When women deliver at home without a skilled birth attendant: A qualitative study on the role of health care systems in the increasing home births among rural women in southwestern uganda

  • International Journal of Women's Health, Volume 12, Year 2020

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Study Justification:
– Uganda has a high maternal mortality rate, with preventable deaths occurring during pregnancy and childbirth.
– Despite high antenatal care attendance, a significant percentage of women still choose to deliver at home without a skilled birth attendant.
– This study aims to explore the barriers that influence women’s decisions to deliver at home and inform interventions to improve skilled facility births.
Study Highlights:
– Qualitative interviews were conducted with 30 postpartum women in rural southwestern Uganda.
– Barriers to delivering in a health care facility were identified, including fear of unresponsive care, mistreatment by health care providers, low perception of risk, preferences for birthing positions, lack of privacy, and perceived poor clinical and interpersonal skills of health providers.
– Women expressed a desire for a supportive, respectful, responsive, and loving environment during childbirth.
– The findings highlight the importance of building better interpersonal relationships between patients and providers to improve trust and patient-provider interaction.
Study Recommendations:
– Develop interventions to address the identified barriers and improve skilled facility births.
– Provide additional training for midwives and other health care providers in communication and dignity in delivering quality health care.
– Create supportive health care systems that prioritize patient-friendly care and address women’s expectations and preferences during pregnancy and childbirth.
Key Role Players:
– Ministry of Health: Responsible for implementing and overseeing interventions to improve skilled facility births.
– Regional Referral Hospital: Provides training and support for health care providers.
– Village Health Teams (VHTs): Community volunteers who can play a role in mobilizing and sensitizing communities to utilize health services.
– Research Team: Conducted the study and can provide expertise and guidance in implementing interventions.
Cost Items for Planning Recommendations:
– Training programs for midwives and health care providers.
– Development and implementation of patient-friendly care protocols.
– Community mobilization and sensitization campaigns.
– Monitoring and evaluation of interventions.
– Research and data collection to assess the impact of interventions.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative study design, which provides valuable insights into the barriers to women’s decisions to deliver in a health care facility. The study was conducted in rural southwestern Uganda, an area with high maternal mortality rates. The researchers used a purposeful sampling strategy to select a diverse group of postpartum women for interviews. The interviews were conducted in the local language and digitally recorded. The data were transcribed and analyzed using an inductive content analytic approach. The findings revealed six key barriers to facility-based delivery, including fear of unresponsive care, fear of mistreatment by health care providers, low perception of risk, preferences for birthing positions, lack of privacy, and perceived poor clinical and interpersonal skills of health providers. The study highlights the importance of building better interpersonal relationships between patients and providers to improve patient-provider interaction and trust. However, the abstract does not provide information on the limitations of the study or any recommendations for improving the evidence. To improve the evidence, the researchers could consider including a larger sample size, conducting interviews in multiple languages to ensure inclusivity, and conducting follow-up interviews to validate the findings. Additionally, providing more context on the study’s limitations and implications for future research would enhance the overall strength of the evidence.

Background: Uganda’s maternal mortality remains unacceptably high, with thousands of women and newborns still dying of preventable deaths from pregnancy and childbirth-related complica-tions. Globally, Antenatal care (ANC) attendance has been associated with improved rates of skilled births. However, despite the fact that over 95% of women in Uganda attend at least one ANC, over 30% of women still deliver at home alone, or in the presence of an unskilled birth attendant, with many choosing to come to hospital after experiencing a complication. We explored barriers to women’s decisions to deliver in a health care facility among postpartum women in rural southwestern Uganda, to ultimately inform interventions aimed at improving skilled facility births. Methods: Between December 2018 and March 2019, we conducted in-depth qualitative face-to-face interviews with 30 post-partum women in rural southwestern Uganda. The purposeful sample was intended to represent women with differing experiences of pregnancy, delivery, and antenatal care. We included 15 adult women who had delivered from their homes and 15 who had delivered from a health facility in the previous 3 months. Women were recruited from 10 villages within 20 km of a regional referral hospital. Interviews were conducted and digitally recorded in a private setting by a trained native speaker to elicit experiences of pregnancy and birth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. Results: Regardless of where they decided to give birth, women wished to deliver in a supportive, respectful, responsive and loving environment. The data revealed six key barriers to women’s decisions to deliver from a health care facility: 1) Fear of unresponsive care, fueling a fear of being neglected or abandoned while at the facility; 2) fear of embarrassment and mistreatment by health care providers; 3) low perception of risk associated with pregnancy and childbirth; 4) preferences for particular birthing positions and their outcome expectations; 5) perceived lack of privacy in public facilities; and 6) perceived poor clinical and interpersonal skills of health providers to adequately explain birthing procedures or support expectant or laboring women and their newborn. Conclusion: Anticipation of unsupportive, unresponsive, disrespectful treatment, and a perceived lack of tolerance for simple, non-harmful traditions prevent women from delivering at health facilities. Building better interpersonal relationships between patients and providers within health systems could reinforce trust, improve patient–provider interaction, and facilitate useful information transfer during ANC and delivery visits. These expectations are important considerations in developing supportive health care systems that provide acceptable patient-friendly care. These findings are indicative of the vital need for midwives and other health care providers to have additional training in the role of communication and dignity in delivery of quality health care.

