Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys

Private sector quality of care for maternal, new-born, and child health in low-and-middle-income countries: a secondary review

The private sector has emerged as a crucial source of maternal, newborn, and child health (MNCH) care in many low- and middle-income countries (LMICs). Quality within the MNCH private sector varies and has not been established systematically. This study systematically reviews findings on private-sector delivery of quality MNCH care in LMICs through the six domains of quality care (QoC) (i.e., efficiency, equity, effectiveness, people-centered care, safety, and timeliness). We registered the systematic review with PROSPERO international prospective register of systematic reviews (registration number CRD42019143383) and followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement for clear and transparent reporting of systematic reviews and meta-analyses. Searches were conducted in eight electronic databases and two websites. For inclusion, studies in LMICs must have examined at least one of the following outcomes using qualitative, quantitative, and/or mixed-methods: maternal morbidity, maternal mortality, newborn morbidity, newborn mortality, child morbidity, child mortality, service utilization, quality of care, and/or experience of care including respectful care. Outcome data was extracted for descriptive statistics and thematic analysis. Of the 139 included studies, 110 studies reported data on QoC. Most studies reporting on QoC occurred in India (19.3%), Uganda (12.3%), and Bangladesh (8.8%). Effectiveness was the most widely measured quality domain with 55 data points, followed by people-centered care (n = 52), safety (n = 47), timeliness (n = 31), equity (n = 24), and efficiency (n = 4). The review showed inconsistencies in care quality across private and public facilities, with quality varying across the six domains. Factors such as training, guidelines, and technical competence influenced the quality. There were also variations in how domains like "people-centered care" have been understood and measured over time. The review underscores the need for clearer definitions of "quality" and practical QoC measures, central to the success of Sustainable Development Goals (SDGs) and equitable health outcomes. This research addresses how quality MNCH care has been defined and operationalized to understand how quality is delivered across the private health sector and the larger health system. Numerous variables and metrics under each QoC domain highlight the difficulty in systematizing QoC. These findings have practical significance to both researchers and policymakers.

Systematic Review Registration

https://bmjopen.bmj.com/content/10/2/e033141.long, Identifier [CRD42019143383].

Trends and geospatial distribution of stillbirths in Uganda, 2014-2020

INTRODUCTION

Uganda with 17.8 stillbirths per 1,000 deliveries in 2021, is among the countries with a high burden of stillbirths globally. In 2014, Uganda adopted the World Health Organization Every New-born Action Plan (ENAP), which targets < 10 stillbirths per 1,000 deliveries by 2035. Little is known about the trends of stillbirth burden since ENAP was introduced. We assessed the temporal, and spatial distribution of stillbirths, in Uganda, 2014-2020, to inform programming for safe pregnancies and deliveries.

METHODS

We obtained and analysed stillbirth surveillance data from the District Health Information System, 2014-2020. A stillbirth was defined as the death of a foetus > 28 weeks of pregnancy or weighing > 1000 g before or during birth and reported to a health facility. We calculated annual incidence rates of stillbirths per 1,000 deliveries at district, regional, and national levels. We used logistic regression to determine the significance of trends.

RESULTS

The overall national annual incidence of stillbirths decreased from 24/1,000 deliveries in 2014 to 17/1,000 deliveries in 2020. During the same period, reporting rates declined from 71% in 2014 to 46% in 2020. The central region continuously had the highest incidence rate for the past 5 years despite the largest decline (OR = 0.79; CI = 0.77-0.83, P < 0.001) while the eastern region had the smallest decline (OR = 0.59; CI = 0.57-0.61, P < 0.001). Districts with persistently high annual incidence rates of stillbirths (> 30/1000) included Mubende, Kalangala, Hoima, and Nebbi. There was no difference in the reporting rates of the most- vs. least-affected districts.

CONCLUSION

Even with suboptimal reporting, the incidence of stillbirths remained above the national target. Specific areas in the country appear to have particularly high stillbirth rates. We recommend continuous capacity building in managing pregnant women with an emphasis on the most affected districts, and investigation into the reasons for low reporting.

Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data

INTRODUCTION

Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.

METHODS

Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.

RESULTS

This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.

DISCUSSION

Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

Do private health providers help achieve Universal Health Coverage? A scoping review of the evidence from low-income countries

Universal Health Coverage (UHC) is the dominant paradigm in health systems research, positing that everyone should have access to a range of affordable health services. Although private providers are an integral part of world health systems, their contribution to achieving UHC is unclear, particularly in low-income countries (LICs). We scoped the literature to map out the evidence on private providers' contribution to UHC progress in LICs. Literature searches of PubMed, Scopus and Web of Science were conducted in 2022. A total of 1049 documents published between 2002 and 2022 were screened for eligibility using predefined inclusion criteria, focusing on formal as well as informal private health sectors in 27 LICs. Primary qualitative, quantitative and mixed-methods evidence was included, as well as original analysis of secondary data. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of the studies. Relevant evidence was extracted and analysed using an adapted UHC framework. We identified 34 papers documenting how most basic health care services are already provided through the private sector in countries such as Uganda, Afghanistan and Somalia. A substantial proportion of primary care, mother, child and malaria services are available through non-public providers across all 27 LICs. Evidence exists that while formal private providers mostly operate in well-served urban settings, informal and not-for-profit ones cater for underserved rural and urban areas. Nonetheless, there is evidence that the quality of the services by informal providers is suboptimal. A few studies suggested that the private sector fails to advance financial protection against ill-health, as costs are higher than in public facilities and services are paid out of pocket. We conclude that despite their shortcomings, working with informal private providers to increase quality and financing of their services may be key to realizing UHC in LICs.

A secondary analysis of the factors associated with women´s adequate utilization of antenatal care services during their last pregnancy in Uganda

BACKGROUND

Adequate antenatal care services (ANC) use is critical to identifying and reducing pregnancy risks. Despite the importance placed on adequate antenatal care service utilization, women in Uganda continue to underutilize antenatal care services. The primary goal of this study is to identify the factors associated with women's adequate utilization of antenatal care services in Uganda.

METHODS

Secondary data from the 2016 Uganda Demographic and Health Survey were used in this study. The study sample consists of 9,416 women aged 15 to 49 who reported giving birth in the five years preceding the survey. The adequate use of antenatal care services is the dependent variable. A woman who used antenatal care services at least four times is considered to have adequately used antenatal care services. We used univariate, bivariate, and multilevel logistic regression modelling to identify the factors associated with adequate utilization of antenatal care services. STATA version 14.2 was used to analyze the data.

RESULTS

The prevalence of adequate utilization of antenatal care services in Uganda was found to be 61.4%. Women with secondary or higher education were 32.0% (AOR = 1.32, 95% CI;1.07-1.63), employed women were 26.0% (AOR = 1.26, 95% CI;1.10-1.44), women who received high-quality antenatal care content were 78.0% (AOR = 1.78, 95% CI;1.58-2.02), and women who belong to the rich category of the wealth index bracket were 27.0% (AOR = 1.27, 95% CI;1.09-1.49), more likely to use antenatal care services adequately. Finally, the study discovered that women from less diverse ethnic communities were 15.0% (AOR, 0.85, 95%CI; 0.73-0.99) less likely to use antenatal care services adequately.

CONCLUSION

Women's adequate utilization of antenatal care was influenced by both community and individual-level characteristics. Policymakers must use a multi-sectoral approach to develop policies that address both individual and community-level characteristics.

Impacts of the COVID-19 Lockdown on Healthcare Inaccessibility and Unaffordability in Uganda

Several studies have reported adverse consequences of the COVID-19 lockdowns on the utilization of healthcare services across Africa. However, little is known about the channels through which lockdowns impacted healthcare utilization. This study focuses on unaffordability as a reason for not utilizing healthcare services. We estimate the causal impacts of the COVID-19 lockdown on healthcare inaccessibility and affordability in Uganda relative to the nonlockdown periods of the pandemic. We use nationally representative longitudinal household data and a household fixed-effects model to identify the impact of the lockdown on whether households could not access medical treatment and whether the reason for not getting care was the lack of money. We find that the lockdown in Uganda was associated with an 8.4% higher likelihood of respondents being unable to access healthcare when treatment was needed relative to the nonlockdown periods. This implies a 122% increase in the share of respondents unable to access healthcare. As lockdown restrictions eased, the likelihood of being unable to access medical treatment decreased. The main reason for the increase in inaccessibility was the lack of money, with a 71% increase in the likelihood of respondents being unable to afford treatment. We find little evidence that the effects of the lockdown differed by wealth status or area of residence. Our results indicate the need for policymakers to consider immediate social support for households as a strategy for balancing the disruptions caused by lockdowns.

Completion of four or more ANC visits among women of reproductive age in Iganga district in Uganda: a quantitative study on the role of service-level factors

BACKGROUND

Evidence indicates that antenatal care (ANC) has both indirect and direct effects on maternal and perinatal morbidity and mortality reduction. In Uganda, the ANC attendance rate stands at 97.3% for one visit, but 59.9% for four or more visits. Given the imminent shift to the eight-contact ANC model in Uganda, combined with a lack of universal coverage for completion of four ANC visits, there is need for research that provides information on the factors that differentiate completers of recommended ANC attendances from non-completers. The aim of this quantitative study was to assess service- level factors affecting completion of ANC attendance defined by completion of four or more visits among women of reproductive age in Iganga district in Uganda.

METHODS

Facility assessment scores on the service-level factors of interest for health facilities were obtained using a service level index tool. The relationship between the ANC completion rates of clients sampled from records at the health facilities and facility scores on service-level factors of interest were analyzed. Regression was conducted to determine the predictive relationship between ANC service availability, ANC service content, and ANC service organization, and completion of ANC attendance.

