Journd of the National Institute of Public Health 2010 Vol. 59 No. 1 p.64−70〈Educational Report〉
GORIN Team No. 2
Master of Public Health in International HealthNational Institute of Public Health, Japan

Investigating the Motivating Factors Behind High Delivery Rates of the
Urban HEART Birthing Facility in San Martin de Porres, Philippines
フィリピン国Urban HEART 助産施設における施設分娩を促進する要因について
Patrice T. SARR, Chamaleen J. KASTURIARACHCHI, He YANG,
Christine Joan R. CO, Ayako SHIMPO, Soko FUJINO, Jieni MORIMATA

keywords: Facility-based delivery, motivating factor, Urban HEART, maternal health, Paranaque City
Instructors: Nobuyoshi WATAHIKI, Nobuyuki HYOI, Michiko BANDO, Tomofumi SONE

２．Objectives of the study

Ⅰ．Introduction

The main objective of this study is to investigate theinfluential factor（s） that motivated mothers to deliverat PAANAKAN Birthing Facility. Specific objectives are to

１．Background
Urban HEART（Health Equity Assessment and Response

identify

thephysical,financial,socio-cultural,

andTool）is an instrument developed by WHO Kobe Center as

knowledge and experience factors, as well as to analyze

a solution to health inequities resulting from high rates ofrelationships between these factors.

urbanization１）. Barangay San Martin de Porres（SMDP）
was chosen by Paranaque City, Philippines as a site for the

Ⅱ．Methods

Urban HEART pilot as it was identified as having theData was collected via self-administered questionnaire forhighest percentage of depressed areas and the lowest

groups of respondents. Volunteer health workers gathered

percentage of facility-based deliveries２）. Paranaque City

respondents in selected places on November 3 and 4, 2009.

established the PAANAKAN（Paranaque Ang Aalalay sa

Inclusion criteria of this study were residents of Paranaque

Nanay at Anak magpaKailAnmaN）Birthing Facility inCity aged 18 years and above who had given birth at

October 2008 in response to this health inequity.

PAANAKAN Birthing Facility from January 1 to November

PAANAKAN is manned by five health workers, provides

4, 2009 based on the SMDP health center s registry. Of theprenatal checkup, normal delivery, postnatal checkup,

target population of 200, 73 respondents were eligible fornewborn screening and breastfeeding services for the pricethis study. A cross-sectional descriptive survey was used toof 2,500 Philippine pesos（Php）.

conduct this study.

Less than a year after its operation, delivery rates at

Data was entered using Microsoft Excel and analyzed

PAANAKAN Birthing Facility continued to increase every

using Epi Info version 3.5.1 and Microsoft Excel. Simple

month while home delivery rates dropped to zero.

calculation and cross-tabulations（Chi-square Test andHowever, there is no system in place to gather feedback

Fisher’s Exact Test）were used to describe the distribution

from mothers or clients after rendering services. To

and to verify the association between factors.

maintain high facility-based delivery rates, it is therefore
important to identify factors that motivate mothers todeliver at PAANAKAN.

Fig. 1 illustrates the conceptual framework that was usedin this study. This framework encompasses the general
information of respondents, motivating factors and their

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Educational Report FY 2009：GORIN Team No. 2

Fig. 1．Conceptual framework on motivating factors for delivering at PAANAKAN Birthing Home

relationships, and the satisfaction level of respondents.

Table 1．Characteristics of respondents（n＝73）

Four motivating factors were identified based on a review of

Variables

literature.

Residence

n

%

SMDP

64

87.7

Respondents voluntarily participated by signing an

Others9

12.3

informed consent, separately, without any link to the

Marital status
Married or living together

66

90.4

Unmarried/single parent

1

1.4

Refused to disclose

5

6.8

Missing1

1.4

questionnaires; therefore responses can not be traced torespective respondents. This study was approved by theCollege of Public Health Institutional Review Board of the
University of the Philippines, Manila.

Respondents Education

Ⅲ．Results
The mean age of respondents is 26.2±5. Table 1 shows
the other general characteristics. Accurate information
could not be drawn regarding the parity of respondents
because it was found that a considerable number have

Elementary2

2.7High school

43

58.9

College vocational

7

9.6

College15

20.5

Missing

6

8.2

--

--

Paritymisunderstood the question.
2,500, whereas the remaining 27（39.1%）believed it should
be lower.

