KNOWLEDGE, PERCEPTIONS AND PRACTICES IN PREGNANCY AND

KNOWLEDGE, PERCEPTIONS AND PRACTICES IN PREGNANCY AND
CHILDBIRTH IN UGANDA: AN EXPLORATORY STUDY OF NANGABO SUBCOUNTY, WAKISO DISTRICT, UGANDA
HARRIET ADONG
BA (SS)
2005/HD14/3641U
A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF THE DEGREE OF MASTER OF ARTS
(SOCIOLOGY) OF MAKERERE UNIVERSITY KAMPALA.
OCTOBER, 2011
DECLARATION
I, Harriet Adong hereby declare to the best of my knowledge that this dissertation is as a
result of my original work and has not been presented elsewhere in part or otherwise for
the award of a degree in any other University/Institution or publication.
Harriet Adong
Signed……………………..
Date………………………..
Supervisor: Dr. Stella Neema, Senior Lecturer
Department of Sociology and Anthropology
School of Social Sciences
Makerere University
P.O. Box 7062,
Kampala, Uganda
Signed...................................
Date....................................
i
DEDICATION
This dissertation is dedicated to my siblings, beloved late parents, my husband and the
children.
ii
ACKNOWLEDGEMENT
I wish to extend my sincere appreciation to those people who facilitated the progress and
completion of this dissertation. My thanks go to the different people who in different
ways have helped me write up this dissertation to the final end, the only research work
done on knowledge, perceptions and practices in the context of pregnancy and childbirth.
I am particularly indebted to my supervisor, Dr Stella Neema for her tireless
participation, academic guidance, support and encouragement towards the success of this
work.
I am equally grateful to the Wakiso District and Nangabo sub county administration that
were of great help when I was conducting fieldwork. These people were of critical
because they introduced me to the relevant authorities who helped me access the
respondents easily.
My heartfelt thanks go to my dear husband and family for the financial, moral and
academic support offered to me during my time of study. Mwami, I feel I owe you more
than just a thank you but it is my sincere prayer that the Almighty God richly rewards
you.
My special thanks go to the Lord God, then to my beloved late parents Mr. and Mrs.
Ekallam Faustine (RIP) and family members Beatrice, Catherine, Paul, Stella, Benedicta,
Jackie, Olive and even little Princess Lisa-Maria Lynnette and Prince Leon-Faustine,
iii
from whom I got a strong foundation from which I have built a superstructure and thus
academic empowerment. I pray that God rewards you all abundantly.
iv
ABSTRACT
Pregnancy and childbirth are important stages in life because they are associated with
social problems, mortality and morbidity of both mother and the child in low income
countries. This study described knowledge, perceptions and practices that influence
pregnancy, delivery and utilization of maternal health care services in Wakiso district
central Uganda. This information is important in planning better maternal and child
health care services.
This was a qualitative study that utilized Focus group discussions (FGDs), Key informant
interviews (KIs), and In-depth interviews. Seven Focus Group Discussions (FGDs) were
held with mothers who had delivered in health units 5 years prior to the study, women
who had come for ante natal care (ANC), and men who had fathered children 5 years and
below. The key issues discussed were knowledge regarding and practices governing
pregnancy and childbirth, the influence of knowledge on the delivery and utilization of
maternal health care services and access to health care facilities. Twenty four key
informant interviews were held with midwives, community leaders, traditional birth
attendant (TBAs), and district health officials. Ten in-depth interviews, aiming at
exploring problems associated with pregnancy and childbirth within their socio-cultural
and economic contexts were conducted with women who had delivered 5 years prior to
the study. Qualitative content analysis was done manually.
Results show that majority of women had knowledge of pregnancy preparation, dangers
of pregnancy and childbirth, and the need for antenatal care and delivering in health
v
facilities. However there were some limitations regarding access and cost related
healthcare. Largely, there was preference for modern health care services though TBAs
were more accessible. This was because TBAs live in the community and offer flexible
terms of payment for the services offered. There is, however, dual health seeking both
from biomedical and traditional health care. In terms of pregnancy and child birth
practices, both traditional and modern practices existed. These included uses of herbal
medicines as well as modern drugs during ANC and delivery.
Women were knowledgeable on pregnancy and child birth i.e. when and how to get
pregnant including the different modern family planning methods. Notwithstanding the
challenges faced such as reported negative attitudes of health workers and poor access to
facilities, biomedical workers were perceived to be more competent to handle pregnancy
and child birth than TBAs. There was wide use of herbal medicines especially for women
suspecting to be barren and those that had failed to deliver normally. Health systems
factors like inadequate human resources for health, poor infrastructure affect health
seeking behavior.
vi
Table of Contents
LIST OF ABBREVIATIONS AND ACRONYMS .................................................................................. IX
DEFINITIONS OF KEY CONCEPTS .......................................................................................................X
CHAPTER ONE: INTRODUCTION ......................................................................................................... 1
1.1
BACKGROUND TO THE STUDY ....................................................................................................... 1
1.2
STATEMENT OF THE PROBLEM....................................................................................................... 5
1.3
OBJECTIVES OF THE STUDY ........................................................................................................... 7
1.3.1 Specific objectives ........................................................................................................................ 7
1.4
SCOPE OF THE STUDY .................................................................................................................... 7
1.5
SIGNIFICANCE OF THE STUDY ........................................................................................................ 8
1.6
CONCEPTUAL FRAMEWORK........................................................................................................... 9
1.7
LAYOUT STRUCTURE OF DISSERTATION .......................................................................................11
CHAPTER TWO: LITERATURE REVIEW ...........................................................................................13
2.1
2.2
2.3
2.4
2.5
2.6
ANTENATAL CARE AND HEALTH SEEKING BEHAVIOR ...................................................................13
KNOWLEDGE ON PREGNANCY AND CHILDBIRTH ..........................................................................14
PERCEPTIONS ON PREGNANCY AND CHILDBIRTH ..........................................................................16
PRACTICES REGARDING MATERNAL HEALTH CARE DURING PREGNANCY AND CHILDBIRTH ..........19
HEALTH SEEKING BEHAVIOUR OF WOMEN DURING PREGNANCY AND CHILDBIRTH .......................21
IDENTIFIED GAPS: ........................................................................................................................24
CHAPTER THREE: METHODOLOGY .................................................................................................27
3.1
RESEARCH DESIGN .......................................................................................................................27
3.2
AREA AND POPULATION OF STUDY ..............................................................................................27
3.3
METHODS OF DATA COLLECTION.................................................................................................29
3.3.1 Focus Group Discussions ...........................................................................................................29
3.3.2
Key Informant Interviews (KI) ..............................................................................................30
3.3.3
In-depth interviews ...............................................................................................................31
3.4
SAMPLING ....................................................................................................................................31
3.5
DATA MANAGEMENT AND ANALYSIS ..........................................................................................33
3.6
QUALITY CONTROL ......................................................................................................................33
3.7
ETHICAL CONSIDERATIONS ..........................................................................................................34
3.8
LIMITATIONS TO THE STUDY ........................................................................................................35
CHAPTER FOUR: RESULTS ...................................................................................................................36
4.1
KNOWLEDGE ON PREGNANCY AND CHILDBIRTH ..........................................................................36
4.1.1
Women‟s knowledge on preparation for pregnancy .............................................................36
4.1.2
Knowledge on health problems faced during pregnancy .....................................................38
4.1.3
Experiences with ANC and Family Planning services .........................................................42
4.1.4 Women‟s knowledge on childbirth ..............................................................................................44
4.2
PERCEPTIONS ON PREGNANCY AND CHILDBIRTH ..........................................................................46
4.2.1 Community views regarding biomedical services .......................................................................47
4.2.2 Community views regarding TBAs and childbirth ......................................................................48
4.3
COMMUNITY PRACTICES REGARDING MATERNAL HEALTH CARE DURING PREGNANCY AND
CHILDBIRTH ..................................................................................................................................50
4.3.1 The pregnancy period .................................................................................................................50
4.3.2 Delivery and post delivery period ...............................................................................................55
4.3.3 Dealing with delivery related problems and risks.......................................................................59
vii
4.4
COPING WITH PREGNANCY RELATED PROBLEMS...........................................................................61
CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS ...................................................65
5.1
5.2
5.3
CONCLUSIONS ..............................................................................................................................65
RECOMMENDATIONS ....................................................................................................................67
PROPOSED AREAS FOR FURTHER RESEARCH .................................................................................69
REFERENCES ............................................................................................................................................71
ANNEXES ....................................................................................................................................................77
KEY INFORMANT GUIDE ......................................................................................................................77
FOCUS GROUP GUIDE ............................................................................................................................79
IN-DEPTH INTERVIEW GUIDE .............................................................................................................82
viii
LIST OF ABBREVIATIONS AND ACRONYMS
ANC:
Antenatal Care
CHNMs:
Community Health Nurse Midwives
DHO:
District Health Officer
DHE:
District Health Educator
DNO:
District Nursing Officer
EmOC:
Emergency Obstetric Care
FGD:
Focus Group Discussions
HUs:
Health Units
KIs:
Key Informants
LOCs:
Local Committees
MDG:
Millennium Development Goal
MOs:
Medical Officers
MOH:
Ministry of Health
NHP:
National Health Policy
OL:
Opinion Leaders
PHC:
Primary Health Care
PPH:
Post Partum Hemorrhage
RH:
Reproductive Health
SDC:
Sub-county Development Committee
TBAs:
Traditional Birth Attendants
TCMP:
Traditional and Complementary Medicine Practice
UBOS:
Uganda Bureau of Statistics
WHO:
World Health Organization
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DEFINITIONS OF KEY CONCEPTS
Childbirth:
Is also called labour, birth or parturition. Is the culmination of
Pregnancy. The emergence of a child from its mother‟s uterus. It is
considered by many to be the beginning of a person‟s life and hence
the opposite of death. Age is defined relative to the event in most
cultures.
Knowledge:
It is what is known and is gained either by experience, learning and
perception or through association and reasoning. It is a justified true
belief.
Perceptions:
It is what your mind tells you something is.
Postpartum
Is excessive genital tract bleeding or bleeding sufficient to cause
Haemorrhage:
deterioration in the woman‟s clinical condition after birth. In majority
of cases, this occurs soon after delivery of the baby and the
commonest cause is failure of the uterus to contract.
Practice:
Is a customary way of operation or behaviour and knowledge of how
something is usually done. It involves translating an idea into action
as generally an accepted method or standardized activity.
Pregnancy:
It is the condition of nurturing the embryo or fetus within the
woman‟s body, lasting from conception to birth. The normal duration
is 265 days from conception to birth, or the more usual calculation of
280 days (40 weeks) from the first day of the last menstrual period.
TBA:
A traditional birth attendant (TBA), also known as a traditional
midwife, is a primary pregnancy and childbirth care provider. They
provide the majority of primary maternity care in low income
countries. TBAs usually learn their trade through apprenticeship,
although some may be wholly self-taught. Many TBAs are older
mothers and often serve as traditional healers or herbalists
x
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study
Pregnancy and childbirth are important stages in life because they are associated with
social problems, mortality and morbidity of both mother and the child especially in low
income countries (LIC). Proper care during pregnancy and delivery are important for the
health of both the mother and the baby.
Globally, it is estimated that 585,000 women die yearly from causes related to pregnancy
and birth; 99 percent of these deaths occur in the LICs
(http://www.path.org/files/eol16_si.pdf: Accessed 23rd). An estimated 358,000 women
died globally in 2008 as a result of pregnancy-related conditions (Hogan MC 2010). In
the majority of cases post partum hemorrhage occurs soon after delivery of the baby and
the commonest cause is failure of the uterus to contract. According to the World Health
Report 2005, postpartum hemorrhage contributes approximately 25 percent to maternal
mortality ratio in Uganda (WHO, 2005).
There is scanty information about socio-cultural influences on pregnancy and childbirth.
Ministries of Health in any country play an important role in providing modern health
care services. Private organizations and institutions such as churches, private
practitioners; industries and traditional health practitioners also contribute to health care
significantly. The World Health Organization (WHO) estimates that eighty percent 80%
1
of maternal deaths are caused by direct obstetric causes such as severe hemorrhage
(25%), infection (15%), eclampsia (12%), obstructed labour (8%), unsafe abortion (13%),
While direct causes (8%). Twenty percent of maternal deaths are attributed to indirect
obstetric causes such as anemia, cardiovascular diseases, malaria and tuberculosis (Olsen
et al 2002).
Despite the fact that biomedicine has been successfully exported globally, in many
contexts women (also young and educated) still resort to local practices creating a
medical syncretism that integrates both.
