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Background: Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Delivery with a skilled birth attendant is a vital intervention for saving lives. Yet many women, particularly where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. In Uganda, only 58% of women deliver in a health facility, despite approximately 95% of women attending antenatal care (ANC). This study aimed to (1) identify key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery; (2) examine the association between advice during antenatal care to deliver at a health facility and actual place of delivery; (3) investigate whether antenatal care services in a post-conflict district of Northern Uganda actively link women to skilled birth attendant services; and (4) make recommendations for policy- and program-relevant implementation research to enhance use of skilled birth attendance services. Methods: This study was carried out in Gulu District in 2009. Quantitative and qualitative methods used included: structured antenatal care client entry and exit interviews [n = 139]; semi-structured interviews with women in their homes [n = 36], with health workers [n = 10], and with policymakers [n = 10]; and focus group discussions with women [n = 20], men [n = 20], and traditional birth attendants [n = 20]. Results: Seventy-five percent of antenatal care clients currently pregnant reported they received advice during their last pregnancy to deliver in a health facility, and 58% of these reported having delivered in a health facility. After adjustment for confounding, women who reported they received advice at antenatal care to deliver at a health facility were significantly more likely (aOR = 2.83 [95% CI: 1.19-6.75], p = 0.02) to report giving birth in a facility. Despite high antenatal care coverage, a number of demand and supply side barriers deter use of skilled birth attendance services. Primary barriers were: fear of being neglected or maltreated by health workers; long distance and other difficulties in access; poverty, and material requirements for delivery; lack of support from husband/partner; health systems deficiencies such as inadequate staffing/training, work environment, and referral systems; and socio-cultural and gender issues such as preferred birthing position and preference for traditional birth attendants. Conclusions: Initiatives to improve quality of client-provider interaction and respect for women are essential. Financial barriers must be abolished and emergency transport for referrals improved. Simultaneously, supply-side barriers must be addressed, notably ensuring a sufficient number of health workers providing skilled obstetric care in health facilities and creating habitable conditions and enabling environments for them.
Civilians in Northern Uganda were living under war conditions for more than 20 years, and the area has only in recent years emerged from conflict. Residents of Gulu District faced massive displacements since 1996 resulting from the Lord’s Resistance Army (LRA) insurgency, which targeted civilians, resulting in tremendous and prolonged suffering. In mid-2006, the Government of Uganda and the LRA signed a Cessation of Hostilities Agreement. Since November 2006, Gulu District Authorities have encouraged Internally Displaced Persons’ (IDP) to return to their villages. This study targeted a public-sector Ministry of Health (MoH) facility (“Lalogi”) in Northern Uganda’s Gulu District, supported by MSF. The facility was located inside an IDP camp to eliminate distance and insecurity as barriers to service utilization. The study employed a quantitative and qualitative approach. Quantitative methods were used to assess whether advice during ANC consultation was associated with increased facility delivery. Qualitative methods were used to understand the dynamics of decision-making by clients, communities, and providers regarding where women give birth. The following data collection techniques were used: The study investigated both demand- and supply-side barriers to utilization of SBA among women who have already used ANC services (see Fig. 1: ANC-SBA link/gap model: factors influencing the link or gap between women’s use of ANC and SBA services, in separately uploaded file). The guiding framework drew on existing studies [46, 49] in describing barriers women face in accessing quality preventive or routine intrapartum care and emergency obstetric care. However, the conceptual framework for this study attempted to integrate roles and perspectives from both the demand-side (women) and the supply-side (ANC providers). Thus, the framework includes several health systems factors not included in the above-referenced studies – namely, health worker knowledge, beliefs, motivation, and incentives, and whether they advise ANC clients to deliver in facilities; health system capacity for SBA; policies regarding SBA – as well as some demand-side factors such as woman’s birthing/obstetric history; whether she was advised at ANC to delivery in a health facility; the timing and progression of labour; and her perception of the quality of care available at health facilities. Please see separate file (Fig. 1: ANC-SBA link/gap model: Factors influencing the link or gap between women’s use of ANC and SBA services) uploaded through the online submission system For the quantitative client entry and exit interviews, data were obtained from women visiting the ANC clinic for the first time during their current pregnancy. All such women were eligible, and the research team attempted to interview all eligible women each day data collection was ongoing. A sample size of 130 women was selected to detect an odds ratio of 4 for the association between having received ANC advice and actually having delivered at a health facility at last birth, assuming 15 % received advice and about 20 % of women who did not receive advice would deliver in a health facility. A total of 139 women were recruited for entry-exit interviews at Lalogi health centre. For the qualitative interviews with ANC clients who