RESULTS

The model was statistically significant, χ2 (6) = 26.118, p ˂ 0.05, and accounted for approximately 17.3% of the variance of ANC attendance completion (R2 = .173). Completion of ANC attendance was primarily predicted by better timing of provision of ANC services, and to a lesser extent by higher levels of availability of medicines and medical supplies.

CONCLUSIONS

This study demonstrated that service-level factors have a predictive value for completion of ANC attendance. The findings can be used to improve availability, content, and organization of ANC services with the aim of enhancing positive experiences for clients and motivating them to complete the recommended number of ANC visits.

How equitable is utilization of maternal health services in Uganda? Implications for achieving universal health coverage

BACKGROUND

Maternal and neonatal mortality in Uganda remain persistently high. While utilisation of maternal health services has been shown to reduce the risk of maternal death, little is known about the inequalities in utilisation of maternal health services in Uganda. This study examined the inequalities in utilisation of maternal health services between 2006 and 2016 to draw implications for achieving universal health coverage.

METHODS

We used the Uganda Demographic Health Survey 2006, 2011 and 2016 to analyse inequalities in utilisation of antenatal care (ANC4+), skilled birth attendance (SBA), postnatal care (PNC) and a package of maternal health services. Equity ratios, concentration curves, concentration indices and regression analysis were used in the estimations.

RESULTS

Inequalities in utilization of single and a package of maternal health services reduced between 2005 and 2016, but remained pro-rich. Inequalities in utilisation of package of maternal health services were greater than for a single service. Women from the richest quintile were 4 times more likely to receive a package of care compared to the poorest women, but were just 1.5 times more likely to receive ANC4 + than those in the poorest quintile. In 2006 women in urban areas were 2.6 times more likely to receive a package of all three maternal health services than their rural counterpart and they had a relative advantage of 23.4% to utilize skilled birth delivery than the poorest women. Each additional year of schooling and living in urban areas was associated with 1.2 and 1.6% point increase in utilisation of a package of care respectively. Wealth, education and living in urban areas were positively associated with utilisation of all maternal healthcare.

CONCLUSION

Declining inequalities in utilisation of maternal healthcare reflect a move towards achieving universal health coverage in Uganda. Pro-rich, education and urban-biased inequalities, imply the need for targeted interventions for the poor, less educated and rural women. Targeted voucher schemes, free distribution of birth kits for poorer and rural women, community-level mobilization to improve uptake of postnatal care, and promoting women's education and incomes are feasible interventions to improve utilisation of maternal health services and equity.

Effects of timed and targeted counselling by community health workers on maternal and household practices, and pregnancy and newborn outcomes in rural Uganda

INTRODUCTION

Pregnancy and birth-related complications claim the lives of millions of women and newborns every year. Improving their survival chances remains an urgent global challenge, including in Uganda. Community health workers (CHWs) play a crucial role in bridging the gap between the community and the official health system in Uganda. Timed and targeted Counselling (ttC) is an individual-level behavioral change communication method used by CHWs, aimed at pregnant women and caregivers of children under the age of two.

AIM

This study examined whether the implementation of the ttC intervention by the CHWs was associated with improved household practices and outcomes during the pregnancy and newborn period.

METHODS

A multi-stage sampling technique was employed with a total of 749 participants in the intervention group (ttC intervention), and 744 participants in the control group (no ttC). Data on quality of maternal and household antenatal care (ANC) and essential newborn care (ENC) practices, as well as on pregnancy and newborn outcomes were collected through questionnaires from May 2018 to May 2020. McNemar's Chi-square tests were used to compare outcomes before and after implementation, and between the intervention and control group.

RESULTS

Results showed that, compared to baseline, ttC contributed significantly to the demand for quality of service during ANC, ENC and partner involvement in maternal and newborn health. In comparison to the control group, the ttC group showed significantly higher early ANC attendance rates and higher quality of ANC and ENC.

CONCLUSION

ttC is a comprehensive, goal-driven approach that seems to contribute to the improvement of quality of maternal and household practices, and pregnancy and newborn outcomes in Uganda.

TRIAL REGISTRATION

PACTR, PACTR202002812123868, registered on 25 February 2020, http://www.pactr.org/PACTR202002812123868.

Timing and Quality of Antenatal Care Among Adolescent Mothers in a Rural Community, Uganda

Background

Most adolescent mothers attend their first antenatal care (ANC) visit later than the recommended time while others do not receive good quality antenatal care (all the required components of ANC such as iron tablets). This study sought to examine the factors associated with timing of the first ANC visit and quality of ANC among adolescent mothers in Uganda.

Methods

This study was based on quantitative data from 248 adolescent mothers aged 10-19 years in Luuka district, Eastern Uganda. We selected adolescent mothers who were either pregnant or had infants aged 0-3 months. We used logistic regression to identify factors associated with timing and receipt of good quality ANC.

Results

The majority of the adolescents (82%) attended ANC for their most recent pregnancy. Of these, 47% made the first visit in the first trimester while 36% received good quality ANC. Having knowledge of danger signs in pregnancy was a determinant of both timing of first ANC visit (aOR = 2.89, 95% CI: 1.04-8.06) and receipt of good quality ANC (aOR = 6.57, 95% CI: 1.75-24.65). Other determinants for timing of first ANC visit were mother's age, partner's age, having ever given birth, decision maker on health care and daily earnings. Other determinants for quality of ANC included distance to health facility and knowledge of family planning methods.

Conclusion

This study recommends expanding the network of public health facilities further into the rural communities in the district as a means of bringing health services closer to adolescent mothers, deliberate efforts to equip adolescent girls with reproductive health information on pregnancy danger signs, and family planning and empowering adolescent girls to start income-generating activities.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens

BACKGROUND

Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA.

METHODS

We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning.

RESULTS

About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had <ANC4+ visits. The majority of the 366 districts in the three countries had ANC4+ coverage of 50-70%. In Kenya, 13% of districts had < 70% coverage, compared to 10% and 27% of the districts in Uganda and mainland Tanzania, respectively. Only one district in Kenya and ten districts in mainland Tanzania were likely met the target coverage. Six percent, 38%, and 50% of the districts had at most 5000 women with <ANC4+ visits in Kenya, Uganda, and mainland Tanzania, respectively, while districts with > 20,000 women having <ANC4+ visits were 38%, 1% and 1%, respectively. In many districts, ANC4+ coverage and likelihood of attaining the target coverage was lower among the poor, uneducated and those geographically marginalized from healthcare.

CONCLUSIONS

These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths.

Designed to Fail? Revisiting Uganda's Maternal Health Policies to Understand Policy Design Issues Underpinning Missed Targets for Reduction of Maternal Mortality Ratio (MMR): 2000-2015

BACKGROUND

Despite Uganda and other sub-Saharan African countries missing their maternal mortality ratio (MMR) targets for Millennium Development Goal (MDG) 5, limited attention has been paid to policy design in the literature examining the persistence of preventable maternal mortality. This study examined the specific policy interventions designed to reduce maternal deaths in Uganda and identified particular policy design issues that underpinned MDG 5 performance. We suggest a novel prescriptive and analytical (re)conceptualization of policy in terms of its fidelity to '3Cs' (coherence of design, comprehensiveness of coverage and consistency in application) that could have implications for future healthcare programming.

METHODS

We conducted a retrospective study. Sixteen Ugandan maternal health policy documents and 21 national programme performance reports were examined, and six key informant interviews conducted with national stakeholders managing maternal health programmes during the reference period 2000-2015. We applied the analytical framework of the 'three delay model' combined with a broader literature on 'policy mixing.'

RESULTS

Despite introducing fourteen separate policy instruments over 15 years with the goal of reducing maternal mortality, by the end of the MDG period in 2015, only 87.5% of the interventions for the three delays were covered with a notable lack of coherence and consistency evident among the instruments. The three delays persisted at the frontline with 70% of deaths by 2014 attributed to failures in referral policies while 67% of maternal deaths were due to inadequacies in healthcare facilities and trained personnel in the same period. By 2015, 37.3% of deaths were due to transportation issues.

CONCLUSION

The piecemeal introduction of additional policy instruments frequently distorted existing synergies among policies resulting in persistence of the three delays and missed MDG 5 target. Future policy reforms should address the 'three delays' but also ensure fidelity of policy design to coherence, comprehensiveness and consistency.

Does hospital variation in intrapartum-related perinatal mortality among caesarean births reflect differences in quality of care? Cross-sectional study in 21 hospitals in Burkina Faso

OBJECTIVES

To examine hospital variation in crude and risk-adjusted rates of intrapartum-related perinatal mortality among caesarean births.

DESIGN

Secondary analysis of data from the DECIDE (DECIsion for caesarean DElivery) cluster randomised trial postintervention phase.

SETTING

21 district and regional hospitals in Burkina Faso.

PARTICIPANTS

All 5134 women giving birth by caesarean section in a 6-month period in 2016.

PRIMARY OUTCOME MEASURE

Intrapartum-related perinatal mortality (fresh stillbirth or neonatal death within 24 hours of birth).

RESULTS

Almost 1 in 10 of 5134 women giving birth by caesarean experienced an intrapartum-related perinatal death. Crude mortality rates varied substantially from 21 to 189 per 1000 between hospitals. Variation was markedly reduced after adjusting for case mix differences (the median OR decreased from 1.9 (95% CI 1.5 to 2.5) to 1.3 (95% CI 1.2 to 1.7)). However, higher and more variable adjusted mortality persisted among hospitals performing fewer caesareans per month. Additionally, adjusting for caesarean care components did not further reduce variation (median OR=1.4 (95% CI 1.2 to 1.8)).

