Gender dynamics affecting maternal health and health care access and use in Uganda

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Study Justification:
– Maternal mortality rate in Uganda remains high despite reduction in the last decade
– Lack of access to maternal health care is a contributing factor
– Quasi-experimental trial using vouchers increased access to institutional delivery
– Sustainability of interventions is a challenge
– Gender dynamics are important in addressing the underlying causes of women’s lack of access
Study Highlights:
– Qualitative study conducted to explore root causes of women’s lack of maternal health care access and utilization
– Gender analysis conducted to identify key gender dynamics affecting maternal health care
– Key gender dynamics identified: access to resources, division of labor, social norms, and decision-making
– Integration of gender into maternal health care interventions is necessary to address root causes of barriers and improve access and utilization
Study Recommendations:
– Integrate gender into maternal health care interventions to address root causes of barriers
– Improve access to resources for women
– Address division of labor by involving men in health facilities and reducing women’s workload
– Challenge social norms related to women’s attitudes and behavior, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behavior
– Empower women in decision-making about maternal health care
Key Role Players:
– Project implementers
– Local leaders
– Village health team leaders
– Community-based organization leaders
– Local political structures (local councils)
– Members of the community with disabilities
Cost Items for Planning Recommendations:
– Training and capacity building for project implementers and health workers
– Awareness campaigns and community mobilization
– Infrastructure improvements in health facilities
– Provision of resources and supplies
– Monitoring and evaluation activities
– Research and data analysis
– Stakeholder engagement and coordination efforts

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a quasi-experimental trial and a follow-up qualitative study. The use of qualitative data collection methods and the inclusion of different perspectives from various groups in the community enhance the credibility of the findings. However, the abstract does not provide information on the sample size or the specific methods used for data analysis. To improve the strength of the evidence, it would be helpful to include more details on the sample size and the specific analytical techniques used in the study.

Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women’s access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women’s lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women’s lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women’s workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women’s attitudes and behaviour during pregnancy, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.

