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Maternal nutrition during pregnancy affects the health of the mother and baby. The objective of this paper is to describe the maternal nutrition education offered by midwives to women attending an antenatal clinic. The study also examined the resources, support, and the needs of the midwives in offering the nutrition education. Six in-depth interviews with the midwives, six direct structured observations of the group education, and 12 one-on-one interactions of midwife and pregnant women observations were completed. The interviews and field observation notes were typed and analyzed using the latent content analysis. The emerging themes were the maternal nutrition education and the education needs of the midwives. The content and presentation of maternal nutrition were inadequate in scope and depth. The maternal nutrition education was offered to only pregnant women attending the first antenatal care visit. The routine antenatal education session lasted 45 minutes to 1 hour, covering a variety of topics, but the nutritional component was allotted minimal time (5-15 minutes). The organization, mode of delivery, guidelines, resources, and service environment were extremely deficient. The relevance of appropriate weight gain during pregnancy, guidelines for healthy habits, avoidance of substance abuse, and nutrition precautions in special circumstances was missing in the nutrition presentation. Information, maternal nutrition education resources, infrastructure, and health system gaps were identified. There was an inefficient nutrition education offered to the pregnant women attending the antenatal clinic. As means of promoting effective nutrition education, appropriate in-service training, mentorship, and support for the midwives are needed, as well as infrastructural and resource provision.
A qualitative description approach was used based on the fact that there were high levels of uncertainty about the current education intervention and very little existing research on prenatal nutrition education in Uganda and at the same time limited resources to conduct the study [23]. The authors conducted six in-depth interviews with midwives who were involved in the direct care of the pregnant women at the ANC clinic. In-depth interviews are useful and appropriate for obtaining detailed information about a person’s thoughts and behaviors and often provide context to other data [24, 25]. In addition to the in-depth interviews, nonparticipant-structured observations of the nutrition education sessions during the routine ANC visits were conducted. The study included sessions conducted by the midwives, and this was the routine at the clinic. The observations included six group education sessions and twelve one-on-one interactions between the midwives and the pregnant women during the physical examination in the antenatal clinic. The study was conducted at an ANC clinic at a referral and teaching hospital in Uganda, and it is one of the busiest maternity units in the country. The ANC is offered to women of various ethnicities, socioeconomic classes, and religions. The clinic operated from Monday to Friday from 8:00 am to 5:00 pm. It offered antenatal services including HIV counseling and testing, syphilis screening, health education that included nutrition education, screening, and examination, and referral services. The clinic was structured in two sections: a low-risk unit which was attended by women with good obstetrical history and a high-risk unit which was attended by women with poor obstetrical history. The clinic is predominantly staffed by midwives. At the time of the study, a total of 2,155 mothers had attended the antenatal clinic between January and March 2015, and the clinic had 29 midwives. In this study, the researchers looked out for any set of planned educational activities that involved teaching pregnant women about nutrition, providing educational materials that reinforced messages about healthy eating, taught nutritional skills essential for making a dietary change, and provided information on how to sustain the changed behavior. Group nutrition education included sessions where the midwife gave nutrition education to a group of pregnant women attending ANC. One-on-one interactions included an interface between a midwife and a pregnant woman with the intention of antenatal nutritional education [26]. The group education session observations were conducted in the morning hours of the antenatal clinic and the one-on-one interactions between women and the midwives continued throughout the day. The observations recorded information on the hospital education environment, organization of the sessions, conduct of the sessions, content of the nutrition class, evidence of planning and preparations for the education activities, documentation done by the midwife of the nutrition education activities, and the resources and the information education and communication (IEC) materials available at the clinic. The observations also included verbal behavior, body language, and objects or resources used during the nutrition education sessions. Midwives were observed during the formal teaching, during the informal teaching, and during the examination of the pregnant women. The researchers observed 6 group education sessions, and each of the midwives was observed at least twice during the informal education or examination sessions. The midwives conducted the education sessions in the local language, and however, the notes taken by the researcher were in English, and the researcher was well conversant with the local language and was able to take notes in English. The in-depth interviews were conducted in English. In-depth interviews and observation were conducted in January and February 2016. The researchers introduced themselves to the area managers and the in-charge nurse of the hospital antenatal care clinic. The purpose and procedure of the study were explained to the midwives in order to obtain permission for conducting the study in the clinic. After informed written consent was obtained, the researcher together with the midwife identified a time that was convenient for the in-depth interviews. An open-ended in-depth interview guide was used for data collection. This majorly focused on how the sessions are given, and the midwives’ challenge in giving the nutrition education. An appropriate time and setting for the interview were identified by the participant. The in-depth interview lasted between 30 and 60 minutes, the interviews were tape recorded, and the notes were also taken. A structured nonparticipant observer method allowed the researcher to look for specific behavior without interfering in the education sessions. The observer was visible and known to the study participants. Ethical review and approval were obtained from the Makerere School of Health Sciences research ethics committee (REF: 2015–026). The hospital gave the researchers administrative clearance to conduct the study. Informed written consent was obtained from the study participants. Confidentiality and privacy were maintained throughout the study period. The data collected were strictly for the purpose of this research, which were anonymized in the writing of this article. The audio data will be stored for 5 years after which they will be destroyed. The data files are stored in a computer with a password to allow only access by the researchers. Data from the in-depth interviews were transcribed verbatim. Notes were also taken during the structured observations. Microsoft word files for the interviews and observations notes were created. The files were password protected and were saved in a portable computer only accessible to the researchers. After the Microsoft word files were ready, all the researchers got copies and analysis began at an individual level. After an understanding of the data, the researchers met several times and a group data analysis was also done. The data were analyzed manually using latent content analysis (Hsieh and Shannon, 2005). The researchers used an interview or an observation as the unit of analysis for coding. This means that the data were not coded sentence-by-sentence or paragraph-by-paragraph but coded for meaning [27]. The transcripts were read and re-read by the researchers to develop coding categories, and a code book was developed to ensure consistent application of the final coding categories. The data were then coded independently by the researchers. The codes were later reviewed by the researchers to ensure agreement and consistency of meaning in situations where differences arose. The agreed upon codes were synthesized and grouped into exhaustive subcategories which were then merged into categories/themes. These represented the most common issues that emerged in the interviews and observations [5].
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