Introduction

The three main points of this paper are community, community and community:

• Other constraints besides quality need to be addressed. To do so, one needs to work with communities.

• To develop good quality of care, one needs the clients’ perspective.

• Community organizations are essential partners in advocacy, in adding the clients’ perspective and in addressing other constraints.

Constraints to Using PAC

The same barriers apply to PAC. In this paper, I will be relying on evidence from community level activities in emergency obstetric care projects, because few PAC projects have addressed community education and mobilization.

Quality of care initiatives address the third delay, but leave the first and second delays largely untouched. What are the factors which lead to each of these delays?

Factors Influencing the Decision to Seek PAC

For lack of time, I won’t discuss each of these in detail, but will just give you a few examples. Many studies show that women in unions usually cannot and do not decide on their own to seek care; the decision belongs to a spouse or senior member of the family. Single women, particularly adolescents, feel that they must keep the pregnancy a secret and will wait to the very last minute before using these services, if they use them at all. And the data clearly show that adolescents are a large part of the group needing PAC services—services for which they probably don’t have sufficient money anyway. As a result, even if quality services are available, they may not be used.

The Africare maternal and child health project in Dioro, Mali was designed to focus on improved prenatal consultations; assisted deliveries; community-based distribution of contraceptives, condoms and spermicide; and training and supervision of traditional birth attendants (Lo and Hoemeke 1998). During the project’s first phase in 1992, a maternity ward was constructed in a central location, 17 kilometers from Dioro. Initially, the center was visited by nearly all women, pregnant or not, and generated much interest among community members. During the maternity ward’s first year of operations, however, the number of deliveries per month, which began at nearly 30 per month, fell to 7 to 10 per month 1 year later. According to site visits and interviews, the center’s community-based management committee was apparently more interested in revenues generated by the maternity ward than in the quality of service.

The project directors might have thought that the only thing they needed to do was change the attitude of the personnel and management committee. Instead, staff conducted focus groups of women and men about their knowledge and attitudes related to pregnancy, maternal care and childbirth. It was discovered that there was little communication between husbands and wives. Both men and women reported a certain "shame" about pregnancy. The women said that they were embarrassed to talk about being pregnant, often hiding that they were pregnant from everyone. Young women were especially embarrassed to talk about their first pregnancy, even though they have to get their husband’s permission to use health services.

Therefore, in developing an IEC strategy, it wasn’t realistic to attack this lack of communication directly. Instead, the project made use of a tradition whereby a married woman wears a small white wrap skirt, called pagne (in French) or pendulu (in Bambara), as a nonverbal way of communicating "feelings of intimacy." The project created a green wrap skirt which became a nonverbal means for a women to tell her partner that she was pregnant and to encourage communication about pregnancy. Wearing of the green skirt increased communication about pregnancy very significantly between husbands and wives, and eventually increased the use of antenatal services and trained birth attendants.

To sum, improved quality of services was a significant factor determining service utilization, but cultural factors were equally important.

Factors Leading to Delays in Reaching a Facility with PAC Capabilities

Improving the quality of PAC at referral facilities would not affect any of these factors, except perhaps distribution of facilities. Therefore the problem for policy and program professionals should not be whether one works with communities but when and how it happens. Do we wait until our services pass the "quality" test or do we simultaneously improve services and work with the community to address other constraints? My answer is that you need to do both from the very beginning.