Miteniece et al. BMC Health Services Research (2018) 18:631
https://doi.org/10.1186/s12913-018-3432-z
RESEARCH ARTICLE
Open Access
Barriers to accessing adequate maternal
care in Georgia: a qualitative study
Elina Miteniece1* , Milena Pavlova1, Lela Shengelia4, Bernd Rechel3 and Wim Groot1,2
Abstract
Background: The maternal health outcomes in Georgia are linked to shortcomings in healthcare such as inequities
in access to adequate maternal care. Due to the macro-level, quantitative approach applied in most previous
studies, little is known about the underlying reasons that influence maternal care and care-seeking behaviour of
pregnant women.
Methods: This qualitative study explores the stakeholders’ perspectives on access to adequate maternal care in
Georgia. Focus-group discussions are conducted with mothers who gave birth within in the past four years and
in-depth interviews are conducted with decision-makers and health professionals in the field. Five access-related
aspects are studied: availability, appropriateness, affordability, approachability and acceptability of maternal care.
The method of direct content analysis is applied.
Results: Results indicate problems with maternal care standards, inequalities across population groups and drawbacks
in maternal care financing. This includes gaps in clinical quality and staff skills, as well as poor communication between
women and health professionals. Geographical barriers to adequate maternal care exist in rural and mountainous areas
due to the weak infrastructure (poor roads and weak transportation), in addition to financial hardships. Despite
improvements in the coverage of maternal care, affordability remains an access barrier. Poorer population groups
are financially unprotected from the high out-of-pocket payments for maternal care services.
Conclusion: These findings imply that micro-level indicators, such as disrespectful behaviour of health professionals
and affordability of care, should be taken into account when assessing maternal care provision in Georgia. It should
complement the existing macro-level indicators for a comprehensive evaluation of maternal care.
Keywords: Georgia, Central and Eastern Europe, Maternal care, Access, Pregnancy, Appropriateness, Approachability,
Cost
Background
The official maternal mortality rate (MMR) in Georgia is
high, at 31 deaths per 100,000 live births in 2014 according to clinical data [1]. The MMR in Georgia is higher
than in neighbouring former Soviet Republics such as
Armenia (19 per 100,000 in 2014) or Azerbaijan (15 per
100,000 in 2014) [1]. It is more than three times higher
than the MMR average for the WHO European region
(10 per 100,000 in 2014) and more than six times the
European Union average (four per 100,000 in 2014) [1].
* Correspondence: e.miteniece@maastrichtuniversity.nl
1
Department of Health Services Research, Maastricht University, Faculty of
Health, Medicine and Life Sciences, Duboisdomein 30, Maastricht 6229 GT,
The Netherlands
Full list of author information is available at the end of the article
Yet, maternal mortality in Georgia might be even higher
(with an estimated 36 deaths per 100,000 live births in
2015), as the official clinical or cause of death data
undercount maternal mortality [2, 3].
The government has taken a number of steps to reduce maternal mortality and reach Millennium Development Goal 5 (MDG5), which aimed to reduce the MMR
by three quarters between 1990 and 2015 [1, 4]. Yet, the
MMR remains higher than desired under the MDG5.
The previous MDG5 fits within the current aim 3.1 of
the Sustainable Development Goals 2015–2030 to reduce the Global MMR. Achieving the desired MMR target by 2030 requires an annual reduction in MMR of at
least 7.5%, which is double the progress of MDG5 [5].
Interventions to achieve this include staff retraining,
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Miteniece et al. BMC Health Services Research (2018) 18:631
infrastructure development, screening programs, and
free-of-charge access to basic maternal care services [3].
The reasons for the high MMR in Georgia can be
found at both the macro level (e.g. availability of infrastructure, facilities and medical staff ) and the micro level
(e.g. provision and use of services, communication, affordability, adequacy, awareness) [3, 6–8]. The high MMR in
Georgia is also linked to inequities in access to adequate
maternal care [3, 4]. Adequate care is understood here as
care with good clinical quality that meets medical standards and is delivered in accordance with the preferences
of service users (the pregnant women) [9].
Previous studies in Georgia have confirmed that
barriers to access adequate maternal care services contribute to poor maternal health [3, 7, 10, 11]. Thus, the
high maternal mortality risk is associated not only with
physiological factors related to higher maternal age
and poor pre-pregnancy health, but also with social
factors, such as living in rural areas, low economic status and late care-seeking behaviour due to insufficient
awareness or inability to pay. Quality of maternal care
is another important aspect that causes a higher MMR
risk [4, 12].
The Georgian maternal care system is rather complex and fragmented. The providers of maternal care
include outpatient and inpatient maternity clinics in
both the public and private sector, providing services
within and outside the various state maternal care programs. The state programs are funded through annual
state budget allocations and cover free-of-charge access to basic antenatal care (four visits), food supplements (folic acid), antenatal and maternal screening,
management of high-risk pregnancies, and birthing
care (including C-section). Outside the state programs,
pregnant women may use additional maternal services
that are paid by the state Universal Health Care program, private insurance schemes or out-of-pocket payments. Similar to such countries as Ukraine, maternal
care in Georgia also seems to follow the so-called
“technocratic model”, which stresses a “mind–body
separation and sees the body as a machine” [13, 14].
