Discharge time following natural birth in Uganda: Do non-clinical factors explain the trend?

doi:10.21203/rs.3.rs-3916970/v1

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Discharge time following natural birth in Uganda: Do non-clinical factors explain the trend?

https://doi.org/10.21203/rs.3.rs-3916970/v1

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Background: The paper examines the socioeconomic, obstetric, and child factors, associated with the mothers’ length of stay in the hospital following vaginal delivery in Uganda.

Method: Self-reported data from the individual record were extracted from the 2016 Uganda Demographic and Health Survey (UDHS) with a sample of 10220 women aged 15 - 49 who had their last birth in the last 5 years preceding the survey was used. Chi-square tests and binary logistic regression models were used to examine the relationship between socio-economic, obstetrics, and child factors, and hospital length of stay.

Results: The study found maternal age, marital status, wealth index, access to radio, place of delivery, child size, the child being a twin, and the child's health checked before discharge, to be associated with the hospital length of stay.

Conclusion: In conclusion, the risks of early discharge following vaginal delivery increased for mothers who were older; mothers from middle and rich income households; mothers giving birth in private health facilities; mothers accessing the media; mothers giving birth to big-sized children and giving birth to one child; and for infants not checked before discharge. Thus, healthcare professionals need to be mindful of the above socioeconomic and infant related factors when planning in-patient and out-patient care.

Early discharge

length of stay

and Uganda

Globally, a significant proportion of women leave healthcare facilities early following childbirth to allow for postnatal care [5]. In many low and middle-income countries, postnatal mothers and newborns are discharged from health facilities early to receive care which has increased the risks of morbidity and mortality both, in infants and mothers due to insufficient time to detect, diagnose, or treat child complications as well as due to readmission of women for complications related to childbirth [15, 17]. Among low-income, middle-income, and high-income countries, the country-level mean length of stay ranges from 0.5 to 6.2 days for singleton vaginal deliveries [5]. In developing countries, a significant proportion of mothers die because of early discharge time and the challenge of the existing health system in keeping them in health facilities for 24 hours after birth [3] as a recommendation by the World Health Organization (WHO) [29]. On the contrary, extended postpartum length of stay in high-income countries remains a problem as it can lead to nosocomial infections, patient dissatisfaction, and higher costs [3].

In developed countries, studies have shown that mothers spend an unnecessarily long time in medical facilities than the WHO recommendation time and the most frequently used threshold of 48 and 96 hours for vaginal and cesarean section deliveries, respectively [2, 7, 8]. In India, women who had a cesarean delivery in a public facility stay longer in comparison to those who deliver in private hospitals. Delivery cost is highly correlated with the length of stay in a private facility for both types of deliveries. Higher levels of education, with lower parity, those belonging to affluent households, and those who are urban residents stay in a facility for extended periods [19].

Mothers and newborns in Sub-Saharan Africa tend to spend less time at healthcare facilities, which has led to increased morbidity and mortality for both. In Ethiopia, mothers spend an average stay of 22 hours in health facilities after delivery which is shorter than the WHO recommendation. Several factors contribute to the shorter post-childbirth stay at healthcare facilities in Ethiopia, including gestational age, birth weight, and mode of delivery (cesarean section) [3]. In Uganda, more than 50% of mothers spend less than 24 hours in healthcare facilities after childbirth, leading to increased rates of illness and death among both mothers and infants [10]. This is because length of stay is an important indicator of the efficiency of healthcare delivery. While the impact of the reduced postpartum period has been widely documented, little is known about the correlates of timely hospital discharge following vaginal delivery. The aim of this study therefore is to examine maternal factors associated with length of stay in the hospital following vaginal delivery in Uganda.