Low Income Countries (LIC) bear a disproportionate share of maternal deaths i.e. 99
percent occur in LICs compared to 1 percent in High Income Countries (HIC) (Hogan
MC 2010). To be precise, Sub-Saharan Africa and South Asia accounted for 87 percent
of global maternal deaths in 2008 and 50 percent of all deaths occurred in six nations:
India, Nigeria, Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of Congo
(Hogan MC 2010;
WHO/UNICEF/UNFPA, 2011). Regional estimates of maternal
deaths are 1,100 deaths per 100,000 live births in sub-Saharan Africa, 430 in South Asia
and 190 in Latin America and the Caribbean, to 12 deaths per 100,000 live births in
industrialized countries (WHO, UNICEF and UNFPA, 2001). One thousand four hundred
women die every day from pregnancy-related causes, 99 per cent of them in LICs. In
Sub-Saharan Africa, a woman has a one in three chance of dying in child birth. In
industrialized countries, the risk is 1 in 4,085. Direct obstetric deaths account for about
75
per
cent
of
all
maternal
deaths
in
developing
countries.
2
(http://www.unicef.org/gender/index_factsandfigures.html: Accessed September 3rd,
2011)
Even these statistics may not reflect fully the magnitude of the problem. Maternal
mortality is difficult to measure due to lack of complete vital registration systems in
many developing countries, particularly in rural areas where the problem is typically
most
severe.
(http://hatefsvoice.wordpress.com/2011/03/08/overview-of-the-violence-
against-women-around-the-world: Accessed July 23rd ,2011)
Antenatal care from a trained provider is important to monitor the pregnancy and treat
complications in pregnancy. According to the 2006 the Uganda Demographic and Health
Survey (UDHS) results, 94 percent of women who gave birth in the five years preceding
the survey received antenatal care (ANC) from a health professional at least once. Urban
women are slightly more likely to receive ANC at least once than rural women (97
percent compared with 93 percent) (UBOS and Macro Org. 2007).
Uganda is one of the poorest countries in the world with per capita income in 2004
estimated at US$ 250 (World Bank, 2004). Uganda‟s population in 2005 was estimated at
27,269,482 and the life expectancy was at an average of 51.59 (males 48 and females 52),
as
compared
to
Kenya
47.99
and
Tanzania
with
45.2
(http://www.airninja.com/worldfacts/LifeExpectancyOfNations.htm: Accessed on 3rd
September, 2011).
3
Substantial progress remains to be seen in the area of maternal health. Uganda, like most
countries of the world, has agreed upon the United Nations Millennium Development
Goal (MDG) to improve maternal health, which targets the reduction of maternal
mortality between 1990 and 2015 by three-quarters. Achieving this goal in Uganda is a
challenge – maternal mortality remains high with an estimated maternal mortality ratio of
435 maternal deaths per 100,000 live births (Uganda Bureau of Statistics (UBOS) and
Macro International Inc. 2007).
In Uganda, the majority of births occur without the help of a skilled assistant (that is a
midwife, nurse trained as midwife or a doctor) at home or in other non-hospital settings.
Presence of a professional attendant at each birth can lead to a marked reduction in
maternal and child mortality and morbidity. Professional health care during childbirth is
one of the process indicators to assess progress towards the millennium development goal
of improving maternal health (http://www.reproductive-health-jorunal.com\content\3/1/2:
Accessed 1st May 2006).
Close relatives, TBAs or friends were often preferred to health workers, who were often
strangers or outsiders and not recognized as part of the local birth culture. Mothers do
not deliberately choose the riskier option of home-based, unskilled care; rather, the
environment in which they live to a great extent limits their choices. In relation to the life
threatening risks associated with pregnancy and childbirth, what an individual knows and
perceives to be right is what he or she practices. This is regardless of the fact that it may
4
be associated with the life threatening risks. Individuals are often faced with a challenge
of choosing between traditional and modern medical practitioners.
The Uganda Demographic and Health Survey (UDHS) 2005-2006, holds it that most
women in Uganda delivered at home (57.8%) (Uganda Bureau of Statistics (UBOS) and
ORC Macro, 2007). Home deliveries in the absence of skilled professional attendants
have been associated with adverse infant and maternal outcome. However deliveries
without a skilled attendant occur for a variety of reasons, including long distances or
difficult access to a health facility, costs of the services and perceived lack of quality of
care in a health facility among others. In an attempt to improve care during home
deliveries and reduce maternal and child mortality and morbidity, Traditional Birth
Attendants (TBAs) have been trained in modern delivery care, although with varying
reports of success.
The study explores how knowledge and perceptions determine the practices in pregnancy
and childbirth. The study is concerned with assessing the practical and socio-cultural
issues that may influence acceptability and accessibility of professional healthcare (safe
antenatal and childbirth practices). This is to reduce neo-natal and maternal mortality in a
Ugandan rural community.
1.2 Statement of the Problem
The clinical causes of maternal deaths, the characteristics of women who die and the
causes inherent to the health care system are well known in Uganda and elsewhere. Less
5
is known about the cultural beliefs that may contribute to women‟s deaths during
pregnancy and childbirth (Kyomuhendo 2003). This study therefore addressed the sociocultural issues to improve Neonatal and maternal health problems. According to the
UDHS 2006, the percentage receiving ANC from a skilled provider was high (93.7) and
overall 42 percent of births are assisted by a skilled provider during delivery that is a
doctor, nurse/midwife, and a medical assistant or clinical officer (UBOS and ORC Macro
2007). The primary contributing factor is women‟s and community‟s lack of equal
access to health care and, specifically, life-saving obstetric care like availability of blood
for transfusion among others. In line with WHO guidelines, the Ministry of Health
(MOH) Uganda recommends that a woman having a normal pregnancy attends four
antenatal care visits, the first of which should take place during the first trimester. Less
than half of women (47 percent) receive four or more visits for antenatal care.
Furthermore, only 17 percent of pregnant women receive their first visit during the first
three months of pregnancy. A high proportion of women (41 percent) make their first
antenatal care visit during the fourth or fifth months of pregnancy, while 37 percent make
their first visit during the sixth month of pregnancy or later. The median gestational age
when women make their first visit is 5.5 months, when the opportunity may have passed
to diagnose problems early, provide treatment, and prevent further complications (UBOS
and ORC Macro, 2007). According to WHO, the annual global estimated toll is close to
600,000 deaths and eight million cases of disability from pregnancy-related causes
(http://www.nationsencyclopedia.com/United-Nations-Related-Agencies/The-WorldHealth-Organization-WHO-ACTIVITIES.html: Accessed on 31st July, 2011) The current
maternal mortality ratio is estimated to be 435/100,000 live birth (UBOS and ORC
6
Macro, 2007). This study therefore sought to understand knowledge and perceptions in
the context of practices in pregnancy and childbirth in Uganda.
1.3 Objectives of the Study
The overall objective of the study was to examine the knowledge, perceptions and
practices in pregnancy and childbirth. This information would be used in planning for
improved maternal and child health services in the district.
1.3.1 Specific objectives
1. To establish knowledge on pregnancy and childbirth (preparations needed, problems
during pregnancy, FP).
2. To describe the local perceptions on pregnancy and childbirth.
3. To explore existing practices during pregnancy and childbirth.
4. To establish how knowledge and perception influence health seeking behavior of
women during pregnancy and childbirth
1.4 Scope of the Study
The study established knowledge and perceptions on pregnancy and childbirth and how it
determines where women seek maternal health care. Various aspects of practices
associated with pregnancy and childbirth were covered. For example, issues of disposal
of the placenta and other products of conception, use of traditional medicine and
abdominal massage, sitting in a container of herbal medicines mixed with water to clean,
7
disinfect and widen the birth canal, preference of traditional kneeling position while
giving birth, perceptions of the significance of postpartum bleeding and assumed
humiliation and mistreatment by midwives during attendance in modern health care units
to mention but a few. The population of study was women who delivered in the past five
years prior to the study, men whose partners had children of 5 years and below,
midwives, medical officers, village leaders and traditional birth attendants.
1.5
Significance of the Study
The findings of the study are useful to the government, Ministry of Health (MOH) and
other organizations involved in improving maternal health care services specifically in
the rural areas. These will also foster designing appropriate strategies for the rural women
and in particular those residing in Nangabo sub-county. These study findings also provide
information for better planning of maternal and child health care services; which could
lead to reduced morbidity and mortality in the district.
The study findings provide data of maternal and perinatal morbidity and mortality in a
defined geographical rural area in Uganda. More so, this study has brought about an
understanding of cultural beliefs and how they contribute to women‟s health and ill
health in pregnancy and childbirth. Furthermore, this study contributes theoretical to the
body of existing literature on maternal health in Wakiso district and Uganda at large.
8
1.6
Conceptual Framework
Based on Figure 1, inadequate knowledge and inappropriate practices in pregnancy and
childbirth contribute to increased neonatal mortality, increased maternal morbidity, low
utilization of maternal healthcare services and high cost of healthcare due to long stay in
hospital admissions and low rates of supervised births. On the other hand adequate
knowledge and good practices in pregnancy and childbirth result to decreased maternal
mortality and morbidity, high utilization of maternal healthcare services, low cost of
healthcare and high rate of supervised births.
There are four main factors that lead to either good or poor practices or adequate or
inadequate knowledge regarding pregnancy and childbirth. These include economic,
cultural, personal and health service related factors.
Economic factors include low/poor household incomes, high costs of transport to the
health unit and poor or no employment. Cultural factors include, strong beliefs in cultural
aspects e.g. use of local herbs. Personal factors include, age, marital status, among others.
Health service related factors include perceived poor quality of care in health units, lack
of appropriate and required equipments, inadequate supply of drugs, perceived poor staff
attitudes towards work (patients).
For example, high costs of available transport to the health units may bring about delays
consequently leading to low rates of supervised births thus death of either the baby or
9
mother or both. Strong belief in cultural practices promotes the use of herbal concoctions.
These may be harmful to both the baby and mother in one way or another leading to poor
growth and or development of the baby among others. High costs of healthcare make the
services unaffordable thus low utilization of maternal healthcare services thus increased
maternal mortality and morbidity. On the other hand, individuals who are employed and
are therefore earning some income are in position to afford transport to the health unit
thus decreased maternal mortality and morbidity. Also friendly or good staff attitudes at
the health units will attract mothers leading to high utilization of maternal healthcare
services. The educated as compared to the illiterate have adequate knowledge to make an
informed decision so as to seek maternal health care in the health unit hence high rates of
supervised births and also low cost of healthcare among others due to short stay in
hospital admissions.
10
Figure 1: Conceptual Framework
1.7
Layout Structure of Dissertation
This dissertation is made up of five chapters. Chapter one looks at the background to the
study and the statement of the problem. Also presented in this chapter are the objectives,
scope and significance of the study as well as the conceptual framework.
Chapter two presents the literature reviewed, which presents findings from the previous
studies done about Knowledge, perceptions and practices regarding pregnancy and
11
childbirth globally. This chapter gives a detailed and critically analyzed presentation of a
variety of studies on the same.
Chapter three presents the methodology that was adopted for the study. It includes the
research design, the area of the study, study population. Also the sampling techniques,
sample size, data collection procedure, data collection process, data analysis and ethical
considerations are presented in here. The chapter also looks at the problems encountered
during the study.
Chapter four presents the findings of the study covering the socio-economic
characteristics as well as he objectives of the study. It presents findings on knowledge on
pregnancy and childbirth, findings on the local perceptions on pregnancy and childbirth,
findings on the existing practices regarding maternal healthcare during pregnancy and
childbirth and findings on the health seeking behaviour of women during pregnancy and
childbirth.
Chapter five presents the summary of the study findings, conclusions, limitations and
policy recommendations to improve maternal and child healthcare. The recommendations
for further research are also presented in this chapter.
12
CHAPTER TWO: LITERATURE REVIEW
This chapter presents literature regarding knowledge, perceptions and practices regarding
pregnancy and child birth form the global, regional and national levels.
2.1
Antenatal care and health seeking behavior
Health seeking behaviour (HSB) refers to any activity undertaken by individuals, who
perceive themselves to have a health problem or to be ill for the purpose of finding an
appropriate remedy (Ward, Mertens et al. 1997). This is, therefore, a sequence of
remedial actions that individuals undertake to rectify perceived illness. It is initiated with
symptom definition upon which a strategy for treatment is devised.
