Contraceptive Use among Young People in Uganda: Exploration of obstacles, enablers, and quality of services

Background: Unsafe abortions, a life shortening condition leading to untimely deaths of young women in low income countries, are a public health concern. The bio-social gap, which is the period between menarche and marriage has widened, thus the time young women/men need contraception has increased. High rates of teen pregnancy, unintended birth, unsafely induced abortions and associated mortality among young women, is attributed to low contraceptive use. Paradoxically, awareness about contraception is high. It is not understood why young people are not using contraceptives, hence this study. Aim: To explore and analyze obstacles and enablers to contraceptive use and quality of services provided to young people aged 15-24 in two districts in Uganda, in order to increase knowledge about why contraceptives are not used and identify areas for improvement. Methods: The studies were carried out among young people 15-24 years and health care providers at public, private not for profit (PNFP), and private for profit (PFP) contraceptive delivery points. Quantitative and qualitative approaches were used. Focus group discussions (FGDs) were used to explore young peoples’ views about obstacles and enabling factors to contraceptive use (study I). Semi-structured questionnaires were used to guide face-face interviews with health care providers to determine factors influencing contraceptive use and provision (Study II). Simulated client methodology was used to assess the quality of contraceptive services and clients experiences of contraceptive care (Study III and IV). Descriptive statistics (II, IV), inferential statistics (II, IV) and factor analysis (III) were performed. Qualitative data were analyzed using content analysis (I) and thematic analysis (IV). Results: Young men and women described multiple obstacles to contraceptive use, which were categorized as misconceptions and fears related to contraception, gender power relations, socio-cultural expectations and contradictions, short term planning, and health service barriers (I). Additionally, young people recounted several enabling factors that included female strategies to overcome obstacles, changing perceptions and attitude towards contraceptive use and smaller family size (I). Contraceptive use and provision to young people were constrained by sporadic contraceptive stocks, poor service organization, limited number of trained personnel, high costs, and unfriendly service. Most providers were not competent enough to provide long-acting methods. There were significant differences in providers’ self-rated competence by facility type. Private for-profit providers’ competence was limited for most contraceptives. Providers had misconceptions about contraceptives, they had negative attitudes towards the provision of contraceptives to young people, and they imposed non-evidence-based age restrictions and consent requirements. Thus, most providers were not prepared or were hesitant to give young people contraceptives. Short-acting methods were, however, considered acceptable for young married women and those with children (II). Means and categorized quality scores for all aspects of quality were low in both public and private facilities. The lowest quality scores were observed in PFP, and medium scores in PNFP facilities. The choice of contraceptive methods and interpersonal relations quality scores were slightly higher in public facilities. Needs assessments scores were highest in PNFP facilities. All facilities were classified as having low scores for appropriate constellation of services. Information given to users was suboptimal and providers promoted specific contraceptive methods. A minority of providers offered young people their preferred method of choice and a minority showed respect for privacy (III, IV). Both qualitative and quantitative results highlighted favorable reception, provider bias, and low client satisfaction. Two thirds of the providers choose a contraceptive method for the client. The clients reported satisfaction with contraceptive services in 29 percent of the consultations. Privacy was reported to be observed in 42 percent and clients felt respectfully treated in 50 percent of the consultations (IV). Conclusion: Our findings suggest changing perceptions and attitudes in favor of contraceptive use and smaller family size although obstacles still exist (I). Provider, client, and health system factors restricted contraceptive provision and use for young people (II). The quality of contraceptive services provided to young people was low (III). Young people were not able to exercise their rights to choose, obtain and use contraceptives when needed. Overall satisfaction with the services was low and client- provider interactions were often unfavorable (IV). Implications: Reducing obstacles and reinforcing enabling factors through education, culturally sensitive behavior change strategies have the potential to enhance contraceptives use. Alternative models of contraceptive service delivery to young people are needed. Contraceptive use prospects are dependent on provider behavior. Concurrent quality improvements and strengthening of health systems are needed

Improving the quality of care for the sick newborn: Focusing on kangaroo mother care and breastfeeding

