The use of facilities for labor and delivery: The views of women in rural Uganda

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[Find the meaning and references behind the names: Louise, Rebecca, Low, Marie, Victoria, Ian]

[Journal of Public Health in Africa 2017; 8:592] [page 89] The use of facilities for labor and delivery: the views of women in rural Uganda Rebecca Newell, 1 Ian Spillman, 2 Marie-Louise Newell 1 1 University of Southampton, UK; 2 Kisiizi Hospital, Uganda Abstract The aim of the paper is to explore factors associated with home or hospital delivery in rural Uganda. Qualitative interviews with recently-delivered women in rural Uganda and statistical analysis of data from the 2011 Ugandan Demographic and Health Survey (DHS) to assess the association between socio-demographic and cultural factors and delivery location in multivariable regression models. In the DHS, 61.7% (of 4907) women had a facility-based delivery (FBD); in adjusted analyses, FBD was associated with an urban setting [adjusted odds ratio (aOR) 3.38, 95% confidence interval (CI) 2.66 to 4.28)], the upper wealth quintile (aOR: 3.69, 95%CI 2.79 to 3.87) and with secondary education (aOR: 3.07, 95%CI 2.37 to 3.96). In interviews women quoted costs and distance as barriers to FBD . Other factors reported in interviews to be associated with FBD included family influence, perceived necessity of care ( weak women needed FBD), and the reputation of the facility (women bypassed local facilities to deliver at better hospitals ) Choosing a FBD is a complex decision and education around the benefits of FBD should be combined with interventions designed to remove barriers to FBD Introduction In 2015 approximately 125 million women gave birth, of which 303,000 died, leaving countless children motherless, increasing infant deaths via perinatal conditions and sub-optimal care and restricting economic progress.1 Nearly all deaths (99%) were in resource-poor countries, with 66% in [sub-Saharan Africa (SSA)] 1 Maternal mortality (MM) and morbidity are largely blamed on poor access to obstetric care, especially intrapartum, with the period around labour and delivery bearing the highest risk 2,3 Consequently, a facilitybased delivery (FBD) is an effective way to reduce MM 4-6 Millennium Development Goal 5 (MDG-5) was created in response to the thousands of maternal deaths from preventable and treatable causes, with the aim to reduce MM by 75% by 2015 through providing universal access to reproductive healthcare 5-7 Progress has been made in reducing MM globally, with an estimated 45% reduction since 1990, and deliveries attended by a skilled birth attendant (SBA) increasing to 71% in 2014 compared to 55% in 1990 1 However, the Maternal Mortality Ratio (MMR) has not fallen by the 75% original target 1 Despite effective strategies and interventions, reducing maternal deaths in resource-poor countries remains a challenge 2 Uganda has a high MMR; 360 in 2014, and despite improvements in FBD rates and increasing numbers of health centres providing community-based care, for some women facilities are still inaccessible and underused 1,5,8 The reasons for low-uptake of FBD are wide-ranging, complex and context specific, transforming the causes of MM from a number of treatable and preventable medical conditions to a wide range of complex, interlinking socio-cultural factors 9-12 To receive FBD women must logistically be able to access a facility and they, or a family-member must make the decision to seek it 12-14 Therefore, it is important to understand the factors that encourage FBD and those act as barriers, to fully reap the benefits of the increasing availability of reproductive healthcare brought about by MDG-5 11,15,16 Recognising a gap in research on socio-cultural factors and their influence on delivery location, this study, through interviews with women and analysis of the Ugandan 2011 DHS aims to inform understanding of decision-making and issues associated with choice of place of delivery Materials and Methods Thirty women from Kisiizi, Uganda, were interviewed in early 2015. This location was utilised to facilitate the interviews due to its rural setting. Purposive sampling was used to ensure a range of delivery locations, and women were recruited through Kisiizi hospital post-natal services, paediatric services or through outreach clinics All women approached were willing to participate and provided with participant information sheets. Written consent was obtained from each participant. Ethical approval was granted by both the University of Southampton and the ethics board of Kisiizi Hospital. The inclusion criteria were aged between 15 and 49 years, having had a delivery of a live-born infant in the past five years and consent; women who were currently pregnant were excluded. Women were interviewed in a secure and private location by the researcher and a translator, following a semi-structured questionnaire. Data were recorded via notetaking on printed questionnaires. The interviews have been explored, analysed and described using thematic analysis. These interviews explored a number of topics concerning women’s beliefs around place of delivery and how they make the decision about where to deliver, including: opinions about healthcare, socio-demographic factors, knowledge about the benefits of hospi- Journal of Public Health in Africa 2017 ; volume 8:592 Correspondence: Rebecca Newell, Frampton Cotterell, Bristol, BS 362 EJ, UK Tel.: +44.07923314874 E-mail: becky.t.newell@googlemail.com Key words: facility-based delivery; Uganda; delivery location Acknowledgements: the authors would like to thank staff from Kisiizi hospital, and the women who gave up their time to participate We would also like to thank members of staff from the University of Southampton faculty of Medicine, specifically the statistics team for their help and input. The Victoria foundation and wellbeing for women trust that financially enabled the research to take place and finally the DHS program for allowing us to use the available 2011 data for Uganda. Contributions: RN and MLN designed the project, RN collected and analysed the data, RN, IS and MLN interpreted the results. RN drafted the first version of the paper, MLN and IS contributed to subsequent versions. All authors agreed the final version for submission. Conflict of interest: the authors declare no potential conflict of interest Funding: RN, as an undergraduate medical student received the wellbeing for women foundation elective bursary and The Victoria foundation undergraduate bursary to enable her to carry out the research Received for publication: 16 August 2016 Revision received: 13 June 2017 Accepted for publication: 14 June 2017 This work is licensed under a Creative Commons Attribution NonCommercial 4.0 License (CC BY-NC 4.0) ©Copyright R. Newell et al., 2017 Licensee PAGEPress, ItalyJournal of Public Health in Africa 2017; 8:592 doi:10.4081/jphia.2017592 Non commercial use only