Antenatal care improves some outcomes through the detection, management of, and
referral for potential complications. Evidence from high income countries (HICs)
suggests that adequate ANC may improve birth weight (Alexander and Korenbrot 1995;
Reynolds, Wong et al. 2006). Antenatal care can also assist in the prevention,
identification and treatment of iron deficiency anemia in adolescent mothers (Brabin,
Verhoeff et al. 1998). This is crucial as severe anemia is linked to maternal and child
mortality (Stoltzfus 2001; Stoltzfus 2001; Thato, Rachukul et al. 2007). The purpose of
ANC is to improve pregnancy outcomes for both the mother and the fetus. The aim of the
first ANC visit is for health staff to establish rapport with the client and to collect
information to evaluate the client‟s health status and preparedness for motherhood.
13
2.2
Knowledge on Pregnancy and Childbirth
Home birth remains a strong preference and often the only option, for many women in
the developing world. A large proportion of these home deliveries take place without
professional attendants (bij de Vaate et al. 2002). Provision of a health worker with
midwifery skills at every birth is considered a crucial intervention for safe motherhood
(De Brouwere, Tonglet and Van Lerberghe (1998), yet the WHO estimates that 47% of
births in the developing world are currently assisted only by traditional birth attendants
(TBAs), family members, or no one (WHO 1997).
A study in one of the villages in Zambia reveals that after the birth of the baby, the
delivered mother will feel dizzy, have headache and weakness of the joints, she will
become thin and gradually die six months after delivery, or the baby will suffer ill health
and not grow (Maimbolwa et al. 2003). There is no clear airway in the newborn,
breastfeeding or the importance of keeping the baby close to the mother. Some of the
traditional routines regarding immediate care, such as leaving the newborn baby
unwrapped, may cause hypothermia and delay initiation of breastfeeding. Neonatal
hypothermia has been reported to be a major cause of neonatal death in Zambia. It is
known that immediate skin-to-skin contact between mother and infant prevents
hypothermia in the newborn, promotes early initiation of breastfeeding and early rise of
oxytocin in the plasma, an important mechanism for uterine contraction to prevent post
partum hemorrhage (Matthiesen et al. 2001).
14
Usually, all pregnant women have to be screened for antenatal syphilis, anemia, preeclampsia and other common complications of pregnancy. However, Myer and Harrison
(2003) noted that in the rural Hlabisa district of South Africa none of the women
demonstrated any understanding of the potential benefits of such programs. In these
circumstances, the possible benefits associated with antenatal services appear to be of
secondary importance to the necessity of procuring an antenatal attendance card. In their
study titled “why do women seek antenatal care late?” they found out that only seven of
the 22 participants (32%) booking for the first visit felt that antenatal care was intended
to address problems in pregnancy that might threaten mother or child. Each participant
for example was asked specifically about her knowledge of syphilis, but the disease was
largely unknown as either a sexually transmitted disease or a threat to antenatal health.
Of the women booking for their first visit, only two had heard of syphilis as a sexually
transmitted disease and none had any knowledge of syphilis as a disease in pregnancy,
even after they tested positive for syphilis during their clinic visit.
Of the seven
participants who tested positive for syphilis and received treatment at the clinic, only one
could identify her illness. However, many women associated syphilis with a traditional
illness, which they knew to be harmful to the fetus.
Inherent in this framework for antenatal health-seeking behaviour is a dichotomy in
which women are poorly informed about the risks of pregnancy and the importance of
antenatal care, while being coerced by the structure of the health care system into using
facility-based services for labour and delivery (Orinda et al 2005). This contrast, highlighted by poor communication between lay women and providers, sharply influences
15
pregnant women‟s perceptions of antenatal care services and helps to shape their service
utilization, reinforcing views of antenatal care as a nuisance and of labour and delivery as
requiring facility-based care. While these approaches to antenatal care provision and
utilization may help contribute to safer childbearing through facility-based delivery, they
also serve to limit women‟s understandings of health and health risks during pregnancy
(http://discuss.prb.org/content/interview/detail/1240/:
Accessed18th
April,
2007).
Women‟s understandings of health in pregnancy contribute to late antenatal health
seeking and inadequate attendance partners, which contribute in turn to avoidable
perinatal deaths (Alison and Salihu 2004).
2.3
Perceptions on pregnancy and childbirth
Women‟s perceptions on pregnancy, recognition of early signs of pregnancy and of
malaria in pregnancy, and the cultural context in which treatment seeking takes place
varies from one community to another. In Mukono district of Uganda, for example,
malaria is locally known as Omusujja was perceived as the most common cause of
disease among pregnant women (Mbonye et al. 2006). Although malaria is known to
commonly cause a fever, some pregnant women feel hot in the womb with or without
signs of fever, and this illness, locally known as Nabuguma. This may lead to progressive
weakness and occasionally to miscarriage. Similarly, anemia and low birth weight were
not associated with malaria; in fact paleness was described as a normal sign of
pregnancy.
16
„Mumbwa‟ is a concoction of traditional medicine prepared by mixing various herbs and
clay soil molded and smoothened into a bar. The bar is then dried and taken in water as a
suspension at various times. It is believed that the Mumbwa helps alleviate pregnancy
complications and in particular shortening labour. For a long time, women in Uganda
have been taking Mumbwa. According to Nambatya, (2005) the head of research at the
Natural Chemotherapeutics Research laboratories in Wandegeya, Kampala, there is no
known figure of how many women use these herbal medicines, but many Ugandan
women use them; even those not living in Uganda send for them. A traditional healer in
Wakaliga Veterans‟ Market in Uganda, who also deals with pregnancy and childbirth,
said that the clay bar has many medicinal herbs. She reported that she prescribes three
bars to be taken from the third month of pregnancy until the ninth month. The mixture
gives women strength and prevents postnatal depression, locally known as Makiro
(http://www.newvision.co.ug/D/9/31/557381: Accessed 3rd September 2011)
Traditional health practitioners make Mumbwa for treatment of various ailments. In
addition to binding the crushed herbs, the clay is also as a source of iron, which most
expectant mothers require. The clay also helps preserve the medicinal properties in the
herbs. Some women crave it because it contains calcium and iron, which they crave
during pregnancy. Most women know that this clay concoction speeds up labour, though
they don‟t know how it does so. Myer and Harrison (2003), argue that most women
appear to see relatively little direct benefit from antenatal care. In their study: “Why do
women seek Antenatal Care late?” they clearly noted that some women were “too lazy”
to book early, a sentiment embodied in the words of one participant: “Most people are too
17
lazy to come early (to the clinic for antenatal care) because then you must come many
times, so, they just wait until late (to book)”. Several women said that they saw no
reason to book for antenatal care early because they had not experienced any problems,
during either the current and/ or the previous pregnancies. Each of the participants had
been screened for antenatal syphilis, anemia, pre-eclampsia and other common
complications of pregnancy, but none of the women demonstrated any understanding of
the potential benefits of such programs.
In these instances, the possible benefits
associated with antenatal services appear to be of secondary importance to the necessity
of procuring an antenatal card.
Illnesses or sicknesses during pregnancies were explained by culturally accepted causes.
Precautions and preventive measures were taken, as a pregnant woman and the fetus were
believed to be in a physically and spiritually weak state and thus more susceptible to
illnesses, sicknesses, witches and evil forces in the environment. One important
preventive measure concerned nutrition, and the belief that certain foods considered
harmful to the unborn baby should be avoided (Maimbolwa et al. 2003). For example, if
a pregnant woman eats eggs, the baby will be born without hair, and this is embarrassing
to her family. A pregnant woman was also advised not to eat fish because this was
believed to cause infant abnormality, such as a large anterior fontanel. The women
encouraged mothers to eat locally defined nourishing foods, such as cooked vegetables
with pounded groundnuts and the staple food of plain maize flour and also a drink
brewed from maize flour was believed to be good for pregnant women (Maimbolwa et al.
2003). The woman who implements traditional reproductive practices said that she
18
administered local traditional medicines to pregnant women in order to prepare and
widen the birth canal. Traditional medicines should be given six months prior to labour
and also if labour is prolonged or obstructed (World Bank 1994).
2.4
Practices regarding maternal health care during pregnancy and childbirth
The umbilical cord of the newborn baby traditionally is cut using various devices such as
„razor blade or sugar canes peel‟ and tied with a string. Various or different mixtures are
also used to dress the umbilical cord in the rural areas such as ash, seashell mixed with
oil, scrapings from a pounding stick (used to pound food) or breast milk. Mothers were
advised to tie any piece of cloth around the male baby‟s abdomen so that the cord did not
drop on the genitals in order to prevent infertility later in life. Their use of different
devices for cutting the cord and application of various mixtures on the cord might
increase the risk of cord infections and tetanus (WHO 1998).
In rural Zambia for
example, it was believed that a new mother should not be allowed to cook until the
baby‟s umbilical cord dropped off, or else the woman would get a mysterious disease.
A study done in Gambia where 22 Traditional birth attendants received training revealed
positive results. After the training, TBAs were able to recognize complications such as
retained placenta and excessive blood loss and were well aware of the need to refer these
women to a health facility quickly. The study further revealed that though the TBAs did
not know the causes of excessive blood loss, they knew that anaemia was a risk factor for
dying from PPH. (bij de Vaate et al. 2002). The training included the delivery of the
placenta and danger signs soon after delivery. In Gambia for example, the health policy
19
for the prevention of PPH, is the routine administration of ergometrine tablets. After this
training the TBAs are certified, if competent, they received a midwifery kit containing
clean dressings, scissors and string, oral ergometrine, disinfectant, and a colour-coded
spring-balance for weighing newborn babies. Government employed Community Health
Nurse-Midwives (CHNMs), who live centrally in a catchment area of four to six Primary
Health Care (PHC) villages, to provide the TBAs with continuing education and
supervision. One of their tasks is to visit each of the TBAs in the villages of their
catchment area at least once per fortnight. CHNMs form the link between village-level
PHC services and referral health services.
Prevailing cultural beliefs among most people in Uganda tend to lead to self care and
consultation of traditional healers which in turn delays in seeking appropriate health care.
This is compounded by lack of physical accessibility of health facilities as still a
significant proportion live more than 5 km radius from the nearest health facility. The
National Health Policy states that in order to achieve government objectives and
strategies, Government shall promote and support good and relevant aspects of
complementary and traditional medicines. This will be under the framework of the Public
Private Partnership in Health (PPP) where the policy will provide a framework for
linkages of the public and private sectors. The private health sector includes Private-Notfor-Profit (PNFP), Private Health Providers (PHP) and Traditional and Complimentary
Medicine Providers (TCMPs). Structures for coordination are in place at the central level
but are weak at district level (MoH, 2010)
20
Matthiesen et al. (2001) argued that, traditional birth attendants had their own ideas about
the origin of excessive blood loss. Such as infection in the womb or the kind of foods the
pregnant women had eaten during pregnancy. The TBAs were aware of an increased risk
of dying due to post partum hemorrhage when a woman is anemic and knew the signs of
anemia, such as edema and paleness. However, not all TBAs knew this and the idea of
some of the TBAs that anemic women only bleed a little during labour is dangerous.
Some women deliver on their own and only asked for assistance when the cord had to be
cut or when there was a problem after the birth of the baby. Different reasons were given
for this, including that people did not want to give payment to the TBAs or that they were
proud to try and deliver the baby without the assistance of an outsider.
2.5 Health seeking behaviour of women during pregnancy and childbirth
Health seeking behavior is related to utilization of health services, which is a complex
behavioural phenomenon. Empirical studies of preventive and curative services have
often found that use of health services is related to the availability, quality and cost of
services as well as to the social structure, health beliefs and personal characteristics of the
users (Chakraborty et al. 2003).
Mothers‟ education is of importance in explaining the utilization of health care services.
Female education retains a net effect on maternal health service use, independent of other
women‟s background, characteristics, household‟s, socio-economic status and access to
health care services. Chakraborty et al. (2003) found that women whose husbands are
involved in business/services also positively influenced the utilization of modern health
21
care services. However, the study results are inconclusive with respect to the influence of
other predisposing and enabling factors, such as women‟s age, number of previous
pregnancies and access to health care services/facilities to mention but a few. It is further
argued that better educated women are more aware of health problems, know more about
the availability of health care services and use this information more effectively to
maintain or achieve good health status. Mother‟s education may also act as a proxy
variable of a number of background variables representing women‟s higher socioeconomic status, thus enabling her to seek proper medical care whenever she perceives it
necessary (De Groot et al.1996).
Myer and Harrison (2003) noted that lack of physical access to health care facilities
presents a fundamental hurdle to receiving care, even in urban settings. Poor quality of
care continues to be a major concern in most health systems, as high patient volume and
limited resources combine to constrain service provision.
Even when facilities are
accessible and quality services are available, many women only recognize pregnancy
relatively late in gestation. Despite these insights, little is known about antenatal care
utilization and the health-seeking behavior of pregnant women more generally, in rural
areas.
These qualitative findings provide important preliminary insights into the
combination of factors shaping antenatal health-seeking behaviors.
