Ugandan health workers' and mothers' views and experiences of the quality of maternity care and the use of informal solutions: A qualitative study

A case study analysis of a successful birth center in northern Uganda

BACKGROUND

Mothers and infants continue to die at alarming rates throughout the Global South. Evidence suggests that high-quality midwifery care significantly reduces preventable maternal and neonatal morbidity and mortality. This paper uses a case study approach to describe the social and institutional model at one birth center in Northern Uganda where, in over 20,000 births, there have been no maternal deaths and the neonatal mortality rate is 11/1000-a rate that is lower than many high-resource countries.

METHODS

This case study combined institutional ethnographic and narrative methods to explore key maternal and neonatal outcomes. The sample included birthing people who intended to or had given birth at the center, as well as the midwives, staff, stakeholders, and community health workers affiliated with the center. Data were collected through individual and small group interviews, participant observation, field notes, data and document reviews. Iterative and systematic analytical steps were followed, and all data were organized and managed with Atlas.ti software.

RESULTS

Findings describe the setting, an overview of the birth center's history, how it is situated within the community, its staffing, administration, clinical outcomes, and model of care. A synthesis of contextual variables and key outcomes as they relate to the components of the evidence-informed Quality Maternal and Newborn Care (QMNC) framework are presented. Three overarching themes were identified: (a) community knowledge and understanding, (b) community integrated care, and (c) quality care that is respectful, accessible, and available.

CONCLUSIONS

This birth center is an example of care that embodies the findings and anticipated outcomes described in the QMNC framework. Replication of this model in other childbearing settings may help alleviate unnecessary perinatal morbidity and mortality.

"If I am alive, I am happy": Defining quality of care from the perspectives of key maternal and newborn health stakeholders in Papua New Guinea

Quality maternal and newborn healthcare is essential to improve experiences and health outcomes for mothers and babies. In many low to middle income countries, such as Papua New Guinea, there are initiatives to increase antenatal care attendance and facility births. To develop and implement initiatives that are appropriate, relevant, and contextualised to a community, it is important to understand how quality of care is perceived and defined by different maternal and newborn healthcare stakeholders. The aim of this study was to understand how women, their partners, healthcare professionals, healthcare managers, and provincial health administrators in East New Britain, Papua New Guinea define quality of pregnancy, childbirth, and immediate postnatal care. An exploratory qualitative study underpinned by a partnership-defined quality approach was undertaken. In total, 42 participants from five different healthcare facilities in East New Britain, Papua New Guinea, were interviewed. These included women, partners, healthcare professionals, healthcare managers, and provincial health administrators. Interviews were analysed using thematic analysis, assisted by NVivo computer software. Four themes were identified aligning with the journey a woman takes throughout the health system. These included (I) Ensuring Access: Arriving at the health centre, (II) Experiencing Positive Care: What the staff do, (III) Having the Bare Minimum: Resources available to the service, and (IV) Meeting Expectations: Outcomes of care. Stakeholder groups had significant overlap in how quality of care was defined, however women and partners focussed more on elements relating to experience of care, while clinical stakeholders focussed on elements relating to provision of care. There is a gap in how stakeholders define quality maternal and newborn healthcare, and the quality of the care which is administered and received.

Perinatal care and its association with perinatal death among women attending care in three district hospitals of western Uganda

BACKGROUND

Provision of effective care to all women and newborns during the perinatal period is a viable strategy for achieving the Sustainable Development Goal 3 targets on reducing maternal and neonatal mortality. This study examined perinatal care (antenatal, intrapartum, postpartum) and its association with perinatal deaths at three district hospitals in Bunyoro region, Uganda.

METHODS

A cross-sectional study was conducted in which a questionnaire was administered consecutively to 872 postpartum women before discharge who had attended antenatal care and given birth in the study hospitals. Data on care received during antenatal, labour, delivery, and postpartum period, and perinatal outcome were extracted from medical records of the enrolled postnatal women using a pre-tested structured tool. The care received from antenatal to 24 h postpartum period was assessed against the standard protocol of care established by World Health Organization (WHO). Poisson regression was used to assess the association between care received and perinatal death.

RESULTS

The mean age of the women was 25 years (standard deviation [SD] 5.95). Few women had their blood tested for hemoglobin levels, HIV, and Syphilis (n = 53, 6.1%); had their urine tested for glucose and proteins (n = 27, 3.1%); undertook an ultrasound scan (n = 262, 30%); and had their maternal status assessed (n = 122, 14%) during antenatal care as well as had their uterus assessed for contraction and bleeding during postpartum care (n = 63, 7.2%). There were 19 perinatal deaths, giving a perinatal mortality rate of 22/1,000 births (95% Confidence interval [CI] 8.1-35.5). Of these 9 (47.4%) were stillbirths while the remaining 10 (52.6%) were early neonatal deaths. In the antenatal phase, only fetal examination was significantly associated with perinatal death (adjusted prevalence ratio [aPR] = 0.22, 95% CI 0.1-0.6). No significant association was found between perinatal deaths and care during labour, delivery, and the early postpartum period.

