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Despite its reduction over the last decade, the maternal mortality rate in Uganda remains high, due to in part a lack of access to maternal health care. In an effort to increase access to care, a quasi-experimental trial using vouchers was implemented in Eastern Uganda between 2009 and 2011. Findings from the trial reported a dramatic increase in pregnant women’s access to institutional delivery. Sustainability of such interventions, however, is an important challenge. While such interventions are able to successfully address immediate access barriers, such as lack of financial resources and transportation, they are reliant on external resources to sustain them and are not designed to address the underlying causes contributing to women’s lack of access, including those related to gender. In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women’s lack of maternal health care access and utilization. Based on emergent findings, a gender analysis of the data was conducted to identify key gender dynamics affecting maternal health and maternal health care. This paper reports the key gender dynamics identified during the analysis, by detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women’s workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women’s attitudes and behaviour during pregnancy, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need for integrating gender into maternal health care interventions if they are to address the root causes of barriers to maternal health access and utilization and improve access to and use of maternal health care in the long term.
This was a cross-sectional study that utilised qualitative data collection methods that comprised of group discussions. Data were collected from the project implementation districts of Pallisa, Kibuku and Kamuli located in Eastern Uganda. These districts were selected to mirror the sites within the original project locations, and to ensure the information collected was representative of all areas. The estimated population in this area is 1 219 172 (UBOS 2012). All of the three districts are rural and the means of living is subsistence farming supplemented by small scale trading in small townships. There were 31 health centre IIIs, four health centre IVs and four district hospitals within this area. The common means of transport to health facilities include walking, using boda boda motorcycles and taxis (commercial vans that sit 14 passengers). Group discussions were held across eight sub counties in three districts in Eastern Uganda, with women who had given birth recently (x16), fathers whose wives had given birth recently (x8) and transport drivers (x8) (Table 1). Female respondents were further disaggregated by age (younger mothers aged 15-25 and older mothers aged 26-55). The female groups were homogenous with respect to age to foster open and free discussions. However, they were heterogeneous with respect to social economic status, disability and positions of responsibility to allow for maximum variation in perspectives. Across all the subgroups, respondents were selected who would be representative of the different levels of social economic status in the community. Social economic status was determined based on commonly used indicators in the community, such as type of housing, education level, occupation and possession of assets, such as land, vehicles and radios. In addition, we included members of the community who held positions of responsibility in different capacities, such as village health team leaders, leaders of community-based organizations and local political structures (local councils), as well as some members of the community with disabilities. Number of group interviews and overview of respondents Respondents were selected with the help of local gatekeepers. For recruitment of mothers and fathers, local leaders were briefed about the kind of respondents needed and helped to identify suitable candidates. Potential respondents were then informed about the study and asked to participate in the group discussions by the study team. Those community members that volunteered were included in discussion groups of 10–15 participants. Similary, as transporters are organized into groups with team leaders at sub-county level, team leaders supported the identification of transporters who could be involved in the discussion groups through a process similar to that of the mothers and fathers. The group discussions included questions related to birth preparedness, transport and quality of care, as the initial intervention identified these as important access and utilization issues. Specifically, respondents were asked questions related to how they prepare for birth, how they save money for use during pregnancy and child birth, how they care for their new born babies, and challenges faced during birth preparedness. Regarding transportation, they were asked about the means of transport that they use to the facility, the state of roads and challenges faced during transportation. Lastly, they were asked about how health workers treat them when they go to seek care for maternal and child health, availability of amenities, drugs, supplies, and infrastructure, as well as barriers to providing quality care. Respondents were also asked to suggest solutions to the problems that they experienced. During these group discussions, researchers used a range of participatory techniques. These included: brainstorming of problems, ranking of problems, facilitated discussions on solutions to problems, creation of a roti diagram depicting solutions, enabling participants to visualize how they could support themselves and areas where support is needed, and feedback discussions. The issues identified in this initial analysis were used to design a maternal and neonatal implementation for equitable systems project (MANIFEST). The project aimed to increase access to maternal and neonatal health services in a more sustainable manner in the three districts using a participatory action research approach. For the gender analysis, transcripts were analyzed using the framework approach, a type of thematic analysis. The framework approach uses a series of steps (indexing, charting, mapping and interpretation) to organize and interpret data and is particularly relevant for policy-orientated research due to its focus on a distinct set of stages (Ritchie and Spencer 1993). Transcripts were reviewed and coded using the themes that were pre-determined by the research team (birth preparedness, quality of care and transport), as well as a gender analysis framework (Table 2) (Morgan et al. 2016). Gender analysis framework: gender as a power relation and driver of inequality The gender analysis framework argues that gender as a power relation and driver of inequality can be understood by how power is constituted and negotiated in relation to access to resources, division of labour, social norms and decision-making. While these factors are presented as distinct categories they interact and reinforce one another, and, as Morgan et al. (2016, p. 3) argue, they “are not static, but are actively fostered, maintained or contested, in intended and unintended ways, as gender power relations […] are negotiated by people and their environments.” The framework was used to explore how gender power relations affect maternal health care access and utilization within these districts. After coding the transcripts, researchers summarized the data into tables and grouped data according to emerging themes and relationships related to the gender analysis framework. Data were analyzed across districts and age groups (in the case of mothers). During the analysis key gender findings emerged upon further examination of the data, which are presented below. During analysis, a distinction was made between gender dynamics that drive inequality, and drivers that have gender implications, such as structural constraints within the health system. For example, while lack of supplies or equipment within health facilities is likely to have a greater impact on women due to their increased use of health facilities, this is a structural constraint that has gender implications. Whereas gendered power relations which inhibit women’s lack of decision-making power about when and where to seek care is a gender dynamic that drives inequality. Ethical clearance for this study was granted from the Makerere University School of Public Health and Uganda National Council for Science and Technology. Permission was also sought from the district health offices of the participating districts. Participation was voluntarily and study details were well explained to the study participants and written consent was obtained. Privacy was ensured and data were kept confidentially with access restricted to only the study investigators and research assistants.
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