According to this model, the obstetrician/gynaecologist
is the key professional during the whole maternal
period. Midwives have only a limited or no involvement in the maternal period. Midwives can be involved
in childbirth but also then play only a secondary role,
except when the obstetrician is not available. In line
with the technocratic model of care, the structure of
obstetric services differs from international standards
of demedicalisation, and the goal to minimize interventions, avoid unnecessary interventions, provide
“evidence-based care as well as intellectual, emotional,
social, and cultural needs of women, their babies, and
families” [15].
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Although the use of antenatal care has increased since
the state programs started funding four antenatal visits,
about a quarter of pregnant women still do not receive
such care in the first trimester and about 15% of pregnant women do not have at least four antenatal visits
[16]. Furthermore, in 2010, around 2% of pregnant
women, increasing to 5% among ethnic minority groups
(mostly Armenians and Azeri), had a home childbirth
without a skilled birth attendant [3]. This might help to
explain why one fifth of maternal deaths occur among
ethnic minorities. Potential reasons for the higher share
of home childbirths among ethnic minorities include
lower socio-economic status as well as insufficient access
to maternal care [7].
According to the 2010 Reproductive Health Survey,
the use of postnatal care in 2010 was only 23% and only
a small share of women reported adequate counselling
experience [3]. Moreover, gynaecological routine visits
outside pregnancy remain low in Georgia (24%). Such
visits are important contributors to the outcome of pregnancy, especially if there are gynaecological conditions
present that negatively affect pregnancy [3, 7].
Another problem is the existence of high out-of-pocket
payments for health services, which undermines access to
care for the poorest population groups [4, 10]. Georgia
stands out among the former Soviet Republics as the one
with the highest share of private expenditures on health
care [17], reaching 79% of total health expenditure in 2014
[1]. The 2010 Reproductive Health Survey found that 25%
of pregnant women delayed the use of medical care, in the
vast majority (82%) due to the high costs involved [3].
Despite the free-of-charge birthing care offered through
the state maternal programs, maternal care providers
(mostly the private establishments) frequently request
extra out-of-pocket payments for the care received during
birth [3, 10]. In this regard, problematic pregnancies are
charged much higher by the providers, especially if the
women need more than four antenatal visits and more
complex childbirth care. Consequently, access to maternal
care in Georgia is expensive and the state programs do
not effectively protect women from this financial risk. Furthermore, there are substantial differences in the quality
of care between providers and women report difficulties
in accessing those providers they deem well-qualified [12].
In order to develop and implement well-designed policies and programs that address equity in maternal
health access, it is necessary to understand the factors
that generate and sustain barriers to maternal care use
in Georgia [4]. Due to the macro-level, quantitative approach applied in most previous studies (some of those
mentioned above), little is known about the underlying
reasons and contextual factors that influence care-seeking
behaviour of pregnant women in Georgia. Furthermore,
since care-seeking behaviour is not only an outcome of
Miteniece et al. BMC Health Services Research (2018) 18:631
individual decision-making, it should be investigated in
the community, taking into account its cultural, social
and political environment. This indicates the need for
qualitative research to gain an in-depth understanding
of access-related factors in maternal care in Georgia [7, 18].
The aim of our study is to explore stakeholder views
on access to adequate maternal care in Georgia. We follow a qualitative research approach, based on data collected among women who have experienced childbirth
within the last four years, providers of maternal care
and decision-makers. This allows us to determine the
extent of stakeholder consensus on barriers to access
and underlying factors.
Access to adequate maternal care – operational definitions
Levesque et al. distinguish five aspects of access to care,
namely availability, appropriateness, affordability, approachability and acceptability [19]. A rather similar
framework with slightly different aspects of access has
been put forward by Obrist et al. and Putrik et al. among
others [20, 21]. We apply the framework developed by
Levesque et al. to study the barriers to accessing adequate
maternal care in Georgia, operationalizing the five aspects
of access in line with Levesque et al., as well as a review of
recent literature on maternal care provision in Central
and Eastern Europe [19, 22].
Availability reflects the geographical location, distribution and number of health care facilities, their opening
hours, as well as the services and providers that the service users (childbearing women in our case) can choose
from [19]. This means that access to maternal care could
be limited in certain locations due to the unavailability
of services because of a lack of professionals, institutions
or certain practices. Availability can be impacted by
spatial and temporal factors [23], such as the distance
between the service user (in our case, the pregnant
woman) and the health care facility, and the time spent
waiting or traveling [24].
Appropriateness reflects the technical and professional
aspects of care and their adequacy, i.e. what services are
provided and how they are provided [19]. It also refers
to the appropriateness of the facilities and their environmental aspects. Appropriateness of care entails two dimensions, namely clinical and social quality [23]. In
maternal care, clinical quality refers to the quality of
procedures and care delivered by health professionals,
while social quality refers to facility maintenance, accommodation and environment [25]. In order to improve the health outcomes, healthcare must be of good
quality: safe, effective, timely, efficient, equitable and
people-centred. In 2016, WHO published standards for
improving the quality of maternal and newborn care,
which place people at the centre of care by improving
both the provision of, and patients’ experience of, health
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care. Provision of healthcare includes evidence-based
practices for routine care and management of complications, actionable information systems and functioning
referral systems while experience of care includes effective
communication, respect and preservation of dignity and
emotional support. These factors, along with competent
and motivated human resources, and essential physical
resources, are a critical part of ensuring the quality of
(maternal) care [26].
