factors affecting utilization of focus antenatal …
TRANSCRIPT
FACTORS AFFECTING UTILIZATION OF FOCUS ANTENATAL CARE SERVICES
AMONG PREGNANT MOTHERS ATTENDING ANTENATAL CARE IN
KITAGATA HOSPITAL-SHEEMA DISTRICT, UGANDA.
BY
ESTELLA BOJO ELlA LADU
REGISTRATION NUMBER: BPH/0005/123/DF
AREPORT SUBMITTED TO THE SCHOOL OF PHARMACY AS A PARTIAL
FULFILMENT OF THE REQUIREMENT FOR THE A WARD OF
BACHELLAR DEGREE OF PHARMACY OF KAMPALA
INTERNATIONAL UNIVERSITY-WESTERN
CAMPUS-UGANDA
NOVEMBER, 2016.
DECLARATION
I ESTELLA BOJO ELIA LADU declare that this research report titled factors affecting the
utilization of focus antenatal care services by pregnant mothers attending antenatal care in
Kitagata hospital of Sheema district- Uganda has been a result of independent findings and has
not been submitted before to any other university or institution of higher learning for any
academic award.
Where the work of other people has been cited, it has been duly acknowledged
Submitted by;
~~-SINATURE ............................. . Ol>l ,~\ ~'G · DATE ........................... . ....... .
APPROVAL
This research report has been submitted with my approval as the researcher's University
supervisor. I hereby certifY that I have examined this research prepared under my supervision
and is ready to be snbmitted to the school of pharmacy Kampala international University. The
views expressed in this piece of work are those of the researcher and not the institution.
Phr. EBOSIE JENNIFER
SUPERVISOR
DATE ... a\ . .t.?::..!.~~~'··············SIGNATURE ..... ~ ............... .
II
DEDICATION
I dedicate this work to my lovely family, especially my mum Perina kiden and my brothers
Daniel and Alex and a sister lily for their tireless effort in making this work a success.
iii
ACKNOWLEDGEMENT
My deep, heartfelt gratitude and glory be upon the almighty God for his endless care upon my
life and indeed his will has always come to pass.
I particularly give my special appreciation to my mum who facilitated my research project and to
my dear friends for their facilitation, blessed you are.
Special thanks go to my supervisor. Phr. EBOSIE JENNIFER for being able to guide me despite
her busy schedule; gratitude was to staff of Kitagata hospital.
IV
TABLE OF CONTENTS
DECLARATION ............................................................................................................................. .i
APPROVAL ................................................................................................................................... ii
DEDICATION ............................................................................................................................... iii
ACKNOWLEDGEMENT .............................................................................................................. iv
TABLE OF CONTENTS ................................................................................................................ v
OPERATIONAL DEFINITIONS OF TERMS ........................................................................... viii
CHAPTER ONE : INTRODUCTION ......................................................................................... !
1.1 Background ................................................................................................................................ !
1.2. Statement of the Problem ......................................................................................................... 4
1.3 Broad objective .......................................................................................................................... 4
1.4 Specific objectives ..................................................................................................................... 4
1.5 Research questions .................................................................................................................... 5
1.6 Study justification: ..................................................................................................................... 5
1.7 Scope of study ........................................................................................................................... 5
1.8 Conceptual frame work: ............................................................................................................ 6
CHAPTER TWO: LITERATURE REVIEW ............................................................................ 9
2.1 General overview on FANC ...................................................................................................... 9
2.2 Early detection and treatment ofcomplication: ......................................................................... 9
2.3 Prevention of complications: ..................................................................................................... 9
2.4 Birth preparedness and complication readiness: ....................................................................... 9
2.5 Health promotion and counseling: ........................................................................................... 1 0
2.6 Focused antenatal care (FANC) model outlined in WHO clinical Guidelines: ...................... 11
2.7. Socio-economic and demographic characteristics of pregnant mothers ................................ 12
v
CHAPTER FIVE : DISCUSSION ............................................................................................. 27
Objective I ..................................................................................................................................... 27
Objective II .................................................................................................................................... 28
Objective III ................................................................................................................................... 29
CHAPTER SIX: CONCLUSION AND RECOMMENDATION ........................................... 31
Reference: ...................................................................................................................................... 32
APPENDIX I: MAP OF UGANDA .............................................................................................. 38
APPENDIX ll: MAP OF SHEEMA DISTRICT SHOWING KITAGATA HOSPITAL ............ 39
VII
OPERATIONAL DEFINITIONS OF TERMS
INADEQUATE
FANC UTILIZATION:
HEALTH WORKER
Includes less than 4 visits, not taking
fansidar, hematinic and Dewormers,
not using mosquito nets and not
getting tetanus injection among
others plus failure to adhere to advise
given during ANC visits
Cadres including midwives, medical
officers, and clinical officers,
Obstetrician and pharmacists.
viii
ABSTRACT
Background: In Low and Medium income countries (LMICs) focus antenatal care (FANC)
services are so low, below the recommended threshold. In Uganda, high maternal and neonatal
mortalities have been attributed to the severe variations in F ANC coverage in rural communities.
Aim: This study was to determine factors affecting utilization of FANC services in Kitagata
Hospital of sheema district, Uganda. Materials and Methods: This was a cross-sectional study
carried out for a period of 5 months involving 100 participants who were chosen randomly. A
semi-structured questionnaire was used to collect data on population demographics, knowledge
on benefits and challenges as well as alternative options associated with F ANCs at the health
center. Data was recorded in MS Excel Version 2013 and analyzed using SPSS Version 20 and
chi-square tests were conducted at 95% significance. Results and Discussion: Majority of
participants in the study were adults in the age of 20-29yrs, with the highest level of education
being secondary. This showed that the community had the ability to read and would definitely
appreciate health care messages passed on to them. This would have affected the high tmnover
for screening, testing and immunization activities in this period, thus showing a great level of
knowledge in this regard. Utilization of fansidar to control malaria was a common practice;
however the uptake of Iron/Folic acid in this community was low, thus showing a need to
emphasis its usage in this community. The major alternative to FANCs was identified to be
herbal therapies for malaria i.e. bothrioclinelongipes which is often taken orally. Conclusion
and Recommendation: The long distances covered to attend F ANCs and high transportation
costs are major factors influencing their full utilization in rmal communities. In addition, the
need to improve on Iron/Folic acid supplementation needs to be emphasized in rmal health
facilities and studies to assess the toxicological effects associated with herbal therapies that are
used in discriminatively need to be carried out in prospective studies.
IX
CHAPTER ONE
1.0 INTRODUCTION
1.1 Background
Focus antenatal care plays a great role in ensuring a healthy mother and baby during pregnancy
and after delivery. It involves a planned program of medical management of mothers from the
time of conception till delivery directed towards a health outcome for the mother and the baby
(Centre, 2010). Again in 2015 world health organization defined FANC as a personalized care
provided to a pregnant woman with emphasis on the woman's overall health, preparation for
childbirth and readiness for complications (W.H.O., 2015). It is timely, friendly, simple and safe
service to a pregnant woman, furthermore, it contributes to maternal and neonatal outcomes
similar to those of traditional ANC model which offers routine ANC services than personalized
in FANCs(Mold eta!., 1991), has no adverse effects on the pregnant mother and unborn baby
even though the number of visits has been reduced to four visits . The model has fundamental
public health implications especially in developing countries where health care resources are
inadequate. It curtails the costs for the woman in terms of time traveling to and from the clinic,
waiting time, transport costs where clinics are located far, loss of working hours, and care of
other children at home. Consequently, time and energy would be saved by the health care
personnel as well (Mold eta!., !991).
Focus antenatal Care is given different meanings by different scholars, among others the
meaning that says, " Focus antenatal Care means care before birth and includes education,
counseling, screening and treatment to monitor and to promote the well - being of the mother and
fetus"(Adewoye KR1 et a/.,2013). In short it is the care that a woman receives during pregnancy
that helps to ensure healthy outcomes for women and newborn. It is a key entry point for
pregnant women to receive a multiple range of health services such as nutritional support and
prevention or treatment of anemia; detection and treatment of malaria, tuberculosis and sexually
transmitted infections.
