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.
Highlights
Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings
Nearly 300,000 women worldwide die from pregnancy and childbirth-related causes each year [1]
Met need for emergency obstetric care, captured via the numbers of EMOC facilities per 100,000 population is estimated at 24 % nationally, but 14 % in the North [6, 9]
Summary
Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. 300,000 women worldwide die from pregnancy and childbirth-related causes each year [1] Most of these deaths are avoidable, as solutions for preventing them are wellknown [2]. Skilled birth attendance (SBA) during labour and delivery has been identified as “the single most important factor in preventing maternal deaths” [4], and is very unequal between the richest and poorest quintiles within countries. Percentages of health facility births are estimated at 90 % in urban areas but 53 % in rural settings. Met need for emergency obstetric care, captured via the numbers of EMOC facilities per 100,000 population is estimated at 24 % nationally, but 14 % in the North [6, 9]
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