It is well recognized that women‟s current age plays an important role in the utilization of
medial services (Chakraborty et al 2003). Mother‟s age may sometimes serve as a proxy
for the women‟s accumulated knowledge of health care services that may have a positive
22
influence on the use of health services. On the other hand, because of development of
modern medicine and improvement in educational opportunities for women in recent
years, younger women might have an enhanced knowledge of modern health care
services and place more value upon modern medicine. Also, because of perceived risk
associated with first pregnancy, a woman is more likely to seek maternal health care
services for first order than high-order births. Having more children may also cause
resource constraints, which have a negative effect on health care utilization. One of the
important predisposing factors for utilization of health care is family size. Women from
large families underutilize various health care services because of too many demands not
only on their time but also on their resources if any.
It is also well known that increased income has a positive effect on the utilization of
modern health care services. Husband‟s occupation can be considered a proxy of family
income, as well as social status. Differences in attitudes to modern health care services by
occupational groups depict occupation as a predisposing factor. Alternatively, viewing
occupation as proxy to income, which enables acquisition of more and better health care,
depicts
it
as
an
enabling
factor
(http://heapro.oxfordjournals.org/cgi/content/
full/18/4/327: Accessed 09/03/207). Besides the 2005/06 UDHS revealed that women in
Kampala were most likely to receive ANC services especially urine and blood tests.
Women with secondary education and those in higher wealth quintiles were also more
likely than other women to receive key ANC services (UBOS and Macro Org. 2007).
23
2.6
Identified Gaps
There is a clear need to raise awareness among women about the health risks in
pregnancy, particularly conditions such as Post partum hemorrhage (PPH) and how these
may be addressed by timely and effective antenatal care. Primary care providers have a
strong influence over women‟s perceptions of antenatal care and are best positioned to
provide appropriate educational messages. However, at present these same providers
may contribute indirectly to poor antenatal health-seeking behaviour frequently leading to
inadequate antenatal care.
Health promotion strategies should be based on future
research exploring patients‟ and providers‟ explanatory models of health in pregnancy
and childbirth. By successfully carrying out this study, adequate knowledge will be
attained to best explain under utilization of maternal services and improve aspects of
utilization as a whole particularly in rural settings..
Pregnant women take Mumbwa. This is a concoction traditional medicine prepared by
mixing various herbs and clay soil molded and smoothened into a bar. But because
women take Mumbwa in unregulated amounts, the contractions may be very strong and at
high speed, making the lower part of the womb stretch as the upper part contracts and in
the process may rupture the womb. When it ruptures, the baby may die first then the
mother. Also depending on the extent of the rupture, the uterus might have to be removed
or repaired. If it over-ruptures, health workers may take it out and the woman will never
give birth again. There is a lot of dependence on indigenous knowledge when it comes to
the practice of drinking Mumbwa. Women have been using some of these things for
generations, which make it difficult to standardize. Mumbwa is actually a good source of
24
iron, but how much do you take? Is it according to your urge? How hygienic is the clay
and the whole mixture? All these leave a lot to be desired.
Traditionally, paternal aunties and uncles were charged with discussing Reproductive
Health (RH) matters with young family members as they approached adolescence. With
increasing urbanization, these traditional systems of education within the community
have become less effective. As parents are uncomfortable talking directly to their
children about sexual matters, nurses have become valued as trained professionals who
can take on this role. For example, the cultural practice of depriving a pregnant woman of
the essential food nutrients may contribute to malnutrition, which is common among
pregnant women in Zambia, and maybe responsible for lower birth weights, congenital
malformations, and maternal and perinatal mortality. Due to urbanization, there are no
longer aunties and/or uncles with the best advice. This is very problematic as the
available knowledge is inadequate and the practices are poor to explain why there are low
rates of supervised births and increased cost of health care due to long stay in hospital
admissions. This study will be able to address this issue too.
Another major cause of delay in recognition and response to PPH is being called late to a
delivery, compounded by the immense difficulty of finding transport in these remote and
poor areas. Death is rapid once hemorrhage starts; the mean period between onset of
PPH and death is estimated at two hours (Maine 1992). If TBAs are to have an impact on
PPH, they need an intervention available to them at the site and time of delivery.
Oxytocin is not an option for TBAs since it needs to be given by injection. Injectible
25
ergometrine is also not practicable since it is to be stored at between 2 degrees celcious
and 4 degrees celcious, without which it loses 30% of its activity within 12 months
(Nazerali and Hogerzeil 1998). There are no means of refrigeration available in the
villages. Alternative methods of achieving uterine contraction have been tested, but both
nipple stimulation and oral ergometrine (still officially recommended practice in The
Gambia in home births) have been shown to be of no benefit (Bullough et al. 1989, De
Groot et al. 1996). This study is therefore important as it attempts to current knowledge,
beliefs and practices regarding pregnancy and child birth
More recently, Mbonye et al (2007) established that few health units had running water;
electricity or a functional operating theater yet these facilities are critical for emergency
obstetric care (EmOC). He further pointed out that having these facilities had a protective
effect on maternal deaths (for example, theater (P<0.0001); electricity (P<0.0001);
laboratory (P<0.0001) and staffing levels (midwives) P<0.0001. He further found that
availability of midwives had the highest protective effect on maternal deaths, reducing
the case fatality rate by 80%. One could therefore say that addressing health system
issues such as human resources, and increasing access to EmOC could reduce maternal
mortality in Uganda and enable the country to achieve the MDG (Mbonye et al 2007).
26
CHAPTER THREE: METHODOLOGY
This Chapter presents the description of the methodological approach used in collecting
and analyzing the data. The following sub-topics are covered in this chapter: research
design, area of study, target population, sample size and selection, research instruments,
data collection procedures and data processing and analysis.
3.1 Research Design
The study used exploratory qualitative methods in order to understand how cultural
factors affect pregnancy and childbirth. The qualitative techniques for data collection
were focus group discussions (FGDs), key informant interviews (KIIs), and in-depth
interviews (IIs) which were administered to all respondents in the sample. The qualitative
study design was most suitable since this study aimed to understand research problem
from the perspectives of the local population (the emic perspective) (Mac Dougall and
Fudge 2001; Sandelowski 1995).
3.2 Area and Population of Study
This study was carried out in Wakiso district, located on the outskirts of Kampala city of
Uganda. This district (particularly Nangabo sub-county) was selected because it has both
peri-urban and rural dimensions. This gave the researcher an opportunity to collect data
more comprehensively for this exploratory study. Wakiso district is located in central
Uganda bordered by Kalangala Islands (in Lake Victoria) to the south, Mpigi and
Mubenda districts to the West, Luweero to the North and Mukono district to the East.
27
The area covered was Nangabo sub-county in Wakiso district. This sub-county was
selected in order to capture both urban and rural experience. Luganda is the commonest
language spoken. The Uganda Population and Housing Census 2002 indicate that the
rural population of Wakiso district was 838,299out of which 406,352 were males,
431,947 females. In the urban areas of Wakiso district, the males were 34,182 and
females were 35,507 totaling to 69,689.Overall gender population in Wakiso district was
907,988out of which 440,534 were males and 467,454were females. Nangabo sub-county
comprises of 8 villages and 10,495 households, 22,772 male and 24,179 female
occupants totaling to 46,951 with an average house hold size of 4.1.
The study population included the traditional birth attendants, medical officers,
midwives, district health officers, women who delivered in the last five years prior to the
study and men who fathered children five years of age and below.
Map of the Republic of Uganda
Map of Wakiso district
(Nanbabo SC in yellow)
28
3.3 Methods of Data Collection
Tree main methods of data collection were employed. These included Focus Group
Discussions, key informant interviews and In-depth interviews. See details below:
3.3.1 Focus Group Discussions
Focus Group Discussions refer to a qualitative method that gathers people of similar
backgrounds or experiences to discuss a specific topic of interest to the researcher
(Dawson and Manderson, 1992). The group participants who are homogeneously
composed (Morgan 1996) are guided by a moderator who introduces the topic and keeps
the discussion lively. Usually, consensus is sought i.e. participants agree or disagree and
a rich description is given. During FGDs about 8-12 participants are gathered together at
a convenient venue. In this study, FGDs were chosen to specifically get general
exploratory information about community knowledge and practices in pregnancy and
child birth. The FGD guide aimed at capturing a rich description of the information
required. Using this guide involved gathering people of similar backgrounds or
experiences to discuss a specific topic of interest to the researcher. It was composed of
open-ended questions.
Seven FGDs were held with several categories of participants‟ namely women who
delivered in the last five years prior to the study and women in this same category but had
come for Antenatal care (ANC) (05), men who fathered children five years of age and
below (02) . The key issues to be discussed were the knowledge, perceptions regarding
29
and practices governing pregnancy and childbirth, the influence of that on the delivery
and utilization of maternal health care services and access to health care facilities.
The guide was translated from the original English version into the local language
(Luganda) by one group of people who know both English and Luganda. Then, another
group translated the Luganda version back to English and compared with the original
version (Lee, More et al.1999). Study instruments were pre-tested and thereafter adjusted
for the main fieldwork. All FGDs were tape recorded (with consent) and transcribed into
English thereafter. Discussions took about 1.5 hours on average. Purposive sampling of
FGD participants was employed (Dawson 1992; Sandelowski 1995). Community leaders
and field guides, participants were identified and invited to participate in the discussions.
During discussions a soft drink was offered.
3.3.2 Key Informant Interviews (KI)
Key informants are people who, because of their position or experience, have greater
knowledge of what is being investigated than the average person. In this study, Twelve
KIs were held: 3 with midwives, 2 with community leaders, 3 with TBAs and four
district health officials (Medical Officer, District Health Educator, District Nursing
Officer and District Health Officer).We used this guide to informants knowledgeable in
the scope of the problem being investigated than the average person for example a village
leader, MOs, DDHS among others. The guide was composed of semi-structured
questions.
30
3.3.3 In-depth interviews
In-depth interviews are face-to-face encounters between the researcher and the informant
directed towards understanding informants‟ perspective on their lives, experiences or
situations as expressed in their own words (MacDougall and Fudge 2001). As implied in
the name, they have the advantage of long, one to one interaction that gives an
opportunity to hear in detail from one individual thereby giving a more complete picture
of the experience and context. In-depth interviews are open ended and flexible in nature
and this allows the interviewee to tell the story in their own words. These aimed at
exploring and analyzing problems associated with pregnancy and childbirth within their
socio-cultural and economic contexts. These interviews were entirely on a one to one
basis with ten women who delivered in the last five years prior to the study. In-depth
interviews lead to increased insight into people‟s thoughts, feelings and behavior on
important issues. This guide is often composed of unstructured or open-ended questions
and thus permits the interviewer to encourage the respondent to discuss at length about
the topic of interest. The in-depth interview uses a flexible interview approach thereby
allowing the interviewee to tell the story in their own words. It aims to ask questions to
explain the reasons underlying a problem or practice in a target group. The free
atmosphere of the interview environment allowed free discussion with respondents.
3.4 Sampling
The study employed purposeful sampling technique. Here, information rich cases were
strategically and purposefully selected. In addition, specific type and number of cases
selected depends study purpose and resources. Sampling of villages was dependent on
31
advice from the local community leaders. Sampling of women for the seven focus group
discussions was purposeful and the FGDs were homogeneously composed. The total
number of the FGD participants was 70.
Sampling of Key Informants such as the medical officers was to include all those
responsible for the area of the study but only got one medical officer in the entire area of
study. Local council members were key in identifying appropriate respondents for indepth interviews (TBA, mothers who had delivered 5 years before the study).
Table 3.1: summary of data collection methods by number of focus groups and respondents
Methods
Category
Number
Focus Group
Young mothers (had delivered in facility 5 years prior the
5 (50)
Discussions
study/had come for ANC)
Fathers with 5 year olds and below
2 (20)
7(70)
Sub-total
Key Informant
Midwives
3
Interviews
Community leaders
2,
Traditional Birth Attendants
3
District health officials
4
Sub-total
In-depth interviews
12
Women who had delivered in the health unit 5 years prior the
10
study
Sub-total
10
32
3.5 Data Management and Analysis
Qualitative data was transcribed, typed in word and cleaned before analysis. Transcripts
from audio tapes and notes from recorders/facilitators were compared, gaps filled, and a
concise version written out. Assertive and overtones of dominant participants (characters)
were removed before analysis. Abbreviations were expanded or explained at this stage.
For FGDs and KIs, manifest content analysis was done. A master sheet tool was used to
log information from the transcripts. Ethnographic summaries were made and emerging
thematic issues at various stages of analysis (Burnard 1991) noted. Typical quotes were
utilized so that the original content of meaning was not lost. All data from the interviews
was analyzed manually (Sandelowski 1994) and findings integrated during analysis and
report writing.