F ANC is an opportunity to promote the benefits of skilled attendants at birth and to encourage
women to seek postpartum care for themselves and their newborn. (Sibley & Sipe, 2006).
I
Even though, Focus antenatal Care have such attractive benefits and strategies, according to the
United Nations Millennium Development Goals, every year, at least half a million women and
girls die as a result of complications during pregnancy, childbirth or the six weeks following
delivery. Almost all (99%) of these deaths occur in developing countries. This shows that the
F ANC activity is very weak in developing countries.
The main reason that hinders the use of focused antenatal Care differs from Country to Country.
But the reason experienced in developing countries are nearly similar such as; hemorrhage,
followed by eclampsia, infection, abortion complications and obstructed labor. Other issues are
due to lack of knowledge and preparedness about reproductive health in the family, community
and health provider. To alleviate such factors, focus antenatal Care is the most important method
for detecting pregnancy problems in the early period since it is the best mechanism to minimize
maternal mortality and give good information to pregnant women about their health and how to
prevent related problems.
The best and most advantage of Focus antenatal Care is to protect the health of women and their
infants as well as indicating the danger that will occurred and needs to be further treated by
advanced health professionals. A number of studies indicate that the FANC utilization rate is still
low due to many factors that need to be examined such as socio demographic factors, knowledge
of social support etc. They conclude that eliminating such factors is important to increase the
women's participation in Focus antenatal Care especially in Kitagata Hospital where the statistics
are still unknown.
Global over view
Globally, an estimated 211 million pregnancies and 136 million births occur every year
While they are natural and usual processes, pregnancy and childbirth put every woman at risk of
complications. Most maternal, fetal and neonatal deaths occur during late pregnancy and the first
month of the child's life. (Aniebue & Aniebue, 2011)
2
Sub-Saharan Africa
Maternal mmiality is the highest by far in sub-Saharan Africa, where the lifetime risk of death
from pregnancy-related conditions is 1 in 16, compared with 1 in 2800 in rich countries (Bates et
al., 2008).
In the sub-Saharan still 72% of pregnant women received FANC visits one or more times and
68% in east Asia, less than one third of pregnant mothers received care in Pakistan, only 64% in
Nigeria received antenatal care from a qualified health care provider. 3 7% of the deliveries take
place in health institutions while 57% take place from home (Eaton et al., 2014).
In Ethiopia, the levels of maternal and infant mortality and morbidity are among the highest in
the world. There are 673 maternal deaths for every 100,000 live births and the infant mortality
rate was 77 per 1,000 live births (Abdella, 201 0).
In developing countries like Uganda and Tanzania, most mothers attend once and Nagoya
(., 2014).elaborates that there is more FANC utilization in towns than villages.
Focus Antenatal care services in Uganda
In Uganda as a developing country, where medical resources are limited giving bi1ih at home is
the rule for both economic and cultural reasons, only screening ,and referring to hospitals
mothers at risk of complicated labor is seen as acceptable (Duja& Din et-a!., 201 0).
In Uganda, the country was expected to reduce its maternal mortality ratio to 131 per 100,000
births in 2015 in line with the Millennium Development Goals (MDGs) (United Nations
.,2005).However, according to a recent repmi, maternal mortality has increased to 438 per
100,000 births. Moreover, the expectation that all bi1ihs would be attended by skilled health
personnel by 2015 has similarly been elusive as only 59% of the birth was attended by skilled
personnel (Uganda Bureau of Statistics., 2011 ). Existing studies show that Jack of awareness
about FANC, inaccessibility of health services, Jack of time due to women's work load, long
waiting time, poor quality of FANC services and husband disapproval are among the major
factors contributing to the low use ofF ANC (Mekonnen., 2008).
Due to the HIV I AIDs epidemic and the common belief that most adolescents are either too
young or are expected to be in schools, F ANC utilization amongst this group, has been accorded
less attention contributing to relatively high maternal mortality rates 33% (MoH., 2008).
3
1.2. Statement of the Problem
Globally, over 0.5Million maternal deaths that occur are in developing countries (Alarm
International., 2008) and a great proportion of these maternal deaths occur in pregnant women
during delivery, thus leading to increased mortalities. In Low and Medium income countries
(LMICs) focus antenatal care (FANC) services are so low, below the recommended threshold
(Hosseinpoor et al., 2011). This shows that underlying factors which influence community usage
of FANC need to be investigated to mitigate this challenge at hand. This is because majority of
deaths in LMICs are due to poor antenatal care(Williams, 2011 )and could be avoided entirely,
thus showing that communities need to appreciate the benefits of FANC services in these
communities.
In Uganda, high maternal and neonatal m01ialities have been reported (Brockerhoff & Hewett,
2000) and these have been attributed to the severe variations in F ANC coverage in rural
communities. This is because pregnant women in rural communities face more challenges
regarding FANC service attendance than urban women. This would have been due to lack of
clear knowledge on the benefits associated with F ANCs and social demographic variations in the
communities (Pmiridge et al., 2012), thus leading to the persistence of the problem.
1.3 BROAD OBJECTIVE
To determine the demographic factors, knowledge and alternative option affecting utilization of
F ANC services among pregnant mothers attending antenatal care in Kitagata hospital -Sheema
District.
1.4 SPECIFIC OBJECTIVES
To determine socio-economical and demographic characteristics of pregnant mothers attending
FANC in kitagata hospital -Sheema District.
To assess the knowledge of pregnant mothers on the benefits of FANC services in Kitagata
Hospital -Sheema District.
To identify any available alternatives to F ANC services among pregnant mothers in Kitagata
Hospital -Sheema District.
4
1.5 RESEARCH QUESTIONS
}- What are socio-demographic characteristics of pregnant mothers attending F ANC
services in Kitagata Hospital -Sheema District.?
}- What is the knowledge of the pregnant mothers on the benefits of utilization ofF ANC
services among expectant mothers Kitagata-Sheema District?
}- What are other alternatives to FANC services among pregnant mothers m Kitagata
Hospital -Sheema District.?
1.6 STUDY JUSTIFICATION:
Uganda is one of the countries with a high fe1iility rate and poor FANC services utilization.
Therefore a high maternal mortality rates hence a problem to women of the childbearing age
(Kiwanuka et al., 2008). At present there is no recent research done at sub-county level as rural
women are less likely to get FANC services than women in urban areas, so this motivated the
researcher to carry out the study and give more light into this problem. The findings of this study
will serve as a reference for giving intervention accordingly by the health care providers and
other concerned bodies for conducting further researches; the findings of this study will have
special importance for health care providers because it will serve as base line for filling gaps of
the actual practices on focused antenatal care. The findings with relevant recommendations will
be also submitted to the policy makers among other relevant organizations in the country
1.7 SCOPE OF STUDY
This study was carried out in Kitagata Hospital -Sheema District from the period between May
to October, 2016.
Only consented pregnant mothers attending FANC at Kitagata hospital were included in this
study.
5
1.8 CONCEPTUAL FRAME WORK:
Socio-economic and demographic
characteristics of pregnant mothers:
-Age
-Education level
-Occupation
-Marital status
-Distance/cost.
LOW UTILIZATION
SERVICES.
Lack of knowledge on benefits of FANC
services.
E.g.-TTV /immunization
-Folic acid
-Fansidar
-anti D
OF FANC
Pregnant mothers' alternatives to FANC services:
-Herbal medication
-Traditional birth attendants
-Traditional healers
(Estella Bojo Elia.,20 16).
6
1.9 DESCRIPTION FOR THE CONCEPTUAL FRAMEWORK
From the above diagram, it shows the interactions between the independent and dependent
variables and how their interplay brings about both negative and positive effects.
Both FANCs and routine ANC utilization can be influenced by economic, demographic and
socio-cultural factors. Maternal age in this case can influence both negatively and positively the
utilization of FANC services. Teenage mothers who are expectant tend to be statistically less
likely to use FANC services although on the other hand they are more likely to start utilizing
FANC services earlier than their older counter parts if there is a system of support system.
