Each year, more than half a million women die worldwide from causes related to pregnancy and childbirth, and nearly 4 million newborns die within 28 days of birth. In Uganda, 15 women die every single day from pregnancy and childbirth-related causes, 94 babies are stillborn, and 81 newborn babies die. Cost-effective solutions for the continuum of care can be achieved through Village Health Teams to improve home care practices and health care-seeking behavior. This study aims at examining the implementation of the timed and targeted counseling (ttC) model, as well as improving maternal and newborn health care practices. We conducted a quantitative longitudinal study on pregnant mothers who were recruited on suspicion of the pregnancy and followed-up until six weeks post-delivery. The household register was the primary data source, which was collected through a secondary review of the ttC registers. All outcome and process variables were analyzed using descriptive statistics. The study enrolled 616 households from 64 villages across seven sub-counties in Hoima district with a 98.5% successful follow-up rate. Over the course of the implementation period of ttC, there was an increase of 29.6% in timely 1st antenatal care, 28.7% in essential newborn care, 25.5% in exclusive breastfeeding, and 17.5% in quality of antenatal care. All these improvements were statistically significant. The findings from this study show that the application of the ttC model through Village Health Teams has great potential to improve the quality of antenatal and newborn care and the health-seeking practices of pregnant and breastfeeding mothers in rural communities.
This was a longitudinal study, with an evaluation of the implementation of ttC as the subject of follow-up and changes overtime. Quantitative measures were used to evaluate the implementation process and to investigate change over time in pregnancy and newborn care. The study team continues to work tirelessly on plans to publish a paper focusing on the effects of ttC implementation. The study was carried out in the Hoima district, located in the western part of Uganda. Hoima has 15 sub-counties and has a population of over 500,000 [22]. The area used to be predominantly inhabited by the native Banyoro, but since the discovery of oil, new economic developments such as road construction, and the establishment of factories and fishing activities, people from other locations in Uganda have been moving to the district. However, most of the households depend on subsistence agriculture and small-scale cash crops such as tobacco and coffee [23]. ttC was implemented in the Hoima district, because this district has one of the highest maternal mortality rates in Uganda [24]. The study population consisted of pregnant mothers registered by VHTs from the time they suspected they were pregnant. The study followed up these participants from pregnancy until six weeks post-delivery. To be included, women had to have either an ANC card (which is used to record vital information about the pregnant woman’s service provision.) [25] or a mother–child passport [26]. After delivery, women with an ANC card would additionally be provided with a Child Health Card [27]. The VHTs [28] were considered the secondary study subjects, since they were the ones responsible for performing the ttC household visits and the counseling as well as documenting in the registers. There were no exclusion criteria for the included women, other than that the pregnant women had to have lived in the project area until at least six weeks after childbirth. Data were collected by 65 VHTs from eight sub-counties in Hoima, with a total of 616 participating women and households. These included Buseruka, Upper and Lower Kabwoya, Busisi, Kigorobya, Bugambe, Kitoba and Mparo. Ethical approval and clearance were received from the Institutional Review Board (IRB) for the School of Public Health, Makerere University College of Health Sciences, the Higher Degrees, Research and Ethics Committee (HDREC) protocol 730 on February 2nd, 2020. In line with the Ugandan government regulations, the approved protocol was then submitted to the Uganda National Council for Science and Technology (UNCST) for approval. This was approved with a research registration number: HS574ES. Since this study was regarded as an anonymized desk review, there was no need for the consent of the pregnant women or mothers (Trial registration: PACTR, PACTR202002812123868. Registered on 25 February 2020—Retrospectively registered, http://www.pactr.org/ PACTR202002812123868, accessed on 25 February 2020. The ttC intervention [29] was rolled out as a behavioral change communication model for pregnancy and newborn care. For ttC to be implemented, a five-day central hands-on training was given for the VHTs by the district health team (these are district health officials qualified as public health assistants that offer supervision and guidance to the VHT), using a two-way counseling approach (participatory approach). Then, these VHTs translated the acquired knowledge to the expectant mothers and mothers with neonates, as they delivered the ttC package during their home visits. VHTs were taught how to communicate with the pregnant women and mothers with neonates, as well as the household heads (mostly the fathers) and any other influential individuals in the family. During the training, the VHTs were equipped with a participant’s manual, and a ttC-specific household register to record participants and kick-start the timely follow-up process [30]. The ttC visits pass on a particular message at set times to trigger the household to encourage the mother to go for a given service at the health center, which is relevant at that moment in pregnancy or the neonatal period. The visits that the VHT makes are in line with the Ministry of Health’s goal-oriented ANC [24] services package and the institutional delivery framework of the road to the reduction of maternal and newborn death in Uganda [31]. For this study, the focus is on the four visits made during pregnancy, the three visits made when the child is in the newborn period for essential newborn care practices, and finally, a fourth postpartum visit at six weeks to enhance exclusive breastfeeding and routine immunization. The VHTs were convened by the sub-county assistant on a monthly