CONCLUSION

Women did not receive all the required perinatal care during the perinatal period. Perinatal mortality rate in Bunyoro region remains high, although it's lower than the national average. The study shows a reduction in the proportion of perinatal deaths for pregnancies where the mother received fetal monitoring. Strategies focused on strengthened fetal status monitoring such as fetal movement counting methods and fetal heart rate monitoring devices during pregnancy need to be devised to reduce the incidence of perinatal deaths. Findings from the study provide valuable information that would support the strengthening of perinatal care services for improved perinatal outcomes.

Exploring the Adaptations of the Free Maternity Policy Implementation by Health Workers and County Officials in Kenya

BACKGROUND

In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to maternal services in private, faith-based, and levels 3-6 public institutions. We explored the adaptive strategies health care workers (HCWs) and county officials used to bridge the implementation challenges and achieve the FMP objectives.

METHODS

We conducted an exploratory qualitative study using Lipsky's theoretical framework in 3 facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved in-depth interviews (n=21) with county officials, facility in-charges and HCWs, and key informants from national and development partner agencies. Data were audio-recorded, transcribed, and analyzed using a framework thematic approach.

RESULTS

The results show that HCWs and county officials applied several strategies that were critical in shaping the policymaking, working practice, and professionalism and ethical aspects of the FMP. Strategies of policymaking: hospitals employed additional staff, and the county developed bylaws to strengthen the flow of funds. Strategies of working practice: hospitals and HCWs enhanced patient referrals, and facilities enhanced communication. Strategies of professionalism and ethics: nurses registered and provided service to mothers, and facilities included employees in planning and budgeting. Maladaptations included facilities having leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some discharged mothers immediately after birth, even before offering the fully costed policy benefits, to avoid incurring additional costs.

CONCLUSIONS

The role of policy implementers and the built-in flexibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementation, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended consequences may need interventions.

Midwives' perspectives about using individualized care plans in the provision of immediate postpartum care in Uganda; an exploratory qualitative study

INTRODUCTION

Individualized care planning has been slowly integrated into practice in Uganda with minimal documentation of how the concept is applied in providing care. This study explored the perceptions of midwives about the use of individualized care plans (ICPs) in the provision of immediate postpartum care.

METHODS

An exploratory descriptive qualitative approach was used in this study. We interviewed fifty midwives from 37 health facilities in Uganda's greater Mpigi region. The midwives, who were certificate and diploma holders, were purposively enrolled in the selected facilities. Deductive content analysis was done based on the COM-B model.

RESULTS

Four themes emerged from the data namely; compatibility, motivation, opportunities, and the midwives' suggested strategies and targets for improved individualized care planning. The midwives were aware of individualized care planning and they utilized it in their provision of immediate postpartum care especially when assessing clients for risks, preparing clients for referral, caring for Human Immunodeficiency virus (HIV) exposed babies and their mothers, and educating/ supporting first-time mothers (automatic motivation). Having a good nurse-patient relationship, privacy, and ample time to care for the clients were noted as motivators for individualized care plan use, while poor documentation of care, high patient load, and perceived patients' lack of understanding of the complexities of illness in the immediate postpartum period were the barriers (social opportunity) identified by midwives to the use of individualized care planning.

CONCLUSION

There are still capability, motivation, and opportunity hindrances to the use of individualized care planning. Staff recruitment, training, and harmonization of the documentation forms may improve the use of care plans in the postpartum period.

Woman-centered care and associated factors among midwives working in urban health centers and public and private hospitals in Tabriz, Iran: a cross-sectional study

BACKGROUND

Woman-centered care (WCC) is the cornerstone of the midwifery profession. However, no study has been conducted on WCC provided by Iranian midwives and its associated factors. Thus, this study aimed to determine WCC and factors associated with midwives' WCC for midwives working in urban health centers and public and private hospitals in Tabriz, Iran.

METHODS

This cross-sectional study was the first part (i.e., the quantitative phase) of a sequential explanatory mixed-method study conducted on 575 midwives working in urban health centers and public and private hospitals in Tabriz-Iran from November 2022 to January 2023. The required data was collected by distributing a socio-demographic and job characteristics questionnaire and woman-centered care scale-midwife self-report (WCCS-MSR). To determine the factors associated with WCC, an independent t-test or one-way analysis of variance (ANOVA) was used in bivariate analysis, and a general linear model (GLM) was employed in multivariate analysis to control possible confounding variables.