3.6 Quality control
To ensure that good data was collected, the investigator trained the research assistants.
Description of the study objectives, methods and one-on-one training on how to ask the
questions was done. The tools were translated into local language. To ensure that the
translations were correct, the back translation method was adopted where one team
translates the questionnaires into the local language (luganda) and another back translates
into English and the two English versions are compared to assess if meanings have
33
changed. Lastly, the Investigator was in the field to collect data and supervise the entire
process.
3.7 Ethical Considerations
A jury from the Higher Degrees Committee of the Faculty of Social Sciences approved
the research proposal. Permission to conduct the study in the area was obtained from the
local council executives (Wakiso district local government). Written informed consent
from all the respondents was sought before interviews were conducted. Participants were
informed that there were no or minimal risks to participating in this study. They were also
informed that refusing to participate would not affect the usual services they normally
access at health units.
In addition, before the interviews were conducted, the purpose and objectives of the study
were carefully explained to the respondents. It was emphasized that the information
collected from them would be treated with maximum confidentiality and the respondents‟
identity would not be required. The benefits and potential risks of the study were
explained to the respondents.
Respondents were informed that they were free to answer or not to respond to those
questions that they felt were embarrassing and therefore free to withdraw from
participation at any one time. During the study, no one withdrew from the study due to
34
anxiety caused by the questions in the question guides. During all FGDs, KIs interviews
and in-depth interviews, the facilitator endeavored to take time to explain to the
participants the purpose of the study and thanked them for having spared their precious
time and accepted to participate upon invitation.
3.8 Limitations to the Study
Some people are evasive about their social lives and in particular reproductive health
issues; the researcher used expert knowledge and experience in order to obtain more
reliable information since it was a sensitive area of study. The rural population in Uganda
is characterized by majority who are not educated hence cannot read and write English.
The questions were translated into the local language (Luganda). This process was time
consuming. Lastly, it ought to be noted that this was a qualitative study and therefore the
results should be interpreted in the context that the sample size is small (true to all
qualitative studies) and sampling non-probabilistic. This means that the results can not be
generalized to the entire population.
35
CHAPTER FOUR: RESULTS
The study investigated peoples‟ knowledge about pregnancy and childbirth. Several
issues emerged from a number of FGDs and in-depth interviews. These included
knowledge on how women prepare to get pregnant, the health problems experienced
during pregnancy, childbirth and post delivery period. The other issues that emerged were
on the risks of pregnancy, delivery and motherhood, and the coping strategies women use
to deal with these risks and problems.
4.1 Knowledge on Pregnancy and Childbirth
This section presents data on women‟s knowledge on preparing for pregnancy, problems
that women face during pregnancy through child birth as well as their experiences with
ANC and FP.
4.1.1 Women’s knowledge on preparation for pregnancy
A number of issues arose from Focus Group Discussions (FGDs) and in-depth interviews
regarding how women prepare themselves when planning to get pregnant. The majority
FGDs (5/7 FGDs) knew that women who are using contraceptives stop using family
planning methods (FP) and when this is done they were more assured of becoming
pregnant. The family planning methods commonly used were pills and condoms. In
addition, most female FGDs pointed out that consistent breastfeeding inhibit conception.
A few discussions highlighted that, once one stops using modern contraceptives, she gets
pregnant soon after. One of the participants in a male FGD remarked:
36
“Our wives prepare for pregnancy by taking contraceptives and when they want
to get pregnant, they stop taking the pills and then conceive. In doing this they
may be preparing for the next pregnancy which is known as family planning…
They may be doing it for proper spacing or otherwise planning for a child for
example looking for a plot to build a house before they produce. However other
women don‟t prepare, they produce only because they are married and they want
to please their husbands but all in all women prepare for a pregnancy by
practicing family planning” [Male FGD – Kasangati].
Similarly, five of the seven FGDs mentioned that women never undergo any form of
preparations in order to get pregnant. Data from in-depth interviews indicated that to be
pregnant was out of a woman‟s “chance” or by “mistake”. This was most experienced by
the unmarried women. It was reasoned that when a woman is not married she cannot say
„I want to get pregnant‟. Besides, data shows that married women do not prepare for
pregnancies often because conception may have been by „mistake‟. In one FGDs, a
woman stressed that she became pregnant unknowingly.
“Many of us here do not prepare for pregnancy, we just find ourselves pregnant
just spontaneously like that without any preparations” ( FGD Mothers attending
ANC)
Women whose spouses were educated had knowledge that in order for one to raise a
child well one has to have a vibrant income generating activity. A few FGDs mentioned
37
that a number of women plan to get pregnant. Couples decide on when to have a child.
Some women first consulted their spouses before they plan to get pregnant. The husbands
agree with the wife first to avoid domestic violence or lack of man‟s support during
pregnancy. Majority of the women do not prepare for pregnancy because of the strong
belief in biblical teaching that “go and pro-create and fill the earth”. So they do not mind
to have a child anytime as all these children are gifts from God and man is fulfilling his
obligation to fill the earth.
4.1.2 Knowledge on health problems faced during pregnancy
Focus group discussions and in-depth interviews discussed health problems the pregnant
women face. In these discussions they described the health problems, how they are
manifested, experienced and dealt with during the gestation period. Majority FGDs and
in-depth interviews reveled that during pregnancy women were likely to be vulnerable to
common diseases like malaria, stomach pains and sexually transmitted diseases (STIs)
especially syphilis, candidiaisis, vaginal itching and smelly vaginal discharge. Other
poor health pregnancy conditions experienced were weight loss, headache, stomach
pains, fever, high blood pressure, cough, anemia, leg pains/swelling and asthma among
others.
Behavioral and psychosocial health problems were also reported. These included loss of
appetite, vomiting, nausea, general body weakness, and psycho-social conditions such as
38
anxiety; lack of support from partner responsible for pregnancy was also highlighted. All
these resulted into stressful conditions for the pregnant woman.
It should be stressed that most in-depth interviews and FGDs revealed that lack of care
from partner‟s especially economic support was one of the serious problems pregnant
women faced. In the male FGD, it was strongly presented that male partners do not offer
adequate economic and social support to their partners. This is further emphasized by the
following typical quote:
“Yes, the point for that gentleman is heavy because if a man does not care for the
pregnant wife, she may develop worries and sometimes she may end up stopping
having sex with this man. So as a result, this man will love other women outside their
marriage which can bring them HIV/AIDS in the family. And on top of that, because
this woman is miserable she will start mistreating children at home who are innocent,
and sometimes this affects the child in the womb and the woman during delivery.
This woman may fail to push the baby because of too much stress” [Male FGD –
Kasangati].
It was reported that there were complications from contraceptives that were more likely
to manifest in pregnancy. Some of the complications were over bleeding, weight
loss/gain and likelihood of delivering an abnormal baby or even at worst failure to
conceive and or deliver. Majority of the female respondents thus expressed fear to use
contraceptives.
39
Other reported problems associated with pregnancy were poverty, though the FGDs and
in-depth interviews admitted that this is not health related. They however said that it
impacts most on pregnant women‟s health. Poverty leads to inadequacies in accessing
appropriate diet, failure to meet material needs for example appropriate dresses, lack of
transport to access health services and payment for the costs related to health care
seeking. Poverty was also reported to bring about domestic violence especially women
demanding for their “pregnancy related desires” such as special diet thus ending up
quarrelling with their spouses, abuses or battered. It should be noted that in all FGDs it
was revealed that lack of most HIV/AIDS services in rural health centres was a problem.
The study further investigated severe pregnancy related health problems. All the FGDs
and in-depth interviews indicated that malaria was a big problem and most of the women
suffered from it during pregnancy. The mistreatment of women by partners or spouses
was the second most reported serious problem. Miscarriages sometimes because of
infections like syphilis featured third most reported problem.
Other very serious
problems were candidiasis, and dislocation of bones during delivery. The quotations
below clearly show how deep pregnancy related problems.
“I used to have miscarriages; I could not deliver a live baby, I went to the hospital
they told me it was malaria which removes my pregnancies. I used to take herbs to
cure miscarriages but it did not help me. I lost 3 pregnancies but the fourth one I
delivered it normally….. These problems are very severe because me I wanted to
40
commit suicide because of the miscarriages I was getting” [Female FGD ANC
Mothers - Kasangati HC IV].
“The problem of men abusing their wives/partners is very common everywhere.
Families are not stable; they even reach extent of beating their wives” [Female FGD
– Kasangati HC IV].
One could say that women were aware of antenatal care benefits and this motivated them
to seek ANC services in reasonably big numbers though at a late stage during pregnancy.
This finding contradicts with findings by (Orinda et al et al 2005). In Orinda (2005)‟
noted that women were poorly informed about the risks of pregnancy and the importance
of antenatal care. The community‟s understanding of benefits of ANC is a positive and
motivating factor that should be used as platform to promote hospital deliveries. For this
community, while majority of them seek ANC, they come late. They visit in the second
trimester (at five months) as opposed to the critical period i.e. the first three months when
the fetus is forming. This means that complications that could have been averted the
initial ANC screening are missed. This affects the health and wellbeing of both the
mother and the child. Currently the WHO guidelines which the Ministry of Health
Uganda has adopted recommend the result oriented ANC where a mother has to attend 4
times including once in the first 3 months (Villar et al 2001). Therefore, this knowledge
and practice gap needs to be addressed probably during child day‟s campaigns and other
health education programs. Possible reasons why women visit fewer times is the lack of
41
knowledge associated benefits of ANC. They mainly visit the health facility when they
are feeling unwell.
Contraceptives were believed to cause complications to the women and affect the
formation of the child. Our results show that although women had good knowledge about
contraceptives, misconception still existed. For instance the view that modern FP causes
deformity to the baby was wide. While it may be true that these contraceptives could
have side effects of varying magnitude (Mugisha and Reynolds 2008, Mbonye 2001),
they do not necessarily cause deformity, and this calls for extensive health education
especially to counteract misinformation.
Male involvement also appears to have an important role during pregnancy and child
birth. This study found that men had low participation and this could be due to low
knowledge on maternal health. Other studies (Nuwaha
et al 1999 and Wolff et al 2000) also established that men serve pivotal role during ANC
and delivery period. In addition men ought to ensure that adequate preparation such as
the purchase of utilities and ensuring that money is available when required. There is,
therefore, a need to target them extensively and mobilize them for effective participation.
4.1.3
Experiences with ANC and Family Planning services
The narrative below shows the knowledge on fertility and perception of pregnancy and
delivery services. Jane (not real name) is a mother of four children with education of up
42
to senior two. She is 27 years and works as a hair dresser. Below she narrates her
experiences.
Box 4.1 Narrative of pregnant mother
Okay I had ever used family planning because I wanted to give birth when my other child was
four years. So I started family planning when the other child was 9 months. Later, I stopped
taking family planning because I wanted to get pregnant. However, because of the side effects of
family planning I experienced irregular periods and used herbal medicine. This was for treating
the painful stomach. One year passed and I was still in the same condition. My stomach had
even increased in size, yet there was no baby. I sought some traditional medicine, used it to
massage the stomach, boiled herbs and drunk some….. These herbs helped me….. „We Baganda
believe that when you drink it, it helps to massage the inside of the stomach to put right what is
wrong and causing trouble in the stomach‟. I used “Kamunye” and “Entwatwa” these helped to
make me get my periods again.
I also went to the nurse near my home and told her that I started having my periods but was not
getting pregnant. So the nurse told me that family planning injectaplan varies in different ways in
various individuals….
My ANC visit here was gainful because I came with malaria and was given some tablets stronger
than fansidar. I don‟t recall their name. But I healed well and the baby started playing very well
again up to now I am really okay.
We come here for ANC because we find here some nurses and doctors who can examine us very
well and treat us if need be. They also give us the ANC cards because if one collapsed on the road
with the ANC card, they rush you here and you are attended to.
It is also good to come here because they help you and take your blood to be tested for many
things or diseases including HIV/AIDS, and then they tell you your status and advise you how to
move on and how to treat that baby when you deliver. They counsel you if you are HIV positive
and help you not to give it to the baby in your womb. (Pregnant mother attending ANC,
Kasangati HC IV)
43
This narrative describes positive experiences with both the folk and the biomedical
traditions of care during pregnancy. It appears that additional skills and basic equipment
to the traditional midwife could be a good reinforcement in provision of maternal
services. Other studies in east and southern Africa also found that ANC card a critical in
helping mother‟s access delivery services. In South Africa, obtaining the ANC card was
mainly viewed important for enabling the mother in labor access to a public health
facility for labor and delivery (Myer and Harrison 2003). Indeed, health workers tend to
respond more positively to women with ANC cards when they come in an emergency
condition.