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[page 90] [Journal of Public Health in Africa 2017; 8:592] tal care, and socio-cultural beliefs about pregnancy and place of delivery These topics provided a basis upon which themes were identified and are used to present the results. Published in 2011, the most recent DHS from Uganda provides information of delivery locations within the country. The DHS is a large, nationally representative, crosssectional survey. Women were asked to report on any births that occurred up to five years prior to interview. The DHS data was entered into the statistical package (SPSS, IBM v 22) with an analysis dataset created by merging Child, Birth and Individual datasets. The inclusion criteria for the DHS section of the study were participants present at the time of interview, female, aged between 15-49, at least one delivery and an outcome for place of delivery. This gave a total of 4907 women. Children and births were only included in the dataset if they were matched with a woman’s data. A proportion of women had multiple children, thus giving a total of 20,869 births. The latest birth for each woman was selected for statistical analysis to align in time as closely as possible with the qualitative interviews, giving a total of 4907 births. The data was analysed using descriptive statistics, univariate and multivariable logistic regression analysis. Variables were selected, categorised and then built into regression models to be statistically informative, least affected by missing data, represent the available literature and to align with the qualitative themes The variables were split into accessibility-related factors which included distance to health facility, accessing money for treatment, means of transport owned by household, attaining permission to go, person who usually dictates how respondents earnings are spent and the person most likely to make decision regarding respondents healthcare; maternal-related factors: current marital status, age in five year groupings, type of place of residence, education level, wealth index and total number of children Facility-related factors included being informed about pregnancy complication, number of ANC visits, use of contraception, vaccination status and visiting a health facility in the last 12 months. Place of delivery was either home delivery, facility-based or other. Home delivery includes all births at respondent’s home, Traditional Birth Attendants (TBA) home or other private residence. Facility-based deliveries included births at a government or private hospitals or health centres, private clinics or other institutions. The outcome in the logistic regression model is facility-based delivery (Yes/No) Ethical approval The Kisiizi Hospital Ethics Board chaired by Dr Banya approved the study on 10/11/2014; the University of Southampton Ethics Board, ERGO 12383, approved the study on 16/11/2014 Results Respondents to the qualitative interviews had between one and eight children and were from a variety of locations, including rural areas and towns. Some women were professionals, including a teacher and a health worker, while others were peasant farmers and homemakers In the 2011 Uganda DHS of the 4,907 eligible deliveries, 61.7% (3030) occurred at a facility, 37.3% (1829) at home and 1% (48) in another location Factors related to accessibility In multivariable analysis (Table 1), Article Table 1. Univariate and multivariable regression analysis of the association between facility-based delivery and accessibility factors, Uganda DHS 2011, 4907 women in total.* Background/variable Univariate Multivariable OR 95%CI aOR 95%CI Sig Lower Upper Lower Upper Distance to health facility Big problem (ref) n= 2129 1.00 1.00 Not a big problem n= 2774 2.07 1.84 2.32 1.77 1.46 2.13 <0.001 Getting money for treatment Big problem (ref) n=2582 1.00 1.00 Not a big problem n=2321 1.88 1.67 2.11 1.54 1.27 1.87 <0.001 Means of transport owned by household Car/truck: No (ref) n=4623 1.00 1.00 ar/truck: Yes n=172 4.47 2.85 7.02 5.33 2.43 11.67 <0.001 Motorcycle/scooter: No (ref) n=4623 1.00 1.00 Motorcycle/scooter: Yes n=403 1.85 1.47 2.33 1.28 0.92 1.76 0.14 Getting permission to go to healthcare facility Big problem (ref) n=273 1.00 1.00 Not a big problem n=4630 1.43 1.12 1.83 1.01 0.69 1.49 0.96 Person who usually decides how to spend respondents earning Respondent alone (ref) n=1229 1.00 1.00 Respondent + partner n=693 0.81 0.67 0.98 0.86 0.69 1.07 0.17 Partner/husband alone n=310 0.56 0.44 0.72 0.59 0.45 0.77 <0.001 Someone else n=7 3.12 0.37 25.96 2.91 0.34 25.34 0.33 Person who usually decides on respondents healthcare Respondent alone (ref) n=1024 1.00 1.00 Respondent + partner/husband: n=1596 1.04 0.88 1.22 1.00 0.79 1.26 1.00 Partner/husband alone n=1484 1.12 0.95 1.32 1.10 0.87 1.40 0.42 Someone else n=11 0.83 0.25 2.74 0.54 0.05 6.19 0.62 Other n=7 1.73 0.33 8.97 1.79 0.17 18.71 0.62 *Factors that determine how accessible facilities are to women: distance to health facility, getting money for treatment, means of transport owned by household, getting permission to go, person who usually decides how to spend respondents earnings, and the person who usually decided on the respondents healthcare. OR, odds ratio; Lower, lower confidence interval; Upper, upper confidence interval; aOR, adjusted odds ratio; Sig, significance/P-value Non commercial use only

