Translating lessons to reinforce national stillbirth response; multi-stakeholder perspectives regarding priorities and opportunities to deliver quality evidence-based interventions within a limited-resource context in Uganda.

BACKGROUND: There is noted increase in attention towards implementation of evidence-based interventions in response to the stillbirth burden in low- and middle-income countries including Uganda. Recent results reporting some of the strategies adopted have tended to focus much attention towards their overall effect on the stillbirth burden. More is needed regarding stakeholder reflections on priorities and opportunities for delivering quality services within a limited resource setting like Uganda. This paper bridges this knowledge gap. METHODS: Data collection occurred between March and June 2019 at the national level. Qualitative interviews were analysed using a thematic analysis technique. RESULTS: Identified priorities included; a focus on supportive functions such as the referral system, attention to the demand side component of maternal health services, and improvements in the support supervision particularly focusing on empowering subnational level actors. The need to strengthen the learning for better implementation of strategies which are compatible with context was also reported. A comprehensive and favourable policy environment with the potential to direct implementation of strategies, harnessing the private sector contribution as well as the role of national level champions and patient advocates to amplify national stillbirth reduction efforts for continued visibility and impact were recommended. CONCLUSION: Great potential exists within the current strategies to address the national stillbirth burden. However, priorities such as improving the supportive functions of MCH service delivery and attention to the demand side need to be pursued more for better service delivery with opportunities including a favourable policy environment primed to better serve the current strategies. This calls for dedicated efforts targeted at addressing gaps within the existing priorities and opportunities for better delivery of national strategies to address the stillbirth burden in Uganda.

The lived experience of South African men having a premature baby.

Background: Much has been written about fathers, fatherhood and premature babies. However, in the South African context, studies about the experiences of fathers having a premature baby are lacking. Aim: This study aimed to explore how South African fathers (n = 10) experience having a premature baby using a descriptive phenomenological approach. Setting: This research study was conducted online using various social media platforms such as WhatsApp, Google Meet and through telephonic conversations. Methods: A descriptive phenomenological approach that allowed for the distillation and elucidation of common core experiences among fathers who had a premature baby. Results: The findings demonstrated that the participants experienced intense fears regarding the survival and well-being of their children. They reported experiencing financial difficulties related to hospital bills and experienced being alienated by hospital institutions. Despite these reported barriers, these fathers were adamant in their resolve to support their children and partners during this challenging time. Conclusion: The experiences of fathers were riddled with fear, uncertainty, ambiguity and alienation, which placed them in very precarious situations when trying to navigate their role in a more sensitive and enlightened way. Having a premature infant calls into question the systems that men are positioned within as these systems to a large extent shape these events and how they are experienced. Contribution: This study is original as no other published studies seem to exist in South Africa that speaks to fathers' lived experiences of having a premature baby.

The juxtaposition of invalidation and "inviting in": a qualitative study of bisexual identity in South Africa.

Understanding one's sexual orientation plays a significant role in contributing to one's sexual identity and developing a coherent sense of self. Misconceptions and prevailing prejudices make it difficult for bisexual individuals to navigate their sexual identities in many societies. Disclosure of one's identity is accompanied by certain risks depending on how the information is received. However, disclosing one's identity can also be positive, especially as it assists in fostering relationships. This article derives from a descriptive study involving 14 semi-structured interviews with young adults aged 18-24 who identified as bisexual. Data were subjected to a reflexive thematic analysis. Themes of invalidation, belongingness and reclaiming through 'inviting in' were identified. By processing the feelings of invalidation regarding their bisexual identities which were placed upon them by their respective cultural groups, and society in general, participants were able to develop a sense of agency and reclaim their power. Findings highlight the need for further research on bisexuality, particularly in South Africa, and the need to understand how bisexual identity development occurs in interaction with other sexual and gender identities.

An exploration of health workers' experiences in providing bereavement care to mothers following a stillbirth: results from a subnational level health system in Uganda.