The project aimed at improving the knowledge and practices of KMC and breastfeeding for the neonates in Stanfield ward. Approximately 90-150 neonates are admitted in Mulago Hospital/month. Fears and misconceptions about having a sick neonate are common leading to distress. This project strengthened the leadership capabilities of the first author to navigate/implement change in newborn care clinical practice/teaching and mentorship with support from team members, Maternal and Child Health Nurse Leadership Academy in Africa/Sigma Theta Tau International A baseline qualitative study was conducted among mothers and nurses. In depth interviews were conducted and data analyzed thematically. We adapted and disseminated instructional/ educational materials on KMC and exclusive breastfeeding, trained two nurses, and 18 undergraduate students. Mothers were also trained in essential care/needs of the sick newborn and how to offer continued peer support. We evaluated the effect of training/support on the newborn outcomes, KMC and exclusive breastfeeding practices of the mothers. Baseline data from the nurses revealed staff shortages, limited knowledge and poor support as challenges to provide support to women with sick newborns in regard to KMC and exclusive breastfeeding. After the training, nurses/midwives and student nurses all reported great improvement in their care and experience in supporting the mothers. There is an increase in the number of mothers trained in breastfeeding and KMC, an observed reduction in newborn deaths and shortened hospital stay. During this leadership journey, I have learnt to challenge the norm, inspire a shared vision, model the way while enabling others to act. Improving the skill set of the nurses/midwives and mothers caring for the sick newborn in regard to Kangaroo Mother Care (KMC) and exclusive breastfeeding improves the quality of care for the sick newborn. The trained nurses/midwives are training others to cascade the improvement initiative. The approach used will be adopted and replicated other neonatal units in Mulago Hospital

Initiating birthing partner support in a low risk maternity unit

The Maternal-Child Health Nurse Leadership Academy Africa (MCHNLA Africa) develops the leadership skills of maternal and child health nurses and midwives who work in a variety of healthcare settings. The academy prepares these nurses for effective interprofessional team leadership as they strive to improve the quality of healthcare for childbearing women and children up to 5 years old. The program is presented in cooperation with our funding partner Johnson & Johnson. Nurses and Midwives from Malawi, South Africa, Swaziland and Uganda participate in an 18-month leadership academy. During MCHNLA Africa the mentees create and effectively lead an interdisciplinary team with the goal of improving maternal-child health practice outcomes. At the end of the academy the mentees present a poster detailing the outcomes of their project and how it improved maternal-child health outcomes. The leadership skills component of the academy is based on the research and teachings of Jim Kouzes and Barry Posner, as described in The Leadership Challenge ®. Their model proposes that leadership is a measurable, learnable, and teachable set of behaviors. The academy believes that these behaviors are learned best when applied to realistic settings. The academy is designed to operationalize these learned behaviors by assisting and supporting the Mentee in developing and implementing an interdisciplinary team project

Perinatal care in Western Uganda: Prevalence and factors associated with appropriate care among women attending three district hospitals

Background: Perinatal mortality remains high globally and remains an important indicator of the quality of a health care system. To reduce this mortality, it is important to provide the recommended care during the perinatal period. We assessed the prevalence and factors associated with appropriate perinatal care (antenatal, intrapartum, and postpartum) in Bunyoro region, Uganda. Results from this study provide valuable information on the perinatal care services and highlight areas of improvement for better perinatal outcomes. Methods: A cross sectional survey was conducted among postpartum mothers attending care at three district hospitals in Bunyoro. Following consent, a questionnaire was administered to capture the participants’ demographics and data on care received was extracted from their antenatal, labour, delivery, and postpartum records using a pre-tested structured tool. The care received by women was assessed against the standard protocol established by World Health Organization (WHO). Poisson regression with robust standard errors was used to assess factors associated with appropriate postpartum care. Results: A total of 872 mothers receiving care at the participating hospitals between March and June 2020 were enrolled in the study. The mean age of the mothers was 25 years (SD = 5.95). None of the mothers received appropriate antenatal or intrapartum care, and only 3.8% of the participants received appropriate postpartum care. Factors significantly associated with appropriate postpartum care included mothers being \u3e35 years of age (adjusted prevalence ratio [aPR] = 11.9, 95% confidence interval [CI] 2.8–51.4) and parity, with low parity (2–3) and multiparous (\u3e3) mothers less likely to receive appropriate care than prime gravidas (aPR = 0.3, 95% CI 0.1–0.9 and aPR = 0.3, 95% CI 0.1–0.8 respectively). Conclusions: Antenatal, intrapartum, and postpartum care received by mothers in this region remains below the standard recommended by WHO, and innovative strategies across the continuum of perinatal care need to be devised to prevent mortality among the mothers. The quality of care also needs to be balanced for all mothers irrespective of the age and parity

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens.