Theoretical Consideration

The study was guided by the theory of care seeking behavior [21]. The theory includes socio-demographical, clinical, beliefs, norms, habits, and external resources. The theory shows that clinical and socio-demographical factors indirectly influence the health care seeking behaviour of screening participants through psychosocial aspects such as beliefs, norms, and habits. Furthermore, the theory suggests that the severity and nature of the symptoms may affect how fast an individual seeks health care. The theory of care seeking behaviour has been used in exploring women’s health behaviour in different settings and ethnic backgrounds such as low-income Caucasian and African American women [20]. The theory has been used in studies in the health field, for instance, [15] adopted it to suit the study of length of stay at health facilities after childbirth among mothers and newborns and their associated factors.

Relating the theory to the Ugandan context, the health seeking behavior may be directly influenced by socio-economic factors, clinical factors, beliefs, norms, habits, and external resources. Concerning length of stay for mothers who had a vaginal delivery, this health seeking behavior might be affected by socio-economic, obstetrics, and child factors in Uganda. These factors are likely to influence the health seeking behavior and length of stay of mothers of vaginal delivery in Uganda.

The study hypotheses included: the social-economic factors are likely to be significantly associated with length of stay of mothers of vaginal delivery in Uganda; the obstetrics factors are likely to be significantly associated with length of stay of mothers of vaginal delivery in Uganda; and the child factors are likely to be significantly associated with length of stay of mothers of vaginal delivery in Uganda.

The study used secondary data from the 2016 Uganda Demographic and Health Survey (UDHS) to model the factors associated with length of stay of mothers of vaginal delivery [26]. The survey targeted 20,880 households which were selected using a two-stage stratified sampling design. In the first stage, a sample of 697 enumeration areas (EAs) was selected from a list of EAs created for the 2014 Uganda National Population and Housing Census (UPHC): 162 EAs in urban areas and 535 in rural areas. The survey removed one cluster from the sub-region of Acholi due to land disputes. In the second stage, households were listed in the 697 EAs which were accessible between the period of April and October 2016. In each selected household, all women aged 15–49 who were residents or visitors on the night before the survey were considered for interviews. The survey selected 19,088 women who were eligible for individual interviews from the selected households and only 18,506 women were able to complete the interviews. The current study considered 10220 women aged between 15 to 49 years whose last birth in the last 5 years preceding the 2016 UDHS survey was by either C-section or Vaginal to whom a woman’s questionnaire was administered and responded to the question “Was (NAME) delivered by cesarean, that is, did they cut your belly open to take the baby out?”

Measures of Outcome Variable

The dependent variable for the study was the length of stay of mothers of vaginal delivery. The WHO recommends 24 hours following vaginal delivery in the hospital. The following question was asked during the UDHS survey regarding the length of stay: “How long after (NAME) was delivered did you stay there?” In this study, whoever spent 24 hours and above after vaginal delivery was coded ‘1’ and ‘0’, for those who spent 23 hours and below.

Measures of Explanatory Variables

The independent variables for this study are social-economic, obstetrics, and child related factors including the age of the mother, education level, place of residence, marital status, wealth index, occupation, and access to media (TV, radio, and newspaper); the number of antenatal visits during pregnancy, the place of delivery, received tetanus injections before birth, and timing of 1st antenatal check (months); and the size of the child at birth, child’s health checked before discharge, sex of the child, the child being twin, and the child being alive or dead after delivery. Age was grouped in terms of: 15–24, 25–34, 35–44, and 45 + years. Education was grouped as no education, primary, secondary, and tertiary education. The place of residence was grouped as rural and urban.

Marital status was grouped as never in a union, married, living with a partner, widowed, divorced, and no longer living together/separated. The wealth index was categorized as poor (combining poorest and poorer), middle (maintained as middle), and rich (combining richer and richest). Access to media was grouped as no access to media (representing not at all) and access to media (combining less than once a week and at least once a week). The place of delivery was categorized as government health facility (merging government hospital, government health center, and other public sector) and private health facility (merging private hospital/clinic and other private sector). The occupation was grouped into: Working (those involved in any work that generates income) and Not working (those who were never involved in any income-generating activity). The number of antenatal visits was categorized into three groups including no antenatal visits, 1–4 times, 5–9 times, and 10 + times. Access to tetanus injections was grouped as received no tetanus injection and received a tetanus injection (merging two times, three times, four times, five times, six times, and seven times plus).

