Acceptability of evidence-based Acceptability of evidence-based maternal-neonatal care practices maternal-neonatal care practices in rural Uganda -implications for in rural Uganda -implications for

programmingprogramming

Peter Waiswa, Margaret Peter Waiswa, Margaret Kemigisa, Juliet Kiguli, Sarah Kemigisa, Juliet Kiguli, Sarah

Naikoba,Naikoba,

George Pariyo, Stefan PetersonGeorge Pariyo, Stefan Peterson

Background-1Background-1

Globally 4 million newborn deaths/year or Globally 4 million newborn deaths/year or 40% of U5M, 98% in developing countries40% of U5M, 98% in developing countries

Therefore achieving MDG4 requires Therefore achieving MDG4 requires reducing newborn deathsreducing newborn deaths

50% occur on D1 and 75% occur in week 50% occur on D1 and 75% occur in week one after birthone after birth

Trend same for maternal deathTrend same for maternal death

Background-2: In UgandaBackground-2: In Uganda

44,500 newborn deaths and 45,100 44,500 newborn deaths and 45,100 stillbirths/year; 31,800 could be prevented; 23% stillbirths/year; 31,800 could be prevented; 23% of U5M are neonatesof U5M are neonates56% excess newborn deaths in rural areas 56% excess newborn deaths in rural areas comapred to urbancomapred to urban60% birth occur at home 60% birth occur at home Only 12% newborns ever get postnatal careOnly 12% newborns ever get postnatal careIganga district: About 900 newborn deaths, 850 Iganga district: About 900 newborn deaths, 850 perinatal deaths (300 perinatal death in Iganga perinatal deaths (300 perinatal death in Iganga hospital alone)hospital alone)

Background-3Background-3

Causes preventableCauses preventable - 86% of neonatal - 86% of neonatal deaths by 3 preventable problems: deaths by 3 preventable problems:

infections infections - 36%- 36%

prematurity prematurity - 27% - 27%

asphyxia asphyxia - 23%- 23%

Recent evidence from Asia and S Recent evidence from Asia and S America: low cost community interventions America: low cost community interventions can reduce neonatal deaths by 20% - 40%can reduce neonatal deaths by 20% - 40%

The Evidence Based PracticesThe Evidence Based Practices

Birth preparedness and promotion of demand for care and Birth preparedness and promotion of demand for care and readiness for emergenciesreadiness for emergenciesCounseling and preparation of for newborn careCounseling and preparation of for newborn careClean deliveryClean deliveryHygienic cord/skin careHygienic cord/skin careThermal careThermal carePromotion of early and exclusive breastfeedingPromotion of early and exclusive breastfeedingHealth home care Health home care Extra care for low birth weight babiesExtra care for low birth weight babiesCommunity case management for pneumoniaCommunity case management for pneumonia4 ANC visits inc. IPT, TT4 ANC visits inc. IPT, TTAwareness and early detection and referral of danger signsAwareness and early detection and referral of danger signs

ObjectivesObjectives

To To explore the acceptability of explore the acceptability of recommended evidence-based maternal-recommended evidence-based maternal-neonatal practices at community levelneonatal practices at community level

To investigate acceptability of home visits To investigate acceptability of home visits by a CHW during pregnancy and in the by a CHW during pregnancy and in the early neonatal period to promote home early neonatal period to promote home carecare

MethodsMethods

10 FGDs consisting of mothers, fathers 10 FGDs consisting of mothers, fathers and child minders-up to 13 years oldand child minders-up to 13 years old

10 IDIs with health workers and traditional 10 IDIs with health workers and traditional birth attendantsbirth attendants

Study done in Iganga/Mayuge Districts in Study done in Iganga/Mayuge Districts in Busoga subregion, Eastern UgandaBusoga subregion, Eastern Uganda

Basoga are almost 10% of UgandansBasoga are almost 10% of Ugandans

Findings: Acceptable PracticesFindings: Acceptable Practices

Attending ANC 4 times during pregnancy Attending ANC 4 times during pregnancy Maintenance of warmth through skin to Maintenance of warmth through skin to skin contactskin contactExclusive breast feeding Exclusive breast feeding Skilled care seeking for danger signs Skilled care seeking for danger signs Facility/Supervised deliveriesFacility/Supervised deliveriesEarly referral for danger signsEarly referral for danger signsHome visits by CHWsHome visits by CHWs

Findings: Less acceptable Findings: Less acceptable PracticesPractices

Early bathing – babies believed to be born “dirty”Early bathing – babies believed to be born “dirty”

““My babies are usually born dirty, so it is a must for me My babies are usually born dirty, so it is a must for me to bathe the baby immediately I am discharged on to bathe the baby immediately I am discharged on that same day of giving birth. You people are your that same day of giving birth. You people are your babies born clean”.babies born clean”. (FGD Older mothers). (FGD Older mothers).

