A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: Implications for programming

BMC Pregnancy and Childbirth, Volume 14, No. 1, Year 2014

Interpretação

Background: Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda.Methods: Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified.Results: The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery.Conclusion: A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed. Karamoja region, near the border with Kenya, occupies an area of 35,007 Km2 and has a population of 1,074,600. This study was conducted in April 2010 in Moroto and Napak districts. The two districts, with a total area of 8,516 Km2, had a population of about 270,650 in 2010. Although both districts are predominantly rural, Moroto District hosts Moroto town which has an urban/peri-urban population of about 11,600. Moroto town is the administrative headquarters of Karamoja Region and has a regional referral Hospital for the entire Karamoja. Most parts of Napak District have a flat terrain but parts of Moroto District are mountainous making them difficult to access even by car. Both districts are inhabited by Karamajong people whose main sources of livelihood are nomadic pastoralism and subsistence crop farming. In Uganda, districts are subdivided into sub-counties, then parishes and villages. At the time of the study, Napak District had 6 sub-counties (Iriiri, Lokopo, Lopei, Lotome, Matany and Ngoloriet) and 200 villages whereas Moroto District had 5 sub-counties (Katikekile, Nadunget, Rupa, Northern Division and Southern Division) and 120 villages [22]. The districts had 61 nurses/midwives of different cadres, 11 doctors, 19 clinical officers and about 315 TBAs. In 2010 only 19% and 10% of deliveries took place in health facilities in Napak and Moroto districts, respectively [23], with most women delivering at home, attended to by either family members or TBAs. About 49% and 59% of the population in Moroto and Napak districts, respectively, is within five kilometres of a health facility. However, some of the health facilities are level II Health Centres which typically don’t offer maternity services. During rainy seasons most parts of the districts become inaccessible by motor vehicles due to muddy roads. The study was conducted in the catchment communities of health facilities in Moroto and Napak districts. These two districts were purposively selected because they were targets of a planned intervention to increase institutional delivery service by Doctors with Africa CUAMM. In consultation with district health authorities, twenty villages (ten in each district) located in 10 different sub-counties were selected purposively, to reflect the different geographic and socio-demographic characteristics of the communities in the districts. Figure 1 summarises the selection of villages and characteristics of the selected villages. In the selected villages, all women who had delivered in the past 5 years and their partners were eligible for the study. Selection of Sub-counties and villages and characteristics of selected villages. Data were collected through participatory rural appraisal (PRA). A total of 887 adult participants (459 women and 428 men) were recruited to participate in the PRA sessions. Participating villages were visited a day before the study and with the help of village leaders, potential participants were verbally invited to participate in the study the following day. The PRA data collection team consisted of a supervisor, two facilitators and two note takers. The supervisor and facilitators were experienced in PRA methodology having conducted similar studies in the same area in the past. The supervisor (co-author RML) further conducted a short training for facilitators and the note takers; covering the PRA methodology, the study objectives and a review of the tools. In order to overcome cultural factors that would limit freedom of expression, participants were divided into male and female groups. A male facilitator guided the male group while the female group was led by female facilitator. All members of data collection team were natives of the study districts and had a good understanding of the local culture and language. Two PRA sessions per group were held in each village and each session was made up of about 20 participants and lasted for about 3 hours. The sessions were held in public spaces selected by the communities, such as under trees and in local school buildings. Tools used during the sessions included community resource maps, Venn diagrams, matrix ranking, daily routines, and seasonal calendars. During the sessions, information on barriers to utilisation of maternal health services in the districts was collected using an open ended question guide which allowed for free discussion of the participants’ perceptions. During the discussions, the two note takers independently took notes. The discussions took place at alternate times for the male and female groups to allow the supervisor to attend both of them and also take notes. All notes were written in English as it was found to be easier to do so than to write in Karamojong (the local language). In case of lack of clarity, immediate clarification was sought. The main topics included in the question guide were: i) traditional practices and beliefs during delivery; ii) family support and decision making on health services during delivery; iii) the role of TBAs; iv) perceived quality of care and fee for services used; v) obstacles when using trained attendants’ services; vi) experience of delivery (including the services provided by the delivery attendants); and vii) reasons for a delivery outside a health care facility. Matrix ranking was performed by asking participants to list main reasons why women in the village don’t deliver in health facilities. Participants were then asked to use stones to assign a score to each reason to reflect the relative weight of the reason in preventing women from using skilled birth attendants. One stone represented a weight of one. A literate member in the group facilitated the scoring exercise which was done by consensus among group members. Locally prepared refreshments were provided at the end of PRA sessions. No cash incentives were provided. This study was approved by the National Bioethics Committee at Uganda National Council for Science and Technology and by the Moroto District Health Management Team. Because most PRA participants were illiterate, and given that they participated in the study in groups, verbal informed consent was obtained from each PRA group after an explanation about the study. Data were analysed using deductive content analysis [24]. At the end of each PRA session, the study team reviewed, edited and harmonized the notes taken. They then read through the notes several times, triangulated the data collected from men and women groups, identified and coded all recurring issues by consensus and summarized them in a table. The issues were grouped under four themes in an adapted framework: (1) socio-cultural factors, (2) perceived benefit/need of skilled attendance, (3) economic inaccessibility and (4) physical inaccessibility [10]. The themes formed the framework for reporting. Scores from matrix ranking were summarized using a spider plot to reflect the perceived relative significance of each barrier identified by participants in preventing utilization of delivery services. Scores for each barrier at each site were rescaled to take values of 0–5 and then summed up.

