Use of antenatal services and delivery care in Entebbe, Uganda: A community survey

BMC Pregnancy and Childbirth, Volume 7, Year 2007

Interpretation

Background: Disparities in perinatal health care occur worldwide. If the UN Millennium Development Goals in maternal and child health are to be met, this needs to be addressed. This study was conducted to facilitate our understanding of the changing use of maternity care services in a semi-urban community in Entebbe Uganda and to examine the range of antenatal and delivery services received in health care facilities and at home. Methods: We conducted a retrospective community survey among women using structured questionnaires to describe the use of antenatal services and delivery care. Results: In total 413 women reported on their most recent pregnancy. Antenatal care attendance was high with 96% attending once, and 69% the recommended four times. Blood pressure monitoring (95%) and tetanus vaccination (91%) were the services most frequently reported and HIV testing (47%), haematinics (58%) and presumptive treatment for malaria (66%) least frequently. Hospital clinics significantly outperformed public clinics in the quality of antenatal service. A significant improvement in the reported quality of antenatal services received was observed by year (p < 0.001). Improvement in the range and consistency of services at Entebbe Hospital over time was associated with an increase in the numbers who sought care there (p = 0.038). Although 63% delivered their newborn at a local hospital, 11% still delivered at home with no skilled assistance and just under half of these women reported financial/transportation difficulties as the primary reason. Less educated, poorer mothers were more likely to have unskilled/no assistance. Simple newborn care practices were commonly neglected. Only 35% of newborns were breastfed within the first hour and delayed wrapping of newborn infants occurred after 27% of deliveries. Conclusion: Although antenatal services were well utilised, the quality of services varied. Women were able and willing to travel to a facility providing a good service. Access to essential skilled birth attendants remains difficult especially for less educated, poorer women, commonly mediated by financial and transport difficulties and several simple post delivery practices were commonly neglected. These factors need to be addressed to ensure that high quality care reaches the most vulnerable women and infants. © 2007 Tann et al; licensee BioMed Central Ltd. The survey was carried out amongst the community of Entebbe Municipality and Katabi Subcounty in central Uganda. The study area comprises 9 parishes divided into 47 wards (each with an elected local executive council) and 5 governmental army barracks. The geographical terrain of the study area is diverse. Entebbe Municipality forms a peninsula projecting into Lake Victoria and is located around 40 km Southwest of the Ugandan capital, Kampala. It is transected by Entebbe International Airport. Katabi Subcounty borders Entebbe and extends either side of the Entebbe-Kampala road. The Katabi community combines the semi-urban population within close proximity to the road and the relatively isolated rural fishing communities residing on small peripheral peninsulas extending out into the waters and marshland of Lake Victoria (Figure (Figure11). Study area. Entebbe General Hospital, the major provider of governmental health services in the area, is located centrally within Entebbe town. In 2002, in accordance with Ministry of Health policy, a programme for prevention of mother-to-child HIV transmission (PMTCT) was established by Entebbe Hospital in collaboration with a research study examining the effect of helminth infections on the response to immunisations in childhood (clinical trial registration: ISRCTN32849447). In addition to training, the ongoing research study employed counsellors to facilitate entry into the PMTCT programme and a laboratory technician to perform rapid antibody testing for HIV and syphilis. Women attending the clinic are routinely offered iron and folate supplementation and intermittent presumptive treatment for malaria in pregnancy (IPTp). Surveillance data from the hospital estimates the prevalence of HIV amongst women attending for antenatal care to be around 12%, while that of active syphilis was less than 2% [9]. A number of other health facilities in the area offer maternity services. These include small government health centres (public clinics); private delivery homes owned and run by retired midwives, and private hospitals. We conducted a cross-sectional retrospective community survey to identify experiences of maternity care and practice for each pregnancy within the past five years. Consent to conduct the survey was obtained from local community leaders and participating women gave verbal consent to be involved. The study was reviewed and approved by the ethics committee at the London School of Hygiene and Tropical Medicine, the Ugandan Virus Research Institute (UVRI) Science and Ethics Committee and the Ugandan National Council for Science and Technology. Wards were chosen as the sampling unit and census statistics (Ugandan Bureau of Statistics) were used to estimate the relative population size of each ward. A sample of 40 wards was randomly selected, by probability proportional to size, and we aimed to select 16 households within each ward, expecting that on average two thirds of these households would have at least one woman who had given birth over the last 5 years. Maps were available for the study area with the location of major roads and landmarks but not the location of individual households. Each ward was divided into segments of equal geographical size (approximately 70 m2) and four segments were randomly selected from each ward (ranging between 99 and 641 segments per ward). The centre point of the segment was used to define the starting point for the sampling of 4 households. The first household was the household closest to the start point. Each subsequent household was selected as the closest to the one before it. The head of selected households was approached by a pair of interviewers and asked about the presence of any women in the household who had had a pregnancy within the past five years. No exclusion criteria were applied and all women who reported a pregnancy in the past five years were invited to respond. If any such person was identified, verbal consent was obtained before administration of the survey questionnaire. Where such a woman was resident but not present at that time, interviewers returned to the property on at least one occasion at a later date. Where a woman was unavailable due to working or travel, interviewers made every effort to return at a time when she might be expected to be at home (such as the evening or weekend). We were unable to use antenatal cards and delivery records to crosscheck information because women do not routinely keep these after delivery and they are often retained by health facilities. Structured questionnaires were designed to identify the antenatal, delivery and postpartum experiences of women. Questionnaires were administered in the local language by pairs of interviewers, with all pairs containing at least one female interviewer. Answers were predefined with tick boxes or were described under 'other'. The questionnaire and sampling strategy within households were pre-tested in a ward not selected for inclusion into the survey. Women were asked to answer questions with regard to each pregnancy experienced within the past five years, starting with the most recent. Information sought regarding antenatal care during each pregnancy included the frequency of antenatal visits, the primary place of attendance and the type of services that they received there. In addition, women were asked about their delivery experience for each pregnancy including the place of delivery, what assistance they received during labour, hygiene practices at birth and care of the infant soon after delivery. Data were entered and checked using Excel (Microsoft) and analysed using Stata version 8 (StataCorp, Texas). Analysis relating to pregnancies was restricted to the most recent pregnancy to minimise recall bias and to avoid using a complicated hierarchical analysis to take into account correlation within woman. A negligible number of households contained more than one eligible woman, so the only level of clustering taken into account in the analysis was that within wards. This was done using the complex survey commands within stata. Initial comparisons were made using simple tables (svytab). To assess associations between demographic or socio-economic variables and antenatal or delivery/perinatal care practices, binary outcome variables were developed and associations examined using logistic regression models (svylogit) to adjust for possible confounding variables. To obtain an overall assessment of the quality of antenatal services and postnatal practices at delivery, scores were developed for this study. One point was given for each service received of the seven listed in table table11 for antenatal care, and one point for each of the postnatal practices considered to be beneficial among the six listed for postnatal practices. Delivery practices were not included in the scores as it was felt that these might be inaccurately recalled; further, over 90% of women reported that appropriate procedures had been used, so that these parameters would not discrimate well between comparison groups in an overall assessment. For each score a binary variable was created with values below the median defined as low score, including and above the median as high score. Antenatal services and delivery/perinatal practices during the most recent pregnancy among 413 Ugandan women