Timing of first antenatal check was coded as less than 1st month (catering for those who had their first antenatal check before the first month), 1st – 4th month (combining those who received their first antenatal check between 1st and 4th months), and 5th month (combining those who received their first antenatal check between 5th and 10th month). Size of the child was coded as large (merging very large, and larger than average), average, and small (merging smaller than average and very small); and sex of the child was grouped as male and female. The child’s health being checked was grouped as Yes and No. A child being a twin was categorized as single birth and 2nd of multiple; and the survival status of the child at the time of delivery was coded as ‘yes and no’.

Statistical Analysis

The analysis was conducted at three levels which include: univariate, bivariate, and multivariate analysis. The first step involved declaring data as a survey set which also involved weighting to cater for complex survey designs [16]. The univariate analysis was used to describe the variables. The bivariate analysis was performed to establish the individual relationship between the length of stay and socio-economic, obstetrics, and child related factors, and tested using the chi-squared test, set at p < 0.05. At multivariate level, the selected independent variables at the bivariate level were entered into a binary logistic regression model to identify the net effect of the independent variables on the dependent. We tested for multicollinearity using the variance inflation factor (VIF) and all variables with a VIF value of less than 10 were considered for analysis (see appendix 1). In addition, to test for the goodness of fit and appropriateness of the model, we used the linktest (see appendix 2). The link-test uses the hatsq value. If the model describes the data correctly and appropriately, the __hat-squared p-value > 0.05, indicates that the predicted data fitted by the model reflects the observed data. In statistics, missing data in logistic models often influences regression coefficients, standard errors, and statistical power. In the current study missing data was assumed to be missing completely at random (MCAR) and does not affect our inferences [1, 14].

Distribution of Respondents by Social-Economic, Obstetric, and Child Characteristics

Table 1 presents the distribution of respondents by socio-economic, obstetric, and child characteristics. Majority of women (43.6%) were aged between 25 and 34 while nearly 1.6% were aged 45 and older. Approximately 57.4% had acquired primary education and 7.3% had tertiary education. Concerning the place of residence, approximately 74.4% lived in rural areas and 25.6% in urban. Nearly 82.4% of the women respondents were working while 17.6% were not working. Regarding marital status, approximately 41.6% of the women were living with a partner. The bigger proportion of respondents (43.4%) belonged to the rich index while 18.3% were middle income earners. With regard to media access, the majority were listening to the radio (75.9%) while a bigger proportion was not watching television (68.4%) and not reading newspapers (78.5%); and nearly 79% delivered in government health facilities.

Table 1

Distribution of Respondents by Social-Economic, Obstetrics, and Child Factors
Covariate	Frequency (N = 6,701)	Percentage (%)
Age group
15–24	2,504	37.37
25–34	2,918	43.55
35–44	1,172	17.49
45 years and above	107	1.60
Education level
No education	611	9.12
Primary	3,843	57.35
Secondary	1,759	26.25
Tertiary	488	7.28
Type of place of residence
Urban	1716	25.61
Rural	4985	74.39
Occupation
Not working	1183	17.65
Working	5518	82.35
Marital Status
Never in union	418	6.24
Married	2654	39.61
Living with partner	2788	41.61
Widowed	87	1.30
Divorced	29	0.43
Wealth Index
Poor	2563	38.24
Middle	1228	18.32
Rich	2911	43.43
Access to radio
No	1618	24.15
Yes	5083	75.85
Access to Television
No	4583	68.39
Yes	2118	31.61
Access to newspapers
No	5263	78.54
Yes	1438	21.46
Place of Delivery
Government facility	5315	79.32
Private facility	1386	20.68
Number of Antenatal visits
1–4 times	5184	77.36
5–9 times	1466	21.88
10 times and above	51	0.76
Access to tetanus injections
No	749	11.18
Yes	5952	88.82
Timing of first Antenatal visit
Less than 1st month	9	0.13
1st-4th month	4084	60.94
Greater than 4th month	2609	38.93
Child Size
Large	1817	27.12
Average	3566	53.22
Small	1318	19.67
Sex of child
Male	3433	51.23
Female	3268	48.77
Child's health checked before discharge
No	2052	30.62
Yes	4649	69.38
Child is twin
Single	6591	98.36
Multiple	110	1.64
Child is alive
No	212	3.16
Yes	6489	96.84

