Customization and acceptability of the WHO labor care guide to improve labor monitoring among health workers in Uganda. An iterative development, mixed method study.

Cognisant of persistently high maternal and perinatal mortality rates, WHO called for adoption and evaluation of new adaptable and context-specific solutions to improve labor monitoring and health outcomes. We aimed at customizing/refining the new WHO labour care guide (LCG) to suite health care provider needs (HCP) in monitoring labour in Uganda. We used mixed methods to customize/refine and pilot test the new WHO LCG using stakeholder perspectives. Between 1st July 2023 and 30th December 2023, we conducted; 1)30 stakeholder interviews to identify user needs/challenges that informed initial modifications of the WHO LCG; 2)15 HCP in-depth interviews to identify any further needs to modify the LCG; 3) Two focus group discussions and 4) Two exit expert panels to identify any further user needs to further refine proposed modifications into the final prototype. Questionnaires were administered to assess acceptability. We interviewed 125 stakeholders with median age of 36 years (IQR;26-48) exposed to the LCG for at least 12 months with 11.8(SD = 4.6) years of clinical practice. Simple useful modifications/customizations based on format, HCP's perceived function and role in improving decision making during monitoring labour included; 1) Customizing LCG by adding key socio-demographic data; 2) Adjusting observation ordering; 3) Modification of medication dosages and 4) Provision for recording key clinical notes/labour outcome data on reverse side of the same A4 paper. All HCPs found the modified WHO LCG useful, easy to use, appropriate, comprehensive, appealing and would recommend it to others for labour monitoring. It was implementable and majority took less than 2 minutes to completely record/fill observations on the LCG after each labour assessment. Active involvement of end-users improved inclusiveness, ownership, acceptability and uptake. The modified LCG prototype was found to be simple, appropriate and easy-to-use. Further research to evaluate large-scale use, feasibility and effectiveness is warranted.

Labour Care Guide implementation as a decision-making tool for monitoring labour among healthcare providers in Uganda: protocol for a mixed-methods study.

INTRODUCTION: The new WHO Labour Care Guide (LCG), also regarded as the 'next-generation partograph', is a core component of 2018 WHO consolidated guidelines on intrapartum care for positive childbirth experience. The Ugandan Ministry of Health is in the process of adopting the new WHO LCG with no local context-specific data to inform this transition. We will explore potential barriers and facilitators to healthcare providers' (HCPs) sustained engagement in labour monitoring in Mbarara city, Southwestern Uganda, and use the data to refine the new WHO LCG and develop a suitable implementation strategy to effectively integrate LCG into routine maternity care in Uganda. We shall then assess effectiveness, validity and other preliminary implementation outcomes of using the new LCG in detecting prolonged labour. METHODS AND ANALYSIS: The study will use a mixed-methods approach to identify key LCG user perspectives to refine and customise the WHO LCG among 120 HCPs and stakeholders involved in maternity care and labour monitoring within facilities in Southwestern Uganda. The refined prototype will be deployed and used to monitor labour in all 14 basic and comprehensive emergency obstetric and newborn care facilities in the study area. We will review labour outcomes of 520 patients monitored using the new LCG and compare these outcomes with a historical cohort of 520 patients monitored using the partograph. The main effectiveness outcome will be the proportion of women diagnosed with prolonged labour and/or obstructed labour. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Mbarara University of Science and Technology Research Ethics Committee (MUST-2023-808) and Uganda National Council for Science and Technology (HS2864ES). We shall obtain written informed consent from each participant. The results of this study will be published in international peer-reviewed journals and presented to the Ugandan Ministry of Health as policy briefs and at selected national/international conferences. TRIAL REGISTRATION NUMBER: NCT05979194.

Dyslipidemia: prevalence and association with precancerous and cancerous lesions of the cervix; a pilot study.

BACKGROUND: In Sub-Saharan Africa, the prevalence of dyslipidemia is on the rise, with studies showing dyslipidemia as a contributing factor to the progression of premalignant lesions to cervical cancer. In Uganda, cervical cancer and dyslipidemia are common health concerns, considering the increasing trends of dyslipidemia in the general population and inadequate information regarding dyslipidemia and cervical lesions. This study aimed to determine the prevalence of dyslipidemia and its association with precancerous and cancerous lesions of the cervix among women attending a cervical cancer clinic at the Uganda Cancer Institute. METHODS: This cross-sectional study was conducted from February to April 2022 among women with premalignant and malignant lesions of the cervix. Data on social demographics and health-seeking behaviours were collected using a pretested structured questionnaire after written informed consent had been obtained. Pap smear collection preceded visual inspection with acetic acid; cervical biopsies were collected appropriately from eligible participants; and cervical lesions were classified using the Bethesda system 2014. Serum lipids, total cholesterol (T.C.), high-density lipoprotein (HDLc), low-density lipoprotein (LDLc), and triglycerides (T.G.s) were analysed using the COBAS™ 6000 Clinical Chemistry Analyser. The associations were assessed using the chi-square test, and P ≤ 0.05 was considered statistically significant. RESULTS: The overall prevalence of dyslipidemia among women with cervical lesions was 118/159 (74%), and low HDLc was the most prevalent at 64.6% (95% CI 39.0-54.3). High T.C. (P = 0.05), high T.G.s (P = 0.011), and low HDL-c (P = 0.05) showed a significant association with precancerous lesions. High LDL-c (P = 0.019), high T.G.s (P = 0.02), and high T.G.s (P < 0.001) showed a statistically significant association with cancerous lesions. CONCLUSION: The prevalence of dyslipidemia was high, with high TC, T.G.s, and low HDL-c significantly associated with precancerous lesions. Also, elevated T.G.s and high LDLc were significantly associated with cancerous lesions. Women may benefit from dyslipidemia screening along with cervical cancer screening. WHAT THIS STUDY ADDS: The present study builds upon previous findings suggesting a link between dyslipidemia and cervical lesions by investigating the relationship between these two factors, specifically in women of this geographical location, where we need adequate information on these associations.