This was a cross-sectional study that utilised qualitative data collection methods that comprised of group discussions. Data were collected from the project implementation districts of Pallisa, Kibuku and Kamuli located in Eastern Uganda. These districts were selected to mirror the sites within the original project locations, and to ensure the information collected was representative of all areas. The estimated population in this area is 1 219  172 (UBOS 2012). All of the three districts are rural and the means of living is subsistence farming supplemented by small scale trading in small townships. There were 31 health centre IIIs, four health centre IVs and four district hospitals within this area. The common means of transport to health facilities include walking, using boda boda motorcycles and taxis (commercial vans that sit 14 passengers). Group discussions were held across eight sub counties in three districts in Eastern Uganda, with women who had given birth recently (x16), fathers whose wives had given birth recently (x8) and transport drivers (x8) (Table 1). Female respondents were further disaggregated by age (younger mothers aged 15-25 and older mothers aged 26-55). The female groups were homogenous with respect to age to foster open and free discussions. However, they were heterogeneous with respect to social economic status, disability and positions of responsibility to allow for maximum variation in perspectives. Across all the subgroups, respondents were selected who would be representative of the different levels of social economic status in the community. Social economic status was determined based on commonly used indicators in the community, such as type of housing, education level, occupation and possession of assets, such as land, vehicles and radios. In addition, we included members of the community who held positions of responsibility in different capacities, such as village health team leaders, leaders of community-based organizations and local political structures (local councils), as well as some members of the community with disabilities. Number of group interviews and overview of respondents Respondents were selected with the help of local gatekeepers. For recruitment of mothers and fathers, local leaders were briefed about the kind of respondents needed and helped to identify suitable candidates. Potential respondents were then informed about the study and asked to participate in the group discussions by the study team. Those community members that volunteered were included in discussion groups of 10–15 participants. Similary, as transporters are organized into groups with team leaders at sub-county level, team leaders supported the identification of transporters who could be involved in the discussion groups through a process similar to that of the mothers and fathers. The group discussions included questions related to birth preparedness, transport and quality of care, as the initial intervention identified these as important access and utilization issues. Specifically, respondents were asked questions related to how they prepare for birth, how they save money for use during pregnancy and child birth, how they care for their new born babies, and challenges faced during birth preparedness. Regarding transportation, they were asked about the means of transport that they use to the facility, the state of roads and challenges faced during transportation. Lastly, they were asked about how health workers treat them when they go to seek care for maternal and child health, availability of amenities, drugs, supplies, and infrastructure, as well as barriers to providing quality care. Respondents were also asked to suggest solutions to the problems that they experienced. During these group discussions, researchers used a range of participatory techniques. These included: brainstorming of problems, ranking of problems, facilitated discussions on solutions to problems, creation of a roti diagram depicting solutions, enabling participants to visualize how they could support themselves and areas where support is needed, and feedback discussions. The issues identified in this initial analysis were used to design a maternal and neonatal implementation for equitable systems project (MANIFEST). The project aimed to increase access to maternal and neonatal health services in a more sustainable manner in the three districts using a participatory action research approach. For the gender analysis, transcripts were analyzed using the framework approach, a type of thematic analysis. The framework approach uses a series of steps (indexing, charting, mapping and interpretation) to organize and interpret data and is particularly relevant for policy-orientated research due to its focus on a distinct set of stages (Ritchie and Spencer 1993). Transcripts were reviewed and coded using the themes that were pre-determined by the research team (birth preparedness, quality of care and transport), as well as a gender analysis framework (Table 2) (Morgan et al. 2016). Gender analysis framework: gender as a power relation and driver of inequality The gender analysis framework argues that gender as a power relation and driver of inequality can be understood by how power is constituted and negotiated in relation to access to resources, division of labour, social norms and decision-making. While these factors are presented as distinct categories they interact and reinforce one another, and, as Morgan et al. (2016, p. 3) argue, they “are not static, but are actively fostered, maintained or contested, in intended and unintended ways, as gender power relations […] are negotiated by people and their environments.” The framework was used to explore how gender power relations affect maternal health care access and utilization within these districts. After coding the transcripts, researchers summarized the data into tables and grouped data according to emerging themes and relationships related to the gender analysis framework. Data were analyzed across districts and age groups (in the case of mothers). During the analysis key gender findings emerged upon further examination of the data, which are presented below. During analysis, a distinction was made between gender dynamics that drive inequality, and drivers that have gender implications, such as structural constraints within the health system. For example, while lack of supplies or equipment within health facilities is likely to have a greater impact on women due to their increased use of health facilities, this is a structural constraint that has gender implications. Whereas gendered power relations which inhibit women’s lack of decision-making power about when and where to seek care is a gender dynamic that drives inequality. Ethical clearance for this study was granted from the Makerere University School of Public Health and Uganda National Council for Science and Technology. Permission was also sought from the district health offices of the participating districts. Participation was voluntarily and study details were well explained to the study participants and written consent was obtained. Privacy was ensured and data were kept confidentially with access restricted to only the study investigators and research assistants.

The recommendation to improve access to maternal health based on the study is to integrate gender into maternal health care interventions. This means addressing the gender dynamics that significantly affect maternal health care access and utilization, such as access to resources, division of labor, social norms, and decision-making.

Interventions should go beyond addressing immediate access barriers, like lack of financial resources and transportation, and focus on addressing the underlying causes related to gender. This can be done by involving men in maternal health care, challenging social norms that hinder women’s access to care, and addressing gender power relations that limit women’s decision-making power.

The study emphasizes the need for sustainability in interventions. While voucher programs and other external resources can address immediate access barriers, they are not designed to address the underlying gender dynamics. Therefore, integrating gender into maternal health care interventions is crucial for long-term improvement in access to and use of maternal health care.

The study was conducted in Eastern Uganda, specifically in the districts of Pallisa, Kibuku, and Kamuli. Data was collected through group discussions with recently pregnant women, fathers whose wives had given birth recently, and transport drivers. The discussions focused on topics such as birth preparedness, transport, quality of care, and challenges faced during maternal and child health care.

