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BMC Health Services Research
Published in: BMC Health Services Research 1/2018

Open Access 01-12-2018 | Research article

Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys

Authors: Lenka Benova, Mardieh L. Dennis, Isabelle L. Lange, Oona M. R. Campbell, Peter Waiswa, Manon Haemmerli, Yolanda Fernandez, Kate Kerber, Joy E. Lawn, Andreia Costa Santos, Fred Matovu, David Macleod, Catherine Goodman, Loveday Penn-Kekana, Freddie Ssengooba, Caroline A. Lynch

Published in: BMC Health Services Research | Issue 1/2018

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Abstract

Background

Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011.

Methods

We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests.

Results

Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency; < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components.

Conclusions

The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care (facility delivery). Providers in both sectors require quality improvements. Achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women despite competing priorities for financial and human resources.
Appendix
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Literature
1.
Victora CG, Requejo JH, Barros AJD, Berman P, Bhutta Z, Boerma T, Chopra M, de Francisco A, Daelmans B, Hazel E, et al. Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival. Lancet. 2015.
2.
Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, Fat DM, Boerma T, Temmerman M, Mathers C, Say L. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN maternal mortality estimation inter-agency group. Lancet. 2016;387:462–74.CrossRef
3.
United Nations Department of Economic and Social Affairs Population Division. World population prospects: the 2015 revision. In: Book World Population Prospects: The 2015 Revision. City; 2015.
4.
WHO, UNICEF, UNFPA, World Bank Group, United Nations Population Division. Trends in maternal mortality: 1990 to 2015. In: Book Trends in maternal mortality: 1990 to 2015. City; 2015.
5.
Orobaton N, Austin A, Fapohunda B, Abegunde D, Omo K. Mapping the prevalence and sociodemographic characteristics of women who deliver alone: evidence from demographic and health surveys from 80 countries. Glob Health Sci Pract. 2016;4:99–113.CrossRef
6.
Kujala S, Waiswa P, Kadobera D, Akuze J, Pariyo G, Hanson C. Trends and risk factors of stillbirths and neonatal deaths in eastern Uganda (1982-2011): a cross-sectional, population-based study. Trop Med Int Health. 2017;22:63–73.CrossRef
7.
Campbell O, Graham W. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368:1284–99.CrossRef
8.
Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, Lumbiganon P, Farnot U, Bersgjø P. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001;357:1565–70.CrossRef
9.
Carroli G, Rooney C, Villar J. How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatr Perinat Epidemiol. 2001;15(Suppl 1):1–42.CrossRef
10.
Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizan J, Farnot U, Al-Mazrou Y, Carroli G, Pinol A, Donner A, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001;357:1551–64.CrossRef
11.
McClure EM, Goldenberg RL, Bann CM. Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries. Int J Gynaecol Obstet. 2007;96:139–46.CrossRef
12.
World Health Organization. Standards for maternal and neonatal care. In: Book standards for maternal and neonatal care. City: World Health Organization. p. 2007.
13.
Abou-Zahr C, Wardlaw T. Antenatal care in developing countries: promises, achievements and missed opportunities: an analysis of trends, levels and differentials, 1990–2001. In: Book Antenatal care in developing countries: promises, achievements and missed opportunities: an analysis of trends, levels and differentials, 1990-2001. City: World Health Organization and UNICEF; 2003.
14.
Ronsmans C, Graham WJ. Maternal mortality: who, when, where, and why. Lancet. 2006;368:1189–200.CrossRef
15.
