, women, practitioners, policy-­makers and NGO staff reported a severe human resource shortage as the main factor hampering quality of care, especially in rural areas. (3) The impact of the ‘call to action’ construct and sources of health information. Practitioners overvalued the impact of the media upon women’s health behavior relative to what women reported themselves; yet both groups highly valued interpersonal communication. More research is needed to tease out the relationship between ‘scare tactics and maternal care-­seeking behavior, and between ‘perceived benefit’ and utilization of maternal care services.