basis to ensure they adhered to the prescribed household visits and registered each action in the ttC household register. The visits are further specified in Table 1. ttC visits by VHTs to mothers during pregnancy or after childbirth [33]. Note: ANC = antenatal care, ttC = timed and targeted counseling, VHT = village health team, HIV = Human Immunodeficiency Virus. In a ttC pilot study among 1556 mothers in Palestine, [32] CHWs targeted mothers with timely key messages and support for positive feeding and caring practices during organized home visits throughout 12 months. The pilot study showed that practices improved significantly among participating mothers: exclusive breastfeeding until six-months increased from 33% to 48.4%; the proportion of mothers who report having four or more antenatal visits increased from 58.4% to 63.6%, and the proportion of mothers who received at least two post-natal visits increased from 26.8% to 52.4%. The ttC household register (this is the register that the VHT uses to tick off or confirm the key services or behaviors the household has implemented at each visit) was the primary data source. Data were collected through secondary review of the existing filled out ttC household registers for mothers who had been followed from the time the VHT identified them as pregnant to at least six weeks after childbirth. These data were collected by the VHTs during their household visits. While the VHTs are doing household counseling, they record information in the household register. The study variables consist of two groups: those that were measured at baseline as well as follow-up, and those that are specific to ttC and therefore were not applicable during the baseline timeframe and thus only collected at follow-up (see Table 2 for details on the study variables). Study variables. Notes: a—Y = Yes the variable was measured at baseline, N = No, the variable was not measured at baseline. ANC = Antenatal care; HF = Health facility; VHT = Village Health Team member; IPT = Intermittent presumptive treatment; TT = Tetanus Toxoid vaccine; LLITN = Long-lasting insecticide-treated net. The principle data collectors were the VHTs who collected the data during household visits at given times within the pregnancy and newborn period [28]. The VHTs were established by the Ministry of Health to empower communities to take part in the decisions that affect their health, mobilize communities for health programs, and strengthen the delivery of health services at the household level. The role of the VHTs included ensuring community participation and empowerment, which is a strategy that enables communities to take responsibility for their own health and wellbeing and to participate actively in the management of their local health services. The VHTs help to reach community participation in health and link the communities to the formal health service delivery system. This helps to bridge the current health human resource gap, especially in rural or peripheral areas, where the majority of the people live. The household counseling procedure facilitated by the VHTs on a household visit was estimated to take up to 45 minutes per session. Access to all data was limited to the research team and secured with a strong password. The principal investigator (GB) had overall responsibility for data management over the course of the study project and monitored compliance with the protocol. A data entry template was created in Microsoft Excel to enter the longitudinal data regarding the participants. Each household page included was given a unique code to be able to identify participants and link baseline to follow-up data. The process of unique coding included sub-county, parish, village, and the house number. Data from Excel were exported to SPSS version 20 (IBM, New York, NY, USA). Then, correctness and consistency were checked before final data files were created for analysis. Descriptive analyses (frequencies and percentages) were used for analyzing all outcome and quality of health care variables. This was done for the four outcome variables: quality of ENC, quality of ANC services at the HF, childbirth practices, and quality of ANC care at home. Cross-tabulation using the McNemar’s Chi-square test was used to compare the percentage of the five key outcome variables before and after implementation: first ANC in first trimester, quality of ENC, quality of ANC, exclusive breastfeeding, and four or more ANC visits. p-values < 0.05 were considered statistically significant. Analysis in preparation for the implementation of the sustainable development goals related to maternal and newborn health [37] revealed a slow progress in the reduction of maternal and newborn mortality by the Ugandan government. Evidence from other community-based interventions, for example a previous large-scale CHW intervention, showed that CHWs were effective in identifying pregnant women in their homes early in pregnancy and before they had attended ANC. The ttC intervention is meant to fulfill some of the conditions that are necessary for CHW to improve timely ANC uptake and newborn care [38] and therefore contribute positively to healthy pregnancy outcomes and reduction of maternal mortality in Uganda. Furthermore, ttC is in line with renewed interest in the potential contribution of strengthening community health systems, including case management of childhood illnesses (e.g., pneumonia, malaria, and neonatal sepsis), delivery of preventive interventions such as immunization, promotion of healthy behavior, and mobilization of communities [39]. Therefore, the results from this study are to be used to asses if any progress in intermediate outcomes has been made in the study district. The ttC model is a World Vision initiative that has not been evaluated before. This study will provide evidence for scale up of ttC and adaptation by the Ministry of Health, as a model of choice for community-based maternal and newborn care at the policy level. The evidence gathered can be used to encourage more expectant mothers to continue using the established government structures, while advocating for scale up to the rest of the country. If implemented accordingly, widespread dissemination to other parts of the country can improve pregnancy outcomes nationwide.
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