Affordability reflects the payments made by the service user, including various types of out-of-pocket payments but also indirect payments (e.g. travel costs) that
make care less affordable and limit access to it [19]. Affordability barriers mean that even if care is available
and appropriate, the childbearing woman might be unable to access it because she cannot pay for it. Outof-pocket expenses can be classified as: formal (regulated
by national legislation), quasi-formal (official charges set
up by providers outside national regulation), informal
(unofficial payments or gifts by the service user) and
quasi-informal (e.g. medical products brought by the
service user) [27]. All types of out-of-pocket payments can
severely limit the ability to access maternal care [15, 28].
Approachability refers to the awareness of service
availability among service users, as well as to the information distributed regarding available treatments and
services [19]. It also refers to the psychological dimension of accessibility, which might be hindered by poor
communication, resulting in social distance and mistrust, and even by discrimination on the side of health
care staff [23]. Thus, care could be available, appropriate
and affordable, but pregnant women may not use it due
to the lack of information or some psychological access
barriers [24].
Acceptability is determined by cultural, traditional and
literacy factors that determine whether institutionalized
care is accepted by individuals, as well as whether and
how often care will be demanded [19, 29]. Thus, care
might be available, appropriate, affordable and approachable, but not acceptable due to cultural, traditional and
health literacy aspects in determining the need for institutionalised care [21]. Acceptability can also be influenced
by the health care provider, such as when non-acceptance
of pregnant women influences care-seeking behaviour and
leads to unwillingness to seek care [30].
Figure 1 illustrates the operational definition of access
to adequate maternal care applied in this study, based
on the framework proposed by Levesque et al. and the
additional considerations outlined above [19].
Methods
This study follows an explorative qualitative approach
and applies the method of directed content analysis [31]
based on pre-selected themes (the five aspects of access
Miteniece et al. BMC Health Services Research (2018) 18:631
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Fig. 1 Barriers to access to adequate maternal care. Source: Authors’ compilation, based on Levesque et al. [19]
shown in Fig. 1). Ethical approval of the study was obtained from the Bioethical Committee of the National
Center for Disease Control and Public Health of Georgia
prior to data collection.
The data were collected in May–June 2015 in two urban
settings (Tbilisi and Kutaisi) and one rural setting (Batumi
area). Tbilisi is the capital city located in the eastern part of
Georgia, Kutaisi is a central region of Georgia and Batumi is
a region located in south-west Georgia. Two methods of
data collection were used, allowing for data triangulation.
First, focus group discussions (FGDs) were carried out with
women who gave birth in the preceding years, to elicit what
barriers (if any) to accessing maternal care they had experienced. This was complemented by semi-structured in-depth
interviews (IDIs) with decision-makers and health care professionals to gain an understanding of their opinions about
access to maternal care. We then identified similarities and
differences in the opinions across the three stakeholder
groups. This allowed us to gain insights from multiple perspectives and to better understand the study phenomenon.
It gave a voice to the experience of stakeholders and offered
the opportunity to explore the depth and complexity of
access to adequate maternal care in Georgia.
In total, six FGDs were conducted, two in each study
setting. Each group consisted of up to 10 women who
had experienced their last childbirth within the preceding
four years. One group in each setting consisted of women
who had one child and the other group consisted of
women who had two or more children. No criteria for age
or economic status were applied to enable exploring possible access barriers among all women in their reproductive age and representing diverse income groups.
The contact details of the women were obtained
through hospital registries, combining the methods of purposive and convenience sampling. The women were
approached by one of the researchers via phone and were
asked to participate. Women who agreed to participate
were asked to reach out for someone in their social network who would meet the inclusion criteria and would be
willing to participate. No refusal to participate was registered. All participants were asked for their verbal informed
consent to participate prior to the FGDs taking place.
The FGDs were conducted in Georgian language. An
experienced discussion moderator led the discussion and
two researchers participated as observers. The discussions
included questions that were developed in accordance
with our operational definition of access to adequate maternal care (see Fig. 1). The questions are presented in
Additional file 1. To facilitate the communication, during
the introduction, all women were provided with cards to
write down their names. The discussion started with stating the general purpose of the FGD and establishing
ground rules. After that, the topic was introduced and discussed based on the pre-selected questions. After each
question, women were given time to note down their
ideas, after which an open discussion took place. At the
Miteniece et al. BMC Health Services Research (2018) 18:631
end of the discussion of each topic, the results were summarised verbally by the FGD leader and at the end of the
FGD, the participating women were asked for additional
comments or opinions. The discussions were recorded,
transcribed and translated into English.
The IDIs followed the FGDs. Five decision-makers and
four health care professionals were involved in the study.
The decision-makers and health care professionals were
selected through purposive and convenience sampling,
based on their position and importance in the field of
maternal care in Georgia. The decision-maker group was
represented by two decision-makers from international
institutions, namely USAID and UNICEF Georgia, one
decision-maker from the National Center for Disease
Control (NCDC) and two decision-makers from the Ministry of Health. The health care professional group was
represented by three gynaecologists of whom two were
also working at the medical university, and one member
of the management team of the biggest maternity house
of Tbilisi. In view of the “technocratic model of care” in
place in Georgia, no midlevel providers such as midwives
were included as participants in the interviews [13].
