Community views on short birth interval in Northern Uganda: a participatory grounded theory

Background: Short birth interval is associated with adverse perinatal, maternal, and infant outcomes, although evidence on actionable factors underlying short birth interval remains limited. We explored women and community views on short birth intervals to inform potential solutions to promote a culturally safe child spacing in Northern Uganda. Methods: Gendered fuzzy cognitive mapping sessions (n = 21), focus group discussions (n = 12), and an administered survey questionnaire (n = 255) generated evidence on short birth intervals. Deliberative dialogues with women, their communities, and service providers suggested locally relevant actions promote culturally safe child spacing. Results: Women, men, and youth have clear understandings of the benefits of adequate child spacing. This knowledge is difficult to translate into practice as women are disempowered to exercise child spacing. Women who use contraceptives without their husbands’ consent risk losing financial and social assets and are likely to be subject to intra-partner violence. Women were not comfortable with available contraceptive methods and reported experiencing well-recognized side effects. They reported anxiety about the impact of contraception on the health of their future children. This fear was fed by rumors in their communities about the effects of contraceptives on congenital diseases. The women and their communities suggested a home-based sensitization program focused on improving marital relationships (spousal communication, mutual understanding, male support, intra-partner violence) and knowledge and side-effects management of contraceptives. Conclusions: The economic context, gender power dynamics, inequality, gender bias in land tenure and ownership regulations, and the limited contraceptive supply reduce women’s capacity to practice child spacing. The project involved three parishes in Nwoya district in the Acholi subregion of Northern Uganda, including some 214,000 people [12]. Most of the population is rural and depends on subsistence-based agriculture. Northern Uganda went through two decades of a civil war between 1986 and 2006. Armed conflict with the Lord’s Resistance Army displaced about 90% of the population to camps of internally displaced persons with disruption of public resources, loss of land, and deterioration of reproductive health indicators [13]. The northern region now has one of the highest maternal mortality levels, neonatal mortality, and teenage pregnancy in the country [5]. The national maternal mortality ratio (MMR) is 336 maternal deaths per 100,000 live births, and almost 28% of maternal deaths occur among women between 15 and 24 years of age. The MMR Northern Uganda, the MMR is near twice this (650 women in every 100,000 live births), and at least ten times this number of children dies before 1 month of age [14]. The maternity risks start early in life, with one in every four women beginning childbearing by the age of 19 years [5]. This study is part of a larger cross-sectional, mixed-methods participatory research initiative that engaged women and their families to work with service providers to improve perinatal care access and promote culturally safe child spacing practices [15]. The participatory research perspective sees women and their communities as knowledge holders and partners in co-design. The grounded theory focuses on the emic perspective and provides inductive strategies for building theories from within the participant’s worldview [16, 17]. The substantive theory that emerged from their collective knowledge informed interventions to promote a culturally safe child spacing approach, implementation of which is outside the scope of this report. Fuzzy cognitive mapping (FCM) collated views of women and their communities’ views on the causes of short birth intervals. Subsequent focus group discussions clarified some of the concepts that emerged from the FCM. An administered questionnaire in a household survey quantified variables on reproductive and family planning outcomes. Deliberative dialogue sessions with women and their communities shared and discussed the results. They suggested potential actions to promote culturally safe child spacing. We used data from these processes to build the emic grounded theory. FCM aims to understand stakeholder knowledge and views on causes, in this case, of short birth intervals. Participants identified links between causal factors and outcomes and assigned a weight to each one based on their perceptions of its relative importance [18, 19]. We purposively sampled seven stakeholder groups: women, men, youth (18–25 years old) (women and men), community health workers, traditional midwives, and service providers. We invited five to eight participants from each group for each session. We met each stakeholder group separately, convening one group per stakeholder category and parish. In each session, participants drew two maps. One map identified child spacing benefits and the other map described the causes of the short birth intervals. Local female trained researchers convened