'Conceiving' Maternal Child Healthscapes in Rural Uganda
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‘Conceiving’ maternal child healthscapes in rural Uganda Thesis submitted to The University of Manchester for the degree of Doctorate of Philosophy in the Faculty of Humanities 2010 Jennifer Rachel O’Brien Geography, School of Environment and Development 1 2 Contents ___________________________________________________________________________ Contents........................................................................................................................ 3 List of figures................................................................................................................. 8 List of tables.................................................................................................................. 10 Abstract.......................................................................................................................... 11 Declaration..................................................................................................................... 12 Copyright statement...................................................................................................... 13 Abbreviations.................................................................................................................. 14 Acknowledgements......................................................................................................... 16 Dedication....................................................................................................................... 19 Chapter 1: Maternal child healthcare, ‘the greatest health divide in the world’ 1.1 Introduction 20 1.2 The ‘greatest health divide in the world’ 22 1.3 Reconceptualising health and healthcare delivery 28 1.4 Research objectives and thesis outline 30 Chapter 2: Ways of knowing healthcare 2.1 Introduction 35 2.2 Different theoretical perspectives in health geography 38 2.2.1 The functional approach and colonial healing 38 2.2.2 The political economy perspective 43 2.3 Social constructions of health in space and place 47 2.3.1 A post-structural approach to social organisation 48 3 2.3.2 Constructed space, place and scale in health in geography 53 2.4 The geographies of socially constructed care 60 2.4.1 Geographies of care and caring geographies 60 2.4.2 What is care? 62 2.4.3 Who cares? 64 2.4.4 Where does caring take place? 66 2.5 Healthscapes 67 2.6 Conclusion 73 Chapter 3: The Black Hole of Uganda 3.1 Introduction 75 3.2 Uganda in 2010: A contemporary country profile 76 3.3 Legacies of the past 80 3.3.1 Colonial conquest. 80 3.3.2 Devastation in Independence 85 3.4 Economic reform over the last 40 years 88 3.4.1 Decentralisation and the construction of ‘the poor’ 89 3.4.2 Decentralisation in the health sector and policy reform 93 3.5 Introducing The Bunyoro Kingdom 100 3.5.1 Overview of the Kingdom 101 3.5.2 Tribal conflict 105 3.6 Conclusion 106 Chapter 4: Researching maternal child health 4.1 Introduction 108 4.2 Methodological approach 110 4.2.1 Disciplinary agendas and the necessity to be useful 111 4.2.2 Where this research comes from – ethical action research 116 4.3 Positionality in ethnographic research 119 4.3.1 Blurring boundaries 124 4.4 Logistics and methodological techniques 126 4.4.1 Preparations in the UK 128 4 4.4.2 Preparations in Uganda 129 4.4.3 Hospital ethnography 131 4.4.4 Focus groups 133 4.4.5 Triangulation and ‘crystallisation’ 137 4.4.6 Data preparation and analysis 137 4.5 Contribution to the field 141 4.6 Conclusion 141 Chapter 5: Spaces of health in Bunyoro 5.1 Introduction 144 5.2 Health in Bugangaizi 146 5.3 Unpacking ‘the poor’: Trading Centre Women and Village Women 150 5.4 Broader societal factors 153 5.4.1 Norms of health in Bugangaizi 154 5.4.2 Gender and culture 158 5.4.3 Kinship 168 5.5 Health seeking behaviour in Bunyoro 172 5.5.1 Traditional models of health in Bunyoro 173 5.5.2 Biomedical health in Bunyoro 180 5.6 Conclusion 185 Chapter 6: The Antenatal Healthscapes 187 6.1 Introduction 6.2 The Antenatal Clinic 188 6.3 Perceptions of the hospital 191 6.4 The proud clinic 195 6.4.1 The clients’ proud clinic 198 6.5.2 The nurses’ proud clinic 201 6.5 The ‘non-clinic’ 201 6.5.1 The clients’ ‘non clinic’ 204 6.5.2 The nurses’ ‘non clinic’ 204 5 6.6 The rushed clinic 209 6.6.1 The clients’ rushed clinic 209 6.6.2 The nurses’ rushed healthscape 214 6.7 The resource - less clinic 217 6.7.1 The clients’ resource-less clinic 218 6.7.2 The nurses’ resource-less healthscape 221 6.8 Conclusion 223 Chapter 7: The Maternity Ward 7.1 Introduction 225 7.2 Changing approaches to birth in Uganda 226 7.3 Birth in Bunyoro and the lutalo lwabakyala (woman’s battle) 228 7.4 Local perceptions of the maternity ward 231 7.4.1 Conceiving the maternity