Trends in antenatal care attendance and health facility delivery following community and health facility systems strengthening interventions in Northern Uganda

BMC Pregnancy and Childbirth, Volume 13, Year 2013

Interpretation

Background: Maternal morbidity and mortality remains high in Uganda; largely due to inadequate antenatal care (ANC), low skilled deliveries and poor quality of other maternal health services. In order to address both the demand and quality of ANC and skilled deliveries, we introduced community mobilization and health facility capacity strengthening interventions. Methods: Interventions were introduced between January 2010 and September 2011. These included: training health workers, provision of medical supplies, community mobilization using village health teams, music dance and drama groups and male partner access clubs. These activities were implemented at Kitgum Matidi health center III and its catchment area. Routinely collected health facility data on selected outcomes in the year preceding the interventions and after 21 months of implementation of the interventions was reviewed. Trend analysis was performed using excel and statistical significance testing was performed using EPINFO StatCal option. Results: The number of pregnant women attending the first ANC visit significantly increased from 114 to 150 in the first and fourth quarter of 2010 (OR 1.72; 95% CI 1.39-2.12) and to 202 in the third quarter of 2011(OR 11.41; 95% CI 7.97-16.34). The number of pregnant women counselled, tested and given results for HIV during the first ANC attendance significantly rose from 92 (80.7%) to 146 (97.3%) in the first and fourth quarter of 2010 and then to 201 (99.5%) in the third quarter of 2011. The number of male partners counseled, tested and given results together with their wives at first ANC visit rose from 13 (16.7%) in the fourth quarter of 2009 to 130 (89%) in the fourth quarter of 2010 and to 180 (89.6%) in the third quarter of 2011. There was a significant rise in the number of pregnant women delivering in the health facility with provision of mama-kits (delivery kits), from 74 (55.2%) to 149 (99.3%) in the second and fourth quarter of 2010. Conclusions: Combined community and facility systems strengthening interventions led to increased first ANC visits by women and their partners, and health facility deliveries. Interventions aimed at increasing uptake of maternal health services should address both the demand and availability of quality services. © 2013 Ediau et al.; licensee BioMed Central Ltd. The interventions were conducted in Kitgum Matidi Sub County in Kitgum District, Northern Uganda. Kitgum Matidi (HC) III serves as the highest level health facility providing health care services in Kitgum Matidi Sub County. The facility serves an estimated population of about 15,000 people. The health facility provides a range of preventive and curative health services including: ANC, skilled attended delivery, other outpatient and inpatient services. The project interventions focused on strengthening both the community and health facility systems in order to increase demand and quality of services, and ultimately utilization of ANC and skilled delivery services at the health facility. The project interventions were implemented between January, 2010 and September, 2011. The interventions mainly targeted pregnant women and their male partners. Details of the program interventions are described below. The key components of the interventions are also summarized in Table 1. Summary of selected program interventions implemented Health facility capacity building was done through training of health workers with ongoing mentorship, and provision of basic supplies such as delivery kits (also known as mama-kits), drugs, and HIV test kits. The mama-kit includes basic delivery supplies: cotton wool (200 g), hydrophilic gauze, sterile surgical gloves, mackintosh (rubber/polythene sheet), washing soap (600 g), surgical blades, umbilical-cord tie and tetracycline eye ointment (for the new born baby). These kits were also supplied to facilities by Ministry of Health (MoH) but stock outs were experienced by the health centre. Stock out of delivery supplies and the requirement for “poor” mothers to buy these supplies has been documented as one of the hindrances to health facility deliveries. In order to attract mothers to deliver at the health facility; baby soap, a baby towel and shawl were also added into the mama-kit. The modified delivery kits (with additional baby items) were given to pregnant women when they turned up to deliver at the health facility since anecdotal information suggested that some mothers used these kits to deliver elsewhere, within the communities, and their distribution at ANC may be viewed as encouraging women to deliver at home. Mama-kits were given free of charge. The community interventions included activities such as music, dance and drama (MDD), use of village health teams (VHT) for community sensitization, and establishment of male partner access clubs to sensitize and mobilize communities. The key messages to the community included benefits of ANC and skilled delivery attendance as well as male partner involvement in ANC. Community mobilization and sensitization was carried out using existing community structures; VHT are the frontline community workers and are recommended by the MoH for community education and health promotion for all diseases and have been used to delivery