RESULTS

The statistical population consisted of 575 midwives, with a response rate of 88.2%. According to the GLM, the total mean WCCS-MSR score of single [β (95% CI) 23.02 (7.94 to 38.10)] and married [β (95% CI) 21.28 (6.83 to 35.72)] midwives was significantly higher than that of divorced midwives after adjusting their demographic and job characteristics. Also, the total mean WCCS-MSR score of midwives with sufficient income was significantly higher than those with insufficient income [β (95% CI) 8.94 (0.12 to 17.77). In addition, the total mean WCCS-MSR score of midwives with < 5 years of work experience [β (95% CI) - 7.87 (- 14.79 to - 0.94)], and midwives with official-experimental employment status [β (95% CI) - 17.99 (- 30.95 to - 5.02)], was significantly lower than those with more than 5 years of work experience and contractual employment status.

CONCLUSIONS

The findings indicate that marital status, level of income, years of practice, and employment status were significantly related to WCC provided by midwives. Focusing only on the midwifery community is insufficient to ensure the improved quality of WCC. However, arrangements should be made at three levels, including policy-makers, managers, and health care provider (midwives).

An exploration of health workers' experiences in providing bereavement care to mothers following a stillbirth: results from a subnational level health system in Uganda

BACKGROUND

Stillbirth is a profound emotion-laden event to the mothers and health workers who provide care due to its sudden and unexpected occurrence. Health workers offering support in regions shouldering the highest-burden experience providing support to a stillbirth mother in their professional lifetime. However, their experiences seldom get documented as much of the focus is on mothers causing a dissonance between parental and clinical priorities. This study aimed to explore the health worker's experiences in the provision of bereavement care to mothers following a stillbirth.

METHODS

An exploratory cross-sectional qualitative study was undertaken on a purposively selected sample of key informants drawn from frontline health workers and health systems managers providing maternal health services at a subnational level health system in Uganda. An interview guide was used to collect data with the audio-recorded interviews transcribed using Microsoft office word. Atlas. ti a qualitative data management software aided in coding with analysis following a thematic content analysis technique.

RESULTS

There was no specialised bereavement care provided due to inadequate skills, knowledge of content, resources and support supervision for the same. However, health workers improvised within the available resources to comfort mothers upon news of a stillbirth. Disclosure to mothers about the stillbirth loss often took the form of forewarnings, direct and sometimes delayed disclosure. A feeling of unpreparedness to initiate the disclosure process to the mother was common while the whole experience had an emotional effect on the health workers when establishing the cause, particularly for cases without clear risk factors. The emotional breakdown was often a reflexive response from the mothers which equally affected the care providers. Health workers engaged in comforting and rebuilding the mothers to transition through the loss and validate the loss. Efforts to identify the skills and health systems gaps for address were a common response targeted at improving the quality of maternal healthcare services to avert similar occurrences in the future.

CONCLUSION

Providing care to mothers after stillbirth was an emotional and challenging experience for health workers requiring different approaches to disclosure and provision of emotional support. The aspect of specialised bereavement care was lacking within the current response. Reflection of unpreparedness to handle the tasks demonstrates a deficit in the required skills. It is a critical gap missing hence calling for dedicated efforts to address it. Targeting efforts to improve health workers' competencies and preparedness to manage grieving mothers is one way to approach it.

Midwives' perceptions towards the ministry of health guidelines for the provision of immediate postpartum care in rural health facilities in Uganda

BACKGROUND

Guidelines for clinical practice have been part of the Ministry of health's efforts to improve the quality of care for over two decades. Their benefits have been documented in Uganda. However, having practice guidelines may not always result in their use in care provision. We explored the midwives' perceptions towards the ministry of health guidelines for providing immediate postpartum care.

METHODS

An exploratory descriptive qualitative study was conducted in three districts in Uganda from September 2020 to January 2021. In-depth interviews with 50 midwives from 35 health centers and 2 hospitals in Mpigi, Butambala, and Gomba districts were done. Thematic analysis of data was done.

RESULTS

Three themes emerged; awareness and use of the guidelines, perceived drivers, and perceived barriers to the provision of immediate postpartum care. The subthemes for theme I included; awareness of the guidelines, variations in the postpartum care practices, variations in preparedness to manage women with complications, and varied access to continuing midwifery education. Fear of complications and litigation were the perceived drivers of guideline use. On the other hand, lack of knowledge, busy maternity units, organization of the care, and the midwives' perceptions about their clients were the barriers to guideline use. Midwives felt that new guidelines and policies regarding immediate postpartum care should be disseminated widely.

