Bypassing or successful referral? A population-based study of reasons why women travel far for childbirth in Eastern Uganda

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Study Justification:
– The study aimed to investigate why women in rural Uganda bypassed their nearest facility for childbirth care.
– Understanding the reasons behind this behavior is crucial for improving maternal and newborn health outcomes.
– Delivery in a facility with a skilled health provider is essential for reducing maternal and early newborn deaths.
– Providing care close to people’s homes is an important strategy for ensuring equitable access to healthcare.
Study Highlights:
– 29% of women in the rural Ugandan setting bypassed their nearest facility to give birth in another facility.
– Bypassing was associated with the readiness of the nearest facility to provide care and the wealth of the household.
– Women in the highest wealth quintile were more likely to bypass their nearest facility.
– The odds of bypassing decreased with an increase in the readiness score of the nearest facility for childbirth.
Study Recommendations:
– Improve the readiness of the nearest facilities to provide quality childbirth care.
– Address the inequalities in bypassing for better quality care.
– Implement strategies to ensure equitable access to skilled health providers for all women, regardless of their wealth.
Key Role Players:
– Ministry of Health, Uganda
– District Health Office
– Health facility staff (doctors, nurses, midwives)
– Community health workers
– Non-governmental organizations (NGOs) working in maternal and newborn health
Cost Items for Planning Recommendations:
– Training and capacity building for health facility staff
– Infrastructure improvement in health facilities
– Equipment and supplies for childbirth care
– Outreach and awareness campaigns
– Monitoring and evaluation activities
– Research and data collection
– Collaboration and coordination efforts between stakeholders

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides specific data and findings from a population-based study conducted in rural Uganda. The study used data collected over a period of three years and employed multilevel logistic regression to analyze the relationship between bypassing the nearest health facility for childbirth and various independent factors. The abstract also mentions the sample size and provides percentages and odds ratios to support the findings. However, the abstract does not provide information on the methodology used to collect the data or the specific quality improvement approach evaluated in the trial. To improve the evidence, the abstract could include more details on the data collection methods and the specific quality improvement approach used in the trial.

Background: Delivery in a facility with a skilled health provider is considered the most important intervention to reduce maternal and early newborn deaths. Providing care close to people’s homes is an important strategy to facilitate equitable access, but many women are known to bypass the closest delivery facility for a higher level one. The aim of this study was to investigate to what extent mothers in rural Uganda bypassed their nearest facility for childbirth care and the determinants for their choice. Methods: The study used data collected as part of the Expanded Quality Management Using Information power (EQUIP) study in the Mayuge District of Eastern Uganda between 2011 and 2014. In this study, bypassing was defined as delivering in a health facility that was not the nearest childbirth facility to the mother’s home. Multilevel logistic regression was used to model the relationship between bypassing the nearest health facility for childbirth and the different independent factors. Results: Of all women delivering in a health facility, 45% (499/1115) did not deliver in the nearest facility regardless of the level of care. Further, after excluding women who delivered in health centre II (which is not formally equipped to provide childbirth care) and excluding those who were referred or had a caesarean section (because their reasons for bypassing may be different), 29% (204/717) of women bypassed their nearest facility to give birth in another facility, 50% going to the only hospital of the district. The odds of bypassing increased if a mother belonged to highest wealth quintile compared to the lowest quintile (AOR 2.24, 95% CI: 1.12-4.46) and decreased with increase of readiness of score of the nearest facility for childbirth (AOR = 0.84, 95% CI: 0.69-0.99). Conclusions: The extent of bypassing the nearest childbirth facility in this rural Ugandan setting was 29%, and was associated primarily with the readiness of the nearest facility to provide care as well as the wealth of the household. These results suggest inequalities in bypassing for better quality care that have important implications for improving Uganda’s maternal and newborn health outcomes.

This study used data collected as part of the Expanded Quality Management Using Information power (EQUIP) study in the Mayuge District of eastern Uganda between 2011 and 2014 [27–29]. Mayuge is a rural district on the shore of Lake Victoria about 160 km northeast of Kampala. The district has 26 level II, nine level III and two level four health centres and one private-not-for-profit missionary hospital. The level II HC provide basic outpatient care and are not mandated to provide delivery care; still they provided care to mothers who arrived late in labour. HC III are staffed by a senior clinical officer and three nurse midwives. They offer antenatal care, basic emergency obstetric care and postpartum services for low-risk pregnancies [6, 26]. HC IV offer all services provided at HC III in addition to operative care and laboratory services for low and high-risk pregnancies. Hospitals provide comprehensive emergency obstetric and newborn care services, blood transfusion, and laboratory services. Maternal delivery services are free except for the missionary hospital. Our study was done using data collected during a trial conducted in Mayuge district evaluating a quality improvement approach. Data was collected via continuous household and health facility surveys [27–29].

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

1. Mobile health clinics: Implementing mobile health clinics that can travel to remote areas in rural Uganda, providing maternal health services closer to women’s homes.