CONCLUSIONS

There is a high burden of intrapartum-related perinatal deaths among caesarean births in Burkina Faso and sub-Saharan Africa more widely. Variation in adjusted mortality rates indicates likely differences in quality of caesarean care between hospitals, particularly lower volume hospitals. Improving access to and quality of emergency obstetric and newborn care is an important priority for improving survival of babies at birth.

TRIAL REGISTRATION NUMBER

ISRCTN48510263.

Estimating global water, sanitation, and hygiene levels and related risks on human health, using global indicators data from 1990 to 2020

Water quality improvement, sanitation, and hygiene have been demonstrated to have positive impacts on health, social, and economic development. However, global understanding of water quality, sanitation, and hygiene is limited. The study extracted data from the Joint Monitoring Programme (WHO/UNICEF) and the Demographic and Health Surveys (DHS) to estimate global water, sanitation, and hygiene (WASH) levels. Statistical tools of univariate and multivariate analyses were used to process global access to WASH. Results show that men (53%) had access to safe water compared to women. Women (67%), on the other hand, demonstrated better hygiene practices than men (33%). In addition, adults had access to safe water compared to children, the elderly, and strangers. Globally, there is low water quality in landlock developing countries compared to small island developing states. The categorisation of countries into economic states of low, upper-middle, and high-income countries directly affects water quality, sanitation, and hygiene. Continentally, Africa recorded the least water quality, sanitation, and hygiene levels. Thus, African countries must learn from the best practice in governmental policies and management systems from other continents regarding water improvement, sanitation, and hygiene.

Continuum of care for maternal health in Uganda: A national cross-sectional study

Introduction

A continuum of maternal care approach can reduce gaps and missed opportunities experienced by women and newborns. We determined the level of coverage and factors associated with the continuum of maternal care in Uganda.

Methods

We used weighted data from the Uganda Demographic and Health Survey (UDHS) 2016. We included 10,152 women aged 15 to 49 years, who had had a live birth within five years preceding the survey. Stratified two-stage cluster sampling design was used to select participants. Continuum of maternal care was considered when a woman had at least four antenatal care (ANC) visits, had delivered in a health facility and they had at least one postnatal check-up within six weeks. We conducted multivariable logistic regression analysis to determine factors associated with completion of the continuum of maternal care using SPSS version 25.

Results

The level of coverage of complete continuum of maternal care was 10.7% (1,091) (95% CI: 10.0–11.2). About 59.9% (6,080) (95% CI: 59.0–60.8) had four or more antenatal visits while 76.6% (7,780) (95% CI: 75.8–77.5) delivered in a health facility and 22.5% (2,280) (95% CI: 21.5–23.2) attended at least one postnatal care visit within six weeks. The following factors were associated with continuum of maternal care; initiating ANC in the first trimester (AOR 1.49, 95% CI: 1.23–1.79), having secondary level of education (AOR 1.60, 95% CI: 1.15–2.22) and tertiary level of education (AOR 2.08 95% CI: 1.38–3.13) compared to no formal education, being resident in Central Uganda (AOR 1.44, 95% CI:1.11–1.89), Northern Uganda (AOR 1.35, 95% CI: 1.06–1.71) and Western Uganda (AOR 0.61, 95% CI: 0.45–0.82) compared to Eastern Uganda, and exposure to newspapers and magazines.

Conclusion

The level of coverage of the complete continuum of maternal care was low and varied across regions. It was associated with easily modifiable factors such as early initiation of ANC, exposure to mass media and level of education. Interventions to improve utilisation of the continuum of maternal care should leverage mass media to promote services, especially among the least educated and the residents of Western Uganda.

Individual-level and community-level factors associated with eight or more antenatal care contacts in sub-Saharan Africa: evidence from 36 sub-Saharan African countries

OBJECTIVE

To reduce maternal mortality, the WHO has been introducing several antenatal care (ANC) measures. Pregnancy-related preventable morbidity and mortality, on the other hand, remain alarmingly high. This study was conducted to estimate the magnitude and the factors associated with eight or more ANC visits in sub-Saharan Africa.

DESIGN

A population-based, cross-sectional investigation was conducted.

SETTING

Sub-Saharan African countries.

PARTICIPANTS

A total of 300 575 women from recent Demographic and Health Surveys (DHS) conducted in 36 sub-Saharan African countries from 2006 to 2018 were included in this study.

METHODS

The data were sourced from sub-Saharan African countries' recent DHS data set from 2006 to 2018. A multilevel logistic regression model was fitted to identify factors associated with ANC use. Adjusted OR, with 95% CI and a p value of less than 0.05, was employed to determine parameters linked to ANC use.

RESULTS

The pooled magnitude of eight or more ANC visits in sub-Saharan African countries was 6.8% (95% CI 6.7% to 6.9%). Residence, maternal education, husband's education, maternal occupation, wealth index, media exposure, contraceptive use and desired pregnancy were all positively associated with eight or more ANC visits in the multilevel logistic regression analysis, whereas birth order was negatively associated with eight or more ANC visits.

CONCLUSIONS

Compliance with the WHO guidelines on the minimum number of ANC contacts in sub-Saharan Africa is poor. We recommend that mother and child health programmes review existing policies and develop new policies to adopt, execute and address the obstacles to maintaining the WHO-recommended minimum of eight ANC interactions. Women's education, economic position, media exposure and family planning uptake should be prioritised and improved. Urgent intervention is required to meet the minimum of eight ANC contacts in sub-Saharan Africa.

Dimensions of women empowerment on access to antenatal care in Uganda: A further analysis of the Uganda demographic health survey 2016

BACKGROUND

Women empowerment has been viewed as a good strategy in the reduction of global maternal morbidity and mortality. Most of the recent studies in Uganda have focussed on antenatal care (ANC) frequency and the associated factors with no focus on the effect of women empowerment. Our study aims at examining the prevalence of optimal access to ANC by considering the timing of initiation, type of ANC provider and ANC frequency and their association with women empowerment.

METHODS

We used Uganda Demographic and Health Survey 2016 data of 9957 women aged 15-49 years. Multistage stratified sampling was used to select study participants and we conducted multivariable logistic regression to establish the association between women empowerment and access to ANC using Statistical package for the social sciences version 25.

RESULTS

Out of 9957 women, 2953 (29.7%: 95% CI: 28.5.0-30.2) had initiated ANC in first trimester, 6080 (61.1%: 95% CI: 60.4-62.3) had 4 or more ANC contacts, and 9880 (99.2%: 95% CI: 99.0-99.3) had received ANC from a skilled provider. Overall, 2399 (24.1%: 95% CI: 23.0-24.6) had optimal access to ANC. Economic empowerment and exposure to media were the only women empowerment indices that were positively associated with optimal access to ANC. Other factors that were significant include; region, wealth index, age, level of education and working status.

CONCLUSION

To ensure increased access to ANC, policy-makers and other stakeholders should prioritise the use of mass media in maternal health programs, equitable allocation of the limited financial resources with a focus on older, poor and uneducated women.

Effect of four or more antenatal care visits on facility delivery and early postnatal care services utilization in Uganda: a propensity score matched analysis

Introduction

Maternal mortality remains a global public health issue, more predominantly in developing countries, and is associated with poor maternal health services utilization. Antenatal care (ANC) visits are positively associated with facility delivery and postnatal care (PNC) utilization. However, ANC in itself may not lead to such association but due to differences that exist among users (women). The purpose of this study, therefore, is to examine the effect of four or more ANC visits on facility delivery and early PNC and also the effect of facility-based delivery on early PNC using Propensity Score Matched Analysis (PSMA).

Methods

The present study utilized the 2016 Uganda Demographic and Health Survey (UDHS) dataset. Women aged 15 – 49 years who had given birth three years preceding the survey were considered for this study. Propensity score-matched analysis was used to analyze the effect of four or more ANC visits on facility delivery and early PNC and also the effect of facility-based delivery on early PNC.

Results

The results revealed a significant and positive effect of four or more ANC visits on facility delivery [ATT (Average Treatment Effect of the Treated) = 0.118, 95% CI: 0.063 – 0.173] and early PNC [ATT = 0.099, 95% CI: 0.076 – 0.121]. It also found a positive and significant effect of facility-based delivery on early PNC [ATT = 0.518, 95% CI: 0.489 – 0.547].

Conclusion

Policies geared towards the provision of four or more ANC visits are an effective intervention towards improved facility-based delivery and early PNC utilisation in Uganda.

No increase in use of hospitals for childbirth in Tanzania over 25 years: Accumulation of inequity among poor, rural, high parity women

Improving childbirth care in rural settings in sub-Saharan Africa is essential to attain the commitment expressed in the Sustainable Development Goals to leave no one behind. In Tanzania, the period between 1991 and 2016 was characterized by health system expansion prioritizing primary health care and a rise in rural facility births from 45% to 54%. Facilities however are not all the same, with advanced management of childbirth complications generally only available in hospitals and routine childbirth care in primary facilities. We hypothesized that inequity in the use of hospital-based childbirth may have increased over this period, and that it may have particularly affected high parity (≥5) women. We analysed records of 16,080 women from five Tanzanian Demographic and Health Surveys (1996, 1999, 2004, 2010, 2015/6), using location of the most recent birth as outcome (home, primary health care facility or hospital), wealth and parity as exposure variables and demographic and obstetric characteristics as potential confounders. A multinomial logistic regression model with wealth/parity interaction was run and post-estimation margins analysis produced percentages of births for various combinations of wealth and parity for each survey. We found no reduction in inequity in this 25-year period. Among poorest women, lowest use of hospital-based childbirth (around 10%) was at high parity, with no change over time. In women having their first baby, hospital use increased over time but with a widening pro-rich gap (poorest women predicted use increased from 36 to 52% and richest from 40 to 59%). We found that poor rural women of high parity were a vulnerable group requiring specifically targeted interventions to ensure they receive effective childbirth care. To leave no one behind, it is essential to look beyond the average coverage of facility births, as such a limited focus masks different patterns and time trends among marginalised groups.