Nearly 77.4% of women made between 1 and 4 antenatal visits. Closely 88.8% of respondents accessed tetanus injections. In light of the timing of the first antenatal visit, approximately 60.9% of women made their first antenatal visit between the first and fourth month. Closely 53% of the women gave birth to average size children and the women (51.2%) gave birth to boys. About 69.4% of the children’s health status was checked before discharge. Approximately 98.4% of women gave birth to singleton children and nearly 96.8% of the women in the survey had live births.

Differentials in Length of Stay of Mothers of Vaginal Delivery by Social-Economic, Obstetrics, and Child Factors in Uganda

Table 2 presents differentials in length of stay by social-economic, obstetrics, and child factors. Education level, type of place of residence, occupation, access to television, access to newspapers, number of antenatal visits, access to tetanus injections, sex of the child, and whether the child was alive or not were not significantly associated with the women’s length of stay after vaginal delivery. Length of stay varied significantly by age group (χ² = 28.02, P = 0.000), marital status (χ² = 18.11, P = 0.016), wealth index (χ² = 25.05, P = 0.000), radio access (χ² = 17.33, P = 0.000), place of delivery (χ² = 8.52, P = 0.036), the timing of first antenatal visit (χ² = 16.11, P = 0.002), child size (χ² = 44.49, P = 0.000), child's health checked before discharge (χ² = 48.57, P = 0.000), and child being a twin (χ² = 7.13, P = 0.010).

