Trends and determinants of adolescent childbirth in Uganda- analysis of rural and urban women using six demographic and health surveys, 1988-2016.

INTRODUCTION: Uganda has high adolescent pregnancy. The details of adolescent childbirth and urban/rural patterns are scarce. We investigated the levels, time trends and determinants of adolescent childbirth in Uganda separately for urban and rural women. METHODS: We estimated the percentage of women 20-24 years at each of the six Uganda Demographic and Health Surveys (1988/89, 1995, 2000/01, 2006, 2011 and 2016) who reported a live childbirth before age 20 years ("adolescent childbirth"), and examined change over time using t-test. A modified multivariable Poisson regression was used to examine determinants of having adolescent childbirth on the 2016 survey. RESULTS: Among these women, 67.5, 66.4, 70.1, 62.3, 57.3 and 54.1% reported an adolescent childbirth in 1988/89, 1995, 2000/01, 2006, 2011 and 2016 surveys, respectively. Between 1988/89 to 2000/01, there was no evidence of change (+ 2.6% point (pp), p = 0.170), unlike between the 2000/01 and 2016 surveys when a significant decline occurred (- 16.0 pp., p < 0.001). First childbirth < 18 years of age declined by - 13.5 pp. (p < 0.001) between 2000/01 and 2016. There was no change over time in the percentage of adolescents 18-19.9 years of age having first childbirth. Among rural residents, childbirth < 18 years declined from 43.8% in 1988/89 to 32.7% in 2016 (- 11.1 pp., p < 0.001), in urban it declined from 28.3 to 18.2% (- 10.1 pp., p = 0.006). There was an increase over time in the percentage of women, both rural and urban, who wanted to delay their first pregnancy. Independent determinants of reporting an adolescent childbirth in both urban and rural residents were: no education/incomplete primary and younger age at first sex. Additional determinants for rural women were residence in Eastern region, Muslim religion, and poor household wealth index. CONCLUSION: In the 30-year period examined, adolescent childbirth in Uganda declined from highs of 7 in 10 to approximately 5 in 10 women, with more wanting to delay the pregnancy. The decline started after the 2000/01 survey and affected predominantly younger adolescent childbirth < 18 years among both rural and urban residence women. Efforts need to be intensified to sustain the decline in adolescent pregnancies. Targeted and specific strategies for urban and rural areas might be required.

The effect of knowledge on uptake of breast cancer prevention modalities among women in Kyadondo County, Uganda.

BACKGROUND: Breast cancer, the third most frequent cancer of women is preventable through knowledge on breast self-examination. Of the 44% of women diagnosed with breast cancer at the Uganda Cancer Institute, only 22% go for check-up in less than three months. This study explored the effect of breast cancer knowledge on the uptake of breast cancer prevention modalities among women in Kyadondo County, Uganda. METHODS: A household survey of women in Kyadondo County was conducted during June, 2014 to August, 2015. This involved studying in-depth using a questionnaire the level of breast cancer knowledge of the respondents. Data was analyzed using logistic regression model. Chi-square test was used to establish relationships between knowledge base factors and the uptake of breast cancer prevention modalities. RESULTS: This study has established an empirical relationship between uptake of breast cancer prevention modalities and source of information especially radio (OR 1.94 95% CI: 1.16-3.24), television (OR 1.82 95%CI: 1.14-2.93), awareness of breast cancer (OR 4.03 95%CI: 1.01-15.98), knowledge on how to reduce risk of breast cancer (OR 1.98 95% CI: 1.20-3.27), what reduces breast cancer acquisition (OR 2.75 95% CI: 1.42-5.35), how to check for signs of breast cancer especially through breast self-examination (OR 3.09 95% CI: 1.62-5.88), and other methods of breast cancer diagnosis in a health care set up. CONCLUSION: The women's level of breast cancer awareness as a primary prevention strategy was found wanting, and requires a boost through community health education.

Early postnatal care use by postpartum mothers in Mundri East County, South Sudan.