The interviews were carried out in Tbilisi and Kutaisi,
while the potential participant (health care professional)
from Batumi region cancelled the interview and it was not
possible to find another suitable replacement in the given
time. Therefore, no interviews were conducted in this region. All interviewees were asked for written informed consent prior to the interview. Two researchers participated
during the interviews, one of whom led the interviews. The
IDIs included questions similar to those used in the FGDs
(Additional file 2). Six interviews were held in English and
three in Georgian. The interviews were recorded, transcribed and, where necessary, translated into English.
As mentioned above, the data collected through the
FGDs and IDIs were analysed based on the qualitative
method of directed content analysis [31]. The guiding
themes for the content analysis were the five aspects of
access to maternal care presented in Fig. 1. The transcripts were first read to identify relevant information,
which was then clustered in the five themes. The categorised information was analysed and similarities and
differences across the stakeholder groups identified. Participant quotes are displayed throughout the Results section to provide a narrative presentation of key findings.
Results
The two FGDs in Tbilisi consisted of 14 women in
total, the two FGDs in the Kutaisi town of 15 women
and the two FGDs in the rural Batumi region of 15
women. The women in all FGDs were aged 19–42. The
IDIs with maternal care professionals (four interviews)
and decision-makers (five interviews) included both
men and women of diverse age groups. The results are
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presented below in accordance with the five access-related
themes and are illustrated with quotes. The full list of
quotes can be found in Additional file 3.
Availability
Almost all women in the FGDs expressed their disappointment with the unavailability of postnatal care. This
is a problem when, for example, women need support
with breast-feeding or assistance with post-childbirth
complications.
‘I had problems with breastfeeding and it was a
problem that there was no postnatal care which strikes
most mothers’ (FGD, single child, Tbilisi).
In the rural area of Batumi, specific services to manage
complicated cases before childbirth are not available according to the participants in our FGDs. For these services, women have to have a journey to Batumi city or
even to the capital, Tbilisi, which means a long-distance
travel for these women to the very east of Georgia. Participants noted that these necessary services should be
available closer to their home. However, even in the
capital city Tbilisi, a participant noted an insufficient
number of incubators and hospital beds. Due to the unavailability of hospital beds, women were discharged
earlier from hospital or asked to find another institution. In addition, some women mentioned a shortage of
staff (e.g. anaesthesiologists) in low capacity institutions, especially in rural areas.
Health care professionals also perceived human resources as an important problem, especially in rural areas.
‘Some kind of services could be unavailable when
needed; especially in rural areas some services are
really missing and could contribute to access issues
and therefore quality of health care. Human resources
are an issue’ (IDI, gynaecologist, Tbilisi).
They mentioned that sometimes pregnant women who
had overcome the spatial barrier in reaching a health
care provider could not access the necessary care because the specific service was not available (e.g. USG).
This created another barrier or delays in health care
utilisation.
Decision-makers identified the recent privatisation of
the health system (which was implemented in 2007) as
an additional barrier in terms of service availability, due
to the freedom of providers to choose the type of services they want to provide based on their interest (thus,
sometimes not providing maternal care). They also mentioned that assistance during pregnancy and the postnatal period was usually provided only by obstetricians,
whereas inclusion of maternal care within family doctor
Miteniece et al. BMC Health Services Research (2018) 18:631
services would improve accessibility. Overall, the opinions of health professionals and decision-makers regarding availability-related barriers were in line with those
expressed in the FGDs.
‘Family doctor involvement and assistance is not
available for pregnant women, but would be useful to
improve access (IDI, Health Ministry, Tbilisi).’
The women in the FGDs indicated that access to maternal care was complicated for women living in rural
areas, especially in high-mountain regions, due to large
travel distances and a weak transportation infrastructure.
‘Distance is an issue for women from rural areas,
because in the capital the care is more adequate and
modern than in rural areas (FGD, single child, Tbilisi).’
Furthermore, the travel costs are high; roads are of poor
quality and public transport, if existent, has a very poor
schedule and only few destinations. In contrast to rural
areas, care in the capital was reported to be more advanced and adequate. In the women’s opinion, these
were the main reasons why geographical distances could
lead to delayed care-seeking behaviour and poor health
outcomes.
Most decision-makers and health professionals agreed
with the women that rural and high-mountain populations are more likely to face access barriers and inadequate maternal care. Both groups emphasized that even
though most women could access some maternal care,
the problem was to access adequate care close to their
place of residence. Therefore, the rural population
groups are most likely to experience pregnancy-related
complications and the need to travel for suitable care.
The representative of the Georgian Ministry of Health
also highlighted the problem of lacking transportation
infrastructure and availability of care in various regions,
especially in remote areas, which were important contributors to access barriers.
Only a few women from Tbilisi and Kutaisi reported
not to have experienced any problems with service availability. One gynaecologist claimed that in his hospital all
services were available at any time of the day. Somewhat
similarly, a decision-maker stated that postnatal care officially existed in Georgia and was covered by the state,
but that women had to be aware of the need for it, since
it worked through self-referral. There was a gap in policy
implementation, because the information on the availability of postnatal services was not reaching all providers and women in need.
All participants agreed that there were no distance-related access problems in the capital city. Participating
women from Batumi region who lived in suburbs or rural
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areas claimed that the distance to adequate care in Batumi
city was not that long, which therefore was not a barrier.
None of the FGD or IDI participants reported waiting lists
for maternal care. Nevertheless, a clinical manager reported
that women usually preferred to receive care in the area in
which they lived. However, when they needed more advanced care available in the capital, the cost was the problem, not the distance they had to travel.