Table 2

Differentials in Length of Stay of Mothers of Vaginal Delivery by Social-Economic, Obstetric, and Child Factors
Covariate	LoS < 24 hours N (%)	LoS ≥ 24 hours N (%)	Chi² (χ²), P-value
Age group
15–24	847 (33.7)	1,657 (39.6)	28.02, (P = 0.000)
25–34	1,176 (46.7)	1,742 (41.6)
35–44	461 (18.3)	711 (17)
45 years and above	33 (1.3)	75 (1.8)
Education level
No education	216 (8.6)	395 (9.4)	3.73, (p = 0.426)
Primary	1,472 (58.5)	2,371 (56.7)
Secondary	659 (26.2)	1,099 (26.3)
Tertiary	170 (6.7)	318 (7.6)
Type of place of residence
Urban	628 (24.9)	1,088 (26)	0.96, (p = 0.459)
Rural	1,889 (75.1)	3,096 (74)	0.96, (p = 0.459)
Occupation
Not working	425 (16.9)	758 (18.1)	1.69, (p = 0.292)
Working	2,092 (83.1)	3,426 (81.9)	1.69, (p = 0.292)
Marital Status
Never in union	133 (5.3)	285 (6.8)	18.11, (p = 0.016)
Married	952 (37.8)	1,702 (40.7)
Living with partner	1,121 (44.5)	1,667 (39.9)
Widowed	32 (1.3)	55 (1.3)
Divorced	9 (0.3)	20 (0.5)
No longer living together/separated	270 (10.7)	455 (10.9)
Wealth Index
Poor	870 (34.6)	1,692 (40.4)	25.05, (p = 0.000)
Middle	509 (20.2)	718 (17.2)
Rich	1,137 (45.2)	1,773 (42.4)
Access to Radio
No	537 (21.3)	1,081 (25.8)	17.33, (p = 0.000)
Yes	1,980 (78.7)	3,103 (74.2)	17.33, (p = 0.000)
Access to Television
No	1,703 (67.7)	2,880 (68.8)	0.96, (p = 0.407)
Yes	814 (32.3)	1,304 (31.2)	0.96, (p = 0.407)
Access to Newspapers
No	1,991 (79.1)	3,272 (78.2)	0.75, (p = 0.448)
Yes	526 (20.9)	912 (21.8)	0.75, (p = 0.448)
Place of Delivery
Government facility	1,949 (77.4)	3,365 (80.4)	8.52, (p = 0.036)
Private facility	568 (22.6)	819 (19.6)	8.52, (p = 0.036)
Number of Antenatal visits
1–4 times	1,945 (77.3)	3,239 (77.4)	0.23, (p = 0.933)
5–9 times	552 (21.9)	914 (21.8)
10 times and above	21 (0.8)	30 (0.7)
Access to Tetanus Injections
No	294 (11.7)	455 (10.9)	1.05, (p = 0.371)
Yes	2,223 (88.3)	3,729 (89.1)	1.05, (p = 0.371)
Timing of first Antenatal Visit
Less than 1st month	2 (0.1)	7 (0.2)	16.11, (p = 0.002)
1st-4th month	1,459 (58)	2,625 (62.7)	16.11, (p = 0.002)
Greater than 4th month	1,056 (41.9)	1,553 (37.1)
Child Size
Large	796 (31.6)	1,020 (24.4)	44.49, (p = 0.000)
Average	1,232 (49)	2,334 (55.8)
Small	488 (19.4)	830 (19.8)
Sex of child
Male	1,283 (51)	2,151 (51.4)	0.13, (p = 0.764)
Female	1,234 (49)	2,033 (48.6)	0.13, (p = 0.764)
Child's Health Checked Before Discharge
No	898 (35.7)	1,154 (27.6)	48.57, (p = 0.000)
Yes	1,619 (64.3)	3,030 (72.4)	48.57, (p = 0.000)
Child is Twin
Single	2,489 (98.9)	4,102 (98)	7.13, (p = 0.010)
Multiple	28 (1.1)	82 (2)	7.13, (p = 0.010)
Child is alive
No	76 (3)	135 (3.2)	0.23, (p = 0.679)
Yes	2,441 (97)	4,049 (96.8)	0.23, (p = 0.679)

LoS = Length of Stay

Multivariate Results

To identify the net effect of each independent factor on the length of stay, binary logistic regression was built based on the identified predictors at bivariate analysis. In this regard, all significant independent variables at the bivariate level were included in the model, in which the outcome variable was the length of stay. The significant independent variables at the bivariate level included age group, marital status, wealth index, access to radio, place of delivery, the timing of the first antenatal visit, child size, child's health checked before discharge, and child being a twin. Table 3 presents the results of the binary logistic regression estimates of the associated factors with the length of stay of mothers who delivered naturally. The model findings show that the odds of women having an extended stay after vaginal delivery were 22.5% lower for women aged between 25 and 34 (95% CI = 0.67–0.89, p = 0.000) and 21.7% lower for women aged 35 to 44 (95% CI = 0.66–0.93, P = 0.006) relative to women aged 15 to 24. The odds of having a longer stay after vaginal delivery decreased by about 23.1% among women living with a partner (OR = 0.769; 95% CI = 0.59-1.00, P = 0.047) compared to women who are not in a union.

The odds of women having a longer stay at the hospital after birth were 22.9% lower among women in middle-class income households (95% CI = 0.65–0.91, P = 0.002) and 14.9% lower among those in the rich (95% CI = 0.74–0.98, P = 0.026) relative to women in the poor households. The odds of having an extended stay after delivery were 19.8% lower for women listening to a radio (OR = 0.802; 95% CI = 0.70–0.92, P = 0.002) compared to those who were not listening to a radio. Women who gave birth in private facilities had a shorter stay after vaginal delivery (OR = 0.840, 95% CI = 0.71–0.99, P = 0.036) compared to those who gave birth in government facilities.

