Acceptability of evidence-based neonatal care practices in rural Uganda - implications for programming.
TL;DR: Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation.
Abstract: Although evidence-based interventions to reach the Millennium Development Goals for Maternal and Neonatal mortality reduction exist, they have not yet been operationalised and scaled up in Sub-Saharan African cultural and health systems. A key concern is whether these internationally recommended practices are acceptable and will be demanded by the target community. We explored the acceptability of these interventions in two rural districts of Uganda. We conducted 10 focus group discussions consisting of mothers, fathers, grand parents and child minders (older children who take care of other children). We also did 10 key informant interviews with health workers and traditional birth attendants. Most maternal and newborn recommended practices are acceptable to both the community and to health service providers. However, health system and community barriers were prevalent and will need to be overcome for better neonatal outcomes. Pregnant women did not comprehend the importance of attending antenatal care early or more than once unless they felt ill. Women prefer to deliver in health facilities but most do not do so because they cannot afford the cost of drugs and supplies which are demanded in a situation of poverty and limited male support. Postnatal care is non-existent. For the newborn, delayed bathing and putting nothing on the umbilical cord were neither acceptable to parents nor to health providers, requiring negotiation of alternative practices. The recommended maternal-newborn practices are generally acceptable to the community and health service providers, but often are not practiced due to health systems and community barriers. Communities associate the need for antenatal care attendance with feeling ill, and postnatal care is non-existent in this region. Health promotion programs to improve newborn care must prioritize postnatal care, and take into account the local socio-cultural situation and health systems barriers including the financial burden. Male involvement and promotion of waiting shelters at selected health units should be considered in order to increase access to supervised deliveries. Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation.
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TL;DR: To investigate causes of and contributors to newborn deaths in eastern Uganda using a three delays audit approach, with a focus on maternal and newborn deaths.
Abstract: Summary
Objectives To investigate causes of and contributors to newborn deaths in eastern Uganda using a three delays audit approach.
Methods Data collected on 64 neonatal deaths from a demographic surveillance site were coded for causes of deaths using a hierarchical model and analysed using a modified three delays model to determine contributing delays. A survey was conducted in 16 health facilities to determine capacity for newborn care.
Results Of the newborn babies, 33% died in a hospital/health centre, 13% in a private clinic and 54% died away from a health facility. 47% of the deaths occurred on the day of birth and 78% in the first week. Major contributing delays to newborn death were caretaker delay in problem recognition or in deciding to seek care (50%, 32/64); delay to receive quality care at a health facility (30%; 19/64); and transport delay (20%; 13/64). The median time to seeking care outside the home was 3 days from onset of illness (IQR 1–6). The leading causes of death were sepsis or pneumonia (31%), birth asphyxia (30%) and preterm birth (25%). Health facilities did not have capacity for newborn care, and health workers had correct knowledge on only 31% of the survey questions related to newborn care.
Conclusions Household and health facility-related delays were the major contributors to newborn deaths, and efforts to improve newborn survival need to address both concurrently. Understanding why newborn babies die can be improved by using the three delays model, originally developed for understanding maternal death.
240 citations
Cites background from "Acceptability of evidence-based neo..."
...These are some of the practices we have found to be deficient in this setting (Waiswa et al. 2008, Waiswa et al. 2010)....
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TL;DR: Uganda's neonatal mortality rate reduced by 2.2% per year between 2000 and 2010, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period.
Abstract: Each year in Uganda 141 000 children die before reaching their fifth birthday; 26% of these children die in their first month of life. In a setting of persistently high fertility rates, a crisis in human resources for health and a recent history of civil unrest, Uganda has prioritized Millennium Development Goals 4 and 5 for child and maternal survival. As part of a multi-country analysis we examined change for newborn survival over the past decade through mortality and health system coverage indicators as well as national and donor funding for health, and policy and programme change. Between 2000 and 2010 Uganda's neonatal mortality rate reduced by 2.2% per year, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period. While existing population-based data are insufficient to measure national changes in coverage and quality of services, national attention for maternal and child health has been clear and authorized from the highest levels. Attention and policy change for newborn health is comparatively recent. This recognized gap has led to a specific focus on newborn health through a national Newborn Steering Committee, which has been given a mandate from the Ministry of Health to advise on newborn survival issues since 2006. This multi-disciplinary and inter-agency network of stakeholders has been able to preside over a number of important policy changes at the level of facility care, education and training, community-based service delivery through Village Health Teams and changes to essential drugs and commodities. The committee's comprehensive reach has enabled rapid policy change and increased attention to newborn survival in a relatively short space of time. Translating this favourable policy environment into district-level implementation and high quality services is now the priority.