BACKGROUND: Globally, most maternal and newborn deaths are within the first week of delivery. Early postnatal-care (EPNC) visits between 2 and 7 days detects early morbidity and averts deaths. However, there is scarcity of information on use of EPNC in Mundri East County, South Sudan. This study investigated factors associated with EPNC use among postpartum mothers in Mundri East County, South Sudan. METHODS: This was an analytical cross-sectional study of 385 postpartum mothers from 13 health facilities. Data was collected by structured questionnaires, entered in EpiData and analyzed with STATA at 5% significance level. Chi-squared, Fisher's exact and Student's t-tests were used for bivariate analysis and logistic regression for multivariable analysis. RESULTS: The mean age of respondents was 27.9-years (standard deviation: 6.7), 276 (71.7%) were below 30-years, 163 (42.3%) were Muru ethnicity, 340 (88.3%) were single and 331 (86.1%) were unemployed. 44 (11.4%; 95% CI: 8.4-15.0) used EPNC. Poor health services access at government health facilities (Adjusted odds ratio (AOR) = 0.18; 95% CI: 0.05-0.61; P = 0.006), more than 1-h access to health facility (AOR = 0.27; 95% CI: 0.09-0.78; P = 0.015), at least secondary maternal education (AOR = 5.73; 95% CI: 1.14-28.74; P = 0.034) and receipt of PNC health education post-delivery (AOR = 3.47; 95% CI: 1.06-11.33; P = 0.004) were associated with EPNC use. CONCLUSIONS: Use of EPNC in Mundri East County, South Sudan was low. It was significantly reduced at government and inaccessible health facilities. However, it increased with receipt of PNC health education after delivery and at least secondary level of education.

Midwife-led quality improvement: Increasing the use of evidence-based birth practices in Uganda.

BACKGROUND: Addressing the evidence-to-practice gap in midwifery is vital for improving maternal and newborn health outcomes. Despite the potential of involving midwives in quality improvement interventions to address this gap, such interventions are understudied. In a Ugandan urban hospital, midwifery practices with a significant evidence-to-practice gap have been identified as areas for clinical improvement. OBJECTIVES: The primary objective of the Quality Improvement was to increase the uptake of identified and essential midwifery practices through a quality improvement approach led by midwives. PARTICIPANTS: We enrolled 703 women aged 18 years and older with uncomplicated full-term pregnancies (between 37+0 and 42+0 weeks) who gave birth at the facility. INTERVENTION: The intervention focused on evidence-based practices with an identified evidence-to-practice gap: dynamic birth position, including women's involvement in birth position decision-making, perineal protection and intrapartum support. A team of midwives led a seven-month co-created quality improvement intervention. The intervention used Plan-Do-Study-Act (PDSA) cycles, following the Model for Improvement and included a train-the-trainer approach and weekly online support meetings. DATA COLLECTION: In this single-case prospective observational study, we compared pre-, during and post-intervention uptake of evidence-based practices. Trained research assistants collected data through interviews and observations. RESULTS: We observed improvements in the uptake of all clinical improvement areas. Dynamic birth positions increased from 0 % to 79 %, decision-making of birth positions from 0 % to 75 %, perineal protection measures from 62 % to 92 % and intrapartum support from 7 % to 67 %. CONCLUSION: A multifactorial midwife-led Quality Improvement resulted in significant and sustained improvements in the uptake of evidence-based practices in maternal and newborn healthcare. If given the mandate and time, midwives can successfully lead Quality Improvements, which enhance the quality of care and close the evidence-to-practice gaps in maternal and newborn health. The study's results underscore the significance of developing effective strategies to enhance care quality and promote the adoption of evidence-based midwifery practices.

Perceptions of adolescent mothers towards adolescent repeat childbirth in Soroti district, Teso sub-region, Uganda: A phenomenological study.

The percentage of adolescent mothers aged 15 to 19 years with a repeat childbirth in Uganda (26.1%) is higher than the global estimate (18.5%). Soroti district tops Teso (a region with highest adolescent childbearing rate nationally) in adolescent childbearing. Adolescent repeat childbearing (ARC) is associated with poor health outcomes, increased risk of stillbirth, maternal and child mortality, thus a public health concern. The explanations to the high prevalence of repeat childbirth in Soroti district remain unknown. We conducted a phenomenological study where theoretical saturation was achieved with 3 focus group discussions; each comprised of 8 respondents. The questions posed focused on modified socio-ecological model regarding the factors associated with repeat childbirth. These included; perceived individual factors of repeat childbirth, factors related to the sexual partner of the adolescent mother, adolescent mother's family related factors and factors related to the peers and community of the adolescent mothers. Transcripts were organized and analyzed by QSR Nvivo following deductive approach. Results: Adolescent marriage was viewed as a privilege, family planning methods were viewed as non-functional, man's demand for sex was unchallengeable and non-supportive families including mistreatment of the participants by their families were perceived as risk factors for ARC. This therefore suggests that in order to prevent repeat adolescent childbearing in Soroti district, and contribute towards the achievement of the SDG numbered three (ensure healthy lives and promote well-being for all at all ages) there is need to awaken and strengthen the implementation of the anti-teen marriage programs and policies; strengthen sexual/reproductive education including family planning programs, and addressing identified myths regarding ARC.