Appropriateness
Most participants stated that there were problems with
the appropriateness of maternal care in Georgia. The
women reported the need to search for adequate care
because quality differed across the country, a city or
even within an institution.
‘Everywhere the care is not of good quality; you need to
search for it’ (FGD, multiple children, Tbilisi).
However, they noted that they were free to choose a
physician, facility and the care they preferred, resulting
in the need to find the best options for them. The adequacy of maternal care was also influenced by the conditions in the facilities, which were reported to have
improved since the privatisation of health care. However,
the participants still reported the existence of old, nonrenovated buildings, unhygienic facilities and bathrooms
that were out of order.
Despite the existing inadequacies in maternal care
that, according to an advisor to the Ministry of Health,
were more prevalent in smaller towns or rural areas,
decision-makers argued that this did not create any barriers for women seeking care, as they were free to
choose where to go. They claimed that inadequate maternal care in some facilities should not result in postponed or unused maternal care in a city. However, they
conceded that quality of care might influence health outcomes. Health professionals added that inadequate antenatal care contributes to the high MMR in Georgia. Part
of the problem was reported to be underqualified staff.
‘In Georgia, maternal mortality is high due to
low quality of antenatal care. Problems are not
identified in time, because of underqualified staff ’
(IDI, gynaecologist, Tbilisi).
In contrast, other participants suggested that the adequacy of maternal care in Georgia was not a barrier to
access. Some women reported that facility conditions
had been critical in the past, but that these had generally
improved and were not a reason for not using maternal
care services. Furthermore, some women highlighted
that the free choice of health care providers and facilities
meant that adequacy of care should not be a barrier.
Miteniece et al. BMC Health Services Research (2018) 18:631
Some women also shared positive experiences, reporting
that they were highly satisfied with the attitudes and
conditions of the care they had received. Women often
relied on advice from family or friends to avoid poor
quality experiences.
‘I knew a good doctor through friends and I was also
very happy with the services, [I did not have any]
negative experiences of quality or attitude’ (FGD,
single child, Tbilisi).
Decision-makers agreed that there should be no major
adequacy problems due to the lack of infrastructure.
However, they pointed out that what happened during
antenatal visits was difficult to measure and that adequacy problems might be involved. Decision-makers
also agreed with the women that, due to the free choice
of care, a woman could “shop” for quality.
‘Women that die have no attendance issues, the
problem can be found in the quality of care and the
poor recognition of health complications. It is
important to know where to go for good care and not
everyone knows those things’ (IDI, USAID, Tbilisi).
Affordability
The majority of the women in the FGDs indicated that
the financial aspect was an important barrier to accessing adequate maternal care. According to these respondents, the state programs covered only the basic needs
of women, but all additional antenatal visits, tests and
medications had to be paid out-of-pocket. Women
claimed that maternal care could become a real burden
for pregnancies with complications and for mothers
from low-income families, especially those living in rural
areas.
‘I needed an extra test due to my high-risk pregnancy
that was expensive. I had to pay out of pocket and I
needed support from family, otherwise it was not possible (FGD, multiple children, Tbilisi).’
The rural population was seen as having limited possibilities to earn an adequate income. Therefore, even indirect costs, such as extra traveling costs of 20 lari (8
Euros) to reach the health care facility could be a financial burden. However, family members were reported to
always support each other, which allowed a number of
women to afford the necessary maternal care that otherwise in many cases would not be affordable. A woman
in Tbilisi reported that due to the high costs of an unexpected caesarean section, she had to change her facility to a cheaper one, because she could not afford it.
Page 7 of 12
Furthermore, another woman from Tbilisi reported that
she was not able to afford necessary laboratory tests that
costed 2000 lari (800 Euros). During the FGDs, affordability
figured as an important barrier to accessing adequate care,
which in some cases made women postpone necessary
care until the issues became more serious and often
even dangerous.
Decision-makers also viewed out-of-pocket payments,
especially for high-risk pregnancies, as an important burden for vulnerable population groups.
‘Providers are charging for additional visits and doing
tests that add costs. It can be a burden for vulnerable
population groups, such as the poor’ (IDI, USAID).
The poor and those living in rural areas were more affected due to their low income and extra travel expenses.
Furthermore, decision-makers claimed that pharmaceutical costs were in most cases paid 100% out-of-pocket
and were not affordable for everyone. According to the
IDIs, even in uncomplicated pregnancies, every additional antenatal visit, test or medical intervention that
was not covered by the state programs, had to be paid
out-of-pocket. Consequently, women were forced to
postpone care and this might endanger their health and
ultimately increase health care costs, if care became unavoidable. A clinical manager from one of the biggest
maternity houses in Georgia pointed out that some
women had to search for another, cheaper institution,
because they could not afford the care in this clinic.
‘In my facility, the price is high and some women
cannot access the care here and have to go somewhere
else. Universal coverage only covers basic needs’
(IDI, maternity house manager, Tbilisi).
Despite a number of participants reporting affordability
problems, several stated the opposite. A woman in
Tbilisi spent around 600 Euros during her pregnancy,
but said she was prepared to pay this price. She added
that women who were able to pay more could choose
more luxurious care options if they preferred. Some
women argued that having a private health insurance
helped in covering maternal care costs. However, only
those with a sufficient regular income could afford and
purchase the insurance packages.
