Determinants of facility based–deliveries among urban slum dwellers of Kampala, Uganda

  • PLoS ONE, Volume 14, No. 4, Year 2019

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Study Justification:
The study aimed to investigate the determinants of facility-based deliveries among women in urban slums of Kampala city, Uganda. This is important because facility-based deliveries are a proxy for skilled birth attendance, which is crucial for reducing maternal and neonatal mortality. Understanding the factors that influence facility-based deliveries can help inform interventions and improve maternal and child health outcomes in urban slum areas.
Highlights:
– 66.1% of women in urban slums of Kampala delivered in a health facility.
– Factors associated with facility-based deliveries included exposure to media concerning facility delivery, attending less than 4 antenatal care visits, and late initiation of antenatal care.
– Increasing awareness about facility deliveries, starting antenatal care early in pregnancy, and attending at least 4 antenatal care visits can help improve health facility births among slum dwellers.
Recommendations:
Based on the study findings, the following recommendations can be made:
1. Implement interventions to increase awareness about the benefits of facility-based deliveries among women in urban slums.
2. Promote early initiation of antenatal care and encourage women to attend at least 4 antenatal care visits.
3. Strengthen the availability and accessibility of health facilities in urban slums to accommodate the increasing population and demand for maternal and child health services.
Key Role Players:
1. Ministry of Health: Responsible for developing and implementing policies and programs related to maternal and child health.
2. Local Government Authorities: Responsible for coordinating and overseeing health services delivery at the local level.
3. Health Facility Staff: Including doctors, nurses, midwives, and other healthcare providers who play a crucial role in delivering quality maternal and child health services.
4. Community Health Workers: Engaged in community outreach and education to promote facility-based deliveries and antenatal care attendance.
5. Non-Governmental Organizations: Involved in implementing interventions and providing support for maternal and child health programs.
Cost Items for Planning Recommendations:
1. Awareness Campaigns: Budget for media campaigns, community outreach activities, and materials to promote awareness about facility-based deliveries.
2. Training and Capacity Building: Allocate funds for training healthcare providers on best practices for antenatal care and delivery services.
3. Infrastructure Development: Invest in the construction and renovation of health facilities in urban slums to improve accessibility and capacity.
4. Equipment and Supplies: Ensure availability of necessary medical equipment, supplies, and medications for safe deliveries.
5. Monitoring and Evaluation: Allocate resources for monitoring and evaluating the implementation and impact of interventions on facility-based deliveries.
Please note that the cost items provided are general categories and the actual cost will depend on the specific context and scale of the interventions.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study utilized quantitative methods and a cross-sectional design, which allows for the examination of associations between variables. The sample size of 420 participants is relatively large, increasing the generalizability of the findings. The study also used multivariable logistic regression analysis to determine independent predictors of facility-based deliveries. However, the abstract does not provide information on the representativeness of the sample or the response rate, which could affect the validity of the results. To improve the strength of the evidence, future studies should ensure a representative sample and report the response rate. Additionally, incorporating qualitative methods could provide a more comprehensive understanding of the determinants of facility-based deliveries among urban slum dwellers.

Background Delivery in health facilities is a proxy for skilled birth attendance, which is an important intervention to reduce maternal and neonatal mortality. We investigated the determinants of facility based deliveries among women in urban slums of Kampala city, Uganda. Methods A cross sectional study using quantitative methods was used. A total of 420 mothers who had delivered in the past one year preceding the survey, were randomly selected and interviewed using a pre-tested interviewer administered questionnaire. Univariate and multivariable logistic regression analysis was done to determine independent predictors of facility based deliveries. Results Ninety-five percent of respondents attended at least one antenatal care visit and 66.1% delivered in a health facility. Independent predictors of health facility births included exposure to media concerning facility delivery (OR = 2.5, 95% CI = 1.6–3.9), ANC attendance less than 4 times (OR = 0.6, 95% CI = 0.3–0.9) and timing of first ANC visit in the 2 and 3rd trimesters of pregnancy (OR = 0.5 95% CI = 0.3–0.8). Conclusion Despite good physical access, a third of mothers did not deliver in health facilities. Increasing health facility births among the slum dwellers can be improved through interventions geared at increased awareness, starting ANC in early stages of pregnancy and attending at least 4 ANC visits.

