title: Exploring inequalities in access to and use of maternal health services in South Africa.
abstract: BACKGROUND
  South Africa's maternal mortality rate (625 deaths/100,000 live births) is high for a middle-income country, although over 90% of pregnant women utilize maternal health services. Alongside HIV/AIDS, barriers to Comprehensive Emergency Obstetric Care currently impede the country's Millenium Development Goals (MDGs) of reducing child mortality and improving maternal health. While health system barriers to obstetric care have been well documented, "patient-oriented" barriers have been neglected. This article explores affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services.
  
  
  METHODS
  A mixed-method study design combined 1,231 quantitative exit interviews with sixteen qualitative in-depth interviews with women (over 18) in two urban and two rural health sub-districts in South Africa. Between June 2008 and September 2009, information was collected on use of, and access to, obstetric services, and socioeconomic and demographic details. Regression analysis was used to test associations between descriptors of the affordability, availability and acceptability of services, and demographic and socioeconomic predictor variables. Qualitative interviews were coded deductively and inductively using ATLAS ti.6. Quantitative and qualitative data were integrated into an analysis of access to obstetric services and related barriers.
  
  
  RESULTS
  Access to obstetric services was impeded by affordability, availability and acceptability barriers. These were unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability, relative to urban residents. Negative provider-patient interactions, including staff inattentiveness, turning away women in early-labour, shouting at patients, and insensitivity towards those who had experienced stillbirths, also inhibited access and compromised quality of care.
  
  
  CONCLUSIONS
  To move towards achieving its MDGs, South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery. More needs to be done to respond to these "patient-oriented" barriers by improving how and where services are provided, particularly in rural areas and for poor women, as well as altering the attitudes and actions of health care providers.
authors.affiliation: Department of Statistical Sciences, University of Cape Town, Rondebosch, South Africa. sheetal.silal@uct.ac.za
authors.forename: Sheetal P
authors.initials: SP
authors.lastname: Silal
authors.forename: Loveday
authors.initials: L
authors.lastname: Penn-Kekana
authors.forename: Bronwyn
authors.initials: B
authors.lastname: Harris
authors.forename: Stephen
authors.initials: S
authors.lastname: Birch
authors.forename: Diane
authors.initials: D
authors.lastname: McIntyre
mesh_terms: D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D005260:Female; D006297:Health Services Accessibility / Q000592:standards / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D008427:Maternal Health Services / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged; D009774:Obstetrics / Q000592:standards; D010342:Patient Acceptance of Health Care / Q000523:psychology* / Q000706:statistics & numerical data; D010817:Physician-Patient Relations; D011247:Pregnancy; D036301:Qualitative Research; D011787:Quality of Health Care / Q000592:standards*; D012044:Regression Analysis; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D013019:South Africa; D013997:Time Factors; D014195:Travel; D014505:Urban Population / Q000706:statistics & numerical data; D000078329:Workforce; D055815:Young Adult