CONCLUSION

The midwives felt that the guidelines were good for the prevention of postpartum complications but their knowledge of the guidelines for the provision of immediate postpartum care was suboptimal. They desired on-job training and mentorship to help them bridge the knowledge gaps. Variations in patient assessment, monitoring, and pre-discharge care were acknowledged and said to be due to a poor reading culture and health facility factors like patient-midwife ratios, unit setup, and prioritization of labor.

Best Practices in Maternal and Child Health from the Perspective of Healthcare Professionals

Objective: To understand healthcare professionals’ perception of best practices in maternal and child health. Materials and methods: This qualitative exploratory-descriptive study was conducted between December 2020 and March 2021. The study corpus consisted of 23 healthcare professionals from southern Brazil. Data were collected using a semi-structured script and coded based on Minayo’s thematic content analysis proposed. Results: Data analysis enabled the delimitation of two thematic categories: “best practices in maternal and child health: from idealization to accomplishment” and “strategies to qualify the maternal and child healthcare network.” Conclusions: Healthcare professionals recognize the relevance of best practices in maternal and child health, although this process must be expanded and consolidated. Continuing education, hospitality, ambiance, improved access, and the professional-user connection stand out among the qualifying strategies.

Readiness of rural health facilities to provide immediate postpartum care in Uganda

BACKGROUND

Nearly 60% of maternal and 45% of newborn deaths occur within 24 h after delivery. Immediate postpartum monitoring could avert death from preventable causes including postpartum hemorrhage, and eclampsia among mothers, and birth asphyxia, hypothermia, and sepsis for babies. We aimed at assessing facility readiness for the provision of postpartum care within the immediate postpartum period.

METHODS

A cross-sectional study involving 40 health facilities within the greater Mpigi region, Uganda, was done. An adapted health facility assessment tool was employed in data collection. Data were double-entered into Epi Data version 4.2 and analyzed using STATA version 13 and presented using descriptive statistics.

RESULTS

Facility readiness for the provision of postpartum care was low (median score 24% (IQR: 18.7, 26.7). Availability, and use of up-to-date, policies, guidelines and written clinical protocols for identifying, monitoring, and managing postpartum care were inconsistent across all levels of care. Lack of or non-functional equipment poses challenges for screening, diagnosing, and treating postnatal emergencies. Frequent stock-outs of essential drugs and supplies, particularly, hydralazine, antibiotics, oxygen, and blood products for transfusions were more common at health centers compared to hospitals. Inadequate human resources and sub-optimal supplies inhibit the proper functioning of health facilities and impact the quality of postpartum care. Overall, private not-for-profit health facilities had higher facility readiness scores.

CONCLUSIONS

Our findings suggest sub-optimal rural health facility readiness to assess, monitor, and manage postpartum emergencies to reduce the risk of preventable maternal/newborn morbidity and mortality. Strengthening health system inputs and supply side factors could improve facility capacity to provide quality postpartum care.

National-level key stakeholders' perspectives regarding intervention progression and emerging challenges within the national stillbirth reduction response in Uganda

INTRODUCTION

Implementation of evidence-based interventions was adopted to respond to the stillbirth burden from the global campaigns. However, new challenges emerge in the process of rolling out such interventions into routine services more so in the context of resource-limited settings. Since the scale-up of policy recommendations to address stillbirth in Uganda, the health system response has seldom been explored. This study was conducted among national-level key stakeholders to elicit their perspectives regarding intervention progression and challenges emerging from the implementation of the national stillbirth reduction strategies in Uganda.

METHODS

The study adopted an exploratory qualitative design with interviews conducted among a purposively selected sample of national-level actors drawn from the maternal and Child Health (MCH) policy networks. Respondents were primed with ongoing national-level stillbirth reduction strategies as a case and later asked for their opinions regarding intervention progression and emerging challenges. All interviews were conducted in English and transcribed verbatim. Atlas. ti was used to facilitate the coding processes which used a pre-determined codebook developed a priori based on the applied framework. A thematic analysis technique was used.

RESULTS

Human resources as reflected in the slow recruitment of essential staff, motivation and attitudes of the available human resource, on and off-drug stockouts, and equipment interruptions posed challenges to the effective implementation of interventions to address the stillbirth burden. The policy translation process was sometimes faced with deviations from the recommended practice. Deviations from guideline implementation, inadequate managerial skills of the health workers and managers in stewarding the implementation processes, inadequate implementation feedback, loops in communication and working with a passive community also posed process-dependent bottlenecks. Outcome expectation challenges stemmed from the inability to deliver stillbirth reduction interventions along the Reproductive Maternal New born Child and Adolescent Health (RMNCAH) continuum of care and the overconcentration of facility-level intervention with less focus on community/demand side interventions.