Evaluating the Feasibility, Acceptability, and Preliminary Efficacy of SupportMoms-Uganda, an mHealth-Based Patient-Centered Social Support Intervention to Improve the Use of Maternity Services Among Pregnant Women in Rural Southwestern Uganda: Randomized Controlled Trial.

BACKGROUND: SMS text messaging and other mobile health (mHealth) interventions may improve knowledge transfer, strengthen access to social support (SS), and promote positive health behaviors among women in the perinatal period. However, few mHealth apps have been taken to scale in sub-Saharan Africa. OBJECTIVE: We evaluated the feasibility, acceptability, and preliminary efficacy of a novel, mHealth-based, and patient-centered messaging app designed using behavioral science frameworks to promote maternity service use among pregnant women in Uganda. METHODS: We performed a pilot randomized controlled trial between August 2020 and May 2021 at a referral hospital in Southwestern Uganda. We included 120 adult pregnant women enrolled in a 1:1:1 ratio to receive routine antenatal care (ANC; control), scheduled SMS text or audio messages from a novel messaging prototype (scheduled messaging [SM]), and SM plus SMS text messaging reminders to 2 participant-identified social supporters (SS). Participants completed face-to-face surveys at enrollment and in the postpartum period. The primary outcomes were feasibility and acceptability of the messaging prototype. Other outcomes included ANC attendance, skilled delivery, and SS. We conducted qualitative exit interviews with 15 women from each intervention arm to explore the intervention mechanisms. Quantitative and qualitative data were analyzed using STATA and NVivo, respectively. RESULTS: More than 85% and 75% of participants received ≥85% of the intended SMS text messages or voice calls, respectively. More than 85% of the intended messages were received within 1 hour of the expected time; 18% (7/40) of women experienced network issues for both intervention groups. Over 90% (36/40) of the intervention participants found this app useful, easy to use, engaging, and compatible and strongly recommended it to others; 70% (28/40), 78% (31/40), and 98% (39/40; P=.04) of women in the control, SM, and SS arms, respectively, had a skilled delivery. Half (20/40), 83% (33/40), and all (40/40; P=.001) of the women in the control, SM, and SS arms attended ≥4 ANC visits, respectively. Women in the SS arm reported the highest support (median 3.4, IQR 2.8-3.6; P=.02); <20% (8/40; P=.002) missed any scheduled ANC visit owing to lack of transportation. Qualitative data showed that women liked the app; they were able to comprehend ANC and skilled delivery benefits and easily share and discuss tailored information with their significant others, who in turn committed to providing them the needed support to prepare and seek help. CONCLUSIONS: We demonstrated that developing a novel patient-centered and tailored messaging app that leverages SS networks and relationships is a feasible, acceptable, and useful approach to communicate important targeted health-related information and support pregnant women in rural Southwestern Uganda to use available maternity care services. Further evaluation of maternal-fetal outcomes and integration of this intervention into routine care is needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT04313348; https://clinicaltrials.gov/ct2/show/NCT04313348.

The interaction between antenatal care and abnormal temperature during delivery and its relationship with postpartum care: a prospective study of 1,538 women in semi-rural Uganda.