AI Digest

Study Justification:

– Disparities in perinatal health care occur worldwide and need to be addressed to meet the UN Millennium Development Goals in maternal and child health.
– This study aims to understand the changing use of maternity care services in a semi-urban community in Entebbe, Uganda.
– The study examines the range of antenatal and delivery services received in health care facilities and at home.

Study Highlights:

– Antenatal care attendance was high, with 96% attending at least once and 69% attending the recommended four times.
– Blood pressure monitoring and tetanus vaccination were the most frequently reported services, while HIV testing, haematinics, and presumptive treatment for malaria were least frequently reported.
– Hospital clinics outperformed public clinics in the quality of antenatal service.
– Improvement in the quality of antenatal services received was observed over time.
– Financial and transportation difficulties were reported as the primary reasons for delivering at home without skilled assistance.
– Less educated and poorer mothers were more likely to have unskilled or no assistance during delivery.
– Simple newborn care practices, such as early breastfeeding and timely wrapping, were commonly neglected.

Recommendations for Lay Reader and Policy Maker:

– Ensure that high-quality care reaches the most vulnerable women and infants.
– Address financial and transportation difficulties to improve access to skilled birth attendants.
– Improve the range and consistency of services at health facilities.
– Promote and educate on the importance of simple newborn care practices.