This was a cross sectional study with quantitative methods of data collection. The study was carried out between August and September 2014 in Kampala Central division, Uganda. Kampala is the capital and largest city of Uganda. It is administratively divided into 5 divisions, (Kampala Central, Nakawa, Kawempe, Lubaga and Makindye division), with the total population of 1.5million according to National census of 2014. It accommodates 45% of all urban residents in Uganda and it has a 3.2% population growth rate which has a significant impact on the capacity to plan and deliver services including health services[24]. The city has experienced a population boom in the past years thus compromising the health system. According to the UDHS, the majority of people residing in Kampala are job seekers with a high dependency ratio of 31%. Children under 5 and women of reproductive age (44.6%) comprise nearly half the population of Kampala. These trends have resulted in unprecedented growth of slums and unplanned settlements on the periphery of most towns which is likely to undermine global improvement in maternal and child health if the needs of urban women are not addressed. The study was conducted in 4 parishes in Kampala Central Division. Kampala city houses the largest urban slums; lying on 14.6sq.km, and administratively divided into 20 Parishes and 135 zones with a population of 90,392. The study area is served by Mulago Hospital, which doubles as the National referral hospital. The population consisted of women aged between 15–49 years, who gave birth in twelve months preceding the study. Sample size was calculated using Kish Leslieformula, 1995 for cross sectional studies. In total 420 participants were interviewed. Random sampling was used for selection of eligible women who had delivered a live baby in the past one year in Kampala Central Division. At Parish level, 4 parishes were purposively selected because they house urban slums according to classification by Kampala City Council Authority and these parishes had 28 zones altogether. A list of all zones in these parishes was obtained and simple random sampling method was used to select zones to be included in the study. Zone names per parish were written on pieces of paper, folded and put in a box for the researcher to blindly select the required zones. Therefore each zone within a parish had an equal chance of being included in the study. In total 22 zones were selected, two fromKamwokya I Parish, nine fromKamyokya II parish, nine from Kisenyi II parish and two from Kisenyi I parish. The sample size was distributed to the selected zones proportionate to the size of their population. At the zone level, households were selected by systematic random sampling based on sampling frame (list of households) obtained from the chairman of the village (LCI). The sampling interval of the households in each zone was determined by dividing the total number of households to the allocated sample size. If more than one eligible woman were encountered in the household, papers were folded and put down for mothers to choose, in order to determine the woman to be interviewed. When no eligible woman was identified in the selected house hold, the next selected household was the nearest and the same inclusion criteria was applied. The study was reviewed and approved by the ethics committee at Makerere University School of Public Health Higher Degrees Research and Ethics Committee (HDREC). Permission was got from Local authorities and study subjects were informed about the purpose of the study, their right to refuse and to withdraw. Informed written consent was obtained from each subject before data collection. Confidentiality of the data were kept by avoiding personal identifier and data was kept in a locked room only accessed by the principal investigator. Andersen’s Behavioral Model of Health Services Utilization was used as the conceptual framework[25]. This model has been used widely in both high and middle income countries to understand health services utilization. The model classifies factors that affect health services utilization into three categories: individual, health facility and need factors. The conceptual framework shows how different factors interplay to influence use and non use of health facilities. Quantitative data were collected usinga structured questionnaire.Interviews were done in the local language (luganda) by trained research assistants. These received training for five days and the content of training included description of study objectives, methods of data collection and sampling techniques. The questionnaire was divided into four major sections; namely; socio-demographics, ANC attendance, labor and delivery and health facility factors. Questionnaires were prepared in English, translated into the local language and back to English to verify if translation reflected the original meaning in English. Research tools were pre-tested from one community in Kampala with similar characteristics as study population. Some questions were refined in a debrief session. Written consent was obtained from respondents before administration of the questionnaire. Interviewstook place on verandas and sometimes inside the house and lasted for an average of 45 minutes. We took measures to ensure that only the respondent was present during the interview. Each research assistant was supervised once during sessions to observe how the sessions were conducted. Meetings were held to address problems and clarify issues that hampered collection of good data with assistants found to have problems. Checking for accuracy of completed data on questionnaires and notebooks was done at the end of each day of data collection and gaps identified. Data were double entered into the computer using EPI data which allowed the setting up of proper “skip rules” and “range checks” during data entry, so that errors during data entry were minimized.Data cleaning were done after data entry by running means and checking for out of range values.Data were exported to Stata 12 software for analysis and data exploration was done to visualize the general feature of the data. Simple cross tabulation and chi square test were used for examining the bivariate relationship between the dependent variable and independent variables. The data were expressed in percentages and frequencies (means) at univariable analysis to describe some important characteristics of respondents. Bivariable analysis using logistic regression technique was done to get the crude association between the independent variables and the dependent variable. The strength of association between dependent variable and independent variables (covariates) was expressed using odds ratios (OR).Finally multivariable analysis using backward elimination regression technique was done to evaluate independent effect of each variable on health facility delivery by controlling the effect of others. Socio economic variables such as household income, wealth status, level of poverty, residential neighborhood (socio-structure) were controlled for at multivariate because they are strong confounders of health facility deliveries.