Focus Group discussions and in-depth interviews described reasons why women
adequately prepare for delivery. Integrity and protection of personal dignity during
delivery appeared to be key drivers for preparation. In that regard, delivery materials and
ANC visits were met. It was noted that this preparation is useful as it could save life of
both the new born and mother.
4.1.4 Women’s knowledge on childbirth
a) Knowledge of problems and risks pregnant women face during delivery
According to FGDs and in-depth interviews, pregnant women face several risks during
delivery. The most frequently mentioned were over bleeding which can result into death
and failure to give birth normally leading to caesarian section. It was reported by
majority FGDs and in-depth interviews that normal delivery was unpredictable. Other
44
risky situations mentioned were retained placenta. Data indicates that the midwives
tendency to delay and their alleged rudeness tends to de-motivate the mothers from
delivering in public health facilities. „Under the table payment‟ was reported to influence
behaviors of health workers while on duty. Mothers who paid were reportedly better
taken-care-of. Conditions such as abnormal baby position, anemia, obstructed labour,
caesarian section, fetus distress, eclampsia, HIV/AIDS, post delivery abdominal pains
and lack of emergency obstetric care at the TBAs care centers were known as very risky.
Below are some of the typical quotes as exemplars:
“Some pregnant women become anemic, and when you don‟t have blood, you most
likely die. It is deadly to be anemic. …you can be walking and fall down” [Female
FGD Kasangati]
“To be operated while delivering is big risk, to get cut, is a bad thing because some
die during that process, though some come out when alive” [Mother respondent
female FGD – Nangabo sub-county]
There are however some socio-economic and psycho-social problems which were
mentioned. The most reported problem by majority respondents in this category was of
affordability of essential delivery items such as gloves, baby‟s clothes, pads, cotton wool,
polythene paper used for delivery, blankets, “delivery kit” and payment for delivery
services in private health facilities. Few key informants reported that there was not
enough care and support from husbands. This included financial and social support
required by mothers and their newborns.
45
b) Importance of preparation for birth:
Majority focus group discussions stressed the importance of preparation for birth. This
preparation included buying child clothes and associated necessities. They for instance
had knowledge that when one delivers at a TBAs home, the child will miss some
vaccines that are given at birth such as DPT, Polio and BCG. It ought to be pointed out,
however, that majority of the discussions and in-depth interviews did not recognize the
importance of postnatal care. Literature in Africa concurs that most women do not know
the importance of PNC. Therefore very few women indeed go for PNC six weeks post
delivery.
A Study done in eastern Uganda indicated that postnatal services were almost nonexistent
in the whole region (Waiswa et al 2008). In addition (Nabukera et al. 2006) also
established that there was low level of knowledge and use about PNC. This was due to
misconceptions regarding the importance of postpartum care, distance to health facilities,
poverty. Health systems factors such as poor facilities, lack of essential drugs, and poor
attitudes of health workers were also highlighted. Therefore in the effort to improve
reproductive health care services, there is an urgent need to improve postpartum services.
4.2 Perceptions on pregnancy and childbirth
This section presents information on views about both biomedical and traditional health
care with a focus on the period of pregnancy and child birth.
46
4.2.1 Community views regarding biomedical services
The researcher investigated the issues and perceptions of pregnant women in view of the
services offered by different health providers in the management of pregnancy and
childbirth.
The study considered biomedical health workers and traditional healers,
including traditional birth attendants.
The majority of in-depth interviews and focus group discussions mentioned that the
biomedical health workers are preferred in as far as management of pregnancy and
childbirth is concerned. They provide treatment after appropriate diagnosis by laboratory
tests and other tests as science warrants. They also provide HIV counseling and testing
services which the pregnant mother requires.
Health workers were also credited for providing health related information in the
community. Most respondents indicated that access to health information enables
mothers to make the necessary preparations and decisions on what to eat and ensure good
hygiene during pregnancy and childbirth. In addition, the other information needed was
on how to detect and avoid dangers in pregnancy. A few FGDs and in-depth interviews
expressed bad experiences with the biomedical health practitioners. Some of the health
systems problems included few health staff that man the health facilities. Such a problem
leads to long waiting time to receive care during pregnancy and childbirth. Lack of
equipment and supplies (not enough delivery beds, gloves, cotton wool, bed sheets and
blankets among others) was also highlighted. Some antenatal and delivery services were
also reported not regularly provided at the lower health units for example HIV testing,
47
scanning, STDs screening and caesarean operations in cases where women are unable to
deliver normally. The voices from women focus groups are presented below:
“After delivery the midwife takes away the baby and the next step is to press your
stomach gently to make sure the placenta comes out and if it fails there are machines
they use to hold this thing and pull it out” [Mother who delivered in health facility –
Kasangati].
“In Kasangati here they don‟t charge money. If you come with the things they want
like gloves and cotton and polythene sheet. They deliver you freely, immunize your
baby, and let you go, but in the private clinic they charge you a lot of money”
[Female FGD participant Nangabo sub-county]
4.2.2 Community views regarding TBAs and childbirth
In as far as the traditional birth attendants services are concerned in the management of
pregnancy and deliveries, most FGDs mentioned that TBAs are usually easy to access
because they live within the neighborhoods, provide low cost services in form of herbal
therapies, consultation and delivery, they even provide a service on credit and mothers
pay later when they get money. Furthermore, it was mentioned by majority of in-depth
interviews that TBAs are friendly to mothers, and provide good counseling services.
Studies in Southern and East Africa show similar experience that TBA are more
accessible to mothers in financial and social terms (Mathole et al 2005; Maimbolwa et al
2003; Atuyambe et al 2009). How good these counseling services were was not
investigated by the study.
48
On the other hand, however, in-depth and FGDs discussed their experiences with TBA
services and reported that they do not detect ill-health or abnormal conditions a pregnant
woman may be faced with. The following views from the various FGDs participants and
in-depth responses clearly illustrate the above mentioned scenarios.
“Okay I have ever delivered from the TBAs but the condition was not good and the
baby died eventually…. I could get labour pains and since it was at night she was
sleeping and she was such an old woman. So she would get some herbs which I
didn‟t even know, she smeared these herbs on the stomach and the problem is that I
had a lot of water in the stomach. Fortunately I delivered but the child died
eventually” [female FGD participant narrating her experience at TBA].
“For me my friend told me she also delivered from the TBA but she almost died
because whenever she got pains the TBA just told her to push and she nearly died. So
their care is not all that good. I would say they are not skilled” [Female participant –
Female FGD Kasangati].
While WHO shows that the use of TBAs does not significantly reduce maternal mortality
ratio, their training is associated with reproductive health benefits such as referral of
complicated cases, knowledge on the timing of ANC services among others. The studies
emphasize that the potential of TBA training to reduce peri-neonatal mortality was
promising when combined with improved health services (Cochrane Database Syst Rev.
2007; Sibley et al 2004). In-spite-of the facts about maternal health benefits associated
49
to TBAs, the reality in the Ugandan community is that they are still the most accessible
service providers to most families especially in rural areas. This is confirmed in the
Second National Health Plan (2010). In the event that a mother goes into labor at night or
transport to the health facility is delayed, TBAs become the most feasible option
4.3 Community practices regarding maternal health care during pregnancy and
childbirth
There were quite a number of practices observed by mothers during pregnancy and
childbirth. These according to FGDs, in-depth interviews and key informants can be
categorized into two sub-themes. There are practices which women observe that take care
of the physical – biological aspects of pregnancy and birthing process. There are also
practices which take care of the psycho-social aspects of the mother and the child.
4.3.1 The pregnancy period
The use of herbs
In-depth interviews and FGDs mentioned that women quite often use herbal medicines
during pregnancy. Traditionally, pregnant women used herbs to prepare for pregnancy.
This was common among women who have taken long to get a child or presumed barren,
including those who have experienced episodes of miscarriages. Three of the five female
and one of the male FGDs asserted that most women consult traditional healers for
traditional therapies to enable them get pregnant. This motivates them to resort to
50
traditional medicine to enable them a possibility to get pregnant as indicated by the
typical quote below:
“They go to traditional healers and sometimes become pregnant, some go to
shrines, others go to Pentecostal churches for prayers to be pregnant” [Male
FGD-Kasangati].
Food and nutrition
It was also reported that some women change the feeding practices during pregnancy or
after delivery. It was for instance common advice and practice to consider eating fruits
and greens as part of the daily menu for the pregnant mothers.
Traditional beliefs and practices
Some practices were related to traditional beliefs during this pregnancy period. For
example, it was reported that a pregnant woman should not engage in extra-marital sexual
intercourse. Failure to abide by this moral could result in pueperal psychosis – “Amakiro”
a mother tending to eat her baby after delivery. This can also result into prolonged labour
during delivery. This has also been observed in Cameroon where it was common among
the married couples (60%) and was associated with low socioeconomic status (85%).
This study also observed that most psychiatric disorders and psychopathologic
manifestations generally began after delivery (80%) (Mbassa 2005).
For the case of a breach baby it was reported that a woman takes „Akeyo‟, „Kyogero‟ or
„akatengo‟ – these are herbal concoctions taken by pregnant women/mothers to prevent
51
or treat this deadly condition. It was also revealed in most FGDs and TBAs interviews
that traditional medicine was used (herbs smeared on the stomach of a pregnant woman)
during gestation period to correct a mal-positioned baby.
Data revealed that there was a common custom practiced by pregnant women in the study
area. Pregnant women were not to look into a deep pit or grave. They were also not to
participate in burial of a person who hangs himself or herself. Not observing these would
result into producing a disabled child for or the child produced would most likely also
suffer the misfortune of hanging himself later in life. These practices appear to protect
pregnant women from participating in risky or stressful activities for their wellbeing.
Some women use cloth belts and insert herbs in the vagina as a method of family
planning. The cloth belt is worn every time they are going to have sexual intercourse,
when they want to become pregnant they stop using it. The quote below vividly shows
this traditional belief:
I think even today it is used because the modern family planning methods have
many side effects so the women resort to using the traditional methods which they
feel are safer).FGD Women with a child less than 5 years
Use of health services
The capacity of health facilities in early detection of abnormalities in pregnancies also
attracted mothers to seek services at the health facilities. Better equipment including the
theatre, incubators to mention but a few to handle complications also motivated women
52
to seek healthcare. Other respondents reported that buying material requirements for the
baby and mother (examples being clothes – maternity dresses, flowers, cotton wool and
so on) was another way they prepared for pregnancy.
Furthermore women sought antenatal care services from the nearby health facilities.
Majority reported to ANC attendance when pregnancy is 5 months old. There were quite
a number of benefits which were mentioned to be associated with attendance of antenatal
care. Some of the benefits of ANC according to all female FGDs were: - getting malaria
prophylaxis, treat cough, malaria, tablets to increase blood in the body, deworming
tablets, examination to check the normality of baby in uterus, immunization against
tetanus, HIV/AIDS testing and care services, get information on hygiene, nutrition, and
general health during pregnancy and information about monthly periods. Mothers also
mentioned that they get to know about safe delivery practices and also are given a card to
enable them easily access assistance from the health facility.
Family planning and gender issues
There were also allegations where some men coerce woman to conceive even when they
have fathered children with other women. In some instances a woman may want to have
only six children, but the man demands for more – on the pretext that it is the
responsibility of the father/man to take care of the children. But women‟s respondents
indicated that they were the ones who suffered most pains/risks of pregnancy and
delivery, experienced poor health, lacked means to support their children. This left no
53
room for planning for a pregnancy independently. The quotation below clearly explains
this scenario.
“I have an in-law who recently got married in church and already had five children. ,
… the husband told her that „now we are married in church, I would like you to
produce up to the number I feel adequate for me‟. This woman did not want to go
above five children which she already had but because she was taken to church for
marriage, she fears that the man will produce children with other women outside
their marriage”. [FGD Mothers at ANC – Kasangati HC IV].
The woman further narrated that the above scenario makes women suffer most and
experience reduced quality of life as expressed in the statement below:
“You find a woman of say twenty three years appearing as if she is thirty eight years.
Those educated women who produce few children keep looking good and healthy.
We love marriage and children but not too many children. You reach at a point where
you regret as to why you did not go higher in school” [ANC Mothers – Kasangati
Hospital].
Majority of the mothers attending ANC at the health centre emphasized that pregnancy is
by mistake, that it happens unknowingly. An example to this situation is demonstrated by
the quote below:
“Sometimes pregnancies come by mistake especially to those who are not married,
because when you are not married, you can‟t say I want to get pregnant, and even
54
married people do not prepare for pregnancies but to some of us pregnancies come
by mistake” [ANC Mothers – Kasangati HC IV].