Some women in the FGDs stated that the state program for maternal care worked quite well and helped
them to cover the costs that arose from complications
or the necessity to be transferred to another institution.
Some women reported that out-of-pocket payments
often seemed high, but that this was not a reason not to
use care. One woman added that childbirth is a happy
event for which a woman is happy to spend money.
Miteniece et al. BMC Health Services Research (2018) 18:631
‘My husband and me are working, therefore we do not
face financial barriers (FGD, single child, Kutaisi).’
A number of stakeholders in the IDIs agreed that
every woman received basic care, so the lack of financial
resources should not constitute an access barrier. They
maintained that, since the new state program has been
implemented, affordability has at least become a much
smaller problem. At the same time, the program was a
stimulus to seek care on time in order to be covered.
‘We have the law that if a woman is delaying her
care then the state program is not supporting her
anymore and she has to pay out of pocket, and in
that way, she is stimulated to seek care on time’
(IDI gynaecologist, Tbilisi).
However, these opinions clashed with those situations
where women lacked money to purchase extra maternal
care services or their condition fell outside the state program. Overall, the opinions of decision-makers and care
providers were divided over the existence of affordability
problems.
All FGD participants denied the presence of informal
payments, arguing that, since the privatization of health
care, all payments in Georgia have been official. However, a number of women reported that they showed
voluntary gratitude to medical staff by giving gifts in
kind.
Page 8 of 12
‘Poor communication can influence quality of care and
when women are unhappy due to poor communication
they are not able to share their experiences or
problems’ (IDI, gynaecologist, Tbilisi).
Approachability and acceptability problems with regards
to information and communication were thus interrelated.
The most important problems reported in the FGDs were
related to a lack of information about maternal care,
which resulted in delayed or irregular visits. Women reported that they sometimes did not understand what doctors meant and that they felt confused by all the medical
terms. In addition to information acquired within social
networks, the women expressed the wish to receive more
education from healthcare professionals, which would
help them throughout the pregnancy and during the postnatal period. For instance, women said they were uninformed about childbirth, breastfeeding and different
programs that covered high-risk pregnancies.
‘I don’t know about programs covering high-risk
women and if we are not informed about different programs we don’t know what services we can have’ (FGD,
multiple children, Batumi).
Decision-makers also reported problematic attitudes
and poor communication by healthcare workers, which
they believed to influence the quality of care and, ultimately, the health outcomes of women.
Healthcare professionals and decision-makers agreed
that pregnant women, especially in rural areas, lacked
information and education. They also agreed that this
information barrier was causing care to be postponed,
with potential complications. If a woman was not
aware of her health condition, she was less likely to
take any preventive measures or to engage in proactive behaviour. The representative of the Ministry of
Health explained that in the Georgian culture there
was a general fear and poor trust in medical help.
Thus, people had little understanding of the benefits
of prevention, which could contribute to poor health
outcomes.
All FGD participants reported that they did not see
any religious or cultural barriers to accessing maternal
care and they did not think there were women who
would not feel the need for professional care during
pregnancy, childbirth and the postnatal period.
‘Attitudes and responsiveness of healthcare providers,
including the consultation time, is worrisome, which
influences the delay in care and safety of women’
(IDI, NCDC, Tbilisi).
‘I haven’t heard of any cultural or religious reasons
that could act as barriers to accessing maternal care,
at least not for the Georgian population’ (FGD, single
child, Tbilisi).
A gynaecologist agreed that, despite improvements,
problematic attitudes from providers exist, especially in
rural areas. Women were then not free to share their
experiences or problems, further impinging on quality
of care.
Despite the large information insufficiencies, a few
women argued that they were very well informed about
their pregnancy and the importance of antenatal visits.
One mother reported a very positive experience with her
physician who gave her daily check-up calls to advise on
Approachability and acceptability
In almost all FGDs, women reported that they had experienced inappropriate attitudes from healthcare staff and
that they would not seek care in the same institution
again.
‘I experienced poor attitudes and ignorance by
healthcare providers’ (FGD, multiple children, Tbilisi).
Miteniece et al. BMC Health Services Research (2018) 18:631
the use of medications. Women from Batumi said they
had no complaints about inappropriate attitudes by
health care providers.
‘We are generally satisfied with the attitudes we
encountered from our doctors’ (FGD, multiple
children, Batumi).
One gynaecologist argued that the lack of information
was unusual, since women shared information within
their social networks. Overall, health professionals and
decision-makers agreed that in general women accepted
maternal care, but they pointed out that it was not always timely or adequate.
‘Even if the women are poorly informed during
the antenatal and postnatal period, insufficient
information is not a barrier to reject the
institutionalized maternal care services’
(IDI, health ministry, Tbilisi).’
None of the IDI participants thought that women were
informed enough about maternal care. The lack of information seemed to increase the risk of delayed and
insufficient care. However, none of the participants
identified other factors, such as culture, religion or gender roles, as constituting barriers to accessing adequate
maternal care.
Discussion
The stakeholder views on access to adequate maternal
care in Georgia reported above indicate several important
problems that need to be addressed in future reforms.
These problems are related to maternal care standards,
inequalities across population groups and maternal care
financing.
