Introduction

Uganda continues to have a high neonatal mortality rate, with 20 deaths per 1000 live births reported in 2018. The country is projected to miss the Sustainable Development Goal (SDG) 3.2 of a neonatal mortality rate of 12/1000 live births in 2030, if the current trend continues [1]. Contributing factors to the high number of neonatal deaths in Uganda are the country’s challenges to implementing multi-level policy strategies for enhancing newborn survival. Policy strategies include implementation of The Uganda Clinical Guidelines (UCG) from 2016 with updates, which have detailed descriptions of recommended health care and medical advice in all aspects involving maternal care [2]. Additional obstacles for optimal maternal and newborn health care include informal out-of-pocket payments for health care services, along with shortage of accessible staff, and low quality of care [3]. WHO defines quality of care as:

The extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centred [4].

Quality of care is contextualized within the phenomena of maternal and newborn support systems. It implies that the mothers have someone to trust and rely on during pregnancy, time of childbirth and the following postnatal period, enhancing the chance for an optimal start in life for the newborns [5]. So that in times of need, or if encountering emergencies, the mothers have a security net around them which can provide practical help and emotional support, such as encouraging mothers to seek professional health care [6]. Evidence from other settings show that women with supportive environments and reliable partners have easier births, healthier babies and better postnatal experiences [7].

The term postnatal is defined by WHO as “the time after birth and up to six weeks (42 days)”. The most vulnerable period for a newborn and its mother is the first month after birth, where the first 24 hours are the most critical. Despite this fact, attention and care for the mother and newborn are often neglected after delivery [8]. The national estimate of mothers receiving postnatal care within two days is only 33%, and studies from Uganda show that giving birth in health facilities is the predominant factor for receiving early postnatal care [9, 10].

Assurance of quality of care through the conjugated components of maternal care is important in ensuring optimal outcome for both the mother and her infant. Family and spousal support through each of these stages are paramount for the mothers’ wellbeing [6]. This study aimed to describe women’s experiences of maternal and newborn health care services and support systems in Buikwe District, focusing on antenatal care, delivery and the postnatal period.

Methods

Setting and population

We conducted research in 7 villages in Buikwe district, in east central Uganda. Buikwe has a total population of approximately 423,000 (2014), where the majority of the people relies on subsistence farming [13]. Most people travel on foot, or they use bicycles or scooters for transportation. Some villages are remote from the closest health facility and traveling at night can be hazardous on narrow dirt roads. Nyenga town contains Saint Francis Hospital and Saint Francis School of Nursing and Midwifery. Kabizzi village includes a Health Centre III for the public in the area, which provide both in-and out-patient services, including a two bed maternity room [14, 15]. The health care system in Uganda is a referral system, with voluntary village health team members (VHTs) operating as the first contact point for patients. The next contact point is Health Centre II, which refers to Health Centre III or IV (District Hospital) if needed. The highest level of care is the National Referral and Teaching Hospital in the capital Kampala [3].

Based on their occupation and involvement in maternity issues, we recruited professional health workers such as midwives, students and nurses from the maternity ward at St. Francis Hospital and Kabizzi Health Centre. We enrolled mothers from the hospital or the villages, with the inclusion criteria that they had given birth within the past month. Traditional birth attendants (TBAs) were included based on their role as often being the first line contact with pregnant mothers in the villages, together with VHTs, who are the local representatives of the professional health care system in Uganda. We have displayed the data collection process in a flow chart below (Fig 1).

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Fig 1. Flow chart of data collection process.

https://doi.org/10.1371/journal.pone.0261414.g001

Sampling

The villages were selected by approaching local village leaders, who lingered after conclusion of a village committee meeting in the urban centre of Nyenga town. We gave an introduction about the study and made arrangements to meet in their respective villages. In cooperation with the village leaders, the main researcher and two local research assistants enrolled a total of 57 participants in the study. Fifteen key informants were recruited for interviews, and 42 mothers attended focus group discussions. The key informants consisted of 4 mothers, 4 TBAs, 3 VHTs and 4 health workers. With exception of the professional health workers, all participants were small-scale subsistence farmers with some having additional small businesses. The education level ranged from none to certificate level for the health workers, as displayed in Table 1.