BACKGROUND: Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA. METHODS: We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning. RESULTS: About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had  20,000 women having <ANC4+ visits were 38%, 1% and 1%, respectively. In many districts, ANC4+ coverage and likelihood of attaining the target coverage was lower among the poor, uneducated and those geographically marginalized from healthcare. CONCLUSIONS: These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens

Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA. We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level&nbsp;for sub-national planning. About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had  20,000 women havin

Constraints and prospects for contraceptive service provision to young people in Uganda: providers' perspectives

<p>Abstract</p> <p>Background</p> <p>Unintended pregnancies lead to unsafe abortions, which are a leading cause of preventable maternal mortality among young women in Uganda. There is a discrepancy between the desire to prevent pregnancy and actual contraceptive use. Health care providers' perspectives on factors influencing contraceptive use and service provision to young people aged 15-24 in two rural districts in Uganda were explored.</p> <p>Methods</p> <p>Semi-structured questionnaires were used for face- to-face interviews with 102 providers of contraceptive service at public, private not-for-profit, and private for-profit health facilities in two rural districts in Uganda. Descriptive and inferential statistics were used in the analysis of data.</p> <p>Results</p> <p>Providers identified service delivery, provider-focused, structural, and client-specific factors that influence contraceptive use among young people. Contraceptive use and provision to young people were constrained by sporadic contraceptive stocks, poor service organization, and the limited number of trained personnel, high costs, and unfriendly service. Most providers were not competent enough to provide long-acting methods. There were significant differences in providers' self-rated competence by facility type; private for-profit providers' competence was limited for most contraceptives. Providers had misconceptions about contraceptives, they had negative attitudes towards the provision of contraceptives to young people, and they imposed non-evidence-based age restrictions and consent requirements. Thus, most providers were not prepared or were hesitant to give young people contraceptives. Short-acting methods were, however, considered acceptable for young married women and those with children.</p> <p>Conclusion</p> <p>Provider, client, and health system factors restricted contraceptive provision and use for young people. Their contraceptive use prospects are dependent on provider behavior and health system improvements.</p

Are midwives ready to provide quality evidence-based care after pre-service training? Curricula assessment in four countries-Benin, Malawi, Tanzania, and Uganda.

This research sought to map midwifery pre-service training curricula as part of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity in sub-Saharan Africa (ALERT) project conducted in Benin, Malawi, Tanzania, and Uganda. We conducted the review in two phases. In the first phase, online interviews were performed with the lead project midwives in all four study countries to get an overview of midwifery care providers' pre-service training courses, registration, and licensing requirements. We performed a mapping review of midwifery care providers' pre-service training curricula from different training institutions in the four study countries during the second phase. Curricula were reviewed and mapped against the International Confederation of Midwives (ICM) Essential Competencies framework to assess whether these curricula included the minimum essential training components described in the ICM framework. We identified 10 different professional titles for midwifery care providers. The number of years spent in pre-service training varied from one and a half to four years. Ten pre-service curricula were obtained and the assessment revealed that none of the curricula included all ICM competencies. Main gaps identified in all curricula related to women-centred care, inclusion of women in decision making, provision of care to women with unintended or mistimed pregnancy, fundamental human rights of individuals and evidence-based learning. This review suggests that there are skills, knowledge and behaviour gaps in pre-service training curricula for midwifery care providers when mapped to the ICM Essential Competencies framework. These gaps are similar among the different training courses in participating countries. The review also draws attention to the plethora of professional titles and different pre-service training curricula within countries. Trial registration: PACTR202006793783148-June 17th, 2020

Quality of Care in Contraceptive Services Provided to Young People in Two Ugandan Districts: A Simulated Client Study

BACKGROUND: Low and inconsistent use of contraceptives by young people contributes to unintended pregnancies. This study assessed quality of contraceptive services for young people aged 15-24 in two rural districts in Uganda. METHODS: Five female and two male simulated clients (SCs) interacted with 128 providers at public, private not-for-profit (PNFP), and private for profit (PFP) health facilities. After consultations, SCs were interviewed using a structured questionnaire. Six aspects of quality of care (client's needs, choice of contraceptive methods, information given to users, client-provider interpersonal relations, constellation of services, and continuity mechanisms) were assessed. Descriptive statistics and factor analysis were performed. RESULTS: Means and categorized quality scores for all aspects of quality were low in both public and private facilities. The lowest quality scores were observed in PFP, and medium scores in PNFP facilities. The choice of contraceptive methods and interpersonal relations quality scores were slightly higher in public facilities. Needs assessment scores were highest in PNFP facilities. All facilities were classified as having low scores for appropriate constellation of services. Information given to users was suboptimal and providers promoted specific contraceptive methods. Minority of providers offered preferred method of choice and showed respect for privacy. CONCLUSIONS: The quality of contraceptive services provided to young people was low. Concurrent quality improvements and strengthening of health systems are needed