May 2004

The major causes of maternal mortality in Guatemala are preventable: hemorrhage (53%), infection (14%), and hypertension (12%). In the western part of the country, between 69% and 80% of women deliver at home, where complications can lead to death if the family and community are not prepared. To address these issues, Guatemalan Ministry of Health and Public Assistance (MOH) and the Maternal and Neonatal Health Program (MNH) implemented by JHPIEGO (an affiliate of Johns Hopkins University) and John Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP) worked to improve essential maternal services and mobilise individuals and communities to respond to obstetric emergencies in an appropriate and timely manner. In an effort to help save Guatemalan women's lives by reducing maternal mortality, collaborators used radio and printed materials to engage communities in efforts to recognise and take action to address obstetrical emergencies.

The impact evaluation began as a quasi-experimental design with a comparison group, but it evolved into pre/post cross-sectional surveys as a result of the MOH institutionalisation and dissemination of the (printed) programme materials in 2003. Researchers surveyed women of childbearing age and their partners and used a method of analysis that compared baseline and follow-up data [comparing those women who had a child in the 12 months prior to the survey in both baseline (n=325) and follow-up (n=787)], as well as individuals exposed with those unexposed to programme messages at the follow-up, adjusting for socio-demographic characteristics. Researchers obtained both qualitative and quantitative information through one-on-one interviews of community leaders and group interviews of health committee members. Researchers also collected case histories of women who experienced obstetrical complications in one of the communities.

Almost a third of women (29%) and men (31%) in the follow-up were exposed to some aspect of the programme's activities and messages.

Significant improvements were seen in the percentage of women and their partners who recognised that severe bleeding during pregnancy and childbirth required immediate attention at a health care facility: 66% of women who were exposed to the programme recognised that severe bleeding is dangerous, compared to 31% in the baseline, and 51% of exposed men recognised the danger of severe bleeding, compared to 22% in the baseline. No significant changes between baseline and follow-up were reported for those not exposed: 37% for women and 30% for men in the follow-up. Results for knowledge of severe bleeding during postpartum were similar to the ones for pregnancy: 9% at baseline vs. 24% at follow-up for women exposed and 6% for those not exposed; and 5% for men at baseline vs. 19% for those exposed at follow-up and 7% among the non-exposed. Knowing that a woman should be taken to a health care facility if the placenta has not be delivered 30 minutes after birth improved significantly among women and men.

In the follow-up, exposed women (93%) were significantly more likely to believe that a woman should receive prenatal care from a skilled provider than non-exposed women (72%), and women in the baseline (66%). A similar pattern was seen regarding women's beliefs that a mother should receive skilled care for childbirth (42%) and postpartum (62%) at baseline compared to those exposed in the follow-up (78% and 82%, respectively). Men in the study reported similar changes.

At baseline 5% of women reported having made a plan for transportation in case of obstetrical emergencies; in contrast, 37% of women exposed to the programme made a plan (vs. 12% among the non-exposed). The percentage of women who reported setting aside money increased in both groups from a baseline of 5%, but to a far higher level among those exposed (74%) than among those not exposed (26%).