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[Find the meaning and references behind the names: Fast, Happy, Don]

allowing for accessibility factors, distance to the health facility, accessing money for treatment, getting permission to go and car ownership were independently associated with the likelihood of FBD; with finding overcoming these factors easier associated with FBD. Similarly, the interview respondents also almost universally quoted cost and distance as barriers to receiving a FBD However, their specific effect on delivery location, according to these women, was also impacted by other factors, such as their economic situation, family and social context and their perceived care needs (PCN). The effect of women’s economic situation was seen in adjusted analysis of maternal variables in the DHS data (Table 2) Variables found to have independent significant positive association with FBD were living in an urban setting, increasing education levels and increasing wealth index Higher maternal age and high number of children were seen to decrease the chance of FBD (Table 2). The qualitative interviews again agreed with these results, finding that wealth, education and urban environment were reported to facilitate FBD through their influence on the barriers costs and distance. Some women in interviews reported that the barriers of costs and distance removed all choice they had regarding place of delivery It was so fast that because of the dis-tance and the transport I delivered at home.We had not money so we had to look for thattoo before I could go and we couldn’t find avehicle to take me.Because of our place being far awayfrom the hospital we deliver before comingbecause of the distance. There is no money,if there was money I could come and wait inthe hospital. Even when the labour hasstarted we cannot get the money to trans-port us to the hospital. My family and hus-band are happy for me to go to the hospitaland the nurses say that it is best, but there isno money so how can I get to the hospital. Other women explained how their jobs, family or social context enabled them to overcome barriers, and often allowed a choice between facilities, with examples of bypassing facilities to travel further or pay more to deliver at perceived better facilities My husband wanted me to go to thehospital though because it is better and wecan afford it and have the transport, sothat is not a problem.Two hours by private taxi - we hire acar from someone where we live…..It is notthe local hospital – there are other hospi-tals where we come from but one of thedoctors from the health centre recommend-ed this hospital as it is one of the best.Yes you don’t know how much it willcost, but I don’t really worry much about itbecause of the jobs of me and my husbandand then the money we receive. Article Table 2. Univariate and multivariable regression analysis of the association between facility-based delivery and maternal factors, Uganda DHS 2011, 4907 women in total.* Background/variable Univariate Multivariable OR 95%CI aOR 95%CI Sig Lower Upper Lower Upper Current marital status Never in Union (ref) n=216 1.00 1.00 Married n=2338 0.43 0.31 0.60 1.11 0.76 1.62 0.58 Living with partner n=1790 0.50 0.36 0.70 1.06 0.73 1.54 0.77 Widowed n=118 0.37 0.23 0.59 1.12 0.66 1.93 0.67 Divorced n=34 0.63 0.29 1.38 1.07 0.44 2.59 0.89 Not together/separated n=409 0.65 0.44 0.94 1.23 0.84 1.88 0.34 Age in 5 year groups 15-19 (ref) n=375 1.00 1.00 20-24 n=1181 0.79 0.62 1.02 0.75 0.57 0.98 0.36 25-29 n=1362 0.65 0.50 0.83 0.70 0.52 0.94 0.02 30-34 n=871 0.59 0.46 0.77 0.74 0.53 1.04 0.85 35-39 n=686 0.63 0.47 0.82 1.00 0.69 1.45 0.99 40-44 n=324 0.46 0.34 0.63 0.77 0.51 1.18 0.23 45-49 n=108 0.37 0.24 0.57 0.80 0.46 1.39 0.43 Type of place of residence Rural n=3722 1.00 1.00 Urban n=1185 8.36 6.83 10.25 3.38 2.66 4.28 <0.001 Education level No education (ref) n=858 1.00 1.00 Primary n=2849 2.40 2.06 2.81 1.71 1.44 2.03 <0.001 Secondary n=967 8.38 6.73 10.42 3.07 2.37 3.96 <0.001 Higher n=233 37.31 19.51 71.35 9.01 4.55 17.84 <0.001 Wealth index Lowest (ref) n=1193 1.00 1.00 Fourth n=932 1.86 1.56 2.21 1.53 1.27 1.83 <0.001 Middle n=840 2.04 1.70 2.44 1.52 1.26 1.84 <0.001 Second n=794 2.84 2.36 3.44 1.78 1.46 2.19 <0.001 Highest n=1148 14.07 11.21 17.67 3.69 2.79 4.87 <0.001 Total number of children 1-3 (ref) n=2303 1.00 1.00 4-6 n=1562 0.56 0.49 0.64 0.78 0.64 0.95 0.01 7-10 n=923 0.44 0.38 0.52 0.75 0.57 0.98 0.04 11-15 n=119 0.39 0.27 0.57 0.75 0.46 1.22 0.25 *Maternal-related factors: current marital status, age in five year groups, type of place of residence, education level, wealth index and total number of children. OR, odds ratio; Lower, lower confidence interval; Upper, upper confidence interval; aOR, adjusted odds ratio; Sig, significance/P-value [Journal of Public Health in Africa 2017; 8:592] [page 91] Non commercial use only