Other than age, maternal education will also influence utilization ofFANCs. Those women with
higher education are more likely to utilize FANC than those with lower education ofFANC.
Other demographic factors such as marital status, occupation, religion, family Size and ethnicity
also will have significant influence on the utilization of F ANC services. Male partner
involvement in the FANCs can have positive effect on FANCs utilization since they encourage
and support their pminers on attending the services and vice versa. Working class expectants
mothers tend to attend less F ANC services compare to their counterpart at home or those women
with no job. This could be due to busy schedules at work etc.
Religion can have both positive and negative influence on FANCs since Some religion permit
the utilization ofF ANCs while other religion prohibits the utilization ofF ANCs. Family size in
this case can influence the F ANC services, the smaller the family size the more they tend to
attend F ANCs compared to the expanded family. Hence that the more the family is planning the
more time they spend on FANC services. Some culture and ethnic group allowed FANCs while
others have different belief to FANCs services and so these can either increase or decrease the
utilization of FANC services. In addition cost of transport and distance to health facility were
found to affect utilization ofF ANCs. High cost and increase distance were associated with less
visits compare to the nearer distance.
Lack of knowledge on the benefit of FANC services affects the level ofF ANC utilization by the
pregnant mothers since it was associated with less number of visit for F ANCs while knowlegible
mothers tend to emphasize on FANCs utilization.
7
Presence of any available alternatives to FANC services such as herbal medications, Traditional
birth attendants will influence pregnant mother's decisions in utilization of FANC services and
vice versa given their accessibility to members of the community.
All in all, for the pregnant mothers to fully utilize the FANC services, they should have
knowledge on the benefits ofFANC services, good educational background, affordability of the
F ANC services and it being accessible to them among other relevant variables.
8
CHAPTER TWO:
LITERATURE REVIEW
2.1 General overview on FANC
Aim and objectives of FANCs the main aim of FANC is to achieve a good outcome for the
mother and the baby, and prevent any complications that may occur in pregnancy, labor, delivery
and Postpartum. This could be achieved through the following objectives;
2.2 Early detection and treatment of complication:
It mainly focuses on assessment and examination of a pregnant woman for chronic conditions
and infectious diseases. Conditions that may threaten the life of the mother and baby when not
treated are; HIV/AIDS, Syphilis, other sexually transmitted diseases, malnutrition, tuberculosis
and malaria. Fmihermore, conditions such as severe anemia (Hb<7g/dl), vaginal bleeding,
eclampsia, fetal distress, fetal mal-presentation after 36 weeks, and chronic conditions such as
kidney failme, diabetes and heart problems should also be taken into consideration if we are to
save the life of the mother and unborn (Crenshaw, 2014).
2.3 Prevention of complications:
F ANC entails that a health service provider should ensure prevention of complications by
providing TTV /Tdap to prevent maternal and neonatal tetanus, and iron and folic acid to prevent
anemia. Moreover, the provider should ensure use of intermittent preventive treatment and
insecticide treated nets to prevent malaria, and enviromnental hygiene to prevent dianhea and
intestinal worms (Baffour-Awuah et al., 2015) .
2.4 Birth preparedness and complication readiness:
IT provides a woman with a plan about place of delivery, transportation, companionship, and
blood donor, items for clean and safe delivery. In addition the woman is imparted with
knowledge about danger signs, and actions to take if they arise. Data indicates that 15% of
women develop pregnancy related complications, and that these women could die if nobody was
there to make timely decision at home and health facility, and also if no plans for transportation
and finances are made (Bintabara et al., 20 15).
9
2.5 Health promotion and counseling:
Encourage dialogue between the woman and service provider. Issues affecting a woman's health
and that of the newborn are discussed at length. It includes dietary and nutrition education, for
example how to get essential nutrients. Fmthermore, the woman is given infmmation about risk
of smoking, use of herbs, rest, hygiene, safer sex, and medication. Information regarding family
plarming, exclusive breast feeding as well as immunization and care of the newborn is included
in counseling (Tumer eta!., 2014).
10
2.6 Focused antenatal care (FANC) model outlined in WHO clinical Guidelines:
FIRST VISIT SECOND VISIT THIRD VISIT Fourth Visit
(8-16 WEEKS) (24-28 weeks) (32 weeks) (36-38 weeks)
Confirm pregnancy Assess matemal and Assess matemal and
fetal well-being. Fetal well-being.
Exclude pregnancy Exclude pregnancy
induced induced hypertension,
hypertension anemia and multiple
and anemia. Pregnancies.
Give preventive Give preventive
measures such iron measures such as iron
Supplements. and second TTV
Review and modify Administration.
birth Review and modify
and emergency
plan.
birth and emergency
Plan. Continue
and expected date of
delivery, classify
women for basic FANC
(four visits) or more
Specialized care.
Screen, treat and give
preventive measures
such as Iron and Folate
supplements, tetanus
Toxoid vaccine (TTV)
and sufadoxine
Pyrimethamine.
Develop a birth and Continue advising advising and
emergency plan.
Advice and counsel on
reproductive health,
breastfeeding, tobacco
and alcohol use
Source :(WHO., 2013.)
and counseling
Counseling.
11
Assess matemal and
Fetal well-being.
Exclude pregnancy
induced hypetiension,
anemia, multiple
pregnancy and
malpresentation
Give preventive
measures such as iron
Supplements.
Review and modify
birth and emergency
Plan.
Repeat advice given
From previous visits.
2.7. SOCIO-ECONOMIC AND DEMOGRAPHIC CHARACTERISTICS OF
PREGNANT MOTHERS
Both F ANC and ANC utilization can be influenced by demographic, economical and socio
cultural factors. Maternal age has been shown to both negatively and positively influence
utilization of F ANC and ANC in general. A study conducted in Turkey demonstrated that
teenage mothers were statistically less likely to use F ANC services. However, in other studies
teenage mothers were more likely to start utilizing F ANC services earlier than their older counter
parts (Ahmed et al., 201 0) .
Other than age, maternal education has also been shown to influence utilization of FANC
services.(Matsumura and Gubhaju.,2001). In a study conducted in Nepal demonstrated that
women with higher education were more likely to utilize F ANC services than those with lower
education.( Pallikadavath et al.,2004) found similar results, in their study they had demonstrated
that both maternal and paternal education positively influence utilization ofF ANC services.
Other demographic factors such as marital status, occupation, religion, family size and ethnicity
also statistically significantly influence utilization ofF ANC services. Studies on social factors
influencing utilization of F ANC services demonstrates that, desirability of pregnancy, is a
statistically significant determinant ofF ANC use. Pregnant women with unplanned pregnancies
were found to make less FANC visits (Magadi et al., 2000, 2013) (Eric., 2003, Parades et al.,
2005). Place of residence has also been shown to influence FANC utilization, women in urban
areas were more likely to use F ANC services more than rural women in Ecuador (Paredes et al.,
2005) and Nepal (Sharma., 2004). On the other hand, a study by (Navaneetham and
Dharmalingam.,2002) in India found that women in urban areas of Karnataka were less likely to
receive FANC than those living in rural areas. Distance to the health facility is directly
associated with FANC utilization (Glei et a/.,2003). A study conducted by (Magadi et al.,2000)
in Kenya demonstrated that an increase in distance to the nearest healthcare facilities was
associated with fewer antenatal visits. Moreover, uncomfortable transport, poor road conditions
and difficulties in crossing big rivers have also been shown to be barriers to utilization ofF ANC
services, in studies conducted in Zimbabwe (Mathole et al., 2004) and in Pakistan (Mumtaz and
Salway., 2005).
12
2.8. Knowledge of pregnant mothers on benefits of FANC Services
Benefits of focus antenatal care contributes to good pregnancy outcomes and often time's
benefits of focus antenatal care are dependent on the timing and quality of the care provided
(Rasmussen et al., 2012). It has been shown that regular focused antenatal care is necessary to
establish confidence between the woman and her health care provider, to individualize health
promotion messages, and to identify and manage any maternal complications or risk factors
(Hollander., 1997).