had delivered within the previous two years, sampling was purposive, to assess the scope of views, which were expected to vary with parity and place of delivery at last birth. The final sample size (N = 36) was determined using a saturation approach. The sampling grid (Table 2) defined profiles of women of reproductive age (15–49 years) selected for interview [31]. For the qualitative interviews, women were purposively selected. Starting at the gate of Lalogi Health Centre IV, researchers randomly selected a direction and walked in that direction in Lalogi camp, within a maximum walking distance of 20 min. While walking, researchers asked around at households, markets, and community gathering sites for women who fit the eligibility criteria. Subsequently, the “snowball” technique was used to identify additional women who met the criteria. Selection of women involved stratification based on whether the woman’s last delivery was at a health facility or at home, and parity. Selection of interviewees also involved restricting for distance, i.e., selecting only women who lived within reasonable access to the health facility and for whom distance was unlikely to be the primary reason for non-use of the facility. These qualitative interviews were conducted with women in their own homes. For example, after locating a woman in the market who met the eligibility criteria, researchers arranged a time to go to her home for an interview, typically the following day. While there is always a possibility of selection bias, the above- described measures aimed to minimize this possibility, and researchers are not aware of any women who refused to participate in interviews or FGDs. Sampling grid of home-based interviews with women Ten semi-structured interviews were conducted with health workers providing maternity care; ten interviews with Ugandan policymakers at sub-district, district, and national levels, selected based upon local co-investigator recommendations and the snowball technique; and six focus group discussions (two with women, two with men, and two with traditional birth attendants) were carried out, comprising 60 participants in total. Recruitment criteria for FGD participants included the following: women in the community surrounding Lalogi who had given birth at least once within the past 2 years; men in the Lalogi community whose wives/partners had given birth in the past 2 years; and TBAs working in partnership with Lalogi Health Centre. Eligible women had a brief interview before entering, and after exiting, the ANC clinic. Content and perceived quality of ANC counselling were addressed in the exit interviews. Interviews were conducted every day during nearly two months to capture a diverse sample of clients receiving ANC services from different providers. Interview schedules for the semi-structured interviews and topic guides for FGDs were adapted from existing tools [32–36]. The tools were translated and back-translated as needed, then piloted and adapted accordingly. Interviews and FGDs were conducted in local language (Acholi and/or Langi) by the trained, local research assistants. All sessions were recorded, transcribed, translated, and back translated to ensure accuracy and quality. We examined the association of several supply- and demand-side factors with the primary outcome of giving birth in a health facility. Quantitative data were double-entered with EpiData (EpiData Association, Odense, Denmark), checked for consistency and validity, and analysed with Stata 10 (StataCorp, College Station, Texas, USA). Following univariable and bivariable analyses, multivariable logistic regression analyses were performed to assess: a) factors associated with women receiving advice at ANC to deliver at a health facility; b) factors associated with previous health facility delivery; and c) the association between ANC advice and place of delivery. In bivariable analysis, crude odds ratios together with 95 % confidence intervals were calculated, and proportions were compared using chi-square test. Stratified analysis was conducted to explore confounding and interaction. In multivariable analysis we used manual forward selection, comparing odds ratios to identify confounders, and performing likelihood ratio tests to identify secondary exposures. In addition to the primary exposure (ANC advice to deliver in a health facility), woman’s education and cost of reaching health services were identified a priori from the literature as potentially important exposures or confounders, and were tentatively included in the multivariable logistic regression model. Gravidity and ethnic group, which had been identified as exposures or confounders in bivariable or stratified analysis, were tentatively included in the model as well. Variables, which had a high proportion of missing values, or which in multivariable analysis turned out to be neither confounder nor secondary exposure, were ultimately removed from the model. For qualitative data, topic guides for semi-structured interviews and focus groups were developed based on themes essential to answering the research questions. A coding scheme was developed, expanded, and modified as the study progressed. Transcripts, observers’ notes, and facilitators’ reports were synthesized and analysed, using a framework approach. Analysis questionnaires and matrices were developed for each group of respondents. We tracked the frequency of recurring themes and compared themes across differing respondent groups to determine patterns, similarities, and differences. Based on frequency, content, and strength of respondents’ statements, factors were assigned relative weight in terms of their impact on ANC clients’ use of SBA services. Ethics approval for the study was obtained from the London School of Hygiene & Tropical Medicine, Gulu University, the Uganda National Council for Science and Technology, and MSF. Written informed consent was requested and obtained from all participants, who were assured of confidentiality of any information given.
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