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A woman’s family was another influential factor on whether she received a FBD Who made financial decisions or decisions about healthcare providers, partner/husband alone or respondent alone etc. was not statistically associated with a specific delivery location in either univariate or multivariable analysis (Table 1). In univariate analysis women were more likely to receive FBD if they didn’t find getting permission to go to a facility a big problem. However, after adjustment for other accessibility factors, this association was no longer statistically significant (Table 1). Through the interviews, family was seen to both enable and prevent FBD. Some families enabled FBD by giving permission, or allowing costs and distance to be overcome. Interviews also demonstrated how men or older family members often controlled the family’s money and made major decisions. Travel and the costs make a differencebut it is not too far for me, and because myhusband said I could go we had put themoney ready so I was able to go. My hus-band and me made the decision together, hesaid I could go.My husband wanted me to deliver in thehospital because it is better. For him themoney doesn’t matter, it is more aboutwhether the wife delivers well and gets ahealthy baby. Also because of the bleedingnow we know it is very important that I goto the hospital, they can stop the bleedingthere.The father of my baby says that the hos-pital is too far and that having a baby isnormal so I should stay at home.From home, my husband was not athome when I started labouring and therewas no one to attend to me or take me to thehospital. My husband does not like to spendthe money when there is another way…Myhusband gave me no money to go andwasn’t there to take me, so he meant I couldnot go.I wanted to go to the hospital but laterwhen I went into labour I delivered at home,I have no partner so I have to please mygrandmother and not ask for a lot of things.My grandmother told me I was delivering athome and would have been very angry if Iwent to the hospital and they had to pay. I am also very blessed that this is not aproblem for me, but it is for many womenhere. They cannot pay the bills and theirhusbands won’t give them the money. Theyhave no money and are left in the house;there is nothing they can do. I try and tellthe women to hide money for themselveswhen they get pregnant so they can come tothe hospital. Maternal factors In addition to the factors discussed above, maternal factors include women’s opinions and education around delivery location and their specific health and PCN In the DHS, women who reported having been told about benefits of FBD were around 1.5 times more likely to have received FBD (Table 3). The majority of women interviewed stated that the hospital was the best place to deliver due to the availability of care, specifically emergency care I know the hospital is better for me, andthe baby, and I think that it is worth thecosts. It is worth the costs for you and yourbaby being okay….I can give the onlydisadvantage is the costs but I would ratherpay a large cost than lose a child or life.….. there is a time when you have acomplicated labour or aggressive labourlike the baby is in the wrong position andthen you try to push at home but you can’tand then they bring you to hospital and it istoo late and you try and save the motherand baby but it is too late and you can’t….Safe, clean, free from infection, in caseof complications and generally reduces thenumber of mother and baby deaths. Lots ofthings, like I said, they help you and canhelp if there are complications. It is much Article Table 3. Univariate and multivariable regression analysis of the association between facility-based delivery and facility factors, Uganda DHS 2011, 4907 women in total.* Background/variable Univariate Multivariable OR 95%CI aOR 95%CI Sig Lower Upper Lower Upper Told about pregnancy complications No (ref) n=2148 1.00 1.00 Yes n=2541 1.47 1.31 1.66 1.49 1.23 1.79 <0.001 Not sure n=35 0.87 0.44 1.69 2.24 0.70 7.19 0.18 Number of ANC visits None (ref) n=80 1.00 1.00 1-5 n=1977 2.84 2.08 3.89 1.69 1.25 2.29 <0.001 6-10 n=291 4.68 3.26 6.74 1.05 0.18 6.15 0.95 11-20 n=7 4.52 1.36 15.01 3.36 1.54 7.35 <0.001 Ever used contraception Never (ref) n=3519 1.00 1.00 Used only folklore method n=18 0.94 0.37 2.39 0.74 0.15 3.71 0.71 Used only traditional method n=145 2.12 1.44 3.10 2.04 1.11 3.75 0.02 Used modern method: n=1225 2.15 1.86 2.49 2.36 1.87 2.99 <0.001 Visited a health facility in last 12 months No (ref) n=1120 1.00 1.00 Yes n=3784 1.16 1.01 1.33 0.99 0.79 1.22 0.89 Ever had a vaccination No (ref) n=275 1.00 1.00 <0.001 Yes n=1781 2.65 2.05 3.45 1.96 1.48 2.59 <0.001 Don’t know n=4 6.28 0.69 56.95 4.95 0.53 46.10 0.16 *Facility-related factors: told about pregnancy complication, number of ANC visits, use of contraception, vaccination status, and visiting a health facility in the last 12 months. OR, odds ratio; Lower, lower confidence interval; Upper, upper confidence interval; aOR, adjusted odds ratio; Sig, significance/P-value [page 92] [Journal of Public Health in Africa 2017; 8:592] Non commercial use only

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[Find the meaning and references behind the names: Real, Good, Tran]

