Ethnicity, gender, and migration status: Applying intersectionality methodology to explore barriers to equitable health systems for maternal and newborn health among immigrant populations in Masindi, Uganda

  • Medicine (United States), Volume 101, No. 30, Year 2022

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Study Justification:
– Maternal mortality rates in Africa are alarmingly high, with Uganda experiencing a marginal reduction in recent years.
– Health facility delivery is crucial for improving maternal and neonatal outcomes, but skilled birth attendance is not popular in Uganda.
– Immigrant populations in the Masindi region use maternal health services less compared to indigenous populations.
– This study aims to understand the barriers faced by immigrant populations in accessing maternal health services and suggest interventions for equitable access.
Study Highlights:
– Qualitative study conducted in Nyantonzi parish, Masindi district, Uganda.
– Data collected through focus group discussions, in-depth interviews, and key informant interviews.
– Themes identified include perceived discrimination based on ethnicity, income, education, and gender as barriers to access.
– Harmful cultural norms, conflicting gender roles, and societal rewards for enduring labor pains contribute to vulnerability and hinder access to care.
– Recommendations include demystifying harmful cultural norms and training health workers on respectful treatment.
Study Recommendations:
– Create platforms to challenge harmful cultural norms and promote equitable access to maternal health services.
– Provide training to health workers on respectful treatment based on the 12 steps to safe and respectful mother-baby-family care.
Key Role Players:
– Researchers and social science experts
– Gender experts and doctoral students
– Local dialect experts
– Health workers at the referral hospital and health centers
– Community leaders and influencers
– Policy makers and government officials
Cost Items for Planning Recommendations:
– Training programs for health workers on respectful treatment
– Community engagement and awareness campaigns
– Translation and interpretation services
– Research and data analysis expenses
– Monitoring and evaluation activities
– Administrative and logistical support
Please note that the cost items provided are for planning purposes and do not reflect the actual costs.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it provides a clear description of the study objectives, methods, and findings. The study used a qualitative approach, including focus group discussions, in-depth interviews, and key informant interviews, to explore barriers to equitable health systems for maternal and newborn health among immigrant populations in Masindi, Uganda. The data were analyzed using content analysis and intersectionality. The study site was purposively selected based on the highest density of immigrant population. The abstract also provides relevant background information on maternal mortality in Uganda and the specific context of Masindi district. The findings highlight perceived discrimination, conflicting gender roles, and societal norms as barriers to access to maternal and newborn care among immigrant women. The study recommends platforms to demystify harmful cultural norms and training of health workers on respectful treatment. To improve the evidence, the abstract could include more specific details on the sample size and characteristics of the participants, as well as the limitations of the study.

Globally, 298,000 women die due to pregnancy related causes and half of this occurs in Africa. In Uganda, maternal mortality has marginally reduced from 526 to 336 per 100,000 live births between 2001 and 2016. Health facility delivery is an important factor in improving maternal and neonatal outcomes. However, the concept of using a skilled birth attendant is not popular in Uganda. An earlier intervention to mobilize communities in the Masindi region for maternal and newborn health services discovered that immigrant populations used maternal health services less compared to the indigenous populations. The aim of this qualitative study was therefore to better understand why immigrant populations were using maternal health services less and what the barriers were in order to suggest interventions that can foster equitable access to maternal health services. Five focus group discussions (FGDs) (three among women; 2 with men), 8 in-depth interviews with women, and 7 key informant interviews with health workers were used to better understand the experiences of immigrants with maternal and newborn services. Interviews and FGDs were conducted from July to September 2016. Data were analyzed using content analysis and intersectionality. Results were based on the following thematic areas: perceived discrimination based on ethnicity as a barrier to access, income, education and gender. Immigrant populations perceived they were discriminated against because they could not communicate in the local dialect, they were poor casual laborers, and/or were not well schooled. Matters of pregnancy and childbearing were considered to be matters for women only, while financial and other decisions at the households are a monopoly of men. The silent endurance of labor pains was considered a heroic action. In contrast, care-seeking early during the onset of labor pains attracted ridicule and was considered frivolous. In this context, perceived discrimination, conflicting gender roles, and societal rewards for silent endurance of labor pains intersect to create a unique state of vulnerability, causing a barrier to access to maternal and newborn care among immigrant women. We recommend platforms to demystify harmful cultural norms and training of health workers on respectful treatment based on the 12 steps to safe and respectful mother baby-family care.