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Table 1. Characteristics of participants.

https://doi.org/10.1371/journal.pone.0261414.t001

Results

One of the interesting aspects with conducting qualitative research is the emergence of views and shift in focus during interviews or focus group discussions. In this study, views about the importance of antenatal care and male involvement in maternal issues were given much attention both from mothers and TBAs, although they were not at the centre of the focus group discussion guides. Hence, the authors decided to give these topics augmented attention in this paper. Many women in the study were discontented with spousal support when they endeavoured to attend antenatal classes, which was often related to financial situations and transport challenges. The mothers had mainly positive experiences with professional health workers and TBAs around the time of delivery, where TBAs often played a key role. Postnatal care initiations from the professional health workers were found close to non-existent, except for the six-week check-up combined with the vaccination program. The mothers revealed disappointment with postnatal spousal support, such as unmet expectations of practical help, challenges related to gender roles, poverty, and inhibitions in own decision-making. Observations by the researcher could occasionally deviate from the view of the participants in the study and are conveyed explicitly. In the following section, the authors present the themes extracted from the analysis: (a) Antenatal care and spousal support, (b) Health care and family support around delivery, (c) Postnatal care and challenges related to gender roles.

Discussion

The initial platform to ensure safe quality care for pregnant women and their unborn babies is antenatal care visits. The presented results indicate that antenatal care was not always accessible for all mothers in Buikwe district, due to distance and transport costs as the biggest obstacles. The women relied heavily on their partners and their support to access the services. WHO/UNICEF Uganda recommends eight antenatal visits during pregnancy, whereas the UCG aim for at least 4 visits [2, 4]. Studies from sub-Saharan Africa have shown clear associations with attending antenatal care and reduction in neonatal mortality [17], even though timing and frequency for antenatal visits vary among regions and socioeconomic status [18]. Studies from Uganda concerning availability and quality of antenatal care provision in rural settings show lack of qualified staff and inadequate check-ups and provision of necessary information as key areas for improvements [19]. One study found that sampling of urine and receiving drugs for intestinal parasites were components most often neglected during antenatal visits, and that the overall quality of antenatal care has been found to be higher in private sector facilities than in public ones [20]. Intervention programs on improving quality of care show promising results, but reveal the need for systemic improvements in infrastructure and education of health care providers [19]. Statements from TBAs and VHTs in this study, reveal concerns about some young women’s low knowledge about issues like hygiene and how to care for newborns. This indicates a need for closer cooperation between TBAs/VHTs and professional health workers in rural Uganda.

Both mothers and TBAs referred to poverty as the key reason why women were not able to attend antenatal care. The same factor can possibly also explain low male involvement in maternity care, since the transport cost would double if two people were to travel instead of one, in addition to income and working time lost. The importance of supportive environments and recognition of partner involvement interventions in maternal health, has gained increased attention since the introduction of WHO’s Maternal and Child Health Care Program (MCH) in the mid 1990’s [21]. The multi-lateral global movement Every Woman Every Child includes strategies of male involvement in maternal health programmes as one of its action areas towards achieving the SDGs before 2030 [22]. Focus on male involvement in maternal care is further strengthened in the national strategy for Sexual and Reproductive Health and Rights (SRHR), which was launched by the Ugandan Government in 2014 [23]. Male involvement in maternal care is also implemented in the UCG by recommending bringing the partner or a family member to at least one antenatal visit [2]. Previous studies from Uganda have confirmed that the spouse often remains at home looking after the household and other children, which allows the woman to go for antenatal care [24]. A documented cost-effective way to increase male attendance is to give a personal invitation letter to the women’s spouses, as an alternative to a general information pamphlet. This intervention has proven to raise the attendance by up to 10% [25], although it does not solve the underlying economic problem.

Traditional and cultural customs of men being unwelcome in the delivery rooms could contribute to signals of men not being wanted or needed in situations around childbirth [26]. Looking at the situation from another angle, the men might not always have a choice of attending to their wives based on work conditions and availability. Given time off work to tend to one’s wife and child around the time of childbirth is constituted in the Employment Act of Uganda from 2006, which gives fathers four days paid leave from work to spend with the family [27]. However, many men do not have regular work conditions to effectuate that. Obstacles to male involvement in maternity care are grounded in both culture and religion, as shown in studies within Nigerian and Ugandan settings, where women tend to share similar views as men when it comes to what is considered appropriate and expected, although it varies within the socioeconomic strata [28, 29]. Many mothers in the study did not have safe environments around the time of childbirth. Challenges related to logistics and economy were explained as reasons for suboptimal birthing experiences, both from the user and provider perspectives. Weather and road conditions reflect the vulnerability of the health system in rural Uganda and add to the challenges of transport costs and low staffed health facilities. Hence, many women must succumb to the environment and give birth in the villages with help from TBAs.