[Journal of Public Health in Africa 2017; 8:592] [page 93] safer in the hospital. I wonder if one deli-vers at home if there will be a trained healthworker to assist, very risky for complica-tions like bleeding too much.The best place is the hospital becauseyou deliver in good health and in case ofany problems the child is attended to pro-perly. If you are HIV positive you can tran-smit the infection to the baby at the hospitalthey try and stop that. In a hospital they canhelp you if the baby is stuck or if you bleed. PCN, the opinions and beliefs about the need for a health service also interacted with knowledge about the benefits of FBD If a woman has a specific health condition, a previous complication, or were worried about their pregnancy, they were more likely to desire FBD It depends on how you feel whether youfeel pain or are normal. If you feel pain it isbest to go to the hospital. If you are well andstrong then that is different. It is differentbecause the pregnancy is normal meaningyou will have a normal labour so lots ofwomen deliver at home and that is normal….. It depends on how you are, I was weakso needed to go to the hospital.Friends and family thought I woulddeliver at home but I wanted to deliver inthe hospital. I wanted to deliver in the hos-pital because I have previous C sectionscars.My husband is happy for me to deliverat home, he thinks the hospital is costly andfar, but when I wanted to go for the 5 th hesaid that was okay because I was scared,and because I hadn’t asked before he knewthere was a real problem. He trusts me tocare of the children. The reverse was also seen with women acknowledging the benefits of FBD in complications, but explaining that if their pregnancy was normal they did not need FBD I always have a choice where to deliverbut the reason I delivers at home is becauseI deliverer quickly and I can’t get there intime. I have had no complications and havealways been strong and well enough todeliver at home. My husband tells me to goto the hospital but I don’t need to.Sometimes the money is not enough andthe midwives at ANC say my pregnancy isokay. I have not much trouble delivering soit is okay and my husband has no troublewith me delivering at home. For me theproblem is the money and the distance fromhome. My husband does not like the costand now I have delivered so many babiesokay I cannot change now because I haveno need to pay the costs when I have done itat home and my husband knows I can do itat home.The money and costs are too much so itis better not to go with no problem.At home it is not as much expensebecause if you don’t have money you canstill deliver at home. They fear being cost alot of money, you might have to sell yourland to pay for the hospital fees but if youcan keep your land you can grow food on itand look after your children. Socio-cultural factors Socio-cultural factors were assessed through the qualitative interviews only Positive views about FBD and the benefits of facility care from a society can be incentives for women to receive FBD Yes it is good to go the hospital every-one knows that.Obviously in the hospital, becauseeveryone knows it is best and you shouldgo if you can. Whereas societal opinions that discourage FBD are that pregnancy, labour and home deliveries are normal and safe. Many people think it is normal to havethe baby at home.Most of them deliver their babies athome as they think they can make it andthey see everyone else do it at home so theythink it is safe especially if they are strongand have had other babies.They expected me to deliver from thevillage, because they say it is better and thatis where they deliver from and most of theold people also used to deliver from home. The community’s views on place of delivery seemed to change depending on the condition and health of the women and pregnancy. This links to PCN, with women expressing that the hospital is for complications and problems They deliver at home but a few go tohospital. If it is the first pregnancy and theyproduce well at home then they don’tchange, they stay producing at home. But ifthere is a complication that is when theyrush to hospital and go back for the nextone.Some deliver from home and othersfrom the hospital it depends on how strongthey are and how there pregnancy is. I havebeen strong and delivered healthy babies somy family and husband are happy. I am verywell and strong for delivering, I have noproblems. It is when you have problems thatyou run to the hospital. It is all about lifeand death you do it and you don’t know, ifyou die you die and if you live you live.Most of the people deliver from home,but others in hospital it depends on howthere pregnancy is – if they have problemsthey go to the hospital. For no problems it isokay but a risk for when the complicationscome.He expected me to come to the hospitalbecause I was weak and expecting threebabies is hard. A deterrent to facility based care was the negative opinions on caesarean section, whilst being able to push was seen as a good thing. They discourage me from going to thehospital as they say they section you for nogood reason.Maybe they cut you and don’t let youpush, I have a friend that that has happenedtoo, and they make you pay more for havingthe surgery.With my second baby everything wasnormal so I could push which was good,having a caesarean was different. It will bevery expensive and I have a scar and a weakstomach.I also see TBA during pregnancybecause they give you other help and drinksto make you strong. They want you to beable to deliver without the surgery. No theTBAs want to help you push, but they arehappy for you to push in the hospital. In many of the quotes women use emotive words such as “weak” and “strong” when describing how and where women should deliver. Those women who pushed or delivered at home where described as strong, whilst delivery at home or caesarean sections where seen as weak. Some go to the hospital and some deliv-er at home; I think this is because those whogo to the hospital think that when they failthey will be helped. I think that if you can-not deliver at home you are weaker.I have been sectioned each time so I Article Non commercial use only

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[Find the meaning and references behind the names: Nancy]