In this study, we used qualitative interview study design to explore and understand barriers to women’s decisions and choices to deliver in a health care facility among postpartum women in rural southwestern Uganda. The study was conducted between December 2018 and March 2019 in the rural southwestern Uganda’s Mbarara district, one of the highest maternal mortality ratio of 489 per 100,000 women Uganda16 with a projected dense population of 524,400, 17 sub-counties, 83 parishes and 757 villages.17 Uganda’s public health system is organized into seven tiers with national and regional referral hospitals, general district hospitals and four levels of community health centers. At the county level are health center IVs (HCIV), sub-county level are health center IIIs (HCIII), the health center IIs (HCII) at the parish level and village level (HC1) that is operated by Village Health Teams (VHTs). The VHTs are community volunteers identified by their community members and are given basic training on major health programs so they can in turn mobilize and sensitize communities to actively participate in utilizing the available health services.18 According to the Uganda Ministry of Health, VHTs also act as an important link between the communities and health facilities, and can provide treatment of uncomplicated diseases like malaria, pneumonia, worm infestations, diarrhea and mass drug administration for Neglected Tropical Diseases. VHTs mobilize communities during specific health campaigns and community disease surveillance activities through active data collection and reporting. Staffing and available services vary across the four levels: HCIII and HCIV should offer Emergency Obstetrics Care (EMOC), whereas HCI and HCII serve as low resource referral units which are not able to provide EMOC and have no ambulances and blood transfusion services.19 In total, there are about 10 public facilities within a 20 km radius from Mbarara Regional Referral Hospital, the main teaching hospital for Mbarara University of Science and Technology. Private providers operate in parallel to the public system to provide maternal health care. A purposeful qualitative sampling strategy was used to construct a sample of postpartum women with varied knowledge and experiences of pregnancy, antenatal care, and childbirth. A trained research assistant initiated contact to one of the VHTs based in each of the study villages. These VHTs in each of the 10 villages located within 20 km from Mbarara Regional Referral Hospital were identified from the list of VHTs provided by the district health office. The VHT contact person helped to identify women who had had their last delivery within the last 3 months. Trained research assistants then initiated a telephone contact to the identified women to seek permission to visit them for an interview. All women contacted were willing to participate in the study. Research assistants explained what the study is all about and obtained voluntary written informed consent from all eligible participants in the local language in a private area of their homes, communities or study office. All consenting participants gave written informed consent, or for those who could not write, a thumbprint was made on the consent form. We identified three women from each of the 10 villages with different facility or home birthing experiences. We purposively selected and recruited a total sample of 15 women who had delivered from their homes and 15 who had delivered from a health facility for their last delivery, and within the last 3 months. The places for facility or home deliveries were regardless of where their previous births happened, bringing a wide mix and range of different experiences, circumstances and decision-making processes from the participating women. Eligible women were: 1) adults of childbearing age (18–49 years); 2) had delivered a child in the previous 3 months; 3) had access to a mobile phone; and 4) were able and willing to give informed consent. Data collection consisted of individual, open-ended interviews with each of the study participants (N=30 interviews). A preliminary interview guide was developed and pilot tested by the primary author amongst five women in one of the 10 participating villages. The guide was revised based on the results of the pilot test. Topics included in the final version of the guide were: 1) perceptions of pregnancy and childbirth; 2) experiences of previous pregnancy or pregnancies; 3) experiences of ANC; 4) engagement with health care providers within a facility; 5) social support; and 6) childbirth experiences. Individualized probes were used to elicit details corresponding to each topic. Field notes and observations were collected by research assistants and included in interview debriefs. As the interviews were conducted and different field notes and observations filed, emerging content was continuously reviewed by the primary and senior authors to sharpen the interview questions and identify new probes. Demographic information (eg, age, occupation, educational background) was collected usually at the outset of each interview. All interviews took place in a private location mutually agreed upon by the participant and the interviewer. Interviews were conducted in the local language (Runyankole), and digitally recorded. Interviews lasted 60–90 minutes. Qualitative interviews were digitally recorded with the participant’s permission and transcribed. A Ugandan research assistant transcribed the interviews from the local language directly to English. The research team comprised of seven senior investigators, inclusive of epidemiologists (ECA, CO), obstetrician (GRM), a medical anthropologist (NCW), maternal/reproductive health expert (LTM), nurse (JN) and a health informatics specialist (AM). Based on our previous research and work experience in maternal health in Uganda, the team sought to explore barriers for low utilization of maternity services in Uganda. Two independently hired (male and female) research assistants were trained to conduct research in human subjects. They are both social scientists. These two research assistants generated transcripts but were not involved in concept development or coding of data. This multi-disciplinary team leveraged on their expertise and experience with maternal health issues in Uganda to design, conduct, analyze and present findings from this study. The aim of this qualitative data analysis was to inductively construct categories describing barriers to facility-based delivery. Analysis began with repeated review of transcripts to identify relevant content. The identified content served as the basis for developing a coding scheme. Coding was done in three stages namely: 1) open coding to identify and describe women’s ideas, meaningful expressions, phenomena or incidents highlighting their experiences during pregnancy and childbirth; 2) axial coding to relate and label codes or data that shared concepts, dimension and properties (relationship identification); and 3) selective coding to delimit coding to the identified core variables/concepts from the data (Strauss and Corbin, 1998). Data were coded with the aid of the qualitative data management software, NVivo10 (Melbourne, Australia). Coded data were iteratively reviewed and sorted to identify themes (repeated patterns in the data). Categories were then developed to describe each identified theme. Categories consisted of descriptive labels, elaborating text to define and specify each category’s meaning, and illustrative quotes taken from the qualitative data. Data analysis was done jointly by ECA, EA, CO, JN and GRM. Both JN and ECA coded five sampled transcripts and compared the results. Together with GRM and CO, we resolved disagreements until we were satisfied with the consistency in our coding. We aimed at ensuring consistency in coding.