Campbell O, Graham W. Measuring maternal mortality and morbidity: levels and trends. In: Book Measuring maternal mortality and morbidity: levels and trends. City: London School of Hygiene and Tropical Medicine; 1990.
16.
WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality 1990 to 2010. In: Book trends in maternal mortality 1990 to 2010. City: World Health Organization; 2012.
17.
Moyer CA, Dako-Gyeke P, Adanu RM. Facility-based delivery and maternal and early neonatal mortality in sub-Saharan Africa: a regional review of the literature. Afr J Reprod Health. 2013;17:30–43.PubMed
18.
UNICEF, World Health Organization. Countdown to 2015: A Decade of Tracking Progress for Maternal, Newborn and Child Survival. The 2015 Report. In: Book Countdown to 2015: A Decade of Tracking Progress for Maternal, Newborn and Child Survival. The 2015 Report. City: WHO. p. 2015.
19.
Uganda Bureau of Statistics (UBOS) and ICF International Inc. Uganda Demographic and Health Survey 2011. In: Book Uganda demographic and health survey 2011. City: UBOS and ICF International Inc; 2012.
20.
Mbonye AK, Sentongo M, Mukasa GK, Byaruhanga R, Sentumbwe-Mugisa O, Waiswa P, Naamala Sengendo H, Aliganyira P, Nakakeeto M, Lawn JE, et al. Newborn survival in Uganda: a decade of change and future implications. Health Policy Plan. 2012;27(Suppl 3):iii104–17.CrossRef
21.
Ssengooba R, Neema S, Mbonye A, Sentubwe O, Onama V. Maternal health review Uganda. In: Book Maternal Health Review Uganda. City: Makerere University Institute of Public Health, Health Systems Development Programme.
22.
Statistics Department [Uganda] and Macro International Inc. Uganda Demographic and Health Survey, 1995. In: Book Uganda demographic and health survey, 1995. City: Statistics Department [Uganda] and Macro International Inc.; 1996.
23.
Uganda Bureau of Statistics (UBOS) and Macro International Inc. Uganda Demographic and Health Survey 2006. In: Book Uganda demographic and health survey 2006. City: UBOS and Macro International Inc; 2007.
24.
Uganda Bureau of Statistics (UBOS) and ORC Macro. Uganda Demographic and Health Survey 2000-2001. In: Book Uganda Demographic and Health Survey 2000–2001. City: UBOS and ORC Macro; 2001.
25.
Nabyonga-Orem J, Karamagi H, Atuyambe L, Bagenda F, Okuonzi SA, Walker O. Maintaining quality of health services after abolition of user fees: a Uganda case study. BMC Health Serv Res. 2008;8:102.CrossRef
26.
Ridde V, Morestin F. A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan. 2011;26:1–11.CrossRef
27.
Nguyen H, Snider J, Ravishankar N, Magvanjav O. Assessing public and private sector contributions in reproductive health financing and utilization for six sub-Saharan African countries. Reprod Health Matters. 2011;19:62–74.CrossRef
28.
Ministry of Health Republic of Uganda. Strategy for improving health service delivery 2016-2021. In: Book Strategy for improving health service delivery 2016–2021. City: MOH; 2014.
29.
Ministry of Health Republic of Uganda. Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda (2007-2015). In: Book Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda (2007–2015). City: MOH; 2008.
30.
Konde-Lule J, Gitta SN, Lindfors A, Okounzi S, Onama VON, Forsberg BC. Private and public health care in rural areas of Uganda. BMC Int Health Hum Rights. 2010;10:29.CrossRef
31.
ACTwatch Group & PACE/Uganda. Household Survey, Uganda, 2012 Survey Report. In: Book Household Survey, Uganda, 2012 Survey report. City: Population Services International; 2013.
32.
Okal J, Kanya L, Obare F, Njuki R, Abuya T, Bange T, Warren C, Askew I, Bellows B. An assessment of opportunities and challenges for public sector involvement in the maternal health voucher program in Uganda. Health Res Policy Syst. 2013;11:11.CrossRef
33.
Kruk ME, Rabkin M, Grepin KA, Austin-Evelyn K, Greeson D, Masvawure TB, Sacks ER, Vail D, Galea S. ‘Big push’ to reduce maternal mortality in Uganda and Zambia enhanced health systems but lacked a sustainability plan. Health Aff. 2014;33:1058–66.CrossRef