Putting co-creation into practice: lessons learned from developing a midwife-led quality improvement intervention.

BACKGROUND: Integrating evidence-based midwifery practices improves healthcare quality for women and newborns, but an evidence-to-practice gap exists. Co-created quality improvement initiatives led by midwives could bridge this gap, prevent resource waste and ensure intervention relevance. However, how to co-create a midwife-led quality improvement intervention has not been scientifically explored. OBJECTIVE: The objective of this study is to describe the co-creation process and explore the needs and determinants of a midwife-led quality improvement targeting evidence-based midwifery practices. METHODS: A qualitative deductive approach using the Consolidated Framework for Advancing Implementation Science was employed. An analysis matrix based on the framework was developed, and the data were coded according to categories. Data were gathered from interviews, focus group discussions, observations and workshops. New mothers and birth companions (n = 19) were included through convenience sampling. Midwives (n = 26), professional association representatives, educators, policymakers, managers, and doctors (n = 7) were purposely sampled. RESULTS: The co-creation process of the midwife-led Quality Improvement intervention took place in four stages. Firstly, core elements of the intervention were established, featuring a group of midwife champions leading a quality improvement initiative using a train-the-trainers approach. Secondly, the intervention needs, context and determinants were explored, which showed knowledge and skills gaps, a lack of shared goals among staff, and limited resources. However, there was clear relevance, compatibility, and mission alignment for a midwife-led quality improvement at all levels. Thirdly, during co-creation workshops with new mothers and companions, the consensus was to prioritise improved intrapartum support, while workshops with midwives identified enhancing the use of birth positions and perineal protection as key focus areas for the forthcoming Quality Improvement intervention. Lastly, the findings guided intervention strategies, including peer-assisted learning, using existing structures, developing educational material, and building stakeholder relationships. CONCLUSIONS: This study provides a practical example of a co-creation process for a midwife-led quality improvement intervention, which can be relevant in different maternity care settings.

Use of collaborative learning approach for increased cure rate among children aged 6-59 months with severe wasting in Karamoja, Uganda.

BACKGROUND: At 10%, Karamoja region has the highest rate of child wasting in Uganda. The region has 126 outpatient therapeutic care (OTC) sites for managing children with severe acute malnutrition. LOCAL PROBLEM: Cure rate (CR) in OTC in Karamoja remains below the international standard of over 75%. The study aimed at increasing the CR in 10 OTC sites in Karamoja, from 74.1% to >75% in 13 months. METHODS: The study commenced in July 2018, up to September 2019, in purposively selected health facilities in six districts in Karamoja. Quality improvement (QI) methods per the Ministry of Health QI Framework were applied. QI teams (QITs) tracked the outcome of the tested changes for 13 months. χ2 tests were used to assess the intrafacility and interdistrict association in CR. INTERVENTION: Institute for Health Improvement (IHI) (2003) improvement model was applied in this collaborative. QITs conducted root cause analysis of CR gaps, which guided them in the development of improvement aims, changes and indicators. QITs used plan-do-study-act cycles to test and adopt the feasible changes. RESULTS: CR increased from 74.1% to 78.6%, with an overall average of 80% within 13 months. Abim district had the highest CR (83.3%) and Kaabong district the lowest (75.2%). Health centre II (84.0%) had the highest CR. Assigning village health teams to follow up caregivers of children in OTC with missed appointments, allocation of village health teams and local leaders to monitor the administration of ready-to-use therapeutic food to children, and screening and treating comorbidities among children in OTC increased CR. CONCLUSIONS: QI methods focusing on collaborative learning increased CR among children in OTC in Karamoja. Sustaining the gains requires district health offices, partners and health facility management's commitment to institutionalise the QI collaborative learning approaches.

Analyzing fast and slow: Combining traditional and rapid qualitative analysis to meet multiple objectives of a complex transnational study.