[page 94] [Journal of Public Health in Africa 2017; 8:592] think it is bad. If you don’t push people thinkyou are not confident enough to try and thatyou are weak.Sometimes you cannot get to the hospi-tal, like when it is night and you cannot gettransport, but you can still be strong andpush at home. There were examples of women choosing to have a FBD despite their community’s opinions and some women described a cultural shift in delivery location They tell you home is best, but I knowthey are wrong so I just smile at them andthen there is no problem.They did not influence the placebecause now there is a mixture of womendelivering at home and at hospital. Noteveryone delivers at home so it is okay.No, we do not worry about those things,Uganda is becoming more modern and peo-ple are moving on from the old ways.Today in Uganda most people go to hos-pital only a small number of people remainbehind. It is improving day by day. In Uganda individuals can seek healthcare in a number of ways including the use of herbs, traditional medicines, traditional practitioners, health centres or hospitals. A theme identified through the interviews was the use of traditional care verses “western care”. The majority of the women interviewed used traditional medicines, and there appeared to be a hierarchy as to when and what healthcare was used. Not many women interviewed used TBA and those that did use TBA’s did not necessarily deliver with them I also use traditional medicines forthings like deworming – when they aresmall problems and we have the medicine, Iuse traditional medicines. This is sensibleas it saves you money and stops you leavinghome. It is when it is a big problem and youdon’t have a solution that you should travelto the hospital.Sometimes they use traditional herbs –some conditions are simple and can betreated by herbs – like a cough should betreated with herbs. If the problem is bad ordoesn’t go away you should go to the clinicand if it is very bad you should go to thehospital.I use both medical and traditionalmedicines; I use traditional herbs for thingslike when the child has diarrhoea. I usethem at different times, first I use traditionalmedicines and then if the child does notrecover then I use that of the medical clinicor hospital. For the second baby I felt the pains andthe leaking so I started to travel but thencould feel to push so I returned home anddelivered there, then the TBA came andhelped me and gave me medicines to keepme strong... I also saw them during preg-nancy… They told me to come to the hospi-tal for ANC and to deliver from the hospitalbecause they also know it is safer. They justhelp you make sure you are healthy beforeand after you labour. Facility-related factors Every facility is unique, placed within a cultural context, with specific attributes that act either as barriers or incentives for women. Facility-related factors include costs and distance, quality of care, patientstaff relationships, ANC influence and any problems with care received. In the DHS, increased use of facility services in general was significantly associated with having had a FBD of the last-born child in both univariate and multivariable analysis: previous vaccinations, modern contraception methods, and use of ANC services were positively associated with FBD (Table 3). ANC was also seen to encourage FBD through the interviews. I had been to the health centre for ANCso I knew they were good and would carefor me.Yes in the old times patients said that ifyou went to Kisiizi they could be rude toyou, but now there is outreach and so yousee the health workers and they are better,not rude how they used to be.My last baby was in Kisiizi but it is notmy local hospital, it is the furthest. I camehere because they had cared for me well(ANC) and given me a date to return forcaring before the delivery.I believe what the health professionalstell you, because they tell you the truth thatthey know. They tell you it is best to go tothe hospital because of the equipment at thehospital and how they can help you. ANC could also reduce the incentive to seek FBD through normal findings reducing woman’s PCN and reassuring women or their families that it was not necessary to seek FBC. Also the nurses said the baby was nor-mal at ANC and in the right place to push soI had less to worry about.When I had the pregnancy checks andtold him everything was normal he wouldsay it was better not to go to the hospitalbecause everything is okay. Although care was mostly quoted as an incentive for FBD, there were several ideas discussed in the interviews that were specific attributes of facility care that acted as barriers to FBD. These included caesarean sections, ANC and relationships between patients and healthcare staff. However, many women expressed improvements in this area Because the child has malnutrition Iface stigma and they, the nurses and doctorswill abuse me and think I am a bad motherbecause I cannot care for my son. I appreci-ate the advice and care that they give meand they care about the child and they getbetter and I am satisfied with the care but Idon’t like the stigma. There are lots of rea-sons I cannot care for my son, and now theyare telling me to pay for different milk,because they say my child cannot have nor-mal milk and things. I think they do notunderstand and have always lived in citieswithout many problems. In admission I amalways stigmatised because I cannot affordto pay for the children and so they give mestigma and tell me how to be a mother.Some if they are tired, can be angry andhard to the patients which is why sometimesthe patients feel stigma and are afraid tocome to the hospital because they think thatthey will not be treated well by staff.Before some of the health workers werebad. Now they are better. They were rudeand treated you stupid. For my first deliverythe healthcare staff where rude.They are kinder than the past. I thinkthey understand now that the child’s sick-ness is not always the mothers fault. Discussion Most maternal deaths occur during the intra-partum and immediate post-partum period, often from unpredictable complications; therefore FBD reduces risks to both mother and baby significantly 4,17,18 Despite improvements, with over 60% of women in the Ugandan 2011 DHS reporting FBD, the results presented here highlight that some sections of Ugandan society still predominantly deliver unaided in the community 19,20 Reasons behind the underuse of facilities are complex and interacting, Article Non commercial use only