BACKGROUND: Postnatal care (PNC) is an important tool for reducing maternal and neonatal morbidity and mortality. However, what predicts receipt and maintenance in PNC, particularly events during pregnancy and the peripartum period, is not well understood. We hypothesized that fever or hypothermia during delivery would engender greater health consciousness among those attending antenatal care, leading to greater PNC engagement after hospital discharge and our objective was to evaluate this relationship. METHODS: Women were prospectively enrolled immediately postpartum at Mbarara Regional Referral Hospital (MRRH). We collected postpartum vital signs and surveyed women by telephone about PNC receipt, fever, and infection at two and six weeks postpartum. Our outcome of interest was receipt of PNC post-discharge, defined as whether a participant visited a health facility and/or was hospitalized in the postpartum period. Our explanatory variables were whether a participant was ever febrile (> 38.0˚C) or hypothermic (< 36.0˚C) during delivery stay and whether a participant attended at least 4 antenatal care (ANC) visits. We used logistic regressions to estimate the association between ANC and fever/hypothermia with PNC, including an interaction term between ANC and fever/hypothermia to determine whether there was a modifying relationship between variables on PNC. Regression models were adjusted for age, marital status, parity, HIV serostatus, Mbarara residency, and whether the participant was referred to MRRH, RESULTS: Of the 1,541 women, 86 (5.6%) reported visiting a health facility and/or hospitalization and 186 (12.0%) had an abnormal temperature recorded during delivery stay. Of those who reported at least one visit, 59/86 (68.6%) delivered by cesarean, 37/86 (43.0%) reported post-discharge fever, and 44/86 (51.2%) reported post-discharge infection. Neither ANC attendance, abnormal temperature after delivery, nor their interaction term, were significantly associated with post-discharge PNC. The included covariates were not significantly associated with the outcome. CONCLUSIONS: While the overall proportion of women reporting post-discharge PNC was low, those who reported visiting a health facility and/or hospitalization had high proportions of post-discharge fever, post-discharge infection, and cesarean delivery, which suggests that these visits may have been related to problem-focused care. No significant associations between ANC and PNC were observed in this cohort. Further research assessing ANC quality and PNC visit focus is needed to ensure ANC and PNC are optimized to reduce morbidity and mortality.

Challenges in accessing maternal and child health services during COVID-19 and the potential role of social networking technologies.

Background: The COVID-19 pandemic causes new challenges to women and their babies who still need to access postnatal care amidst the crisis. The novel application of social network technologies (SNTs) could potentially enhance access to healthcare during this difficult time. Objectives: This study describes the challenges experienced in accessing maternal and child health services by women with limited or no education during this COVID-19 pandemic and discusses the potential of SNTs to support maternal and child health amidst this crisis. Methods: We administered surveys to women who had recently given birth in a rural setting and interviewed a purposively selected subset to ascertain their experiences of accessing maternal and child health services during the COVID-19 pandemic. Our analysis involved descriptive analysis of quantitative data using STATA 13 to describe study participants' characteristics, and content analysis of qualitative data to derive categories describing maternal health challenges. Results: Among 50 women, the median age was 28 years (interquartile range 24-34), 42 (84%) completed upper primary education. Access to the health facility was constrained by transport challenges, fear of contracting COVID-19, and delays at the facility. Due to the COVID-19 crisis, 42 (84%) women missed facility visits, 46 (92%) experienced financial distress, 43 (86%) had food insecurity, and 44 (88%) felt stressed. SNTs can facilitate remote and timely access to health services and information, and enable virtual social connections and support. Conclusion: SNTs have the potential to mitigate the challenges faced in accessing maternal and child health services amidst the ongoing COVID-19 pandemic.

Short interbirth interval and associated factors among women with antecedent cesarean deliveries at a tertiary hospital, Southwestern Uganda.

BACKGROUND: Women with previous cesarean deliveries, have a heightened risk of poor maternal and perinatal outcomes, associated with short interbirth intervals. We determined the prevalence of short interbirth interval, and associated factors, among women with antecedent cesarean deliveries who delivered at Mbarara Regional Referral Hospital (MRRH), in southwestern Uganda. METHODS: We conducted a cross-sectional study on the postnatal ward of MRRH from November 2020 to February 2021. We enrolled women who had antecedent cesarean deliveries through consecutive sampling. We obtained participants' socio-demographic and obstetric characteristics through interviewer-administered structured questionnaires. We defined short interbirth interval as an interval between two successive births of < 33 months. Modified Poisson regression was used to identify factors associated with short interbirth intervals. RESULTS: Of 440 participants enrolled, most had used postpartum family planning (PPFP) prior to the current pregnancy (67.5%), and most of the pregnancies (57.2%) were planned. The mean age of the participants was 27.6 ± 5.0 years. Of the 440 women, 147 had a short interbirth interval, for a prevalence of 33% (95%CI: 29-38%). In multivariable analysis, non-use of PPFP (adjusted prevalence ratio [aPR] = 2.24; 95%CI: 1.57-3.20, P < 0.001), delivery of a still birth at an antecedent delivery (aPR = 3.95; 95%CI: 1.43-10.9, P = 0.008), unplanned pregnancy (aPR = 3.59; 95%CI: 2.35-5.49, P < 0.001), and young maternal age (aPR = 0.25 for < 20 years vs 20-34 years; 95%CI: 0.10-0.64, P = 0.004), were the factors significantly associated with short interbirth interval. CONCLUSION: One out of every three womenwith antecedent caesarean delivery had a short interbirth interval. Short interbirth intervals were more common among women with history of still births, those who did not use postpartum family planning methods, and those whose pregnancies were unplanned, compared to their counterparts. Young mothers (< 20 years) were less likely to have short interbirth intervals compared to those who were 20 years or older. Efforts should be made to strengthen and scale up child-spacing programs targeting women with previous cesarean deliveries, given the high frequency of short interbirth intervals in this study population.