The Extent of Universal Health Coverage for Maternal Health Services in Eastern Uganda: A Cross Sectional Study

Objective

Monitoring essential health services coverage is important to inform resource allocation for the attainment of the Sustainable Development Goal 3. The objective was to assess service, effective and financial coverages of maternal healthcare services and their equity, using health and demographic surveillance site data in eastern Uganda.

Methods

Between Nov 2018 and Feb 2019, 638 resident women giving birth in 2017 were surveyed. Among them, 386 were randomly sampled in a follow-up survey (Feb 2019) on pregnancy and delivery payments and contents of care. Service coverage (antenatal care visits, skilled birth attendance, institutional delivery and one postnatal visit), effective coverage (antenatal and postnatal care content) and financial coverage (out-of-pocket payments for antenatal and delivery care and health insurance coverage) were measured, stratified by socio-economic status, education level and place of residence.

Results

Coverage of skilled birth attendance and institutional delivery was both high (88%), while coverage of postnatal visit was low (51%). Effective antenatal care was lower than effective postnatal care (38% vs 76%). Financial coverage was low: 91% of women made out-of-pocket payments for delivery services. Equity analysis showed coverage of institutional delivery was higher for wealthier and peri-urban women and these women made higher out-of-pocket payments. In contrast, coverage of a postnatal visit was higher for rural women and poorest women.

Conclusion

Maternal health coverage in eastern Uganda is not universal and particularly low for postnatal visit, effective antenatal care and financial coverage. Analysing healthcare payments and quality by healthcare provider sector is potential future research.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-021-03357-3.

Women's experiences of maternal and newborn health care services and support systems in Buikwe District, Uganda: A qualitative study

BACKGROUND

Uganda continues to have a high neonatal mortality rate, with 20 deaths per 1000 live births reported in 2018. A measure to reverse this trend is to fully implement the Uganda Clinical Guidelines on care for mothers and newborns during pregnancy, delivery and the postnatal period. This study aimed to describe women's experiences of maternal and newborn health care services and support systems, focusing on antenatal care, delivery and the postnatal period.

METHODS

We used triangulation of qualitative methods including participant observations, semi-structured interviews with key informants and focus group discussions with mothers. Audio-recorded data were transcribed word by word in the local language and translated into English. All collected data material were stored using two-level password protection or stored in a locked cabinet. Malterud's Systematic text condensation was used for analysis, and NVivo software was used to structure the data.

FINDINGS

Antenatal care was valued by mothers although not always accessible due to transport cost and distance. Mothers relied on professional health workers and traditional birth attendants for basic maternal services but expressed general discontentment with spousal support in maternal issues. Financial dependency, gender disparities, and lack of autonomy in decision making on maternal issues, prohibited women from receiving optimal help and support. Postnatal follow-ups were found unsatisfactory, with no scheduled follow-ups from professional health workers during the first six weeks.

CONCLUSIONS

Further focus on gender equity, involving women's right to own decision making in maternity issues, higher recognition of male involvement in maternity care and improved postnatal follow-ups are suggestions to policy makers for improved maternal care and newborn health in Buikwe District, Uganda.

Determinants of continued maternal care seeking during pregnancy, birth and postnatal and associated neonatal survival outcomes in Kenya and Uganda: analysis of cross-sectional, demographic and health surveys data

OBJECTIVES

To examine how maternal and sociodemographic factors determine continued care-seeking behaviour from pregnancy to postnatal period in Kenya and Uganda and to determine associated neonatal survival outcomes.

DESIGN

A population-based analysis of cross-sectional data using multinomial and binary logistic regressions.

SETTING

Countrywide, Kenya and Uganda.

PARTICIPANTS

Most recent live births of 24 502 mothers within 1-59 months prior to the 2014-2016 Demographic and Health Surveys.

OUTCOMES

Care-seeking continuum and neonatal mortality.

RESULTS

Overall, 57% of the mothers had four or more antenatal care (ANC) contacts, of which 73% and 41% had facility births and postnatal care (PNC), respectively. Maternal/paternal education versus no education was associated with continued care seeking in majority of care-seeking classes; relative risk ratios (RRRs) ranged from 2.1 to 8.0 (95% CI 1.1 to 16.3). Similarly, exposure to mass media was generally associated with continued care seekin; RRRs ranged from 1.8 to 3.2 (95% CI 1.2 to 5.4). Care-seeking tendency reduced if a husband made major maternal care-seeking decisions. Transportation problems and living in rural versus urban were largely associated with lower continued care use; RRR ranged from 0.4 to 0.7 (95% CI 0.3 to 0.9). The two lowest care-seeking categories with no ANC and no PNC indicated the highest odds for neonatal mortality (adjusted OR 4.2, 95% CI 1.6 to 10.9). 23% neonatal deaths were attributable to inadequate maternal care attendance.

CONCLUSION

Strategies such as mobile health specifically for promoting continued maternal care use up to postnatal could be integrated in the existing structures. Another strategy would be to develop and employ a brief standard questionnaire to determine a mother's continued care-seeking level during the first ANC visit and to use the information to close the care-seeking gaps. Strengthening the community health workers system to be an integral part of promoting continued care seeking could enhance care seeking as a stand-alone strategy or as a component of aforementioned suggested strategies.

Lived experiences of frontline healthcare providers offering maternal and newborn services amidst the novel corona virus disease 19 pandemic in Uganda: A qualitative study

BACKGROUND

The COVID-19 pandemic has brought many health systems in low resource settings to their knees. The pandemic has had crippling effects on the already strained health systems in provision of maternal and newborn healthcare. With the travel restrictions, social distancing associated with the containment of theCOVID-19 pandemic, healthcare providers could be faced with challenges of accessing their work stations, and risked burnout as they offered maternal and newborn services. This study sought to understand the experiences and perceptions of healthcare providers at the frontline during the first phase of the lockdown as they offered maternal and newborn health care services in both public and private health facilities in Uganda with the aim of streamlining patient care in face of the current COVID-19 pandemic and in future disasters.

METHODS

Between June 2020 and December 2020, 25 in-depth interviews were conducted among healthcare providers of different cadres in eight Public, Private-Not-for Profit and Private Health facilities in Kampala, Uganda. The interview guide primarily explored the lived experiences of healthcare providers as they offered maternal and newborn healthcare services during the COVID-19 pandemic. All of the in depth interviews were audio recorded and transcribed verbatim. Themes and subthemes were identified using both inductive thematic and phenomenological approaches.

RESULTS

The content analysis of the in depth interviews revealed that the facilitators of maternal and newborn care service delivery among the healthcare providers during the COVID-19 pandemic included; salary bonuses, the passion to serve their patients, availability of accommodation during the pandemic, transportation to and from the health facilities by the health facilities, teamwork, fear of losing their jobs and fear of litigation if something went wrong with the mothers or their babies. The barriers to their service delivery included; lack of transport means to access their work stations, fear of contracting COVID-19 and transmitting it to their family members, salary cuts, loss of jobs especially in the private health facilities, closure of the non-essential services to combat high patient numbers, inadequate supply of Personal Protective equipment (PPE), being put in isolation or quarantine for two weeks which meant no earning, brutality from the security personnel during curfew hours and burnout from long hours of work and high patient turnovers.

CONCLUSION

The COVID-19 Pandemic has led to a decline in quality of maternal and newborn service delivery by the healthcare providers as evidenced by shorter consultation time and failure to keep appointments to attend to patients. Challenges with transport, fears of losing jobs and fear of contracting COVID-19 with the limited access to personal protective equipment affected majority of the participants. The healthcare providers in Uganda despite the limitations imposed by the COVID-19 pandemic are driven by the inherent passion to serve their patients. Availability of accommodation and transport at the health facilities, provision of PPE, bonuses and inter professional teamwork are critical motivators that needed to be tapped to drive teams during the current and future pandemics.

Poor quality for the poor? A study of inequalities in service readiness and provider knowledge in Indonesian primary health care facilities

BACKGROUND

For many low and middle-income countries poor quality health care is now responsible for a greater number of deaths than insufficient access to care. This has in turn raised concerns around the distribution of quality of care in LMICs: do the poor have access to lower quality health care compared to the rich? The aim of this study is to investigate the extent of inequalities in the availability of quality health services across the Indonesian health system with a particular focus on differences between care delivered in the public and private sectors.

METHODS

Using the Indonesian Family Life Survey (wave 5, 2015), 15,877 households in 312 communities were linked with a representative sample of both public and private health facilities available in the same communities. Quality of health facilities was assessed using both a facility service readiness score and a knowledge score constructed using clinical vignettes. Ordinary least squares regression models were used to investigate the determinants of quality in public and private health facilities.

RESULTS

In both sectors, inequalities in both quality scores existed between major islands. In public facilities, inequalities in readiness scores persisted between rural and urban areas, and to a lesser extent between rich and poor communities.

CONCLUSION

In order to reach the ambitious stated goal of reaching Universal Health Coverage in Indonesia, priority should be given to redressing current inequalities in the quality of care.