Much of the methodological literature on rapid qualitative analysis describes processes used by a relatively small number of researchers focusing on one study site and using rapid analysis to replace a traditional analytical approach. In this paper, we describe the experiences of a transnational research consortium integrating both rapid and traditional qualitative analysis approaches to develop social theory while also informing program design. Research was conducted by the Innovations for Choice and Autonomy (ICAN) consortium, which seeks to understand how self-injection of the contraceptive subcutaneous depot medroxyprogesterone acetate (DMPA-SC) can be implemented in a way that best meets women's needs, as defined by women themselves. Consortium members are based in Kenya, Uganda, Malawi, Nigeria, and the United States. Data for the ICAN study was collected in all four countries in sub-Saharan Africa. In order to both illuminate social phenomena across study sites and inform the program design component of the study, researchers developed tools meant to gather both in-depth information about women's contraceptive decision-making and data targeted specifically to program design during the formative qualitative phase of the study. Using these two bodies of data, researchers then simultaneously conducted both a traditional qualitative and rapid analysis to meet multiple study objectives. To complete the traditional analysis, researchers coded interview transcripts and kept analytical memos, while also drawing on data collected by tools developed for the rapid analysis. Rapid analysis consisted of simultaneously collecting data and reviewing notes developed specifically for this analysis. We conclude that integrating traditional and rapid qualitative analysis enabled us to meet the needs of a complex transnational study with the added benefit of grounding our program design work in more robust primary data than normally is available for studies using a human-centered design approach to intervention development. However, the realities of conducting a multi-faceted study across multiple countries and contexts made truly "rapid" analysis challenging.

Many Cooks in the Kitchen: Iterating a Qualitative Analysis Process Across Multiple Countries, Sites, and Teams.

Establishing and proving methodological rigor has long been a challenge for qualitative researchers where quantitative methods prevail, but much published literature on qualitative analysis assumes a relatively small number of researchers working in relative proximity. This is particularly true for research conducted with a grounded theory approach. Different versions of grounded theory are commonly used, but this methodology was originally developed for a single researcher collecting and analyzing data in isolation. Although grounded theory has evolved since its development, little has been done to reconcile this approach with the changing nature and composition of international research teams. Advances in technology and an increased emphasis on transnational collaboration have facilitated a shift wherein qualitative datasets have been getting larger and the teams collecting and analyzing them more diverse and diffuse. New processes and systems are therefore required to respond to these conditions. Data for this article are drawn from the experiences of the Innovations for Choice and Autonomy (ICAN) Research Consortium. ICAN aims to understand how self-injectable contraceptives can be implemented in ways that best meet women's needs in Kenya, Uganda, Malawi, and Nigeria. We found that taking a structured approach to analysis was important for maintaining consistency and making the process more manageable across countries. However, it was equally important to allow for flexibility within this structured approach so that teams could adapt more easily to local conditions, making data collection and accompanying analysis more feasible. Meaningfully including all interested researchers in the analysis process and providing support for learning also increased rigor. However, competing priorities in a complex study made it difficult to adhere to planned timelines. We conclude with recommendations for both funders and study teams to design and conduct global health studies that ensure more equitable contributions to analysis while remaining logistically feasible and methodologically sound.

Obstetric referrals, complications and health outcomes in maternity wards of large hospitals during the COVID-19 pandemic: a mixed methods study of six hospitals in Guinea, Nigeria, Uganda and Tanzania.

OBJECTIVES: The COVID-19 pandemic affected provision and use of maternal health services. This study describes changes in obstetric complications, referrals, stillbirths and maternal deaths during the first year of the pandemic and elucidates pathways to these changes. DESIGN: Prospective observational mixed-methods study, combining monthly routine data (March 2019-February 2021) and qualitative data from prospective semi-structured interviews. Data were analysed separately, triangulated during synthesis and presented along three country-specific pandemic periods: first wave, slow period and second wave. SETTING: Six referral maternities in four sub-Saharan African countries: Guinea, Nigeria, Tanzania and Uganda. PARTICIPANTS: 22 skilled health personnel (SHP) working in the maternity wards of various cadres and seniority levels. RESULTS: Percentages of obstetric complications were constant in four of the six hospitals. The percentage of obstetric referrals received was stable in Guinea and increased at various times in other hospitals. SHP reported unpredictability in the number of referrals due to changing referral networks. All six hospitals registered a slight increase in stillbirths during the study period, the highest increase (by 30%-40%) was observed in Uganda. Four hospitals registered increases in facility maternal mortality ratio; the highest increase was in Guinea (by 158%), which had a relatively mild COVID-19 epidemic. These increases were not due to mortality among women with COVID-19. The main pathways leading to these trends were delayed care utilisation and disruptions in accessing care, including sub-optimal referral linkages and health service closures. CONCLUSIONS: Maternal and perinatal survival was negatively affected in referral hospitals in sub-Saharan Africa during COVID-19. Routine data systems in referral hospitals must be fully used as they hold potential in informing adaptations of maternal care services. If combined with information on women's and care providers' needs, this can contribute to ensuring continuation of essential care provision during emergency.

