Gendered health systems: evidence from low- and middle-income countries.

BACKGROUND: Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems. METHODS: The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. RESULTS: Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. CONCLUSION: The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.

Primary healthcare worker knowledge related to prenatal and immediate newborn care: a cross sectional study in Masindi, Uganda.

BACKGROUND: Global neonatal mortality remains unacceptably high. Health workers who attend to prenatal and postnatal mothers need to be knowledgeable in preventive and curative care for pregnant women and their newborn babies. This study aimed to determine the level of knowledge related to prenatal and immediate newborn care among primary healthcare workers in Masindi, Uganda. METHODS: A cross-sectional study was conducted. Interviews comprised of 25 multiple-choice questions were administered to health workers who were deployed to offer prenatal and postnatal care in Masindi in November 2011. Questions were related to four domains of knowledge: prenatal care, immediate newborn care, management of neonatal infections and identifying and stabilizing Low-Birth Weight (LBW) babies. Corresponding composite variables were derived; level of knowledge among health workers dichotomized as 'adequate' or 'inadequate'. The chi-square statistic test was used to examine associations with independent variables including level of training (nursing assistant, general nurse or midwife), level of care (hospital/health centre level IV or health centre level III/II) and years of service (five years or less, six years or more). RESULTS: 183 health workers were interviewed: general nurses (39.3%), midwives (21.9%) and nursing assistants (38.8%). Respectively, 53.6%, 46.5%, 7.1% and 56.3% were considered to have adequate knowledge in prenatal care, newborn care, management of neonatal infections and identifying/stabilizing LBW babies. Being a general nurse was significantly associated with having adequate knowledge in identifying and stabilizing LBW babies (p < 0.001) compared to being a nursing assistant. Level of care being hospital/health centre level IV was not significantly associated with having adequate knowledge in prenatal or newborn care with reference to health centres of level III/II. CONCLUSION: Knowledge regarding prenatal and newborn care among primary healthcare workers in Masindi was very low. The highest deficit of knowledge was in management of neonatal infections. Efforts are needed to orientate health workers regarding prenatal and newborn care especially the offer of infection management among newborns. Similar levels of knowledge between health workers deployed to hospital/health centre level IV and health centres of level III/II raise important implementation questions for the referral system which is crucial for maternal and newborn survival.

Missed Diagnosis of Gestational Diabetes Mellitus Due to Selective Screening: Evidence from a Cross-Sectional Study in the West Nile Sub-Region, Uganda.

Purpose: To ascertain the prevalence and risk factors of gestational diabetes mellitus (GDM) in pregnant women receiving antenatal care (ANC) services within the West Nile subregion of Uganda. Patients and Methods: An analytical cross-sectional study was conducted on 233 pregnant women who are within 24-28 weeks of gestation and are receiving ANC services in selected hospitals. GDM was diagnosed according to the World Health Organization (WHO) criteria (2013). A questionnaire and anthropometric measurements were used to obtain relevant data. The chi-square test and logistic regression were used to determine the association between GDM and the study variables, including participants' sociodemographic and medical characteristics. Results: The prevalence of hyperglycemia first detected in pregnancy among the participants tested was 8%. Overall, 7.45% had GDM and 0.53% had diabetes mellitus in pregnancy. The fasting plasma glucose test alone was positive in 86.7% of the GDM cases. The factors that were significantly associated with GDM included age ≥25 years (p = 0.017, AOR = 3.51) and body mass index (BMI) ≥25 kg/m2 (p = 0.024, AOR = 2.67). Out of the participants diagnosed with GDM, 28.6% did not have a known risk factor. Of the pregnant women with GDM, 57% would have been missed if the selective screening in the national clinical guidelines had been followed. Urinary tract infection (UTI) and Candida were detected in 36.36% and 13.85% of the participants, respectively. Conclusion: The study provides new data on the prevalence of GDM in rural settings in the West Nile subregion of Uganda. Of the participants, 7.5% were diagnosed with GDM, of which 57% would have been missed based on the selective screening of the national clinical guidelines. The study findings support the universal screening of GDM in pregnant women.

The effect of prenatal counselling on postpartum family planning use among early postpartum women in Masindi and Kiryandongo districts, Uganda.

INTRODUCTION: Globally, most postpartum pregnancies are unplanned, mainly as a result of low level of knowledge and fear of contraceptive use especially in low-income settings. The aim of this study was to evaluate the effect of prenatal contraceptive counselling on postpartum contraceptive use and pregnancy outcomes after one year. METHODS: Sixteen health centres were equally and randomly allocated to control and intervention arms. Mothers were consecutively recruited during their first antenatal clinic consultations. In the intervention arm Village Health Team members made home visits and provided prenatal contraceptive advice and made telephone consultations with health workers for advice while in the control arm mothers received routine antenatal care offered in the health centres. Data were collected in 2014 in the two districts of Kiryandongo and Masindi. This data was collected 12-14 months postpartum. Mothers were asked about their family planning intentions, contraceptive use and screened for pregnancy using human Chorionic Gonadotropin (hCG) levels. Socio-demographic and obstetric indices were recorded. Our primary outcomes of interests were current use of modern contraceptive, decision to use a modern contraceptive method and pregnancy status. Multilevel analysis using the xtmelogit stata command was used to determine differences between intervention and control groups. RESULTS: A total of 1,385 women, 748 (control) and 627 (intervention) were recruited. About 80% initiated breastfeeding within six hours of delivery 78.4% (control) and 80.4% (intervention). About half of the mothers in each arm had considered to delay the next pregnancy 47.1% (control) and 49% (intervention). Of these 71.4% in the control and 87% in the intervention had considered to use a modern contraceptive method, only 28.2% of the control and 31.6% in the intervention were current modern contraceptive users signifying unmet contraceptive needs among immediate postpartum mothers. Regarding pregnancy, 3.3% and 5.7% of the women were found to be pregnant in the control and intervention arms respectively. There were no statistical differences between the control and intervention arms for all primary outcomes of interests. CONCLUSION: Prenatal contraceptive counseling did not affect postpartum contraceptive use among immediate postpartum mothers in Masindi and Kiryandongo districts. Interventions aiming at improving postpartum contraceptive use should focus on addressing unmet contraceptive needs.