How equitable is utilization of maternal health services in Uganda? Implications for achieving universal health coverage.

BACKGROUND: Maternal and neonatal mortality in Uganda remain persistently high. While utilisation of maternal health services has been shown to reduce the risk of maternal death, little is known about the inequalities in utilisation of maternal health services in Uganda. This study examined the inequalities in utilisation of maternal health services between 2006 and 2016 to draw implications for achieving universal health coverage. METHODS: We used the Uganda Demographic Health Survey 2006, 2011 and 2016 to analyse inequalities in utilisation of antenatal care (ANC4+), skilled birth attendance (SBA), postnatal care (PNC) and a package of maternal health services. Equity ratios, concentration curves, concentration indices and regression analysis were used in the estimations. RESULTS: Inequalities in utilization of single and a package of maternal health services reduced between 2005 and 2016, but remained pro-rich. Inequalities in utilisation of package of maternal health services were greater than for a single service. Women from the richest quintile were 4 times more likely to receive a package of care compared to the poorest women, but were just 1.5 times more likely to receive ANC4 + than those in the poorest quintile. In 2006 women in urban areas were 2.6 times more likely to receive a package of all three maternal health services than their rural counterpart and they had a relative advantage of 23.4% to utilize skilled birth delivery than the poorest women. Each additional year of schooling and living in urban areas was associated with 1.2 and 1.6% point increase in utilisation of a package of care respectively. Wealth, education and living in urban areas were positively associated with utilisation of all maternal healthcare. CONCLUSION: Declining inequalities in utilisation of maternal healthcare reflect a move towards achieving universal health coverage in Uganda. Pro-rich, education and urban-biased inequalities, imply the need for targeted interventions for the poor, less educated and rural women. Targeted voucher schemes, free distribution of birth kits for poorer and rural women, community-level mobilization to improve uptake of postnatal care, and promoting women's education and incomes are feasible interventions to improve utilisation of maternal health services and equity.

Health technology assessment (HTA) readiness in Uganda: stakeholder's perceptions on the potential application of HTA to support national universal health coverage efforts.

INTRODUCTION: Health technology assessment (HTA) is an area that remains less implemented in low- and lower middle-income countries. The aim of the study is to understand the perceptions of stakeholders in Uganda toward HTA and its role in decision making, in order to inform its potential implementation in the country. METHODS: The study takes a cross-sectional mixed methods approach, utilizing an adapted version of the International Decision Support Initiative questionnaire with both semi-structured and open-ended questions. We interviewed thirty key informants from different stakeholder institutions in Uganda that support policy and decision making in the health sector. RESULTS: All participants perceived HTA as an important tool for decision making. Allocative efficiency was regarded as the most important use of HTA receiving the highest average score (8.8 out of 10), followed by quality of healthcare (7.8/10), transparency (7.6/10), budget control (7.5/10), and equity (6.5/10). There was concern that some of the uses of HTA may not be achieved in reality if there was political interference during the HTA process. The study participants identified development partners as the most likely potential users of HTA (66.7 percent of participants), followed by Ministry of Health (43.3 percent). CONCLUSION: Interviewed stakeholders in Uganda viewed the role of HTA positively, suggesting that there exists a promising environment for the establishment and operationalization of HTA as a tool for decision making within the health sector. However, sustainable development and application of HTA in Uganda will require adequate capacity both to undertake HTAs and to support their use and uptake.

Maternal health challenges experienced by adolescents; could community score cards address them? A case study of Kibuku District- Uganda.

INTRODUCTION: Approximately 34.8% of the Ugandan population is adolescents. The national teenage pregnancy rate is 25% and in Kibuku district, 17.6% of adolescents aged 12-19 years have begun child bearing. Adolescents mothers are vulnerable to many maternal health challenges including; stigma, unfriendly services and early marriages. The community score card (CSC) is a social accountability tool that can be used to point out challenges faced by the community in service delivery and utilization and ultimately address them. In this paper we aimed to document the challenges faced by adolescents during pregnancy, delivery and postnatal period and the extent to which the community score card could address these challenges. METHODS: This qualitative study utilized in-depth interviews conducted in August 2018 among 15 purposively selected adolescent women who had given birth 2 years prior to the study and had attended CSC meetings. The study was conducted in six sub counties of Kibuku district where the CSC intervention was implemented. Research assistants transcribed the audio-recorded interviews verbatim, and data was analyzed manually using the framework analysis approach. FINDINGS: This study found five major maternal health challenges faced by adolescents during pregnancy namely; psychosocial challenges, physical abuse, denial of basic human rights, unfriendly adolescent services, lack of legal and cultural protection, and lack of birth preparedness. The CSC addressed general maternal and new born health issues of the community as a whole rather than specific adolescent health related maternal health challenges. CONCLUSION: The maternal health challenges faced by adolescents in Kibuku have a cultural, legal, social and health service dimension. There is therefore need to look at a multi-faceted approach to holistically address them. CSCs that are targeted at the entire community are unlikely to address specific needs of vulnerable groups such as adolescents. To address the maternal health challenges of adolescents, there is need to have separate meetings with adolescents, targeted mobilization for adolescents to attend meetings and deliberate inclusion of their maternal health challenges into the CSC.