１．Motivating Factors
Physical Factors. Of the 73 respondents, 71（97.3%）knew
the location of PAANAKAN Birthing Facility before theySocio-cultural factors. Results of our study showed that

decided on where to deliver. Among this population, as

61（83.6%）of 73 respondents noticed that it started toseen in Table 2, all considered PAANAKAN’s location.

become popular to give birth at PAANAKAN. Among thisFinancial factors. As displayed in Table 2, 59（93.7%）of

considered this information in their decision-making

63 respondents considered the cost or price of delivering at

process.

population, as shown in Table 2, 34（55.7%）respondents

PAANAKAN prior to their decision of utilizing its services.
Cross-tabulations could not be done due to the small

When asked to identify who chose PAANAKAN as thenumber of respondents who did not consider cost. Open-place for giving birth, 66（90.4%）of 73 respondents claimed

ended questions asked their opinions on a reasonable pricethat they themselves were the primary decision-makers.

for delivering at PAANAKAN considering the services theyreceived. Forty two（60.9%）of 69 respondents believed that

Table 2 illustrates that of 73 respondents, 70（95.9%）

a reasonable price was higher than the actual price of Php

knew that their relatives would be allowed to take care of

J. Natl. Inst. Public Health, 59（1）: 2010

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Educational Report FY 2009：GORIN Team No. 2
Table 2．Factors considered by respondents (n=73)
Factors

Aware of factors

Considered

Not considered

n

%

n

%

n

%

71

97.3

71

100

0

0

63

86.3

59

93.7

4

6.3

Popularity or trend

61

83.6

34

55.7

27

44.3

Presence of relatives for help

70

95.9

66

94.3

4

5.7

Information heard on services at PAANAKAN

70

95.9

70

100

0

0

Information heard on the experience of other mothers

62

84.9

58

93.5

4

6.5

Information heard on health workers’ skills at PAANAKAN

64

87.7

61

95.3

3

4.7

Information heard on discouraging home deliveries

59

80.8

59

100

0

0

Prenatal checkup advice to deliver at PAANAKAN

57

78.1

57

100

0

0

Physical
Location of PAANAKAN
Financial
Cost or price of delivery
Socio-cultural

Knowledge and experience

Table 3．Reputation of information heard
Information

Mainly good

Mainly fair or poor

n

%

n

%

Services at PAANAKAN

65

92.9

5

7.1

Experience of other mothers

52

83.9

10

16.1

Health workers’ skills at PAANAKAN

53

82.8

11

17.2

them during their stay at PAANAKAN prior to deciding on
where to deliver.

Table 4．Respondents reasons for not delivering at home（n＝67）
Reasons

Knowledge and experience. Knowledge as a factor was
divided into five basic components pertaining to specificinformation heard and prenatal checkup advice to deliver at
PAANAKAN. Of respondents who were aware of specificknowledge factors, information heard about the services at
PAANAKAN, about discouraging home deliveries andprenatal checkup advice to deliver at PAANAKAN wereconsidered by 100% of respondents, as seen in Table 2.
They were also asked to recall what the over-all impression
was about the information they received. Table 3 shows

n

%

50

74.6

19

28.4

3

4.5

1

1.5

Knowledge Factors
Ensure safe delivery, fear of delivering
at home, personal preference, pastexperience, health workers advice
Physical Factors
Infrastructure, human resources,
presence of services, inconvenience ofhome delivery
Socio-cultural Factor
Decision maker influence
Financial Factor
Cost

that consistently more than 80% of information received
about services, health workers’ skills and experiences ofother mothers was good.

３．Recommendations for the improvement of
PAANAKAN

２．Reasons respondents did not deliver at home
All 73 respondents were asked in an open-ended question

A total of 62 respondents provided 67 recommendations
for the improvement of PAANAKAN. Of those who

for their reason（s）, in retrospect, for not delivering at

responded,

home. Out of 67 respondents 50 answered that they wanted

infrastructure,

to ensure a safe delivery, 19 answered infrastructure,

recommended the facility to maintain its good services, 18

human resources, presence of services, inconvenience of（29%） recommended

home delivery and the least number of respondents

knowledge, skills and attitude, and 5（8.1%）wanted to see

answered cost. This is represented in Table 4.

improvements in the financing scheme or cost.

66

23（37.1%）wanted
equipment

J. Natl. Inst. Public Health, 59（1）: 2010

to&improvements
supplies,

improveinthe

21 （33.9%）

humanresource

Educational Report FY 2009：GORIN Team No. 2

Fig. 2．Distribution of respondents priority motivating factors

actual price of delivering at PAANAKAN is lower than what
After receiving services from PAANAKAN, 62（84.9%）

they considered as reasonable. One explanation is that the

respondents rated their satisfaction level as high. Among

cost of a midwife-attended home delivery is higher at Php

those

11 （15.1%）

4,000. Although midwife-based home deliveries in SMDP

recommendations were made to improve infrastructure,offer installment payment schemes to families who cannot

equipment & supplies and human resources（knowledge,

afford to pay all at one time, respondents could feel moreskills and attitude）.

secure giving birth in a facility with more than one health

with

lower

satisfactionlevels,professional, emergency medical equipment and supplies.
４．Prioritization of factors
From a given set of choices, all 73 respondents wereSocio-cultural factors. Compared to other factors, theasked to provide their top three important factors thattrend factor received the least number of considerations.

motivated them to deliver at PAANAKAN. Fig. 2 illustrates

Since PAANAKAN was established, not all respondents

the three most common responses were location（n＝50,

would have noticed the trend of delivering in this new

68.5%）, perceived cost（n＝48, 65.8%）and the presence offacility. Another reason is that other factors may have been

relatives for help（n＝30, 41.1%）.

prioritized over the trend to deliver there.