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[Journal of Public Health in Africa 2017; 8:592] [page 95] including logistics, demographics, PCN and cultural beliefs 9-13 Interviews found that the barriers of cost and distance were important in the decision, and for some women they were so obstructive as to remove all choice However, the barriers of cost and distance to FBD are not the whole picture, with other factors such as SES, education level and place of residence influencing their relative importance 9-11 These interacting factors offer explanations for the finding from the multivariable analysis of DHS data. Women from an urban area, who are generally closer to facilities, are three-fold more likely to deliver in a facility than women from rural areas and women from the upper four wealth quintiles were 1.5 to 3.7-fold more likely to deliver in a facility than those in the lowest quintile for whom costs are most obstructive The restrictive impact of cost and distance on receiving FBD shows the importance of removing them as barriers 13,14,21 This can be achieved through increasing free facilities or ambulance services as well as designing interventions that reduce their impact such as community health insurance or waiting houses for expecting mothers, as being initiated in Kisiizi hospital 4,18,22 However, with the reality of overstretched budgets, poor infrastructure and socio-cultural barriers, solely focusing on removing these barriers is not always feasible or effective 4,22,23 Therefore this study would suggest other reasons women don’t receive FBD are also addressed The recently published intervention study Saving Mothers, Giving Life supports this approach, with comprehensive interventions to improve access to and quality of care, which were built upon existing health strategies, resulting in a 30% reduction in population based MM in Uganda over one year 24 This intervention design used the three delays model, which splits factors that stop effective FBD into delays in seeking appropriate services, delays in reaching those services and then delays in receiving timely and quality care at the facilities 24 This highlights the importance of not only providing facilities, but also encouraging women to use then, and insuring they are adequate quality, concurring with the findings of this study 24 A major way to promote women seeking appropriate services identified in this study was education about the benefits of FBD and the risks of labour 25,26 Women’s PCN and knowledge about the benefits of FBD were shown to influence women’s willingness to overcome barriers, with women in the interviews choosing to overcome barriers if they believed it necessary, whereas low PCN justified home delivery 16,26 This was also seen in the DHS data with women educated to secondary level three-times more likely to receive FBD than those without formal education, and women told about the complications of pregnancy 1.5- times more likely to receive FBD than those not told ANC can be a tool used to deliver this education, alongside having several other effects on delivery location and MM. ANC monitors pregnancies, identifies high risk situations and allows for community level interactions between patients and staff, 22 which if positive, can allow for fear to be reduced and trust to develop between facilities and women 11,15 However ANC can act as a deterrent to FBD, through negative experiences and normal finding were shown to reassure women and reduce their PCNs for FBD 22 Developing trust between communities and facilities will be essential in increasing FBD, but this will only be achieved if facilities provide good quality care. Large numbers of maternal and neonatal deaths occur in facilities, and interestingly some studies have shown that neonatal maternity is not reduced through FBD 27-29 This is thought to be explained by facilities lacking skilled personnel and necessary equipment. Again, l the success of the Saving Mothers, Giving life intervention initiative, which aimed to provide evidence-based interventions in facilities, with facilities upgraded with medical equipment and staffing, showed that MMR fell by 35%, confirming that good quality facilities is essential to effectively reduce neonatal and maternal mortality 24 Along with promoting knowledge about the benefits of FBD, education can promote gender equality, increase earning potential, and contribute to changing societal norms around delivery locations 9,30 A common belief is that if women had greater autonomy they would choose FBD 15,30 However, in the 2011 DHS data there were no significant difference in delivery location when the decision was taken by women or their partners. In Uganda males traditionally take the major decisions 13 Some interviewed women explained if their husband did not give them permission or money then FBD was impossible. For other women, permission from family members gave them the resources to receive FBD. Family acting as both a barrier and enabling factor to FBD may reflect disagreements within the literature 9,13,15 Therefore this study would suggest that alongside women, men and the wider community should be educated about the benefits of FBD. Societies have opinions on whether healthcare providers are good or bad, when it is appropriate to seek healthcare and where it should be sought from. This is seen specifically through the case of childbirth, with how a community views childbirth determining what healthcare is viewed as appropriate. As with PCN the societal belief that pregnancy and labour are normal and therefore hospital care is unnecessary can discourage FBD 13,23 It is worth considering whether this view of FBD as unnecessary is linked to the beliefs that western healthcare should only be sought in severe illness or as a last resort. Through the interviews traditional medicine appeared to be used first, with western medicine used when the problem was severe or wasn’t healing after being treated with the traditional medicines. This theory was identified for general healthcare usage in this study, and for obstetric care in Uganda in a study by Kyomuhendo 13 These are hypothesised as explanations for the delays in women going to facilities and why facility benefits, as seen by the community, predominantly focus on complications. More research would be beneficial in this area not solely to promote FBD, but to generally encourage the appropriate usage of healthcare. Another societal barrier to FBD hypothesised through these interviews was that weaker women sought FBD whilst stronger women could deliver at home unaided. This could also be linked to the negative opinions about caesarean sections, as women who had caesarean sections seemed to experience some stigma, whilst woman who pushed to deliver vaginally were described as strong. If women believe seeking FBD makes them weaker, this could be a major deterrent to FBD. Again, Kyomuhendo identified similar findings, identifying cultural beliefs that strong women deliver unaided 13 In these interviews many women identified a cultural shift in delivery location favouring FBD, resulting in positive reinforcement, with increasing numbers of women receiving FBD, increasing its social acceptability and dispelling some negative cultural beliefs. Strengths There is considerable literature about the demographics behind women’s delivery locations, whilst far less is known about the socio-cultural factors. The qualitative interviews allowed these to be explored along with identifying potential causal relationships to the statistical associations. Limitations The 2011 Uganda DHS is cross sectional, with data collected up to five years after delivery; data may thus be subject to recall and reporting bias. The DHS data depends Article Non commercial use only

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[Find the meaning and references behind the names: Campbell, Brown, Mustafa, Asia, Lai, Iris, Rahman, Hum, Chou]

