In five districts in Bolivia, no obstetricians or anesthesiologists were found in two of the district hospitals. In a large urban district, no blood bank was available to support the district hospitals. There was a general shortage of client education materials. Privacy for provider-client counseling was lacking in the district hospitals (Seoane and Castrillo, 1995).

In Nigeria, Ghana, and Sierra Leone, there were declines in deliveries in seven referral facilities from 1983 to 1989, paralleling increased costs to patients for drugs and services (especially in Ghana and Nigeria). These declines are believed to coincide with the introduction of fees in five of the seven sites. The effect of user fees on the number of complicated obstetric cases seen at a referral site is mixed, although the scant data suggest that the patients with complications are continuing to come in for management (Prevention of Maternal Mortality Network, 1995).

In Indonesia, however, the obstacle of cost cannot be overestimated. According to one Indonesian woman: "I have to live through today, before I can think about tomorrow. I can't put away money for a hospital birth, because if I do, we may not be able to eat tonight" (quoted in Ambaretnani, Hessler-Radelet, and Carlin, 1993) Traditional care in Indonesia for prenatal and postpartum massages and child care plus delivery costs a total of U.S. $7.50 (1994), but a complicated delivery at a health center would cost nearly three times as much. If a hospital delivery with caesarean section is required, it could cost even 100 times the rate for traditional care (Achadi et al., 1994). Yet if a recognizable complication arises during delivery, most Indonesian families say that they will spare no expense to ensure that the woman and her baby are safe. But one husband expressed anger that his wife was referred to a hospital and then had a normal delivery there. He felt that they had spent a tremendous amount of money on something that they did not really need (Ambaretnani, Hessler-Radelet, and Carlin, 1993).

It is not only the lack of supplies, logistics, or costs that create barriers. Provider attitudes remain a major hurdle. An example is seen from a focus group report from Nigeria. Doctors in the Yoruba community believe that good prenatal care could prevent many of the complications they see, but that "pregnancy is considered to be a natural thing …" and "ignorance" is pervasive. Hence, women obtain prenatal care only late in pregnancy. Nurses and midwives claim this late registration is due to the fact that attendance for prenatal care is very expensive, and women want to delay registering as long as possible (Public Opinion Polls, 1993).

Step 4: Provision of Appropriate Care

The few studies of the quality of maternity care point to major deficiencies



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