BACKGROUND: Stillbirth is a profound emotion-laden event to the mothers and health workers who provide care due to its sudden and unexpected occurrence. Health workers offering support in regions shouldering the highest-burden experience providing support to a stillbirth mother in their professional lifetime. However, their experiences seldom get documented as much of the focus is on mothers causing a dissonance between parental and clinical priorities. This study aimed to explore the health worker's experiences in the provision of bereavement care to mothers following a stillbirth. METHODS: An exploratory cross-sectional qualitative study was undertaken on a purposively selected sample of key informants drawn from frontline health workers and health systems managers providing maternal health services at a subnational level health system in Uganda. An interview guide was used to collect data with the audio-recorded interviews transcribed using Microsoft office word. Atlas. ti a qualitative data management software aided in coding with analysis following a thematic content analysis technique. RESULTS: There was no specialised bereavement care provided due to inadequate skills, knowledge of content, resources and support supervision for the same. However, health workers improvised within the available resources to comfort mothers upon news of a stillbirth. Disclosure to mothers about the stillbirth loss often took the form of forewarnings, direct and sometimes delayed disclosure. A feeling of unpreparedness to initiate the disclosure process to the mother was common while the whole experience had an emotional effect on the health workers when establishing the cause, particularly for cases without clear risk factors. The emotional breakdown was often a reflexive response from the mothers which equally affected the care providers. Health workers engaged in comforting and rebuilding the mothers to transition through the loss and validate the loss. Efforts to identify the skills and health systems gaps for address were a common response targeted at improving the quality of maternal healthcare services to avert similar occurrences in the future. CONCLUSION: Providing care to mothers after stillbirth was an emotional and challenging experience for health workers requiring different approaches to disclosure and provision of emotional support. The aspect of specialised bereavement care was lacking within the current response. Reflection of unpreparedness to handle the tasks demonstrates a deficit in the required skills. It is a critical gap missing hence calling for dedicated efforts to address it. Targeting efforts to improve health workers' competencies and preparedness to manage grieving mothers is one way to approach it.

National-level key stakeholders' perspectives regarding intervention progression and emerging challenges within the national stillbirth reduction response in Uganda.

INTRODUCTION: Implementation of evidence-based interventions was adopted to respond to the stillbirth burden from the global campaigns. However, new challenges emerge in the process of rolling out such interventions into routine services more so in the context of resource-limited settings. Since the scale-up of policy recommendations to address stillbirth in Uganda, the health system response has seldom been explored. This study was conducted among national-level key stakeholders to elicit their perspectives regarding intervention progression and challenges emerging from the implementation of the national stillbirth reduction strategies in Uganda. METHODS: The study adopted an exploratory qualitative design with interviews conducted among a purposively selected sample of national-level actors drawn from the maternal and Child Health (MCH) policy networks. Respondents were primed with ongoing national-level stillbirth reduction strategies as a case and later asked for their opinions regarding intervention progression and emerging challenges. All interviews were conducted in English and transcribed verbatim. Atlas. ti was used to facilitate the coding processes which used a pre-determined codebook developed a priori based on the applied framework. A thematic analysis technique was used. RESULTS: Human resources as reflected in the slow recruitment of essential staff, motivation and attitudes of the available human resource, on and off-drug stockouts, and equipment interruptions posed challenges to the effective implementation of interventions to address the stillbirth burden. The policy translation process was sometimes faced with deviations from the recommended practice. Deviations from guideline implementation, inadequate managerial skills of the health workers and managers in stewarding the implementation processes, inadequate implementation feedback, loops in communication and working with a passive community also posed process-dependent bottlenecks. Outcome expectation challenges stemmed from the inability to deliver stillbirth reduction interventions along the Reproductive Maternal New born Child and Adolescent Health (RMNCAH) continuum of care and the overconcentration of facility-level intervention with less focus on community/demand side interventions. CONCLUSION: In this exploratory study, national-level stakeholders perceive the adopted stillbirth reduction strategies as having the potential to address the burden. They, however, highlight potential challenges along the input-process-outcome continuum which ought to be addressed and opportunities to explore potential solutions befitting the national-level context.

Examining the variations in the implementation of interventions to address stillbirth from the national to subnational levels: experiences from Uganda.