2. Telemedicine: Introducing telemedicine services that allow women in rural areas to consult with healthcare providers remotely, reducing the need for long-distance travel for routine check-ups and consultations.

3. Strengthening lower-level health facilities: Investing in improving the readiness and capacity of level II and level III health centers to provide comprehensive maternal health services, reducing the need for women to bypass these facilities for higher-level ones.

4. Community-based education and awareness programs: Conducting community-based education programs to raise awareness about the importance of delivering in a facility with a skilled health provider and the services available at nearby health facilities, encouraging women to seek care closer to their homes.

5. Financial incentives: Introducing financial incentives, such as transportation vouchers or cash transfers, to offset the costs associated with accessing maternal health services, particularly for women from lower wealth quintiles.

6. Collaboration with traditional birth attendants: Collaborating with traditional birth attendants to improve their skills and knowledge on safe delivery practices, enabling them to provide basic emergency obstetric care and refer women to nearby health facilities when necessary.

7. Improving transportation infrastructure: Investing in improving transportation infrastructure, such as roads and transportation networks, to make it easier for women to access health facilities for maternal health services.

8. Quality improvement initiatives: Implementing quality improvement initiatives in health facilities to ensure that they provide high-quality maternal health services, addressing the concerns of women who bypass their nearest facility for better quality care.

These are just a few potential innovations that could be considered to improve access to maternal health based on the study’s findings. It is important to further assess the feasibility and effectiveness of these innovations in the specific context of rural Uganda.
AI Innovations Description
Based on the study titled “Bypassing or successful referral? A population-based study of reasons why women travel far for childbirth in Eastern Uganda,” the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening and equipping lower-level health facilities: The study found that women were more likely to bypass their nearest facility if it was not adequately equipped to provide childbirth care. To address this, the innovation could focus on improving the readiness and capacity of lower-level health facilities to provide quality maternal health services. This could involve training healthcare providers, ensuring the availability of essential equipment and supplies, and improving infrastructure.

2. Enhancing referral systems: The study identified that some women bypassed their nearest facility due to the need for specialized care or interventions. To address this, the innovation could focus on strengthening referral systems to ensure timely and appropriate referrals for women in need of higher-level care. This could involve improving communication and coordination between different levels of healthcare facilities, implementing standardized referral protocols, and providing transportation support for women who need to travel for specialized care.

3. Addressing financial barriers: The study found that women from higher wealth quintiles were more likely to bypass their nearest facility. To improve access for all women, the innovation could focus on addressing financial barriers by implementing strategies such as providing free or subsidized maternal health services, expanding health insurance coverage, or establishing community-based financing mechanisms.

4. Community engagement and awareness: The study highlighted the importance of addressing inequalities in access to quality care. The innovation could involve community engagement and awareness campaigns to educate women and their families about the importance of delivering in a facility with skilled health providers and the available services at their nearest facility. This could include community dialogues, health education sessions, and the involvement of community leaders and influencers.

Overall, the innovation should aim to improve the readiness and capacity of health facilities, strengthen referral systems, address financial barriers, and promote community engagement and awareness to ensure equitable access to maternal health services in rural Uganda.
AI Innovations Methodology
Based on the study mentioned, here are some potential recommendations to improve access to maternal health:

1. Strengthening readiness of nearest facilities: The study found that the readiness of the nearest facility for childbirth care was associated with the likelihood of bypassing. Therefore, one recommendation could be to invest in improving the readiness of these facilities by ensuring they have the necessary equipment, trained staff, and essential supplies to provide quality maternal health services.

2. Addressing wealth-related disparities: The study found that women from the highest wealth quintile were more likely to bypass their nearest facility. To improve access, interventions could focus on reducing financial barriers by providing financial support or subsidies for maternal health services, particularly for women from lower socioeconomic backgrounds.

3. Enhancing referral systems: The study mentioned that some women bypassed their nearest facility due to referrals or the need for specialized care. Strengthening referral systems and ensuring efficient communication between facilities can help ensure that women are appropriately referred to higher-level facilities when needed, while still maintaining access to care closer to their homes whenever possible.

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

1. Collect baseline data: Gather information on the current status of maternal health access, including the percentage of women bypassing their nearest facility, reasons for bypassing, and the readiness of facilities.

2. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of women bypassing their nearest facility, the readiness score of facilities, and the socioeconomic disparities in access.

3. Introduce interventions: Implement the recommended interventions, such as improving facility readiness, implementing financial support programs, and strengthening referral systems.

4. Monitor and evaluate: Continuously collect data on the indicators identified in step 2 to assess the impact of the interventions. This can be done through surveys, interviews, or health facility records.

5. Analyze data: Analyze the collected data to determine the changes in the indicators and assess the effectiveness of the interventions in improving access to maternal health.

6. Adjust and refine: Based on the findings, make adjustments to the interventions as needed and refine the methodology for further evaluation.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health and assess their effectiveness in the specific context of the study area.

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