HEALTH CARE AND SUPPORT SYSTEMS FOR WOMEN AND NEWBORNS AROUND DELIVERY IN BUIKWE DISTRICT UGANDA A QUALITATIVE STUDY This thesis is presented for the degree of Master of Philosophy in Global Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen Marte Bodil Rød Lamp | M.Phil. Global Health | September 2019 Supervisor: Professor Ingunn Marie S. Engebretsen [email protected] Acknowledgements The past two years have been the greatest so far in my academic career. I have found my field of interest in Global Health, at the Centre for International Health, and the experiences have been beyond any of my expectations. The Professors and lecturers at CIH are exceptional and they gave me the background knowledge and skills needed to complete this M.Phil. degree. First and foremost, my gratitude goes to my supervisor Professor Ingunn Marie S. Engebretsen. Her encouragement, knowledge and genuine interest in people has enabled me to grow intellectually as well as personally. Similar gratitude goes to Anne-Mette Tjønn Hansen and Anne Grete Kjørrefjord, founders of Nyenga Foundation. Their hospitality and helpfulness in providing me with accommodation and assistance during my time in Uganda is invaluable. The Memorandum of understanding between Centre of International Health (CIH), Makerere School of Public Health (MSPH) and the Nyenga Foundation (NF) was a great contributor in enabling me to carry out the research. Henry Wamani and Wilson Tusiime: I couldn’t have finished my research without your continuous support and help in navigating through the labyrinth of ethical issues in Uganda. I am forever grateful. My thanks extend further to other staff members at MSPH, and especially to Dr. Suzanne Kiwanuka for her interest and detailed feedback on the proposal. To Apio Okiria and Nathan Wamala: Thank you for assisting me with translations and for valuable academic discussions. Warm thanks go to the entire staff at Nyenga foundation in Uganda. You have been supportive and helpful throughout the time of my study period. To Scovia, Phoebie, Francisco, Alice, Gerald, Peter and Damalie. Thank you for helping me with translations, suggestions and proof reading of the proposal. Weebale nyo! To Abraham: I am thankful to have known you for a short time. RIP. Page 1 of 132 Special thanks go to Robert Mangeni and Irene Manata. I couldn’t have done this without you two. Your skills of organizing, socializing and transcribing were invaluable. Thank you also to Dr. Zziwa for your support and hospitality and extensive knowledge shared with me during my study. To all the participants in the study: Thank you for your time and cooperation. For all my fellow students, both in M. Phil, Global Health as well as in elective courses: You made the past two years fun and exciting, and mentally stimulating. Yoldas Sahan, Shuvashis Saha, Tulani Francis, Nawa Mukumbuta: Your friendship is a treasure. Lastly, but most important: Thank you to my dear family for giving me time and support in achieving my goals of studying Global Health. I love you. Page 2 of 132 Abstract Background: Globally, 7000 newborns die every day. The neonatal period is when children have the highest risk of dying, with the first 24 hours as the most critical. Sub- Saharan Africa is the region with the highest neonatal mortality rate, with 27 deaths per 1000 live births. Safe pregnancies and deliveries, early initiation of breastfeeding and god health care and support systems are important interventions to prevent neonatal mortality. Objective: To understand health care and support systems for women and newborns around delivery in Buikwe district, central rural Uganda. Methods: A qualitative study using purposeful sampling including in-depth interviews with key- informants and mothers, focus-group discussions with mothers and participant observations in hospital and local health clinic. Malterud’s systematic text condensation analysis was used for interpreting the data. Results: Antenatal care was highly valued amongst the participants. Various determinants influenced the choice of delivery place, with the economical aspect as the most protruding. High-quality health care was documented, although with low use of partograms. Newborn procedures such as oronasopharyngeal suction, timing for cord clamping and kangaroo care was found different to a large extent from what is recommended by the Uganda Clinical Guidelines. Timing for initiation of breastfeeding was found satisfying. Mixed feelings about initiation of breastfeeding were displayed amongst the mothers and extensive use of pre-lacteals was detected, although colostrum was regarded as good for the baby. High potential for improved family support and postnatal care was discovered. Reliance on health workers and traditional birth attendants was cherished. Conclusion: High-quality health care was found amongst professional health workers and traditional birth attendants. Discrepancies were detected when linking the Uganda Clinical Guidelines and performed clinical procedures on issues such as oronasopharyngeal suction, timing of cord clamping and kangaroo care. Continued focus on negative effects of pre-lacteals is necessary. Support and care from family members have high potential for improvement, together with better quality care and higher frequencies in postnatal follow-up consultations from health workers. Further focus on women’s empowerment and gender structures in a Ugandan setting is recommended. Page 3 of 132 Table of Contents Acknowledgements ......................................................................................................... 1 Abstract ........................................................................................................................... 3 Abbreviations .................................................................................................................. 7 Definitions ....................................................................................................................... 8 Introduction ..................................................................................................................... 9 Background ................................................................................................................. 9 Antenatal care ........................................................................................................... 10 Labour and birth......................................................................................................... 11 Home versus facility delivery ..................................................................................... 12 Kangaroo care ........................................................................................................... 12 Early infant feeding practices ..................................................................................... 13 Initiation of breastfeeding - Timing ............................................................................. 13 Colostrum .................................................................................................................. 14 Pre-lacteals ................................................................................................................ 15 Gender roles .............................................................................................................. 15 Postnatal care ............................................................................................................ 16 The Uganda Clinical Guidelines (UCG) ..................................................................... 17 Justification for the study ............................................................................................... 18 Study objectives ............................................................................................................ 19 Methodology .................................................................................................................. 20 Study site ................................................................................................................... 20 Description of field workers ........................................................................................ 21 Study population ........................................................................................................ 21 Page 4 of 132 Study design .............................................................................................................. 22 Participants ................................................................................................................ 24 Sampling procedure ................................................................................................... 24 Study period .............................................................................................................. 25 Data collection ........................................................................................................... 25 Data management and analysis ................................................................................ 26 Reflexivity and role of researcher .............................................................................. 28 Ethical considerations ................................................................................................... 30 Discussion of methods .................................................................................................