other health interventions in Uganda [23]. Sixty VHT members were identified and trained. These included both males and females. Selection of the VHT members to support these program interventions was done in close consultation with the district and health facility workers. The trained VHTs were involved in community sensitization and mobilization of pregnant mothers (and their male partners) for ANC attendance and health facility deliveries under the care of skilled birth attendants. The training was based on the national (MoH) 5-day training curriculum. Each VHT member was given a bicycle to facilitate movement within the community. Information Education and Communication (IEC) materials (charts) were designed and provided to VHTs to act as job aides. In addition to community sensitization and mobilization, VHTs were involved in tracking mothers who missed ANC visits and encouraging them to deliver in the health facility. Monthly performance review meetings attended by VHTs and health workers were conducted to improve performance and the relationship between VHTs and health workers, and also acted as supervisory encounter by health workers. Two male partner PMTCT access clubs were formed and engaged. These clubs comprised selected men from the community, who were viewed as role models in participating in ANC with their pregnant wives and ensuring that their wives delivered in the health facility. Male partner access clubs were facilitated to conduct two ‘male dialogue’ meetings in each month with other men in the communities. The aim of these meetings was to promote male partner involvement in ANC and skilled attended deliveries by their pregnant wives. Two MDD groups were established, trained and provided with the necessary costumes. Each of the two groups was facilitated to conduct two community mobilization and sensitization performances monthly. These groups focused on promoting ANC and skilled deliveries attendance as well as PMTCT services. Pregnant women and their husbands who turned up at health facility for ANC were counseled, tested and they received their HIV results together (as couples) on their first ANC visit. Pregnant women who turned up for ANC without their husbands were also counseled, tested and received their HIV results as individuals and encouraged to come with their partners on subsequent visits. All data which also included the estimated (expected) number of pregnant women in the first trimester were abstracted from the Health Information Management System (HIMS) data collection and reporting tools as well as registers of MOH that are used routinely by the health workers to capture patient care and treatment data. These included: the ANC register, delivery and birth register as well as quarterly and annual HMIS reports. Based on the population demographics, the health facility with technical support from the district health office and MoH set the annual targets on expected pregnancies. These facility level targets contributed to the district and national annual targets [24,25]. The data that was used for this paper was collected over a period of 21 months (from January, 2010 to September, 2011); during implementation of interventions. In order to evaluate the outcomes of the project, data for the same indicators was collected for the year preceding the interventions (January to December, 2009). The data was abstracted from the registers using a standardized tool and entered into an excel sheet for storage and analysis. Data was analyzed using Excel and Epi Info soft ware. Although data was collected on a monthly basis, during analysis data was collapsed into quarters and years (annually). The variables of interest included: total number of pregnant women attending first ANC visit and this was compared with the estimated annual number of pregnant women in the first trimester who were expected to attend ANC. Other measures included; total number of women attending the fourth ANC, number of pregnant women attending the first ANC visit who were counseled, tested for HIV and received their results (this was compared with the total number of pregnant women attending the first ANC visit rather than the total number of pregnancies in the community), number of male partners of pregnant women attending the first ANC and counseled, tested for HIV and received their results together with their wives (this was compared with number of pregnant women attending the first ANC visit who were counseled, tested for HIV and received their results);first-time ANC pregnant women were expected to be counseled, tested for HIV and given their HIV status results together with their husbands, as couples. The other variable was total number of skilled attended (health facility) deliveries recorded in the facility registers. Pregnant women who attended ANC but did not return to deliver in the health facility were considered to have delivered in the community/at home with the help of unskilled personnel. Using EPINFO StatCal option, we performed a Chi square test for trend and generated Odds Ratios (OR), 95%CI and p-Values to check whether the trends in these indicators were statistically significant. The Confidence Intervals (CI) were computed using the usual Chi-square in EPINFO. This manuscript was based on routine program data analysis for purposes of program monitoring and evaluation. The data that were analyzed had no identifiers for any of the individuals that were served and was exempt from ethical approval.

