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

1. Acceptability of evidence-based maternal-neonatal care practices in rural Uganda -implications for programming Peter Waiswa, Margaret Kemigisa, Juliet Kiguli, Sarah Naikoba, George Pariyo, Stefan Peterson

2. Background-1 • Globally 4 million newborn deaths/year or 40% of U5M, 98% in developing countries • Therefore achieving MDG4 requires reducing newborn deaths • 50% occur on D1 and 75% occur in week one after birth • Trend same for maternal death

3. Background-2: In Uganda • 44,500 newborn deaths and 45,100 stillbirths/year; 31,800 could be prevented; 23% of U5M are neonates • 56% excess newborn deaths in rural areas comapred to urban • 60% birth occur at home • Only 12% newborns ever get postnatal care • Iganga district: About 900 newborn deaths, 850 perinatal deaths (300 perinatal death in Iganga hospital alone)

4. Background-3 • Causes preventable - 86% of neonatal deaths by 3 preventable problems: infections - 36% prematurity - 27% asphyxia - 23% • Recent evidence from Asia and S America: low cost community interventions can reduce neonatal deaths by 20% - 40%

5. The Evidence Based Practices • Birth preparedness and promotion of demand for care and readiness for emergencies • Counseling and preparation of for newborn care • Clean delivery • Hygienic cord/skin care • Thermal care • Promotion of early and exclusive breastfeeding • Health home care • Extra care for low birth weight babies • Community case management for pneumonia • 4 ANC visits inc. IPT, TT • Awareness and early detection and referral of danger signs

6. Objectives • To explore the acceptability of recommended evidence-based maternal-neonatal practices at community level • To investigate acceptability of home visits by a CHW during pregnancy and in the early neonatal period to promote home care

7. Methods • 10 FGDs consisting of mothers, fathers and child minders-up to 13 years old • 10 IDIs with health workers and traditional birth attendants • Study done in Iganga/Mayuge Districts in Busoga subregion, Eastern Uganda • Basoga are almost 10% of Ugandans

8. Findings: Acceptable Practices • Attending ANC 4 times during pregnancy • Maintenance of warmth through skin to skin contact • Exclusive breast feeding • Skilled care seeking for danger signs • Facility/Supervised deliveries • Early referral for danger signs • Home visits by CHWs

9. Findings: Less acceptable Practices • Early bathing – babies believed to be born “dirty” “My babies are usually born dirty, so it is a must for me to bathe the baby immediately I am discharged on that same day of giving birth. You people are your babies born clean”. (FGD Older mothers). • Putting nothing on cord – that substances encourage ‘early cord healing’ • Care of premature babies at home – belief that this should be in health facilities

10. Findings: Key challenges to home care • Knowledge barriers, service delivery gaps; cultural, traditional beliefs and practices and financial constraints • Limited community knowledge on: importance of attending ANC four times during pregnancy

11. Findings: Key challenges to home care • Deep rooted beliefs in herbs • Decision making not by women • B/preparedness is hindered by poverty, cultural beliefs, limited awareness, lack of adequate male involvement and the fear of preparing for the unborn • Most labour occurring at night • No community knowledge on postnatal care except for immunisation

12. Key challenges to home care ANC misconstrued as provision of medicine for sick pregnant women (okunwa obulezi) “Yes, I was given three Fansidars and they are at home. I came back quarrelling. I went for ANC for assistance but by giving me only three tablets, how were they helping? Three tablets only! Yet I explained my condition in detail”. (FGD Young Mothers) “Yes, she (TBA) delivers and also changes the position of the baby if it is not laying right. She can also change the sex of the baby if you want. For instance if you have been giving birth to only boys and you want a girl, she can change the sex for you so that you deliver a girl”. (FGD, older mothers)

13. Preparing for birth is a burden to women and hinders facility deliveries Alternative domestic services while mother is away • Stocking food and firewood • Finding other person to take care of home and children Gathering personal effects for mother-to-be and newborn • Vaseline and soap • A jerrycan for water and a basin for bathing • Mother and Baby clothes and powder Buying materials for use by health care providers • Gloves and razorblade (for cutting the cord) • Threads (to be used as cord ligatures) • Syringes, needles and injectable ergometrine (to stop postpartum haemorrge) • Cotton wool • ‘Kavera’/plastic sheet (an improvised mackintosh) Preparation for emergencies • Asking transport money from male partners or saving from own sources

14. Conclusions • Evidence based practices for MN health may not be universally acceptable • A “one size fits all strategy” to scale-up for all of SubSaharan Africa is likely to fail • We suggest rapid appraisal and local adaptation of evidence-based practices and packages to address the local socio-cultural situation • Health systems strengthening will be needed for community strategies to be effective • Male involvement is key and promotion of waiting shelters at selected health units should be considered

15. Acknowledgements • Funders:- Sida/SAREC, Saving Newborn Lives initiative of Save the Children/USA through a grant from the Bill and Melinda Gates Foundation. • Study participants, DSS staff and research assistants, and the Study Policy Advisory Group. • We acknowledge the useful comments on the manuscript made by Dr Joy Lawn.