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

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services to provide pregnant women with information about antenatal care, safe delivery practices, and postpartum care. These interventions can also send reminders for appointments and provide access to teleconsultations with healthcare providers.

2. Community-based education and awareness programs: Implement community-based programs that educate women and their families about the importance of skilled birth attendance and the risks associated with home births. These programs can also address cultural beliefs and misconceptions that may discourage women from seeking care at health facilities.

3. Strengthening health systems: Improve the quality and availability of maternal health services at health facilities, particularly in rural areas. This can include training healthcare providers in effective communication and respectful maternity care, ensuring the availability of essential supplies and equipment, and improving referral systems for emergency obstetric care.

4. Task-shifting and training of community health workers: Train and empower community health workers, such as Village Health Teams (VHTs) in Uganda, to provide basic maternal health services, including antenatal care, health education, and referrals. This can help bridge the gap between communities and health facilities, particularly in areas with limited access to healthcare.

5. Addressing barriers to facility-based delivery: Address the specific barriers identified in the study, such as fear of unresponsive care, mistreatment by healthcare providers, low perception of risk, preferences for birthing positions, lack of privacy, and perceived poor clinical and interpersonal skills of health providers. This can be done through targeted interventions, such as provider training programs, improving facility infrastructure, and promoting patient-centered care.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of rural southwestern Uganda.
AI Innovations Description
Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Improve communication and interpersonal skills of health care providers: The study identified fear of unresponsive care and mistreatment by health care providers as a barrier to delivering in a health care facility. To address this, additional training can be provided to midwives and other health care providers to enhance their communication and interpersonal skills. This can help build better relationships between patients and providers, reinforce trust, and improve patient-provider interaction.