Ⅳ．DISCUSSION

Most respondents made the decision themselves to

１．Motivating Factorsdeliver at PAANAKAN. At the same time, it was also foundPhysical Factors. Paranaque City constructed a newin this study that the educational attainment of respondents

birthing facility within the premises of the SMDP healthis mostly high school level or above. This finding iscenter with easy access. The presence and location of a newconsistent with another research claiming that education isfacility might lead respondents to deliver there. The

likely to enhance the status of women and enable them topresence of a new facility conveniently located within adevelop greater confidence and capacity to make decisions

vulnerable community could greatly increase theabout their own health４）.

accessibility to healthcare services.
The presence of relatives for help is considered in thisFinancial Factors. The majority of respondents took coststudy as various assistance from any relative willing to

into consideration in choosing where to deliver. This

provide support and care for respondents before and after

finding supports the results of another survey conducted

their delivery. This is most especially pronounced when

within Paranaque City that identified cost as a financial

services regularly offered in hospitals（e.g., serving ofbarrier for facility-based delivery３）. As PAANAKAN was

meals）is not available in birthing Facilities. The presence of

established to cater to the vulnerable population, this was

relatives to prepare the daily meals and attend to otheran expected result. However, this contradicts the finding

children of mothers（clients）becomes a crucial factor inthat more than half of the respondents believed that thedecision making. The World Health Organization

J. Natl. Inst. Public Health, 59（1）: 201067

Educational Report FY 2009：GORIN Team No. 2

recommends allowing mothers’ relatives to stay at thehaving respondents prioritize their top three mostfacility for assistance and support. The adoption of thisimportant factors, we can gauge the weight of each. This

strategy by the PAANAKAN has contributed largely to its

will identify the most commonly considered factors for

success as the presence of relatives for help was often

respondents.

considered by respondents.
Location was identified as the most important factor
Knowledge and experience. The skill of health workers

for delivering at PAANAKAN, followed by perceived costis an important component of quality of service. As

and the presence of relatives for help. These areinformation about the services, skills of health workers andcategorized into physical, financial and socio-cultural factors

experiences of mothers was often good, we can infer that

respectively. Previous studies show that these factors

the good reputation of the facility contributed as an

influence the decision of mothers as to the place ofenabling factor. Moreover, since all deliveries weredelivery５,６,８）.

previously facilitated at home, it is likely that there is nobaseline skill to compare with other than that fromtraditional birth attendants or midwives.

Prior to the establishment of PAANAKAN, residents of
SMDP could only choose from delivering in a hospital, abirthing facility in another district or at home. The high

Newly established facilities such as PAANAKAN arecost of hospital care and the inconvenience of traveling toprone to much speculation or doubt. In vulnerable

another district to deliver in a facility had pushed mothers

communities, the tendency to rely more on word-of-mouth

to deliver at the convenience of their own home for a lower

news or information from trusted sources such as

price. With the establishment of a new public birthingneighbors or other members of the same community who

facility within the vicinity of SMDP that offers standard

have utilized this facility. Shared subjective experiences offacility care at a competitive price, physical and financial

community members play a critical role in shaping the over-disabling factors may have been overcome. Furthermore,

all reputation of PAANAKAN and could have positively

as PAANAKAN is located within their community, relatives

affected a respondent’s choice to deliver there. In contrast

of respondents are more accessible for support. With this,to the other information received, the discouragement of

PAANAKAN has the advantage of physical, financial andhome deliveries is supported by new policies of Paranaquesocio-cultural enabling factors over other hospitals andCity and barangay SMDP. This might be one reason

private birthing facilities.

respondents considered this information.
３．Reasons respondents did not deliver at home
Many of the respondents received and considered advice

When asked in retrospect why mothers avoided home

to deliver at PAANAKAN during their prenatal checkup.

delivery, awareness of safe delivery and concerns

This is anticipated as health education campaigns towards

regarding the dangers of home delivery were mostfacility delivery are conducted during prenatal checkups

commonly identified. This awareness or gain in knowledge

and Mother’s Class Program. This strategy is consistentcoincides with the health education campaigns of thewith studies that show antenatal care as a strong factor for

PAANAKAN through prenatal checkups and the Mother’s

enticing women to choose hospital delivery care５,６）.

