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Background: Promotion of birth preparedness and raising awareness of potential complications is one of the main strategies to enhance the timely utilisation of skilled care at birth and overcome barriers to accessing care during emergencies. Objective: This study aimed to investigate factors associated with birth preparedness in three districts of eastern central Uganda. Design: This was a cross-sectional baseline study involving 2,010 women from Iganga [community health worker (CHW) strategy], Buyende (vouchers for transport and services), and Luuka (standard care) districts who had delivered within the past 12 months. ‘Birth prepared’ was defined as women who had taken all of the following three key actions at least 1 week prior to the delivery: 1) chosen where to deliver from; 2) saved money for transport and hospital costs; and 3) bought key birth materials (a clean instrument to cut the cord, a clean thread to tie the cord, cover sheet, and gloves). Logistical regression was performed to assess the association of various independent variables with birth preparedness. Results: Only about 25% of respondents took all three actions relating to preparing for childbirth, but discrete actions (e.g. financial savings and identification of place to deliver) were taken by 75% of respondents. Variables associated with being prepared for birth were: having four antenatal care (ANC) visits [adjusted odds ratio (ORA) = 1.42; 95% confidence interval (CI) 1.10-1.83], attendance of ANC during the first (ORA = 1.94; 95% CI 1.09-3.44) or second trimester (ORA = 1.87; 95% CI 1.09-3.22), and counselling on danger signs during pregnancy or on place of referral (ORA = 2.07; 95% CI 1.57-2.74). Other associated variables included being accompanied by one’s husband to the place of delivery (ORA = 1.47; 95% CI 1.15-1.89), higher socio-economic status (ORA=2.04; 95% CI 1.38-3.01), and having a regular income (ORA = 1.83; 95% CI 1.20-2.79). Women from Luuka and Buyende were less likely to have taken three actions compared with women from Iganga (ORA = 0.72; 95% CI 0.54-0.98 and ORA = 0.37; 95% CI 0.27-0.51, respectively). Conclusions: Engaging CHWs and local structures during pregnancy may be an effective strategy in promoting birth preparedness. On the other hand, if not well designed, the use of vouchers could disempower families in their efforts to prepare for birth. Other effective strategies for promoting birth preparedness include early ANC attendance, attending ANC at least four times, and male involvement.
This study used a cross-sectional design in three districts (Buyende, Luuka, and Iganga) of the eastern central region of Uganda. The total fertility rate in this region is above the national average (3). Almost a quarter (24%) of 15–19-year-old females are pregnant or have a child, and 42% of women have an unmet need for family planning (3). During ANC visits just 32% of women are counselled about pregnancy-related DS; 67% deliver with the assistance of health professionals; and 29% have a postnatal check within 22 days of delivery (3). The three districts were selected because they were close to each other, have people who speak the same language, and have similar cultural practices. However, Iganga has about 4% of its population classified as semi-urban as opposed to the other two that are completely rural (Table 1). Demographic and healthcare characteristics for the three study districts MNC=maternal and newborn care. Buyende district had been home to the Safe Deliveries Study, which promoted access to care through use of vouchers (14). Pregnant women received vouchers for health services (to deliver in the nearest health facility, to attend ANC, and for postnatal care); and for transportation (to use local means, e.g. motorcycle, bicycle) to reach health facilities for ANC, delivery, and one postnatal care visit. The package promoted was comprehensive and included counselling on preparation for childbirth, but in practice was dominated by the vouchers. Provision of these vouchers removed access barriers and led to significantly increased use of maternal, newborn, and obstetric care services (14). Iganga district was the setting of the Uganda Newborn Study (UNEST) which employed CHWs to promote maternal and newborn care through making home visits (12). CHWs conducted five home visits: two during the pregnancy, and three during the first week after delivery. During each pregnancy visit, CHWs counselled and showed women and families items they needed to have or steps to take as part of their birth preparations. In addition, they informed women about DS during pregnancy, and if present, the CHWs referred women to a health facility. On subsequent visits CHWs followed up how many and which actions had been taken to prepare for childbirth (12). Luuka district had no additional intervention beyond the standard of