Maternal and newborn health needs for women with walking disabilities; "the twists and turns": a case study in Kibuku District Uganda.

BACKGROUND: In Uganda 13% of persons have at least one form of disability. The United Nations' Convention on the Rights of Persons with Disabilities guarantees persons with disabilities the same level of right to access quality and affordable healthcare as persons without disability. Understanding the needs of women with walking disabilities is key in formulating flexible, acceptable and responsive health systems to their needs and hence to improve their access to care. This study therefore explores the maternal and newborn health (MNH)-related needs of women with walking disabilities in Kibuku District Uganda. METHODS: We carried out a qualitative study in September 2017 in three sub-counties of Kibuku district. Four In-depth Interviews (IDIs) among purposively selected women who had walking disabilities and who had given birth within two years from the study date were conducted. Trained research assistants used a pretested IDI guide translated into the local language to collect data. All IDIs were audio recorded and transcribed verbatim before analysis. The thematic areas explored during analysis included psychosocial, mobility, health facility and personal needs of women with walking disabilities. Data was analyzed manually using framework analysis. RESULTS: We found that women with walking disabilities had psychosocial, mobility, special services and personal needs. Psychosocial needs included; partners', communities', families' and health workers' acceptance. Mobility needs were associated with transport unsuitability, difficulty in finding transport and high cost of transport. Health facility needs included; infrastructure, and responsive health services needs while personal MNH needs were; personal protective wear, basic needs and birth preparedness items. CONCLUSIONS: Women with walking disabilities have needs addressable by their communities and the health system. Communities, and health workers need to be sensitized on these needs and policies to meet and implement health system-related needs of women with disability.

Cost-effectiveness of GeneXpert Omni compared with GeneXpert MTB/Rif for point-of-care diagnosis of tuberculosis in a low-resource, high-burden setting in Eastern Uganda: a cost-effectiveness analysis based on decision analytical modelling.

OBJECTIVE: To determine the cost-effectiveness of Xpert Omni compared with Xpert MTB/Rif for point-of-care diagnosis of tuberculosis among presumptive cases in a low-resource, high burden facility. DESIGN: Cost-effectiveness analysis from the provider's perspective. SETTING: A low-resource, high tuberculosis burden district in Eastern Uganda. PARTICIPANTS: A provider's perspective was used, and thus, data were collected from experts in the field of tuberculosis diagnosis purposively selected at the local, subnational and national levels. METHODS: A decision analysis model was contracted from TreeAge comparing Xpert MTB/Rif and Xpert Omni. Cost estimation was done using the ingredients' approach. One-way deterministic sensitivity analyses were performed to identify the most influential model parameters. OUTCOME MEASURE: The outcome measure was incremental cost per additional test diagnosed expressed as the incremental cost-effectiveness ratio. RESULTS: The total cost per test for Xpert MTB/Rif was US$14.933. Cartridge and reagent kits contributed to 67% of Xpert MTB/Rif costs. Sample transport costs increased the cost per test of Xpert MTB/Rif by $1.28. The total cost per test for Xpert Omni was $16.153. Cartridge and reagent kits contributed to over 71.2% of Xpert Omni's cost per test. The incremental cost-effectiveness ratio for using Xpert Omni as a replacement for Xpert MTB/Rif was US$30.73 per additional case detected. There was no dominance noted in the cost-effectiveness analysis, meaning no strategy was dominant over the other. CONCLUSION: The use of Xpert Omni at the point-of-care health facility was more effective but with an increased cost compared with Xpert MTB/Rif at the centralised referral testing facility.

Effect of community-level intervention on antenatal care attendance: a quasi-experimental study among postpartum women in Eastern Uganda.