Over-nutrition and associated factors among 20 to 49-year-old women in Uganda: evidence from the 2016 Uganda demographic health survey

Introduction

low- and middle-income countries are currently faced with a double burden of malnutrition. There has, however, been little focus on research and interventions for women with over-nutrition. We aimed to determine the prevalence and factors associated with over-nutrition among 20 to 49-year-old women in Uganda.

Methods

we used the Uganda demographic and health survey (UDHS) 2016 data of 4,640 women. We analysed data using SPSS (version 25), and we used multivariable logistic regression to determine factors associated with over-nutrition among 20 to 49-year-old women in Uganda.

Results

the prevalence of over-nutrition was 28.2% (95% confidence interval (CI): 26.8-29.4) with overweight at 19.3% and obesity at 8.9%. Women belonging to the poorer (adjusted odds ratio (AOR)=1.63; 95% CI: 1.17-2.28), middle (AOR=2.24; 95% CI: 1.61-3.13), richer (AOR=3.02; 95% CI: 2.14-4.25) and richest (AOR=6.35; 95% CI: 4.52-8.93) wealth index quintiles were more likely to be over-nourished compared to women in the poorest wealth index quintile. Married women (AOR=1.52; 95% CI: 1.26-1.83) were more likely to be over-nourished compared to non-married women. Older women were more likely to be over-nourished compared to younger women. Women in the Western (AOR=2.12; 95% CI: 1.66-2.71), Eastern (AOR=1.40; 95% CI: 1.04-1.88) and Central (AOR=2.25; 95% CI: 1.69-2.99) regions were more likely to be over-nourished compared to women in the Northern region.

Conclusion

the design of multi-faceted over-nutrition reduction programs with an emphasis on older, married, financially stable women, and those living in the Western, Eastern and Central regions of the country is needed.

Factors associated with health facility utilization during childbirth among 15 to 49-year-old women in Uganda: evidence from the Uganda demographic health survey 2016

BACKGROUND

Almost all maternal deaths and related morbidities occur in low-income countries. Childbirth supervised by a skilled provider in a health facility is a key intervention to prevent maternal and perinatal morbidity and mortality. Our study aimed to establish the factors associated with health facility utilization during childbirth in Uganda.

METHODS

We used the Uganda Demographic and Health Survey 2016 data of 10,152 women aged 15 to 49 years. The study focused on their most recent live birth in 5 years preceding the survey. We applied multistage stratified sampling to select study participants and we conducted multivariable logistic regression to establish the factors associated with health facility utilization during childbirth, using SPSS (version 25).

RESULTS

The proportion of women who gave birth at a health facility was 76.6% (7780/10,152: (95% confidence interval, CI, 75.8-77.5). The odds of women aged 15-19 years giving birth at health facilities were twice as those of women aged 40 to 49 years (adjusted odds ratio, AOR = 2.29; 95% CI: 1.71-3.07). Residing in urban areas and attending antenatal care (ANC) were associated with health facility use. The odds of women in the northern region of Uganda using health facilities were three times of those of women in the central region (AOR = 3.13; 95% CI: 2.15-4.56). Women with tertiary education (AOR = 4.96; 95% CI: 2.71-9.11) and those in the richest wealth quintile (AOR = 4.55; 95% CI: 3.27-6.32) had higher odds of using a health facility during child birth as compared to those with no education and those in the poorest wealth quintile, respectively. Muslims, Baganda, women exposed to mass media and having no problem with distance to health facility had higher odds of utilizing health facilities during childbirth as compared to Catholic, non Baganda, women not exposed to mass media and those having challenges with distance to access healthcare.

CONCLUSION

Health facility utilization during childbirth was high and it was associated with decreasing age, increasing level of education and wealth index, urban residence, Northern region of Uganda, ANC attendance, exposure to mass media, tribe, religion and distance to the nearby health facility. We recommend that interventions to promote health facility childbirths in Uganda target the poor, less educated, and older women especially those residing in rural areas with less exposure to mass media.

Mobility for maternal health among women in hard-to-reach fishing communities on Lake Victoria, Uganda; a community-based cross-sectional survey

BACKGROUND

Maternal mortality is still a challenge in Uganda, at 336 deaths per 100,000 live births, especially in rural hard to reach communities. Distance to a health facility influences maternal deaths. We explored women's mobility for maternal health, distances travelled for antenatal care (ANC) and childbirth among hard-to-reach Lake Victoria islands fishing communities (FCs) of Kalangala district, Uganda.

METHODS

A cross sectional survey among 450 consenting women aged 15-49 years, with a prior childbirth was conducted in 6 islands FCs, during January-May 2018. Data was collected on socio-demographics, ANC, birth attendance, and distances travelled from residence to ANC or childbirth during the most recent childbirth. Regression modeling was used to determine factors associated with over 5 km travel distance and mobility for childbirth.

RESULTS

The majority of women were residing in communities with a government (public) health facility [84.2 %, (379/450)]. Most ANC was at facilities within 5 km distance [72 %, (157/218)], while most women had travelled outside their communities for childbirth [58.9 %, (265/450)]. The longest distance travelled was 257.5 km for ANC and 426 km for childbirth attendance. Travel of over 5 km for childbirth was associated with adolescent girls and young women (AGYW) [AOR = 1.9, 95 % CI (1.1-3.6)], up to five years residency duration [AOR = 1.8, 95 % CI (1.0-3.3)], and absence of a public health facility in the community [AOR = 6.1, 95 % CI (1.4-27.1)]. Women who had stayed in the communities for up to 5 years [AOR = 3.0, 95 % CI (1.3-6.7)], those whose partners had completed at least eight years of formal education [AOR = 2.2, 95 % CI (1.0-4.7)], and those with up to one lifetime birth [AOR = 6.0, 95 % CI (2.0-18.1)] were likely to have moved to away from their communities for childbirth.

CONCLUSIONS

Despite most women who attended ANC doing so within their communities, we observed that majority chose to give birth outside their communities. Longer travel distances were more likely among AGYW, among shorter term community residents and where public health facilities were absent.

TRIAL REGISTRATION

PACTR201903906459874 (Retrospectively registered). https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5977 .

Underweight and associated factors among lactating women in Uganda: Evidence from the Uganda demographic health survey 2016

BACKGROUND

Lactating mothers are at increased risk of being underweight because of the physiological changes that lead to disproportionately higher energy and nutrient requirements compared to their non-pregnant and non-lactating counterparts.

OBJECTIVE

We aimed to determine the prevalence and factors associated with being underweight among lactating women in Uganda.

METHODS

We used the Uganda Demographic and Health Survey (UDHS) 2016 data of 1356 women aged 20 to 49 years. Multistage stratified sampling was used to select study participants. The data were collected using validated questionnaires. We used multivariable logistic regression to determine factors associated with underweight among 20 to 49-year-old lactating women in Uganda.

RESULTS

The prevalence of underweight was 8.2% (111/1356) (95% confidence interval, [CI]: 7.0-10.0). Women who had no education were 10.21 (adjusted odds ratio, [AOR] = 10.21; 95% CI: 1.61-64.74) times as likely to be underweight as those who had higher (post-secondary) education levels. Women who were not working were 50% (AOR = 0.50; 95% CI: 0.26-0.94) less likely to be underweight compared to those who were working. Women in the Western (AOR = 0.15; 95% CI: 0.07-0.32), Eastern (AOR = 0.34; 95% CI: 0.18-0.66), and Central (AOR = 0.30; 95% CI: 0.12-0.74) regions were 85%, 66% and 70% respectively less likely to be underweight compared to those in the Northern region.

CONCLUSION

Based on the findings of this and other studies, it is important for the different stakeholders to design targeted nutrition programs for lactating women particularly those with low levels of education and those from the Northern region.

Impact of cesarean section on timely initiation of breastfeeding in Ethiopia: a systematic review and meta-analysis

Background

Timely initiation of breastfeeding is feeding of breast milk within one hour of birth, however, three in five babies were not breastfed in the first hour of birth globally. There is evidence that cesarean section is the major constraint for this low prevalence, but the impact of cesarean section on timely initiation of breastfeeding in Ethiopia is limited. Therefore, this meta-analysis aimed to provide evidence for policy makers, health professionals and program implementers.

Methods

This systematic review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Electronic bibliographic databases such as PubMed/Medline, EMBASE, PsycINFO, CINHAL, Scopus, Google Scholar, Science Direct and Cochrane Library were used to search relevant studies and was conducted up to February 2021. Random effects model meta-analysis was applied to estimate the pooled impact of cesarean section on timely initiation of breastfeeding with 95% confidence intervals (CI). I² statistical test and, funnel plot and Egger’s test were used to check heterogeneity and publication bias across included studies respectively.

Results

According to meta-analysis of 17 studies, the pooled estimate of timely initiation of breastfeeding among women who had cesarean section in Ethiopia was 40.1% (95% CI 33.29, 46.92). The meta-analysis of 29,919 study participants showed that cesarean section was associated with a 79% lower odds of timely initiation of breastfeeding compared with vaginal birth (OR 0.21; 95% CI 0.16, 0.28).

Conclusions

In Ethiopia, almost only one-third of mothers who gave birth by cesarean section initiate breastfeeding within one hour of birth, much lower than the pooled prevalence among general population. Special health promotion, intervention and healthcare provider support during immediate or early skin to skin contact, and having focused breastfeeding guidelines for post-operative patient and trained health professionals should be considered for mothers who give birth through cesarean section.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00399-9.

Immediate postnatal care following childbirth in Ugandan health facilities: an analysis of Demographic and Health Surveys between 2001 and 2016

Introduction

Progress in reducing maternal and neonatal mortality, particularly in sub-Saharan Africa, is insufficient to achieve the Sustainable Developmental Goals by 2030. The first 24 hours following childbirth (immediate postnatal period), where the majority of morbidity and mortality occurs, is critical for mothers and babies. In Uganda,<50% of women reported receiving such care. This paper describes the coverage, changes over time and determinants of immediate postnatal care in Uganda after facility births between 2001 and 2016.

