Background
Methods
Study design
Study setting
ANC and IPTp in Uganda
Study regions and districts
ANC1a
| ANC4b
| IPT1c
| IPT2d
| |||||
---|---|---|---|---|---|---|---|---|
2011 | 2012 | 2011 | 2012 | 2011 | 2012 | 2011 | 2012 | |
Uganda | 90 | 84 | 29 | 28 | 58 | 79 | 44 | 50 |
Eastern | 73 | 67 | 18 | 18 | 79 | 83 | 51 | 52 |
Urban study district | 57 | 66 | 15 | 29 | 97 | 96 | 70 | 76 |
Rural study district | 43 | 61 | 6 | 9 | 78 | 93 | 66 | 55 |
West Nile | 46 | 57 | 18 | 22 | 83 | 86 | 59 | 62 |
Urban study district | 61 | 101 | 19 | 36 | 76 | 81 | 50 | 54 |
Rural study district | 20 | 22 | 13 | 11 | 92 | 92 | 71 | 69 |
Health facilities
Participant selection
Type of respondent | Number of respondents | Approached by | Location of interview |
---|---|---|---|
District health officials | |||
Malaria Focal Persons | 3 | District health officer, 1 week prior to research team’s visit to district | Respondents’ usual place of work |
Assistant District Health Officer (Maternal and Child Health) | 1 | ||
Health Educator | 1 | ||
Health Management Information System Focal Person | 1 | ||
Stores Assistant | 1 | ||
Total district health officials | 7 | ||
Health workers | |||
In-charges | 7 | Facility in-charge, 1 week prior to research team’s visit to facility | Respondents’ usual place of work |
Midwives | 8 | ||
Total health workers | 15 | ||
Women | |||
Pregnant and received IPTp | 8 | Researcher on day of visit to community | Respondents’ home or health facility |
Recently given birth and received IPTp | 8 | ||
Recently given birth and did not receive IPTp | 3 | ||
Total women | 19 | ||
Opinion leaders | |||
Traditional birth attendants | 2 | Researcher on day of visit to community | Respondents’ home |
Community councillor | 1 | ||
Teacher | 1 | ||
Retired midwife | 1 | ||
Total opinion leaders | 5 |
District health officials
Health workers
Women
Opinion leaders
Data collection
Field work
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ANC register to establish number of first (IPT1) and second (IPT2) doses of IPTp provided and number of first (ANC1) and fourth (ANC4) visits;
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Monthly reports filed by the facility to the district level to compare IPTp and ANC data reported to the district level with data recorded in the facility’s register;
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SP stock cards to determine availability of SP for the provision of IPTp.
Data collection tools
Topic | District health officials | Health workers | Women | Opinion leaders |
---|---|---|---|---|
Role/responsibilities | X | X | – | X |
Stakeholders and coordination | X | – | – | – |
Policies and guidelines | X | X | – | – |
Provision of ANC services | – | X | X | X |
Supply chain | X | X | X | X |
Capacity building | – | X | – | – |
Health worker knowledge and perceptions of IPTp | – | X | – | – |
Transcription and translation
Data analysis
Results and discussion
Stakeholders and coordination
District official 1: If—maybe—majority of them—like HIV. That’s where they now are. They are there. If maybe we could talk with them and integrate it there. Because malaria has an effect with HIV positive persons. If they talk to— maybe they could integrate. But most of their activity that I see, there’s no malaria.
District official 5: Well – the organization which, err, handles aspect of – specific organization which addresses aspect of malaria in pregnancy is – not so far well streamlined.
Policies and guidelines
Consistency and relevance of guidelines
District official 2: Then maybe one can receive that one who is at 36. What do I do? They told me 28. You are late. You have missed out.
Male involvement in ANC
Opinion leader 5: Sometimes when the pregnant women go without their partners, they are sent back and such a woman will refuse to go again unless the partner is there—and when the partners is far from her, the woman will not even step the health [facility] again.