BACKGROUND: Early Initiation of antenatal care (ANC) and at least four visits during pregnancy allow screening and support for a healthy lifestyle and self-care during pregnancy however, community-directed interventions to improve access to these services are rarely explored. OBJECTIVE: To assess the effect of community health worker (CHW) involvement on utilisation of antenatal services during pregnancy in resource-constrained rural settings in Uganda. METHODS: We conducted a quasi-experimental evaluation study among mothers from Eastern Uganda. We used Difference in Differences (DiD) analysis to assess the effect of CHW intervention on ANC attendance. Components of the intervention included community dialogues and empowering CHWs to educate pregnant women about using maternal health services. The primary endpoints were early initiation of ANC and completion of at least 4 ANC visits. RESULTS: Overall, the intervention significantly improved attendance of ≥ 4 ANC visits (DiD = 5.5%). The increase was significant in both intervention and comparison areas (46.2-64.4% vs. 54.1-66.8%, respectively), with slightly greater gains in the intervention area. Other elements that predicted ≥4 ANC attendance besides the intervention were post-primary education (PR1.14, 95%CI 1.02-1.30), higher wealth quintile (PR1.17, 95%CI 1.06-1.30), and early initiation of ANC (PR1.58, 95%CI 1.49-1.68). The intervention did not significantly improve early initiation of ANC (DiD =-1.3%). Instead, early initiation of ANC was associated with higher husband education (PR1.19,95%CI 1.02-1.39), larger household size (PR = 0.81, 95%CI 0.70-0.95), and higher wealth index (PR1.19,95%CI 1.03-1.37). CONCLUSIONS: The CHW intervention improved attendance of at least 4 ANC visits but not early initiation of ANC. There is need to promote CHW-led health education to increase attendance at 4+ ANC visits, but other approaches to promote early initiation are urgently required.

A case-control study of factors associated with caesarean sections at health facilities in Kabarole District, Western Uganda, 2016.

INTRODUCTION: World Health Organization estimates that the appropriate caesarean section rates should range from 10% to 15% at the population level. There is limited access and utilisation of caesarean section services in Uganda. This case-control study explored factors associated with caesarean section delivery, focusing on service-related and individual level factors. METHODS: we interviewed 134 cases that had a caesarean section and 134 controls that had a "normal" vaginal delivery. The study was conducted at health facilities in Kabarole district during March to May 2016. Multivariable logistic regression was used to determine individual factors associated with caesarean sections, at a significance level of p < 0.05. Key Informant (KI) data obtained from health workers was analysed using MAXQDA (version 12) software to determine health service factors affecting caesarean section service delivery. RESULTS: the mean age of the overall sample was 26 years (SD ± 6.5 years). Cases had 5% more women who belonged to the eldest age group (> 35 years) compared to the controls. The factors associated with caesarean section delivery were: having a previous caesarean section delivery (adjusted odds ratio (AOR): 4.5 CI: 2.22-9.0), attendance of four or more ANC visits (AOR: 2.0 CI: 1.04-3.83). Inadequate human resource, medicines and supplies affected access to the service. Misconceptions such as negative branding of women that have caesarean section deliveries as "lazy" reduced its acceptance thus low utilisation of the service. CONCLUSION: health system inadequacies and misconceptions about caesarean section delivery contributed to the low access and utilisation of the service.

Strategies for helping families prepare for birth: experiences from eastern central Uganda.

BACKGROUND: Promotion of birth preparedness and raising awareness of potential complications is one of the main strategies to enhance the timely utilisation of skilled care at birth and overcome barriers to accessing care during emergencies. OBJECTIVE: This study aimed to investigate factors associated with birth preparedness in three districts of eastern central Uganda. DESIGN: This was a cross-sectional baseline study involving 2,010 women from Iganga [community health worker (CHW) strategy], Buyende (vouchers for transport and services), and Luuka (standard care) districts who had delivered within the past 12 months. 'Birth prepared' was defined as women who had taken all of the following three key actions at least 1 week prior to the delivery: 1) chosen where to deliver from; 2) saved money for transport and hospital costs; and 3) bought key birth materials (a clean instrument to cut the cord, a clean thread to tie the cord, cover sheet, and gloves). Logistical regression was performed to assess the association of various independent variables with birth preparedness. RESULTS: Only about 25% of respondents took all three actions relating to preparing for childbirth, but discrete actions (e.g. financial savings and identification of place to deliver) were taken by 75% of respondents. Variables associated with being prepared for birth were: having four antenatal care (ANC) visits [adjusted odds ratio (ORA)=1.42; 95% confidence interval (CI) 1.10-1.83], attendance of ANC during the first (ORA=1.94; 95% CI 1.09-3.44) or second trimester (ORA=1.87; 95% CI 1.09-3.22), and counselling on danger signs during pregnancy or on place of referral (ORA=2.07; 95% CI 1.57-2.74). Other associated variables included being accompanied by one's husband to the place of delivery (ORA=1.47; 95% CI 1.15-1.89), higher socio-economic status (ORA=2.04; 95% CI 1.38-3.01), and having a regular income (ORA=1.83; 95% CI 1.20-2.79). Women from Luuka and Buyende were less likely to have taken three actions compared with women from Iganga (ORA=0.72; 95% CI 0.54-0.98 and ORA=0.37; 95% CI 0.27-0.51, respectively). CONCLUSIONS: Engaging CHWs and local structures during pregnancy may be an effective strategy in promoting birth preparedness. On the other hand, if not well designed, the use of vouchers could disempower families in their efforts to prepare for birth. Other effective strategies for promoting birth preparedness include early ANC attendance, attending ANC at least four times, and male involvement.