Table 3

Binary Logistic Regression Estimates showing the Social-Economic, Obstetric, and Child Factors Associated with the Length of Stay of Mothers of Vaginal Delivery
Covariate	Odds Ratio (OR)	P-value	95% CI
Age group
15–24 (Ref)	1.000	-	-
25–34	0.775	0.000	0.67, 0.89
35–44	0.783	0.006	0.66, 0.93
45 years and above	1.176	0.470	0.76, 1.83
Marital Status
Never in union (Ref)	1.000	-	-
Married	0.935	0.610	0.72, 1.21
Living with partner	0.769	0.047	0.59, 1.00
Widowed	0.876	0.628	0.51, 1.50
Divorced	1.140	0.764	0.48, 2.69
No longer living together/separated	0.878	0.373	0.66, 1.17
Wealth Index
Poor (Ref)	1.000	-	-
Middle	0.771	0.002	0.65, 0.91
Rich	0.851	0.026	0.74, 0.98
Access to Radio
No (Ref)	1.000	-	-
Yes	0.802	0.002	0.70, 0.92
Place of Delivery
Government facility (Ref)	1.000	-	-
Private facility	0.840	0.036	0.71, 0.99
Child Size
Large (Ref)	1.000	-	-
Average	1.516	0.000	1.32, 1.74
Small	1.281	0.006	1.07, 1.53
Child's Health Checked Before Discharge
No (Ref)	1.000	-	-
Yes	1.491	0.000	1.30, 1.71
Child is Twin
Single (Ref)	1.000	-	-
Multiple	1.860	0.008	1.18, 2.94

Ref = Reference Category; Cl = Confidence Interval

There was an increased likelihood of staying longer in the hospital after vaginal delivery among women who gave birth to an average-sized child (OR = 1.516; 95% CI = 1.32–1.74, P = 0.000) and for a small-sized child (OR = 1.281; 95% CI = 1.07–1.53, P = 0.006) compared to those who gave birth to a large sized child. Women with children whose health was checked before discharge were 49.1% more likely to stay longer in the hospital after normal delivery (OR = 1.491; 95% CI = 1.30–1.71, P = 0.000) relative to those whose children were not checked before discharge. The women who gave birth to multiple children were 86% more likely to be hospitalized longer after vaginal delivery (OR = 1.860; 95% CI = 1.18–2.94, P = 0.008) compared to those who gave birth to singleton children.

In this study, the question of: ‘What are the associated factors with the Length of Stay of Mothers of Vaginal Delivery in Uganda’ was examined. Accordingly, we tested three hypotheses including, social-economic factors are likely to be significantly associated with the length of stay of mothers of vaginal deliveries; obstetrics factors are likely to be significantly associated with the length of stay of mothers of vaginal deliveries; and child factors are likely to be significantly associated with length of stay of mothers of vaginal deliveries. The factors associated with the length of stay of mothers of vaginal delivery included: the age of the mother, marital status, wealth index, access to media/radio, place of delivery, child size, whether the child's health was checked before discharge, and whether a child is a twin. The study found that women aged 25 and 34 and those aged 35 to 44 had a shorter hospital length of stay after vaginal delivery compared to those aged 15 to 24. The findings from the study contradict those of [28] and [4] who found that women of older age had the most extended length of stay after vaginal delivery. One perspective that can be used to explain this finding is that most younger women may have a higher risk of postpartum complications, such as hemorrhage or infection, which could require a longer hospital stay as compared to older women [6].

The findings revealed that married women had a longer hospital length of stay after vaginal delivery compared to those living with a partner. The findings are in agreement with [28] who found that the longest length of stay after vaginal birth was among married mothers who were living with the baby's father. One of the arguments that can be used to explain this finding is that married women may have more support from the baby's father (husband), making it easier for them to manage costs and care which may lead to an extended hospital stay [13].

