Kruk et al.’s article “Bypassing Primary Care Facilities for Childbirth” struck a chord with me because I work as a Health Educator at Morris Heights Health Center (MHHC) in Bronx, NY. While I realize few comparisons can be drawn between rural Tanzania and the community that MHHC services, they do share a common challenge: bridging the gap between people’s perceptions of quality care and the objective realities that exist.
In the case of the rural Kasulu District of Tanzania, the authors link quality of care to access and the availability of primary health care facilities. WHO—as well as many actors in the global health community—would also agree that the availability of primary health care facilities with the capacity for basic emergency obstetric care is especially critical for reducing rates of maternal mortality.
Yet, the availability of these local facilities has not translated into their utilization for childbirth services. While 99.3% of the women surveyed made at least one antenatal care visit for their most recent pregnancy, only 36.4% delivered their most recent child in a health facility—42.2% of whom bypassed their nearest health facility and traveled an average of 20 km farther to deliver elsewhere.
This paradox of increased access and low utilization is also facing Morris Heights Health Center. MHHC provides primary heath care to the Central and South Bronx—communities that are characterized among the poorest in the nation. MHHC serves more than 48,000 patients annually, 79.5% of whom live at or under the poverty level. MHHC’s Women’s Health and Birthing Pavilion (WHBP) is one of only two freestanding birthing centers in all New York City. In the 1980s and 1990s, the WHBP did upwards of 150 births a year. But in recent years, the number of births has declined significantly. While the number of antenatal care visits remains high, few women choose to deliver at MHHC. Last year, the WHBP only conducted about 50 births, while the large majority of their patients delivered at a hospital.
MHHC has launched a Performance Improvement initiative to track women’s antenatal care visits and determine what factors influence their decision of where to deliver. (As part of a group assignment for my Managing Public Service Organizations class, I am analyzing the P.I. project.) An initial patient survey indicated that a major factor was women’s perceptions of quality care. Women perceived quality of care to be better in a hospital. To the frustration of the P.I. project managers, the definition of “quality” is unclear. When my MPSO group interviewed the P.I. Director, she expressed that cultural perception may come into play. As MHHC services a large immigrant population, some patients have expressed the appeal of a “modern” hospital over traditional midwifery, as is the practice at the WHBP.
The P.I. project has also identified more objective factors that may influence women’s choice to deliver elsewhere, including long wait-times for appointments and the constant shortage of medical providers. Research of Kasulu District in Tanzania also indicated that aside from perceptions, quality of care was in fact an issue. For example, only 35% of primary care facilities had emergency transportation, and many lacked 24-hour services (286).
Like the community health centers in the Kasulu District in Tanzania, Morris Heights Health Center is facing the hard-learned lesson that simply being available to needy populations is not enough. Quality of care matters. When patients are willing to travel farther and pay more for health services, both patients and health systems suffer. It’s important to realize that “quality of care” can mean different things to different people. Quality of care is measured differently by a patient, a health care provider, a policy maker, and a financial donor.
Delivering quality health services therefore demands a more integrated approach. Primary care facilities cannot be effective without buy-in from the community itself. Primary care facilities must work with the community to determine what their needs are, and adopt approaches that create a sense of community ownership. Furthermore, administrators, policy makers, and donors must ensure that health care facilities are equipped with the necessary staff, drugs, and medical equipment to deliver services when they are needed. These supply-side issues must be resolved; people’s perceptions of quality care will not change until the care available actually delivers on their needs.