A Cross-Sectional Analytic Study of Postpartum Health Care Service Utilization in The Philippines
A Cross-Sectional Analytic Study of Postpartum Health Care Service Utilization in The Philippines
A Cross-Sectional Analytic Study of Postpartum Health Care Service Utilization in The Philippines
Abstract
Background: The maternal mortality ratio in the Philippines remains high; thus, it will be difficult to achieve the Millennium
Development Goals 5 by 2015. Approximately two-thirds of all maternal deaths occur during the postpartum period.
Therefore, we conducted the present study to examine the current state of postpartum health care service utilization in the
Philippines, and identify challenges to accessing postpartum care.
Methods: A questionnaire and knowledge test were distributed to postpartum women in the Philippines. The questionnaire
collected demographical characteristics and information about their utilization of health care services during pregnancy and
the postpartum period. The knowledge test consisted of 11 questions regarding 6 topics related to possible physical and
mental symptoms after delivery. Sixty-four questionnaires and knowledge tests were analyzed.
Results: The mean time of first postpartum health care visit was 5.165.2 days after delivery. Postpartum utilization of health
care services was significantly correlated with delivery location (P,0.01). Women who delivered at home had a lower rate of
postpartum health care service utilization than women who delivered at medical facilities. The majority of participants
scored low on the knowledge test.
Conclusion: We found inadequate postpartum health care service utilization, especially for women who delivered at home.
Our results also suggest that postpartum women lack knowledge about postpartum health concerns. In the Philippines,
Barangay health workers may play a role in educating postpartum women regarding health care service utilization to
improve their knowledge of possible concerns and their overall utilization of health care services.
Citation: Yamashita T, Suplido SA, Ladines-Llave C, Tanaka Y, Senba N, et al. (2014) A Cross-Sectional Analytic Study of Postpartum Health Care Service Utilization
in the Philippines. PLoS ONE 9(1): e85627. doi:10.1371/journal.pone.0085627
Editor: Abdisalan Mohamed Noor, Kenya Medical Research Institute - Wellcome Trust Research Programme, Kenya
Received August 22, 2013; Accepted December 6, 2013; Published January 20, 2014
Copyright: 2014 Yamashita et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported in part by Grants-in-Aid for Scientific Research no. 24792581 from the Japanese Ministry of Education(website; http://www.
jsps.go.jp/english/e-grants/index.html). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
No additional external funding was received for this study.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: tadashi_y_kobe@yahoo.co.jp
Introduction
Through the Millennium Development Goals 5 (MDGs5),
countries have committed to reducing the maternal mortality ratio
(MMR) by three-quarters between 1990 and 2015 [1]. In the
Philippines, the MMR has dropped from 170 (per 100,000 live
births) in 1990 to 99 in 2010 (120 in 2000), but the rate of annual
change is slowing down [24]. If the MMR remains high in the
Philippines, it will be difficult to accomplish the MDGs5 by 2015.
Four measures have been undertaken to improve the MMR in the
Philippines: 1) the implementation of a capacity-enhancement
project for midwives in maternal and newborn care [5], 2)
education by hospitals on the Safe Motherhood Policy [6], 3) the
establishment of facilities to provide emergency obstetric care for
every 125,000 members of the population [7], and 4) the
recommendation of at least four visits for antenatal care [8].
These measures have contributed to the improvement of the
MMR in the Philippines. However, the major causes of maternal
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Methods
Participants
Seventy-seven postpartum women from 3 hours to six weeks
post-delivery with no complications were enrolled in this study,
which was conducted from January to March, 2013. The
questionnaire and knowledge tests were distributed to women
who received postpartum checkups at Philippine General Hospital
(PGH) and those who participated in a postpartum health
education seminar at Muntinlupa City Hall. Participants were
recruited using a two-stage stratified random sampling method.
The seminar addressed several issues, including current status and
problems related to maternal death in postpartum women.
Thirteen incomplete questionnaires and knowledge tests were
excluded; thus, 64 questionnaires and knowledge tests (PGH: 22,
Muntinlupa: 42) were included in the analyses. In this study,
health care services were defined as medical care such as
prescriptions, blood pressure measurement, and urinalysis, as well
as preventive care (e.g., checkups and breastfeeding education).