Putting nothing on cord – that substances encourage Putting nothing on cord – that substances encourage ‘early cord healing’‘early cord healing’

Care of premature babies at home – belief that this Care of premature babies at home – belief that this should be in health facilities should be in health facilities

Findings: Key challenges to Findings: Key challenges to home carehome care

Knowledge barriers, service delivery gaps; Knowledge barriers, service delivery gaps; cultural, traditional beliefs and practices cultural, traditional beliefs and practices and financial constraints and financial constraints

Limited community knowledge on: Limited community knowledge on: importance of attending ANC four times importance of attending ANC four times during pregnancyduring pregnancy

Findings: Key challenges to Findings: Key challenges to home carehome care

Deep rooted beliefs in herbs Deep rooted beliefs in herbs Decision making not by womenDecision making not by womenB/preparedness is hindered by poverty, B/preparedness is hindered by poverty, cultural beliefs, limited awareness, lack of cultural beliefs, limited awareness, lack of adequate male involvement and the fear of adequate male involvement and the fear of preparing for the unbornpreparing for the unbornMost labour occurring at nightMost labour occurring at nightNo community knowledge on postnatal No community knowledge on postnatal care except for immunisationcare except for immunisation

Key challenges to home careKey challenges to home care

ANC misconstrued as provision of medicine for sick ANC misconstrued as provision of medicine for sick pregnant women (pregnant women (okunwa obulezi)okunwa obulezi)

““Yes, I was given three Fansidars and they are at home. I Yes, I was given three Fansidars and they are at home. I came back quarrelling. I went for ANC for assistance but came back quarrelling. I went for ANC for assistance but by giving me only three tablets, how were they helping? by giving me only three tablets, how were they helping? Three tablets only! Yet I explained my condition in Three tablets only! Yet I explained my condition in detail”detail”. (FGD Young Mothers). (FGD Young Mothers)

““Yes, she (TBA) delivers and also changes the position of Yes, she (TBA) delivers and also changes the position of the baby if it is not laying right. She can also the baby if it is not laying right. She can also change the change the sex of the babysex of the baby if you want. For instance if you have if you want. For instance if you have been giving birth to only boys and you want a girl, she been giving birth to only boys and you want a girl, she can change the sex for you so that you deliver a girl”. can change the sex for you so that you deliver a girl”. ((FGD, older mothers)FGD, older mothers)

Preparing for birth is a burden to Preparing for birth is a burden to women and hinders facility deliverieswomen and hinders facility deliveries

Alternative domestic services while mother is away Alternative domestic services while mother is away Stocking food and firewoodStocking food and firewoodFinding other person to take care of home and childrenFinding other person to take care of home and childrenGathering personal effects for mother-to-be and newbornGathering personal effects for mother-to-be and newbornVaseline and soapVaseline and soapA jerrycan for water and a basin for bathingA jerrycan for water and a basin for bathingMother and Baby clothes and powderMother and Baby clothes and powderBuying materials for use by health care providers Buying materials for use by health care providers – Gloves and razorblade (for cutting the cord) Gloves and razorblade (for cutting the cord) – Threads (to be used as cord ligatures) Threads (to be used as cord ligatures) – Syringes, needles and injectable ergometrine (to stop postpartum Syringes, needles and injectable ergometrine (to stop postpartum

haemorrge)haemorrge)– Cotton woolCotton wool– ‘‘Kavera’/plastic sheet (an improvised mackintosh)Kavera’/plastic sheet (an improvised mackintosh)

Preparation for emergencies Preparation for emergencies Asking transport money from male partners or saving from own Asking transport money from male partners or saving from own sourcessources

ConclusionsConclusions

Evidence based practices for MN health may not Evidence based practices for MN health may not be universally acceptablebe universally acceptableA “one size fits all strategy” to scale-up for all of A “one size fits all strategy” to scale-up for all of SubSaharan Africa is likely to failSubSaharan Africa is likely to failWe suggest rapid appraisal and local adaptation We suggest rapid appraisal and local adaptation of evidence-based practices and packages to of evidence-based practices and packages to address the local socio-cultural situationaddress the local socio-cultural situationHealth systems strengthening will be needed for Health systems strengthening will be needed for community strategies to be effectivecommunity strategies to be effective Male involvement is key and promotion of Male involvement is key and promotion of waiting shelters at selected health units should waiting shelters at selected health units should be consideredbe considered

AcknowledgementsAcknowledgements

Funders:- Sida/SAREC, Saving Newborn Funders:- Sida/SAREC, Saving Newborn Lives initiative of Save the Children/USA Lives initiative of Save the Children/USA through a grant from the Bill and Melinda through a grant from the Bill and Melinda Gates Foundation. Gates Foundation.

Study participants, DSS staff and research Study participants, DSS staff and research assistants, and the Study Policy Advisory assistants, and the Study Policy Advisory Group. Group.

We acknowledge the useful comments on We acknowledge the useful comments on the manuscript made by Dr Joy Lawn.the manuscript made by Dr Joy Lawn.