AI Digest

Study Justification:

– Skilled attendance at delivery is crucial for preventing maternal deaths.
– Many women in low- and middle-income countries still give birth without skilled assistance.
– This study aimed to identify barriers to the utilization of institutional delivery services in two districts in Uganda.

Study Highlights:

– Data collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts.
– Main barriers to utilization of maternal health services identified: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food and supplies, poor quality of care, lack of participation in planning, and the availability of traditional birth attendants (TBAs).
– Economic and physical inaccessibility and lack of infrastructure, drugs, and supplies at health facilities were highly ranked barriers.
– A comprehensive approach is needed to increase the utilization of maternal health care services in Karamoja, addressing both demand and supply side barriers.
– Collaboration between skilled health workers and TBAs is necessary to increase institutional deliveries.

Recommendations for Lay Reader and Policy Maker:

– Implement a multi-sectorial approach to address the identified barriers to utilization of institutional delivery services.
– Improve security in the region to ensure safe access to health facilities.
– Address poverty through targeted interventions and social support programs.
– Promote awareness and education on the importance of skilled attendance at delivery, addressing socio-cultural factors that may hinder utilization.
– Improve transportation infrastructure to reduce the distance to health facilities.
– Ensure availability of food, supplies, drugs, and basic infrastructure at health facilities.
– Enhance the quality of care provided at health facilities.
– Involve the community in the planning and decision-making processes for health services.
– Develop a model for collaboration between skilled health workers and TBAs to increase institutional deliveries.

Key Role Players:

– District health authorities
– Doctors with Africa CUAMM
– Skilled health workers
– Traditional birth attendants (TBAs)
– Community leaders and influencers
– Non-governmental organizations (NGOs)
– Community health workers

Cost Items for Planning Recommendations:

– Security measures and infrastructure improvements
– Poverty alleviation programs
– Awareness and education campaigns
– Transportation infrastructure development
– Procurement of food, supplies, drugs, and basic infrastructure for health facilities
– Training and capacity building for health workers and TBAs
– Community engagement and participation initiatives
– Monitoring and evaluation systems

Força da prova

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it provides a clear description of the study methodology, including the data collection process and analysis. The study was conducted in two districts in Uganda, with a large number of participants. The main barriers to utilization of institutional delivery services were identified and ranked by the participants. The abstract also highlights the need for a comprehensive approach to address these barriers. However, to improve the evidence, the abstract could provide more details on the demographics of the participants, such as age, education level, and socioeconomic status. Additionally, it would be helpful to include specific recommendations for addressing the identified barriers, such as improving infrastructure, increasing access to supplies and drugs, and promoting collaboration between skilled health workers and traditional birth attendants.

