Primary healthcare worker knowledge related to prenatal and immediate newborn care : a cross sectional study in Masindi, Uganda

BACKGROUND: Global neonatal mortality remains unacceptably high. Health workers who attend to prenatal and postnatal mothers need to be knowledgeable in preventive and curative care for pregnant women and their newborn babies. This study aimed to determine the level of knowledge related to prenatal and immediate newborn care among primary healthcare workers in Masindi, Uganda. METHODS: A cross-sectional study was conducted. Interviews comprised of 25 multiple-choice questions were administered to health workers who were deployed to offer prenatal and postnatal care in Masindi in November 2011. Questions were related to four domains of knowledge: prenatal care, immediate newborn care, management of neonatal infections and identifying and stabilizing Low-Birth Weight (LBW) babies. Corresponding composite variables were derived; level of knowledge among health workers dichotomized as 'adequate' or 'inadequate'. The chi-square statistic test was used to examine associations with independent variables including level of training (nursing assistant, general nurse or midwife), level of care (hospital/health centre level IV or health centre level III/II) and years of service (five years or less, six years or more). RESULTS: 183 health workers were interviewed: general nurses (39.3%), midwives (21.9%) and nursing assistants (38.8%). Respectively, 53.6%, 46.5%, 7.1% and 56.3% were considered to have adequate knowledge in prenatal care, newborn care, management of neonatal infections and identifying/stabilizing LBW babies. Being a general nurse was significantly associated with having adequate knowledge in identifying and stabilizing LBW babies (p < 0.001) compared to being a nursing assistant. Level of care being hospital/health centre level IV was not significantly associated with having adequate knowledge in prenatal or newborn care with reference to health centres of level III/II. CONCLUSION: Knowledge regarding prenatal and newborn care among primary healthcare workers in Masindi was very low. The highest deficit of knowledge was in management of neonatal infections. Efforts are needed to orientate health workers regarding prenatal and newborn care especially the offer of infection management among newborns. Similar levels of knowledge between health workers deployed to hospital/health centre level IV and health centres of level III/II raise important implementation questions for the referral system which is crucial for maternal and newborn survival

Exploring the focus of prenatal information offered to pregnant mothers regarding newborn care in rural Uganda

Background: Neonatal death accounts for one fifth of all under-five mortality in Uganda. Suboptimal newborn care practices resulting from hypothermia, poor hygiene and delayed initiation of breastfeeding are leading predisposing factors. Evidence suggests focused educational prenatal care messages to mitigate these problems. However, there is a paucity of data on the interaction between the service provider and the prenatal service user. This study aims to understand the scope of educational information and current practices on newborn care from the perspectives of prenatal mothers and health workers. Methods: A qualitative descriptive methodology was used. In-depth interviews were conducted with lactating mothers (n = 31) of babies younger than five months old across Masindi in western Uganda. Additional interviews with health workers (n = 17) and their employers or trainers (n = 5) were conducted to strengthen our findings. Data were audio-taped and transcribed verbatim. A thematic content analysis was performed using NVivo 8. Results: Vertical programmes received more attention than education for newborn care during prenatal sessions. In addition, attitudinal and communication problems existed among health workers thereby largely ignoring the fundamental principles of patient autonomy and patient-centred care. The current newborn care practices were largely influenced by relatives' cultural beliefs rather than by information provided during prenatal sessions. There is a variation in the training curriculum for health workers deployed to offer recommended prenatal and immediate newborn care in the different tiers of health care. Conclusions: Findings revealed serious deficiencies in prenatal care organisations in Masindi. Pregnant mothers remain inadequately prepared for childbirth and newborn care, despite their initiative to follow prenatal sessions. These findings call for realignment of prenatal care by integrating education on newborn care practices into routine antenatal care services and be based on principles of patient-centred care

A Cascade Model of Mentorship for Frontline Health Workers in Rural Health Facilities in Eastern Uganda: Processes, Achievements and Lessons

Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers. Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model. Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors. Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better. Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff

Gendered health systems: evidence from low- and middle-income countries

Background Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems. Methods The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. Results Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. Conclusion The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally

Is antenatal care preparing mothers to care for their newborns? : a community-based cross-sectional study among lactating women in Masindi, Uganda

