The use of facilities for labor and delivery: The views of women in rural Uganda

Abstract

The aim of the paper is to explore factors associated with home or hospital delivery in rural Uganda. Qualitative interviews with recently-delivered women in rural Uganda and statistical analysis of data from the 2011 Ugandan Demographic and Health Survey (DHS) to assess the association between socio-demographic and cultural factors and delivery location in multivariable regression models. In the DHS, 61.7% (of 4907) women had a facility-based delivery (FBD); in adjusted analyses, FBD was associated with an urban setting [adjusted odds ratio (aOR) 3.38, 95% confidence interval (CI) 2.66 to 4.28)], the upper wealth quintile (aOR: 3.69, 95%CI 2.79 to 3.87) and with secondary education (aOR: 3.07, 95%CI 2.37 to 3.96). In interviews women quoted costs and distance as barriers to FBD. Other factors reported in interviews to be associated with FBD included family influence, perceived necessity of care (weak women needed FBD), and the reputation of the facility (women bypassed local facilities to deliver at better hospitals). Choosing a FBD is a complex decision and education around the benefits of FBD should be combined with interventions designed to remove barriers to FBD. Goal 5 (MDG-5) was created in response to the thousands of maternal deaths from preventable and treatable causes, with the aim to reduce MM by 75% by 2015 through providing universal access to reproductive healthcare.5-7 Progress has been made in reducing MM globally, with an estimated 45% reduction since 1990, and deliveries attended by a skilled birth attendant (SBA) increasing to 71% in 2014 compared to 55% in 1990.1 However, the Maternal Mortality Ratio (MMR) has not fallen by the 75% original target.1 Despite effective strategies and interventions, reducing maternal deaths in resource-poor countries remains a challenge.2 Uganda has a high MMR; 360 in 2014, and despite improvements in FBD rates and increasing numbers of health centres providing community-based care, for some women facilities are still inaccessible and underused.1,5,8 The reasons for low-uptake of FBD are wide-ranging, complex and context specific, transforming the causes of MM from a number of treatable and preventable medical conditions to a wide range of complex, interlinking socio-cultural factors.9-12 To receive FBD women must logistically be able to access a facility and they, or a family-member must make the decision to seek it.12-14 Therefore, it is important to understand the factors that encourage FBD and those act as barriers, to fully reap the benefits of the increasing availability of reproductive healthcare brought about by MDG-5.11,15,16 Recognising a gap in research on socio-cultural factors and their influence on delivery location, this study, through interviews with women and analysis of the Ugandan 2011 DHS aims to inform understanding of decision-making and issues associated with choice of place of delivery.