Maternal care standards
Our findings suggest that the standards of maternal care
provision in Georgia are a major concern. This involves
gaps in clinical quality and staff skills, as well as inadequate attitudes by health workers and poor communication between women and health professionals. These
findings are in line with what has been documented in the
literature, including the so-called “technocratic model”
[13, 14], mentioned in the Background section. This
model undermines the needs of women, their babies and
families, which results in women not being in the centre
of care. The model explains the highly-specialised model
of care and the exclusion of midlevel providers such as
midwives [15].
Quality standards of medical care and medical technologies in Georgia are not regulated by law and service
providers, including those in the private sector, are
Page 9 of 12
responsible for setting their own indicators [4]. However,
it should not be overlooked that many women seem to
comply with two international standards: four antenatal
care visits and skilled delivery. Maternal care providers
who are well known for their good services are reported
to increase their prices, but more expensive services do
not always secure higher quality standards [4, 7]. The
existing evidence supports our participants’ arguments
that medical staff have poor professional standards due
to the lack of continuous education programs in the
Georgian health system [32]. The low salaries of health
care professionals also demotivate them to perform adequately [12].
The literature also supports the finding from our study
that the information that women in Georgia receive
about the importance of adequate maternal care is insufficient, especially among those with lower levels of education and populations living in rural areas. This may
lead to delayed care-seeking behaviour and overlooked
complications, which may result in poor health outcomes
[7, 33]. None of the women and only one decision-maker
in our study had information about the existence of postnatal services. In the literature, it is reported that only
about 20% of women who had given childbirth in Georgia
use postnatal services. There might be a problem with the
implementation of maternal care programs and the dissemination of related information [4, 7] Poor health literacy of maternal care users is aggravated by problematic
attitudes of health care providers. Due to disrespectful behaviour and miscommunication of some maternal care
providers, women may tend to mistrust health care professionals and be unwilling to share their thoughts and
preferences for care. This communication barrier might
be another reason that prevents women from receiving
adequate care and early detection of complications.
Nevertheless, throughout the findings there are also
indications of new and positive developments. Thus,
overall there are mixed findings on quality of care - there
are improvements (e.g. improved coverage of care, increased use of maternal care services, reduction of informal payments, free choice of institution and healthcare
provider, improvements in the conditions of facilities and
also some improvements in the attitudes of healthcare
staff), in addition to the challenges outlined above.
Rural, mountain and minority population groups
According to our study, geographical barriers to access
maternal care only exist in rural and mountainous areas.
The distance to urban maternal care facilities that provide the necessary care can be a problem for people living in these areas due to the weak infrastructure (poor
roads and weak transportation) combined with financial
hardships [7, 32]. Such rural and mountainous areas suffer from a shortage of medical staff and adequate
Miteniece et al. BMC Health Services Research (2018) 18:631
equipment, and only limited health care services are
available. Even though Georgia has an oversupply of
medical doctors, there is no incentive for them to work
in the distant rural areas. Many of those who choose this
option lack skills to provide adequate support to women
and to manage pregnancy complications [4, 12, 32].
It has been suggested that many maternal care services could be handled by family doctors to improve
geographical access and efficiency. Currently, these providers are not involved in the provision of maternal
care [4].
Georgians do not seem to have problems with utilizing
maternal care, at least as far as antenatal care and childbirth are concerned. This is supported by official statistics showing almost 100% use of antenatal care and
professional birth attendance during childbirth [7, 34].
However, the literature also suggests that the use of maternal care services might be an issue for women from
other cultures (ethnic minorities) [7]. Minority groups
were not among the study participants and therefore this
remains an open question.
Maternal care financing
Both in rural and urban areas, good quality medical
equipment seems to be frequently unavailable. This
might be due to the underfunding of the healthcare sector
and the inefficient use of resources [35]. Despite improvements in the coverage of maternal care, affordability remains an access barrier. Poorer population groups are
financially unprotected from the high out-of-pocket payments in the healthcare sector and therefore suffer from
the high costs of accessing adequate health care, including
maternal care services [4, 32, 33]. In particular, all
additional antenatal care visits (beyond the four visits
covered), all medical tests, medications and extra childbirth costs are being paid out of pocket. Vertical programs (also known as stand-alone programs or vertical
approaches) in Georgia cover cases with serious complications, which may encourage women to postpone
care-seeking behaviour [7, 36].
In 2016, WHO came up with new recommendations
on antenatal care for a positive pregnancy experience,
which include antenatal care models with a minimum of
eight visits. The eight-visit plan aims to reduce maternal
mortality and improve women’s experience of care [37].
This plan could potentially be realised in Georgia as
many women in Georgia already receive nearly ten
visits following the physician’s request [36]. However,
the current model is based on the previous four-visits
standard publicly provided free-of-charge. As mentioned above, after this number of visits women pay for
every additional visit out-of-pocket and these payments
remain a considerable burden for households due to the
additional antenatal care visits and fees for “personal
Page 10 of 12
doctors”. The implementation of the new WHO standard
would mean an extension of a basic antenatal care package from four to eight visits, but it is not certain how feasible it will be for a resource-constrained country such as
Georgia [36].
Those participants in our study who claim that adequate maternal care in Georgia is affordable might
see it from their perspective only and overlook the
situation of the very limited resources some women
have. Women who are satisfied with the amount of
out-of-pocket payments during the maternal period
most often have a stable income that allows them to
afford the care they need [32]. Overall, informal payments do not seem to be contributing to barriers to
accessing adequate care.
