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Background: Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda.Methods: Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified.Results: The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery.Conclusion: A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.
Karamoja region, near the border with Kenya, occupies an area of 35,007 Km2 and has a population of 1,074,600. This study was conducted in April 2010 in Moroto and Napak districts. The two districts, with a total area of 8,516 Km2, had a population of about 270,650 in 2010. Although both districts are predominantly rural, Moroto District hosts Moroto town which has an urban/peri-urban population of about 11,600. Moroto town is the administrative headquarters of Karamoja Region and has a regional referral Hospital for the entire Karamoja. Most parts of Napak District have a flat terrain but parts of Moroto District are mountainous making them difficult to access even by car. Both districts are inhabited by Karamajong people whose main sources of livelihood are nomadic pastoralism and subsistence crop farming. In Uganda, districts are subdivided into sub-counties, then parishes and villages. At the time of the study, Napak District had 6 sub-counties (Iriiri, Lokopo, Lopei, Lotome, Matany and Ngoloriet) and 200 villages whereas Moroto District had 5 sub-counties (Katikekile, Nadunget, Rupa, Northern Division and Southern Division) and 120 villages [22]. The districts had 61 nurses/midwives of different cadres, 11 doctors, 19 clinical officers and about 315 TBAs. In 2010 only 19% and 10% of deliveries took place in health facilities in Napak and Moroto districts, respectively [23], with most women delivering at home, attended to by either family members or TBAs. About 49% and 59% of the population in Moroto and Napak districts, respectively, is within five kilometres of a health facility. However, some of the health facilities are level II Health Centres which typically don’t offer maternity services. During rainy seasons most parts of the districts become inaccessible by motor vehicles due to muddy roads. The study was conducted in the catchment communities of health facilities in Moroto and Napak districts. These two districts were purposively selected because they were targets of a planned intervention to increase institutional delivery service by Doctors with Africa CUAMM. In consultation with district health authorities, twenty villages (ten in each district) located in 10 different sub-counties were selected purposively, to reflect the different geographic and socio-demographic characteristics of the communities in the districts. Figure 1 summarises the selection of villages and characteristics of the selected villages. In the selected villages, all women who had delivered in the past 5 years and their partners were eligible for the study. Selection of Sub-counties and villages and characteristics of selected villages. Data were collected through participatory rural appraisal (PRA). A total of 887 adult participants (459 women and 428 men) were recruited to participate in the PRA sessions. Participating villages were visited a day before the study and with the help of village leaders, potential participants were verbally invited to participate in the study the following day. The PRA data collection team consisted of a supervisor, two facilitators and two note takers. The supervisor and facilitators were experienced in PRA methodology having conducted similar studies in the same area in the past. The supervisor (co-author RML) further conducted a short training for facilitators and the note takers; covering the PRA methodology, the study objectives and a review of the tools. In order to overcome cultural factors that would limit freedom of expression, participants were divided into male and female groups. A male facilitator guided the male group while the female group was led by female facilitator. All members of data collection team were natives of the study districts and had a good understanding of the local culture and language. Two PRA sessions per group were held in each village and each session was made up of about 20 participants and lasted for about 3 hours. The sessions were held in public spaces selected by the communities, such as under trees and in local school buildings. Tools used during the sessions included community resource maps, Venn diagrams, matrix ranking, daily routines, and seasonal calendars. During the sessions, information on barriers to utilisation of maternal health services in the districts was collected using an open ended question guide which allowed for free discussion of the participants’ perceptions. During the discussions, the two note takers independently took notes. The discussions took place at alternate times for the male and female groups to allow the supervisor to attend both of them and also take notes. All notes were written in English as it was found to be easier to do so than to write in Karamojong (the local language). In case of lack of clarity, immediate clarification was sought. The main topics included in the question guide were: i) traditional practices and beliefs during delivery; ii) family support and decision making on health services during delivery; iii) the role of TBAs; iv) perceived quality of care and fee for services used; v) obstacles when using trained attendants’ services; vi) experience of delivery (including the services provided by the delivery attendants); and vii) reasons for a delivery outside a health care facility. Matrix ranking was performed by asking participants to list main reasons why women in the village don’t deliver in health facilities. Participants were then asked to use stones to assign a score to each reason to reflect the relative weight of the reason in preventing women from using skilled birth attendants. One stone represented a weight of one. A literate member in the group facilitated the scoring exercise which was done by consensus among group members. Locally prepared refreshments were provided at the end of PRA sessions. No cash incentives were provided. This study was approved by the National Bioethics Committee at Uganda National Council for Science and Technology and by the Moroto District Health Management Team. Because most PRA participants were illiterate, and given that they participated in the study in groups, verbal informed consent was obtained from each PRA group after an explanation about the study. Data were analysed using deductive content analysis [24]. At the end of each PRA session, the study team reviewed, edited and harmonized the notes taken. They then read through the notes several times, triangulated the data collected from men and women groups, identified and coded all recurring issues by consensus and summarized them in a table. The issues were grouped under four themes in an adapted framework: (1) socio-cultural factors, (2) perceived benefit/need of skilled attendance, (3) economic inaccessibility and (4) physical inaccessibility [10]. The themes formed the framework for reporting. Scores from matrix ranking were summarized using a spider plot to reflect the perceived relative significance of each barrier identified by participants in preventing utilization of delivery services. Scores for each barrier at each site were rescaled to take values of 0–5 and then summed up.
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