Using mass media campaigns to influence ‘place of birth’ decisions

There is a need to increase the number of deliveries by skilled birth attendants in Nepal in order to continue reduction of the maternal mortality ratio (MMR) and the rate of neonatal mortality. Researchers have already noted a decrease in MMR which can be attributed to various factors including better roads and increased numbers of health clinics. There have also been more mothers using health services for family planning, antenatal visits, skilled delivery, postnatal visits, and national policy and foreign aid has been directed towards achieving the Millennium Development Goals, one of which is improved maternal health.1 Using a skilled birth attendant for childbirth (defined broadly as a midwife, doctor or nurse trained in safe childbirth techniques) is assumed to be one of the most important factors that can provide optimum outcomes for mothers and their newborns.1

Mothers in Nepal often deliver their babies at home unattended or with a family member only. This is particularly common in rural areas, and even more so in the mountainous areas, even though there may be a medical facility in the vicinity.3 Actions are needed to provide safer birthing environments with life-saving medications and skilled attendants. Mass media campaigns are one of the ways that knowledge brokers promote decisions to use skilled attendance at birth. The following quotation from the Overseas Development Institute’s report on maternal health offers one possible reason for the increasing numbers of parturient women using skilled birth attendants (and in this case, an institutional delivery), being a mass media campaign.1

Previously, we conducted only 40 or 50 deliveries in one year, but last year we had 190. I think there are several reasons for this: the MDGs, more doctors, awareness raising by female community health volunteers and radio and newspaper advertisements.’ – Medical superintendent in the mountain region.1

When mass media campaigns are used, high proportions of large populations are exposed to messages through use of media such as television, radio and newspapers.4 In countries where mothers-in-law and husbands make family decisions around maternity care and place of delivery, it is important to promote messages to all members of the public, not just to pregnant women who attend antenatal visits in a health care facility.3 Mass media messages can be promoted for a short or long period of time, and may be presented alone or linked to other program efforts.4 In order to have the intended benefits, the desired message should be derived from the use of the ‘knowledge to action process’. The knowledge to be presented needs to be selected and adapted to fit the local context.2 Promotion of the messages of health and safety through use of skilled birth attendants should be carefully considered to fit the culture. As the next step in the knowledge translation action cycle, barriers to knowledge use should be assessed. Barriers to changes in childbirth practices may involve geography, finances, gender or social inequities, or cultural norms. If policies are already in place to provide for transportation financing (the case currently in Nepal), then cultural norms may be one of the barriers addressed through mass media. The usual norm is childbirth unattended, but messages can also appeal specifically to the mothers-in-law and husbands to care for parturient women by adopting health-seeking behaviours for birth.

The intervention needs to be tailored to its users and the right media modalities selected. Radio is a mass media available in many rural Nepalese homes, stores, and community gathering places. Radio messages may be the most favorable way to reach the largest number of people, and can be disseminated in the home language or dialect of the community. Successful mass media campaigns can broadcast messages to many people repeatedly over time and at a low cost per person. Newspapers are also common but not all rural people are literate, especially women of childbearing age and their mothers-in-law. It is likely that if all members of the family hear the radio messages in their own language they may begin to discuss the health issue both within the family and within the community. If the campaign is successful, it may make the behaviour change a new cultural norm.
The next steps to see if the mass media campaign is working is to monitor the knowledge use and evaluate the outcomes through inquiry at the institutional and community levels.4

Together with mass media campaigns about the benefits of using a skilled birth attendant, required services and products must be made available. For childbirth, this means a clean and relatively comfortable room for delivery, essential life-saving medications and the ability to make referrals to higher level facilities if more assistance is needed for delivery, such as caesarean section or blood transfusions. A 24-hour availability of skilled birth attendant is also needed, as babies do not arrive on convenient schedules. Policies that are favourable to sustainability of satisfactory maternal health services and supportive to rural caregivers will help improve services and therefore reinforce behaviour changes in the public.

References
1. Engel J, Glennie J, Adhikari S, Bhattarai, Prasai D, Samuels F. ODI. (2013). Nepal’s story: understanding improvements in maternal health. Overseas Development Institute.

2. Graham I, Logan J, Harrison M, Straus S, Tetroe J, Caswell W, Robinson N. (2006). Lost in knowledge translation: time for a map?

3. MoHP, New Era and ICF International Inc. (2012) ‘Nepal Demographic and Health Survey 2011’. Kathmandu: MoHP, New Era and ICF International.

4. Wakefield M, Loken B. (2010). Use of mass media campaigns to change health behaviour. The Lancet. 376: 1261-1271.

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