CONCLUSION

In this exploratory study, national-level stakeholders perceive the adopted stillbirth reduction strategies as having the potential to address the burden. They, however, highlight potential challenges along the input-process-outcome continuum which ought to be addressed and opportunities to explore potential solutions befitting the national-level context.

Transition from hospital to home care for preterm babies: A qualitative study of the experiences of caregivers in Uganda

Improving care for preterm babies could significantly increase child survival in low-and middle income countries. However, attention has mainly focused on facility-based care with little emphasis on transition from hospital to home after discharge. Our aim was to understand the experiences of the transition process among caregivers of preterm infants in Uganda in order to improve support systems. A qualitative study among caregivers of preterm infants in Iganga and Jinja districts in eastern Uganda was conducted in June 2019 through February 2020, involving seven focus group discussions and five in-depth interviews. We used thematic-content analysis to identify emergent themes related to the transition process. We included 56 caregivers, mainly mothers and fathers, from a range of socio-demographic backgrounds. Four themes emerged: caregivers' experiences through the transition process from preparation in the hospital to providing care at home; appropriate communication; unmet information needs; and managing community expectations and perceptions. In addition, caregivers' views on 'peer-support' was explored. Caregivers' experiences, and their confidence and ability to provide care were related to preparation in the hospital after birth and until discharge, the information they received and the manner in which healthcare providers communicated. Healthcare workers were a trusted source of information while in the hospital, but there was no continuity of care after discharge which increased their fears and worries about the survival of their infant. They often felt confused, anxious and discouraged by the negative perceptions and expectations from the community. Fathers felt left-out as there was very little communication between them and the healthcare providers. Peer-support could enable a smooth transition from hospital to home care. Interventions to advance preterm care beyond the health facility through a well-supported transition from facility to home care are urgently required to improve health and survival of preterm infants in Uganda and other similar settings.

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.

'No other alternative than to compromise': Experiences of midwives/nurses providing care in the context of scarce resources

Midwives and nurses play a critical role in safeguarding the lives of women in resource-constrained African countries. Working within the context of scarce resources may undermine their moral agency and hinder their ability to care. The purpose of this paper is to understand the influence of resource scarcity on midwifery and nursing care and practice. A critical ethnography was conducted in the obstetric department of three tertiary-level facilities in Ghana. Purposive sampling was used to recruit 30 midwives and nurses and semistructured interviews, field notes and documentary materials were used to generate in-depth understanding. Ethical approval was granted from Canada and Ghana and written, and ongoing informed consent was obtained from the participants. Five conceptual themes depicting the impact of scarce resources on midwifery and nursing care were discovered: compromised care, constrained care, dehumanized care, missed care and disengaged care. Improving the maternal health of women and averting avoidable maternal morbidity and mortality require governments and institutions to invest in health infrastructure that will support the delivery of ethical and safe midwifery care for women in their most vulnerable period.

Impact of reliable light and electricity on job satisfaction among maternity health workers in Uganda: A cluster randomized trial

BACKGROUND

Maintaining a motivated health workforce is critical to health system effectiveness and quality of care. Scant evidence exists on whether interventions aimed to strengthen health infrastructure in low-resource settings affect health workers. This study evaluated the impact of an intervention providing solar light and electricity to rural maternity facilities in Uganda on health workers' job satisfaction.

METHODS

We used a mixed-methods design embedded in a cluster randomized trial to evaluate whether and how the We Care Solar Suitcase intervention, a solar electric system providing lighting and power, affected health workers in rural Ugandan maternity facilities with unreliable light. Facilities were randomly assigned to receive the intervention or not without blinding in a cluster-randomized controlled trial. Outcomes were assessed through two rounds of surveys with health workers. We used regression analyses to examine the intervention's impact on job satisfaction. We used an inductive approach to analyze qualitative data to understand the study context and interpret quantitative findings.

RESULTS

We interviewed 85 health workers across 30 facilities, the majority of whom were midwives or nurses. Qualitative reports indicated that unreliable light made it difficult to provide care, worsened facility conditions, and harmed health workers and patients. Before the intervention, only 4% of health workers were satisfied with their access to light and electricity. After the installation, satisfaction with light increased by 76 percentage points [95% confidence interval (CI): 61-92 percentage points], although satisfaction with electricity did not change. Experience of negative impacts of lack of overhead light also significantly decreased and the intervention modestly increased job satisfaction. Qualitative evidence illustrated how the intervention may have strengthened health workers' sense of job security and confidence in providing high-quality care while pointing towards implementation challenges and other barriers health workers faced.