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 urban slums and provide maternal health services, including antenatal care and delivery services, could improve access for women who may have difficulty accessing traditional health facilities.

2. Community health workers: Training and deploying community health workers in urban slums could help increase awareness about the importance of facility-based deliveries and provide education on antenatal care. Community health workers could also provide support and guidance to pregnant women throughout their pregnancy and help them navigate the healthcare system.

3. Telemedicine: Using telemedicine technology, healthcare providers could remotely provide consultations and support to pregnant women in urban slums. This could help address barriers such as transportation and distance to health facilities.

4. Financial incentives: Implementing financial incentives, such as cash transfers or vouchers, for women who choose to deliver in health facilities could help incentivize facility-based deliveries and reduce financial barriers.

5. Improving infrastructure: Investing in the improvement of health facilities in urban slums, including ensuring they have adequate staffing, equipment, and supplies, could help increase the attractiveness and accessibility of facility-based deliveries.

6. Public awareness campaigns: Conducting public awareness campaigns to educate the community about the benefits of facility-based deliveries and the importance of antenatal care could help increase demand for these services.

These are just a few potential innovations that could be considered to improve access to maternal health in urban slums. It’s important to note that the specific context and needs of the community should be taken into account when implementing any innovation.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health would be to implement interventions that focus on increasing awareness, promoting early initiation of antenatal care (ANC), and encouraging women to attend at least four ANC visits. This recommendation is based on the findings of the study, which identified exposure to media concerning facility delivery, ANC attendance less than four times, and late initiation of ANC visits as independent predictors of facility-based deliveries.

To increase awareness, health education campaigns can be conducted through various media channels, such as radio, television, and community outreach programs. These campaigns should emphasize the importance of delivering in a health facility and the benefits of skilled birth attendance for both the mother and the newborn.

To promote early initiation of ANC, efforts should be made to ensure that women are aware of the recommended timing for their first ANC visit, which is ideally in the first trimester of pregnancy. This can be achieved through community health workers, antenatal clinics, and community-based organizations that provide information and support to pregnant women.

To encourage women to attend at least four ANC visits, barriers to accessing ANC services need to be addressed. These barriers may include financial constraints, lack of transportation, and cultural beliefs. Strategies such as providing financial assistance for ANC visits, improving transportation options, and engaging community leaders and influencers to promote the importance of ANC can help overcome these barriers.

By implementing these interventions, it is expected that the proportion of facility-based deliveries among urban slum dwellers in Kampala, Uganda will increase, leading to improved maternal and neonatal outcomes.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Increase awareness: Implement interventions to increase awareness about the importance of facility-based deliveries among women in urban slums. This can be done through community outreach programs, health education campaigns, and the use of media to disseminate information.

2. Early initiation of antenatal care (ANC): Encourage women to start ANC visits in the early stages of pregnancy. This can be achieved by providing information about the benefits of early ANC and addressing any barriers that may prevent women from seeking care early on.

3. Increase ANC attendance: Promote the importance of attending at least four ANC visits during pregnancy. This can be done through targeted messaging, reminders, and incentives to encourage women to complete the recommended number of visits.

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

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the percentage of facility-based deliveries, ANC attendance rates, and timing of first ANC visit.

2. Collect baseline data: Gather data on the current status of these indicators among women in urban slums of Kampala city, Uganda. This can be done through surveys, interviews, or existing data sources.

3. Develop a simulation model: Create a simulation model that incorporates the identified determinants of facility-based deliveries. This model should take into account factors such as awareness, ANC attendance, and timing of ANC visits.

4. Input data and run simulations: Input the baseline data into the simulation model and run simulations to estimate the potential impact of the recommended interventions. This can be done by adjusting the values of the determinants and observing the resulting changes in the indicators.

5. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This can include quantifying the expected increase in facility-based deliveries, ANC attendance rates, and timing of ANC visits.

6. Validate and refine the model: Validate the simulation model by comparing the simulated results with real-world data. Refine the model as needed to improve its accuracy and reliability.

7. Communicate findings: Present the findings of the simulation study to relevant stakeholders, such as policymakers, healthcare providers, and community leaders. Use the results to advocate for the implementation of the recommended interventions and inform decision-making processes.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available resources.


Statistics:
Citations: 15
Identifiers:
DOI: 10.1371/journal.pone.0214995
Research Areas:
Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Uganda
Study Design:
Cross Sectional Study, Grounded Theory, Phenomenological Study, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Female
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