Methods

We analysed the 2006, 2011 and 2016 Ugandan Demographic and Health Surveys, including women 15–49 years with most recent live birth in a healthcare facility during the survey 5-year recall period. Immediate postnatal care coverage and changes over time were presented descriptively. Multivariable logistic regression was used to examine determinants of immediate postnatal care.

Results

Data from 12 872 mothers were analysed. Between 2006 and 2016, births in healthcare facilities increased from 44.6% (95% CI: 41.9% to 47.3%) to 75.2% (95% CI: 73.4% to 77.0%) and coverage of immediate maternal postnatal care from 35.7% (95% CI 33.4% to 38.1%) to 65.0% (95% CI: 63.2% to 66.7%). The majority of first checks occurred between 1 and 4 hours post partum; the median time reduced from 4 hours to 1 hour. The most important factor associated with receipt of immediate postnatal care was women having a caesarean section birth adjusted OR (aOR) 2.93 (95% CI: 2.28 to 3.75). Other significant factors included exposure to mass media aOR 1.38 (95% CI: 1.15 to 1.65), baby being weighed at birth aOR 1.84 (95% CI: 1.58 to 2.14) and receipt of antenatal care with 4+Antenatal visits aOR 2.34 (95% CI: 1.50 to 3.64).

Conclusion

In Uganda, a large gap in coverage remains and universal immediate postnatal care has not materialised through increasing facility-based births or longer length of stay. To ensure universal coverage of high-quality care during this critical time, we recommend that maternal and newborn services should be integrated and actively involve mothers and their partners.

Prevalence and factors associated with sexual violence among women aged 15-49 years in rural Uganda: evidence from the Uganda Demographic and Health Survey 2016

OBJECTIVES

Sexual violence is a serious global health problem with short- and long-term physical, mental, and reproductive adverse effects. This study aimed to determine the prevalence and factors associated with sexual violence among women of reproductive age in rural Uganda.

STUDY DESIGN

This was a cross-sectional study based on the Uganda Demographic and Health Survey (UDHS) 2016 data.

METHODS

UDHS 2016 data for 5259 rural women aged 15-49 years were used in this study. Multistage stratified sampling was used to select participants, and data were collected using validated questionnaires. Multivariable logistic regression was used to determine factors associated with sexual violence. All analyses we carried out in SPSS (version 25).

RESULTS

The overall prevalence of sexual violence among rural women was 24.3% (95% confidence interval [CI]: 23.4-25.7) compared with 18.4% (95% CI: 17.0-20.7) among urban women. Rural women who had received only primary education had higher odds of sexual violence compared with those who had received tertiary education (adjusted odds ratio [AOR] = 3.01, 95% CI: 1.17-7.72). Women living in the Western region were more likely to experience sexual violence than those living in the Northern region of Uganda (AOR = 2.01, 95% CI: 1.41-2.87). In addition, women in the poorest wealth quintile had higher odds of sexual violence compared with those in the richest quintile (AOR = 2.06, 95% CI: 1.02-4.17). Women justifying beating, health care decision-making, and husband's/partner's frequency of getting drunk were also significantly associated with sexual violence.

CONCLUSIONS

The prevalence of sexual violence among rural Ugandan women was high and is associated with factors such as educational level, region, wealth index, justified beating, health care decision-making, and husband's/partner's frequency of getting drunk. Thus, there is a need to improve the livelihoods and income of rural women, including the promotion of continued education for girls, as well as to strengthen protective laws and policies to curb this public health issue.

The Ambiguity Imperative: "Success" in a Maternal Health Program in Uganda

Global health programs are compelled to demonstrate impact on their target populations. We study an example of social franchising - a popular healthcare delivery model in low/middle-income countries - in the Ugandan private maternal health sector. The discrepancies between the program's official profile and its actual operation reveal the franchise responded to its beneficiaries, but in a way incoherent with typical evidence production on social franchises, which privileges simple narratives blurring the details of program enactment. Building on concepts of not-knowing and the production of success, we consider the implications of an imperative to maintain ambiguity in global health programming and academia.

Determinants of the continuum of maternal health care in Cambodia: an analysis of the Cambodia demographic health survey 2014

Introduction

Cambodia has achieved significant progress in maternal health, yet remains in the group of countries with the highest maternal mortality ratio in South-East Asia. Extra efforts are needed to improve maternal health through assessing the coverage of maternal health services as a continuum of care (CoC) and identifying the gaps. Our study aims to explore the coverage level of the Optimal CoC by (1) measuring the continuity of optimal antenatal care (ANC), skilled birth attendance (SBA) and optimal post-natal care (PNC), (2) identifying the determinants of dropping out from one service to another and (3) of not achieving the complete CoC.

Method

The study employed data from the Cambodia Demographic Health Survey 2014. We restricted our analysis to married women who had a live birth in the five years preceding the survey (n = 5678). Bi-variate and multivariate logistic regression were performed using STATA version 14.

Results

Almost 50% of women had achieved the complete optimal CoC, while the remaining have used only one or two of the services. The result shows that the level of women’s education was positively associated with the use of optimal ANC, the continuation to using optimal PNC and achieving the complete CoC. More power of women in household decision making was also positively associated with receiving the complete CoC. The birth order was negatively associated with achieving the complete CoC, while exposure to the mass media and having health insurance increased the odds of achieving the complete CoC. Household wealth consequently emerged as an influential predictor of dropping out and not achieving the complete CoC. Receiving all different elements of ANC care improved the continuity of care from optimal ANC to SBA and from SBA to optimal ANC.

Conclusion

The findings urge policy makers to approach maternal health care as a continuum of care with different determinants at each step. Household wealth was found to be the most influential factor, yet the study discovered also other barriers to optimal maternal health care which need to be addressed: future intervention should thus not only aim to increase wealth or health insurance coverage but also stimulate the education of women and empower women to claim power in household decision-making.

Hepatitis B birth dose vaccination for newborns in Uganda: A qualitative inquiry on pregnant women's perceptions, barriers and preferences

BACKGROUND

Sub-Saharan Africa continues with very low hepatitis B (HBV) birth dose vaccination coverage. To guide policy on HBV vaccine for newborns, we explored perceptions, barriers and preferences of pregnant women regarding HBV and the HBV birth dose vaccination.

METHODS

We conducted eight focus groups discussions (FGDs) among 70 pregnant women, stratified by rural-urban residence, age and education level, using a structured focus group discussion guide to explore birth dose awareness, perceptions, barriers and preferences. Data were transcribed, coded and analysed using framework analysis.

RESULTS

Perceptions related to HBV and liver cancer causes and prevention were diverse; most FGD participants did not perceive illnesses as distinctly different. Older women-groups, both urban and rural, had never heard about HBV, but were aware of liver cancer, viewing the disease as fatal. No FGD participants were aware of HBV birth dose. Concerns included vaccine safety, its availability to women who deliver outside the health system and mistrust in health-care worker (HCWs) when handling newborns. Rural-dwelling groups perceived absence of HBV services, while FGDs with young participants believed vaccine side-effects hampered birth dose planning. Most women-groups preferred (i) oral to injectable vaccines; (ii) receiving birth dose education during antenatal, to media-based education; (iii) that newborns receive the birth dose immediately after delivery in the mother's presence.

CONCLUSION

Although the birth dose is acceptable among pregnant women, planners need to continuously engage them as key stakeholders during planning to address concerns, in order to raise confidence, maximize uptake and strengthen HBV eradication efforts.

Can the Timed and Targeted Counseling Model Improve the Quality of Maternal and Newborn Health Care? A Process Analysis in the Rural Hoima District in Uganda

Each year, more than half a million women die worldwide from causes related to pregnancy and childbirth, and nearly 4 million newborns die within 28 days of birth. In Uganda, 15 women die every single day from pregnancy and childbirth-related causes, 94 babies are stillborn, and 81 newborn babies die. Cost-effective solutions for the continuum of care can be achieved through Village Health Teams to improve home care practices and health care-seeking behavior. This study aims at examining the implementation of the timed and targeted counseling (ttC) model, as well as improving maternal and newborn health care practices. We conducted a quantitative longitudinal study on pregnant mothers who were recruited on suspicion of the pregnancy and followed-up until six weeks post-delivery. The household register was the primary data source, which was collected through a secondary review of the ttC registers. All outcome and process variables were analyzed using descriptive statistics. The study enrolled 616 households from 64 villages across seven sub-counties in Hoima district with a 98.5% successful follow-up rate. Over the course of the implementation period of ttC, there was an increase of 29.6% in timely 1st antenatal care, 28.7% in essential newborn care, 25.5% in exclusive breastfeeding, and 17.5% in quality of antenatal care. All these improvements were statistically significant. The findings from this study show that the application of the ttC model through Village Health Teams has great potential to improve the quality of antenatal and newborn care and the health-seeking practices of pregnant and breastfeeding mothers in rural communities.

Viewpoints of pregnant mothers and community health workers on antenatal care in Lweza village, Uganda

BACKGROUND

Uganda is a low-income country with high fertility, adolescent birth, and maternal mortality rates. How Ugandan Ministry of Health antenatal education guidelines have been implemented into standardized health education and how pregnant women utilize health facilities remains unclear.

OBJECTIVE

We aimed to determine how women obtain education during pregnancy, what guidelines health educators follow, and what barriers exist to receiving antenatal care in Lweza Village, Uganda.