Class Program. In contrast to a previous survey done, theFurther studies show that the association between prenatal

reasons for home delivery reflected physical and financial

checkups and facility-based deliveries are due to thedisabling factors３）. The shift from identifying physical andmothers’ concerns and their willingness to learn about

financial barriers to improved knowledge and awarenessfacility-based deliveries７）. Therefore, advocating delivery atreflects how health education can affect behavioral change

PAANAKAN is an effective strategy to instill effective

and the decisions of respondents to deliver at a facility.

knowledge on facility delivery.

Since almost all respondents were primary decision
makers, health education programs that target expecting
mothers would be the most beneficial.

２．Prioritization of factors
Based on the results of this study, respondents haveconsidered nearly all factors presented except for the
popularity of giving birth at PAANAKAN. From this

４．Respondents recommendations for the improvementof PAANAKAN

perspective, it is difficult to identify the factors that areAmongst all respondents who gave recommendations,most influential for their decision to deliver at a facility. By

improvement in infrastructure, equipment and supplies was

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J. Natl. Inst. Public Health, 59（1）: 2010

Educational Report FY 2009：GORIN Team No. 2

the most popular answer. Respondents may also have felt

for respondents. However, the most common reasons

the need for a larger room to accommodate their need for a

respondents avoided home deliveries was related to theircompanion or relative to stay with them. This reflected theirknowledge on the dangers of home deliveries. Thispreference to use more updated equipment, more medical

inconsistency

supplies, medicines and better nursing supplies such as

interventions from the local government unit such as healthbedding. The second most common recommendation was

education campaigns（prenatal checkup and Mother’s Class）

to maintain the already good services. This shows theand new policies of Paranaque City to discourage home

effort of PAANAKAN to fully utilize all available resourcesdeliveries.

may

have

been

brought

about

byas this facility was initially funded by support agencies. The
third most popular answer was to improve human resource

In contrast to the most common motivating factors

knowledge, skills and attitude, which includes theidentified, the presence of a facility, its equipment andrecommendation to improve the health education skills ofprofessional health and the inconvenience of home delivery

staff. This is reflective of our respondents’ eagerness towere less common compared to knowledge or awareness ofreceive better and more comprehensive health advice fromensuring safe deliveries. Therefore, despite interventions,the PAANAKAN health workers which eventually creates

the location and presence of an equipped facility is still antrust between the client and provider.

important underlying concern for respondents.

The least number of recommendations pertained to

Ⅵ．Limitations of study

improving the financing scheme of PAANAKAN to render

The survey, conducted in SMDP, relied on volunteer

the facility even more financially accessible for the mostbarangay health workers to gather respondents in chosen

economically deprived populations. This shows that anareas. Subsequently, health volunteers and some community

improvement of financing schemes was not given muchmembers explained questions and watched respondents

priority among respondents, as opposed to a previous

answer questionnaires. This may have resulted to bias thesurvey done２）. Taking into consideration the averageappraisal of PAANAKAN. Furthermore, the results of thisamount respondents were willing to pay for delivery

research apply only to the respondents in this study andservices, it can be seen that a majority believed that thecannot be a basis for generalizations of characteristics ofactual cost（≥Php 2,500）was reasonable. The low number

vulnerable populations within Paranaque City.

of recommendations to improve financing schemes is
consistent with the finding that more respondents believedthat a reasonable price for delivering at PAANAKAN is
higher than actual.

Ⅶ．Recommendations
An increase in knowledge on safe delivery as well as theefficacy of new policies on discouraging home deliveries
has become evident in respondents. In contrast to the

Recommendations from respondents serve as a reminder

results of previous research, it was found that the top

that despite the presence of a public birthing facility,

reasons for not delivering at home were more closely

inequity gaps in maternal health care service delivery still

related to their improved knowledge rather than theexists. Future assessments using the Urban HEART or

previously identified financial barrier３）. It is therefore

further studies should be carried out to attend to theserecommended that:（1）health education campaigns beremaining gaps.

strengthened and continued especially during prenatal
checkups; and（2）a structured feedback system be installed

Ⅴ．Conclusions

to follow-up with clients and eventually maintain adequate

Physical, financial, socio-cultural, and knowledge andexperience factors were all considered by respondents prior
to their decision to deliver at PAANAKAN Birthing Facility.

health services.

Ⅷ．Acknowledgements
We would like to express our gratitude to the University

Physical factors were identified as the most commonof Philippines College of Public Health, Paranaque City

motivating factor for respondents to deliver at PAANAKAN

Health Office, staff and barangay health workers of theBirthing Facility. This was followed by financial and socio-

SMDP, its health center, PAANAKAN Birthing Facility andcultural factors that ranked second and third respectively.

members of the Gawad Kalinga. Finally, we would like toextend our deepest appreciation to the respondents of thisKnowledge factors were not important motivating factors

study.

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Nairobi, Kenya. Matern Child Health J.［serial on the

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