care provided by the routine package of the Ministry of Health. Multistage sampling was performed by selecting parishes at the subcounty level and then villages within these parishes. In total, 17 parishes and 39 villages were included in the study (Fig. 1). Buyende had five subcounties and one parish was randomly selected. From each parish, subsequently three villages were chosen and about 53 mothers were interviewed from each village. Luuka had seven subcounties and seven parishes randomly chosen; in each parish two villages were selected for interviewing (about 56 mothers from each village). In Iganga, we randomly selected five parishes from five subcounties; and two villages per parish were picked (about 40 mothers from each village). Sampling procedure in three study districts in eastern central Uganda. All women who had delivered a child in the past 12 months and were living in one of the selected villages were listed and selected. Exclusion criteria included a woman being ill at the time of the study, but we found none fitting that criterion. In total, 2,011 women were interviewed, but one woman was excluded from further analysis due to lack of data on outcome variables. Informed consent was obtained from the participants. The study was approved by the Makerere University School of Public Health Institutional Review Board and the Uganda National Council of Science and Technology. A structured questionnaire with information on ANC, delivery and postnatal care, family planning, socio-demographic factors, and socio-economic data was used. The survey tool was translated into the local Lusoga language and was piloted and changed accordingly. The questionnaire was created following validated JHPIEGO guidelines (9). Thirty locally recruited field assistants with a minimum of secondary school education underwent a 3-day training (including 1 day of piloting) on data collection. Each interview lasted for about an hour. Data were collected from October 2011 to January 2012. Data were coded, entered, cleaned, and analysed using SPSS version 21.0 (17). A ‘birth prepared’ woman was defined as a woman who had taken three actions at least 1 week prior to the delivery: 1) chosen where to deliver; 2) saved money for transport and hospital costs; and 3) bought key birth materials (razor, thread, cover sheet, and gloves). These actions do not constitute the sum total of possible activities related to birth preparedness, but were chosen for analysis purposes and because they aligned with messages promoted in the three different settings during pregnancy. If the respondent or her husband’s main occupation was running a business or having salaried work, then she was coded as having ‘regular income’. On the other hand, if the main occupation of both respondent and husband was having a daily-wage job or being a farmer, then she was coded as having ‘irregular income’. Marital status was dichotomised within the categories ‘married’ and ‘not married’; widows, single, and divorced women belonged to the latter group. Education had three categories: ‘no formal education’, ‘primary’ which included finished or started primary schooling, and ‘secondary’ which contained secondary and higher schooling. The age groups of respondents were stratified as follows: under the age of 19 (less experienced women); 20–39 years old; older than 40 years (women who are experienced, but might be already in a risk group); and women who did not know their age. The following were the independent variables: district, number of household members, number of children, sequence of pregnancy, marital status, mother’s age group, religion, mother’s education, husband’s education, mother’s income, husband’s income, receiving information about DS, number of ANC visits, trimester during which the first ANC visit was undertaken, receiving care from a healthcare provider during the pregnancy, quintile of asset ownership, decision maker, and accompanied by husband to the place of delivery. For logistical reasons, no further verification of responses was done. First, absolute and relative frequencies for all categorical dependent and independent variables were calculated. Second, the relationship between the outcome (birth preparedness) and selected independent variables was tested by Pearson’s Chi-square test. Subsequently, all variables with p value<0.2 were inserted in a stepwise logistical regression model to investigate the association by obtaining the adjusted odds ratios (ORA) with 95% confidence intervals (CIs), thereby adjusting for confounders and effect modifiers likely to influence the outcomes. Absence of multi-colinearity between independent variables in the final model was tested and confirmed. Four different multivariable logistical regression models were tested: all cases together and one for each of the three study districts separately.
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