2. Create a supportive and patient-friendly environment: Women expressed a desire to deliver in a supportive, respectful, responsive, and loving environment. Health care systems can work towards creating such an environment by ensuring privacy in public facilities, addressing concerns about embarrassment and mistreatment, and promoting a culture of patient-centered care. This can be achieved through staff training, policy changes, and infrastructure improvements.

3. Increase awareness about the risks of home births: The study found that some women had a low perception of the risks associated with pregnancy and childbirth, leading them to choose home births. It is important to educate women about the potential complications that can arise during childbirth and the benefits of delivering in a health care facility with skilled birth attendants. This can be done through community outreach programs, antenatal care visits, and health education campaigns.

4. Strengthen the role of Village Health Teams (VHTs): VHTs play a crucial role in mobilizing and sensitizing communities to utilize available health services. They can be further empowered to provide information and support to pregnant women, promote the importance of skilled facility births, and facilitate referrals to health care facilities. Training and capacity-building programs can be conducted to enhance the knowledge and skills of VHTs in maternal health care.

5. Improve access to emergency obstetric care: The study highlighted the importance of having access to emergency obstetric care in health care facilities. Efforts should be made to ensure that health centers at all levels, especially HCIII and HCIV, are equipped to provide emergency obstetric care. This includes having trained staff, necessary equipment, ambulances, and blood transfusion services. Collaboration between public and private providers can also help improve access to emergency obstetric care.

By implementing these recommendations, it is possible to develop innovative solutions that address the barriers identified in the study and improve access to maternal health care in rural southwestern Uganda.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Improve communication and interpersonal skills of health care providers: Training programs can be implemented to enhance the communication and interpersonal skills of health care providers. This can help build trust and improve patient-provider interactions, leading to better patient experiences and increased utilization of health care facilities for childbirth.

2. Enhance privacy in public health facilities: Addressing the perceived lack of privacy in public health facilities can be crucial in encouraging women to choose facility-based deliveries. Measures such as creating separate spaces for laboring women, ensuring confidentiality, and providing comfortable and private birthing areas can help alleviate this barrier.

3. Promote community engagement and awareness: Community mobilization and sensitization efforts can be undertaken to raise awareness about the importance of skilled facility births and the available maternal health services. This can be done through the involvement of Village Health Teams (VHTs) and other community volunteers who can educate and encourage women to seek care at health facilities.

4. Address fear and misconceptions: Addressing the fear of unresponsive care, mistreatment, and neglect experienced by women at health care facilities is crucial. This can be achieved through training programs for health care providers on respectful and patient-centered care, as well as community education programs to dispel misconceptions and myths surrounding childbirth in health facilities.

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 data on the current utilization of health care facilities for childbirth in the target area, including the percentage of women delivering at home or with unskilled birth attendants.

2. Intervention implementation: Implement the recommended interventions, such as training programs for health care providers, improving privacy in health facilities, and community engagement activities.

3. Monitoring and evaluation: Collect data on the utilization of health care facilities for childbirth after the implementation of the interventions. This can be done through surveys, interviews, or health facility records.

4. Comparative analysis: Compare the post-intervention data with the baseline data to assess the impact of the interventions on improving access to maternal health. Analyze the changes in the percentage of women delivering at health facilities and identify any significant improvements.

5. Feedback and adjustment: Based on the findings, provide feedback to stakeholders and policymakers. If necessary, make adjustments to the interventions to further enhance their effectiveness.

6. Continuous monitoring and improvement: Continuously monitor the utilization of health care facilities for childbirth and make further improvements as needed. Regularly assess the impact of the interventions and adjust strategies accordingly to ensure sustained improvements in access to maternal health.

It is important to note that this is a general methodology and may need to be adapted based on the specific context and resources available for the study.


Statistics:
Citations: 9
Identifiers:
DOI: 10.2147/IJWH.S248240
Research Areas:
Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce
Study Countries:
Uganda
Study Design:
Cross Sectional Study, Exploratory Study, Grounded Theory, Phenomenological Study
Study Approach:
Qualitative
Participants Gender:
Male & Female
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