METHODS

Household surveys were conducted with women in Lweza who were or had previously been pregnant. Focus group discussions were conducted with community members and Lweza Primary School teachers. Interviews were conducted with key informants, including midwives, a traditional birth attendant, a community leader, and a Village Health Team member. Data collection was done in English along with a Luganda translator.

RESULTS

Of the 100 household surveys conducted, 86% of women did not meet the WHO recommendation of 8 antenatal appointments during their pregnancies. Reasons cited for inadequate visits included facing long wait times (>7 h) at health facilities, getting education from family or traditional healers, or being told to delay antenatal care until 6 months pregnant. Informant interviews revealed that no standardized antenatal education program exists. Respondents felt least educated on family planning and postpartum depression, despite 37% of them reporting symptoms consistent with postpartum depression. Education was also lacking on the use of traditional herbs, although most women (60%) reported using them during pregnancy.

CONCLUSIONS

Most women in Lweza do not receive 8 antenatal appointments during their pregnancies or any standardized antenatal education. Educational opportunities on family planning, postpartum depression, and the safety of traditional herbs during pregnancy exist. Future studies should focus on ways to overcome barriers to antenatal care, which could include implementing community-based education programs to improve health outcomes for women in Lweza Village.

Factors associated with undernutrition among 20 to 49 year old women in Uganda: a secondary analysis of the Uganda demographic health survey 2016

BACKGROUND

Women are at risk of undernutrition due to biological, socio-economic, and cultural factors. Undernourished women have higher risk of poor obstetric outcomes. We aimed to determine the prevalence and factors associated with undernutrition among women of reproductive age in Uganda.

METHODS

We used Uganda Demographic and Health Survey (UDHS) 2016 data of 4640 women aged 20 to 49 years excluding pregnant and post-menopausal women. Multistage stratified sampling was used to select study participants and data were collected using validated questionnaires. We used multivariable logistic regression to determine factors associated with underweight and stunting among 20 to 49 year old women in Uganda.

RESULTS

The prevalence of underweight and stunting were 6.9% (318/4640) and 1.3% (58/4640) respectively. Women who belonged to the poorest wealth quintile (Adjusted Odds Ratio (AOR) 3.60, 95% CI 1.85-7.00) were more likely to be underweight compared to those who belonged to the richest wealth quintile. Women residing in rural areas were less likely to be underweight (AOR 0.63, 95%CI 0.41-0.96) compared to women in urban areas. Women in Western (AOR 0.30, 95% CI 0.20-0.44), Eastern (AOR 0.42, 95% CI 0.28-0.63) and Central regions (AOR 0.42, 95% CI 0.25-0.72) were less likely to be underweight compared to those in the Northern region. Women belonging to Central (AOR 4.37, 95% CI 1.44-13.20) and Western (AOR 4.77, 95% CI 1.28-17.78) regions were more likely to be stunted compared to those in the Northern region.

CONCLUSION

The present study showed wealth index, place of residence and region to be associated with undernutrition among 20 to 49 year old women in Uganda. There is need to address socio-economic determinants of maternal undernutrition mainly poverty and regional inequalities.

Components of antenatal care received by women in fishing communities on Lake Victoria, Uganda; a cross sectional survey

BACKGROUND

Uganda has one of the highest maternal deaths at a ratio of 336 per 100,000 live births. As Uganda strives to achieve sustainable development goals, appropriate antenatal care is key to reduction of maternal mortality. We explored women's reported receipt of seven of the Uganda guidelines components of antenatal care, and associated factors in hard to reach Lake Victoria island fishing communities of Kalangala district.

METHODS

A cross sectional survey among 486 consenting women aged 15-49 years, who were pregnant at any time in the past 6 months was conducted in 6 island fishing communities of Kalangala district, Uganda, during January-May 2018. Interviewer administered questionnaires, were used to collect data on socio-demographics and receipt of seven of the Uganda guidelines components of antenatal care. Regression modeling was used to determine factors associated with receipt of all seven components.

RESULTS

Over three fifths (65.0%) had at least one ANC visit during current or most recent pregnancy. Fewer than a quarter of women who reported attending care at least four times received all seven ANC components [(23.6%), P < 0.05]. Women who reported receipt of ANC from the mainland were twice as likely to have received all seven components as those who received care from islands (aOR = 1.8; 95% CI:0.9-3.7). Receipt of care from a doctor was associated with thrice likelihood of receiving all components relative to ANC by a midwife or nurse (aOR = 3.2; 95% CI:1.1-9.1).

CONCLUSIONS

We observed that the delivery of antenatal care components per Ugandan guidelines is poor in these communities. Cost effective endeavors to improve components of antenatal care received by women are urgently needed. Task shifting some components of ANC to community health workers may improve care in these island communities.

TRIAL REGISTRATION

PACTR201903906459874 (Retrospectively registered).

Population-level viral suppression among pregnant and postpartum women in a universal test and treat trial

OBJECTIVE(S)

We sought to determine whether universal 'test and treat' (UTT) can achieve gains in viral suppression beyond universal antiretroviral treatment (ART) eligibility during pregnancy and postpartum, among women living with HIV.

DESIGN

A community cluster randomized trial.

METHODS

The SEARCH UTT trial compared an intervention of annual population testing and universal ART with a control of baseline population testing with ART by country standard, including ART eligibility for all pregnant/postpartum women, in 32 communities in Kenya and Uganda. When testing, women were asked about current pregnancy and live births over the prior year and, if HIV-infected, had their viral load measured. Between arms, we compared population-level viral suppression (HIV RNA <500 copies/ml) among all pregnant/postpartum HIV-infected women at study close (year 3). We also compared year-3 population-level viral suppression and predictors of viral suppression among all 15 to 45-year-old women by arm.

RESULTS

At baseline, 92 and 93% of 15 to 45-year-old women tested for HIV: HIV prevalence was 12.6 and 12.3%, in intervention and control communities, respectively. Among HIV-infected women self-reporting pregnancy/live birth, prevalence of viral suppression was 42 and 44% at baseline, and 81 and 76% (P = 0.02) at year 3, respectively. Among all 15 to 45-year-old HIV-infected women, year-3 population-level viral suppression was higher in intervention (77%) versus control (68%; P < 0.001). Pregnancy/live birth was a predictor of year-3 viral suppression in control (P = 0.016) but not intervention (P = 0.43). Younger age was a risk factor for nonsuppression in both arms.

CONCLUSION

The SEARCH intervention resulted in higher population viral suppression among pregnant/postpartum women than a control of baseline universal testing with ART eligibility for pregnant/postpartum women.

Women's Choice to Deliver at Home: Understanding the Psychosocial and Cultural Factors Influencing Birthing Choices for Unskilled Home Delivery among Women in Southwestern Uganda

BACKGROUND

Utilization of perinatal services in Uganda remains low, with correspondingly high rates of unskilled home deliveries, which can be life-threatening. We explored psychosocial and cultural factors influencing birthing choices for unskilled home delivery among postpartum women in rural southwestern Uganda.

METHODS

We conducted in-depth qualitative face-to-face interviews with 30 purposively selected women between December 2018 and March 2019 to include adult women who delivered from their homes and health facility within the past three months. Women were recruited from 10 villages within 20 km from a referral hospital. Using the constructs of the Health Utilization Model (HUM), interview topics were developed. Interviews were conducted and digitally recorded in a private setting by a native speaker to elicit choices and experiences during pregnancy and childbirth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive categories using inductive content analytic approach.

RESULTS

Eighteen women (60%) preferred to deliver from home. Women's referent birth location was largely intentional. Overall, the data suggest women choose home delivery (1) because of their financial dependency and expectation for a "natural" and normal childbirth, affecting their ability and need to seek skilled facility delivery; (2) as a means of controlling their own birth processes; (3) out of dissatisfaction with facility-based care; (4) out of strong belief in fate regarding birth outcomes; (5) because they have access to alternative sources of birthing help within their communities, perceived as "affordable," "supportive," and "convenient"; and (6) as a result of existing gender and traditional norms that limit their ability and freedom to make family or health decisions as women.

CONCLUSION

Women's psychosocial and cultural understandings of pregnancy and child birth, their established traditions, birth expectations, and perceptions of control, need, and quality of maternity care at a particular birthing location influenced their past and future decisions to pursue home delivery. Interventions to address barriers to healthcare utilization through a multipronged approach could help to debunk misconceptions, increase perceived need, and motivate women to seek facility delivery.

Trends and determinants of adolescent childbirth in Uganda- analysis of rural and urban women using six demographic and health surveys, 1988-2016

Introduction

Uganda has high adolescent pregnancy. The details of adolescent childbirth and urban/rural patterns are scarce. We investigated the levels, time trends and determinants of adolescent childbirth in Uganda separately for urban and rural women.

Methods

We estimated the percentage of women 20–24 years at each of the six Uganda Demographic and Health Surveys (1988/89, 1995, 2000/01, 2006, 2011 and 2016) who reported a live childbirth before age 20 years (“adolescent childbirth”), and examined change over time using t-test. A modified multivariable Poisson regression was used to examine determinants of having adolescent childbirth on the 2016 survey.