213 citations
Cites methods from "Acceptability of evidence-based neo..."
...We examined demand for care through published literature on barriers and facilitators to care-seeking (Waiswa et al. 2008; Waiswa et al. 2010b; Waiswa et al. 2010c) and through newborn messages and scope of the national behaviour change communication strategy (Newborn Steering Committee 2010)....
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TL;DR: This article provides a comprehensive overview of qualitative research on social and cultural factors relevant to uptake of MiP interventions in sub-Saharan Africa and concludes that women's vulnerability is often considered less disease-specific and MiP interpreted in locally defined categories.
Abstract: Background Malaria during pregnancy (MiP) results in adverse birth outcomes and poor maternal health. MiP-related morbidity and mortality is most pronounced in sub-Saharan Africa, where recommended MiP interventions include intermittent preventive treatment, insecticide-treated bednets and appropriate case management. Besides their clinical efficacy, the effectiveness of these interventions depends on the attitudes and behaviours of pregnant women and the wider community, which are shaped by social and cultural factors. Although these factors have been studied largely using quantitative methods, qualitative research also offers important insights. This article provides a comprehensive overview of qualitative research on social and cultural factors relevant to uptake of MiP interventions in sub-Saharan Africa. Methods and Findings A systematic search strategy was employed: literature searches were undertaken in several databases (OVID SP, IS Web of Knowledge, MiP Consortium library). MiP-related original research, on social/cultural factors relevant to MiP interventions, in Africa, with findings derived from qualitative methods was included. Non-English language articles were excluded. A meta-ethnographic approach was taken to analysing and synthesizing findings. Thirty-seven studies were identified. Fourteen concentrated on MiP. Others focused on malaria treatment and prevention, antenatal care (ANC), anaemia during pregnancy or reproductive loss. Themes identified included concepts of malaria and risk in pregnancy, attitudes towards interventions, structural factors affecting delivery and uptake, and perceptions of ANC. Conclusions Although malaria risk is associated with pregnancy, women's vulnerability is often considered less disease-specific and MiP interpreted in locally defined categories. Furthermore, local discourses and health workers' ideas and comments influence concerns about MiP interventions. Understandings of ANC, health worker-client interactions, household decision-making, gender relations, cost and distance to health facilities affect pregnant women's access to MiP interventions and lack of healthcare infrastructure limits provision of interventions. Further qualitative research is however required: many studies were principally descriptive and an in-depth comparative approach is recommended.
140 citations
Cites background from "Acceptability of evidence-based neo..."
...Ideas about the purpose of ANC services influenced ANC attendance [55,70,80]: women viewed ANC as providing treatment rather than prevention, and only attended when ill....
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...Waisa and colleagues also reported that diseases during pregnancy tend to be treated at first with herbs in the home prior to seeking assistance at the clinic [70]....
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...Several studies identified obtaining the maternity (or health or ANC) card as a factor that motivated women to attend a health facility for ANC [55,56,57,65,67,70,71]....
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...2008 [70] Obtaining the ‘‘maternity’’ card motivated women to attend a health facility for ANC....
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...In Uganda, pregnant women did not view ANC clinics as offering disease prevention, but attended ANC services when ill [55,70]....
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TL;DR: To improve newborn survival, newborn care should be integrated into the current maternal and child interventions, and should be implemented at both community and health facility level as part of a universal coverage strategy.