Key Role Players Needed to Address Recommendations:

– Local community leaders
– Health facility staff
– Government officials
– Non-governmental organizations (NGOs)
– Community health workers

Cost Items to Include in Planning Recommendations:

– Training and capacity building for health facility staff
– Transportation services for pregnant women
– Equipment and supplies for health facilities
– Community outreach and education programs
– Monitoring and evaluation activities

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted a community survey among 413 women to describe the use of antenatal services and delivery care in Entebbe, Uganda. The study provides detailed information on the attendance and quality of antenatal services, as well as the delivery practices and challenges faced by women in the community. The study was conducted using structured questionnaires and obtained verbal consent from participants. However, the abstract does not mention the sampling method used, which could affect the generalizability of the findings. To improve the strength of the evidence, future studies could consider using a more representative sampling method and include a larger sample size.

Abstract

The survey was carried out amongst the community of Entebbe Municipality and Katabi Subcounty in central Uganda. The study area comprises 9 parishes divided into 47 wards (each with an elected local executive council) and 5 governmental army barracks. The geographical terrain of the study area is diverse. Entebbe Municipality forms a peninsula projecting into Lake Victoria and is located around 40 km Southwest of the Ugandan capital, Kampala. It is transected by Entebbe International Airport. Katabi Subcounty borders Entebbe and extends either side of the Entebbe-Kampala road. The Katabi community combines the semi-urban population within close proximity to the road and the relatively isolated rural fishing communities residing on small peripheral peninsulas extending out into the waters and marshland of Lake Victoria (Figure (Figure11). Study area. Entebbe General Hospital, the major provider of governmental health services in the area, is located centrally within Entebbe town. In 2002, in accordance with Ministry of Health policy, a programme for prevention of mother-to-child HIV transmission (PMTCT) was established by Entebbe Hospital in collaboration with a research study examining the effect of helminth infections on the response to immunisations in childhood (clinical trial registration: ISRCTN32849447). In addition to training, the ongoing research study employed counsellors to facilitate entry into the PMTCT programme and a laboratory technician to perform rapid antibody testing for HIV and syphilis. Women attending the clinic are routinely offered iron and folate supplementation and intermittent presumptive treatment for malaria in pregnancy (IPTp). Surveillance data from the hospital estimates the prevalence of HIV amongst women attending for antenatal care to be around 12%, while that of active syphilis was less than 2% [9]. A number of other health facilities in the area offer maternity services. These include small government health centres (public clinics); private delivery homes owned and run by retired midwives, and private hospitals. We conducted a cross-sectional retrospective community survey to identify experiences of maternity care and practice for each pregnancy within the past five years. Consent to conduct the survey was obtained from local community leaders and participating women gave verbal consent to be involved. The study was reviewed and approved by the ethics committee at the London School of Hygiene and Tropical Medicine, the Ugandan Virus Research Institute (UVRI) Science and Ethics Committee and the Ugandan National Council for Science and Technology. Wards were chosen as the sampling unit and census statistics (Ugandan Bureau of Statistics) were used to estimate the relative population size of each ward. A sample of 40 wards was randomly selected, by probability proportional to size, and we aimed to select 16 households within each ward, expecting that on average two thirds of these households would have at least one woman who had given birth over the last 5 years. Maps were available for the study area with the location of major roads and landmarks but not the location of individual households. Each ward was divided into segments of equal geographical size (approximately 70 m2) and four segments were randomly selected from each ward (ranging between 99 and 641 segments per ward). The centre point of the segment was used to define the starting point for the sampling of 4 households. The first household was the household closest to the start point. Each subsequent household was selected as the closest to the one before it. The head of selected households was approached by a pair of interviewers and asked about the presence of any women in the household who had had a pregnancy within the past five years. No exclusion criteria were applied and all women who reported a pregnancy in the past five years were invited to respond. If any such person was identified, verbal consent was obtained before administration of the survey questionnaire. Where such a woman was resident but not present at that time, interviewers returned to the property on at least one occasion at a later date. Where a woman was unavailable due to working or travel, interviewers made every effort to return at a time when she might be expected to be at home (such as the evening or weekend). We were unable to use antenatal cards and delivery records to crosscheck information because women do not routinely keep these after delivery and they are often retained by health facilities. Structured questionnaires were designed to identify the antenatal, delivery and postpartum experiences of women. Questionnaires were administered in the local language by pairs of interviewers, with all pairs containing at least one female interviewer. Answers were predefined with tick boxes or were described under 'other'. The questionnaire and sampling strategy within households were pre-tested in a ward not selected for inclusion into the survey. Women were asked to answer questions with regard to each pregnancy experienced within the past five years, starting with the most recent. Information sought regarding antenatal care during each pregnancy included the frequency of antenatal visits, the primary place of attendance and the type of services that they received there. In addition, women were asked about their delivery experience for each pregnancy including the place of delivery, what assistance they received during labour, hygiene practices at birth and care of the infant soon after delivery. Data were entered and checked using Excel (Microsoft) and analysed using Stata version 8 (StataCorp, Texas). Analysis relating to pregnancies was restricted to the most recent pregnancy to minimise recall bias and to avoid using a complicated hierarchical analysis to take into account correlation within woman. A negligible number of households contained more than one eligible woman, so the only level of clustering taken into account in the analysis was that within wards. This was done using the complex survey commands within stata. Initial comparisons were made using simple tables (svytab). To assess associations between demographic or socio-economic variables and antenatal or delivery/perinatal care practices, binary outcome variables were developed and associations examined using logistic regression models (svylogit) to adjust for possible confounding variables. To obtain an overall assessment of the quality of antenatal services and postnatal practices at delivery, scores were developed for this study. One point was given for each service received of the seven listed in table table11 for antenatal care, and one point for each of the postnatal practices considered to be beneficial among the six listed for postnatal practices. Delivery practices were not included in the scores as it was felt that these might be inaccurately recalled; further, over 90% of women reported that appropriate procedures had been used, so that these parameters would not discrimate well between comparison groups in an overall assessment. For each score a binary variable was created with values below the median defined as low score, including and above the median as high score. Antenatal services and delivery/perinatal practices during the most recent pregnancy among 413 Ugandan women