Results

Among these women, 67.5, 66.4, 70.1, 62.3, 57.3 and 54.1% reported an adolescent childbirth in 1988/89, 1995, 2000/01, 2006, 2011 and 2016 surveys, respectively. Between 1988/89 to 2000/01, there was no evidence of change (+ 2.6% point (pp), p = 0.170), unlike between the 2000/01 and 2016 surveys when a significant decline occurred (− 16.0 pp., p < 0.001). First childbirth < 18 years of age declined by − 13.5 pp. (p < 0.001) between 2000/01 and 2016. There was no change over time in the percentage of adolescents 18–19.9 years of age having first childbirth. Among rural residents, childbirth < 18 years declined from 43.8% in 1988/89 to 32.7% in 2016 (− 11.1 pp., p < 0.001), in urban it declined from 28.3 to 18.2% (− 10.1 pp., p = 0.006). There was an increase over time in the percentage of women, both rural and urban, who wanted to delay their first pregnancy. Independent determinants of reporting an adolescent childbirth in both urban and rural residents were: no education/incomplete primary and younger age at first sex. Additional determinants for rural women were residence in Eastern region, Muslim religion, and poor household wealth index.

Conclusion

In the 30-year period examined, adolescent childbirth in Uganda declined from highs of 7 in 10 to approximately 5 in 10 women, with more wanting to delay the pregnancy. The decline started after the 2000/01 survey and affected predominantly younger adolescent childbirth < 18 years among both rural and urban residence women. Efforts need to be intensified to sustain the decline in adolescent pregnancies. Targeted and specific strategies for urban and rural areas might be required.

Maternal health services utilisation among primigravidas in Uganda: what did the MDGs deliver?

BACKGROUND

Achieving maternal health outcomes in the SDGs requires the implementation of more targeted policies and strategies. While the MDGs may have deepened our understanding in this regard, we know little about the trends in maternal health services utilisation among primigravidas, and how age and geographical regions could have influenced these trends. In this study, we examined utilisation of antenatal and skilled delivery services among primigravidas in Uganda, a country with one of the highest maternal mortality ratios, and where early childbearing and its attendant challenges are common.

METHODS

Guided by Andersen's Behavioural Model, we fitted multivariate regression models to a pooled dataset of the 2006, 2011 and 2016 Ugandan Demographic and Health Survey (n = 3477) to understand the dynamics in Antenatal Care (ANC) and Skilled Birth Attendance (SBAs) utilisation among primigravidas. Post-estimation margins were employed to further highlight the effect of age and geographical regions.

RESULTS

The analyses show an improvement in access to maternal health services among primigravidas from 2006 to 2016. Compared to 2006, primigravidas in 2016 were 48%, 24% and 2.98 times more likely to have early ANC, four or more ANC visits, and SBAs, respectively. Altogether, a primigravida in 2016 relative to 2006 was 42% more likely to meet all three maternal health service indicators. Post-estimation margins analyses on age and geographical disparities revealed that younger primigravidas have lower probability, while primigravidas in Eastern Region, one of the most deprived in the country, have the lowest probability of accessing maternal health services. Also, the study found education, wealth, women's household decision-making power, place of residence as important determinants of ANC visits and SBAs.

CONCLUSIONS

Based on our findings, it is important to address the vulnerabilities of primigravidas, particularly younger individuals, in accessing early ANC. Uganda should scale-up decentralisation and integration of maternal health delivery in local communities as a strategy of addressing lingering geographical disparities, and ultimately improve maternal health outcomes in the SDGs period.

Mobile Money Use and Healthcare Utilization: Evidence from Rural Uganda

Lack of cash on hand is a significant obstacle in accessing healthcare services in developing countries. Many expectant mothers in the least developed countries do not receive sufficient care during pregnancy due to financial constraints. If such hurdles in accessing healthcare can be overcome, it will contribute to reduction in maternal and newborn mortality, which is a key target of Sustainable Development Goal 3. This study reports the first assessment of the impact of mobile money services on maternal care utilization. We hypothesize that mobile money adoption would motivate rural Ugandan women to receive antenatal care and to deliver their children at health facilities or with skilled birth attendants. By receiving remittances utilizing mobile money, poor rural households may obtain more cash in hand, which might change women’s health-seeking behavior. We apply community- and mother-fixed effects models with heterogeneity analysis to longitudinal panel data (the RePEAT [Research on Poverty, Environment, and Agricultural Technology] survey) of three waves (2009, 2012, and 2015). The analysis uses pregnancy reports of 2007–2015 from 586 rural Ugandan households. We find suggestive evidence that mobile money adoption positively affects the take-up of antenatal care. Heterogeneity analysis indicates that mobile money brings a larger benefit to geographically challenged households by easing their liquidity constraint as they face higher cost of traveling to distant health facilities. The models failed to reject the null hypothesis of no mobile money effect on the delivery-related outcome variables. This study suggests that promoting financial inclusion by means of mobile money motivates women in rural and remote areas to make antenatal care visits while the evidence of such effect is not found for take-up of facility delivery or delivery with skilled birth attendants.

Risk factors for obstructed labour in Eastern Uganda: A case control study

Introduction

Obstructed labour (OL) is an important clinical and public health problem because of the associated maternal and perinatal morbidity and mortality. Risk factors for OL and its associated obstetric squeal are usually context specific. No epidemiological study has documented the risk factors for OL in Eastern Uganda. This study was conducted to identify the risk factors for OL in Mbale Hospital.

Objective

To identify the risk factors for OL in Mbale Regional Referral and Teaching Hospital, Eastern Uganda.

Methods

We conducted a case control study with 270 cases of women with OL and 270 controls of women without OL. We consecutively enrolled eligible cases between July 2018 and February 2019. For each case, we randomly selected one eligible control admitted in the same 24-hour period. Data was collected using face-to-face interviews and a review of patient notes. Logistic regression was used to identify the risk factors for OL.

Results

The risk factors for OL were, being a referral from a lower health facility (AOR 6.80, 95% CI: 4.20–11.00), prime parity (AOR 2.15 95% CI: 1.26–3.66) and use of herbal medicines in active labour (AOR 2.72 95% CI: 1.49–4.96). Married participants (AOR 0.59 95% CI: 0.35–0.97) with a delivery plan (AOR 0.56 95% CI: 0.35–0.90) and educated partners (AOR 0.57 95% CI: 0.33–0.98) were less likely to have OL. In the adjusted analysis, there was no association between four or more ANC visits and OL, adjusted odds ratio [(AOR) 0.96 95% CI: 0.57–1.63)].

Conclusions

Prime parity, use of herbal medicines in labour and being a referral from a lower health facility were identified as risk factors. Being married with a delivery plan and an educated partner were protective of OL. Increased frequency of ANC attendance was not protective against obstructed labour.

Key Decision Makers and Actors in Selected Newborn Care Practices: A Community-Based Survey in Northern Uganda

Knowledge of key decision makers and actors in newborn care is necessary to ensure that health interventions are targeted at the right people. This was a cross-sectional study carried out in Lira district, Northern Uganda. Multivariable logistic regression was used to determine factors associated with mothers being the key decision maker regarding where to give birth from and when to initiate breastfeeding. Fathers were the key decision makers on the place of birth (54.3%, n = 505) and on whether to seek care for a sick newborn child (47.7%, n = 92). Grandmothers most commonly bathed the baby immediately after birth (55.5%, n = 516), whereas mothers and health workers were common decision makers regarding breastfeeding initiation. Predictors for a mother being the key decision maker on the place of birth included: Mother having a secondary education (AOR 1.9: 95% C.I (1.0–3.6)) and mother being formally employed (AOR 2.0: 95% (1.5–2.9)). Mothers, fathers, grandmothers, health-workers, and traditional birth attendants were the most influential in the selected newborn care practices. Programs that aim to promote newborn care need to involve husbands, grandmothers, and health workers in addition to mothers.

National policies and care provision in pregnancy and childbirth for twins in Eastern and Southern Africa: A mixed-methods multi-country study

BACKGROUND

High-risk pregnancies, such as twin pregnancies, deserve particular attention as mortality is very high in this group. With a view to inform policy and national guidelines development for the Sustainable Development Goals, we reviewed national training materials, guidelines, and policies underpinning the provision of care in relation to twin pregnancies and assessed care provided to twins in 8 Eastern and Southern African countries: Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe.

METHODS AND FINDINGS

We located policies and guidelines by reviewing national repositories and by contacting experts to systematically map country-level maternal and newborn training materials, guidelines, and policies. We extracted recommendations for care for twins spanning ante-, intra-, and postpartum care that typically should be offered during twin pregnancies and childbirth. We compared care provided for mothers of twins to that provided for mothers of singletons during the ante-, intra-, and postpartum period and computed neonatal mortality rates using the most recent Demographic and Health Surveys (DHS) data for each country. There was a paucity of guidance on care specifically for twin or multiple pregnancies: None of the countries provided clear guidance on additional number of antenatal care visits or specific antenatal content, while 7 of the 8 countries recommended twins to be delivered in a comprehensive emergency obstetric and neonatal care facility. These results were mirrored by DHS results of 73,462 live births (of which 1,360 were twin) indicating that twin pregnancies did not receive more frequent or intensified antenatal care. The percentage of twin deliveries in hospitals varied from 25.3% in Mozambique to 63.0% in Kenya, and women with twin deliveries were between 5 and 27 percentage points more likely to deliver in hospitals compared to women with singleton live births; this difference was significant in 5 of the 8 countries (t test p < 0.05). The percentage of twin deliveries by cesarean section varied from 9% in Mozambique to 36% in Rwanda. The newborn mortality rate among twins, adjusted for maternal age and parity, was 4.6 to 7.2 times higher for twins compared to singletons in all 8 countries.

CONCLUSIONS

Despite the limited sample size and the limited number of clinically relevant services evaluated, our study provided evidence that mothers of twins receive insufficient care and that mortality in twin newborns is very high in Eastern and Southern Africa. Most countries have insufficient guidelines for the care of twins. While our data do not allow us to make a causal link between insufficient guidelines and insufficient care, they call for an assessment and reconceptualisation of policies to reduce the unacceptably high mortality in twins in Eastern and Southern Africa.