Resumo

Karamoja region, near the border with Kenya, occupies an area of 35,007 Km2 and has a population of 1,074,600. This study was conducted in April 2010 in Moroto and Napak districts. The two districts, with a total area of 8,516 Km2, had a population of about 270,650 in 2010. Although both districts are predominantly rural, Moroto District hosts Moroto town which has an urban/peri-urban population of about 11,600. Moroto town is the administrative headquarters of Karamoja Region and has a regional referral Hospital for the entire Karamoja. Most parts of Napak District have a flat terrain but parts of Moroto District are mountainous making them difficult to access even by car. Both districts are inhabited by Karamajong people whose main sources of livelihood are nomadic pastoralism and subsistence crop farming. In Uganda, districts are subdivided into sub-counties, then parishes and villages. At the time of the study, Napak District had 6 sub-counties (Iriiri, Lokopo, Lopei, Lotome, Matany and Ngoloriet) and 200 villages whereas Moroto District had 5 sub-counties (Katikekile, Nadunget, Rupa, Northern Division and Southern Division) and 120 villages [22]. The districts had 61 nurses/midwives of different cadres, 11 doctors, 19 clinical officers and about 315 TBAs. In 2010 only 19% and 10% of deliveries took place in health facilities in Napak and Moroto districts, respectively [23], with most women delivering at home, attended to by either family members or TBAs. About 49% and 59% of the population in Moroto and Napak districts, respectively, is within five kilometres of a health facility. However, some of the health facilities are level II Health Centres which typically don’t offer maternity services. During rainy seasons most parts of the districts become inaccessible by motor vehicles due to muddy roads. The study was conducted in the catchment communities of health facilities in Moroto and Napak districts. These two districts were purposively selected because they were targets of a planned intervention to increase institutional delivery service by Doctors with Africa CUAMM. In consultation with district health authorities, twenty villages (ten in each district) located in 10 different sub-counties were selected purposively, to reflect the different geographic and socio-demographic characteristics of the communities in the districts. Figure 1 summarises the selection of villages and characteristics of the selected villages. In the selected villages, all women who had delivered in the past 5 years and their partners were eligible for the study. Selection of Sub-counties and villages and characteristics of selected villages. Data were collected through participatory rural appraisal (PRA). A total of 887 adult participants (459 women and 428 men) were recruited to participate in the PRA sessions. Participating villages were visited a day before the study and with the help of village leaders, potential participants were verbally invited to participate in the study the following day. The PRA data collection team consisted of a supervisor, two facilitators and two note takers. The supervisor and facilitators were experienced in PRA methodology having conducted similar studies in the same area in the past. The supervisor (co-author RML) further conducted a short training for facilitators and the note takers; covering the PRA methodology, the study objectives and a review of the tools. In order to overcome cultural factors that would limit freedom of expression, participants were divided into male and female groups. A male facilitator guided the male group while the female group was led by female facilitator. All members of data collection team were natives of the study districts and had a good understanding of the local culture and language. Two PRA sessions per group were held in each village and each session was made up of about 20 participants and lasted for about 3 hours. The sessions were held in public spaces selected by the communities, such as under trees and in local school buildings. Tools used during the sessions included community resource maps, Venn diagrams, matrix ranking, daily routines, and seasonal calendars. During the sessions, information on barriers to utilisation of maternal health services in the districts was collected using an open ended question guide which allowed for free discussion of the participants’ perceptions. During the discussions, the two note takers independently took notes. The discussions took place at alternate times for the male and female groups to allow the supervisor to attend both of them and also take notes. All notes were written in English as it was found to be easier to do so than to write in Karamojong (the local language). In case of lack of clarity, immediate clarification was sought. The main topics included in the question guide were: i) traditional practices and beliefs during delivery; ii) family support and decision making on health services during delivery; iii) the role of TBAs; iv) perceived quality of care and fee for services used; v) obstacles when using trained attendants’ services; vi) experience of delivery (including the services provided by the delivery attendants); and vii) reasons for a delivery outside a health care facility. Matrix ranking was performed by asking participants to list main reasons why women in the village don’t deliver in health facilities. Participants were then asked to use stones to assign a score to each reason to reflect the relative weight of the reason in preventing women from using skilled birth attendants. One stone represented a weight of one. A literate member in the group facilitated the scoring exercise which was done by consensus among group members. Locally prepared refreshments were provided at the end of PRA sessions. No cash incentives were provided. This study was approved by the National Bioethics Committee at Uganda National Council for Science and Technology and by the Moroto District Health Management Team. Because most PRA participants were illiterate, and given that they participated in the study in groups, verbal informed consent was obtained from each PRA group after an explanation about the study. Data were analysed using deductive content analysis [24]. At the end of each PRA session, the study team reviewed, edited and harmonized the notes taken. They then read through the notes several times, triangulated the data collected from men and women groups, identified and coded all recurring issues by consensus and summarized them in a table. The issues were grouped under four themes in an adapted framework: (1) socio-cultural factors, (2) perceived benefit/need of skilled attendance, (3) economic inaccessibility and (4) physical inaccessibility [10]. The themes formed the framework for reporting. Scores from matrix ranking were summarized using a spider plot to reflect the perceived relative significance of each barrier identified by participants in preventing utilization of delivery services. Scores for each barrier at each site were rescaled to take values of 0–5 and then summed up.

Materiais

N/A

Inovações

Based on the information provided, here are some potential innovations that could improve access to maternal health in the Karamoja region of Uganda:

1. Mobile health clinics: Implementing mobile health clinics that can travel to remote areas, including mountainous regions, to provide maternal health services. This would help overcome the barrier of long distances to health facilities.

2. Telemedicine: Introducing telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video calls or phone calls. This would provide access to medical advice and support without the need for physical travel.

3. Community-based education programs: Developing community-based education programs that raise awareness about the importance of skilled attendance at delivery and the risks associated with home births. This would help address socio-cultural factors that influence women’s decision to deliver at home.

4. Improving infrastructure: Investing in improving the infrastructure of health facilities in the region, including ensuring the availability of basic supplies, drugs, and equipment. This would address the barrier of poor quality of care at health facilities.