Prevalence and factors associated with teenage pregnancy among parturients in Mbale Regional Referral Hospital: a cross sectional study.

Introduction: In Uganda, 12% of the audited maternal deaths occur among teenagers. The prevalence and factors associated with teenage pregnancy in health facilities is not well documented. We determined the prevalence and factors associated with teenage pregnancy in Mbale Regional Referral Hospital. Materials and Methods: We conducted a cross sectional study between July and September 2019.We consecutively enrolled and collected information from 427 respondents. Associated factors were determined using logistic regression, a P-value < 0.05. Results: The prevalence of teenage pregnancy was 20.6% [95% CI : (17.0% - 24.7%)]. Rural residence [(AOR: 2.8 (1.08 - 7.09)], primary level of education [(AOR: 9.57 (3.48 - 26.3)], unhappy feelings about the current pregnancy [(AOR: 3.57(1.05 - 12.15)], primiparity [(AOR: 21.05 (7.36 - 60.15)] increased the likelihood of teenage pregnancy. While, history of ever use of contraceptives [(AOR: 0.32 (0.12 - 0.84)], age at coitarche [(AOR: 0.68 (0.54 - 0.85)], grand multiparity [(AOR: 0.06 (0.01 - 0.51)], and exposure to sex education at home [(AOR: 0.37 (0.15 - 0.89)] decreased its likelihood. Conclusion: The prevalence of teenage pregnancy was high. It was associated with being resident in rural area, low level of education and ever use of contraception. Promotion of reproductive health education may prevent teenage pregnancy.

Women's Experiences With Family Planning Under COVID-19: A Cross-Sectional, Interactive Voice Response Survey in Malawi, Nepal, Niger, and Uganda.

INTRODUCTION: We conducted an assessment in Malawi, Nepal, Niger, and Uganda to document access-related reasons for not using contraceptive methods during the COVID-19 pandemic that led to unintended pregnancies, describe use of modern contraception among women in potential need of contraception compared to before the pandemic, examine method choice, and describe barriers to contraceptive access and use. METHODS: Between December 2020 and May 2021, we conducted an opt-in phone survey with 21,692 women, followed by an outbound survey with 5,124 women who used modern nonpermanent contraceptive methods or who did not want to get pregnant within 2 years but were not using a modern contraceptive method. The surveys examined current behaviors and documented behaviors before the pandemic retrospectively. We used multivariable logistic regression models to examine factors associated with contraceptive use dynamics during COVID-19. RESULTS: Pregnant women surveyed reported that the pandemic had affected their ability to delay or avoid getting pregnant, ranging from 27% in Nepal to 44% in Uganda. The percentage of respondents to the outbound survey using modern contraception decreased during the pandemic in all countries except Niger. Fear of COVID-19 infection was associated with discontinuing modern contraception in Malawi and with not adopting a modern method among nonusers in Niger. Over 79% of surveyed users were using their preferred method. Among nonusers who tried obtaining a method, reasons for nonuse included unavailability of the preferred method or of providers and lack of money; nonusers who wanted a method but did not try to obtain one cited fear of COVID-19 infection. CONCLUSION: We found evidence of surveyed women attributing unintended pregnancies to the pandemic and examples of constraints to contraceptive access and use on the supply and demand side. The effects of the pandemic must be interpreted within the local contraceptive, health system, and epidemiological context.

A mixed-methods study of maternal health care utilisation in six referral hospitals in four sub-Saharan African countries before and during the COVID-19 pandemic.

INTRODUCTION: In sub-Saharan Africa, referral hospitals are important sources of key maternal health services, especially during a crisis such as the COVID-19 pandemic. This study prospectively assessed the effect of the COVID-19 pandemic on maternal health service utilisation in six large referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the pandemic. METHODS: Mixed-methods design combining three data sources: (1) quantitative data based on routine antenatal, childbirth and postnatal care data collected March 2019-February 2021, (2) qualitative data from recurring rounds of semi-structured interviews conducted July 2020-February 2021 with 22 maternity skilled heath personnel exploring their perceptions of service utilisation and (3) timeline data of COVID-19 epidemiology, global, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on the timeline analysis and triangulated when reporting. RESULTS: Three periods including a first wave, slow period and second wave were identified. Maternal health service utilisation was lower during the pandemic compared with the prepandemic year in all but one selected referral hospital. During the pandemic, service utilisation was particularly lower during the waves and higher or stable during the slow period. Fear of being infected in hospitals, lack of transportation, and even when available, high cost of transportation and service closures were key reasons affecting utilisation during the waves. However, community perception that the pandemic was over or insinuation by Government of the same appeared to stabilise use of referral hospitals for childbirth. CONCLUSION: Utilisation of maternal health services across the continuum of care varied through the different periods and across countries. In crisis situations such as COVID-19, restrictions and service closures need to be implemented with consideration given to alternative options for women to access and use services. Information on measures put in place for safe hospital use should be communicated to women.