BACKGROUND: The current global burden of stillbirth disproportionately affects regions such as sub-Saharan Africa, where Uganda is located. To respond to this burden, policies made at the national level were diffused from the centre and translated into service delivery at the district level, which is charged with implementation under the decentralization of health services arrangement. Variations emerge whenever policy recommendations are moved from national to subnational levels, with some aspects often lost along the way. Tools are available to facilitate knowledge of determinants of policy and innovation implementation within the healthcare system. However, the extent to which these have been applied to explain variations in implementation of interventions to address stillbirth reduction in Uganda remains scant. The aim of this article was to examine the variations in the implementation of interventions to address stillbirth from the national to the subnational levels in Uganda using the Consolidated Framework for Implementation Research (CFIR). METHODS: The study adopted a qualitative case study design. Data were collected from a purposively selected sample of key informants drawn from both the national and subnational levels. All interviews were conducted in English and transcribed verbatim. ATLAS.ti was used to guide the coding process, which used a codebook developed following the CFIR domains as codes and constructs as sub-codes. Analysis followed a content analysis technique. RESULTS: National-level factors that favoured implementation of interventions to address stillbirth included the desire to comply with global norms, incentives to improve performance for stillbirth reduction indicators for better comparison with global peers, and clear policy alternatives as process implementation advanced by champions. Variations at the subnational level revealed aspirations to address service delivery gaps which fell within maternal health routine standard of care and ongoing health systems strengthening initiatives. Coalescing existing networks around maternal and child health was a key mobilization factor for advocacy and programming, with a promise that the set targets would be operationalized at the subnational level. The key champions were defined by their official roles within the district health systems, which enhanced accountability. Feedback and reflection were distinguished from the national to subnational through joint assemblies and formal audit reviews, respectively. CONCLUSIONS: A heavy influence of the global events directed national-level adaptation of interventions to address stillbirth. Implementation context at the subnational level led to local adaptation and translation of policy provisions from the national level to suit the context, which to a greater extent explains the variations in the final content of policy provisions delivered.

Health workers' social networks and their influence in the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda.

Health workers' peer networks are known to influence members' behaviours and practices while translating policies into service delivery. However, little remains known about the extent to which this remains true within interventions aimed at addressing the stillbirth burden in low-resource settings like Uganda. The objective of this study was to examine the health workers' social networks and their influence on the adoption of strategies to address the stillbirth burden at a subnational level health system in Uganda. A qualitative exploratory design was adopted on a purposively selected sample of 16 key informants. The study was conducted in Mukono district among sub-national health systems, managers, health facility in-charges, and frontline health workers. Data was collected using semi-structured interview guides in a face-to-face interview with respondents. The analysis adopted a thematic approach utilising Atlas. ti software for data management. Participants acknowledged that workplace social networks were influential during the implementation of policies to address stillbirth. The influence exerted was in form of linkage with other services, caution, and advice regarding strict adherence to policy recommendations perhaps reflective of the level of trust in providers' ability to adhere to policy provisions. At the district health management level and among non-state actors, support in perceived areas of weak performance in policy implementation was observed. In addition, timely initiation of contact and subsequent referral was another aspect where health workers exerted influence while translating policies to address the stillbirth burden. While the level of support from among network peers was observed to influence health workers' adoption and implementation of strategies to address the stillbirth burden, different mechanisms triggered subsequent response and level of adherence to recommended policy aspects. Drawing from the elicited responses, we infer that health workers' social networks influence the direction and extent of success in policy implementation to address the stillbirth burden at the subnational level.

The role and attributes of social networks in the provision of support to women after stillbirth: experiences from Uganda.

INTRODUCTION: Communities exert stigma on mothers after stillbirth despite their potential to offer social support to the grieving family. Maternal healthcare-seeking behaviors are socially reinforced rendering a social network approach vital in understanding support dynamics which when utilized can improve community response to mothers experiencing stillbirth. However, the form and direction of social support for women when in need is not clear. The study explored the role and attributes of women's social networks in the provision of support to mothers who have experienced a stillbirth in Uganda. METHODS: An exploratory cross-sectional study design adopting a social network approach was conducted. Data collection following established procedures was conducted on a convenient sample of 17 mothers who had experienced a stillbirth six months before the study. Frequencies and bivariate analysis were conducted to determine the factors influencing the provision of social support from 293 network members elicited during the alter generation. We then performed a Poisson regression on each of the social support forms and the explanatory variables. Network structure variables were calculated using UCINET version 6 while Netdraw facilitated the visualization of networks. RESULTS: Overall, social support was available from all network relations mentioned by the respondents. No major variations were observed between the two time periods during pregnancy and following a stillbirth. The most common support received was in form of intangible support such as emotional and information support, mainly from females who were married and from the naturally occurring networks such as family and friends. We also observed that social support followed patterns of network relational characteristics including trust, frequency of contact and alters counted on for support more likely to provide the same. CONCLUSIONS: A great potential for social support exists within women's social networks to help address stillbirth risk factors during pregnancy and cope after experiencing the same. Alter characteristics like being female, married, and from naturally occurring networks together with relational characteristics such as trust, frequency of contact, and count on alter for support were predictors of eventual social support. Interventions aiming at addressing stillbirth risks at the community level ought to harness these network characteristics for benefits to the mothers.

Building on momentum from the global campaigns: an exploration of factors that influenced prioritization of stillbirth prevention at the national level in Uganda.

