Karen Odberg Pettersson

Knowledge of obstetric danger signs and birth preparedness practices among women in rural Uganda

BackgroundImproving knowledge of obstetric danger signs and promoting birth preparedness practices are strategies aimed at enhancing utilization of skilled care in low-income countries. The aim of the study was to explore the association between knowledge of obstetric danger signs and birth preparedness among recently delivered women in south-western Uganda.MethodsThe study included 764 recently delivered women from 112 villages in Mbarara district. Community survey methods were used and 764 recently delivered women from 112 villages in Mbarara district were included in study. Interviewer administered questionnaire were used to collect data. Logistic regression analyses were conducted to explore the relationship between knowledge of key danger signs and birth preparedness.ResultsFifty two percent of women knew at least one key danger sign during pregnancy, 72% during delivery and 72% during postpartum. Only 19% had knowledge of 3 or more key danger signs during the three periods. Of the four birth preparedness practices; 91% had saved money, 71% had bought birth materials, 61% identified a health professional and 61% identified means of transport. Overall 35% of the respondents were birth prepared. The relationship between knowledge of at least one key danger sign during pregnancy or during postpartum and birth preparedness showed statistical significance which persisted after adjusting for probable confounders (OR 1.8, 95% CI: 1.2-2.6) and (OR 1.9, 95% CI: 1.2-3.0) respectively. Young age and high levels of education had synergistic effect on the relationship between knowledge and birth preparedness. The associations between knowledge of at least one key danger sign during childbirth or knowledge that prolonged labour was a key danger sign and birth preparedness were not statistically significant.ConclusionsThe prevalence of recently delivered women who had knowledge of key danger signs or those who were birth prepared was very low. Since the majority of women attend antenatal care sessions, the quality and methods of delivery of antenatal care education require review so as to improve its effectiveness. Universal primary and secondary education programmes ought to be promoted so as to enhance the impact of knowledge of key danger signs on birth preparedness practices.

Associations between mass media exposure and birth preparedness among women in southwestern Uganda: a community-based survey

Background Exposure to mass media provides increased awareness and knowledge, as well as changes in attitudes, social norms and behaviors that may lead to positive public health outcomes. Birth preparedness (i.e. the preparations for childbirth made by pregnant women, their families, and communities) increases the use of skilled birth attendants (SBAs) and hence reduces maternal morbidity and mortality. Objective The aim of this study was to explore the association between media exposure and birth preparedness in rural Uganda. Method A total of 765 recently delivered women from 120 villages in the Mbarara District of southwest Uganda were selected for a community-based survey using two-stage cluster sampling. Univariate and multivariate logistic regression was performed with generalized linear mixed models using SPSS 21. Results We found that 88.6% of the women surveyed listened to the radio and 33.9% read newspapers. Birth preparedness actions included were money saved (87.8%), identified SBA (64.3%), identified transport (60.1%), and purchased childbirth materials (20.7%). Women who had taken three or more actions were coded as well birth prepared (53.9%). Women who read newspapers were more likely to be birth prepared (adjusted OR 2.2, 95% CI 1.5–3.2). High media exposure, i.e. regular exposure to radio, newspaper, or television, showed no significant association with birth preparedness (adjusted OR 1.3, 95% CI 0.9–2.0). Conclusion Our results indicate that increased reading of newspapers can enhance birth preparedness and skilled birth attendance. Apart from general literacy skills, this requires newspapers to be accessible in terms of language, dissemination, and cost.Background Exposure to mass media provides increased awareness and knowledge, as well as changes in attitudes, social norms and behaviors that may lead to positive public health outcomes. Birth preparedness (i.e. the preparations for childbirth made by pregnant women, their families, and communities) increases the use of skilled birth attendants (SBAs) and hence reduces maternal morbidity and mortality. Objective The aim of this study was to explore the association between media exposure and birth preparedness in rural Uganda. Method A total of 765 recently delivered women from 120 villages in the Mbarara District of southwest Uganda were selected for a community-based survey using two-stage cluster sampling. Univariate and multivariate logistic regression was performed with generalized linear mixed models using SPSS 21. Results We found that 88.6% of the women surveyed listened to the radio and 33.9% read newspapers. Birth preparedness actions included were money saved (87.8%), identified SBA (64.3%), identified transport (60.1%), and purchased childbirth materials (20.7%). Women who had taken three or more actions were coded as well birth prepared (53.9%). Women who read newspapers were more likely to be birth prepared (adjusted OR 2.2, 95% CI 1.5-3.2). High media exposure, i.e. regular exposure to radio, newspaper, or television, showed no significant association with birth preparedness (adjusted OR 1.3, 95% CI 0.9-2.0). Conclusion Our results indicate that increased reading of newspapers can enhance birth preparedness and skilled birth attendance. Apart from general literacy skills, this requires newspapers to be accessible in terms of language, dissemination, and cost.