34.
Alfonso YN, Bishai D, Bua J, Mutebi A, Mayora C, Ekirapa-Kiracho E. Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda. Health Policy Plan. 2015;30:88–99.CrossRef
35.
Akwara P, Alayon S, Barry S, Lettenmaier C, David V. Uganda Delivery of Improved Services for Health (DISH) facility survey 2002. In: Book Uganda Delivery of Improved Services for Health (DISH) facility survey 2002. City: Chapel Hill, North Carolina, University of North Carolina at Chapel Hill, Carolina Population Center, MEASURE Evaluation Project, 2003 May; 2003.
36.
Haemmerli M, Santos A, Penn-Kekana L, Lange I, Matovu F, Benova L, Wong KLM, Goodman C. How equitable is social franchising? Case studies of three maternal healthcare franchises in Uganda and India. Health Policy Plan. 2018;33:411–9.CrossRef
37.
World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. In: Book pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. City: World Health Organization; 2003.
38.
World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. In: Book WHO recommendations on antenatal care for a positive pregnancy experience. City: WHO; 2016.
39.
Campbell OM, Calvert C, Testa A, Strehlow M, Benova L, Keyes E, Donnay F, Macleod D, Gabrysch S, Rong L, et al. The scale, scope, coverage, and capability of childbirth care. Lancet. 2016;388:2193–208.CrossRef
40.
World Health Organization. Making pregnancy safer : the critical role of the skilled attendant : a joint statement by WHO, ICM and FIGO. In: Book making pregnancy safer : the critical role of the skilled attendant : a joint statement by WHO, ICM and FIGO. City: World Health Organization; 2004.
41.
Cavallaro FL, Cresswell JA, Franca GV, Victora CG, Barros AJ, Ronsmans C. Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Bull World Health Organ. 2013;91:914–922d.CrossRef
42.
Betran AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol. 2007;21:98–113.CrossRef
43.
Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, Shah A, Campodonico L, Bataglia V, Faundes A, et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet. 2006;367:1819–29.CrossRef
44.
Filmer D, Pritchett LH. Estimating wealth effects without expenditure data-or tears: an application to educational enrollments in states of India. Demography. 2001;38:115–32.PubMed
45.
Campbell OM, Cegolon L, Macleod D, Benova L. Length of stay after childbirth in 92 countries and associated factors in 30 low- and middle-income countries: compilation of reported data and a cross-sectional analysis from nationally representative surveys. PLoS Med. 2016;13:e1001972.CrossRef
46.
47.
Nabyonga Orem J, Mugisha F, Kirunga C, Macq J, Criel B. Abolition of user fees: the Uganda paradox. Health Policy Plan. 2011;26(Suppl 2):ii41–51.PubMed
48.
Nabyonga J, Desmet M, Karamagi H, Kadama PY, Omaswa FG, Walker O. Abolition of cost-sharing is pro-poor: evidence from Uganda. Health Policy Plan. 2005;20:100–8.CrossRef
49.
Yates J, Cooper R, Holland J. Social protection and health: experience in Uganda. Development Policy Rev. 2006;24:339–56.CrossRef
50.
Kajula PW, Kintu F, Barugahare J, Neema S. Political analysis of rapid change in Uganda's health financing policy and consequences on service delivery for malaria control. Int J Health Plann Manag. 2004;19(Suppl 1):S133–53.CrossRef
51.
Anastasi E, Borchert M, Campbell OM, Sondorp E, Kaducu F, Hill O, Okeng D, Odong VN, Lange IL. Losing women along the path to safe motherhood: why is there such a gap between women's use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda. BMC Pregnancy Childbirth. 2015;15:287.CrossRef
52.
Kiwanuka SN, Ekirapa EK, Peterson S, Okui O, Rahman MH, Peters D, Pariyo GW. Access to and utilisation of health services for the poor in Uganda: a systematic review of available evidence. Trans R Soc Trop Med Hyg. 2008;102:1067–74.CrossRef
53.
Orem JN, Mugisha F, Kirunga C, Macq J, Criel B. Abolition of user fees: the Uganda paradox. (special issue: user fee removal in the health sector in low-income countries: lessons from recent national initiatives.). Health Policy Plan. 2011;26.