Quality of Antenatal care services in eastern Uganda: implications for interventions.

INTRODUCTION: More efforts need to be directed to improving the quality of maternal health in developing countries if we are to keep on track with meeting the fifth millennium development goal. The World Health Organization says developing countries account for over 90% of maternal deaths of which three fifths occur in Sub-Saharan African countries like Uganda. Abortion, obstetric complications such as hemorrhage, dystocia, eclampsia, and sepsis are major causes of maternal deaths here. Good quality Antenatal Care (ANC) provides opportunity to detect and respond to risky maternal conditions. This study assessed quality of ANC services in eastern Uganda with a goal of benchmarking implications for interventions. METHODS: Data was collected from 15 health facilities in Eastern Uganda to establish capacity of delivering ANC services. Observation checklists were used to assess structural components and completeness of the ANC consultation process among 291 women attending it. Lastly, structured exit-interviews were conducted to assess satisfaction of patients. Data analysis was done in STATA Version 10. RESULTS: There was an overall staffing gap of over 40%, while infection control facilities, drugs and supplies were inadequate. However, there was good existence of physical infrastructure and diagnostic equipment for ANC services. It was observed that counseling for risk factors and birth preparedness was poorly done; in addition essential tests were not done for the majority of clients. CONCLUSION: To improve the quality of ANC, interventions need to improve staffing, infection control facilities and drug-supplies. In addition to better counseling for risk factor-recognition and birth preparedness.

The Uganda Newborn Study (UNEST): an effectiveness study on improving newborn health and survival in rural Uganda through a community-based intervention linked to health facilities - study protocol for a cluster randomized controlled trial.

BACKGROUND: Reducing neonatal-related deaths is one of the major bottlenecks to achieving Millennium Development Goal 4. Studies in Asia and South America have shown that neonatal mortality can be reduced through community-based interventions, but these have not been adapted to scalable intervention packages for sub-Saharan Africa where the culture, health system and policy environment is different. In Uganda, health outcomes are poor for both mothers and newborn babies. Policy opportunities for neonatal health include the new national Health Sector Strategic Plan, which now prioritizes newborn health including use of a community model through Village Health Teams (VHT). The aim of the present study is to adapt, develop and cost an integrated maternal-newborn care package that links community and facility care, and to evaluate its effect on maternal and neonatal practices in order to inform policy and scale-up in Uganda. METHODS/DESIGN: Through formative research around evidence-based practices, and dialogue with policy and technical advisers, we constructed a home-based neonatal care package implemented by the responsible VHT member, effectively a Community Health Worker (CHW). This CHW was trained to identify pregnant women and make five home visits - two before and three just after birth - so that linkages will be made to facility care and targeted messages for home-care and care-seeking delivered. The project is improving care in health units to provide standardized care for the mother and the newborn in both intervention and comparison areas.The study is taking place in a new Demographic Surveillance Site in two rural districts, Iganga and Mayuge, in Uganda. It is a two-arm cluster randomized controlled design with 31 intervention and 32 control areas (villages). The comparison parishes receive the standard care already being provided by the district, but to the intervention villages are added a system for CHWs to visit the mother five times in her home during pregnancy and the neonatal period. Both areas benefit from a standardized strengthening of facility care for mothers and neonates. DISCUSSION: UNEST is designed to directly feed into the operationalization of maternal and newborn care in the national VHT strategy, thereby helping to inform scale-up in rural Uganda. The study is registered as a randomized controlled trial, number ISRCTN50321130.