Understanding the Effect of a Healthcare Provider-Led Family Planning Support Intervention on Contraception use and Pregnancy Desires among Postpartum Women Living with HIV in Southwestern Uganda.

Modern contraceptive prevalence among women living with HIV (WLWH) in Uganda is still low at 45%, and up to a third of women are likely to discontinue the method within the first year of initiation. This increases risks of unplanned pregnancies, perinatal HIV transmission and pregnancy complications. We aim to explore and explain the mechanism of effect of a family planning support intervention investigated in a randomized controlled trial conducted between October 2016 and June 2018 among 320 postpartum WLWH at a referral hospital in Southwestern Uganda that led to improved uptake, decreased contraception discontinuation and lowered pregnancy rates. Thirty WLWH and 10 of their primary sexual partners who participated in this trial were purposively selected and interviewed in the local language; interviews were digitally recorded. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. Up to 83% of women wanted to avoid pregnancy within the first year postpartum. Qualitative data showed that contraception uptake and use were influenced by: 1) Participant awareness and understanding of different methods available; 2) Participant perception of offered health services; 3) Healthcare provider (HCP) socio-cultural sensitivity to individual experiences and (mis)conceptions surrounding contraception; 4) Having tactile engagement, follow-up reminders and a reference to prompt action or discussions with partners. Supportive and culturally sensitive HCPs and systems facilitated information sharing leading to increased patient awareness and understanding of the contraceptive methods, and improved health user experience, care engagement, confidence and willingness to take up and continue using modern contraceptive methods.

Incidence and predictors of preterm neonatal mortality at Mbarara Regional Referral Hospital in South Western Uganda.

INTRODUCTION: Preterm neonatal mortality contributes substantially to the high neonatal mortality globally. In Uganda, preterm neonatal mortality accounts for 31% of all neonatal deaths. Previous studies have shown variability in mortality rates by healthcare setting. Also, different predictors influence the risk of neonatal mortality in different populations. Understanding the predictors of preterm neonatal mortality in the low-resource setting where we conducted our study could guide the development of interventions to improve outcomes for preterm neonates. We thus aimed to determine the incidence and predictors of mortality among preterm neonates born at Mbarara Regional Referral Hospital (MRRH) in South Western Uganda. METHODS: We prospectively enrolled 538 live preterm neonates born at MRRH from October 2019 to September 2020. The neonates were followed up until death or 28 days, whichever occurred first. We used Kaplan Meier survival analysis to describe preterm neonatal mortality and Cox proportional hazards regression to assess predictors of preterm neonatal mortality over a maximum of 28 days of follow up. RESULTS: The cumulative incidence of preterm neonatal mortality was 19.8% (95% C.I: 16.7-23.5) at 28 days from birth. Birth asphyxia (adjusted hazard ratio [aHR], 14.80; 95% CI: 5.21 to 42.02), not receiving kangaroo mother care (aHR, 9.50; 95% CI: 5.37 to 16.78), delayed initiation of breastfeeding (aHR, 9.49; 95% CI: 2.84 to 31.68), late antenatal care (ANC) booking (aHR, 1.81 to 2.52; 95% CI: 1.11 to 7.11) and no ANC attendance (aHR, 3.56; 95% CI: 1.51 to 8.43), vaginal breech delivery (aHR, 3.04; 95% CI: 1.37 to 5.18), very preterm births (aHR, 3.17; 95% CI: 1.24 to 8.13), respiratory distress syndrome (RDS) (aHR, 2.50; 95% CI: 1.11 to 5.64) and hypothermia at the time of admission to the neonatal unit (aHR, 1.98; 95% CI: 1.18 to 3.33) increased the risk of preterm neonatal mortality. Attending more than 4 ANC visits (aHR, 0.35; 95% CI: 0.12 to 0.96) reduced the risk of preterm neonatal mortality. CONCLUSIONS: We observed a high cumulative incidence of mortality among preterm neonates born at a low-resource regional referral hospital in Uganda. The predictors of mortality among preterm neonates were largely modifiable factors occurring in the prenatal, natal and postnatal period (lack of ANC attendance, late ANC booking, vaginal breech delivery, birth asphyxia, respiratory distress syndrome, and hypothermia at the time of admission to the neonatal unit, not receiving kangaroo mother care and delayed initiation of breastfeeding). These findings suggest that investment in and enhancement of ANC attendance, intrapartum care, and the feasible essential newborn care interventions by providing the warm chain through kangaroo mother care, encouraging early initiation of breastfeeding, timely resuscitation for neonates when indicated and therapies reducing the incidence and severity of RDS could improve outcomes among preterm neonates in this setting.

Structured and sustained family planning support facilitates effective use of postpartum contraception amongst women living with HIV in South Western Uganda: A randomized controlled trial.