Postnatal check-ups are recommended in the UCG at 6 hours after birth, after 2–7 days and after six weeks, and include counselling on emergency issues, hygiene and general baby care [2]. Neither the health workers nor the mothers were familiar with the UCG recommendation of 2–7-day check-ups [2], which would give the mothers a good platform for expression of concerns around breastfeeding issues or other postnatal conditions. Some of the health workers interviewed recommended mothers to come back if they faced any trouble post-partum, but that was not routine. The recommended level of professional support in the postnatal period has changed over the years, but recent WHO guidelines give higher attention to this vulnerable time in a mother’s and her baby’s life. The new guidelines include postnatal care on the first day, third day, between 7–14 days and six weeks [8], but these recent recommendations are not yet included in the UCG. Postnatal contact between mothers and TBAs was more common, and a study from Nigeria show that both monetary and non-monetary payments to TBAs gave incentives for referral of mothers to health facilities [30].

A feeling of security and supportive surroundings are requirements for a good bonding- and early breastfeeding experience, and the lack of such may lead to post-partum depression and trouble with, or discontinuation of, exclusive breastfeeding [31]. Emotional wellbeing and family support is equally important [8]. Midwives reported challenges with time constraints as factors for not providing sufficient information and support in breastfeeding issues for the mothers. This study points towards shortcomings both in frequency and quality of postnatal encounters between health workers and mothers.

Some mothers showed resentment towards their spouses for not assisting them during and after birth and uttered disappointment with spousal neglect in providing them with nutritious food and support with household chores they normally were doing. Stories told with anger and bitterness reflected the hopelessness and despair many women found themselves to be in. Some of the mothers mentioned sharing concerns and advice with neighbours and friends, but when it came to provision of physical help it often seemed to be each woman for herself. The resentment was coupled with aversion against early sexual demands. In the Ugandan culture, many women are subjected to the wants and decisions of men, as described clearly in an article in The Observer by Kiiza and Akumu [32]. Although the Uganda Children’s Act deems the parents equal [33], culturally the children are seen as the property of the father, and the mother of the child cannot deny the father sexual favours [32]. In addition to the feeling of lack of support and care, women also face the problem of being economically dependent on their partners, enhanced by legislative regulations that favour males [34].

The mothers interviewed in this study complained about unreliable financial support from their husbands and made them partly responsible for the poverty. This study did not capture fathers’ views on the situation, however, other studies from Uganda describe gender disparities as the causal factor of poor access to sexual and reproductive services [24]. Additionally, men’s lack of financial support in maternal health could often be justified by the overall lack of financial resources at home [26]. The women’s discontent with support from their partners could be an indication of alterations of traditional gender roles in view of recent years’ access to internet services and influences from social media [35].

Findings from the presented study, related to women’s autonomy in reproductive health issues mirror similar findings concerning maternal health and support systems in Uganda [26]. Maternal and newborn health research could continue with gender sensitive perspectives, taking into account disparities that may arise from the presence or lack of family support in vulnerable pregnant and delivering women, and for the mother and baby in the postnatal period.

Study strengths and limitations

The authors sought to obtain reliability by using local translators and trained interviewers of both sexes. Possible bias includes that the main researcher and primary analyst was a foreign person and holds an etic, meaning subjective, view of the situation witnessed in Uganda during the research period. Alternatively, sometimes being from a different country or culture can have a positive effect on the interviewees as it is seen as less threatening, as someone from the same culture may be more prone to criticize local practices. Also, the supportive statements and validation of data from local women give extra strength to the observations from the study. A majority of the negative statements about partners’ support on maternal issues were from the same focus group discussion, where many women were gathered. Being many may have encouraged others who otherwise would have kept silent. The study did not include interviews with fathers or partners, which could be seen as limitations to the study. Including the voice of partners could have given a more nuanced picture of the situation reflected in the study, and a better understanding of their situation. Proofreading of transcriptions added credibility to the study. Issues with electric power and technical difficulties resulted in written notes only, from one focus group discussion and one in-depth interview. Dependability of the study was sought obtained through triangulation of qualitative methods, although no participant observations were done outside of the health facilities. Previous research results from rural settings in Uganda makes the study transferable to settings with similar context and clienteles.

Conclusions

Maternal support and care were highly sought and valued by the mothers in the study, but not always accessible due to logistic and financial problems. Resources were scarce both in the homes and within the health system. Further focus on gender equity on all policy making levels, involving women’s right to own decision making in maternity issues and higher recognition of male involvement in maternity care, are suggestions to policy makers for improved maternal health and newborn survivals in rural Uganda. This study highlights a continued need for higher awareness and incentives for implementation of recent WHO recommendations on postnatal care in the combat against infant mortality.

Supporting information

Acknowledgments

The authors wish to thank the participants in the study for their interest and cooperation. Authors also extend gratitude to Nyenga Foundation Norway/Uganda, and School of Public Health Makerere University, Uganda and Centre for International Health/ University of Bergen, Norway Collaboration 2018–2021.