Influence of Birth Preparedness, Decision-Making on Location of Birth and Assistance by Skilled Birth Attendants among Women in South-Western Uganda

Introduction Assistance by skilled birth attendants (SBAs) during childbirth is one of the strategies aimed at reducing maternal morbidity and mortality in low-income countries. However, the relationship between birth preparedness and decision-making on location of birth and assistance by skilled birth attendants in this context is not well studied. The aim of this study was to assess the influence of birth preparedness practices and decision-making and assistance by SBAs among women in south-western Uganda. Methods Community survey methods were used to identify 759 recently delivered women from 120 villages in rural Mbarara district. Interviewer-administered questionnaires were used to collect data. Logistic regression analyses were conducted to assess the relationship between birth preparedness, decision-making on location of birth and assistance by SBAs. Results 35% of the women had been prepared for childbirth and the prevalence of assistance by SBAs in the sample was 68%. The final decision regarding location of birth was made by the woman herself (36%), the woman with spouse (56%) and the woman with relative/friend (8%). The relationships between birth preparedness and women decision-making on location of birth in consultation with spouse/friends/relatives and choosing assistance by SBAs showed statistical significance which persisted after adjusting for possible confounders (OR 1.5, 95% CI: 1.0–2.4) and (OR 4.4, 95% CI: 3.0–6.7) respectively. Education, household assets and birth preparedness showed clear synergistic effect on the relationship between decision-maker on location of birth and assistance by SBAs. Other factors which showed statistical significant relationships with assistance by SBAs were ANC attendance, parity and residence. Conclusion Women’s decision-making on location of birth in consultation with spouse/friends/relatives and birth preparedness showed significant effect on choosing assistance by SBAs at birth. Education and household assets ownership showed a synergistic effect on the relationship between the decision-maker and assistance by SBAs.

The pathway of obstructed labour as perceived by communities in south-western Uganda: a grounded theory study

Background : Obstructed labour is still a major cause of maternal and perinatal morbidity and mortality in Uganda, where many women give birth at home alone or assisted by non-skilled birth attendants. Little is known of how the community view obstructed labour, and what actions they take in cases where this complication occurs. Objective : The objective of the study was to explore community members’ understanding of and actions taken in cases of obstructed labour in south-western Uganda. Design : Grounded theory (GT) was used to analyse data from 20 focus group discussions (FGDs), 10 with women and 10 with men, which were conducted in eight rural and two urban communities. Results : A conceptual model based on the community members’ understanding of obstructed labour and actions taken in response is presented as a pathway initiated by womens desire to ‘protecting own integrity’ (core category). The pathway consisted of six other categories closely linked to the core category, namely: (1) ‘taking control of own birth process’; (2) ‘reaching the limit – failing to give birth’ (individual level); (3) ‘exhausting traditional options’; 4 ‘partner taking charge’; (5) ‘facing challenging referral conditions’ (community level); and finally (6) ‘enduring a non-responsive healthcare system’ (healthcare system level). Conclusions : There is a need to understand and acknowledge womens reluctance to involve others during childbirth. However, the healthcare system should provide acceptable care and a functional referral system closer to the community, thus supporting the communitys ability to seek timely care as a response to obstructed labour. Easy access to mobile phones may improve referral systems. Upgrading of infrastructure in the region requires a multi-sectoral approach. Testing of the conceptual model through a quantitative questionnaire is recommended.

Adaptation of health care seeking behavior during childbirth: Focus group discussions with women living in the suburban areas of Luanda, Angola

The aim of this study was to explore how various factors influenced womens decisions regarding place of confinement in Luanda, Angola. Ten focus group discussions were conducted with pregnant and nonpregnant women residing in suburban areas of Luanda and the data were analyzed using the grounded theory technique. Four patterns of action of the main theme, “the molding of womens care-seeking behavior during childbirth,” were identified: (I) the “labor process ‘on-course’ avoiding pattern”; (II) the “labor process ‘off-course’ avoiding pattern”; (III) the “labor process ‘on-course’ approaching pattern”; and (IV) the “labor process ‘off-course’ approaching pattern.” Our findings indicate that personal “courage” and social support empowered women and impacted on their preference for home birth, whereas demand for informal user fees and perceived low quality of care influenced women to avoid institutional care during childbirth, sometimes even in spite of complications. Ability to meet demands for informal user fees and knowledge of childbirth influenced women to seek institutional care. The study highlights the need to improve the quality of available maternal health care addressing the implicit educational, attitudinal, and ethical issues.