BACKGROUND: Despite low pregnancy intentions, many women accessing contraception discontinue use, increasing the risk of unwanted pregnancies among women living with HIV (WLWH). We evaluate whether a family planning support intervention, inclusive of structured immediate one-on-one postpartum counseling, and a follow-up mechanism through additional health information and SMS reminders affects continuous contraceptive use and pregnancy incidence among recently postpartum WLWH. METHODS: We performed a randomized controlled trial between October 2016 and June 2018 at a referral hospital in southwestern Uganda. We included adult WLWH randomized and enrolled in a 1:1 ratio to receive family planning support or standard of care (control) and completed an interviewer-administered questionnaire at enrolment, 6 and 12 months postpartum. Our two primary outcomes of interest were; continuous use of contraception, and incidence of pregnancy. Secondary outcomes included contraception uptake, method change, discontinuation and pregnancy intentions. The trial was registered with clinicaltrials.gov (NCT02964169). RESULTS: A total of 317(99%) completed all study procedures. Mean age was 29.6 (SD = 6.0) vs 30.0 (SD = 5.9) years for the intervention vs control groups respectively. All women were enrolled on ART. Total women using contraception continuously were 126 (79.8%) in the intervention compared to 110 (69.2%) in control group (odds ratio (OR) = 1.75; confidence interval (CI) = 1.24-2.75, P = 0.003). Pregnancy rates were 2% (N = 3) in the intervention vs 9% (N = 14) in the control group (OR = 0.20, 95% CI = 0.05-0.62, P = 0.006). Pregnancy intention was lower in the intervention vs control group (OR = 0.23, 95% CI = 0.08-0.64, P = 0.002). Women actively enrolled on contraception reduced more in the control compared to the intervention group (OR = 3.92, 95% CI = 1.66-9.77, P = 0.001). Women enrolled on each contraceptive method did not differ by group except for implants. More women initiating contraception use within three months postpartum had better continued use for either intervention (N = 123, 97.6% vs N = 3,2.4%) or control group (N = 86,78.2% vs N = 24,21.8%). Method-related side effects were less reported in the intervention group (OR = 0.25, 95% CI = 0.10-0.60, P = 0.001). CONCLUSION: We found that sustained and structured family planning support facilitates continuous use of contraception and lowers rates of pregnancy amongst postpartum WLWH in rural southwestern Uganda. Women who initiated contraception within three months postpartum were more likely to maintain continuous use of contraception than those initiating later. Further evaluation of actual and perceived facilitators to the continuous contraception use by this support intervention will help replication in similar settings. TRIAL REGISTRATION: NCT02964169.

Factors associated with delayed onset of active labor following vaginal misoprostol administration among women at Mbarara Regional Referral Hospital, Uganda.

OBJECTIVE: To determine the factors associated with delayed onset of active labor following labor induction with vaginal misoprostol. METHODS: We conducted a prospective cohort study over 6 months at a tertiary hospital in Uganda. We enrolled mothers with pregnancies of at least 28 weeks, who were undergoing labor induction with 50 µg of vaginal misoprostol, administered every 6 hours with a maximum of four doses, and followed them up until onset of active labor. Labor onset was considered delayed if it occurred later than 12 hours after the first dose. Bivariate and multivariate analysis was performed to determine factors associated with delayed onset of active labor. RESULTS: Of the 88 mothers enrolled, 22.7% (n=20) had delayed onset of active labor. Nulliparity (adjusted relative risk [aRR] 2.34, 95% confidence interval [CI] 1.17-4.68) and gestational age less than 37 weeks (aRR 3.79, 95% CI 1.40-10.23) were associated with delayed onset of active labor following vaginal misoprostol administration whereas higher body mass index (aRR 0.38, 95% CI 0.18-0.79) decreased the risk. CONCLUSION: Delayed onset of active labor following labor induction remains an important obstetric care challenge. Mothers undergoing labor induction should have their body mass index documented, and nulliparous women and mothers at less than 37 weeks of gestation should have their labor monitored for a longer duration following labor induction.

Antenatal Care Visit Attendance Frequency and Birth Outcomes in Rural Uganda: A Prospective Cohort Study.