Study site: The study was conducted in Nyantonzi parish in Masindi district. This parish was purposively selected because it had the highest density of immigrant population. In Uganda, a parish is a geographical area with a population of approximately 10,000 to 20,000 inhabitants. Nyantonzi parish has a population of approximately 15,300 inhabitants, accounting for 4% of the total population of Masindi district. Masindi district consists of 27 parishes, with a total population of 391,900 inhabitants. The local inhabitants of Masindi are predominantly Banyoro, which belong to the large ethnic group known as the Bantu, and they speak the Runyoro dialect. Immigrant populations come mainly from the West Nile districts of Nebbi and Arua, and they belong to the Sudanic Ma’di ethnic group. Immigrant populations are essentially economic immigrants seeking job opportunities within the sugarcane plantations of Kinyala Sugar. The Bantu and Sudanic Ma’di dialects are completely unrelated. In Masindi district, about 35% of women attend 4 antenatal visits and 30% deliver in a health facility, compared to the national average of 57%.[19] Neonatal mortality in the western region of Uganda is 30/1000 live births compared to the national average of 27/1000 live births.[20] Data collection: Data were collected through focus group discussions (FGDs), in-depth interviews, and key informant interviews. Five FGDs with immigrant men and women (three with women and 2 with men) were conducted, with each group having 8 participants. Two of the FGDs were conducted with women who had recently delivered and 1 was conducted with pregnant women. The FGDs with men included 1 group whose spouses were pregnant and 1 group whose spouses had recently delivered. All groups were selected based on their Lugbara immigrant status. Focus group discussion questions related to perceived barriers to accessing care at the health facility, experiences of care in health facilities (health centers and hospitals), reasons for negative health facility experiences, gender relations at the household level, and suggestions for improving access to and utilization of maternal health care. In-depth interviews were conducted with lactating women who had experience interacting with the health system during pregnancy or labor. Key informant interviews were conducted with health workers at the referral hospital and 2 health centers in Nyantonzi parish. All interviews lasted approximately 45–60 minutes. Interviews were conducted until saturation was reached. All interviews were conducted by 2 female social science researchers. One researcher was a gender expert and doctoral student from the school of gender studies at Makerere University, while a second researcher was well versed with the local dialect commonly spoken among the immigrant population. Both researchers were trained on the objectives of the study and were oriented to the question guide. Data analysis: FGDs and in-depth interviews were audiotaped, and translation was performed during interview transcription. Key informant interviews with health workers were conducted and transcribed in English. Thematic analysis was conducted. The first and second authors read the scripts several times and exported them to NVivo software for analysis. Data were coded based on a coding framework which mirrored the themes discussed during the interviews and included intersectional considerations. From the initial codes, texts with similar meaning were grouped together from which subthemes were developed, and subsequently meaningful thematic narrations were developed. This study was approved by the Higher Degrees Research and Ethics Committee of the School of Public Health, HDREC no. 324. Verbal consent to participate in the study was obtained from each study participant. The results of the study were reported to ensure anonymity.

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The study titled “Ethnicity, gender, and migration status: Applying intersectionality methodology to explore barriers to equitable health systems for maternal and newborn health among immigrant populations in Masindi, Uganda” aimed to understand why immigrant populations in Masindi, Uganda, have lower utilization of maternal health services compared to indigenous populations. The study used qualitative methods, including focus group discussions, in-depth interviews, and key informant interviews, to gather data from immigrant men and women, health workers, and lactating women.

The study found that immigrant populations perceived discrimination based on ethnicity as a barrier to accessing maternal health services. Factors such as language barriers, being poor casual laborers, and low education levels contributed to this perceived discrimination. Additionally, gender roles and societal expectations played a role, as matters of pregnancy and childbearing were considered solely the responsibility of women, while financial and household decisions were controlled by men. The study also highlighted the societal expectation for women to endure labor pains silently, which discouraged seeking care early during labor.

Based on these findings, the study recommends interventions to improve access to maternal health services among immigrant populations. These recommendations include demystifying harmful cultural norms through awareness campaigns and training health workers on respectful treatment based on the 12 steps to safe and respectful mother-baby-family care.

The study was conducted in Nyantonzi parish in Masindi district, which has a high density of immigrant population. The local inhabitants of Masindi are predominantly Banyoro, while immigrant populations mainly come from the West Nile districts of Nebbi and Arua and belong to the Sudanic Ma’di ethnic group. In Masindi district, the percentage of women attending four antenatal visits and delivering in a health facility is lower than the national average.

The data collection for the study involved conducting focus group discussions, in-depth interviews, and key informant interviews. The interviews were conducted with immigrant men and women, including pregnant women and those who had recently delivered, as well as health workers at the referral hospital and health centers in Nyantonzi parish. The interviews were conducted by two female social science researchers who were trained on the study objectives and question guide.

Thematic analysis was performed on the collected data, and codes were developed based on the themes discussed during the interviews, including intersectional considerations. The study was approved by the Higher Degrees Research and Ethics Committee of the School of Public Health, and verbal consent was obtained from each study participant.