The pregnancy period is an important stage in the life of a mother and the baby. The
practices of the mother at this stage affects the growth of the foetus and health of the
mother. Therefore, attention for result oriented ANC helps this process. Screening for
diseases such as syphilis and other STDs and abnormalities need to be detected early
enough. Traditional practices could interfere with this process by giving a false sense of
security to the mother resulting to late attendance of ANC i.e. first attendance after 3
months. Studies elsewhere confirm the benefit for early ANC attendance. For instance in
Kenya at first ANC visit, malaria parasitaemia was 18.0%, prevalence of any anaemia
(haemoglobin < 11 g/dl) was 69.1% and prevalence of moderate anaemia was
(haemoglobin < 8 g/dl) 11.8% (Ouma et al 2007; Ouma et al 2010).
4.3.2 Delivery and post delivery period
The results showed that women undergo various preparations during and after delivery.
Most preparations aim at enabling easy and quick delivery. Most female respondents
mentioned that the pregnant woman does all possible preparations in order to have safe
delivery. In all FGDs and in-depth interviews responses indicated that when a woman in
the study area is pregnant they use herbs that include taking herbal concoctions as well
55
and other herbal preparations such as “clay mixed with herbs” (Emumbwa) medicine1 as
suggested by the following quote:
“They use „Emumbwa‟ to soften the bones during delivery but there is also the
one that stimulates the labour pains and this is given at the time of delivery”
[Female FGD – Kasangati HC IV].
“You have come to talk to me at a time when I have stocks of some samples of
„Clay medicine‟ which I have here (TBA displays the already displayed
concoctions) and I give it to women when they have pregnancy complications. In
the clay soil I put in herbal medicine which works like and is related to the
„capsules” in the biomedical system” [TBA Magera village Kasangati].
This practice was reported to be common to all most all pregnant women and this is
called “Okumenya2”. A traditional birth attendant had this to say:
“For the young girls who may be presumed unable to deliver normally…. I give
them that drug of herbal concoctions (TBA points at bottles full of the
concoctions). I limit the amount, because it can make the pelvic bones to soften
and weaken too much, to avoid that side effect I limit the amount/quantity given.
For the rest of the women I give it when they are nine months pregnant. I give it
two weeks to delivery – they drink it and some of it they smear it around the
pelvis” [TBA Nangabo sub-county).
1
“Emumbwa‟ is clay soil mixed with herbs and dried. It helps to make bones flexible during delivery
2
“Okumenya” refers to enabling the tissues/ligaments of a pregnant female become flexible, and easy to expand when
time of delivery comes so as to allow easy delivery
56
On delivery, women had several options. Some delivered at home, at traditional birth
attendants places while others delivered at the health facilities (public and private). There
were quite a number of motivational factors that made them deliver in these places
mentioned. Those who delivered in the health facilities were motivated by the availability
of a range of services. These included HIV counseling and testing, postnatal care
services, screening and treatment of diseases for example malaria, typhoid, STDs.
Preventive services including health education and immunization were identified as
important. In addition, clinical services like ability to perform caesarean section and
skilled health workers and free ambulance to referral/specialized health facilities were
motivation factors.
In addition, all respondents acknowledged use of “Ekyogero” bathing of the baby in
some herbal concoctions that are believed to prevent several diseases including the bad
skin or skin rashes, bad luck or misfortunes and increase the child‟s opportunities and
well being as it grows up. During the postnatal periods, herbal baths were reportedly used
to „clean‟ the uterus and also heal the vaginal tears. This process involved sitting in basin
containing herbs. Most in-depth interviews also indicated that the child‟s cord is treated
using herbs – for instance a mixture of ghee and mushroom are applied to make cord
healing quick and also reduce pain on the child.
Other important aspects though not visible in our data that are usually taken into
consideration towards delivery and the period after include stocking of food items,
acquiring a helper (often a relative or paid house helper), buying personal effects for
57
mother and baby (clothes, vaseline etc) among others. In this whole process men tend to
take an upper hand in making decisions especially where to deliver from as it involves
financial considerations. This was also observed by other studies (Amooti-Kaguna and
Nuwaha, 2000; Byaruhanga et al 2007) where they found that social influence from the
spouse was important in making decision on choice of delivery. In a study on barriers to
prevention of mother-to-child transmission of HIV in Uganda, Mbonye (2010) also found
that, overall having had an HIV test was highest when both men and women made
decisions together or when women were empowered to make their own decisions. The
use of herbs among women indeed is rampant during thought pregnancy and post partum.
One explanation to this beyond cultural beliefs is the access to highly trained health
workers. There are very few medical doctors working in the district. We need to note
thought that the Kasangati situation is not unique to the rest of Uganda.
Traditional birth attendant‟s preparation for delivery:
Traditional birth attendants handle cases of different facets. The narrative below is of a
TBA who has been in practice for 37 years. In the description, she highlights her
experience with conditions like nausea, malaria, backaches as well as complications like
breach pregnancies. This narrative also shows that some TBAs appreciate that they may
not be experts in all conditions and therefore some refer to the modern health sector. The
narrative below depicts this message:
58
Box 4.2: A TBA Narrative: treatment of pregnant women
Now when a woman becomes pregnant, they usually come to me for examination. And I check
them; tell them the age of the pregnancy. Some pregnant women get several complications such
as vomiting. For this, I give herbal drugs which effectively stop the vomiting. I also treat fever in
pregnancy effectively. I have all the herbs to deal with even malaria in pregnancy. But the herbs
for fever in pregnancy are different from those for malaria. I prescribe and give different herbal
concoctions for the different conditions.
In addition, pregnant women get nausea, a feeling of
spitting out saliva all the time which I also treat with herbs. In case the baby is mispositioned in
the womb, I give the herbs. Those that I fail to correct mispositioned baby I refer them but that is
for the cases that come in late otherwise for those who come in early pregnancy, I correct this
condition. Those who come to me with the problem of the placenta coming out first I advise them
not to engage in any kind of work, tell them to keep resting – lying on bed – till delivery. There
are some who come with backache complications, for those with this complaint I advise them to
be patient and counsel them that they will deliver well. In addition sometimes pregnant women
get an abnormality whereby the umbilical cord folds around the neck of the baby. I also deal with
this problem using herbs. I also have a special variety of banana plants, whereby I cut a small
piece give it to the women with this problem to wear around her neck. (TBA, Magere Village –
Nangabo sub-county)
4.3.3 Dealing with delivery related problems and risks
There were several ways through which women dealt with the problems faced during
delivery. The women who failed to deliver at lower level health centres are referred to
the hospitals by use of ambulatory services that have been provided at the health centre
IVs. The concerned mother however buys fuel for the ambulance.
Mothers who do not have money to deliver at private health facilities opted to deliver at
the TBA‟s centers where costs were affordable or credit facilities offered. In addition,
59
TBAs live within the communities. It was mentioned that women who fail to get the
delivery kits required by public health systems were assisted by friends, and sympathetic
women found at the maternity wards.
The problem of over bleeding was treated by midwives using injections or tablets. The
TBAs also advised the affected mothers to chew sugarcane to stop over bleeding. The
issue of stressed mothers resulting from unfriendly behavior of nurses was dealt by
mothers responding to deliver at traditional birth attendants‟ places who they find and
perceive to be more friendly and understanding.
The pregnant women utilized traditional therapies, usually herbal medicines for various
ailments and pregnancy/delivery related conditions, herbals were taken to make pelvic
bones flexible, heal vaginal tears and treat abdominal pains and fevers to mention but a
few. Herbal therapies were also utilized to induce labour, for bathing child and mother
and various mixtures used to dress the umbilical cord before it falls off. This is in
agreement with findings in a report by WHO (WHO 1998, Atuyambe et al, 2009) which
report utilization of these traditional therapies during pregnancy and delivery.
60
4.4 Coping with pregnancy related problems
There were several ways reported across all respondents of how pregnant women deal
with the problems mentioned above. As far as malaria and fevers were concerned;
normally treatment was sought from the health facilities in the communities. In case of
anemia, women were advised by the biomedical staff to improve on diet such as eating
beans, green vegetables and fruits. The following voice form a female focus group
demonstrates this:
“Malaria is also a problem to these women; they normally give us antimalarials from
the different health centres around here where we go” [Female FGD Kasangati].
In as far as vomiting during pregnancy was concerned, majority responses mentioned that
pregnant women usually get tablets from the health facilities, and also take herbal
medicines from the TBAs. The quote below indicates how both biomedical and
traditional birth attendants play a role in dealing with pregnancy problems in the first few
months.
“The TBAs always have some herbs that help us stop vomiting. … but also as she has
said, it is right that at times the health professionals give us some tablets for vomiting
during pregnancy but the traditional herbs work better” (Female FGD, Kasangati)
61
For sexually transmitted infections such as syphilis, treatment was in form of drugs from
the health centres as well as traditional healers that used herbs. Herbs used included
Kamunye and bathing salt solution. Other problems categorized as medical, social and
economic were mitigated (table 4.1).
62
Table 4.1: Problem experienced and coping strategy
Problem/Disease
A) Medical
1. Lack of appetite/vomiting during
pregnancy
Coping strategy
Perseverance until when it is worse then seek
medical attention
Seek treatment from health facilities
Herbal therapies from traditional healers
2. Bleeding
Treatment from health facilities
3. Fever (Malaria)
Treatment from health facilities
Sleep under treated mosquito nets
Take herbal concoctions when biomedical remedies
fail
4. Asthma
Seek treatment from health facilities
Herbal medicine (traditional)
Treatment from health units
Treatment at health facilities
5. High blood pressure
Eat Katunkuma ( Gallic)
Herbal therapies
6. Lack of HIV/AIDS services
Travel to health facilities where HIV/AIDS services
are given
B) Social
7. Pregnant woman abandoned by
husband/partner
Go back to live and be supported by parents
Sometimes seek support from relatives
Seek employment to support self or engage in
economic activity to earn own income
8. Domestic violence anxiety
Counsel men to stop abusing women
women seek personal sources of income
C) Economic
9. Poverty, lack of proper diet
Men provide for their spouses/partners
Seek assistance from parents, friends, relatives,
good Samaritans and or well-wishers
Engage in economic activities
63
The traditional birth attendants and biomedical health services are in most cases utilized
concurrently by the pregnant mothers. The utilization of herbal therapies with unknown
side effects however needs to be investigated and evaluated – because its health impacts
on the users are not known. The health workers should explain this practice well to the
mothers in order to take the traditional therapies cautiously or stop them.
64
CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS
5.1 Conclusions
This research came up with important information on the knowledge, perceptions,
practices, and how women cope with pregnancy and childbirth. It also provides
implications for policy and programming relating to health seeking and ultilization of
biomedical health services.
Regarding knowledge on pregnancy child birth, women were knowledgeable on when
and how to get pregnant. They were aware of the different modern family planning
methods though misconceptions existed. They in addition know that during pregnancy
women face multiple vulnerabilities especially to communicable diseases such as
malaria. The importance of ANC was known and women articulated the importance of
male involvement to the well being of the pregnant woman. Complications associated
with pregnancy and child birth were also well known. Majority of women were
knowledgeable about the risks women face during pregnancy and the common
complications resulting from pregnancy. Preparing for delivery (buying clothes, keeping
reserve money) was viewed by majority as important
Another conclusion is that there was a general perception that biomedical workers were
more competent to handle pregnancy and child birth. However, the problem of negative
attitude towards health workers, poor access to facilities in terms of distance and costs are
65
prohibitive. There is a health benefit to mothers when they get access to written and oral
information during pregnancy and delivery.
Traditional birth attendants are popular because they are friendly and offer also tend to
offer services on credit.
Male participation in support for reproductive health activities was low and yet valued as
important by the women. Male involvement also appears to have an important role during
pregnancy and child birth. This study found that men had low participation and this could
be due to low knowledge on maternal health.
Biomedical services were preferred by majority of mothers mainly because of the
technical competencies and equipment. On the other hand, TBAs were most accessible as
they live in the same communities and have flexible terms of payment
Thirdly, in terms of practices during pregnancy and child birth, there is wide use of
herbal medicines especially for women suspecting to be barren as well and those that
have failed to deliver normally. Infertility was a big worry and this was one of the main
that led one of the women to visit the traditional healers.
There is a wide range of practices regarding pregnancy and child birth. The commonest
practices focus on nutrition, family planning methods and use of herbal remedies.
66
Lastly the health seeking behavior is affected by social, economic and health systems
factors. Some of the health systems factors include inadequate human resources for
health, appropriate infrastructure to mention but a few.