OBJECTIVES: Antenatal care (ANC) is designed to improve pregnancy outcomes by providing screening and treatment for preventable and treatable diseases. However, data are lacking on whether ANC affects stillbirth risk. We hypothesized stillbirth risk in Uganda is lower in women attending the recommended ≥ 4 ANC visits compared to those attending ≤ 3. METHODS: We performed a secondary analysis of subset of 1,785 women enrolled in a prospective cohort of postpartum infection who presented to a regional referral hospital for delivery. Our primary outcome was documented stillbirth; a secondary composite poor birth outcome included stillbirth, early neonatal death, low birth weight (< 2500 g), and 5-min APGAR score < 7. We performed multivariable logistic regression analyses to identify independent correlates of stillbirth and poor birth outcome. RESULTS: Of 1,785 participants, 58 (3%) pregnancies resulted in stillbirth and 198 (11%) had a poor birth outcome. Of 1,236 women attending ≥ 4 ANC visits, 31 (2.5%) had a stillbirth, compared to 27/510 (5.2%) attending ≤ 3. In multivariable analyses controlling for age, parity, distance traveled, referral status to hospital, malaria prophylaxis, and syphilis infection; attending ≥ 4 ANC visits was associated with significantly reduced odds of stillbirth (aOR 0.5, 95% CI 0.3-0.9, P = 0.02) and poor birth outcome (aOR 0.66, 95% CI 0.4-0.96, P = 0.03). Malaria prophylaxis was also independently associated with reduced odds of stillbirth (aOR 0.05, 95% CI 0.2-1.0, P = 0.04). CONCLUSIONS: Attending ≥ 4 ANC visits was associated with reduced odds of stillbirth and poor birth outcomes in this Ugandan cohort, which may be related to more comprehensive infection screening, treatment, and prevention services.

Women's Choice to Deliver at Home: Understanding the Psychosocial and Cultural Factors Influencing Birthing Choices for Unskilled Home Delivery among Women in Southwestern Uganda.

BACKGROUND: Utilization of perinatal services in Uganda remains low, with correspondingly high rates of unskilled home deliveries, which can be life-threatening. We explored psychosocial and cultural factors influencing birthing choices for unskilled home delivery among postpartum women in rural southwestern Uganda. METHODS: We conducted in-depth qualitative face-to-face interviews with 30 purposively selected women between December 2018 and March 2019 to include adult women who delivered from their homes and health facility within the past three months. Women were recruited from 10 villages within 20 km from a referral hospital. Using the constructs of the Health Utilization Model (HUM), interview topics were developed. Interviews were conducted and digitally recorded in a private setting by a native speaker to elicit choices and experiences during pregnancy and childbirth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive categories using inductive content analytic approach. RESULTS: Eighteen women (60%) preferred to deliver from home. Women's referent birth location was largely intentional. Overall, the data suggest women choose home delivery (1) because of their financial dependency and expectation for a "natural" and normal childbirth, affecting their ability and need to seek skilled facility delivery; (2) as a means of controlling their own birth processes; (3) out of dissatisfaction with facility-based care; (4) out of strong belief in fate regarding birth outcomes; (5) because they have access to alternative sources of birthing help within their communities, perceived as "affordable," "supportive," and "convenient"; and (6) as a result of existing gender and traditional norms that limit their ability and freedom to make family or health decisions as women. CONCLUSION: Women's psychosocial and cultural understandings of pregnancy and child birth, their established traditions, birth expectations, and perceptions of control, need, and quality of maternity care at a particular birthing location influenced their past and future decisions to pursue home delivery. Interventions to address barriers to healthcare utilization through a multipronged approach could help to debunk misconceptions, increase perceived need, and motivate women to seek facility delivery.

When Women Deliver at Home Without a Skilled Birth Attendant: A Qualitative Study on the Role of Health Care Systems in the Increasing Home Births Among Rural Women in Southwestern Uganda.

BACKGROUND: Uganda's maternal mortality remains unacceptably high, with thousands of women and newborns still dying of preventable deaths from pregnancy and childbirth-related complications. Globally, Antenatal care (ANC) attendance has been associated with improved rates of skilled births. However, despite the fact that over 95% of women in Uganda attend at least one ANC, over 30% of women still deliver at home alone, or in the presence of an unskilled birth attendant, with many choosing to come to hospital after experiencing a complication. We explored barriers to women's decisions to deliver in a health care facility among postpartum women in rural southwestern Uganda, to ultimately inform interventions aimed at improving skilled facility births. METHODS: Between December 2018 and March 2019, we conducted in-depth qualitative face-to-face interviews with 30 post-partum women in rural southwestern Uganda. The purposeful sample was intended to represent women with differing experiences of pregnancy, delivery, and antenatal care. We included 15 adult women who had delivered from their homes and 15 who had delivered from a health facility in the previous 3 months. Women were recruited from 10 villages within 20 km of a regional referral hospital. Interviews were conducted and digitally recorded in a private setting by a trained native speaker to elicit experiences of pregnancy and birth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. RESULTS: Regardless of where they decided to give birth, women wished to deliver in a supportive, respectful, responsive and loving environment. The data revealed six key barriers to women's decisions to deliver from a health care facility: 1) Fear of unresponsive care, fueling a fear of being neglected or abandoned while at the facility; 2) fear of embarrassment and mistreatment by health care providers; 3) low perception of risk associated with pregnancy and childbirth; 4) preferences for particular birthing positions and their outcome expectations; 5) perceived lack of privacy in public facilities; and 6) perceived poor clinical and interpersonal skills of health providers to adequately explain birthing procedures or support expectant or laboring women and their newborn. CONCLUSION: Anticipation of unsupportive, unresponsive, disrespectful treatment, and a perceived lack of tolerance for simple, non-harmful traditions prevent women from delivering at health facilities. Building better interpersonal relationships between patients and providers within health systems could reinforce trust, improve patient-provider interaction, and facilitate useful information transfer during ANC and delivery visits. These expectations are important considerations in developing supportive health care systems that provide acceptable patient-friendly care. These findings are indicative of the vital need for midwives and other health care providers to have additional training in the role of communication and dignity in delivery of quality health care.

Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial.

BACKGROUND: Unwanted pregnancies remain a burden for women living with HIV (WLWH). Family planning prevents unplanned pregnancies while promoting longer birth intervals, key strategies to eliminate perinatal transmission of HIV and promote maternal and child health. We evaluated the effect of a family planning voucher, inclusive of immediate postpartum counseling, on uptake, early initiation, and continuation of modern contraceptive methods among recently postpartum WLWH delivering at a publicly funded regional referral hospital in rural, southwestern Uganda. METHODS AND FINDINGS: We performed a randomized controlled trial between October, 2016 and June, 2018 at a referral hospital in southwestern Uganda. This interim analysis includes adult WLWH randomized and enrolled equally to receive a family planning voucher or standard of care (control). Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrollment and 6 months postpartum. Our primary outcome of interest for this analysis is initiation of a modern family planning method within 8 weeks postpartum. Secondary outcomes included family planning initiation at 12, 14, 16, and 20 weeks postpartum, family planning discontinuation and/or change, pregnancy incidence, and mean time without contraception. The trial was registered with clinicaltrials.gov (NCT02964169). At enrollment, half of the women in both the voucher (N = 87, 55%) and control (N = 86, 54%) groups wanted to have a child in 2 years postpartum. Over 80% of referent pregnancies in the voucher (N = 136, 86%) and control (N = 128, 81%) groups were planned. All women were accessing ART. The mean CD4 count was 396 cells/mm3 (SD = 61) for those enrolled in the control group versus 393 cells/mm3 (SD = 64) in the family planning voucher group. By 8 weeks postpartum, family planning was initiated in 144 (91%) participants in the voucher group and 83 (52%) participants in the control group (odds ratio [OR] 9.42; CI 4.67-13.97, P < 0.001). We also found high family planning uptake rates for both groups, with higher rates among the intervention group at 12 weeks (OR 5.66; CI 2.65-12.12, P < 0.001), 14 weeks (OR 2.51; CI 1.31-4.79, P < 0.001), 16 weeks (OR 4.02; CI 1.66-9.77, P = 0.001), and 20 weeks (OR 3.65; CI 1.40-9.47, P = 0.004) postpartum. The average time to family planning initiation was reduced to 5.9 weeks (SD = 2.4) for those in the voucher group compared to 9.3 weeks (SD = 5) in the control (P < 0.001). One pregnancy was recorded in the group receiving standard of care; none were reported in the voucher group. Method mix did not differ by group: injectables were selected by most women (N = 150, 50%), and 52% of this proportion were in the experimental arm, with <10% in each arm selecting condoms, oral contraception, or intrauterine devices (IUDs). Similar proportions of women changed contraceptive methods over the 6-month follow-up in the voucher and control groups (N = 8, 5% versus N = 5, 4%; P = 0.467). More women in the control group discontinued contraception for 1 to 2 weeks (N = 19, 13% versus N = 7, 5%; P = 0.008) or more than 4 weeks (N = 15, 10% versus N = 3, 2%; P = 0.002) compared to those given a family planning voucher. The main limitation of this study is that its findings may not be generalized to settings without improved availability of contraceptives in publicly funded facilities. CONCLUSION: These findings indicate that a well-structured, time-bound family planning voucher program appeared to increase early postpartum contraceptive uptake and continuation in a setting in which users are faced with financial, knowledge, and structural barriers to contraceptive services. Further work should clarify the role of vouchers in empowering WLWH to avoid unintended pregnancies over time. TRIAL REGISTRATION: ClinicalTrials.gov NCT02964169.

Factors Associated with Pregnancy Intentions Amongst Postpartum Women Living with HIV in Rural Southwestern Uganda.