Background: Neonatal mortality has remained resistant to change in the wake of declining child mortality. Suboptimal newborn care practices are predisposing factors to neonatal mortality. Adherence to four ANC consultations is associated with improved newborn care practices. There is limited documentation of this evidence in sub-Saharan Africa where suboptimal newborn care practices has been widely reported. Methods: Structured interviews were held with 928 women having children under-five months old at their homes in Masindi, Uganda, from October-December 2011. Four/more ANC consultations (sufficient ANC) was considered the exposure variable. Three composite variables (complete cord care, complete thermal care and complete newborn vaccination status) were derived by combining related practices from a list of recommended newborn care practices. Logistic regression models were used to assess for associations. Results: One in five women 220(23.7%) were assessed to practice complete cord care. Less than ten percent 57(6.1%) were considered to practice complete thermal care and 611(65.8%) were assessed to have complete newborn vaccination status. Application of substance on the cord 744 (71.6%) and early bathing 816 (87.9%) were main drivers of sub-optimal newborn care practices. Multivariable logistic models did not demonstrate significant association between four/more ANC consultations and complete cord care, complete thermal care or complete newborn vaccination status. Secondary or higher education was associated with complete cord care [adjusted Odds Ratio (aOR): 2.72; 95% CI: 1.63-4.54] and complete newborn vaccination [aOR: 1.37; 95% CI: 1.04-1.82]. Women who reported health facility delivery were more likely to report complete thermal care [aOR: 3.63; 95% CI: 2.21-5.95] and newborn vaccination [aOR: 1.84; 95% CI: 1.23-2.75], but not complete cord care. Having the first baby was associated with complete thermal care [aOR: 2.00; 95% CI: 1.24-3.23]. Conclusion: Results confirm suboptimal newborn care practices in Masindi. Despite being established policy, adherence to four or more ANC consultations was not associated with complete cord care, complete thermal care or complete newborn vaccination. This finding has important implications for the implementation of focused ANC to improve newborn care practices. Future ANC interventions should focus on addressing application of substance on the cord and early bathing of the baby during the immediate neonatal period

Effect of village health team home visits and mobile phone consultations on maternal and newborn care practices in Masindi and Kiryandongo, Uganda : a community-intervention trial

Introduction : The World Health Organisation recommends home visits conducted by Community Health Workers (in Uganda known as Village Health Teams-VHTs) in order to improve maternal and newborn health. This study measured the effect of home visits combined with mobile phone consultations on maternal and newborn care practices. Method : In a community intervention trial design 16 health centres in Masindi and Kiryandongo districts, Uganda were randomly and equally allocated to one of two arms: control and intervention arms. Eight control health centres received the usual maternal and newborn educational messages offered by professional health workers and eight intervention health centres that received an intervention package for maternal care and essential newborn care practices. In the intervention arm VHTs made two prenatal and one postnatal home visit to households. VHTs were provided with mobile phones to enable them make regular telephone consultations with health workers at the health centre serving the catchment area. The primary outcome was health facility delivery. Other outcomes included antenatal attendances, birth preparedness, cord and thermal care and breastfeeding practices. Analysis was by intention-to-treat. Results : A total of 1385 pregnant women were analysed: 758 and 627 in the control and intervention arms respectively. Significant post-intervention differences were: delivery place [adjusted Odds Ratio aOR: 17.94(95% CI: 6.26-51.37); p< 0.001], cord care [aOR: 3.05(95% CI: 1.81-5.12); p< 0.001] thermal care [aOR: 7.58(95% CI: 2.52-22.82); p< 0.001], and timely care-seeking for newborn illness [aOR: 4.93(95% CI: 1.59-15.31); p = 0.006]. Conclusion : VHTs can have an effect in promoting proper cord and thermal care for the newborn and improve timely care-seeking for health facility delivery and newborn illness, because they could answer questions and refer patients correctly. However, VHTs should be supported by professional health workers through the use of mobile phones

Use of mobile phone consultations during home visits by Community Health Workers for maternal and newborn care: community experiences from Masindi and Kiryandongo districts, Uganda

Background: Home visits by Community Health Workers [In Uganda Community Health Workers are given the collective term of Village Health Teams (VHTs). Hereafter referred to as VHTs] is recommended to improve maternal and newborn care. We investigated perceived maternal and newborn benefits of home visits made by VHTs, combined with mobile phone consultations with professional health workers for advice. Methods: A qualitative study was conducted in Masindi and Kiryandongo districts, Uganda, in December-2013 to March-2014. Study participants were drawn from the intervention arm of a randomised community-intervention trial. In-depth interviews were conducted with 20 prenatal and 16 postnatal women who were visited by VHTs; 5 group discussions and 16 key informant interviews were held with VHTs and 10 Key Informant Interviews with professional health workers. Data were analysed using latent content analysis techniques. Results: Majority women and VHTs contend that the intervention improved access to maternal and newborn information; reduced costs of accessing care and facilitated referral. Women, VHTs and professional health workers acknowledged that the intervention induced attitudinal change among women and VHTs towards adapting recommended maternal and newborn care practices. Mobile phone consultations between VHTs and professional health workers were considered to reinforce VHT knowledge on maternal newborn care and boosted the social status of VHTs in community. A minority of VHTs perceived the implementation of recommended maternal and newborn care practices as difficult. Some professional health workers did not approve of the transfer of promotional maternal and newborn responsibility to VHTs. For a range of reasons, a number of professional health workers were not always available on phone or at the health centre to address VHT concerns. Conclusions: Results suggest that home visits made by VHTs for maternal and newborn care are reasonably well accepted. Our study highlights potential benefits of combining home visits with phone consultations between VHTs and professional health workers. However, the challenge of attitudinal change among VHTs towards certain strongly culturally-embedded behavioural post-partum practices, resistance from part of the professional health workforce to collaborate with VHTs and the problematic availability of professional health workers are important systemic problems that need to be addressed

Trial Profile using the CONSORT Flow Diagram.

<p>Trial Profile using the CONSORT Flow Diagram.</p