'We are not going to shut down, because we cannot postpone pregnancy': a mixed-methods study of the provision of maternal healthcare in six referral maternity wards in four sub-Saharan African countries during the COVID-19 pandemic.

INTRODUCTION: Referral hospitals in sub-Saharan Africa are located in crowded urban areas, which were often epicentres of the COVID-19 pandemic. This paper prospectively assesses how maternal healthcare was provided in six referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the COVID-19 pandemic. METHODS: Mixed-methods design using three data sources: (1) qualitative data from repeated rounds of semi-structured interviews conducted between July 2020 and February 2021 with 22 maternity skilled heath personnel (SHP) on perceptions of care provision; (2) quantitative monthly routine data on caesarean section and labour induction from March 2019 to February 2021; and (3) timeline data of COVID-19 epidemiology, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on timeline analysis, and triangulated during reporting. RESULTS: We identified three periods: first wave, slow period and second wave. The first wave was challenging for SHP given little knowledge about COVID-19, lack of infection prevention and control training, and difficulties reaching workplace. Challenges that persisted beyond the first wave were shortage of personal protective equipment and no rapid testing for women suspected with COVID-19. We noted no change in the proportion of caesarean sections during the pandemic, and a small increase in the proportion of labour inductions. All hospitals arranged isolation areas for women suspected/confirmed with COVID-19 and three hospitals provided care to women with suspected/confirmed COVID-19. Breastfeeding was not discouraged and newborns were not separated from mothers confirmed with COVID-19. Care provision was maintained through dedication of SHP, support from hospital management and remote communication between SHP. CONCLUSION: Routine maternal care provision was maintained in referral hospitals, despite first wave challenges. Referral hospitals and SHP contributed to guideline development for pregnant women suspected/confirmed with COVID-19. Maternity SHP, women and pregnancy must always be included in priority setting when responding to health system shocks, including outbreaks.

" I would have left that man long time ago but, " exploring circumstances of and motivators for repeat adolescent birth in Eastern Uganda.

BACKGROUND: First birth before 18 years has declined in Uganda unlike repeat adolescent birth (=second or more births before age 20 years). We explored the circumstances of and motivators for repeat adolescent birth in Eastern Uganda. METHODS: Between January and March 2020, we conducted a qualitative study involving 70 individual in-depth interviews with purposively selected respondents - 20-25-year-old women with and without repeat adolescent birth, their partners, and parents, in the communities of Teso sub-region. We conducted latent content analysis. RESULTS: Four major themes emerged: poverty, vulnerability, domestic violence, and demotivators. Sub-themes identified under poverty were: "limited provisions", "peasantry", "large families", "dropping out of school", "alcohol abuse", and "broken family structure". Vulnerability included "marital entrapment" and "partner coercion". Demotivators included: "abandonment", "stern warning", "objection to marriage", and "empowerment". Extreme poverty resulted in inadequate provision of basic needs leading to unprotected sexual activity in a bid to secure financial support. Following the first birth, more than three quarters of the women with repeat adolescent birth reported increased economic distress that forced them to remain in unwanted marriage/union, often characterized by partner coercion, despite wanting to delay that repeat birth. Women without repeat adolescent birth avoided a second birth by empowerment through: an economic activity, contraception use, and resumption of schooling. CONCLUSION: Repeat adolescent birth in Uganda is premised around attempts to address the economic distress precipitated by first birth. Many women want to delay that repeat birth but the challenges robbed them of their reproductive autonomy. Beyond efforts to prevent first birth, programs need to address economic empowerment, ensure contraceptive access, and school re-integration for adolescent mothers in order to prevent shortly-spaced repeat births.

