Experiences of mothers and significant others in accessing comprehensive healthcare in the first 1000 days of life post-conception during COVID-19 in rural Uganda

Background: COVID-19 presented an unprecedented global public health challenge because of its rapid and relentless spread, and many countries instituted lockdowns to prevent the spread of infection. Although this strategy may have been appropriate to reduce infection, it presented unintended difficulties in rural Uganda, especially in maternal and born newborn care. For example, some services were suspended, meaning the nearest health facility was at a considerable distance. This study explored the experiences of mothers and their significant others of comprehensive care in the first 1000 days of life post-conception during the COVID-19 pandemic in Bunghokho-Mutoto sub-county, Mbale District, Uganda. Methods: A qualitative exploratory descriptive design was used with data collected in semi-structured interviews. Mothers (pregnant or with a child under 2 years) and their significant others were purposively recruited for this study. The sample size (N = 14) was determined by data saturation. Data. were analysed using thematic analysis. Results: One theme emerged “Increasing barriers to healthcare”, which encompassed six sub-themes: accessing healthcare, distressing situations, living in fear, making forced choices, navigating the gatekeepers, and ‘coping with increased poverty. Conclusion: This study found that the COVID-19 pandemic increased barriers to accessing healthcare services in the region. Participants’ narratives emphasised the lack of access to expert care and the shortage of skilled health workers, especially midwives. This research was conducted using a descriptive qualitative design. This design allowed us to conduct in-depth interviews with mothers and their significant others in the family The participants narrated stories of their experiences of accessing comprehensive healthcare. during the COVID-19 pandemic. The design guaranteed the richness of data which allowed us to gain a deeper understanding of their experiences individually [24]. Mbale District is in the Eastern region of Uganda. It is bordered by Sironko and Bulambuli districts in the North, Bukedea district in the Northwest, Budaka, and Pallisa in the west, Tororo and Butaleja districts in the south-west, Manafwa, and Bududa districts in the east. It lies between latitudes 00,450 North and longitudes 340 East and 350 East. The district has a total area of 538.16 sq. km and a population density of 915 persons per square km. This district has three constituencies which include Mbale municipality, Bungokho North, and Bungokho South [25]. Secondly, it has a total population of 465,000 people across its 27 sub-counties. Its central town and its commercial center are Mbale Municipality, with a population of 96,189 people [26]. In 2015 Mbale district had an outbreak of Cholera registering 143 cases and eight deaths. During that time, the government of Uganda instituted restrictive measures and the outbreak was well-managed. This time, during the COVID-19 pandemic, statistics show that Mbale Regional Referral Hospital, the reference point for those who had COVID-19 in the Mbale district registered 847 cases, discharged 669, and had 149 death [25]. The researchers used this history of managing infectious diseases to select this district. The study was conducted in the sub-county of Bungokho-Mutoto, which has five parishes and 82 villages, out of which four villages namely, Luyekhe B, Bukasakya, Bunamwani, and Makere were selected. BungokhoMutoto was randomly selected from the six high-index sub-counties in the district namely Nakaloke, Namabasa, Namanyonyi, Bukasakya, Busiu, Bungokho, Bungokho-Mutoto, and Industrial division. These villages were numbered, papers were shaffled and the researchers randomly picked one that indicated Bungokho-Mutot. With the help of the LC 1 Chairperson and the VHT, the researchers conveniently selected the villages that were on the main road and had easy access to the health facilities in this sub-county. Secondly, this area was sampled because it had an activity; “Mothers Heart Uganda Mutoto Mbale” that aimed at promoting safe motherhood had been initiated in this sub-county, therefore, this community had the advantage of receiving services that would promote maternal and child healthcare outcomes [27]. Similarly, information-rich mothers in the 1000 days of life and their significant others were purposively selected to participate in the study. The researchers interviewed the participants at times convenient to them until repetitive statements were received from the subsequent interviews. This was the point at which data saturation was reached with a sample size of 14 participants [28]. To gain access to the participants, the researchers approached the Local Council (LC) II Chairperson of the Bungokho-Mutoto sub-county with a permission letter from the Uganda National Council for Science and Technology who eventually, introduced them to the LC I chairperson of the Bukasakya parish Bungokho-Mutoto sub-county. The LC1 Chairperson introduced the researchers to one of the Village Health Team (VHT) members for this as they had good knowledge of the information regarding the community members in the area. The purpose of the study was explained and the mothers and their significant others in the first 1000 days of life post-conception during the COVID-19 pandemic were recruited from the selected villages. Data was collected between 10th October and 9th November 2020, two months after the first lockdown was eased, during the pandemic in Uganda. Data were collected using individual in-depth, semi-structured interviews. The interviews were scheduled and conducted in the participants’ homes after they had returned from their work (e.g., in gardens/shops). COVID-19 standard operating procedures (SOPs) were strictly observed. Each participant was given a mask and hand sanitizer, and social distancing was always observed. The data collection tool comprised two parts. Part one covered participants’ demographic characteristics including the participant identifier (anonymised name), age, gender, marital status, level of education, number of children, and village. Part two included key open-ended questions regarding participants’ experiences and their understanding of these experiences. All interviews were audio-recorded in Lumasaba, with the transcript later translated into English by a professional translator. The researcher worked with one other interviewer who could speak the local language. This interviewer completed a 1-day training session, which was critical to ensure the collection of accurate data and adherence to the ethical guidelines. The interviews were transcribed verbatim, in the local language (Lumasaba), and then translated to English and entered into the NVivo software package and analysed as they came in until a point of saturation was reached. Analysis was based on the method developed by Braun and Clarke [29]. NVivo was used to generate initial codes for each interview. Thematic analysis was explored, two researchers iteratively read through the interview, developed codes, and grouped them first within each interview and then between the interviews to seek common themes that described the experiences of mothers and their significant others in accessing comprehensive healthcare in the first 1000 days of life post-conception during COVID-19. The entire research team then discussed and amended these initial themes as required. Finally, the main theme and subthemes were agreed upon in another round table discussion following minor amendments. The mother presented with a relative (significant other) that she considered equally responsible for her healthcare and the healthcare of the children in the family. Eight females; seven mothers participated in the study. One female parent to one of the mothers, and six males; five husbands, and one father-in-law to one of the mothers. The age of the female participants ranged between 23 to 57 years and the males range from 30 to 67 years. Some participants were farmers, and some had small businesses (e.g., shops). Most of the mothers interviewed had no source of independent income yet, and the participants’ family sizes ranged from two to seven children (Table ​(Table11). Demographic Characteristics of the participants