Viewpoints of pregnant mothers and community health workers on antenatal care in Lweza village, Uganda

Background Uganda is a low-income country with high fertility, adolescent birth, and maternal mortality rates. How Ugandan Ministry of Health antenatal education guidelines have been implemented into standardized health education and how pregnant women utilize health facilities remains unclear. Objective We aimed to determine how women obtain education during pregnancy, what guidelines health educators follow, and what barriers exist to receiving antenatal care in Lweza Village, Uganda. Methods Household surveys were conducted with women in Lweza who were or had previously been pregnant. Focus group discussions were conducted with community members and Lweza Primary School teachers. Interviews were conducted with key informants, including midwives, a traditional birth attendant, a community leader, and a Village Health Team member. Data collection was done in English along with a Luganda translator. Results Of the 100 household surveys conducted, 86% of women did not meet the WHO recommendation of 8 antenatal appointments during their pregnancies. Reasons cited for inadequate visits included facing long wait times (>7 h) at health facilities, getting education from family or traditional healers, or being told to delay antenatal care until 6 months pregnant. Informant interviews revealed that no standardized antenatal education program exists. Respondents felt least educated on family planning and postpartum depression, despite 37% of them reporting symptoms consistent with postpartum depression. Education was also lacking on the use of traditional herbs, although most women (60%) reported using them during pregnancy. Conclusions Most women in Lweza do not receive 8 antenatal appointments during their pregnancies or any standardized antenatal education. Educational opportunities on family planning, postpartum depression, and the safety of traditional herbs during pregnancy exist. Future studies should focus on ways to overcome barriers to antenatal care, which could include implementing community-based education programs to improve health outcomes for women in Lweza Village. Ethical approval was received via the University of Wisconsin School of Medicine and Public Health Institutional Review Board (IRB). The Principal Medical Officer of Mukono wrote a letter to the IRB committee expressing support for the project and stating that IRB approval was not necessary for the scope of the project. The chairman of Lweza Village signed a letter of approval for participation in the study. Written consent was given by the Principal Health Officer of Mukono Municipality, Uganda to conduct the study in Lweza. Verbal consent was given by all participating community members and leaders; declining to be involved in the study did not affect any woman’s treatment. Verbal, rather than written, consent was obtained as approved by the IRB. Given that the study was occurring in an area of low literacy and was being conducted verbally, verbal consent was deemed appropriate. A consent statement was read aloud and participants signed or used their thumb print to agree to the verbal consent on the questionnaire. No identifiable patient information was included in the questionnaire. Women under the age of 18 years were excluded. An exploratory, community-based, cross-sectional study was conducted, in the form of a semi-structured patient questionnaire with open and closed question types. Both quantitative and qualitative approaches were taken with the understanding that the qualitative data was necessary for illustrating community member experiences with pregnancy and health care. A variety of antenatal care topics were discussed with community women who access these services, midwives, community leaders, and a Village Health Team member who provides care and education. Data collection tools included a standardized questionnaire, in-depth interview question guides, and focus group discussion guides. Each of these guides explored various aspects of antenatal care including: number of pregnancies, antenatal care practices, health education topics, nutrition and medications, breastfeeding, family planning, HIV and malaria transmission, postpartum depression, and preparedness for the first baby. As a part of the household questionnaire, women were asked to rate their knowledge of various health topics on a scale of 0 to 5, where 0 represented that they knew nothing about the topic and 5 represented they knew everything about that topic, even enough to teach someone else. To assess education during pregnancy and barriers to receiving antenatal care in rural Uganda the authors (M.D., A.K., and R.M.) developed a questionnaire. The questionnaire was pilot tested with two women from Lweza to ensure proper wording and adequate translation of the questions, but was not validated. The household interviews were done in the participants language of choice and were led by the translator who conducted the questionnaire in a verbal manner and filled out the appropriate responses on the questionnaire. The translator was not part of the research team. The in-depth interviews and focus group discussions, conducted mostly in English and occasionally in Luganda, were translated to English in real-time as needed. The key informant interviews and focus group discussions were all recorded with permission and later transcribed. The