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Background: Armed conflict potentially poses serious challenges to access and quality of maternal and reproductive health (MRH) services, resulting in increased maternal morbidity and mortality. The effects of armed conflict may vary from one setting to another, including the mechanisms/channels through which the conflict may lead to poor access to and quality of health services. This study aims to explore the effects of armed conflict on MRH in Burundi and Northern Uganda. Methods: This is a descriptive qualitative study that used in-depth interviews (IDIs) and focus group discussions (FGDs) with women, health providers and staff of NGOs for data collection. Issues discussed include the effects of armed conflict on access and quality of MRH services and outcomes, and the mechanisms through which armed conflict leads to poor access and quality of MRH services. A total of 63 IDIs and 8 FGDs were conducted involving 115 participants. Results: The main themes that emerged from the study were: armed conflict as a cause of limited access to and poor quality of MRH services; armed conflict as a cause of poor MRH outcomes; and armed conflict as a route to improved access to health care. The main mechanisms through which the conflict led to poor access and quality of MRH services varied across the sites: attacks on health facilities and looting of medical supplies in both sites; targeted killing of health personnel and favouritism in the provision of healthcare in Burundi; and abduction of health providers in Northern Uganda. The perceived effects of the conflict on MRH outcomes included: increased maternal and newborn morbidity and mortality; high prevalence of HIV/AIDS and SGBV; increased levels of prostitution, teenage pregnancy and clandestine abortion; and high fertility levels. Relocation to government recognised IDP camps was perceived to improve access to health services. Conclusions: The effects of armed conflict on MRH services and outcomes are substantial. The mechanisms through which armed conflict leads to poor access and quality of MRH services vary from one setting to another. All these issues need to be considered in the design and implementation of interventions to improve MRH in these settings.
Data was collected from two provinces in Burundi, namely Bujumbura Marie and Ngozi and Gulu district in Northern Uganda. Participants in Burundi were recruited from the cities of Bujumbura and Ngozi and the communes of Ruhororo and Kinama, while in Gulu, participants were recruited from the sub-counties of Koro, Bobi and Bungatira and Gulu municipality (made up of four sub-counties: Pece, Layibi, Bar-dege, and Laroo). Study participants were recruited from staff members of local and international non-governmental organizations (NGOs) and local health providers (nurses, midwives, doctors and senior administrators) working in the domain of MRH, and women of reproductive age, living in rural and semi-urban areas. Since we were interested in capturing the effect the conflict had on MRH outcomes and services, the NGOs and health providers invited to participate in the study had developed, supported and/or provided such services during the conflict, while the women had lived in the area during the crisis. This is a descriptive and explanatory qualitative study that used semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs) for data collection. Interviews and FGDs were conducted in the local languages, French or English (where applicable) by the principal investigator (PCC) or trained local research assistants. Prior to the study, our target number of interviews and FGDs in each of the study sites was 10 IDIs and 1 FGD for each category of study participants. However, while on the field we observed that it will be logistically challenging to organise one FGD for our women category of participants, who live in different counties or communes. As such, we decided to organise two FGDs for these women in each of our study areas, with each FGD comprising of women living in the same county or commune. Data collection was therefore stopped when we had attained the target number of interviews and FGDs. A total of 63 IDIs and 8 FGDs were conducted. The fieldwork took place from June – September 2013. The interviews and FGDs focused specifically on how the past armed conflict affected the general state of MRH, in the process exploring the negative consequences the conflict had on MRH services and the various channels through which the conflict led to limited access to and poor quality of health services. A sample of some of the questions posed to the respondents included: ‘How did the war affect the accessibility to, affordability of and quality of MRH services?; Describe some eyewitness accounts of the negative consequences of the war on MRH; Can you describe your experience in accessing MRH services at your local health facility: (a)before, (b)during and (c)after the war?’ The detailed guides for the interviews and FGDs for each of the participant categories have been published elsewhere [20]. Interviews and FGDs with local health providers typically lasted from 50 – 130 minutes while those for the women lasted from 35 – 90 minutes. All interviews and FGDs were audio-recorded and later transcribed and translated into English (where applicable). Three team members open-coded the transcripts on QSR Nvivo (QSR International, 2012) and Microsoft® Word (where the texts of interest are highlight and the code first labeled using the ‘New Comment’ sub-menu under the ‘Review’ menu). Microsoft® Word was used for coding and analysis by one of the co-authors who did not have access to Nvivo. The codes were descriptions or labels of specific ideas as the transcripts were read. Two team members reviewed the codes that were developed and the inter-coder reliability was high. Inter-related or similar codes were then clustered into different categories, and the categories were subsequently grouped into specific themes. We used the framework method [21], combining both the deductive and inductive approaches in the data. This allowed us to explore the main themes covered in the interviews and FGDs while being open to other unexpected aspects of participant experiences. There was therefore a constant interplay between data collection, analysis and theme development, where re-occurring unexpected themes were further explored in subsequent interviews and FGDs. Ethics and administrative approvals were obtained from the relevant authorities in Norway, Burundi, and Uganda. Ethics approval for the study was obtained from the following ethics committees: Regional Committee for Medical and Health Research Ethics, South-East (Norway), ‘le Comité National d’Ethique pour la Protection des êtres Humains Participant à la Recherche Biomédicale et Comportementale’ (Burundi), and Gulu University Institutional Review Committee (Uganda). All participants gave their informed consent before participating in the study and their anonymity, privacy and confidentiality was respected. Written or oral consent were appropriate and acceptable for our settings and approved by the relevant ethics committees. The detailed and comprehensive methodology of the study, compliant with the COREQ and RATS reporting guidelines can be found at the additional file section below (Additional file 1).