During focus antenatal care visits, essential services such as tetanus toxoid immunization, iron
and folic acid tablets, and nutrition education are also provided (Brockerhoff & Hewett, 2000).
Lack of focused antenatal care has been identified as one of the risk factors for maternal
mortality and other adverse pregnancy outcomes in developing countries(Gross et al., 2011).
Moreover, many studies have demonstrated the association between lack of focused antenatal
care and perinatal mortality, low birth weight, premature delivery, pre-eclampsia, and anaemia
(Were & Karanja, 1994).In a study conducted in Mexico by Coria-Soto et al., 1996, inadequate
number of visits was associated with 63 percent higher risk of intra uterine growth retardation.
Similar results were reported in a Bangladeshi study where birth weight was positively correlated
with the frequency of visits at antenatal clinics (Ahmed and Das., 1992).
All these results, point to the important role of focused antenatal care m identifying and
mitigating the potential complications during pregnancy. Moreover, a study conducted in Canada
by Heaman et al., 2008. on inadequate prenatal care and association with adverse pregnancy
outcome indicated that preterm bitih, low birth weight, small-for age gestational and increased
mmiality rate were associated with inadequate prenatal care. Raatikainenetal., 2007. Showed
similar findings in a study conducted in Finland, where an increase in low birth weight infants,
more fetal deaths, and more neonatal deaths were common among those under attending F ANC
services.
13
2.9. Alternatives to FANC undertaken in early phases of pregnancy.
The study set out to establish whether there were alternatives used by pregnant women in the
area of study. According to the respondents 'responses, many pregnant women reported that
indeed there were alternatives being undertaken by mothers and pregnant women in Nyakabande
and Chahi sub-counties. F ANC providers were asked to give their views about alternatives
mothers try out in the early phases of pregnancy; their responses showed that mothers were
trying out other alternatives before accessing focused antenatal care (Roy et al., 20 13).
The study findings show that many mothers and pregnant women in the area of study use a
number of alternatives during pregnancy. Respondents indicated use of TBAs and the use of
herbs. The table indicates, some of the respondents were trying out FANC alternatives in the
early phases of pregnancy (Centenary Gloria., 20 I 0).
Table below shows the respondents 'responses on the FANC alternatives.
Alternatives Frequencies
Herbs 14
TBAs 32
Traditional healers 10
14
2.10. Traditional Birth Attendants:
The study established that TBAs are widely used by pregnant women and mothers in the study
area. The study revealed that TBAs are appreciated in the community as they adhere to the norm
of deliveries, always being an emergency in the community and that they act quickly and are
always available. The respondents mentioned visiting TBAs because they are nearer/closer to the
mothers than FANC facility. The commonly cited reason for use of TBA 's was the difficulty in
transpmt that left mothers with no alternative but to use TBAs. The respondents added that
TBA's were more accessible, and flexible enough to cany out a delivery in one's home than
health units (Montagu et al., 2011).
2.11. Use of herbs:
The use of herbs is a common phenomenon among traditional African women. The study
findings indicated use of local herbs ( strawbeny leaves) by most women in the area of study as
an alternative to seeking F ANC from health facilities. It was reported that, the majority of
women and mothers take traditional medicine during pregnancy, labor, or delivery. These were
taken orally and bath tonics (Centenary Gloria., 2010). Other reasons as cited for their use of
herbs included stimulating/intensifying contractions; quicken healing and readjusting the baby's
breech position. There was a general feeling in the focus group discussions that women should
use local herbs to help with minor problems during early pregnancy. However, it was observed
that this prevents them from attending antenatal care during that period. To emphasize the
reasons why women use herbs, another respondent stressed these herbs treat syphilis which is
greatly feared by all communities because it is known that it affects both the mother and the
baby. They felt that none of the drugs given to them in the health facility give them strength.
Such feeling has greatly influenced F ANC attendance (Mbonye et al., 201 0).
2.12. Traditional healers:
The respondents stated that, the use of traditional healers is imbedded in the beliefs of many
women in Kisoro and Nyakabande in particular (Ssali et al., 2005). In an FGD session for men it
was revealed that some mothers use traditional healers especially if the mother had a miscaniage
in the previous pregnancy. To demonstrate the high use of traditional healers in the area of study,
one district official stated that, in search for traditional healers, many women go as far as DRC
(Katuura et al., 2007). . While explaining the use of traditional healers by some women, a
15
pregnant woman at Kisoro hospital stated; some women visit traditional healers because of
having failed to conceive after a long period of time or having a child with frequent sickness and
sometimes having pregnancy related complications that trained health providers cannot address.
The above demonstrates a high level of ignorance among many women in the rural Nyakabande
and Chahi. However, this demonstrates the laxity of the health sector in Uganda for the level
sensitization to the local communities as regards the benefits of seeking FANC in health units is
still low.
16
METHOD AND MATERIAL
3.1 Study design:
CHAPTER THREE
This was a facility based cross-sectional descriptive study design with quantitative and
qualitative data collection techniques were used to collect the data from pregnant mothers.
3.2 Study Area:
The area for this study was Kitagata Hospital where F ANC services are offered.
The kitagata general hospital also known as kitagata hospital is in western region of Uganda. The
hospital is located in Kitagata Sub County, sheema district south western, western Uganda about
62 km (39miles) southwest ofMbarara town.
The kitagata hospital was established in 1969 by the first government of Prime Minister H.E.
Milton obote. It has a bed capacity of 120, and like many government hospitals build at the same
time, the hospital infrastructure is in a dilapidated state with antiquated equipment.
3.3 Study Population:
The study populations were all pregnant mothers attending F ANC as per the time of data
collection in Kitagata Hospital.
3.4 Inclusion Criteria:
All consented pregnant mothers attending FANC at Kitagata Hospital
3.5 Exclusion Criteria:
Very sick pregnant mothers and those who did not consent to study.
3.6 Sample size calculation
Sample size was determined using Fisher et al., (1998) method for calculation of the constant
(n);
Where: n-Desired sample size
17
Z- Standard normal deviation usually set at 1.96 which corresponds to the 95% interval p
Proportion of the target population, estimate of 0.5 is used.
Q=l-p (1-0.5
d= Degree of accuracy desired set at 0.05 level
Therefore:
I.e. =Z]m
= (1.96l x 0.5 x0.5 n=384.16i.e. 384
0.05 x0.05
The desired sample size was 3 84 but due to inadequate resources and time allocation, 26% of the
desired sample size was used
i.e. 26/100 x 384 =99.84 which is approximately to 100 intended sample size to be used in the
study.
3.7Sampling technique:
The researcher was using the systematic random sampling procedure in which every 3'd woman
in line for antenatal care was interviewed until the required number was achieved.
3.8 Data collection tool:
Semi structured questionnaire with mainly quantitative and qualitative questions was developed,
pretested and used to collect information on relevant variables such as;
• Socio-economic and demographic characteristics
• Information on perceived benefits concerning F ANC services
• Alternatives to F ANC services among other vital variables.
3.9. Study Variables:
3.9.1 Dependant Variables:
Low utilization ofFANC services was dependant variable for the study.
18
3.9.2 Independent Variables:
These were Characteristics that might lead to low utilization ofF ANC services such as;
• Socio-demographic characteristics
• Knowledge on the Benefits ofFANC services offered
• FANC practices of the mothers
• Presence of other alternatives to F ANC services like herbal medications, Traditional birth
attendance or traditional healers
3.10. Data Analysis:
Data analysis and processing was done by using Chi-square test in SPSS software version 20 to
test for significant association between variables. Level of significance P < 0. 05
The collected data was reviewed for completeness, accuracy, clarity, and consistency by the
researcher and Codes were assigned to the completed questionnaires.
3.11. Quality control:
Structured questionnaires were pre-tested away from the actual study area before the exact
period of data collection. The necessary corrections and adjustments were made accordingly.
3.12. Ethical considerations:
Ethical clearance was obtained from Kampala International University Research Ethics
Committee (IREC).The letter of entry to study area was written by the Dean School of Pharmacy
to introduce the researcher for the study to be conducted. The participants in this study were
voluntarily recruited through their informed consent and the codes were used instead of names.