Results
Participant Characteristics
Participant characteristics are summarized in Table 1. The
mean postpartum period was 13.669.3 days (mean 6 SD), and
ranged from 0 to 38. Mean age of participants was 26.066.9
years, ranging from 16 to 45. Delivery locations were divided into
four categories: health center (31.3%), hospital or clinic (50.0%),
home (15.6%), and other (3.1%). Annual family income
(Philippine pesos; php) was classified into four categories: under
100,000 (45.3%), 100,001250,000 (18.8%), 250,001500,000
(3.1%), and over 500,001 (1.6%). The majority (77.2%) of
participants had no health insurance, and most (98.4%) reported
having family support for childrearing.
Self-report Questionnaire
The questionnaire comprised 3 sections. The first section
assessed characteristics including age, delivery location, past
delivery history, number of household members, health insurance
status, and annual family income. The second section assessed the
utilization of health care services during pregnancy (HS-pre):
number of HS-pre, the time of the first HS-pre visit, place HS-pre
was received, and difficulties with receiving HS-pre. The third
section assessed the utilization of postpartum health care services
(HS-post): number of HS-post, the time of first HS-post visit, place
HS-post was received, difficulties with receiving HS-post, family
support, possession of the Maternal and Child Health Handbook
(MCH), and the place where the MCH had been obtained.
Total N (%)
Mean 6 SD
Range
62
13.669.3
038
Age (years)
61
26.066.9
1645
,20
11 (18.0)
2034
41 (67.2)
9 (14.8)
.35
Number of family members
60
5.662.2
210
64
2.361.9
111
Delivery location
64
Health Center
20 (31.3)
Hospital or clinic
32 (50.0)
Home
10 (15.6)
Other
2 (3.1)
44
Under 100,000
29 (45.3)
100,001250,000
12 (18.8)
Statistics
250,001500,000
2 (3.1)
Over 500,001
1 (1.6)
Health insurance
57
Have
11 (19.3)
Do not have
44 (77.2)
Do not know
2 (3.5)
63
Yes
62 (98.4)
No
1 (1.6)
Total
N (%)
Mean 6 SD
Range
Number of HS-prea
64
4.963.8
013
56
Within 11 weeks
19 (33.9)
1219 weeks
8 (14.3)
2027 weeks
15 (26.8)
28 or more weeks
9 (16.1)
Do not know
5 (8.9)
HS-pre provider
62
Obstetrician or health
center doctor
36 (58.1)
Nurse
Midwife
Other
Place HS-pre was received
Hospital or clinic
Health center
Home
Mean 6 SD Range
Number of HS-posta
64
1.862.8
013
38
5.165.2
018
18 (47.4)
27 (61.4)
Nurse
6 (13.6)
Midwife
8 (18.2)
3 (6.8)
21 (34.4)
38 (62.3)
2 (3.3)
10 (16.1)
341 days
Other
1 (1.6)
52 (83.9)
15 (39.4)
44
61
No
5 (13.2)
2448 hours
Obstetrician or health
center doctor
19 (30.6)
Yes
423 hours
HS-post provider
6 (9.7)
38
Hospital or clinic
25 (52.1)
Health center
15 (31.3)
Home
3 (6.3)
Other
5 (10.4)
Total
N (%)
Yes
46
8 (17.4)
No
38 (82.6)
18
21
Cost
12 (66.7)
Cost
Access
10 (47.7)
5 (23.8)
Access
3 (16.7)
1 (5.6)
2 (9.5)
0 (0)
Other
4 (19.0)
1 (5.6)
Possession of MCHb
61
Have
24 (39.3)
Do not have
37 (60.7)
Hospital or clinic
7 (26.9)
Health center
14 (53.8)
Other
5 (19.2)
Use of MCH
23
11 (47.8)
2 (8.7)
9 (39.1)
1 (4.3)
26
Table 4. Factors affecting postpartum health care service utilization in the Philippines.