This situation leads women to
cope in several ways. Pregnant mothers cope with health challenges by concurrently
using traditional birth attendants and biomedical health workers.
5.2 Recommendations
A number of recommendations can be drawn from this study:
There is need for focused sensitization and information dissemination regarding modern
family planning methods. This will counteract the misconceptions widely held by the
community regarding modern family planning technologies. One way in which
sensitization about FP methods could be done is the use of individual users to identify
their social networks and influence them. This method is likely to be effective since
individual questions and concerns will be attended to in a more freely. Information
dissemination should also be delivered through leaflets and distributed in strategic places
such as ANC and child health clinics. Translations into local dialects should be done to
make it easy for those who do not read English to read on their own and grasp FP
concepts. Health facilities both private and public should be involved in delivering these
Information, Education and Communication (IEC) materials. In addition, exploration as
to whether traditional birth attendants could also have IEC materials to give to mothers
when they visit them should be made.
67
Family values and support should be cherished. Men should be encouraged to support
their partners in all aspects of reproductive health. Particularly important includes
accompanying them to seek healthcare at health facilities, providing and taking care of
the pregnancy period, during delivery and the period after birth. In central Uganda where
this study was done, the Ganda culture has a super infrastructure that could be utilized.
This includes the Bisaakaate, okumanyagana and the inter clan games usually presided
over by the cultural leaders or royals including the King or Queen. Masses of people
usually attend and this would be a „hot spot‟ to disseminate health messages.
There is need to increase geographic and social access of maternity care. Services that are
close to community are likely to be better utilized. In the mean time, un trained
traditional birth attendants could be given short and skills tailored trainings that enable
them provide essential services as majority of women still prefer to deliver at home
usually unsupervised by skilled attendants. The training courses should include
knowledge of when and where to refer, information on vaccination for both mother and
new born, good nutrition and prevention of mother to child transmission services
(PMTCT) to mention but a few.
There is need to address negative attitudes towards herbal remedies. Some of the herbs
have health benefits and therefore ought to be promoted. The National Chemotherapy
Laboratory Research Center would be the most appropriate body to disseminate these
herbs in conjunction with the Ministry of Health division of Community Health. Existing
structures such as the Village Health Teams (VHT) could be an excellent entry point.
68
In addition, the Ministry of Health in collaboration with local governments need to
increase women‟s understanding of the pregnancy and childbirth process. This should be
through user friendly communication strategies where IEC materials are distributed at
grass root level targeting women and families. Collaborations with civil society
organizations at national and community level ought to be explored. One way to increase
knowledge about child birth is by making evidence based reproductive health information
more readily available.
Gender issues affecting male participation in safe motherhood activities should be
addressed. Men should be viewed as integral element of to maternal and child health
service delivery. Even when some of the problems are structural in nature, focus should
be laid to health workers and planners to for instance provide for men that accompany
their wives for ANC, and deliveries.
5.3 Proposed areas for further research
Research to address the problem regarding quality of TBA services being offered should
be initiated. There is need to build the evidence through a detailed study on effectiveness
of TBAs in improving maternal health. This will contribute towards the MDG-5. Some of
the questions to address should include: What is the quality of care offered by TBAs?
What are the range of services offered by Traditional healers including TBAs. Do TBAs
play any role in PMTCT, FP, and immunization? Are TBAs an essential partner in
maternal health in resource limited settings?
69
Another study that would give the understanding of post natal care issues would reveal
important information. This study would flag out that PNC services as absent. Literature
also points out that PNC services are nearly not in existence. A study needs s to establish
why there services are not provided is of essence. Is it that they are not demanded for,
poorly offered or women are not aware of their importance? Why are health workers
reluctant to offer them? Could it be that the health system itself does not value them or
viewed as a way to reduce workload since staffing levels in are low?
70
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76
ANNEXES
FIELD TOOLS
Knowledge, Perceptions and Practices in Pregnancy and Childbirth in Uganda: A
Study of Nangabo Sub-county Wakiso District
Key Informant Guide
Respondents to be interviewed
Category of respondent Tick where it applies
Midwives
Y/N
MOs
Y/N
Village leaders
Y/N
DHE
Y/N
DNO
Y/N
DDHS
Y/N
TBAs
Y/N
Name of health facility ____________________________________________________
1.
Age of respondent _________________________________________________
2.
Sex _____________________________________________________________
3.
Position _________________________________________________________
4.
Level of education _________________________________________________
How long have you served in your current profession_______________________
Section B.
5.
a) What health care services do pregnant women seek in this community?
b) For each of the health services sought what motivates them to seek those
services?
6.
At what stages during pregnancy do most pregnant women seek the antenatal
care services? And why?
7.
What health care services do you have/give to pregnant women at this facility?
77
8.
a) In your opinion, what services do you offer/have for women seeking delivery
services at this facility?
b) How accessible are these services (distance, cost, quality, flexibility)?
9.
a) What problems do pregnant women in this community face to access the
various health services in this community? (Probe: at health units, TBAs,
Home)
b) How do they deal with these problems?
10.
a) What problems do women face during delivery in this community?
b) How are these problems faced during delivery dealt with?
11.
a) What interventions exist in this community to help majority pregnant women
come to health centres for delivery and during pregnancy?
b) How successful are these interventions?
12.
In your opinion, how can maternal care be improved in this community?
(Probe: What can be done to bring about the desirable changes?)
13.
What aspects of midwifery (Obstetric & Gynecology) require improvement (in
terms of training, equipment, etc) in this community?
14.
Any other questions or comments
Thank you for your participation
78
Knowledge, Perceptions and Practices in Pregnancy and Childbirth in Uganda: A
Study of Nangabo Sub-county Wakiso District
Focus Group Guide
Target: women who delivered in the last five years prior to the study and men whose
wives have children 5 years and below.
Section A:
Name of village ……………………………….
Sub-county …………………………
Number of participants ………………………
Sex …………………………………
Names ………………………………………………………………………………..…….
Age range of participants …………………………………………….. ……………..…….
Place of discussion ……………………. …………………………………………..………
Marital status of participants ……………………………………………………………….
Time started …………………………….. Time ended …………………………………
Name of moderator ………………………………………...................................................
Name of note taker …………………………………………………………………………
Language(s) ………………………………………………………………………………...
Other relevant characteristics/descriptions ……………………………….………………..
79
Introduction:
Good morning/afternoon participants. You are welcome to this discussion. I am/we are
from Makerere University Kampala. We would like to discuss with you the issues that
concern you and your community. We would like to explore your views regarding
pregnancy and childbirth. The purpose of this discussion is to provide information useful
in designing interventions to further reduce maternal and neonatal mortality in Uganda
and specifically in a rural setting.
Feel free to discuss among yourselves and ask for clarification where necessary. All the
information is strictly confidential and nothing you will say will make us unhappy. You
do not have to reveal any personal information if you do not want to, but if you are
willing to share your experiences; it will be very helpful to us in further understanding
pregnancy and childbirth related issues. I/we would request that you be audible and
speak one at a time so that all your important views are understood and written down.
We also have a tape recorder that will help us to capture the discussion to ensure that we
do not miss anything. May we use it? (Moderator seeks consent.)
Thank you very much.
Section B:
1. a) What are the main health problems affecting pregnant women in this community?
b) How severe are these problems?
2. How do women in this community prepare for pregnancy? (Probe for: Nutrition,
health care practices both traditional or biomedical e.g. TT injections, etc)
3. a) Where do women seek antenatal care services in this community?
b) Why do they seek antenatal care in those places?
c) What benefits do pregnant women gain in seeking antenatal care?
4. a) What do you consider to be risks faced by women during pregnancy? (Probe for:
Malaria, STDs e.g. syphilis, anaemia, paleness, etc)
b) How are those risks dealt with in this community?
5. a) What traditional practices do pregnant women seek during gestation in this
community?
b) Why do they seek for the practices mentioned above?
6. a) How do expectant women prepare for delivery?9Probe for reasons why they do
what they do)
7. How do pregnant women view the services of TBAs, biomedical workers,
neighbours, relatives, traditional healers in the management regarding pregnancy
related conditions?9Probe for: reasons of the various perceptions given)
8. Where do majority of women go for delivery? And what motivates them to deliver
where they do?
9. a) What health care practices do they get during delivery and why? What health care
practices do they get immediately after delivery? (Probe for: baby cord care
practices, immunisation, initiation of breastfeeding, traditional practices)
b) For mother (Probe: Control of post partum haemorrhage, control of bleeding.
Explore both biomedical and traditional practices)
80
10. a) What risks do mothers face during delivery?
b) How are these risks dealt with?
11. What can be done to improve maternal health care in this community?
Any other questions or comments
Thank you for your participation
81
Knowledge, Perceptions and Practices in Pregnancy and Childbirth in Uganda: A
Study of Nangabo Sub-county Wakiso District
In-depth Interview Guide
Target: women who delivered in the last five years prior to the study
Introduction:
Good morning/afternoon participants. You are welcome to this discussion. I am from
Makerere University Kampala. I would like to discuss with you the issues that concern
you and your community. I would like to explore your views regarding pregnancy and
childbirth. The purpose of this discussion is to provide information useful in designing
interventions to further reduce maternal and neonatal mortality in Uganda and
specifically in a rural setting.
Feel free to discuss among yourselves and ask for clarification where necessary. All the
information is strictly confidential and nothing you will say will make us unhappy. You
do not have to reveal any personal information if you do not want to, but if you are
willing to share your experiences; it will be very helpful to us in further understanding
pregnancy and childbirth related issues. I would request that you be audible and speak
one at a time so that all your important views are understood and written down. I also
have a tape recorder that will help me to capture the discussion to ensure that I do not
miss anything. May I use it?
Thank you very much.
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Section A:
Name of village ………………………………. Sub-county …………………………
Sex of Respondent ………………………………
Marital status ………………………….. Type of marital relationship ……………….
Highest level of education of respondent ………………………………………………
Number of deliveries the respondent has had …………………………………...……..
Live births …………..………………….
Still births …………………….…….
6. Religion of the respondent ……………………………………………………………..
7. Highest level of education of husband/partner ………………………………………...
8. Main source of income of husband/partner ……………………………………………
9. Distance to the nearest health facility ………………………………………………….
10. Tribe of the respondent ………………………………………………………………...
11. Age of the respondent ………………………………………………………………….
1.
2.
3.
4.
5.
Section B:
12. a) How did you prepare for pregnancy of your last birth?
b) Why did you have to undergo each of those preparations mentioned?
c) How do women in this community prepare for pregnancy? (Probe for nutrition,
health care practices both traditional/biomedical, etc).
13. a) Did you seek antenatal care services for your last pregnancy? If yes, what services
did you receive and why?(Probe for: number of times she went for ANC,at what age
of pregnancy she went to seek ANC for the first time)
b) What gains did you receive for each of those services you got?
14. a) What health care services do pregnant women in this community seek and why?
b) Where do the majority of pregnant women seek care during pregnancy and why?
15. a)What problems did you face during your last pregnancy?(Probe for:
STDs,Syphilis,Gonorrhea etc)
b) How did you manage these problems?
16. a) What problems do pregnant women face during gestation period in this
community?
b) How do they deal/manage each of the problems mentioned?
17. a) Would you consider STDs especially syphilis, gonorrhoea a problem to a pregnant
woman in this community?
b) How do pregnant women manage STDs especially syphilis or gonorrhoea during
pregnancy? (Probe for access to services, affordability, compliance to treatment, etc)
18. a) Do you think malaria during pregnancy is a problem? If so why?
b) How do you recognise that you have malaria when pregnant?
c) What preventive and curative options do pregnant women receive for malaria
during pregnancy?
d) In your opinion how effective are those options?
Note: Need to ask about knowledge on anaemia, paleness, bleeding during pregnancy
and how they are managed during pregnancy.
19. Where did you deliver from and what determined this choice of delivery?
20. What delivery options do pregnant women have in this community? Where do
majority women deliver from and why?
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21. What immediate care practices did you receive during and after delivery :
a) For baby (Probe: cord care practices, immunization, initiation of breastfeeding,
herbal remedies, etc)
b) For mother (Probe for control of post partum haemorrhage, Vitamin A
supplementation, traditional practices, etc)
22. What immediate care practices do women receive during pregnancy and after
delivery? (Probe for: cord care practices, initiation of breast feeding, immunisation
for the baby etc)
For mother, probe for: control of postpartum haemorrhage, Vitamin A
supplementation, traditional practices etc)
23. What problems did you experience during and immediately after delivery?
b) How did you deal with these problems?
24. a) What problems do pregnant women face during delivery?
b) After delivery
c) How are those problems managed in the community?
25. What can be done to improve maternal health care in this community?
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