Abstract: Four million neonatal deaths are estimated to occur each year and almost all in low income countries, especially among the poorest. There is a paucity of data on newborn health from sub-Saharan Africa and few studies have assessed inequity in uptake of newborn care practices. We assessed socioeconomic differences in use of newborn care practices in order to inform policy and programming in Uganda. All mothers with infants aged 1-4 months (n = 414) in a Demographic Surveillance Site were interviewed. Households were stratified into quintiles of socioeconomic status (SES). Three composite outcomes (good neonatal feeding, good cord care, and optimal thermal care) were created by combining related individual practices from a list of twelve antenatal/essential newborn care practices. Multiple logistic regression analysis was used to identify determinants of each dichotomised composite outcome. There were low levels of coverage of newborn care practices among both the poorest and the least poor. SES and place of birth were not associated with any of the composite newborn care practices. Of newborns, 46% had a facility delivery and only 38% were judged to have had good cord care, 42% optimal thermal care, and 57% were considered to have had adequate neonatal feeding. Mothers were putting powder on the cord; using a bottle to feed the baby; and mixing/replacing breast milk with various substitutes. Multiparous mothers were less likely to have safe cord practices (OR 0.5, CI 0.3 - 0.9) as were mothers whose labour began at night (OR 0.6, CI 0.4 - 0.9). Newborn care practices in this setting are low and do not differ much by socioeconomic group. Despite being established policy, most neonatal interventions are not reaching newborns, suggesting a "policy-to-practice gap". To improve newborn survival, newborn care should be integrated into the current maternal and child interventions, and should be implemented at both community and health facility level as part of a universal coverage strategy.
135 citations
Cites background from "Acceptability of evidence-based neo..."
...Mothers apply substances to the cord for several reasons, including to “help the cord heal fast” so that they can go back to their domestic chores [17]....
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TL;DR: Routine testing for HIV of women at the antenatal clinic was highly acceptable and appreciated by men, while other programme components, notably partner testing, condom use and the infant feeding recommendations, were met with continued resistance.
Abstract: Background: Partner involvement has been deemed fundamental in prevention of mother to child transmission (PMTCT) programmes, but is difficult to achieve. This study aimed to explore acceptability of the PMTCT programme components and to identify structural and cultural challenges to male involvement. Methods: The study was conducted during 2007-2008 in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used, and included focus group discussions with fathers and mothers, in-depth interviews with fathers, mothers and health personnel, and a survey of 426 mothers bringing their four-week-old infants for immunization at five reproductive and child health clinics. Results: Routine testing for HIV of women at the antenatal clinic was highly acceptable and appreciated by men, while other programme components, notably partner testing, condom use and the infant feeding recommendations, were met with continued resistance. Very few men joined their wives for testing and thus missed out on PMTCT counselling. The main barriers reported were that women did not have the authority to request their husbands to test for HIV and that the arena for testing, the antenatal clinic, was defined as a typical female domain where men were out of place. Conclusions: Deep-seated ideas about gender roles and hierarchy are major obstacles to male participation in the PMTCT programme. Empowering women remains a huge challenge. Empowering men to participate by creating a space within the PMTCT programme that is male friendly should be feasible and should be highly prioritized for the PMTCT programme to achieve its potential.
125 citations
Cites result from "Acceptability of evidence-based neo..."
...These findings concur with those of a study done in two districts of eastern Uganda where stock out of maama kits was a common occurrence and a barrier for women to deliver at health facilities [27]....
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References
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TL;DR: An overview of important concepts related to qualitative content analysis is provided and measures to achieve trustworthiness (credibility, dependability and transferability) throughout the steps of the research procedure are proposed.
16,695 citations
"Acceptability of evidence-based neo..." refers background in this paper
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TL;DR: Haemorrhage and hypertensive disorders are major contributors to maternal deaths in developing countries and these data should inform evidence-based reproductive health-care policies and programmes at regional and national levels.
3,593 citations
"Acceptability of evidence-based neo..." refers background in this paper
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TL;DR: The proportion of child deaths that occurs in the neonatal period (38% in 2000) is increasing, and the Millennium Development Goal for child survival cannot be met without substantial reductions in neonatal mortality.
3,481 citations
"Acceptability of evidence-based neo..." refers background in this paper
...Initiatives to scale-up the recommended practices for improving neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of packages to address the local health system and socio-cultural situation....
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...However, it is not clear how feasible and locally acceptable these recommended practices are, or which delivery strategies to use in SubSaharan Africa (SSA)....
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...In addition, over 515,000 women die from pregnancyrelated complications each year, about half in Africa [6]....
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...Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation....
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...Most of these maternal and newborn deaths are caused by preventable causes [4,7]....
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TL;DR: Findings from a broad body of research on the factors that delay the decision to seek care are presented and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.
2,754 citations
TL;DR: The importance of undernutrition as an underlying cause of child deaths associated with infectious diseases, the effects of multiple concurrent illnesses, and recognition that pneumonia and diarrhoea remain the diseases that are most often associated with child deaths as mentioned in this paper.
2,680 citations