Willingness and acceptability of cervical cancer screening among HIV positive Nigerian women

BackgroundThe proven benefit of integrating cervical cancer screening programme into HIV care has led to its adoption as a standard of care. However this is not operational in most HIV clinics in Nigeria. Of the various reasons given for non-implementation, none is backed by scientific evidence. This study was conducted to assess the willingness and acceptability of cervical cancer screening among HIV positive Nigerian women.MethodsA cross sectional study of HIV positive women attending a large HIV treatment centre in Lagos, Nigeria. Respondents were identified using stratified sampling method. A pretested questionnaire was used to obtain information by trained research assistants. Obtained information were coded and managed using SPSS for windows version 19. Multivariate logistic regression model was used to determine independent predictor for acceptance of cervical cancer screening.ResultsOf the 1517 respondents that returned completed questionnaires, 853 (56.2%) were aware of cervical cancer. Though previous cervical cancer screening was low at 9.4%, 79.8% (1210) accepted to take the test. Cost of the test (35.2%) and religious denial (14.0%) were the most common reasons given for refusal to take the test. After controlling for confounding variables in a multivariate logistic regression model, having a tertiary education (OR = 1.4; 95% CI: 1.03-1.84), no living child (OR: 1.5; 95% CI: 1.1-2.0), recent HIV diagnosis (OR: 1.5; 95% CI: 1.1-2.0) and being aware of cervical cancer (OR: 1.5; 95% CI: 1.2-2.0) retained independent association with acceptance to screen for cervical cancer.ConclusionsThe study shows that HIV positive women in our environment are willing to screen for cervical cancer and that the integration of reproductive health service into existing HIV programmes will strengthen rather than disrupt the services.

Inadequate Knowledge of Neonatal Danger Signs among Recently Delivered Women in Southwestern Rural Uganda: A Community Survey

Background Early detection of neonatal illness is an important step towards improving newborn survival. Every year an estimated 3.07 million children die during their first month of life and about one-third of these deaths occur during the first 24 hours. Ninety-eight percent of all neonatal deaths occur in low- and middle-income countries like Uganda. Inadequate progress has been made globally to reduce the amount of neonatal deaths that would be required to meet Millennium Development Goal 4. Poor knowledge of newborn danger signs delays care seeking. The aim of this study was to explore the knowledge of key newborn danger signs among mothers in southwestern Uganda. Methods Results from a community survey of 765 recently delivered women were analyzed using univariate and multivariate logistic regressions. Six key danger signs were identified, and spontaneous responses were categorized, tabulated, and analyzed. Results Knowledge of at least one key danger sign was significantly associated with being birth prepared (adjusted OR 1.7, 95% CI 1.2–2.3). Birth preparedness consisted of saving money, identifying transportation, identifying a skilled birth attendant and buying a delivery kit or materials. Overall, respondents had a poor knowledge of key newborn danger signs: 58.2% could identify one and 14.8% could identify two. We found no association between women attending the recommended number of antenatal care visits and their knowledge of danger signs (adjusted OR 1.0, 95% CI 0.8–1.4), or between women using a skilled birth attendant at delivery and their knowledge of danger signs (adjusted OR 1.2, 95% CI 0.9–1.7). Conclusions Our findings indicate the need to enhance education of mothers in antenatal care as well as those discharged from health facilities after delivery. Further promotion of birth preparedness is encouraged as part of the continuum of maternal care.

Individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda

BackgroundObstructed labour is still a major cause of maternal morbidity and mortality and of adverse outcome for newborns in low-income countries. The aim of this study was to investigate the role of individual and health facility factors and the risk for obstructed labour and its adverse outcomes in south-western Uganda.MethodsA review was performed on 12,463 obstetric records for the year 2006 from six hospitals located in south-western Uganda and 11,180 women records were analysed. Multivariate logistic regression analyses were applied to control for probable confounders.ResultsPrevalence of obstructed labour for the six hospitals was 10.5% and the main causes were cephalopelvic disproportion (63.3%), malpresentation or malposition (36.4%) and hydrocephalus (0.3%). The risk of obstructed labour was statistically significantly associated with being resident of a particular district [Isingiro] (AOR 1.39, 95% CI: 1.04-1.86), with nulliparous status (AOR 1.47, 95% CI: 1.22-1.78), having delivered once before (AOR 1.57, 95% CI: 1.30-1.91) and age group 15-19 years (AOR 1.21, 95% CI: 1.02-1.45). The risk for perinatal death as an adverse outcome was statistically significantly associated with districts other than five comprising the study area (AOR 2.85, 95% CI: 1.60-5.08) and grand multiparous status (AOR 1.89, 95% CI: 1.11-3.22). Women who lacked paid employment were at increased risk of obstructed labour. Perinatal mortality rate was 142/1000 total births in women with obstructed labour compared to 65/1000 total births in women without the condition. The odds of having maternal complications in women with obstructed labour were 8 times those without the condition. The case fatality rate for obstructed labour was 1.2%.ConclusionsIndividual socio-demographic and health system factors are strongly associated with obstructed labour and its adverse outcome in south-western Uganda. Our study provides baseline information which may be used by policy makers and implementers to improve implementation of safe motherhood programmes.