CONCLUSIONS

Reliable access to light and electricity directly affects health workers' ability to provide maternal and neonatal care and modestly improves job satisfaction. Policy makers should invest in health infrastructure as part of multifaceted policy strategies to strengthen human resources for health and to improve maternal and newborn health services. Trial registration socialscienceregistry.org: AEARCTR-0003078. Registered June 12, 2018, https://www.socialscienceregistry.org/trials/3078 Additionally registered on: ClinicalTrials.gov: NCT03589625, Registered July 18, 2018, https://clinicaltrials.gov/ct2/show/NCT03589625 ).

Experiences of Postnatal Mothers with Healthcare Providers in Rural Kenya: Insights from Applying the Mmogo Method

PURPOSE

To explore the experiences of postnatal mothers with health care providers during postnatal care in rural Kenya.

DESIGN

This was a visual-based narrative inquiry study that applied the Mmogo method® - a visual projective data-collection method.

METHODS

The participants were women (n=26) receiving postnatal care at purposively sampled rural health facilities (n=4) in Laikipia County Kenya.

FINDINGS

Two themes emerged from this study. First, the mothers had positive experiences with health care providers. Secondly, the mothers expressed expectations to enhance future experiences with health care providers.

CONCLUSIONS

Mothers had positive experiences and various expectations to enhance future experiences with health care providers that related to their postnatal needs. The mothers proposed the possible use of mobile phones by health care providers to meet their health education needs as well as receive psychological support.

CLINICAL EVIDENCE

Health care providers can use mobile phone devices to call and address some of the postnatal needs during the postnatal period.

Impact of Solar Light and Electricity on the Quality and Timeliness of Maternity Care: A Stepped-Wedge Cluster-Randomized Trial in Uganda

Lack of access to reliable energy is a major neglected health system challenge to maternal and child health. We found that installing a solar energy system intervention in rural Ugandan maternity facilities led to modest increases in the quality of maternity care and reductions in delays in care.

Background:

We evaluated the impact of solar light installation in Ugandan maternity facilities on implementation processes, reliability of light, and quality of intrapartum care.

Methods:

We conducted a stepped-wedge cluster-randomized trial of the We Care Solar Suitcase, a complete solar electric system providing lighting and power for charging phones and small medical devices, in 30 rural Ugandan maternity facilities with unreliable lighting. Facilities were randomly assigned to receive the intervention in the first or second sequence in a 1:1 ratio. We collected data from June 2018 to April 2019. The intervention was installed in September 2018 (first sequence) and in December 2018 (second sequence). The primary effectiveness outcomes were a 20-item and a 36-item index of quality of intrapartum care, a 6-item index of delays in care provision, and the percentage of deliveries with bright light, satisfactory light, and adequate light.

Results:

We observed 1,118 births across 30 facilities. The intervention was successfully installed in 100% of facilities. After installation, the intervention was used in 83% of nighttime deliveries. Before the intervention, providers on average performed 42% of essential care actions and accumulated 76 minutes of delays during nighttime deliveries. After installation, quality increased by 4 percentage points (95% confidence interval [CI]=1,8) and delays in care decreased by 10 minutes (95% CI=−16,−3), with the largest impacts on infection control, prevention of postpartum hemorrhage, and newborn care practices. One year after the end of the trial, 90% of facilities had LED lights in operation and 60% of facilities had all components in operation.

Conclusions:

Reliable light is an important driver of timely and adequate health care. Policy makers should invest in renewable energy systems for health facilities; however, even when reliable lighting is present, quality of care may remain low without a broader approach to quality improvements.

Midwives' perspectives on person-centred maternity care in public hospitals in South-east Nigeria: A mixed-method study

Background

Person-centred maternity care (PCMC) is acknowledged as essential for achieving improved quality of care during labour and childbirth. Yet, evidence of healthcare providers’ perspectives of person-centred maternity care is scarce in Nigeria. This study, therefore, examined the perceptions of midwives on person-centred maternity care (PCMC) in Enugu State, South-east Nigeria.

Materials and methods

This study was conducted in seven public hospitals in Enugu metropolis, Enugu State, South-east Nigeria. A mixed-methods design, involving a cross-sectional survey and focus group discussions (FGDs) was used. All midwives (n = 201) working in the maternity sections of the selected hospitals were sampled. Data were collected from February to May 2019 using a self-administered, validated PCMC questionnaire. A sub-set of midwives (n = 56), purposively selected using maximum variation sampling, participated in the FGDs (n = 7). Quantitative data were entered, cleaned, and analysed with SPSS version 20 using descriptive and bivariate statistics and multivariate regression. Statistical significance was set at alpha 0.05 level. Qualitative data were analysed thematically.

