title: Casas Maternas in the Rural Highlands of Guatemala: A Mixed-Methods Case Study of the Introduction and Utilization of Birthing Facilities by an Indigenous Population.
abstract: BACKGROUND
  An international NGO, with financial and managerial support from "partner" communities, established Casas Maternas (birthing facilities) in 3 municipalities in the isolated northwestern highlands of the department of Huehuetenango in Guatemala-an area with high maternal mortality ratio (338 maternal deaths per 100,000 live births). Traditional birth attendants are encouraged to bring patients for delivery at the Casas Maternas, where trained staff are present and access to referral care is facilitated.
  
  
  METHODS
  We conducted a mixed-methods study in San Sebastian Coatán municipality to assess the contribution of 2 Casas Maternas to health facility deliveries among partner and non-partner communities, with particular emphasis on equity in access. We surveyed all women who delivered in the study area between April 2013 and March 2014, the first full year in which both Casas Maternas in the study area were operating. In addition, using purposive sampling, we conducted in-depth interviews with 22 women who delivered and 6 focus group discussions with 42 community leaders, traditional birth attendants, and Casas Maternas staff members. We analyzed the quantitative data using descriptive statstics and the qualitative data with descriptive content analysis.
  
  
  RESULTS
  Of the 321 women eligible for inclusion in the study, we surveyed 275 women (14.3% could not be located or refused to participate). Between April 2013 and March 2014, 70% of women living in partner communities delivered in a health facility (54% in a Casa Materna) compared with 30% of women living in non-partner communities (17% in a Casa Materna). There was no statistically significant difference in uptake of the Casa Materna by maternal education and only a weak effect by household wealth. In contrast, distance from the Casa Materna had a pronounced effect. Traditional birth attendants were strong advocates for utilization of the Casa Materna and played an important role in the decision regarding where the birth would take place. In addition, the program's outreach component, in which peer volunteers visit homes to promote healthy behaviors and appropriate use of health facilities, was identified as a key factor in encouraging mothers to deliver in facilities.
  
  
  CONCLUSIONS
  The Casa Materna approach to strengthening maternity care as developed by Curamericas has potential to increase health facility utilization in isolated mountainous areas inhabited by an indigenous population where access to government services is limited and where maternal mortality is high. The approach shows promise for broader application in Guatemala and beyond.
authors.affiliation: Curamericas Global, Raleigh, NC, USA.
authors.forename: Ira
authors.initials: I
authors.lastname: Stollak
authors.affiliation: Curamericas/Guatemala, Calhuitz, Guatemala.
authors.forename: Mario
authors.initials: M
authors.lastname: Valdez
authors.affiliation: Centro Universitario de Occidente, Quetzaltenango, Guatemala.
authors.forename: Karin
authors.initials: K
authors.lastname: Rivas
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Henry
authors.initials: H
authors.lastname: Perry
mesh_terms: D000328:Adult; D016550:Birthing Centers / Q000706:statistics & numerical data*; D003657:Decision Making; D036861:Delivery, Obstetric; D005260:Female; D017144:Focus Groups; D006166:Guatemala; D006268:Health Facilities; D006293:Health Promotion; D006297:Health Services Accessibility; D006801:Humans; D008428:Maternal Mortality; D008880:Midwifery; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D012017:Referral and Consultation; D012111:Residence Characteristics; D012424:Rural Population