In the last 30 years, the proportion of adolescents (10­19 years) in Uganda having a first live birth before age 18 years has declined. However, among these, the proportion who proceed to have another live birth before age 20 years (=repeat adolescent birth) has not declined. We therefore set out to find out what motivated or were the circumstance under which these adolescent girls had repeat adolescent birth. We answered this question by interviewing people in Eastern Uganda: 1) women age 20­25 years who had first birth before age 18 years; those with and without history of repeat adolescent birth, 2) the parents with girls who had first birth before 18 years, 3) partners to women with repeat adolescent birth, and 4) community leaders.We found that the financial challenges that had escalated following the first birth was responsible for the events or decisions that culminated into a repeat adolescent birth. In an attempt to find a solution to the financial challenges, the adolescent girls end up in unwanted unions with men and ultimately lost their power to decide on whether or not to get pregnant again. Many wanted to have this repeat birth later but were robbed of the opportunity to do so. The study findings suggest that beyond helping adolescent girls prevent the first birth, they need to be supported with economic empowerment activities, improved contraception services, and re-integration in school.

Later life outcomes of women by adolescent birth history: analysis of the 2016 Uganda Demographic and Health Survey.

OBJECTIVES: To describe the long-term socioeconomic and reproductive health outcomes of women in Uganda by adolescent birth history. DESIGN: Cross-sectional study. SETTING: Uganda. PARTICIPANTS: Women aged 40-49 years at the 2016 Uganda Demographic and Health Survey. OUTCOME MEASURES: We compared socioeconomic and reproductive outcomes among those with first birth <18 years versus not. Among those with a first birth <18 years, we compared those with and without repeat adolescent births (another birth <20 years). We used two-sample test for proportions, linear regression and Poisson regression. FINDINGS: Among the 2814 women aged 40-49 years analysed, 36.2% reported a first birth <18 years and 85.9% of these had a repeat adolescent birth. Compared with women with no birth <18 years, those with first birth <18 years were less likely to have completed primary education (16.3% vs 32.2%, p<0.001), more likely to be illiterate (55.0% vs 44.0%, p<0.001), to report challenges seeking healthcare (67.6% vs 61.8%, p=0.002) and had higher mean number of births by age 40 years (6.6 vs 5.3, p<0.001). Among women married at time of survey, those with birth <18 years had older husbands (p<0.001) who also had lower educational attainment (p<0.001). Educational attainment, household wealth score, total number of births and under-5 mortality among women with one adolescent birth were similar, and sometimes better, than among those with no birth <18 years. CONCLUSIONS: Results suggest lifelong adverse socioeconomic and reproductive outcomes among women with adolescent birth, primarily in the category with repeat adolescent birth. While our results might be birth-cohort specific, they underscore the need to support adolescent mothers to have the same possibilities to develop their potentials, by supporting school continuation and prevention of further unwanted pregnancies.

Assessment of Maternal Health Services Quality at Juba Teaching Hospital, South Sudan.

BACKGROUND: Client satisfaction is an important outcome of healthcare services and is regarded as an indicator for quality of care. Not much research has been conducted to investigate satisfaction with maternal health care in Sub-Saharan Africa and especially no or little in South Sudan. This study was carried out to assess quality of maternal health services (MHS) at Juba Teaching Hospital, South Sudan. METHODS: This cross-sectional research study was done among women of reproductive age at a time of taking their infants for routine immunization services in June to July 2015. A structured questionnaire was used to gather information by interviewers. The data were analysed using SPSS Statistics v20. The frequency tables were for describing data and chi-square test and logistic regression were used to determine whether there was statistical association of sociodemographic factors with satisfaction with MHS. RESULTS: Of 207 women, 193 (93.0%) were satisfied with the services. There was statistically significant association of family monthly income with antenatal careand delivery care satisfaction [OR at 95%CI = 8.30 (2.04 - 33.79), p-value=0.003 and OR at 95%CI = 0.12 (0.03 - 0.56), p-value = 0.007 respectively]. Furthermore, there was a significant association of education attainment with place of delivery [OR at 95%CI =3.06 (1.40 - 6.71), p-value = 0.005]. CONCLUSION: Women were satisfied with maternal healthcare services. Level of education and monthly family earnings were associated with maternity care. Hence, there should be emphasis on the education of women and their earnings.

Time trends in and factors associated with repeat adolescent birth in Uganda: Analysis of six demographic and health surveys.