54.
Alam N, Hajizadeh M, Dumont A, Fournier P. Inequalities in maternal health care utilization in sub-saharan african countries: a multiyear and multi-country analysis. PLoS One. 2015;10:e0120922.CrossRef
55.
Neal S, Channon AA, Carter S, Falkingham J. Universal health care and equity: evidence of maternal health based on an analysis of demographic and household survey data. Int J Equity Health. 2015;14:56.CrossRef
56.
Orinda V, Kakande H, Kabarangira J, Nanda G, Mbonye A. A sector-wide approach to emergency obstetric care in Uganda. Int J Gynaecol Obstet. 2005;91:285–91.CrossRef
57.
Xu K, Evans DB, Kadama P, Nabyonga J, Ogwal PO, Nabukhonzo P, Aguilar AM. Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda. Soc Sci Med. 1982;2006(62):866–76.
58.
Vogel JP, Betran AP, Widmer M, Souza JP, Gulmezoglu AM, Seuc A, Torloni MR, Mengestu TK, Merialdi M. Role of faith-based and nongovernment organizations in the provision of obstetric services in 3 African countries. Am J Obstet Gynecol. 2012;207:495 e491–497.CrossRef
59.
Waiswa P, Akuze J, Peterson S, Kerber K, Tetui M, Forsberg BC, Hanson C. Differences in essential newborn care at birth between private and public health facilities in eastern Uganda. Glob Health Action. 2015;8:24251.CrossRef
60.
Ministry of Health. 2009/2010 Health Financing Review. In: Book 2009/2010 Health financing review. City: MOH; 2010.
61.
Kruk ME, Vail D, Austin-Evelyn K, Atuyambe L, Greeson D, Grepin KA, Kibira SP, Macwan'gi M, Masvawure TB, Rabkin M, et al. Evaluation of a maternal health program in Uganda and Zambia finds mixed results on quality of care and satisfaction. Health affairs (Project Hope). 2016;35:510–9.CrossRef
62.
Chandler CI, Kizito J, Taaka L, Nabirye C, Kayendeke M, Diliberto D, Staedke SG. Aspirations for quality health care in Uganda: how do we get there? Hum Resour Health. 2013;11:13.CrossRef
63.
Litorp H, Mgaya A, Mbekenga CK, Kidanto HL, Johnsdotter S, Essen B. Fear, blame and transparency: obstetric caregivers’ rationales for high caesarean section rates in a low-resource setting. Soc Sci Med. 1982;2015(143):232–40.
64.
65.
Mazzoni SE, Carter EB. Group prenatal care. Am J Obstet Gynecol. 2017;216:552–6.CrossRef
66.
Finlayson K, Downe S. Why do women not use antenatal services in low- and middle-income countries? A meta-synthesis of qualitative studies. PLoS Med. 2013;10:e1001373.CrossRef
67.
Liu L, Li M, Yang L, Ju L, Tan B, Walker N, Bryce J, Campbell H, Black RE, Guo Y. Measuring coverage in MNCH: a validation study linking population survey derived coverage to maternal, newborn, and child health care records in rural China. PLoS One. 2013;8:e60762.CrossRef
68.
Benova L, Macleod D, Footman K, Cavallaro F, Lynch CA, Campbell OM. Role of the private sector in childbirth care: cross-sectional survey evidence from 57 low- and middle-income countries using demographic and health surveys. Trop Med Int Health. 2015;20:1657–73.CrossRef
69.
Powell-Jackson T, Macleod D, Benova L, Lynch C, Campbell OM. The role of the private sector in the provision of antenatal care: a study of demographic and health surveys from 46 low- and middle-income countries. Trop Med Int Health. 2014;20:230–9.CrossRef
70.
Hussein J, Clapham S. Message in a bottle: sinking in a sea of safe motherhood concepts. Health Policy. 2005;73:294–302.CrossRef
71.
Benova L, Tuncalp O, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Global Health. 2018;3:e000779.CrossRef
Metadata
Title
Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys
Authors
Lenka Benova
Mardieh L. Dennis
Isabelle L. Lange
Oona M. R. Campbell
Peter Waiswa
Manon Haemmerli
Yolanda Fernandez
Kate Kerber
Joy E. Lawn
Andreia Costa Santos
Fred Matovu
David Macleod
Catherine Goodman
Loveday Penn-Kekana
Freddie Ssengooba
Caroline A. Lynch
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2018
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-018-3546-3

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