Magnitude and trends of inequalities in antenatal care and delivery under skilled care among different socio-demographic groups in Ghana from 1988 - 2008.

BackgroundImproving maternal and reproductive health still remains a major challenge in most low-income countries especially in sub-Saharan Africa. The growing inequality in access to maternal health interventions is an issue of great concern. In Ghana, inadequate attention has been given to the inequality gap that exists amongst women when accessing antenatal care during pregnancy and skilled attendance at birth. This study therefore aimed at investigating the magnitude and trends in income-, education-, residence-, and parity-related inequalities in access to antenatal care and skilled attendance at birth.MethodsA database was constructed using data from the Ghana Demographic and Health Surveys (DHS) 1988, 1993, 1998, 2003, and 2008. The surveys employed standard DHS questionnaires and techniques for data collection. We applied regression-based Total Attributable Fraction (TAF) as an index for measuring socioeconomic inequalities in antenatal care and skilled birth attendance utilization.ResultsThe rural–urban gap and education-related inequalities in the utilization of antenatal care and skilled birth attendants seem to be closing over time, while income- and parity-related inequalities in the use of antenatal care are on a sharp rise. Income inequality regarding the utilization of skilled birth attendance was rather low and stable from 1988 to 1998, increased sharply to a peak between 1998 and 2003, and then leveled-off after 2003.ConclusionsThe increased income-related inequalities seen in the use of antenatal care and skilled birth attendance should be addressed through appropriate strategies. Intensifying community-based health education through media and door-to-door campaigns could further reduce the mentioned education- and parity-related inequalities. Women should be highly motivated and incentivized to attend school up to secondary level or higher. Education on the use of maternal health services should be integrated into basic schools so that women at the lowest level would be inoculated with the appropriate health messages.

The Association between HIV Infection, Antiretroviral Therapy and Cervical Squamous Intraepithelial Lesions in South Western Nigerian Women

Introduction Findings from studies that evaluated the effect of antiretroviral drug use on the development of cervical squamous intraepithelial lesion differed in their conclusions. This study investigated the association between HIV infection, antiretroviral drug use and cervical squamous intraepithelial lesion in a high HIV and cervical cancer burden setting- Nigeria. Methods A cross sectional study among 1140 women of known HIV status enrolled in a randomised study to determine the test characteristics of visual inspection in detecting cytology diagnosed squamous intraepithelial lesion. Multivariate analysis was used to determine the association between HIV infection, antiretroviral drug use and the twin outcome variables of cervical squamous intraepithelial lesion (SIL) and High grade squamous intraepithelial lesion (HSIL) while controlling for confounders. Results Prevalence of cervical squamous intraepithelial lesion was 8.5%, with a higher prevalence of 14.3% in HIV positive compared to 3.3% in HIV negative women (aOR: 5.4; 95% CI: 2.9–8.8). Not using antiretroviral drugs was found to be associated with an increased risk of SIL (aOR: 2.1; 95% CI: 1.4–3.5) and HSIL (aOR: 2.6; 95% CI: 1.1–6.4). Participants who had a CD4 cell count <200 cells/mm3, were also found to be at increased risk for SIL (aOR: 1.9; 95% CI: 1.1–5.9) and HSIL (aOR: 5.7; 95% CI: 1.1–7.2). Conclusion HIV infection and severe immunosuppression were found to be associated with increased risk of cervical squamous intraepithelial lesion but not viral load. For the first time, in the West African sub-region with specific HIV type and strains, we established the protective effect of antiretroviral drug use against the development of SIL. Integration of cervical cancer screening programme into HIV services and early initiation of antiretroviral drug in HIV positive women especially those with severe immune-suppression could therefore prove to be useful in preventing and controlling cervical cancer development in HIV positive women.