BACKGROUND: Information on repeat adolescent birth remains scarce in sub-Sahara Africa. We investigated the prevalence and time trends in repeat adolescent birth in Uganda, and associated factors. METHODS: We analyzed Uganda Demographic and Health Survey data of women age 20-24 years collected on 6 surveys (1988/89-2016) to estimate repeat adolescent birth (first live birth <18 years of age followed by another live birth(s) <20 years). Further, we estimated the wantedness of the second order birth and the prevalence of short birth intervals birth (<13 months) between the first and second such birth. On the 2016 survey, we examined factors associated with repeat adolescent birth using bivariate and multivariate modified Poisson regression. RESULTS: At the 1988/89 survey, 58.9% of women with first birth <18 years reported a repeat adolescent birth. This percentage increased to 66.8% in 2006 (+7.9 percentage points [pp], p = 0.010) and thereafter declined to 55.6% by 2016 (-11.2 pp, p<0.001), nevertheless, no change occurred between 1988/89 and 2016 (-3.3pp, p = 0.251). Among women with repeat adolescent births, the mean number of live births by exact age 20 years (2.2 births) and prevalence of short birth intervals (3.5% in 1988/89, 5.4% in 2016) (+1.9pp, p = 0.245) did not change. Increasingly more women with repeat adolescent births preferred to have had the second child later, 22.5% in 1995 and 43.1% in 2016 (+20.6pp, p = <0.001). On the 2016 survey, women from poorer households and those of younger age at first birth were significantly more likely to report repeat adolescent birth. CONCLUSION: Following a first birth <18 years, more than half of the women report a repeat adolescent birth (<20 years), with no decline observed in 30 years. Increasingly more women wanted the second adolescent pregnancy later, highlighting the need to support adolescents with improved family planning services at each contact.

Determinants of Postpartum Contraception Use Among Teenage Mothers in Eastern Uganda: A Cross-Sectional Study.

INTRODUCTION: In Uganda, the proportion of women having another live birth before age 20 years (repeat adolescent birth) has not declined in 30 years. More women want to delay the next birth. We determined the prevalence and factors associated with postpartum contraceptive use among teenage mothers in Mbale City. PATIENTS AND METHODS: We conducted a cross-sectional study in all the six government-supported health facilities within Mbale City. Over a period of 3 months, 511 teenage mothers in the postpartum period were consecutively enrolled by midwives/nurses. Data were collected using a pretested interviewer-administered questionnaire. We used logistic regression in STATA version 14, to determine the association between various sociodemographic characteristics and utilization of contraception. We set the level of significance at 5% and report odds ratios and the corresponding 95% confidence intervals. RESULTS: Most of the respondents - 314/511 [61.5%, 95% CI= 57.1-65.6%] - were using contraceptives. More than three-fourth (238/314) of the respondents opted for short-term methods of contraception. In the adjusted analyses, intention to resume school [AOR 1.79 (1.16-2.74)], and utilization of maternal Child Heath services such as postnatal care services [AOR 0.40 (0.25-0.63)] were significantly associated with utilisation of postpartum contraception. CONCLUSION: We found a high prevalence of postpartum contraceptives use - over 6 in 10 women - although they were using mainly short-term methods. Those with intentions of resuming schooling and utilised postnatal care services were most likely to use contraceptives. This is encouraging and calls for inquiry into why their use is higher than the national averages. Further, the results call for renewed efforts to maintain adolescent mothers in school.

Improving the quality of maternity services in Uganda through accelerated implementation of essential interventions by healthcare professional associations.

OBJECTIVE: To assess whether the implementation of a package of activities through the joint action of the three international healthcare professionals associations (HCPAs) increased the use of intrapartum and postnatal essential interventions (EIs) in two hospitals in Uganda. METHODS: A non-controlled before-and-after study was undertaken to evaluate the effect of a package of activities designed to change practice relating to nine EIs among providers. Coverage of the EIs was measured in a 3-month pre-implementation period and a 3-month post-implementation period in 2014. Data were obtained for women older than 18 years who delivered vaginally or by cesarean. RESULTS: Overall, 4816 women were included. Level of use remained high for EIs used widely at baseline. Some EIs that had low use at baseline did not show improvement after the implementation. Promotion of breastfeeding showed a significant improvement in the Kampala hospital, from 8.5% (8/94) to 25.6% (30/117; P=0.001), whereas promotion of hygiene in cord care improved at the Mbarara hospital, from 0.1% (2/1592) to 46.0% (622/1351; P<0.001). CONCLUSION: These exploratory results show that a package delivered through the joint work of the three HCPAs was feasible to implement along with rigorous data collection. Although the data show disparities, trends suggest that improvement could be achieved.