The collected data was kept under key and lock for confidential purposes.
3.13. STUDY LIMITATIONS:
Language barrier was anticipated for the researcher and for this reason, a translator was provided
as delimitation in this study.
19
CHAPTER FOUR
RESULTS
Objective I
31.2% of participants were in the aged 20-24yrs and most of these had attained secondary level
of education. These were followed by the 25-29 age group at 29.9% and of these 13% had also
attained a secondary level of education. 44.2% of the patticipants were Catholics and most of
them had attained secondary level of education .these were followed by protestants (36.4%) and t
84.40 of the participants attending FANC services at Kitagata hospital were the Muuyankole
tribe. and The highest population were business people (31.2%) followed by teachers (24.7%) as
shown in Table I.
Table 1 Social demographic factors in population
Parameter Variable Freguency (%) ifEarticiEants P- value Primary Secondary Tertiary None Total
15-19 3(3.9) 5(6,5) 2(2.6) 0(0.0) 11(14.3) 20-24 8(10.4) 11(14.3) 4(5.2) 0(0.0) 24(31.2)
Age (yrs) 25-29 7(9 .1) 1 0(13.0) 4(5.2) 2(2.6) 23(29.9) 0.723 30-40 4(5.2) 3 (3.9) 4(5.2) 0(0.0) 13(16.9) >41 1(1.3) 2(2.6) 2(2.6) 0(0.0) 5(7.8)
Catholic 11(14.3) 13(16.9) 6(7.8) 1 (1.3) 34(44.2) Muslim 3(3.9) 2(2.6) 3(3.9) 0(0.0) 8(10.4)
Religion Protestant 7(9.1) 13(16.9) 5(6.5) 1(1.3) 28(36.4) 0.985 Adventist 2(2.6) 2(2.6) 2(2.6) 0(0.0) 6(7.8) Others 0(0.0) 1(1.3) (0.0) 0(0.0) 1(1.3)
Munyankole 21(27.3) 26(33 .8) 13(16.9) 1(1.3) 65(84.40 Tribe Muganda 2(2.6) 2(2.6) 3(3.9) 0(0.0) 0(0.0) 0.105
Others 0(0.0) 3(3.9) 0(0.0) 1(1.3) 4(6.50
Teacher 3(3.9) 5(6.5) 11(14.3) 0(0,0) 19 (24.7) Business 5(6.5) 16(20.8) 2(2.6) 1(1.3) 24(31.2) Health 1 (1.3) 1 (1.3) 2(2.6) 0(0.0) 4(5.2) 0.000
Occupation Worker Student 1(1.3) 3(3.9) 1(1.3) 0(0.0) 6(7.8) Others 13(16.9) 6(7.8) 0(0.0) 5(6.5) 24(31.2)
20
The most common means of transport used by most participants was bodaboda and these
pmticipants travelled a distance of 2-5km as shown in Table 2.
Table 2 Factors affecting attendance at Health center with distance.
Vm·iable Frequency(%) of participants living away from health center
2km 2-5km 5km Means of walking 12(15.6) 7(9.1) 0(0.0) transport Taxi 1(1.3) 1(1.3) 3(3.9)
Bodaboda 9(11.7) 15(19.5) 14(18.2) Others 0(0.0) 0(0.0) 0(0.0)
Cost <1000 17(22.4) 12(15.8) 4(5.3) >1000 4(5.30 11(14.5) 13(17.1)
Source of Myself 17(22.1) 16(20.8) 7(9.1) influence Husband 5(6.5) 6(7.8) 10(13.0)
Others 0(0.0) 1(1.3) 0(0.0)
::!km J-5km 5km 5-1 Okm > 1 Olan
Distance from Hospital
En·or Bars: 95% CI
21
5- 10km 1(1.3) 6(7.8) 7(9.1) 1(1.3)
2(2.6) 13(17.1)
9(11.7) 5(6.50 1(1.3)
Cost of u·ansport
0< 1000 ~>1000
Total 20(26.0) 11(14.3) 45(58.4) 1(1.30
35(46.1) 41(53.9)
49(63.6) 26(33.8) 2(2.6)
P- value
0.000
0.000
0.188
Objective II
The FANC services offered at Kitagata hospital were immunization e.g. tetanus toxoid,
screening for HIV, STis, prevention of malaria and anemia, health education on hygiene and
sanitation and counseling on nutrition. 40.0% of the participants who were using F ANC services
at Kitagata hospital turned up screening and testing services and 38.6% of the participants
received immunization and health education. Only 12.9% of those participants tum up for all
F ANC services at Kitagata hospita1.28.8% of the participants received screening and testing at
second trimester and 25.5%took immunization for TTV at second trimester and 17.3% of the
participants received at third trimester. 39.4% of the participants used vaccination TTV and
knows it for preventing tetanus and majority who used TTV thought for prevention of malaria
(3.3%). 43.7% of the participants received fansidar during pregnancy and 44.9% of the
participants had knowledge on the benefit and purposed of fansidar. 44.9 % of the pmiicipants
did not received iron and folic acid supplements 43.7% of respondents who had experienced side
effects. 31.4% had nausea and vomiting and as major side effect and 21.4% had dizziness. 43.7%
of the participants repmied hunger and long time waiting as challenges .50.1% of the participants
who had perceived benefit of FANC services and 50.1% lack perceived benefits on FANC
services.
Parmneter Variable
Received Yes TTV No
When last Second received TTV
TTVFor
Fansidar for Malaria
trimester Third trimester Tetanus malm·ia Yes
No
Iron and Yes folic acid No
Frequency (% ) of participants who responsed to F ANC P - value services
28(40.0) 2(2.9)
15(28.8)
5(9.6)
26(39.4) 2(3.0) 31(43.7)
0(0.0)
0(0) 31(44.9
Medications All of Total and health above
27(38.6) 0(0.0)
13(25.0)
9(17.3)
26(39.4) 0(0.0) 26(36.6)
1(1.4)
education
3(4.3) 0(0)
2(3.8%)
0(0.0%)
3(4.5) 0(0.0) 3(4.2)
0(0.0)
2(2.9) 0(0) 24(34.8%) 3(4.3%)
22
9(12.9) 1(1.4)
6(11.5)
2(3.8)
3(13.6) 0(0.0) 9(12.7)
1(1.4)
0(0.0%) 9(13)
67(95.7) 3(4.3)
36(69.2)
16(30.8)
64(97.0) 2(3.0) 69(97.2)
2(2.8)
0.466
0.495
0.424
0.400
2(2.9) 0.333 67(97.1)
%) Which First 30(42.3) 27(38.0) 3(4.2) 10(14.1) 70(98.6) 0.727 trimester Second I (1.4) 0(0.0) 0(0) 0(0) I (1.4)
Side Nausea/vomi 22(31.4) 12(17.1) 2(2.9%) 8(11.4) 44(62.9) 0.085 effects ting
dizziness 8(11.4) 15(21.4) 1(1.4%) 2(2.9%) 26(37.1)
Challenge Hunger while Waiting in line 27(38.8) 8(11.3) 69(97.2) 0.006 s towards Lack of transport 0(0) 2(2.8) 2(2.8) FANC
Majority of the participant had attended screening service ,this was followed by immunization
and counselling however few of the participants had taken medications/supplements during their
visits to ACs.
23
F ANC service offered
0 Screening services ~ I.mmuni.zati on an cl
Cotmselling []Medications ~All services
About 40% of the respondents had not taken iron and folic acids however the few who had taken
such medication reported side effects such as nausea, vomiting and dizziness.