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile clinics: Implementing mobile clinics that travel to remote areas or underserved communities can provide antenatal and delivery care to women who may have difficulty accessing healthcare facilities.

2. Telemedicine: Using telemedicine technology, healthcare providers can remotely monitor and provide consultations to pregnant women, reducing the need for them to travel long distances for check-ups.

3. Community health workers: Training and deploying community health workers who can provide basic antenatal and delivery care, as well as education and support to pregnant women in their own communities.

4. Transportation support: Establishing transportation services or subsidies to help pregnant women overcome financial and logistical barriers to accessing healthcare facilities for antenatal care and delivery.

5. Health education programs: Developing and implementing health education programs that focus on maternal health, including the importance of antenatal care, safe delivery practices, and newborn care, to improve knowledge and awareness among women and their families.

6. Public-private partnerships: Collaborating with private healthcare providers to expand access to maternal health services, especially in areas where public healthcare facilities are limited.

7. Financial incentives: Providing financial incentives or subsidies to pregnant women who attend antenatal care visits and deliver at healthcare facilities, to encourage utilization of maternal health services.

8. Improving infrastructure: Investing in the improvement of healthcare infrastructure, including the construction and renovation of healthcare facilities, to ensure that they are equipped to provide quality maternal health services.

9. Strengthening referral systems: Establishing and strengthening referral systems between primary healthcare facilities and higher-level facilities, to ensure that pregnant women can access appropriate care when needed.

10. Quality improvement initiatives: Implementing quality improvement initiatives in healthcare facilities to ensure that antenatal and delivery care services are provided in a safe and effective manner, improving the overall experience for pregnant women.

AI Innovations Description

Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Strengthening Antenatal Care Services: Based on the survey findings, antenatal care attendance was high, but the quality of services varied. To improve access to maternal health, it is recommended to focus on improving the quality of antenatal care services. This can be done by:

– Training healthcare providers: Provide training to healthcare providers on best practices for antenatal care, including blood pressure monitoring, tetanus vaccination, HIV testing, haematinics, and presumptive treatment for malaria.
– Standardizing care: Develop guidelines and protocols for antenatal care to ensure consistent and high-quality services across all healthcare facilities.
– Increasing availability: Ensure that antenatal care services are available in both hospital clinics and public clinics to cater to the needs of all women in the community.
– Addressing financial and transportation difficulties: Implement strategies to address financial and transportation difficulties that prevent women from accessing antenatal care, especially for those who are less educated and poorer.