spaces 233 7.5 The ‘caring for’ maternity space 236 7.5.1 The clients’ ‘caring for’ maternity space 236 7.5.2 The midwives’ ‘caring for’ maternity space 242 7.6 The cultural maternity space 245 7.6.1 The clients’ cultural maternity space 246 7.6.2 The midwives’ cultural maternity space 251 7.7 The ‘budibyo’ maternity space 252 7.7.1 The client’s ‘budibyo’ maternity space 253 7.7.2 The midwives ‘budibyo’ maternity space 256 7.8 Conclusion 258 Chapter 8: Conclusion 8.1 Introduction 260 8.2 Empirical findings 261 8.3 The healthscape concept 269 8.4 Methodological lessons and research limitations 271 8.5 Potential future contributions to the research and policy agenda 274 6 References................................................................................................................... 278 Appendix 1: Copy of ‘fieldnotes’ showing data preparation ............................................... 344 Appendix 2: Details of the field notes directly referred to in the thesis ............................... 345 Appendix 3: Details of the antenatal cases specifically referred to in the analysis ............. 347 Appendix 4: Details of the medical cases specifically referred to in the analysis ................ 348 Appendix 5: Details of personal communication ................................................................. 349 Word Count: 92,922 7 List of Figures: _______________________________________________________________ Figures: 2.1 Diagrammatical representation of a healthscape 70 2.2 The space of the healthcare transaction 72 3.1 Map locating Uganda in Africa 76 3.2 Map to illustrate the administrative districts of Uganda 77 3.3 The prevalence of attendance of birth from 1989 to 2006 98 3.4 Consultation room of Kakindo HCIV showing the endless boxes of condoms 99 3.5 Map of the Bunyoro Kingdom 102 3.6 Varieties of trading centre housing 103 3.7 Typical ‘village’ housing 104 3.8 Drawing water from the borehole 104 3.9 Local road conditions in Bugangaizi 105 4.1 The methods used in the research 127 4.2 An informal focus group in the maternity ward 135 4.3 Extract from the coding frame illustrating the double – coded themes 140 5.1 Florence’s tailoring business in Kakindo 151 5.2 Mamma Beatrice making chapatti in Nalweyo 151 5.3 A local village Functional Adult Literacy group 152 5.4 Example of kwashiorkor; a common health problem in Bugangaizi 165 5.5 The local herbalists’ ‘stall’ at the market 174 5.6 A witchdoctor’s home and ‘clinic’ 175 5.7 Melda, the traditional birth attendant, and her herbs 178 5.8 Melda’s maternity ward 178 5.9 Melda’s delivery suite 179 5.10 The exterior of Kakindo HCIV taken from the road 181 5.11 The veranda where OPD patients waited to be consulted 182 5.12 The consultation space 182 5.13 Referral process in the seeking of medical care at Kakindo HCIV 183 6.1 Immunisation clinic on a busy Thursday 189 6.2 The open air antenatal space where registration took place 190 8 6.3 One of the antenatal treatment rooms 192 6.4 Errors in the HIV register 210 7.1 The maternity ward 233 7.2 The delivery suite 233 7.3 The eight maternity cases that conceived the maternity spaces 235 9 List of Tables: 2.1 The principle ideas of post-structuralism 50 3.1 The key characteristics of the three tribes specific to this research 77 3.2 Timeline of Uganda’s history 81 3.3 Hierarchical structure and details of the services provided at each health level 95 3.4 Ugandan health status outcomes 100 4.1 Details of the nine formal focus groups conducted 134 4.2a Example of the unique codes given to antenatal cases 138 4.2b Example of the coding given to general fieldnotes 138 4.3 Extract from the coding frame illustrating the double-coded themes 140 5.1 Comparison of health indicators between Uganda and Kibaale 148 5.2 Increase in cases of the top ten illnesses in Nalweyo and Kissita 2002-2005 148 5.3 Broad differences between Village Women and Trading Centre Women 153 5.4 Roles for Women and Men in 24 hours clock 164 7.1 The cases used to code up the maternity spaces 235 10 Abstract This thesis examines the complexities of delivering high quality pro-poor maternal child healthcare. The research recognises that good maternal child health (MCH) is a fundamental development imperative in which initiatives are not achieving targets. There is a chronic deficit of well trained healthcare workers and increasing reports of abuse being suffered by poor patients. The research suggests that current mechanistic results orientated approaches to healthcare should be foregone in favour of an appreciation of the fundamentally fluid and social nature of health and healthcare delivery. It is also suggested that whilst current literature focus on either a patient or a healthcare provider perspective, examining the relationship between the two provides a complete picture of the