The study was published in the journal Medicine (United States), Volume 101, No. 30, in the year 2022.
AI Innovations Description
The study titled “Ethnicity, gender, and migration status: Applying intersectionality methodology to explore barriers to equitable health systems for maternal and newborn health among immigrant populations in Masindi, Uganda” aims to understand why immigrant populations in Masindi, Uganda, have lower utilization of maternal health services compared to indigenous populations. The study used qualitative methods, including focus group discussions, in-depth interviews, and key informant interviews, to gather data from immigrant men and women, health workers, and lactating women.

The study found that immigrant populations perceived discrimination based on ethnicity as a barrier to accessing maternal health services. Factors such as language barriers, being poor casual laborers, and low education levels contributed to this perceived discrimination. Additionally, gender roles and societal expectations played a role, as matters of pregnancy and childbearing were considered solely the responsibility of women, while financial and household decisions were controlled by men. The study also highlighted the societal expectation for women to endure labor pains silently, which discouraged seeking care early during labor.

Based on these findings, the study recommends interventions to improve access to maternal health services among immigrant populations. These recommendations include demystifying harmful cultural norms through awareness campaigns and training health workers on respectful treatment based on the 12 steps to safe and respectful mother-baby-family care.

The study was conducted in Nyantonzi parish in Masindi district, which has a high density of immigrant population. The local inhabitants of Masindi are predominantly Banyoro, while immigrant populations mainly come from the West Nile districts of Nebbi and Arua and belong to the Sudanic Ma’di ethnic group. In Masindi district, the percentage of women attending four antenatal visits and delivering in a health facility is lower than the national average.

The data collection for the study involved conducting focus group discussions, in-depth interviews, and key informant interviews. The interviews were conducted with immigrant men and women, including pregnant women and those who had recently delivered, as well as health workers at the referral hospital and health centers in Nyantonzi parish. The interviews were conducted by two female social science researchers who were trained on the study objectives and question guide.

Thematic analysis was performed on the collected data, and codes were developed based on the themes discussed during the interviews, including intersectional considerations. The study was approved by the Higher Degrees Research and Ethics Committee of the School of Public Health, and verbal consent was obtained from each study participant.

The study was published in the journal Medicine (United States), Volume 101, No. 30, in the year 2022.
AI Innovations Methodology
To simulate the impact of the main recommendations of this study on improving access to maternal health, a potential methodology could involve the following steps:

1. Designing an intervention: Based on the study’s recommendations, an intervention could be designed to address the identified barriers to accessing maternal health services among immigrant populations in Masindi, Uganda. This intervention could include awareness campaigns to demystify harmful cultural norms and training programs for health workers on respectful treatment based on the 12 steps to safe and respectful mother-baby-family care.

2. Implementing the intervention: The designed intervention should be implemented in the study area, Nyantonzi parish in Masindi district. The intervention could be carried out over a specific period, such as six months or one year, to allow for sufficient time to observe any changes in access to maternal health services.

3. Collecting pre- and post-intervention data: Before implementing the intervention, baseline data should be collected on the utilization of maternal health services among immigrant populations in Nyantonzi parish. This data could include information on the percentage of women attending antenatal visits, delivering in a health facility, and receiving postnatal care. Additionally, data on perceived barriers to accessing maternal health services, such as discrimination based on ethnicity, language barriers, and gender roles, should be collected.

4. Monitoring and evaluating the intervention: During the implementation of the intervention, regular monitoring should be conducted to assess its progress and identify any challenges or adjustments needed. This could involve tracking the number of individuals reached through awareness campaigns, evaluating the effectiveness of training programs for health workers, and gathering feedback from immigrant populations on their experiences with accessing maternal health services.

5. Collecting post-intervention data: After the intervention period, post-intervention data should be collected using the same indicators and methods as the baseline data. This will allow for a comparison of the utilization of maternal health services before and after the intervention, as well as any changes in perceived barriers to access.

6. Analyzing and interpreting the data: The pre- and post-intervention data should be analyzed to determine the impact of the intervention on improving access to maternal health services among immigrant populations. This could involve comparing the percentage of women attending antenatal visits, delivering in a health facility, and receiving postnatal care before and after the intervention. Additionally, changes in perceived barriers to access can be assessed.

7. Reporting and disseminating the findings: The findings of the analysis should be reported and disseminated to relevant stakeholders, including policymakers, healthcare providers, and community members. This will help raise awareness about the importance of addressing barriers to access and inform future interventions and policies aimed at improving maternal health services for immigrant populations.

It is important to note that this methodology is a hypothetical approach to simulate the impact of the study’s recommendations. The actual implementation and evaluation of an intervention would require careful planning, coordination, and collaboration with local stakeholders and organizations involved in maternal health services in Masindi, Uganda.


Statistics:
Citations: 1
Identifiers:
DOI: 10.1097/MD.0000000000029698
ISSN: 00257974
Research Areas:
Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Uganda
Study Design:
Cross Sectional Study, Grounded Theory, Phenomenological Study, randomised-control-trial
Study Approach:
Qualitative
Participants Gender:
Male & Female
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