Comprehensive HIV treatment and care makes it safer for women living with HIV (WLWH) to have the children they desire, partly through provision and appropriate use of effective contraception. However, nearly one third of WLWH in-care in a large Ugandan cohort became pregnant within 3 years of initiating ART and half of these incident pregnancies (45%) were unplanned. We therefore describe future pregnancy plans and associated factors among postpartum WLWH in rural southwestern Uganda in order to inform interventions promoting postpartum contraceptive uptake. This analysis includes baseline data collected from adult WLWH enrolled into a randomized controlled trial to evaluate the effect of family planning support versus standard of care at 12 months postpartum in southwestern Uganda. Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrolment. Among 320 enrolled women, mean age, CD4 count, and duration on ART was 28.9 (standard deviation [SD] 5.8) years, 395 cells/mm3 (SD = 62) and 4.6 years (SD = 3.9), respectively. One-hundred and eighty nine (59%) of women reported either personal (175, 55%) or partner (186, 58%) desire for more children in the next 2 years. Intentions to have more children was strongly associated with partner's desire for more children (AOR = 31.36; P < 0.000), referent pregnancy planned (AOR = 2.69; P = 0.050) and higher household income > 150,000 Shs per month (AOR = 1.37; P = 0.010). Previous use of modern contraception (AOR = 0.07; P = 0.001), increasing age (AOR = 0.34; P = 0.012), having > 2 own children living in a household (AOR = 0.42; P = 0.021) and parity > 2 (AOR = 0.59; P = 0.015) were associated with reduced odds of pregnancy intention. Our findings highlight the role male partners play in influencing pregnancy intentions postpartum and the importance of engaging men in sexual and reproductive health counselling about child spacing for the health of women, children, and families. This should be addressed alongside key individual-level social, demographic, economic and structural factors within which couples can understand risks of unplanned pregnancies and access effective contraceptive methods when they need or want them.

Functionality and acceptability of a wireless fetal heart rate monitoring device in term pregnant women in rural Southwestern Uganda.

BACKGROUND: Over 3 million stillbirths occur annually in sub Saharan Africa; most occur intrapartum and are largely preventable. The standard of care for fetal heart rate (FHR) assessment in most sub-Saharan African settings is a Pinard Stethoscope, limiting observation to one person, at one point in time. We aimed to test the functionality and acceptability of a wireless FHR monitor that could allow for expanded monitoring capacity in rural Southwestern Uganda. METHODS: In a mixed method prospective study, we enrolled 1) non-laboring healthy term pregnant women to wear the device for 30 min and 2) non-study clinicians to observe its use. The battery-powered prototype uses Doppler technology to measure fetal cardiotocographs (CTG), which are displayed via an android device and wirelessly transmit to cloud storage where they are accessible via a password protected website. Prototype functionality was assessed by the ability to obtain and transmit a 30-min CTG. Three obstetricians independently rated CTGs for readability and agreement between raters was calculated. All participants completed interviews on acceptability. RESULTS: Fifty pregnant women and 7 clinicians were enrolled. 46 (92.0%) CTGs were successfully recorded and stored. Mean scores for readability were 4.71, 4.71 and 4.83 (out of 5) with high agreement (intra class correlation 0.84; 95% CI 0.74 to 0.91). All pregnant women reported liking or really liking the device, as well as high levels of comfort, flexibility and usefulness of the prototype; all would recommend it to others. Clinicians described the prototype as portable, flexible, easy-to-use and a time saver. Adequate education for clinicians and women also seemed to improve correct usage and minimise concerns on safety of the device. CONCLUSIONS: This prototype wireless FHR monitor functioned well in a low-resource setting and was found to be acceptable and useful to both pregnant women and clinicians. The device also seemed to have potential to improve the experience of the users compared with standard of care and expand monitoring capacity in settings where bulky, wired or traditional equipment are unreliable. Further research needs to investigate the potential impact and cost of such innovations to improve perinatal outcomes.

Occurrence of anti-D alloantibodies among pregnant women in Kasese District, Western Uganda.

OBJECTIVES: This study was undertaken to determine the distribution of ABO/RhD (rhesus D antigen) blood phenotypes, prevalence of anti-D alloantibodies, and the risk factors for alloimmunization among pregnant women in Kasese District, Western Uganda. MATERIALS AND METHODS: Ethylenediamine tetraacetic acid-containing plasma samples and serum samples were taken from pregnant women attending the antenatal clinic. The blood groups were identified using the microplate grouping method, while the presence of anti-D alloantibodies was detected by the indirect antiglobulin test (IAT). Data were also collected from the pregnant women on the risk factors associated with anti-D alloantibody formation. RESULTS: Among the 726 participants, the blood group distribution was as follows: O: 356 (49.%); A: 190 (26.%); B: 152 (21%); and AB: 28 (4%). A total of 28 (3.86%) pregnant women were RhD negative. Anti-D alloantibodies were detected in 88 (12.1%) of the participants; and of these, 13 (14.8%) were RhD negative. Statistically significant risk factors for anti-D alloimmunization included miscarriage, stillbirth, and postpartum hemorrhage. CONCLUSION: Blood group O was the most common among the pregnant women in this study and the prevalence of Rh negativity was 3.8%. The frequency of anti-D alloimmunization among pregnant women in Kasese District was 12.12%, with 85.5% of these being RhD positive. Risk factors such as a history of stillbirths, miscarriages, and incidence of postpartum hemorrhage were significantly associated with anti-D alloimmunization. There is a need to routinely carry out antenatal blood grouping and IAT screening on pregnant women in Uganda to detect anti-D alloimmunization. Given the high prevalence of anti-D alloantibody formation among RhD-positive women, we recommend additional research studies on the role of autoimmunity among antigen-positive women, as well as the occurrence of RhD variants plus their implications on hemolytic disease of the fetus and newborn, in Uganda.