BACKGROUND: Of the close to 2.6 million stillbirths that happen annually, most are from low-income countries where until recently policies rarely paid special attention to addressing them. The global campaigns that followed called on countries to implement strategies addressing stillbirths and the adoption of recommendations varied according to contexts. This study explored factors that influenced the prioritization of stillbirth reduction in Uganda. METHODS: The study employed an exploratory qualitative design adopting Shiffman's framework for political prioritization. Data collection methods included a document review and key informants' interviews with a purposively selected sample of 20 participants from the policy community. Atlas. Ti software was used for data management while thematic analysis was conducted to analyze the findings. FINDINGS: Political prioritization of stillbirth interventions gained momentum following norm promotion from the global campaigns which peaked during the 2011 Lancet stillbirth series. This was followed by funding and technical support of various projects in Uganda. A combination of domestic advocacy factors such as a cohesive policy community converging around the Maternal and Child Health cluster accelerated the process by vetting the evidence and refining recommendations to support the adoption of the policy. The government's health systems strengthening aspirations and integration of interventions to address stillbirths within the overall Maternal and Child Health programming resonated well. CONCLUSIONS: The transnational influence played a key role during the initial stages of raising attention to the problem and provision of technical and financial support. The success and subsequent processes, however, relied heavily on domestic advocacy and the national political environment, and the cohesive policy community.

Scoping review of the psychosocial aspects of infertility in developing countries: protocol.

INTRODUCTION: Infertility is a widespread social phenomenon. For both women and men, there are several psychosocial issues associated with infertility. Numerous systematic reviews have focused on individuals' psychosocial issues pertaining to infertility, however, these have been conducted in developed countries. Thus, there is a gap in the current literature to analyse individuals' psychosocial issues associated with infertility in developing countries. Given that there are various contextual factors to consider for appropriate interventions to be implemented, it is vital to explore this topic in a developing context. METHODS AND ANALYSIS: A scoping review will be conducted. A total of 12 databases were identified and a search string including terms related to infertility, psychosocial aspects and developing countries was developed. The inclusion and exclusion of each article will be determined through the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart. Quantitative and qualitative data will be collated. The findings will summarise existing research on psychosocial aspects of infertility in developing countries and identify gaps in the research corpus. ETHICS AND DISSEMINATION: Data will not be collected from participants. Instead, data will be extracted from published studies and therefore no ethical approval is required. The findings will be published in a peer-reviewed journal.

Exploring adversities among parents convicted of killing their children.

Experiencing adversities has been associated with the use of violence but this has not been explored with filicide offenders in South Africa. Individual, semi-structured interviews were conducted with 22 parents/stepparents/caregivers convicted of child homicide in South Africa, resulting in 49 in-depth interviews. Data were analyzed by means of grounded theory. Using an ecological framework, this study alludes to the widespread and cumulative nature of violence and trauma experiences within multiple domains of the participants' lives. The study highlighted the absence of support in the aftermath of experiencing trauma, possibly resulting in these parents lacking resources to mitigate the sequelae of adverse experiences. This study calls for trauma related, mental health components to be integrated into violence interventions and for these to address the impact of trauma at the individual, family, and societal levels, to prevent the transition from victim to offender.

A systematic review regarding women's emotional and psychological experiences of high-risk pregnancies.

BACKGROUND: High-risk pregnancy refers to a pregnancy that negatively affects the health of the mother, the baby, or both. High-risk pregnancy evokes a range of emotional and psychological experiences for the expectant mother, and can adversely affect both the mother and the baby's health. Medical research on high-risk pregnancy abounds, while women's emotional/psychological experiences are not sufficiently documented, and hence much less attention and/or programming is directed to support women with high risk pregnancies. METHODS: The aim of this review is to present published evidence of how studies reported on the emotional and psychological experiences of a woman's high-risk pregnancy journey. The systematic review examined qualitative studies over a 10 year period that were published between January 2006 and June 2017. These studies were identified on 10 databases. The study utilised three stages of review (i.e. abstract reading, title reading, and full-text reading) and for a successful conduction of the meta-synthesis, this study applied one of the phases provided by Noblit and Hare. RESULTS: The findings provide empirical evidence that women's emotional and psychological experiences (i.e. shock, fear, frustration, grief, isolation and loneliness, anger, sadness, guilt, and mental health disorder) are evident throughout their high-risk pregnancies experience.

The hegemonic role of biomedical discourses in the construction of pregnancy loss.

