Acceptability of evidence-based maternal-neonatal care practices in rural Uganda -implications for programming

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Acceptability of evidence-based maternal-neonatal
care practices in rural Uganda -implications for
programming

• Peter Waiswa, Margaret Kemigisa, Juliet Kiguli,
  Sarah Naikoba,
• George Pariyo, Stefan Peterson

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Background-1

• Globally 4 million newborn deaths/year or 40 of
  U5M, 98 in developing countries
• Therefore achieving MDG4 requires reducing
  newborn deaths
• 50 occur on D1 and 75 occur in week one after
  birth
• Trend same for maternal death

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Background-2 In Uganda

• 44,500 newborn deaths and 45,100
  stillbirths/year 31,800 could be prevented 23
  of U5M are neonates
• 56 excess newborn deaths in rural areas comapred
  to urban
• 60 birth occur at home
• Only 12 newborns ever get postnatal care
• Iganga district About 900 newborn deaths, 850
  perinatal deaths (300 perinatal death in Iganga
  hospital alone)

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Background-3

• Causes preventable - 86 of neonatal deaths by 3
  preventable problems infections - 36
• prematurity - 27
• asphyxia - 23
• Recent evidence from Asia and S America low cost
  community interventions can reduce neonatal
  deaths by 20 - 40

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The Evidence Based Practices

• Birth preparedness and promotion of demand for
  care and readiness for emergencies
• Counseling and preparation of for newborn care
• Clean delivery
• Hygienic cord/skin care
• Thermal care
• Promotion of early and exclusive breastfeeding
• Health home care
• Extra care for low birth weight babies
• Community case management for pneumonia
• 4 ANC visits inc. IPT, TT
• Awareness and early detection and referral of
  danger signs

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Objectives

• To explore the acceptability of recommended
  evidence-based maternal-neonatal practices at
  community level
• To investigate acceptability of home visits by a
  CHW during pregnancy and in the early neonatal
  period to promote home care

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Methods

• 10 FGDs consisting of mothers, fathers and child
  minders-up to 13 years old
• 10 IDIs with health workers and traditional birth
  attendants
• Study done in Iganga/Mayuge Districts in Busoga
  subregion, Eastern Uganda
• Basoga are almost 10 of Ugandans

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Findings Acceptable Practices

• Attending ANC 4 times during pregnancy
• Maintenance of warmth through skin to skin
  contact
• Exclusive breast feeding
• Skilled care seeking for danger signs
• Facility/Supervised deliveries
• Early referral for danger signs
• Home visits by CHWs

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Findings Less acceptable Practices

• Early bathing babies believed to be born
  dirty
• My babies are usually born dirty, so it is a
  must for me to bathe the baby immediately I am
  discharged on that same day of giving birth. You
  people are your babies born clean. (FGD Older
  mothers).
• Putting nothing on cord that substances
  encourage early cord healing
• Care of premature babies at home belief that
  this should be in health facilities

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Findings Key challenges to home care

• Knowledge barriers, service delivery gaps
  cultural, traditional beliefs and practices and
  financial constraints
• Limited community knowledge on importance of
  attending ANC four times during pregnancy

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Findings Key challenges to home care

• Deep rooted beliefs in herbs
• Decision making not by women
• B/preparedness is hindered by poverty, cultural
  beliefs, limited awareness, lack of adequate male
  involvement and the fear of preparing for the
  unborn
• Most labour occurring at night
• No community knowledge on postnatal care except
  for immunisation

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Key challenges to home care

• ANC misconstrued as provision of medicine for
  sick pregnant women (okunwa obulezi)
• Yes, I was given three Fansidars and they are at
  home. I came back quarrelling. I went for ANC for
  assistance but by giving me only three tablets,
  how were they helping? Three tablets only! Yet I
  explained my condition in detail. (FGD Young
  Mothers)
• Yes, she (TBA) delivers and also changes the
  position of the baby if it is not laying right.
  She can also change the sex of the baby if you
  want. For instance if you have been giving birth
  to only boys and you want a girl, she can change
  the sex for you so that you deliver a girl.
  (FGD, older mothers)

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Preparing for birth is a burden to women and
hinders facility deliveries

• Alternative domestic services while mother is
  away
• Stocking food and firewood
• Finding other person to take care of home and
  children
• Gathering personal effects for mother-to-be and
  newborn
• Vaseline and soap
• A jerrycan for water and a basin for bathing
• Mother and Baby clothes and powder
• Buying materials for use by health care
  providers
• Gloves and razorblade (for cutting the cord)
• Threads (to be used as cord ligatures)
• Syringes, needles and injectable ergometrine (to
  stop postpartum haemorrge)
• Cotton wool
• Kavera/plastic sheet (an improvised mackintosh)
• Preparation for emergencies
• Asking transport money from male partners or
  saving from own sources

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Conclusions

• Evidence based practices for MN health may not be
  universally acceptable
• A one size fits all strategy to scale-up for
  all of SubSaharan Africa is likely to fail
• We suggest rapid appraisal and local adaptation
  of evidence-based practices and packages to
  address the local socio-cultural situation
• Health systems strengthening will be needed for
  community strategies to be effective
• Male involvement is key and promotion of waiting
  shelters at selected health units should be
  considered

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Acknowledgements

• Funders- Sida/SAREC, Saving Newborn Lives
  initiative of Save the Children/USA through a
  grant from the Bill and Melinda Gates Foundation.
  
• Study participants, DSS staff and research
  assistants, and the Study Policy Advisory Group.
• We acknowledge the useful comments on the
  manuscript made by Dr Joy Lawn.