Woman 5: The two visits I made with my husband we were attended quickly and we didn’t take long at the facility, but when I went alone, I took long, because those with partners are attended first.
Provision of ANC services
Availability and accessibility of ANC services
Woman 16: They said each institution has different rules and regulations and at such a time they do other things, not to attend to mothers now.
Opinion leader 2: So these women from the village, they come footing up to the dispensary. Now, reaching there, they will get the nurses already selected twenty. The first twenty –Opinion leader 1: Are the ones they handle.Opinion leader 2: They will tell the majority, “Go back and come back next week.” […] Because now, for them they will always select the first twenty.
Opinion leader 2: You know like these village women, they come on their skirts, what – like that [indicates tight fitting skirt]. So these nurses want, “You come when you are putting on your maternity [refers to a wide, loose-fitting skirt conventionally worn by pregnant women]. You have a leso [a cloth wrapped around the waist], we will attend to you.”
Job satisfaction
District official 1: Maybe also the other factor is—I cannot fear to mention this—is the attitude of the health workers—the ANC midwives. Their treatment to the – to the mothers. Also—possibly also can make them shy away.
Woman 2: In this health centre, you are welcomed and treated well. They mind of your health and the wellbeing of pregnant women.
Incentives
District official 5: But, you’ll realize that some of these indicators just improve—sometimes they just improve by themselves when a cer—especially when certain incentives are there. Like, recently, there is net—because of the net, the enrolment has started changing.
Researcher: Is there anything else that encouraged you to go for ANC that first time?Woman 3: Yes, I went to the hospital they gave me my net I came back to sleep under my net.
Supply chain
Availability of SP
Health worker 7: Because now our mothers are used – […] It motivates them that when you are going to a facility, there is that saying – they say that, “alosingo amat ekiya” [Ateso for ‘I am going to take medicine’], so if she goes away without any medicine, it will imply that her visit was not fruitful, so it demoralizes them.
Availability of water and cups
Capacity building
Individual supervision
Health worker 11: Actually I don’t know how I should say it has not really been so much there. It is just once in a while.
Training
Health worker 11: I think the training would be better on job here – not carrying people somewhere, but it would be better here just on job. Like it is an antenatal day, mothers are also there – we get mothers so – kind of mentorship I think it would be better.
Health worker knowledge and perceptions of IPTp
Health worker knowledge
Safety and efficacy
Health worker 11: But about how efficient, I have some questions about it and am not really very sure if it is really efficient. As I told you before, much as mothers take it, they still suffer from malaria. So my concern is in that area how efficient it works.
Health worker 12: Well, there is this slight side effect of having maybe headache, dizziness—the dizziness is there. Maybe nausea—feeling like vomiting. But we have not got very serious side effects which is adverse effect—adverse —which is worse side effect. We have not got it. But this one of nausea—feeling like vomiting—abdominal pain—they complain. But it’s mild. It’s mild. Not very serious yet.
Offering IPTp
Researcher: What reasons were you told for not getting the tablets?Woman 19: The nurse did not tell me why I didn’t receive the tablets.Researcher: There was nothing you were told completely?Woman 19: The nurse only examined me and there after she did not tell me the reason for not getting the tablets.
Health worker 8: We got one who said in the previous pregnancy she took it and it really worsened her condition – as in she started vomiting – that thing – and you know, so we just – what we did was to give her the information – ok to give her the benefits of taking IPTp, but we didn’t force her to take.
Health worker 9: Of course during health education talks they can ask you questions. In case when somebody develops side effects like rush and they—and in case somebody develop—feel sometimes nausea, but with the help of health information given to them, they accept.
Observing DOT
Health worker 12: Well, practically what we do is when these people come for antenatal, we tell them to take it at DOT. […] But the challenge is some mothers—they have come minus having breakfast. So they fear taking the drugs minus food. We tell them, “No you can take and go home, then have food.” But some insists they are going to take it, they first want to eat then they take the drugs, which is also right.