,_ 60
,_ 50
j = 40 0
,_
"" "' ~ 'a ~ 30
,_
" 1 ~ ::w ,_
,_ 10
0
-~
_L -~
_L
T I
Nausea and Vomiting Dizziness
Sicle Effects Reported
En·or Bars: 95% CI
24
T
h·on and folic acid
h1take Ono ~yes
Objective III
27.1% of the participants reported seeking alternative services to F ANC from TBA followed by
13.6% herbalist and 18.6% from traditional healer. On assessing the difference between FANC
services offered at hospital and those at traditional facilities, 52.2% of the respondents reported
that the F ANC services are better in terms of free services. Most or over half of the respondents
reported used of herbal medication from herbalists (57.1 %) and 3.6% from their neighbor before
seeking FANC services at Kitagata hospital. 14.4% of the participants mentioned that those
herbs were used to relieved abdominal pain. 13.8% reported to induced labor and 6.9% also
reported that those herbs were used to treat infection such as STis). Among the herbs which were
used 40.7% of the participants were using ekyoganyanja and herbs were mainly use orally.
Variable
Source
services
of Herbalists
TBA
Traditional
healers
Frequency (%) of response of participants to
seeking of alternatives before FANC
Yes No Total
8(13.6%) 6(10.2%) 14(23.7%)
16(27.1%) 11(18.6%) 27(45.8%)
11(18.6%) 7(11.9%) 18(30.5%)
FANC Better services 6(9. 0%) 5(7.5%) 11(16.4%)
services -vs- in F ANC
Alternative Free services 35(52.2%) 21(31.3%) 56(38.6%)
sources
Used herbs herbalist 16(57.1 %) 5(17.9%) 21(74.0%)
from neighbor 2(3.6%) 4(14.3%) 6(21.4%)
other 1(3.6%) 0(0.0%) 1(3.6%)
Purposes of Relieved 12(14.4%) 8(27.6%) 20(69.0%)
those herbal abdominal
medicines pam
25
P- value
0.975
0.110
Names of the
herbal
medications
used.
Induce labor 4(13.8)
Treat
infections e.g 2(6.9)
STis/STDs
ekyoganyanja 11(40.7%)
ekitutu 0(0.0%)
entahonda 1(3.7%)
sununu 2(7.4%)
omubarama 1(3.7%)
omuteete 3(11.1 %)
Mode of orally 17(58.6%)
usage Smear on the
belly 1(3.4%)
2(6.9) 6(20.7%) 0.943
1(3.4) 3(10.3%)
2(7.4%) 13(48.1%)
1(3.7%) 1(3.7%) 0.179
2(7.4%) 3(11.1%)
3(11.1 %) 5(18.5%)
0(0.0%) 1(3.7%)
1(3.7%) 4(14.8%)
11(37.9%) 28(96.6%) 0.621
0(0.0%) 1(3.4%)
26
CHAPTER FIVE
DISCUSSION
Objective I
The study showed that majority of pregnant women are in the age of 20-29yrs and highest level
of education is secondary where most of them were business people and teacher who are
utilizing the FANCs. Majority of the participants in this study were motivated to come for check
up since they were educated and were able to read and know their gestation age. This is
important compared to a previous study which had demonstrated a prevalence of 72.7% in case
where pregnant women didn't know their right gestation age, thus demonstrating the relevance of
attending antenatal clinics (Kisuule et a!., 20 13). In contrast to this study, majority of
participants travelled from 2-5km and often relied on motorcycle as a means of transport. This is
important since transportation has been highlighted as a major obstacle to seek focus antenatal
care services in communities of Uganda amongst pregnant women (Sacks et a!., 2016). In
addition, a previous study from central Uganda has also shown that improved attendance at
antenatal Clinics is impmiant for improved maternal and neonatal health, however transportation
to facilitate pregnant mothers to seek professional assistance have been reported to be a
challenge(Tann et a!., 2007). Bearing in mind that Central Uganda has a relatively stable
community per capita, it's possible that the financial burden on pregnant women in rural
communities, especially in neglected parts of the country face greater challenges as demonstrated
in this study.
In Ethiopia, challenges on transportation of pregnant mothers have been addressed through
improved policy (Berhanu, 2006), which has seen the establishment of motorized ambulances,
increased research in the population to understand changing trends in the communities, and
partnerships from the ministries for improved training and cooperation through local and
international organizations. This seems feasible since in Eastern Uganda, motorized and non
motorized ambulances transportation systems have been tried since majority of pregnant mothers
can not afford to pay for the transportation services using commercial means (M. eta!., 2010),
thus showing the need to work closely with communities this mitigate the challenge. Since the
transportation system in Uganda is poor, it's essential that medical officers and service providers
27
attending to pregnant mothers work closely through increased private-public partnerships, which
would lead to increased transportation incentives and discounts to assist pregnant mothers in
rural communities (Benmaamar et al., 2002).
Objective II
The Focus Antenatal Care (F ANC) services offered at Kitagata hospital were immunization such
as tetanus toxoid, screening for HIV, STis, prevention of malaria and anemia, health education
on hygiene and sanitation and counseling on nutrition. The study showed that majority of the
participant turned up for screening and testing services and received immunization and health
education during this period. This is important since focus antenatal care has been shown to have
the potential to reduce maternal morbidity and improve on survival in newborns (Gross et al.,
2011). In addition, participants in this study seem to have a positive attitude towards FANCs thus
showing a contrast from findings in West Africa where paiiicipants were not motivated toward
FANC services (Aniebue& Aniebue, 2011). These differences would have been due to the high
level of education in this community (Table 1 ), thus making it easier to forward FANCs in this
aJ'ea (Babalola, 2014). The study further showed that immunization to tetanus was common
amongst the participants in the second and third trimester of their pregnancies. Though in second
trimester; the majority were given tetanus vaccines with the goal to protects those mother who
may be at risk of preterm delivery or those who may not reach 40weeks of gestation. This
observation is important since immunizations against tetanus have been shown to increase
survival hood in neonates and mothers (Blencowe et al., 2010), thus showing that the community
in this area is appreciative of the health benefits attached to FANCs.
Fansidar was commonly used for the control of malaJ·ia amongst the participants and this
confirmed that the population had a clear knowledge on the importance of visiting the health
facility for intermittent prevention of malaria. Consequences of malaria in pregnancy include:
low birth weights, severe maternal anemia. In Uganda, malaria has been recognized as a major
public health concern in pregnant women and children (Mbonye et a!., 20 13), thus observations
from this study show that F ANCs play a crucial role in the control of this public health
challenge.
However, majority of participants didn't take iron and folic acid supplements and those who took
them reported unpleasant side effects such as nausea, vomiting, and dizziness in this community.
28
This would be a major setback since endemic levels of malaria have been reported in central
Uganda (Obai et al., 2016). The possibility of these side effects may also result from the possible
interaction of those herbs with the iron/folic acid supplements causing non compliance on the use
of the drugs. The importance of folic and iron cannot be over emphasized. They are essential in
management of anemia, its stabilizes maternal and neonatal health, neuronal development of
fetus, eye and immune system development. Thus these result given by the participants for lack
of compliance to routine antenatal dmgs reveal a high rate of ignorant among the participant thus
showing the need to increase on the level of awareness and the level of education on the routine
use of iron and folic acid uptake in the community (Mbule et al., 20 13).
Objective III
The study showed also showed that TBA are major sources of alternatives to FANCs in the
community. TBAs are highly prevalent in Uganda and their role in antenatal management has
been recognized (Kabakyenga et al., 2012). The study also showed that majority of the
community appreciates the F ANCs simply because they are free thus showing that the
community often seeks for the TBAs whenever the F ANCs are not available. this show the
participants patronage of TBA is strongly embedded in their belief. In Uganda, over I 04 herbal
plants have been identified in Southern Uganda, thus showing their relevance to the communities
(Hamill et al., 2000), though there is limited information on their therapeutically effects (Tabuti
et al., 2003). In the study, the herbal therapies were associated with relieving of pain, induction
of labor and others have been used for control of STis. In Bushenyi district of South Western
Uganda, 7 5 plants have been reported to have oxytocic effect thus showing the role of herbal
plants in this community (Kamatenesi-Mugisha & Oryem-Origa, 2007). The study in west and
have registered plants believed to have oxytoxic effect and control of abdominal pain. This
shows that the plants used by TBAs and the communities would mimic therapeutically agents,
however safety on dosage and administration still need to be investigated. In Eastern Uganda,
herbal therapies have been reported to help in the control of abdominal ailments thus showing
the need to assess their toxicological effects for safe usage in the communities (Tabuti et al.,
2012).
