Background
Methods
Stage 1: problem statement
Stage 2: field studies
Study population and sampling criteria
Category | Sample size | Sampling approach | Criteria | Comment |
---|---|---|---|---|
Mothers | 282 | Random sampling | Mothers who delivered in the last 12 months residing in Rubaga and Kawempe divisions | Overall, 274 interviews were considered; 8 had significant missing information |
Village health workers (VHWs) and community leaders | 16 VHWs and 10 community leaders | Convenience sampling approach | VHWs and community leaders residing in Rubaga and Kawempe divisions | We stopped identifying new interviewees when no new issues were raised in the last interviews |
Frontline health workers (FHWs) | 20 FHWs (13 nurse/midwife/clinical officers and 7 doctors) | Purposive sampling inclusive of both government and private health units in the two divisions. | Officers-in-charge of the facility and/or health workers providing voluntary counselling and testing, or prevention of mother to child transmission services | One staff was interviewed from each available cadre/level |
Healthcare decision and policy makers | 7 leaders/policy makers | A purposive sampling approach. | Selected on the basis of their role in formulation and implementation of neonatal health policies | All the leaders/policy makers were interviewed |
Mothers
Village health workers and community leaders
Front-line health workers
-
Kawempe: Mulago National Referral Hospital, one private hospital, Kawempe government health centre IV and three private health centres.
-
Rubaga: Mengo hospital (mission hospital private not-for-profit), one private hospital, two private health Centres, and two government health centre III.
Healthcare decision and policy makers
Ethical consideration
Variable | Category | n (Percentage) |
---|---|---|
Age | 15–20 | 49 (17.9) |
21–30 | 162 (59.1) | |
31–40 | 59 (21.5) | |
40+ | 4 (1.5) | |
Total
|
274 (100)
| |
Marital status | Married | 209 (76.4) |
Not married | 64 (23.2) | |
Widowed/divorced | 1 (0.4) | |
Total
|
274 (100)
| |
Highest level of education | None | 9 (3.3) |
P1–P7 | 72 (26.2) | |
Secondary education | 140 (51.7) | |
Post-secondary education | 51 (18.8) | |
Total
|
274 (100)
| |
Occupation | Farmer | 5 (1.8) |
Housewife/does not work | 122 (44.7) | |
Health worker | 9 (3.3) | |
Teacher | 13 (4.8) | |
Business woman | 94 (34.1) | |
Other professions | 31 (11.4) | |
Total
|
274 (100)
| |
Household income per month (UGX) (1 USD = 2,500 UGX) | Below 50,000 | 34 (12.4) |
50,000–100,000 | 66 (24.1) | |
Above 100,000 | 144 (52.6) | |
Not indicated | 30 (10.9) | |
Total
|
274 (100)
| |
Number of pregnancies | 1–3 | 204 (74.4) |
4–6 | 63 (23.1) | |
7+ | 7 (2.6) | |
Total
|
274 (100)
| |
Had lost neonate | Yes | 18 (6.6) |
No | 256 (93.43) | |
Total
|
274 (100)
|
Stage 3: model building and validation of the causal loop diagrams
Development of casual loop diagrams
Validation of the causal loop diagrams
Position | Affiliation | Number |
---|---|---|
Head of Paediatrics Department | Mengo Hospital, Uganda | 1 |
Obstetrician and Gynaecologist | Mulago Referral Hospital, Uganda | 2 |
Lecturer, Department of Obstetrics and Gynaecology | College of Health Sciences, Makerere University, Uganda | 1 |
Nursing Officer In-charge of Maternity Department | Mengo Hospital, Uganda | 1 |
Head, Obstetrician and Gynaecologist | Mengo Hospital, Uganda | 1 |
Paediatrician and researcher in maternal, neonatal, and child health issues | Universidad Peruana Cayetano Heredia and Universidad Nacional Mayor de San Marcos, Lima, Perú | 1 |
Paediatrician/Professor | Department of Global Public Health and Primary Care, University of Bergen, Norway | 1 |
Paediatrician/Neonatologist | WHO, Coordinator, of the maternal, neonatal and child research and development team | 1 |
Findings
Demand side issues
Pre-conception
Antenatal care
Delivery
Postnatal care
Attitudes and beliefs
Sources of information
Supply side issues
Quality of health service and hygiene
Health workers motivation
Availability of supplies and equipment
Record keeping
Policy enforcement
Supervision
Causal loop diagrams
Dynamics of the demand for neonatal and maternal healthcare service
Dynamics of the supply for neonatal and maternal healthcare service
Validation of the causal loop diagrams
Parameter | Rating categories | Number of respondents |
---|---|---|
Were they reasonable (realistic)? | Very reasonable | 2 |
Reasonable | 6 | |
Fairly reasonable | 1 | |
Not reasonable | ||
How well did they represent issues related to neonatal health services? | Very good | 4 |
Good | 5 | |
Fairly good | ||
Not at all good | ||
Are they useful as a communication tool? | Very useful | 2 |
Useful | 6 | |
Fairly useful | 1 | |
Not at all useful | ||
Are they a useful aid tool that can be used by stakeholders in decision making? | Very useful | 3 |
Useful | 5 | |
Fairly useful | 1 | |
Not at all useful |
Discussion
Leverages
-
Increased awareness on maternal and neonatal healthcare can weaken the vicious cycle exhibited by the myths loop (R3) while strengthening the virtuous cycle of the awareness loop (R1). Mothers’ awareness on the recommended feeding, nutrition, hygiene, household environment, and mothers’ birth preparedness and efforts to avoid untreated diseases results in improved health of the mothers, which in turn lowers neonatal mortality rates. Some of the short-term interventions which may improve awareness include aggressive advertising, campaigns, sensitization, and education of the women and girl child as well as increasing the effectiveness of the health education sessions during ANC and PNC. Special gender considerations to ensure that girls receive essential education thereby increasing maternal mortality rates is a longer term strategy but would synergistically address many other health and non-health issues.
-
The low socio-economic status is a key determinant in the health of the mothers and the neonates. With improved socio-economic status, mothers are able to obtain the recommended nutrition, healthcare, and the requirements for birth preparedness. While introducing incentives, such as transport vouchers and free birth kits for pregnant women, would motivate them to attend ANCs and enable them to be better prepared for health facility deliveries in the short term, the government should work towards improving the socioeconomic status of the nation.
-
Funding for maternal and neonatal health care should be prioritized at the national level. Efforts by the government and policy makers to upgrade the health service infrastructure as well as build systems for monitoring the resources (staffing, drugs, and stocks) would go a long way in minimizing the effects arising out of the frustration loop B1. Improved maternal and neonatal health service delivery will strengthen the virtuous cycle created by the motivation loop R5. In addition, without a motivated health work force that is well trained, adequately remunerated, and with an acceptable workload there is not much to be expected in terms of the quality of the care provided nor the likelihood that mothers will come to seek care at health facilities. Other short- and long-term strategies may include improved supervision and internal audits at health facilities to ensure that maternal and neonatal guidelines are adhered to as well as establish the current conditions and gaps in resources (human, logistics, and drugs) to guide the funding for national health care.