Losing women along the path to safe motherhood: why is there such a gap between women’s use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda

Abstract

BackgroundThousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Delivery with a skilled birth attendant is a vital intervention for saving lives. Yet many women, particularly where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. In Uganda, only 58 % of women deliver in a health facility, despite approximately 95 % of women attending antenatal care (ANC).This study aimed to (1) identify key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery; (2) examine the association between advice during antenatal care to deliver at a health facility and actual place of delivery; (3) investigate whether antenatal care services in a post-conflict district of Northern Uganda actively link women to skilled birth attendant services; and (4) make recommendations for policy- and program-relevant implementation research to enhance use of skilled birth attendance services.MethodsThis study was carried out in Gulu District in 2009. Quantitative and qualitative methods used included: structured antenatal care client entry and exit interviews [n = 139]; semi-structured interviews with women in their homes [n = 36], with health workers [n = 10], and with policymakers [n = 10]; and focus group discussions with women [n = 20], men [n = 20], and traditional birth attendants [n = 20].ResultsSeventy-five percent of antenatal care clients currently pregnant reported they received advice during their last pregnancy to deliver in a health facility, and 58 % of these reported having delivered in a health facility. After adjustment for confounding, women who reported they received advice at antenatal care to deliver at a health facility were significantly more likely (aOR = 2.83 [95 % CI: 1.19–6.75], p = 0.02) to report giving birth in a facility. Despite high antenatal care coverage, a number of demand and supply side barriers deter use of skilled birth attendance services. Primary barriers were: fear of being neglected or maltreated by health workers; long distance and other difficulties in access; poverty, and material requirements for delivery; lack of support from husband/partner; health systems deficiencies such as inadequate staffing/training, work environment, and referral systems; and socio-cultural and gender issues such as preferred birthing position and preference for traditional birth attendants.ConclusionsInitiatives to improve quality of client-provider interaction and respect for women are essential. Financial barriers must be abolished and emergency transport for referrals improved. Simultaneously, supply-side barriers must be addressed, notably ensuring a sufficient number of health workers providing skilled obstetric care in health facilities and creating habitable conditions and enabling environments for them.

Who delivers where? The effect of obstetric risk on facility delivery in East Africa

“…Women not receiving ANC might be unaware of their risk; advice given during ANC to deliver in a health facility has been shown to predict use of skilled facility delivery care [54,55] and ANC was strongly associated with facility delivery in this study, except in Uganda. The large majority of women (96-99%) attended at least one antenatal appointment; however, from the DHS reports for these countries, we know only around half of women attended the recommended four visits [56][57][58][59].…”

Access barriers to obstetric care at health facilities in sub-Saharan Africa—a systematic review

“…Generally, women expect to receive care promptly on reaching a health facility; therefore, long waiting times present a significant challenge to accessing health facility-based services [22, 29, 31, 53, 82, 87, 97, 107, 115, 123, 154, 155]. A shortage or absence of drugs and other essential supplies in health facilities were reported in other studies [31, 48, 56, 67, 76, 111, 115, 150, 155, 157, 163, 165–168], and poor referral practices/systems [104, 105, 159, 165] such as referred clients being transported unaccompanied by healthcare staff [89], lack of feedback mechanisms on referred patients [152], and late or no referral [29] hinder efficient patient care and may result in adverse outcomes.…”

Factors behind Institutional Delivery Preference in the Republic of Benin: An Analysis of 2011-2012 Benin Demographic and Health Survey (BDHS) data

“…However, a study using mixed method design in north Uganda showed that poor quality of care constituted a key barrier to health facility delivery. A number of respondents described their fear or past experience of being hurt, shamed, humiliated, or treated negligently at the hands of health workers (Anastasi et al, 2015). Moreover, utilization of private health services is seen as an index of wealth and status (Kesterton et al, 2010).…”