Most prevalent herb was bothrioclinelongipes (local name = ekyoganyanja) which is often taken
orally. This plant has been reported to have a strong anti-plasmodium activity and it appears to
be effective in the treatment of malaria as often used by the communities ( Katuura et al.,
29
2007)apmt from to that it has also been reported to have secondary usages in the treatment of
skin infections, diarrhea, syphilis, appetite and these would be due to the photochemical and
physiochemical composition of the plant (Jakupovic et al., 1987).However there is limited
information on the likely adverse effect these herbs might have on the health of the fetus.
30
CHAPTER SIX
6.0 CONCLUSION AND RECOMMENDATION
F ANC seeking services by the community is influenced by education level, distance and
economic status since majority of the respondents were seeking free antenatal services from
government health facility and a few from private clinics and other from traditional healers.
However age and marital status have no effect on where one seeks antenatal care services from.
Among the services majority of the participants turned up for screening and testing services and
received immunization and health education during this period. This is important since antenatal
care has been shown to have the potential to reduce maternal morbidity and improve on survival
in newborns ,most participants were not using irons and folic acids offered to them since many
are discourage by the side effects associated with this drugs hence majority of respondents have
shown knowledge gap on the importance of these supplements. The study also confirmed that
the present of alternative services to F ANC services and inadequate lmowledge on benefits of
F ANC are responsible for low utilization of F ANC services in the area of the study since
majority reported the use of herbal medicine. These were more in uneducated mothers than
educated mothers.
The facility should encourage health education on causes and prevention of complications during
and after delivery and should also counseled the expectant mothers on the need to use iron and
folic acid supplements regularly during pregnancy because of its beneficial effects to the mother
and the fetus. Pregnant mothers should take the F ANC services very serious and should be
encouraged to deliver in the hospital to reduce on maternal and neonatal mortality.
Photochemical analysis should be done on bothrioclinelongipes (local name = ekyoganyanja) to
evaluate their effects on pregnancy and the women.
31
Reference:
Abdella, A. (2010). Maternal mortality trend in Ethiopia. Ethiopian Journal of Health
Development, 24(SPEC. ISSUE 1 ), 115-122. https://doi.org/1 0.4314/ejhd.v24il.62953
Ahmed, S., Creanga, A. A., Gillespie, D. G., & Tsui, A. 0. (2010). Economic status, education
and empowerment: Implications for maternal health service utilization in developing
countries. PLoS ONE, 5(6). https://doi.org/10.1371/joumal.pone.0011190
Aniebue, U. U., & Aniebue, P. N. (2011). Women's perception as a barrier to focused antenatal
care in Nigeria: The issue of fewer antenatal visits. Health Policy and Planning, 26(5), 423-
428. https://doi.org/1 0.1 093/heapol/czq073
Babalola, S. (2014). Women's education level, antenatal visits and the quality of skilled
antenatal care: a study of three African countries. Journal of Health Care for the Poor and
Underserved, 25(1), 161-79. https://doi.org/10.1353/hpu.2014.0049
Baffour-Awuah, a., Mwini-Nya1edzigbor, P. P., & Richter, S. (2015). Enhancing focused
antenatal care in Ghana: An exploration into perceptions of practicing midwives.
International Journal of Africa Nursing Sciences, 2, 59-64.
https://doi.org/1 0.10 16/j .ijans.20 15.02.001
Bates, I., Chapotera, G. K., McKew, S., & Van Den Broek, N. (2008). Maternal mortality in sub
Saharan Africa: The contribution of ineffective blood transfusion services. BJOG: An
International Journal of Obstetrics and Gynaecology. https://doi.org/10.1111/j.l471-
0528.2008.01866.x
Benmaamar, M., Ellis, S., & Dunkerley, C. (2002). Urban Transport Services in Sub-Saharan
Africa: Recommendations for Reform in Uganda. Transportation Research Record,
1812(1), 112-118. https://doi.org/10.314111812-14
Berhanu, T. (2006). Transport for pregnant women m Ethiopia. Retrieved from
http:/ /www.eldis.org/id21 ext/insights63art4.html.reviewed on 30/10/2016.
Bintabara, D., Mohamed, M.A., Mghamba, J., Wasswa, P., & Mpembeni, R.N. M. (2015). Birth
preparedness and complication readiness among recently delivered women in chamwino
32
district, central Tanzania: a cross sectional study. Reproductive Health, 12(1), 44.
https://doi.org/1 0.1186/sl2978-015-0041-8
Blencowe, H., Lawn, J., Vandelaer, J., Roper, M., & Cousens, S. (2010). Tetanus toxoid
immunization to reduce mortality from neonatal tetanus. International Journal of
Epidemiology, 39(SUPPL. 1). https://doi.org/10.1093/ije/dyq027
Brockerhoff, M., & Hewett, P. (2000). Inequality of child mortality among ethnic groups in sub
Saharan Africa. Bulletin of the World Health Organization. https://doi.org/10.1590/S0042-
96862000000100004
Centre, N. C. (2010). Antenatal care: routine care for the healthy pregnant woman. Health San
Francisco, 26, 189-201. https://doi.org/10.1016/j.midw.2008.03.005
Crenshaw, J. T. (2014). Healthy Birth Practice #6: Keep Mother and Baby Together- It's Best for
Mother, Baby, and Breastfeeding. The Journal of Perinatal Education, 23(4), 211-7.
https://doi.org/1 0.1891/1058-1243.23.4.211
Eaton, J. W., Rehle, T. M., Jooste, S., Nkambule, R., Kim, A. A., Mahy, M., & Hallett, T. B.
(2014). Recent HIV prevalence trends among pregnant women and all women in sub
Saharan Africa: implications for HIV estimates. AIDS (London, England), 28 Suppl 4(4),
S507-14. https://doi.org/1 0.1097 /QAD.0000000000000412
Gross, K., Armstrong Schellenberg, J., Kessy, F., Pfeiffer, C., & Obrist, B. (2011). Antenatal
care in practice: an exploratory study in antenatal care clinics in the Kilombero Valley,
south-eastern Tanzania. BMC Pregnancy and Childbirth, 11(1), 36.
https://doi.org/1 0.1186/1471-2393-11-36
Hamill, F. A., Apio, S., Mubiru, N. K., Mosango, M., Bukenya-Ziraba, R., Maganyi, 0. W., &
Soejarto, D. D. (2000). Traditional herbal drugs of southern Uganda, I. Journal of
Ethnopharmacology, 70(3), 281-300. https://doi.org/10.1 016/S0378-8741(00)00180-X
Hosseinpoor, A. R., Victora, C. G., Bergen, N., Banos, A. J.D., & Boerma, T. (2011). Towards
universal health coverage: The role of within-country wealth-related inequality in 28
countries in sub-Saharan Africa. Bulletin of the World Health Organization, 89(12), 881-
33
890. https://doi.org/10.2471/BLT.ll.087536
Jakupovic, J., Boeker, R., Schuster, A., Bohlmann, F., & Jones, S. B. (1987). Further
guaianolides and 5-alkylcoumarins from gutenbergia and bothriocline species.
Phytochemistry, 26( 4), I 069-1075. https://doi.org/1 0.1 016/S0031-9422(00)82352-3
Kabakyenga, J. K., Ostergren, P. 0., Turyakira, E., & Pettersson, K. 0. (2012). Influence of birth
preparedness, decision-making on location of bi1ih and assistance by skilled birth attendants
among women m south-western Uganda. PLoS ONE, 7(4).
https://doi.org/1 0.1371/journal.pone.003574 7
Kamatenesi-Mugisha, M., & Oryem-Origa, H. (2007). Medicinal plants used to induce labour
during childbirth in western Uganda. Journal of Ethnopharmacology, 109(1), 1-9.
https://doi.org/1 0.1 016/j.jep.2006.06.0 11
Katuura, E., Waako, P., Ogwal-Okeng, J., & Bukenya-Ziraba, R. (2007). Traditional treatment of
malaria in Mbarara District, western Uganda. African Journal of Ecology, 45(SUPPL. 1),
48-51. https://doi.org/10.1111/j.1365-2028.2007.00737.x
Katuura, E., Waako, P., Tabuti, J. R. S., Bukenya-Ziraba, R., & Ogwal-Okeng, J. (2007).