2. Promoting Skilled Birth Attendance: The survey found that a significant number of women still delivered at home without skilled assistance. To improve access to skilled birth attendance, the following recommendations can be considered:

– Community-based education: Conduct community-based education programs to raise awareness about the importance of skilled birth attendance and the potential risks associated with home deliveries without skilled assistance.
– Strengthening referral systems: Improve the referral systems between communities and healthcare facilities to ensure that women in need of skilled birth attendance can easily access appropriate care.
– Addressing financial and transportation barriers: Develop strategies to address financial and transportation barriers that prevent women from accessing healthcare facilities for skilled birth attendance.
– Training traditional birth attendants: Provide training and support to traditional birth attendants to ensure that they have the necessary skills and knowledge to provide safe and effective care during childbirth.

3. Improving Postpartum Care Practices: The survey identified several postpartum care practices that were commonly neglected, such as delayed wrapping of newborn infants and delayed initiation of breastfeeding. To improve postpartum care practices, the following recommendations can be implemented:

– Education and counseling: Provide education and counseling to women and their families about the importance of early initiation of breastfeeding and proper newborn care practices.
– Supportive environments: Create supportive environments in healthcare facilities and communities that promote and facilitate early initiation of breastfeeding and proper newborn care practices.
– Training healthcare providers: Train healthcare providers on best practices for postpartum care, including proper newborn care practices and support for breastfeeding.
– Monitoring and evaluation: Implement monitoring and evaluation systems to track the adherence to postpartum care practices and identify areas for improvement.

By implementing these recommendations, access to maternal health can be improved, ensuring that high-quality care reaches the most vulnerable women and infants in the community.

AI Innovations Methodology

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

1. Strengthen antenatal care services: Focus on improving the quality and consistency of antenatal services, including increasing access to essential services such as HIV testing, haematinics, and presumptive treatment for malaria. This can be achieved by training healthcare providers, ensuring the availability of necessary supplies and equipment, and implementing regular monitoring and evaluation systems.

2. Enhance transportation and financial support: Address the financial and transportation difficulties faced by pregnant women, especially those in rural areas or with lower socioeconomic status. This can be done by providing subsidies or vouchers for transportation to healthcare facilities, establishing community-based transportation systems, and implementing health insurance schemes that cover maternal health services.

3. Increase availability of skilled birth attendants: Improve access to skilled birth attendants, particularly for women in remote areas or with limited resources. This can be achieved by training and deploying more midwives and other skilled healthcare providers to underserved areas, incentivizing their practice in these areas, and promoting the establishment of birthing centers or maternity waiting homes in communities.

4. Promote community awareness and education: Increase community awareness about the importance of maternal health and the available services. This can be done through community outreach programs, health education campaigns, and the involvement of community leaders and influencers. Additionally, providing education and counseling to pregnant women and their families about the benefits of antenatal care and skilled birth attendance can help improve access and utilization of maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Gather information on the current utilization of maternal health services, including antenatal care attendance, place of delivery, and availability of skilled birth attendants. This can be done through surveys, interviews, or analysis of existing data.

2. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage increase in antenatal care attendance, the reduction in home deliveries without skilled assistance, or the improvement in the quality of antenatal services received.

3. Develop a simulation model: Create a simulation model that incorporates the baseline data and the potential impact of the recommendations. This model should consider factors such as population demographics, geographical distribution, healthcare infrastructure, and resource availability.

4. Input data and assumptions: Input the baseline data into the simulation model and define the assumptions for the potential impact of the recommendations. For example, assume a certain percentage increase in antenatal care attendance based on the implementation of transportation subsidies or the training and deployment of skilled birth attendants.

5. Run simulations: Run multiple simulations using different scenarios and assumptions to assess the potential impact of the recommendations on improving access to maternal health. This can help identify the most effective strategies and estimate the magnitude of the expected improvements.

6. Analyze results: Analyze the simulation results to determine the projected changes in access to maternal health services. Assess the feasibility, cost-effectiveness, and sustainability of the recommendations based on the simulation outcomes.

7. Refine and implement recommendations: Based on the simulation findings, refine the recommendations and develop an implementation plan. Consider factors such as resource allocation, stakeholder engagement, policy changes, and monitoring and evaluation mechanisms.

8. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommendations to assess their actual impact on improving access to maternal health. Adjust strategies as needed based on the feedback and lessons learned from the monitoring and evaluation process.

Author

Dima Health

Statistics:

Citations: 77

Identifiers:

DOI: 10.1186/1471-2393-7-23

Research Areas:

Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Uganda

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female