BACKGROUND AND PROBLEM: Pregnancy is constructed as a joy-filled and natural experience with a taken-for-granted expectation that the outcome will be a healthy baby. However, in South Africa approximately 1 in 4 pregnancies end in miscarriage and the stillbirth rate is 24 per 100 live births. Despite the overwhelming statistics, reproductive loss is considered a cultural taboo and continues to be silenced in various ways by the medical fraternity and society in general. AIM: Our study aimed to demonstrate the role that biomedical discourses play in shaping both women's experiences of reproductive loss as well as how those close to them respond to these losses. The study was located within a social constructionist framework. METHODS: Seven South African women were recruited via snowball sampling to participate in in-depth interviews. A discourse analysis was conducted to deconstruct hegemonic discourses implicit in the participants' dialogues. FINDINGS: The adoption of medical framing of miscarriage and the social awkwardness of loss framed the participants talk about their miscarriages. Our study highlights the centrality of biomedical discourses in influencing both the experiences of our participants as well shaping social discourses. The adoption of the medical framing of miscarriage were identified in the following themes: no answers to first trimester miscarriage and the normalization of miscarriage. The social awkwardness of loss were identified as lack of cultural scripts, lack of acknowledgement and unhelpful words and actions. CONCLUSION: The paper highlights the power inherent in medicine and demonstrates how this hegemony pervades societal understandings of reproductive loss. Caught in this crossfire are grieving mothers with few alternatives in terms of their grief processes.

Exploring the Intersection Between Violence Against Women and Children from the Perspective of Parents Convicted of Child Homicide.

Violence against women and violence against children are distinct research fields. Quantitative studies have demonstrated their intersection, but qualitative data provides an opportunity for a comprehensive understanding of this interface. Interviews with 22 parents/caregivers convicted of child homicide provided an opportunity to explore the context of violent experiences in their lives including their use of violence and their experiences of it in their intimate and parenting relationships. Using a feminist framework, we found that patriarchal family structures, gender and power dynamics contribute to the use of violence. Revenge child homicide was common with distinct gendered differences. This study calls for closer collaboration between the two fields to assist in developing prevention interventions to address and eradicate both forms of violence.

Exploring adverse parent-child relationships from the perspective of convicted child murderers: A South African qualitative study.

Child homicide is the most extreme form of violence against children. Within South Africa, children face the highest risk of homicide by parents/caregivers. It is suggested that prolonged exposure to adverse relationships with one's own parents may be linked to committing child homicide as it may lead to psychological damage and disturb neurological functioning. This paper explores the adverse parent-child relationships of 22 men and women incarcerated for the murder of either a biological child, a stepchild or a child in their care and draws on 49 in-depth interviews with these participants. We illustrate that traumatic parent-child experiences in the form of absent parents, neglect and abuse have a profound impact on establishing unhealthy attachment styles and emphasize the importance of early adverse parent-child bonds in setting the tone for future bonds as adults. The pathway to adopting an adverse attachment with one's own child is argued to be influenced by these early traumatic emotional experiences within the home. This study highlights the need to acknowledge the impact that adverse parent-child experiences have on the formation of violent forms of parental behavior. It is imperative to reduce children's emotional vulnerabilities by implementing strategies to strengthen current parenting practices, to promote the development of less violent parent-child relationships and to work towards resolving parents' experiences of trauma in reducing child homicide.

The Psychological Experience of Women who Survived HELLP Syndrome in Cape Town; South Africa

Background: Haemolysis; elevated liver enzymes and low platelet count (HELLP syndrome) is a high-risk pregnancy condition that could be fatal to mother and/or baby. It is characterised; as the acronym indicates; by haemolysis; elevated liver enzymes and low blood platelets.Objective: This study explored women in Cape Town's psychological experience of HELLP syndrome. Method: Six participants who previously experienced HELLP syndrome were interviewed. Using a grounded theory approach; themes emerged and a model illlustrating the psychological experience of HELLP syndrome was constructed. Results: The major themes that emerged were the perceived lack of information; a need to assign blame and a shift in focus. Themes of not knowing and trance and/or surreal experience underpin the cognitive aspects of the HELLP syndrome experience. Themes that expressed feelings of an inability to control; whirlwind and/or rapid pace and support acted together to bind the experience. Finally; emotions such as anger; ambivalence; disbelief; anxiety; guilt; loneliness and fear were present throughout the experience. Conclusion: This study developed an initial exploratory model representing the psychological experience of HELLP syndrome in a sample of South African women. Underlying this entire experience was a perceived lack of information which had a profound effect on numerous aspects of the experience ranging from where to locate blame to the varied emotions experienced