Antiplasmodial activity of extracts of selected medicinal plants used by local communities
in western Uganda for treatment of malaria. African Journal of Ecology, 45, 94-98.
https://doi.org/http://dx.doi.org/10.1111/j.1365-2028.2007.00864.x
Kisuule, I., Kaye, D. K., Najjuka, F., Ssematimba, S. K., Arinda, A., Nakitende, G., & Otim, L.
(20 13). Timing and reasons for coming late for the first antenatal care visit by pregnant
women at Mulago hospital, Kampala Uganda. BMC Pregnancy and Childbirth, 13(1), 121.
https://doi.org/1 0.1186/14 71-2393-13-121
Kiwanuka, S. N., Ekirapa, E. K., Peterson, S., Okui, 0., Rahman, M. H., Peters, D., & Pariyo, G.
W. (2008). Access to and utilisation of health services for the poor in Uganda: a systematic
review of available evidence. Transactions of the Royal Society of Tropical Medicine and
Hygiene. https://doi.org/1 0.10 16/j .trstrnh.2008.04.023
M., T., E.K., E., J., B., A., M., & R., T. (2010). Acceptability of transport cost payment for
34
mothers seeking antenatal and delivery care services: A survey of transporters' attitudes -
Eastern Uganda, 2009. American Journal of Tropical Medicine and Hygiene. Retrieved
from
http:/ /ovidsp.ovid.corn/ovidweb.cgi ?T= JS&P AGE=reference&D=emed9&NEWS=N &AN=
70442546
Mbonye, A. K., Asimwe, J. B., & A.K., M. (2010). Factors associated with skilled attendance at
delivery in Uganda: results from a national health facility survey. International Journal of
Adolescent Medicine and Health. https://doi.org/1 0.1515/ijamh.201 0.22.2.249
Mbonye, A. K., Birungi, J., Yanow, S., & Magnussen, P. (2013). Prescription patterns and drug
use among pregnant women with febrile Illnesses in Uganda: a survey in out-patient clinics.
BMC Infectious Diseases, 13(1), 237. https://doi.org/10.1186/1471-2334-13-237
Mbule, M. A., Byaruhanga, Y. B., Kabahenda, M., & Lubowa, A. (2013). Determinants of
anaemia among pregnant women in rural Uganda. Rural and Remote Health, 13(2), 2259.
Mold, J. W., Blake, G. H., & Becker, L. A. (1991). Goal-oriented medical care. Family
Medicine, 23(1), 46-51.
Montagu, D., Yamey, G., Visconti, A., Harding, A., & Yoong, J. (2011). Where do poor women
in developing countries give bi1ih? a multi-country analysis of Demographic and health
survey data. PLoS ONE, 6(2). https://doi.orgll0.1371/journal.pone.0017155
Obai, G., Odongo, P., & Wanyama, R. (2016). Prevalence of anaemia and associated risk factors
among pregnant women attending antenatal care in Gu1u and Hoima Regional Hospitals in
Uganda: A cross sectional study. BMC Pregnancy and Childbirth, 16(1), 76.
https://doi.org/1 0.1186/s12884-0 16-0865-4
Partridge, S., Balayla, J., Holcroft, C. A., & Abenhaim, H. A. (2012). Inadequate prenatal care
utilization and risks of infant mortality and poor birth outcome: A retrospective analysis of
28,729,765 U.S. deliveries over 8 years. American Journal of Perinatology, 29(10), 787-
793. https://doi.org/10.1055/s-0032-1316439
Rasmussen, S. A., Jamieson, D. J., & Uyeki, T. M. (2012). Effects of influenza on pregnant
35
women and infants. American Journal of Obstetrics and Gynecology, 207(3 SUPPL.).
https://doi.org/1 0.10 16/j .ajog.20 12.06.068
Roy, M. P., Mohan, U., Singh, S. K., Singh, V. K., & Srivastava, A. K. (2013). Determinants of
utilization of antenatal care services in mral lucknow, India. Journal of Family Medicine
and Primary Care, 2(1), 55-9. https://doi.org/10.4103/2249-4863.109946
Sacks, E., Vail, D., Austin-Evelyn, K., Greeson, D., Atuyambe, L. M., MacWan'Gi, M., ...
Grepin, K. A. (20 16). Factors influencing modes of transport and travel time for obstetric
care: A mixed methods study in Zambia and Uganda. Health Policy and Planning, 31(3),
293-301. https://doi.org/1 0.1 093/heapol/czv057
Sibley, L. M., & Sipe, T. A. (2006). Transition to skilled birth attendance: Is there a future role
for trained traditional birth attendants? Journal of Health, Population and Nutrition, 24(4),
472-478.
Ssali, A., Butler, L. M., Kabatesi, D., King, R., Namugenyi, A., Kamya, M. R., ... McFarland,
W. (2005). Traditional healers for HIV I AIDS prevention and family planning, Kiboga
district, Uganda: Evaluation of a program to improve practices. AIDS and Behavior, 9( 4),
485-493. https://doi.org/1 0.1 007/sl 0461-005-9019-9
Tabuti, J. R., Kukunda, C. B., Kaweesi, D., & Kasilo, 0. M. (2012). Herbal medicine use in the
districts of Nakapiripirit, Pallisa, Kanungu, and Mukono in Uganda. Journal of
Ethnobiology and Ethnomedicine, 8(1 ), 35. https://doi.org/1 0.1186/1746-4269-8-35
Tabuti, J. R. S., Lye, K. A., & Dhillion, S. S. (2003). Traditional herbal dmgs of Bulamogi,
Uganda: Plants, use and administration. Journal of Ethnopharmacology, 88(1), 19-44.
https://doi.org/1 0.1 016/S0378-8741 (03)00 161-2
Tann, C. J., Kizza, M., Morison, L., Mabey, D., Muwanga, M., Grosskurth, H., & Elliott, A.M.
(2007). Use of antenatal services and delivery care in Entebbe, Uganda: a community
survey. BMC Pregnancy and Childbirth, 7, 23. https://doi.org/10.1186/1471-2393-7-23
Turner, S. R., Lai, H., & Bedard, E. L. R. (2014). Smoking cessation counseling by surgical and
nonsurgical residents: Opportunities for health promotion education. Journal of Surgical
36
Education, 71(6), 892-895. https://doi.org/10.1016/j.jsurg.2014.03.011
Were, E. 0., & Karanja, J. K. (1994). Low birth weight deliveries at the Nyanza General
Hospital Kisurnu, Kenya. East African Medical Journal, 71 (1 0), 667-670.
Williams, D. (2011). Long-Term Complications of Preeclampsia. Seminars in Nephrology,
31(1), 111-122. https://doi.org/10.1016/j.semnephrol.2010.10.010
37
APPENDIX 1: MAP OF UGANDA
EM. REP. OF CONGO
Ntcrtt.o--j/
:....6ll.q(.l _L
i Kao.ne > •
l
/ /
.A. /
, SUDAN ,. / ~., \ ., ..... ·, ,/ ....
' ...... -..... / . /·-·-· ·-·- ..... J. ...... ...... i '-"'!' \ / ) ~O .! ~U'II~ / ~1o'10 '\ .
l -.j·/""· . '-'n:h:. ............. \ .
j. \
• !we
_) . ~ _(. ~.. ,.~ r ···-·· ~mc:.,;'" 'lm
'..J ' \...1
'· ~Jlj.nirl
ti."IU1J
'iN 'I) ";I
) /
/ Bu~ Kl)..,dcugu
l.on">lll
• GuiJ
Oy:r:-o
Kl:l;o Lta
A.111til
.4jl.Jc •• .):jcoo
/
N
38
KD:dc
{ \ I ."\
\ .......
~-lo·olo I'-. > \ \ (
KENYA
60
km
i20
40