Monitoring and evaluation
Data recording and reporting practices
Health worker 5: Yes—and also with our reporting. […] So it’s a daily thing—so it is something which is every day. So I think you cannot even forget it since you’ve started it and something which is in record that you are supposed to do it on daily basis whenever a mother—it’s a routine.
District official 7: Okay now, secondly, when we get it—like we—we do—we have ANC1—ANC first visit is 218. IPT1 is rated maybe 300. That one can’t happen. So we reduce that one to this [indicates act of replacing one figure for another].
Data accuracy
District official 1: Then at the end of the month, you say, “Ah, what do I do?” That’s where I’m—the other—maybe the other issue of exaggerating data comes in. You can feel, “Ah, now, I need to be performing better. Well, my mothers have been—and the numbers have been ok. Then this time, what will they think, hm?” I think that’s what I—my mind takes me that maybe that’s where it sometimes—you get these figures interchanged.
Health worker 3: Challenges when women are very many, you get tired and sometimes, recording, you need to record, you need to go for other things, examinations.
Conclusions
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Stakeholders and coordination Governments and implementation partners should increase efforts to build strong linkages and improve integration in order to ensure that health programmes reach those most in need.
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Policies and guidelines In its latest policy recommendation, WHO acknowledges that “confusion among health workers” contributed to a slowing down of efforts to scale up IPTp and expresses the hope that the new simplified guidelines will help increase uptake of IPTp through avoiding ambiguity in terms of number of doses required and ideal timing [16]. While Uganda adopted this recommendation in May 2016, ensuring that health workers are aware of the policy change and implement it in their day-to-day job should be treated as a matter of priority. In the light of reports of preferential treatment for women attending with their partners, the national-level policy, which encourages male ANC attendance, should be clarified, emphasizing the imperative to provide ANC services to all women equally, regardless of whether or not they attend with their partner.
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Provision of ANC services ANC should be offered consistently at all suitable health facilities in line with national policy. Governments must provide for adequate staffing levels, but health workers also need to observe professional and respectful behaviour towards all ANC clients and ensure all pregnant women attending ANC have equal access to services. In particular, this applies to women who miss appointments, present late for ANC or are perceived to be inadequately dressed. Early and regular ANC attendance should be encouraged through the provision of incentives, such as mosquito nets.
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Supply chain While only one PNFP facility was visited and this type of service provider was therefore under-represented in the sample, the issue of persisting stock-outs of SP in PNFP facilities was confirmed more widely by district health officials. In the interest of equity, the Government should enable PNFP facilities to offer IPTp to pregnant women by providing SP free-of-charge. In addition to ensuring IPTp is provided to women who attend ANC, ensuring availability of SP will also positively influence communities’ attitudes towards ANC and hence help to maintain high ANC uptake.
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Capacity building and health worker knowledge and perceptions of IPTp To improve health worker knowledge of IPTp guidelines, opportunities for training and supervision should be intensified. Training should emphasize that it is safe to take SP on an empty stomach and that women should be encouraged to take IPTp as DOT, even if they ask to take the drug home, for example, because they have not eaten. Clear guidance with regard to distinguishing between mild and severe side effects should be provided, emphasizing that women should still be encouraged to take SP if they have previously experienced mild side effects. Taking into account health workers’ preference for non-disruptive training, innovative methods such as peer learning, mentoring or the use of mobile technology should be trialled in addition to traditional classroom training.
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Monitoring and evaluation In order to improve the quality and reliability of data relating to ANC and IPTp at the facility and district level, supply of standard recording and reporting tools to all health facilities needs to be ensured. It will also be necessary to improve health workers’ data management skills, provide clear guidelines with regard to recording practices and ensure data entry forms are designed to capture all plausible scenarios. In addition to assessing completeness and timeliness of reported facility-level data, districts should also provide feedback with regard to data accuracy.