AI Digest

Study Justification:

– Maternal morbidity and mortality rates in Uganda are high due to inadequate antenatal care (ANC), low skilled deliveries, and poor quality of maternal health services.
– The study aimed to address these issues by introducing community mobilization and health facility capacity strengthening interventions.
– The interventions focused on increasing the demand and quality of ANC and skilled deliveries.

Highlights:

– The number of pregnant women attending the first ANC visit significantly increased after the interventions were implemented.
– The number of pregnant women counseled, tested, and given results for HIV during the first ANC visit also significantly increased.
– The number of male partners counseled, tested, and given results together with their wives at the first ANC visit rose significantly.
– There was a significant rise in the number of pregnant women delivering in the health facility with the provision of mama-kits (delivery kits).

Recommendations:

– Interventions aimed at increasing uptake of maternal health services should address both the demand and availability of quality services.
– Continued training and mentorship of health workers, provision of medical supplies, and community mobilization activities should be sustained.
– Efforts should be made to ensure consistent availability of delivery kits in health facilities.
– Male partner involvement in ANC and skilled deliveries should be promoted through the establishment of male partner access clubs and community sensitization activities.

Key Role Players:

– Health workers: Training and mentorship of health workers is essential for improving the quality of maternal health services.
– Village Health Teams (VHTs): VHTs play a crucial role in community sensitization and mobilization for ANC and skilled deliveries.
– Male partner access clubs: These clubs can help promote male involvement in ANC and skilled deliveries.
– Music, dance, and drama groups: These groups can be used for community mobilization and sensitization activities.

Cost Items for Planning Recommendations:

– Training and mentorship programs for health workers
– Provision of medical supplies, including delivery kits
– Community mobilization activities, such as music, dance, and drama performances
– Transportation and logistics for VHTs and health workers
– Communication materials, such as charts and IEC materials
– Incentives or support for male partner access clubs and community groups
Please note that the cost items provided are general categories and not actual cost estimates. The specific costs will depend on the context and implementation strategy.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it presents quantitative data showing significant increases in the number of pregnant women attending ANC visits, receiving HIV counseling and testing, and delivering in the health facility. The study also provides a clear description of the interventions implemented and the methods used for data collection and analysis. To improve the evidence, the abstract could include more information on the sample size and demographic characteristics of the population studied, as well as any potential limitations or biases in the data collection process.