The data was analyzed using a gender analysis framework, which highlighted the key gender dynamics affecting maternal health care access and utilization. The findings from the analysis were used to inform the design of the maternal and neonatal implementation for equitable systems project (MANIFEST), which aimed to increase access to maternal and neonatal health services in a more sustainable manner.

The study was published in the Health Policy and Planning journal in 2017. Ethical clearance was obtained, and participants provided voluntary consent. Privacy and confidentiality of the data were ensured.
AI Innovations Description
The recommendation to improve access to maternal health based on the study is to integrate gender into maternal health care interventions. The study found that gender dynamics, such as access to resources, division of labor, social norms, and decision-making, significantly affect maternal health care access and utilization. By addressing these gender dynamics, interventions can address the root causes of barriers to maternal health access and utilization.

The study suggests that interventions should go beyond addressing immediate access barriers, such as lack of financial resources and transportation, and focus on addressing the underlying causes related to gender. This can be done by involving men in maternal health care, challenging social norms that hinder women’s access to care, and addressing gender power relations that limit women’s decision-making power.

The study also emphasizes the need for sustainability in interventions. While voucher programs and other external resources can successfully address immediate access barriers, they are not designed to address the underlying gender dynamics. Therefore, integrating gender into maternal health care interventions is crucial for long-term improvement in access to and use of maternal health care.

The study was conducted in Eastern Uganda, specifically in the districts of Pallisa, Kibuku, and Kamuli. The data was collected through group discussions with recently pregnant women, fathers whose wives had given birth recently, and transport drivers. The discussions focused on topics such as birth preparedness, transport, quality of care, and challenges faced during maternal and child health care.

The data was analyzed using a gender analysis framework, which highlighted the key gender dynamics affecting maternal health care access and utilization. The findings from the analysis were used to inform the design of the maternal and neonatal implementation for equitable systems project (MANIFEST), which aimed to increase access to maternal and neonatal health services in a more sustainable manner.

The study was published in the Health Policy and Planning journal in 2017. Ethical clearance was obtained, and participants provided voluntary consent. Privacy and confidentiality of the data were ensured.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, a mixed-methods approach could be used. Here is a brief description of a possible methodology:

1. Quantitative Data Collection:
– Conduct a survey to collect quantitative data on access to maternal health care before and after implementing interventions that integrate gender dynamics.
– Randomly select a sample of women of reproductive age from the study area.
– Collect data on indicators such as the percentage of women receiving antenatal care, the percentage of women delivering in health facilities, and the percentage of women receiving postnatal care.
– Compare the data before and after the interventions to assess the impact on access to maternal health care.

2. Qualitative Data Collection:
– Conduct in-depth interviews and focus group discussions with women, men, and health care providers to gather qualitative data on their experiences and perceptions of the interventions.
– Explore how the interventions addressing gender dynamics have influenced their access to and utilization of maternal health care.
– Use open-ended questions to allow participants to share their thoughts and experiences in their own words.
– Analyze the qualitative data using thematic analysis to identify common themes and patterns related to the impact of the interventions.

3. Integration of Quantitative and Qualitative Data:
– Compare the quantitative findings with the qualitative findings to gain a comprehensive understanding of the impact of the interventions.
– Look for patterns and correlations between the quantitative indicators and the qualitative themes.
– Use the qualitative data to provide context and explanations for the quantitative findings.

4. Stakeholder Engagement:
– Involve key stakeholders, such as policymakers, health care providers, and community leaders, in the analysis and interpretation of the findings.
– Organize workshops or meetings to present the results and gather feedback from stakeholders.
– Discuss the implications of the findings for policy and practice and identify potential areas for further improvement.

5. Recommendations and Action Plan:
– Based on the findings, develop recommendations for scaling up and sustaining interventions that integrate gender dynamics into maternal health care.
– Collaborate with stakeholders to develop an action plan for implementing the recommendations.
– Ensure that the action plan includes strategies for addressing the underlying gender dynamics identified in the study, such as involving men in maternal health care and challenging social norms.

By using this methodology, researchers can assess the impact of integrating gender into maternal health care interventions and provide evidence-based recommendations for improving access to maternal health care in the long term.

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