Relevance of the study to other settings
Although our study focuses on Georgia, given the general theoretical framework applied, it may be relevant to
researchers and decision-makers in other countries as
well. Our results show the importance of micro-level indicators, such as disrespectful behaviour by health professionals and their attitudes towards pregnant women,
as well as women’s trust in maternal care providers and
care acceptability. In addition to existing macro-level indicators, e.g. the numbers of providers and facilities in
the country, such micro-level indicators have to be taken
into account for a comprehensive evaluation of the
provision of maternal care. This is especially relevant for
countries in Eastern Europe where maternal care problems might remain concealed by comparatively good
macro-level indicators [22, 38, 39].
Strengths and limitations of the study
Our study has several strengths and limitations. The
qualitative design allowed us to capture a rich and detailed picture of the researched topic. However, the small
number of participants and settings covered makes it
difficult to generalize findings. The quality of the data
collection and analysis is highly dependent on the researcher’s skills. This bias was mitigated to some degree
by involving two researchers during the interviews and
focus-group discussions, and an experienced discussion
moderator. We also acknowledge possible recall bias and
the potential for socially-desirable answers in both, the
focus-group discussions and the interviews. A part of
the interviews was held in English, which might have
created a language barrier for some respondents. The
rest of the interviews and all of the focus-group discussions were transcribed in Georgian and then translated
into English, due to which some nuances might have
been lost. An important advantage of our study was the
possibility to triangulate the opinions of the three stakeholder groups, which allowed for a broader view on
Miteniece et al. BMC Health Services Research (2018) 18:631
Page 11 of 12
access-related problems in maternal care in Georgia to
emerge, as well as for the validation of findings.
Abbreviations
FGDs: Focus group discussions; IDIs: In-depth interviews; MMR: Maternal
mortality rate; NCDC: National Center for Disease Control and Public Health
Conclusions
The study presented in this paper has explored stakeholder views on access to adequate maternal care in
Georgia. Based on Levesque et al. [19], we distinguished
five groups of access domains related to availability, adequacy, affordability, acceptability and approachability of
maternal care. We used these domains to examine the
views of maternal care stakeholders and to identify key
barriers to accessing adequate maternal care. Our findings
indicate the existence of a number of barriers, including
inadequate quality standards, low government funding,
and gaps in coverage for specific population groups. These
shortcomings in maternal care in Georgia may help to explain the high maternal mortality in the country.
Problems in maternal care provision involve the lack
of equipment, human resources and evidence-based
treatment. Geographical distance is also problematic for
rural and high-mountain population groups due to care
being concentrated in the capital city, weak transport infrastructure and high traveling costs. In addition to this,
Georgian women have to carefully select an available
provider of care to avoid problems such as inadequate
attitudes, poor clinical quality or appalling conditions at
the maternal care institution. This will be challenging
even for well-off and better informed and educated
women, but even more so for women with fewer resources and provider options. Gaps in the knowledge
and skills of health professionals, the low health literacy
of women and the resulting communication problems
may prevent women from receiving high-quality care,
which may contribute to poor health outcomes.
These findings imply that micro-level indicators, e.g.
disrespectful behaviour by health professionals, their attitudes towards pregnant women, women’s trust in maternal care providers and care acceptability, should be taken
into account when assessing maternal care provision in
Georgia. Such micro-level indicators should complement
the existing macro-level indicators for a comprehensive
evaluation of maternal care, both in Georgia and in other
countries.
Acknowledgements
We thank all stakeholders who took part in the group discussions and
interviews.
Additional files
Additional file 1: Key question included in the focus group discussions.
This file contains a list of questions used during focus group discussions
with mothers. (DOCX 15 kb)
Additional file 2: Key question included in the in-depth interviews. This
file contains a list of questions used during in-depth interviews with
healthcare professionals and decision makers. (DOCX 15 kb)
Additional file 3: Boxes with participant quotes. This file contains the
full list of study participant quotes in accordance to the five accessrelated themes. (DOCX 22 kb)
Availability of data and materials
Datasets generated and analysed in this study are not publicly available due
to individual privacy rights that cannot be compromised.
Authors’ contributions
EM and LS set up the survey and collected the data. MP and WG reviewed
and commented on the data collection instrument and the study methodology.
EM contributed to data analysis and writing up the first draft. MP, WG and BR
reviewed and edited all drafts. All authors approved the final version and agreed
with its publication.
Ethics approval and consent to participate
Ethical approval of the study was obtained from the Bioethical Committee of
the National Center for Disease Control and Public Health of Georgia prior to
data collection in April, 2015.
Every participant gave a consent before taking part in this study. Focus group
discussion participants gave an oral consent while in-depth interview participants
provided a written consent.
Consent for publication
Not applicable
Competing interests
Dr. Milena Pavlova acts as a Section Editor for BMC Health Services Research.
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Health Services Research, Maastricht University, Faculty of
Health, Medicine and Life Sciences, Duboisdomein 30, Maastricht 6229 GT,
The Netherlands. 2Top Institute Evidence-Based Education Research (TIER),
Maastricht University, Kapoenstraat 2, 6211 KH Maastricht, The Netherlands.
3
European Observatory on Health Systems and Policies, London School of
Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. 4National
Center for Disease Control and Public Health (NCDC) Georgia, Asatiani street
9, 0177 Tbilisi, Georgia.
Received: 13 October 2017 Accepted: 30 July 2018
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