Results

The mean age of midwives was 41.8 years ±9.6 years. About 53% of midwives have worked for ≥10 years, while 60% are junior midwives. Overall, the prevalence of low, medium, and high PCMC among midwives were 26%, 49% and 25%. The mean PCMC score was 54.06 (10.99). High perception of PCMC subscales ranged from 6.5% (dignity and respect) to 19% (supportive care). Midwives’ perceived PCMC was not significantly related to any socio-demographic characteristics. Respectful care, empathetic caregiving, prompt initiation of care, paying attention to women, psychosocial support, trust, and altruism enhanced PCMC. In contrast, verbal and physical abuses were common but normalised. Midwives’ weakest components of autonomy and communication were low involvement of women in decision about their care and choice of birthing position. Supportive care was constrained by restrictive policy on birth companion, poor working conditions, and cost of childbirth care.

Conclusion

PCMC is inadequate in public hospitals as seen from midwives’ perspectives. Demographic characteristics of midwives do not seem to play a significant role in midwives’ delivery of PCMC. The study identified areas where midwives must build competencies to deliver PCMC.

Review of midwifery education in Uganda: Toward a framework for integrated learning and midwifery model of care

OBJECTIVE

To examine the current approach to midwifery education and deployment in Uganda against the backdrop of the evidence presented in the Lancet Series on Midwifery and the International Confederation of Midwives Global Standards for Midwifery Education. To make a distinction between 'Midwifery Model of Care' and training in maternal health nursing and highlight the need for midwifery education that is in alignment with international standards and reflexive to the realities of the Ugandan clinical context.

SETTING/PARTICIPANTS

A review of Ugandan nursing and midwifery education structure, curricula and current workforce configurations. A review of government reports and published literature regarding nursing and midwifery education.

FINDINGS

The pathways for nursing and midwifery education in Uganda are too numerous and without clear pathways for educational advancement. The scope of practice for new graduates is not realistic to the context midwives will practice in. Overall, nursing and midwifery education curricula does not prepare graduates to International Confederation of Midwives Standards and lacks training and mentorship in the 'Midwifery Model of Care' making graduates closer to 'maternity nurses' than midwives.

KEY CONCLUSIONS

The Ugandan midwifery education curricula and model needs to bring education standards into alignment with International Confederation of Midwives such that midwives are equipped to practice using the Quality Maternal Newborn Care Framework. Until this is accomplished maternal and newborn mortality rates will remain high, Uganda will continue to lose one of it's greatest resources, it's human capital, and the Sustainable Development Goal 3 will remain out of reach.

Mothers' Experiences and Perceptions of Facility-based Delivery Care in Rural Ethiopia

In Ethiopia, delivery wards are a part of primary healthcare services. However, although the maternal mortality rate is very high, approximately 50% of mothers use skilled birth attendants. This study focused on how women in a rural southern district of Ethiopia experience maternity care offered at the local delivery wards. In this qualitative, exploratory study, 19 women who had given birth in a healthcare facility were interviewed in 2019. Individual in-depth interviews were supplemented with observations conducted at 2 different delivery wards in the same district in 2020. Two main themes emerged from the thematic content analysis: increased awareness and safety were the primary reasons for giving birth at a healthcare facility, and traditions and norms affected women’s birth experiences in public maternity wards. The main shortcomings were a shortage of medicine, ambulance not arriving in time, and lack of care at night. For some women, being assisted by a male midwife could be challenging, and the inability to afford necessary medicine made adequate treatment inaccessible. Providing continuous information gave the women a certain feeling of control. Strong family involvement indicated that collectivistic expectations were key to rural delivery wards. The healthcare system must be structured to meet women’s needs. Moreover, managers and midwives should ensure that birthing women receive high-quality, safe, timely, and respectful care.

Neonatal care practices in Buikwe District, Uganda: a qualitative study

Background

Sub-Saharan Africa is the region with the highest neonatal mortality rate, with Uganda reporting 20 deaths per 1000 live births. The Uganda Clinical Guidelines (UCG) from 2016 have detailed descriptions on care for mothers and their newborns during pregnancy, delivery and the post-partum period. The objective of the study was to identify provider and user perspectives regarding the knowledge of and adherence to the UCG recommendations in aspects of delivery and newborn care, both in cases of normal as well as complicated births.

Methods

The study used qualitative methods with data collection from participant observations, interviews with key-informants and focus group discussions. Malterud’s Systematic Text Condensation (STC) was used for analysis.

Results

The study found low knowledge about the UCG among the health workers. Various discrepancies between performed hands-on-procedures and the UCG were found related to neonatal care practices, including low use of partograms, uncertainty around timing for cord clamping, routine oronasopharyngeal suction of newborns and inadequate implementation of skin-to-skin care.