participants for the mapping sessions. One researcher facilitated the sessions in the Acholi language, and the other one took systematic notes. We conducted focus groups to explore the concepts that emerged from the mapping sessions. A female anthropologist part of the research team designed the focus group guide. We invited participants by phone. The local female researchers moderated the groups with the same women, men, and youth who participated in the mapping sessions. We conducted 12 sessions (three women, three women youth (18–25 years old), three men, three men youth), each group with 5–8 participants. The local researchers met groups separately. Each focus group lasted 1 h in the Acholi language and was held in public places (outside near a health center or a school). We did not record the proceedings to allow the participants to speak freely [20, 21]. The questionnaire collated socio-demographic characteristics and gynecology history: age, number of children, women education and occupation, husband occupation, agriculture land and size, decision on land issues, children external support, household sources of income, food, known risk factors: knowledge on danger signs for pregnancy, and childbirth, blurred vision, dizziness, repeated headaches, verbal, mental, physical abuse, outcomes for the most recent pregnancy: male support, transport to health facility, antenatal check-ups, blood and urine tests, childbirth in facility, post-partum: fever within the 6 weeks after delivery, foul discharge within 6 weeks after delivery, and contraception: attitude towards modern contraceptives, contraceptive currently used, capability to use modern contraceptives, factors affecting decision on spacing children. The local team pretested the e-questionnaire among women who had given birth in the past 2 years. We used a cluster sampling method to select the villages in each parish. We used Android tablets and Open Data Kit (ODK) software to administer the questionnaires. ODK is an open-source software to collect data offline at scale. The duration of administering the questionnaire was approximately 30 min. Deliberative dialogue is a reflective evidence-based discussion where members from each stakeholder group listen to each other’s interpretation of the evidence before identifying, in this case, ways to promote culturally safe child spacing. The participants discussed the findings from the mapping and focus groups [22]. Local researchers facilitated three deliberative dialogue sessions in Acholi, one in each parish and each attended by 15–20 participants. Each deliberative dialogue lasted 3–4 h (Table ​(Table11). Synthesis of data collection methods Men and women ≥ 18 year old 5–8 participants for 7 groups, per parish Total: 21 FCM sessions Men and women ≥ 18  year old Men and women ≥ 18 year old DD each 15–20 participants Total: 3 sessions Women ≥ 18 year old We digitized the fuzzy cognitive maps using yEd software [23]. Based on a thematic approach, we condensed the factors from the maps into fewer categories using Excel sheet tables (Additional file 1: Appendix S1a, Additional file 2: Appendix S1b). Transitive closure analysis identified the most influential factors in the maps and a pattern-matching table showed similarities and differences across stakeholder groups (Additional file 3: Appendix S2a, Additional file 4: Appendix S2b). We aggregated the weights from combined maps and calculated the cumulative influence as the sum of all the weights. The final map scaled the cumulative influences dividing them by the maximum cumulative influence in the map to obtain values between 0 and 1. We used Ciet map 2.2, a windows-like interface for R, to conduct the transitive closure analysis. The local researchers translated the focus groups and deliberative dialogue notes into English. Using an inductive thematic analysis and an open coded approach, we constructed the code structure based on a sample of transcriptions [24]. We consolidated the coding structure and coded the transcriptions manually. We looked for patterns, similarities, and contrasts between women, men, youth, and parishes. The survey provided baseline indicators, response rates, and variances for calculating sample size for a future impact evaluation study. We tested the handset tablet application in this setting, including training, quality control, data collation, and cleaning. This survey was not powered to measure impact but settled the feasibility and acceptability issues. We used Excel to quantify reproductive outcomes and complement the mapping and focus groups’ data. The mapping and focus groups’ findings built the emic theory, and the data from the deliberative dialogue enriched the grounded theory on short birth intervals. The female anthropologist drafted this narrative report. This study respected the principles in the Declaration of Helsinki. We obtained ethical approvals from the Uganda National Council for Science and Technology (SS479) and the Faculty of Medicine and Health Sciences of McGill University (A08-B01-19A) in Canada. We sought informed verbal consent from the participants. We treated all information from participants as confidential.