questionnaire, which involved 47 questions, most of which (45/47) were closed-ended, included questions about patient demographics, pregnancy history and information, health education and practices, and rating the level of knowledge about various pregnancy health topics. Closed-ended question data were entered in Excel and descriptive statistics were used to analyze the results. Quantitative data were analyzed using IBM SPSS Statistics for Windows, build 1.0.0.1508 (IBM Corp., Armonk, N.Y., USA) for descriptive statistics such as frequencies and percentages. Open-ended question responses were manually analyzed by the authors using a thematic approach in which similar responses were grouped into thematic categories. To limit author bias, no responses were eliminated. Direct respondent statements were included to avoid translation bias. Qualitative data (e.g., open-ended question responses) were transcribed and analyzed by the authors using thematic analysis following the steps similar to those recommended by Braun and Clarke [12]. To become familiar with the data, the first author (M.D.) read through all the transcripts and field notes recorded from the standardized questionnaire, in-depth interviews, and focus group discussions multiple times. Data were coded, manually analyzed, and grouped by assessing for relationships between them to form sub-themes. Based on this process, the key themes examined included navigating the available healthcare systems, pregnancy health education, herbal medicine, common community concerns, family dynamics, and family planning. This study was performed in Lweza Village, Uganda, which is located in the Mukono District, just east of Kampala, Uganda’s capital city. Mukono is comprised of 602 villages and spans nearly 3,000 square kilometers. Most of the population belong to the Baganda ethnic group, the largest kingdom in Uganda’s central region. The major public health care facility in Mukono is the Mukono District Health Center IV, a government hospital that provides numerous services including primary care, laboratory testing, surgery, mental health, dental and eye care, pharmacy, radiology, HIV/AIDS, TB, and maternal and child health (antenatal, maternity, family planning, post-natal, immunizations). Each year, this 45 bed facility serves thousands of patients, including performing 7,789 deliveries, 15,126 antenatal care visits, and 1,708 cesarean sections [13]. The Mukono District Health Center IV is located in close proximity to Lweza Village, only about a 3 km walk or boda boda (motorcycle taxi) ride away. In addition to this health facility, private hospitals are available to patients throughout the district. Besides these formal health care services, traditional medicine and herbal medicine facilities are available, including TBAs for pregnant and laboring women. Each village elects two Village Health Team members who are responsible for community health promotion, health education, and passing along health messages from the government hospitals. The study target population was women who currently reside in Lweza Village and who had given birth in the Mukono District. Lweza Village was selected due to prior established relationships between the research team and the community. Lweza Village has a population of about 7,000 people. The research team, comprised of a University of Wisconsin School of Medicine and Public Health medical student (M.D.), a translator, and a Village Health Team member, started from a central location in Lweza and randomly selected a direction to begin household interviews. The translator and Village Health Team members were not part of the research team. The Village Health Team member identified households with eligible women for interviewing and every other household was interviewed until the team reached the end of the village. A new direction was then randomly selected and the interviews were carried out in this new direction working back through Lweza Village until there were 100 respondents. In addition to the household interviews, six key informant interviews were held. Informant participants were selected based off of recommendations from the Mukono Municipality Principal Medical Officer. After permission was obtained, in-depth interviews occurred in private spaces at each informants’ place of employment. The informants were compensated for their time with 10,000 UGX or roughly 2.71 USD. The key informants included: two government midwives, one private midwife, a local TBA, a Village Health Team member from the neighboring village of Basiima-Kikooza to minimize bias, and a leader from the Child Care and Youth Empowerment Foundation (CCAYEF). The CCAYEF is a local organization that was established to provide a gathering place for young girls and teenage mothers to share experiences, learn skills, and provide support to one another. Two focus group discussions were conducted. These group discussions were arranged by a local translator who was familiar with the community. The first focus group discussion was with ten teachers at the Lweza Primary School. The second focus group discussion was with nine women who were all part of the Village Health Project Uganda, a local community organization that meets weekly for learning activities and participates in local sustainable projects like sack gardening or building rain-water tanks. Each of these focus group participants were compensated a small amount of money for their time.