Abstract

The interventions were conducted in Kitgum Matidi Sub County in Kitgum District, Northern Uganda. Kitgum Matidi (HC) III serves as the highest level health facility providing health care services in Kitgum Matidi Sub County. The facility serves an estimated population of about 15,000 people. The health facility provides a range of preventive and curative health services including: ANC, skilled attended delivery, other outpatient and inpatient services. The project interventions focused on strengthening both the community and health facility systems in order to increase demand and quality of services, and ultimately utilization of ANC and skilled delivery services at the health facility. The project interventions were implemented between January, 2010 and September, 2011. The interventions mainly targeted pregnant women and their male partners. Details of the program interventions are described below. The key components of the interventions are also summarized in Table 1. Summary of selected program interventions implemented Health facility capacity building was done through training of health workers with ongoing mentorship, and provision of basic supplies such as delivery kits (also known as mama-kits), drugs, and HIV test kits. The mama-kit includes basic delivery supplies: cotton wool (200 g), hydrophilic gauze, sterile surgical gloves, mackintosh (rubber/polythene sheet), washing soap (600 g), surgical blades, umbilical-cord tie and tetracycline eye ointment (for the new born baby). These kits were also supplied to facilities by Ministry of Health (MoH) but stock outs were experienced by the health centre. Stock out of delivery supplies and the requirement for “poor” mothers to buy these supplies has been documented as one of the hindrances to health facility deliveries. In order to attract mothers to deliver at the health facility; baby soap, a baby towel and shawl were also added into the mama-kit. The modified delivery kits (with additional baby items) were given to pregnant women when they turned up to deliver at the health facility since anecdotal information suggested that some mothers used these kits to deliver elsewhere, within the communities, and their distribution at ANC may be viewed as encouraging women to deliver at home. Mama-kits were given free of charge. The community interventions included activities such as music, dance and drama (MDD), use of village health teams (VHT) for community sensitization, and establishment of male partner access clubs to sensitize and mobilize communities. The key messages to the community included benefits of ANC and skilled delivery attendance as well as male partner involvement in ANC. Community mobilization and sensitization was carried out using existing community structures; VHT are the frontline community workers and are recommended by the MoH for community education and health promotion for all diseases and have been used to delivery other health interventions in Uganda [23]. Sixty VHT members were identified and trained. These included both males and females. Selection of the VHT members to support these program interventions was done in close consultation with the district and health facility workers. The trained VHTs were involved in community sensitization and mobilization of pregnant mothers (and their male partners) for ANC attendance and health facility deliveries under the care of skilled birth attendants. The training was based on the national (MoH) 5-day training curriculum. Each VHT member was given a bicycle to facilitate movement within the community. Information Education and Communication (IEC) materials (charts) were designed and provided to VHTs to act as job aides. In addition to community sensitization and mobilization, VHTs were involved in tracking mothers who missed ANC visits and encouraging them to deliver in the health facility. Monthly performance review meetings attended by VHTs and health workers were conducted to improve performance and the relationship between VHTs and health workers, and also acted as supervisory encounter by health workers. Two male partner PMTCT access clubs were formed and engaged. These clubs comprised selected men from the community, who were viewed as role models in participating in ANC with their pregnant wives and ensuring that their wives delivered in the health facility. Male partner access clubs were facilitated to conduct two ‘male dialogue’ meetings in each month with other men in the communities. The aim of these meetings was to promote male partner involvement in ANC and skilled attended deliveries by their pregnant wives. Two MDD groups were established, trained and provided with the necessary costumes. Each of the two groups was facilitated to conduct two community mobilization and sensitization performances monthly. These groups focused on promoting ANC and skilled deliveries attendance as well as PMTCT services. Pregnant women and their husbands who turned up at health facility for ANC were counseled, tested and they received their HIV results together (as couples) on their first ANC visit. Pregnant women who turned up for ANC without their husbands were also counseled, tested and received their HIV results as individuals and encouraged to come with their partners on subsequent visits. All data which also included the estimated (expected) number of pregnant women in the first trimester were abstracted from the Health Information Management System (HIMS) data collection and reporting tools as well as registers of MOH that are used routinely by the health workers to capture patient care and treatment data. These included: the ANC register, delivery and birth register as well as quarterly and annual HMIS reports. Based on the population demographics, the health facility with technical support from the district health office and MoH set the annual targets on expected pregnancies. These facility level targets contributed to the district and national annual targets [24,25]. The data that was used for this paper was collected over a period of 21 months (from January, 2010 to September, 2011); during implementation of interventions. In order to evaluate the outcomes of the project, data for the same indicators was collected for the year preceding the interventions (January to December, 2009). The data was abstracted from the registers using a standardized tool and entered into an excel sheet for storage and analysis. Data was analyzed using Excel and Epi Info soft ware. Although data was collected on a monthly basis, during analysis data was collapsed into quarters and years (annually). The variables of interest included: total number of pregnant women attending first ANC visit and this was compared with the estimated annual number of pregnant women in the first trimester who were expected to attend ANC. Other measures included; total number of women attending the fourth ANC, number of pregnant women attending the first ANC visit who were counseled, tested for HIV and received their results (this was compared with the total number of pregnant women attending the first ANC visit rather than the total number of pregnancies in the community), number of male partners of pregnant women attending the first ANC and counseled, tested for HIV and received their results together with their wives (this was compared with number of pregnant women attending the first ANC visit who were counseled, tested for HIV and received their results);first-time ANC pregnant women were expected to be counseled, tested for HIV and given their HIV status results together with their husbands, as couples. The other variable was total number of skilled attended (health facility) deliveries recorded in the facility registers. Pregnant women who attended ANC but did not return to deliver in the health facility were considered to have delivered in the community/at home with the help of unskilled personnel. Using EPINFO StatCal option, we performed a Chi square test for trend and generated Odds Ratios (OR), 95%CI and p-Values to check whether the trends in these indicators were statistically significant. The Confidence Intervals (CI) were computed using the usual Chi-square in EPINFO. This manuscript was based on routine program data analysis for purposes of program monitoring and evaluation. The data that were analyzed had no identifiers for any of the individuals that were served and was exempt from ethical approval.

Materials

N/A

Innovations

Based on the information provided, here are some innovations that can be recommended to improve access to maternal health:

1. Community mobilization using village health teams (VHT): Training and engaging VHT members to conduct community sensitization and mobilization activities can help increase awareness and demand for antenatal care (ANC) and skilled delivery services. VHT members can educate pregnant women and their partners about the benefits of ANC and skilled delivery attendance, as well as provide information on HIV testing and prevention of mother-to-child transmission (PMTCT) services.

2. Music, dance, and drama (MDD) groups: Establishing MDD groups can be an effective way to engage the community and promote ANC and skilled delivery attendance. These groups can perform in the community, delivering key messages about the importance of maternal health services and encouraging pregnant women and their partners to seek care at health facilities.

3. Male partner access clubs: Forming male partner access clubs can help promote male involvement in ANC and skilled attended deliveries. These clubs can organize regular meetings to discuss the importance of male participation in maternal health and encourage men to accompany their pregnant wives to ANC visits and deliveries at health facilities.

4. Health facility capacity building: Strengthening the capacity of health facilities is crucial for providing quality maternal health services. This can include training health workers, providing essential medical supplies (such as delivery kits), and ensuring the availability of HIV test kits. Additionally, addressing stockouts of delivery supplies and providing mama-kits free of charge can incentivize women to deliver at health facilities.