5. Collaborative model with traditional birth attendants (TBAs): Establishing a collaborative model between skilled health workers and TBAs to increase institutional deliveries. This would involve training TBAs on safe delivery practices and integrating them into the formal healthcare system.

6. Financial incentives: Introducing financial incentives for women to deliver in health facilities, such as providing transportation allowances or covering the cost of delivery services. This would help address economic barriers to accessing maternal health services.

7. Improving road infrastructure: Working on improving road infrastructure, especially during rainy seasons, to ensure that health facilities are accessible by motor vehicles. This would help overcome physical inaccessibility barriers.

These are just a few potential innovations that could be considered to improve access to maternal health in the Karamoja region. It is important to conduct further research and engage with local communities to identify the most suitable and effective strategies for addressing the specific barriers identified in the study.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health in the Karamoja region of Uganda is to implement a comprehensive approach that addresses both demand and supply side barriers. This approach should involve a multi-sectorial collaboration to tackle the main barriers, which are outside the scope of the health sector.

Some specific recommendations based on the barriers identified in the study include:

1. Addressing insecurity: Implement measures to improve security in the region, such as increased police presence and community policing initiatives.

2. Addressing poverty: Develop programs that provide economic support to pregnant women and their families, such as cash transfer programs or income-generating activities.

3. Addressing socio-cultural factors: Conduct community sensitization and education programs to address cultural beliefs and practices that hinder the utilization of institutional delivery services. Engage community leaders and traditional birth attendants (TBAs) in these programs.

4. Improving infrastructure and supplies: Invest in improving the infrastructure of health facilities in the region, including ensuring the availability of essential supplies, drugs, and basic infrastructure for maternal health services.

5. Enhancing the quality of care: Train and support healthcare providers to deliver high-quality maternal health services. Implement monitoring and evaluation systems to ensure the provision of quality care.

6. Promoting participation in planning: Involve community members, especially women, in the planning and decision-making processes related to maternal health services. This can be done through community engagement activities and the establishment of community health committees.

7. Collaboration between skilled health workers and TBAs: Develop a model for collaboration between skilled health workers and traditional birth attendants to increase institutional deliveries. This can involve training TBAs on safe delivery practices and referral systems.

It is important to note that these recommendations should be tailored to the specific context of the Karamoja region and take into account the cultural, social, and economic factors that influence maternal health utilization in the area.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations for improving access to maternal health in the Karamoja region:

1. Strengthen security measures: Addressing the issue of insecurity in the region is crucial to ensure the safety of pregnant women and healthcare providers. This can be done through increased law enforcement presence, community engagement, and awareness campaigns.

2. Enhance economic opportunities: Poverty was identified as a barrier to accessing maternal health services. Implementing programs that promote income generation and economic empowerment for women and their families can help alleviate this barrier.

3. Address socio-cultural factors: Cultural beliefs and practices can influence the decision to utilize institutional delivery services. Engaging with community leaders, traditional birth attendants, and influential individuals to promote the importance of skilled attendance at birth can help overcome these barriers.

4. Improve transportation infrastructure: Long distances and difficult terrain were identified as challenges in accessing healthcare facilities. Investing in transportation infrastructure, such as roads and ambulances, can help improve access to maternal health services.

5. Enhance healthcare facilities: Lack of supplies, drugs, and basic infrastructure at health facilities were identified as barriers. Ensuring that healthcare facilities are well-equipped and adequately staffed can improve the quality of care and encourage women to seek institutional delivery services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Baseline data collection: Gather information on the current utilization of maternal health services, including the number of deliveries taking place in health facilities, distance to the nearest health facility, and the availability of essential supplies and infrastructure.

2. Define indicators: Identify specific indicators that will measure the impact of the recommendations, such as the percentage increase in institutional deliveries, the reduction in travel time to health facilities, and the availability of essential supplies.

3. Develop a simulation model: Create a model that incorporates the identified recommendations and their potential impact on the defined indicators. This model should consider factors such as population size, geographical distribution, and existing healthcare infrastructure.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations. Adjust the parameters of the recommendations (e.g., the level of investment in transportation infrastructure) to observe different scenarios.

5. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. Compare the different scenarios to identify the most effective strategies.

6. Refine and validate the model: Continuously refine the simulation model based on feedback and additional data. Validate the model by comparing the simulation results with real-world data and observations.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different recommendations on improving access to maternal health in the Karamoja region. This information can guide decision-making and resource allocation to effectively address the identified barriers.

Autor

Dima Health

Statistics:

Citations: 47

Identifiers:

DOI: 10.1186/1471-2393-14-259

Research Areas:

Community Interventions, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Technology and Innovations, Workforce

Study Countries:

Kenya, Multi-Countries, Uganda

Study Design:

Cross Sectional Study, Exploratory Study, Grounded Theory, randomised-control-trial

Study Approach:

Qualitative

Participants Gender:

Male & Female

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