[page 96] [Journal of Public Health in Africa 2017; 8:592] on key informant responses at household level and may not be the best way to investigate individual socio-cultural factors, which is the rationale behind conducting additional interviews. Selection and recruitment of women through Kisiizi hospital could introduce biases: social desirability bias, as it is not neutral when discussing choices between hospital and home; selection bias as women were more likely to have knowledge and experience of the hospital. This could also be due to Kisiizi’s good reputation as a nongovernment hospital and its insurance system meaning it is not an accurate representation of a Ugandan hospital. These were addressed by explained confidentiality and outreach recruitment of women. Conclusions The influence of factors on women’s choice of place of delivery is unique, with each woman having a specific balance of incentives and barriers determining their final decision 9-11,23 Those women least likely to receive FBD are also most likely to be affected by socio-cultural pressures discouraging FBD .19,20 Therefore, this study would suggest that there is no single intervention enough to successfully increase FBD rates among all population groups, and therefore interventions should take a broad approach, aiming to tip this balance in favour of FBD. These should target women least likely to delivery in a facility, women from a low SES and rural area, to ensure they are not left further behind. References 1. WHO. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2015. Available frm: http://apps.who.int/iris/bitstream/10665 /194254/1/9789241565141_eng.pdf?ua =1 2. Ronsmans C, Graham WJ, group LMSSs. Maternal mortality: who, when, where, and why. Lancet 2006;368:1189-200 3. Gribble J, Haffey J. Reproductive health in Sub-Saharan Africa Population Reference Bureau. 2008 Available from: http://www.prb.org/pdf 08/reproductivehealth_subsaharanafrica.pdf 4. Kongnyuy EJ, Hofman JJ, van den Broek N. Ensuring effective essential obstetric care in resource poor settings BJOG 2009;116:41-7 5. Campbell OM, Graham WJ, group LMSSs. Strategies for reducing maternal mortality: getting on with what works. Lancet 2006;368:1284-99 6. Darmstadt GL, Marchant T, Claeson M, et al. A strategy for reducing maternal and newborn deaths by 2015 and beyond. BMC Pregnancy Childbirth 2013;13:216 7. Zureick-Brown S, Newby H, Chou D, et al. Understanding global trends in maternal mortality. Int Perspect Sex Reprod Health 2013;39:32-41 8. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010;375: 1609-23 9. Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 2009;9:34 10. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Newsl Womens Glob Netw Reprod Rights 1991:22-4 11. Moyer CA, Mustafa A. Drivers and deterrents of facility delivery in sub- Saharan Africa: a systematic review Reprod Health 2013;10:40 12. Parkhurst JO, Rahman SA, Ssengooba F. Overcoming access barriers for facility-based delivery in low-income settings: insights from Bangladesh and Uganda. J Health Popul Nutr 2006;24:438-45 13. Kyomuhendo GB. Low use of rural maternity services in Uganda: impact of women’s status, traditional beliefs and limited resources. Reprod Health Matters 2003;11:16-26 14. McPake B, Witter S, Ensor T, et al Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health. Hum Res Health 2013;11:46 15. Tey NP, Lai SL. Correlates of and barriers to the utilization of health services for delivery in South Asia and Sub- Saharan Africa. Sci World J 2013;2013:423403 16. Kabakyenga JK, Östergren PO, Turyakira E, Pettersson KO. Influence of birth preparedness, decision-making on location of birth and assistance by skilled birth attendants among women in south-western Uganda. PLoS One 2012;7:e 35747 17. Say L, Chou D, Gemmill A, et al Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2:e 323-33 18. Mbizvo MT, Say L. Global progress and potentially effective policy responses to reduce maternal mortality. Int J Gynaecol Obstet 2012;119:S 9-12 19. Giroux SC, Eloundou-Enyegue PM, Lichter DT. Reproductive inequality in sub-Saharan Africa: differentials versus concentration. Stud Fam Plann 2008;39:187-98 20. Victora CG, Barros AJ, Axelson H, et al. How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys. Lancet 2012;380:1149-56 21. Parkhurst JO, Ssengooba F. Assessing access barriers to maternal health care: measuring bypassing to identify health centre needs in rural Uganda. Health Policy Plan 2009;24:377-84 22. Ediau M, Wanyenze RK, Machingaidze S, et al. Trends in antenatal care attendance and health facility delivery following community and health facility systems strengthening interventions in Northern Uganda. BMC Pregnancy Childbirth 2013;13:189 23. Stephenson R, Baschieri A, Clements S, et al. Contextual influences on the use of health facilities for childbirth in Africa. Am J Public Health 2006;96:84- 93 24. Serbanescu F, Goldberg HI, Danel I, et al. Rapid reduction of maternal mortality in Uganda and Zambia through the saving mothers, giving life initiative: results of year 1 evaluation. BMC Pregnancy Childbirth 2017;17:42 25. Doctor HV, Findley SE, Cometto G, Afenyadu GY. Awareness of critical danger signs of pregnancy and delivery, preparations for delivery, and utilization of skilled birth attendants in Nigeria. J Health Care Poor Underserved 2013;24:152-70 26. Dako-Gyeke P, Aikins M, Aryeetey R, et al. The influence of socio-cultural interpretations of pregnancy threats on health-seeking behavior among pregnant women in urban Accra, Ghana BMC Pregnancy Childbirth 2013;13:211 27. Kananura RM, Tetui M, Mutebi A, et al The neonatal mortality and its determinants in rural communities of Eastern Uganda. Reprod Health 2016;13:13 28. Kananura RM, Wamala R, Ekirapa- Kiracho E, et al. A structural equation analysis on the relationship between maternal health services utilization and newborn health outcomes: a cross-sec- Article Non commercial use only

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[Journal of Public Health in Africa 2017; 8:592] [page 97] tional study in Eastern Uganda. BMC Pregnancy Childbirth 2017;17:98 29. Kassar SB, Melo AM, Coutinho SB, et al. Determinants of neonatal death with emphasis on health care during pregnancy, childbirth and reproductive history. J Pediatr (Rio J) 2013;89:269-77 30. J Espey, N. Dolata. An equal start. Why Gender equality matters for child survival and maternal health. London: Save the Children UK; 2011 Article Non commercial use only

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