5. Couple counseling and testing for HIV: Offering HIV counseling and testing services to pregnant women and their partners together can help identify and address HIV-related risks during pregnancy. This approach promotes shared decision-making and encourages couples to support each other in accessing appropriate care and treatment.

These innovations, when implemented together, can contribute to increased access to maternal health services, improved ANC attendance, and increased rates of skilled delivery at health facilities.

AI Innovations Description

The recommendation to improve access to maternal health based on the described intervention is to implement a combination of community mobilization and health facility capacity strengthening interventions. This includes training health workers, providing medical supplies, and utilizing community structures such as village health teams and male partner access clubs for sensitization and mobilization. The interventions should focus on increasing the demand for and availability of quality antenatal care (ANC) and skilled delivery services.

Specific recommendations include:

1. Health facility capacity building: Train health workers and provide them with ongoing mentorship. Ensure the availability of basic supplies such as delivery kits, drugs, and HIV test kits. Address stock-outs of delivery supplies to encourage health facility deliveries.

2. Community mobilization: Use existing community structures like village health teams (VHTs) to conduct sensitization and mobilization activities. Train VHT members to educate the community about the benefits of ANC and skilled delivery attendance. Provide them with bicycles for easy movement within the community. Use Information Education and Communication (IEC) materials to support their work.

3. Male partner involvement: Establish male partner access clubs to engage men in ANC and skilled attended deliveries. Conduct regular meetings to promote male partner involvement and address any barriers or misconceptions.

4. Music, dance, and drama (MDD): Form MDD groups and train them to perform community mobilization and sensitization activities. Use these performances to promote ANC and skilled delivery attendance, as well as prevention of mother-to-child transmission (PMTCT) services.

5. HIV counseling and testing: Ensure that pregnant women and their husbands are counseled, tested, and receive their HIV results together on their first ANC visit. Encourage pregnant women to bring their partners for subsequent visits.

6. Data collection and analysis: Collect and analyze data on key indicators such as the number of pregnant women attending ANC, the number of women counseled and tested for HIV, and the number of skilled attended deliveries. Use this data for program monitoring and evaluation.

By implementing these recommendations, it is expected that there will be an increase in the utilization of ANC and skilled delivery services, leading to improved access to maternal health care and a reduction in maternal morbidity and mortality.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Strengthening health facility capacity: Continue training health workers and providing them with necessary medical supplies to ensure they can deliver quality maternal health services. This includes ensuring the availability of delivery kits (mama-kits) to encourage facility deliveries.

2. Community mobilization and sensitization: Continue using village health teams (VHTs) for community education and health promotion. Provide ongoing support and resources to VHTs, such as bicycles for easier movement within the community. Use music, dance, and drama (MDD) groups to engage and educate the community about the benefits of antenatal care (ANC) and skilled delivery attendance.

3. Male partner involvement: Establish and engage male partner access clubs to promote male involvement in ANC and skilled attended deliveries. Conduct regular meetings and dialogues to encourage male partners to accompany their pregnant wives to ANC visits and support facility deliveries.

4. HIV testing and counseling: Continue providing HIV testing and counseling services to pregnant women and their partners during ANC visits. Encourage couples to receive their HIV results together and provide support for those who test positive.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the number of pregnant women attending the first ANC visit, the number of skilled attended deliveries, and the number of pregnant women counseled and tested for HIV.

2. Collect baseline data: Gather data on the selected indicators for the year preceding the implementation of the interventions. This data will serve as a baseline for comparison.

3. Implement interventions: Implement the recommended interventions, including health facility capacity strengthening, community mobilization, male partner involvement, and HIV testing and counseling.

4. Collect intervention data: Collect data on the selected indicators during the implementation of the interventions. This data should cover a similar time period as the baseline data.

5. Analyze the data: Use statistical analysis software, such as Excel or Epi Info, to analyze the data. Compare the baseline data with the intervention data to determine any changes or improvements in the selected indicators.

6. Calculate impact: Calculate the impact of the interventions by comparing the percentage change in the selected indicators between the baseline and intervention periods. This will provide an estimate of the improvements in access to maternal health resulting from the interventions.

7. Interpret the results: Interpret the findings to understand the effectiveness of the interventions in improving access to maternal health. Identify any trends or patterns that may inform future interventions or program improvements.

It is important to note that this methodology is based on the information provided and may need to be adapted or modified based on specific context and data availability.

Author

Dima Health

Statistics:

Citations: 36

Identifiers:

DOI: 10.1186/1471-2393-13-189

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Uganda

Study Design:

Cross Sectional Study, Grounded Theory

Participants Gender:

Male & Female