Total N
Utilization (+)c
Utilization (2)d
n (%)
n (%)
P-value
Delivery location
Health Center
20
13 (65.0)
7 (35.0)
Hospital or clinic
32
24 (75.0)
8 (25.0)
Home
10
2 (20.0)
8 (80.0)
Have
11
8 (72.7)
3 (27.3)
Do not have
44
25 (56.8)
19 (43.2)
Health insurance
.007*
0.335
Age (years)
,20
11
9 (81.8)
2 (18.2)
2134
41
22 (53.7)
19 (46.3)
.35
6 (66.7)
3 (33.3)
,4
22
15 (68.2)
7 (31.8)
.5
38
21 (55.3)
17 (44.7)
,100,000
29
19 (65.5)
10 (34.5)
.100,001
15
8 (53.3)
7 (46.7)
Primiparous
28
18 (64.3)
10 (35.7)
Multiparous
35
21 (60.0)
14 (40.0)
,4
17
11 (64.7)
6 (35.3)
.5
39
24 (61.5)
15 (38.5)
,27
27
15 (55.6)
12 (44.4)
.28
24
18 (75.0)
6 (25.0)
Yes
10
7 (70.0)
3 (30.0)
No
52
32 (61.5)
20 (38.5)
0.219
Number of HS-prea
0.822
Possession of MCHb
Have
22
15 (68.2)
7 (31.8)
Do not have
37
24 (64.9)
13 (35.1)
Hospital or clinic
5 (83.3)
1 (16.7)
Health center
12
8 (66.7)
4 (33.3)
Other
3 (60.0)
2 (40.0)
Yes
56
34 (60.7)
22 (39.3)
No
1 (100.0)
0 (0.0)
0.795
*Significant (P,0.01).
HS-pre: Health care services during pregnancy,
b
MCH: Maternal and Child Health Handbook.
c
Utilization (+): Postpartum women who utilized one or more postpartum health care services.
d
Utilization (2): Postpartum women who had no utilization of postpartum health care services.
doi:10.1371/journal.pone.0085627.t004
a
Figure 1. Accuracy rate of knowledge test in postpartum women, Philippines. This figure shows accuracy rate of knowledge test on
postpartum health issues.
doi:10.1371/journal.pone.0085627.g001
Discussion
As the first survey of postpartum health care service utilization
and its limitations conducted in the Philippines, this study found
the following: participants did not receive postpartum health care
services at the appropriate time, those who delivered at home
utilized fewer health care services after delivery compared to those
who delivered at medical facilities, and they had a poor overall
understanding of postpartum health issues.
In the Philippines, postpartum health care guidance may be
inadequate due to the large number of deliveries, few skilled birth
attendants, and short post-delivery stays (i.e., only 24 hours) at
perinatal medical facilities. As a result, postpartum women may
have less knowledge of postpartum issues and receive fewer
postpartum health care services [16]. WHO reported that the first
24 to 48 hours are the most critical time for postpartum woman
[17]. It indicates that postpartum women should receive first HSpost within 2 days after delivery. Actually, this survey revealed that
47.4% of postpartum women attended their first HS-post in 3
41 days after delivery, which is very late. This length of time
before the first HS-post visit and poor overall understanding of
postpartum health issues might contribute to late detection of
postpartum health problems. Interestingly, most women in this
study indicated that they had no difficulty utilizing HS-post. It may
be possible that most postpartum women in the Philippines have
access to HS-post; however, they may not utilize them at the
appropriate time due to a lack of understanding about postpartum
health issues. Therefore, it is important to address womens
knowledge of the postpartum period and related health issues and
provide adequate postpartum health care guidance.
Our study supports previous research that has found that HSpost utilization might be related to postpartum womens characteristics (e.g., age, family income, delivery history, and health
insurance status, among others) and HS-pre utilization [1829].
Therefore, it is important that health care providers such as
midwives, nurses, obstetricians, and gynecologists provide HS-post
based on womens characteristics and HS-pre utilization history.
In the Philippines, 40% of women deliver at home with the
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Acknowledgments
The authors wish to acknowledge the support of all the staff at the
Muntinlupa City Office and the Cervical Cancer Prevention Program
(CECAP), Philippines.
Author Contributions
Conceived and designed the experiments: TY SAS CLL HM. Performed
the experiments: TY SAS CLL YT NS HM. Analyzed the data: TY SAS
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