Conclusions

Continued focus on systemic strategies for further implementation of the UCG is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03699-4.

An examination of the moral habitability of resource-constrained obstetrical settings

BACKGROUND

While there have been studies exploring moral habitability and its impact on the work environments of nurses in Western countries, little is known about the moral habitability of the work environments of nurses and midwives in resource-constrained settings.

RESEARCH OBJECTIVE

The purpose of this research was to examine the moral habitability of the work environment of nurses and midwives in Ghana and its influence on their moral agency using the philosophical works of Margaret Urban Walker.

RESEARCH DESIGN AND PARTICIPANTS

A critical moral ethnography was conducted through the analysis of interviews with 30 nurses and midwives, along with observation, and documentary materials.

ETHICAL CONSIDERATIONS

After receiving ethics approval, signed informed consent was obtained from participants before data collection.

RESULTS

Five themes were identified: (1) holding onto the values, identities, and responsibilities of being a midwife/nurse; (2) scarcity of resources as limiting capacity to meet caring responsibilities; (3) gender and socio-economic inequities shaping the moral-social context of practice; (4) working with incoherent moral understandings and damaged identities in the context of inter- and intra-professional relationships; and (5) surviving through adversity with renewed commitment and courage.

DISCUSSION

The nurses and midwives were found to work in an environment that was morally uninhabitable and dominated by the scarcity of resources, overwhelming and incoherent moral responsibilities, oppressive conditions, and workplace violence. These situations constrained their moral agency and provoked suffering and distress. The nurses and midwives negotiated their practice and navigated through morally uninhabitable work environment by holding onto their moral values and commitments to childbearing women.

CONCLUSION

Creating morally habitable workplaces through the provision of adequate resources and instituting interprofessional practice guidelines and workplace violence prevention policies may promote safe and ethical nursing and midwifery practice.

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.

A review of fetal cardiac monitoring, with a focus on low- and middle-income countries

There is limited evidence regarding the utility of fetal monitoring during pregnancy, particularly during labor and delivery. Developed countries rely on consensus ‘best practices’ of obstetrics and gynecology professional societies to guide their protocols and policies. Protocols are often driven by the desire to be as safe as possible and avoid litigation, regardless of the cost of downstream treatment. In high-resource settings, there may be a justification for this approach. In low-resource settings, in particular, interventions can be costly and lead to adverse outcomes in subsequent pregnancies. Therefore, it is essential to consider the evidence and cost of different fetal monitoring approaches, particularly in the context of treatment and care in low-to-middle income countries.

This article reviews the standard methods used for fetal monitoring, with particular emphasis on fetal cardiac assessment, which is a reliable indicator of fetal well-being. An overview of fetal monitoring practices in low-to-middle income counties, including perinatal care access challenges, is also presented. Finally, an overview of how mobile technology may help reduce barriers to perinatal care access in low-resource settings is provided.

Maternal health-related barriers and the potentials of mobile health technologies: Qualitative findings from a pilot randomized controlled trial in rural Southwestern Uganda

Background:

Maternal mortality rate remains unacceptably high in Uganda. In-depth evidence about the barriers to access and utilization of maternal health services specifically among the rural illiterate pregnant women remains lacking. The potentials of mobile health technologies in addressing the maternal health challenges remain unclear.

Aim:

To explore the maternal health-related barriers among illiterate pregnant women in rural Southwestern Uganda and highlight the potentials of mobile health technologies.

Material and Methods:

This is a midline qualitative study conducted with the participants of a pilot randomized controlled trial. Between October 2019 and December 2019, we carried out semi-structured interviews with 30 illiterate pregnant mothers. Interviews elicited information on the barriers to access and utilization of maternal health services. An inductive, content analytic approach was used to analyze qualitative data. Quantitative sociodemographic and socioeconomic data were summarized descriptively.

Results:

Participants reported that lack of money (for transport and medical costs), unfriendly maternal health services, and delays at the maternal health clinic constrain access and utilization of maternal health services. Given their widespread adoption, mobile technologies can potentially address some of these barriers e.g., money for transport or microenterprise start-up can be sent to women through their mobile phones or maternal health-related services (such as health education and consultation) can be provided electronically.

Conclusion:

Future efforts should focus on utilizing mobile health technologies to not only enable women overcome the critical financial challenges but also facilitate remote access and utilization of maternal health services.

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.

Implementing the skilled birth attendance strategy in Uganda: a policy analysis

Background

Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda’s skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care.

Methods

This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis.

Results

The skilled birth attendance policy was an important priority on Uganda’s maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional.

Conclusion

Uganda’s skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4503-5) contains supplementary material, which is available to authorized users.