One of the most important variables that explain the change in the maternal mortality rate is adolescent fertility rate. However, in El Salvador MMR decreased more than expected from the reduction of adolescent fertility rate, as this did not decrease that much compared to the countries in similar situation, as can be noticed from the Table 1. How this happened?
The reason is that El Salvador was not so successful in preventing the adolescents from getting pregnant but was more successful in preventing the deaths of the adolescents during or after the delivery of the baby. We suggest that this partial success can be explained by Family Health Community Teams (Unidades Comunitarias de Salud Familiar: UCSF) and maternity waiting home.
The 3rd report on the Progress of the Millennium Development Goals of El Salvador states:
Non-hospital maternal mortality, in particular, has been occurring with decreasing frequency. Healthcare representatives and more recently, Family Health Community Teams successfully managed to implement the Birth Plan strategy, mainly in rural communities, with the primary purpose of encouraging women and their families to take any necessary steps to give birth at the hospital. This has made it possible today for more than 90% of births to take place in hospitals, mainly belonging to the public network and the Salvadoran Institute of Social Insurance.
Considering the level of economic development, El Salvador has relatively well-established health care system, especially for the primary health care [5,6]. At the level of municipal health networks, UCSF health centres are in charge of primary medical services [7]. Nationwide, there are more than 360 UCSF that are in charge of health promotion, prevention, treatment and rehabilitation [7,8]. Medical team that work in UCSF is called ECOS (Community Health Team: Equipos Comunitarios de Salud), and consists of doctors, nurses, nutritionists, health education specialists, psychology counselors, and nurse assistants [9]. ECOS provides primary care on checkup, treatment, vaccination, and medicine provision [10]. Local community health personnel in UCSF health centres are trained for a certain period of time and placed in UCSF to learn, research, and routinely report health problems of the designated region. Furthermore, they are to keep track of conditions of expectant mothers in mother and child health related issues and report it to health centres [11]. One local community health worker is required to attend 200 households residing in the region [7].
In 2009, to strengthen primary medical services and prevent exclusion of remote residents [12], especially pregnant women, the government of El Salvador established a program of Maternity Waiting Home for Expectant Mothers (Hogar de Espera Materna: HEM). With assistance from international community, 16 HEMs were set up by 2013[1]. The objective of HEM was to induce expectant mothers that are spread out over remote mountain areas to clinics, so that they could rest in proximity areas until due dates when they would be transported to nearby hospitals for the delivery [12,13]. Therefore, HEM in El Salvador is located with UCSF or nearby health centres so that patients can be requested to be transferred to connected hospitals that are equipped with childbirth delivery facilities. Expectant mothers reside in and wait for their due dates in HEM health clinics near their resident homes [7,12]. At impending delivery, expectant mothers and their treatment records from respective HEM can both be transferred to hospitals via UCSF vehicles, ambulances, or taxis.
When distance between residence and hospitals are too far or hospital visits are geographically difficult, expectant mothers can come a day early and stay at HEM until their hospital check-up and can return home after receiving treatment [7,14,15]. After delivery, mothers can also come a day early to stay at HEM before giving vaccinations to newborn babies the next day. Furthermore, HEM health clinics act as safe havens for expectant mothers and newborn babies facing social risks. Fees to use HEM are all free of charge. During expectant mothers’ stay at HEM, they are provided with housing and meals that are particularly essential during pregnancy. After delivery, mothers that want support are provided with clothing for their newborn babies [7,13].
At the HEM, licensed specialists in mother and child health reside on-site 24 hours and manage health conditions of both expectant mother and fetus by checking on the health of expectant mothers and listening to cardiac sounds of the fetus twice a day. Functions of HEM are to provide facilities for at high-risk expectant mothers and newborn babies and to strengthen geographical accessibility. Either nearby or situated together with UCSF, the clinic provides health education for reproductive health and childbirth delivery [12]. As expectant mothers who enter HEM mostly reside in regions that have difficult accessibility and transportation to hospitals, the health clinic estimates around 40% of the nearby regions’ expectant mothers to be its target population [7]. For all other expectant mothers in the region, it seems that although they may reside in remote areas they have access to means of transport to hospitals for delivery and do not need to enter HEMs. Entrance into HEMs takes place through recommendations from local community health personnel, UCSF, or other expectant mothers who have previously experienced the clinics. The majority of expectant mothers get into clinics around 2-3 days before delivery. Although mothers voluntarily come to clinics, for those without transportation and with difficulty reaching the clinic, UCSF provides vehicles for transportation.
In 2013, the total number of users of HEM was 2,587, as shown in Table 5. Among them, 913 users were adolescents. The percentage of adolescents among the pregnant women who used HME was 35%. This extremely high proportion of adolescent users may be explained by the high adolescent pregnancy in the remote rural areas [16], by the high reliance of adolescent on this facility, and by the efficient work of UCSF in guiding the pregnant adolescents to the HEM.
In 2013, expectant mothers’ average use of HEM throughout seven HEM was around 70%, which is close to the Department of Health’s goal of 80% coverage. El Salvador’s mountainous geography makes transportation difficult and medical facility accessibility challenging in many regions; various conditions such as transportation are not readily supported in El Salvador particularly in case of expectant mothers in remote areas that rapidly try to access hospitals at impending stages before delivery. HEMs were constructed to target expectant mothers from such remote areas so that they could be attracted to better utilize medical facilities and have facility deliveries. It appears that the project has positively influenced the region in increasing facility-based deliveries and reducing maternal and child mortality rates. It is expected that many users would have given home childbirth without HEM, which was confirmed by fieldwork interviews with expectant mothers using HEM.
It is obvious that the system of UCSF and HEM has reduced MMR by inducing vulnerable expectant mothers to the hospitals and enabling facility-based delivery. As the most important group of vulnerable expectant mothers are adolescents [17], this system inarguably reduced the number of adolescent deaths related to the maternity. However, the system was not so successful in reducing the pregnancy of adolescents. Adolescent were given education about sex and maternity once they were pregnant and hosted in HEM, not before getting pregnant. Of course, there was sexual education in the schools, but this was not so effective in reducing the adolescent pregnancy [16,17].