Surprisingly, women from poor households stayed longer in hospital after normal delivery compared to women from middle and rich income households. These findings contradict previous studies which found that women from wealthier households stayed longer in hospital after vaginal deliveries compared to those from poor households [19]. We advance two perspectives that can be used to explain these results: First, women from poor families may be malnourished which heightens the risk of maternal morbidity, and inadequate prenatal care which may lead to an increased risk of complications during delivery thus requiring a longer hospital stay. Secondly, women from poor households may have limited access to healthcare including antenatal, resulting in delayed diagnosis and treatment of medical complications. This could prolong their hospital stay after delivery [12].

As expected, women who listened to the radio had a shorter length of stay after vaginal delivery compared to those who never listened to radio. Two perspectives may be used to explain these results. First, women who listen to the radio may have access to valuable information and resources which improves their overall level of knowledge and confidence about childbirth and the postpartum period. Perhaps, such knowledge prepares them for a smooth and more efficient labor and delivery process, which in turn reduce the length of hospital stay. Secondly, access to media before birth may help to reduce anxiety and stress levels among mothers, which may also reduce the hospital length of stay [9].

Mothers who gave birth in government health facilities were more likely to stay longer after vaginal delivery compared with those in private health facilities. The findings contradict that of Tsiga-Ahamed and his colleagues [25] who found that women who delivered in government hospitals, in three sub-Saharan African countries, had a shorter length of stay than those who gave birth in private hospitals. The longer stay in government health facilities is because of the many expectant mothers using these facilities amidst the smaller number of health workers available. This may take a longer time for the health of the mother and the baby to be examined which may create an extended length of stay compared to mothers who give birth in private health facilities [24].

Women who gave birth to big sized children were likely to stay shorter after vaginal delivery compared to those who gave birth to small and average-sized children. The findings are in agreement with the previous studies which found that women who gave birth to children with a big weight were independently associated with a shorter length of stay compared to those who gave birth to low birth weight children [3, 11, 25]. This could be because small size children are often premature, which means they may have underdeveloped organs and require additional medical attention. Furthermore, women who give birth to small children may also be at higher risk of experiencing complications during delivery, such as preterm labor, difficulty in breathing, or preeclampsia. As a result, they may require a longer hospital stay to monitor the baby's health and to ensure that the mother recovers fully from any complications [23].

The extended length of stay for children who were checked before discharge compared to children who were not checked is not surprising. The reason could be that thorough health checks for newborns before discharge from the hospital can lead to a longer hospital stay as any health issues that require treatment or monitoring can be identified and addressed before the mother and child leave the hospital [22, 27].

Women who gave birth to multiple children were more likely to be hospitalized longer. The findings are consistent with the previous studies which found that mothers who gave birth to twins were more likely to stay longer after childbirth compared to those with a singleton child [5]. Probably, staying longer in a health facility after delivering multiple children is because having multiple pregnancies is associated with increased risk for complications including preterm labour and birth, hypertension, anemia, postpartum hemorrhage, and abnormality in amniotic fluids. Similarly, multiple births are usually small and have low birth weight which may result in an extended stay after natural delivery given that such babies require close monitoring by health professionals [18].

In summary, the study used a binary logistic regression model to investigate factors associated with the length of stay for mothers who deliver naturally. Accordingly, the study investigated the social-economic, obstetrics, and child factors associated with the length of stay for mothers delivering naturally. The study found maternal factors such as the age of the mother, marital status, wealth index, and access to radio were the socioeconomic factors associated with the length of stay for mothers following vaginal delivery in Uganda. The place of delivery was the obstetrics factor associated with the length of stay. The study also revealed that child size, the child being a twin, and the child's health checked before discharge were the child factors associated with the length of stay.

The study concludes that both maternal and child factors in Uganda influence the length of stay of mothers who had natural delivery such as the age of the mother, marital status, wealth index, access to media/radio, place of delivery, child size, child's health checked before discharge, and child being a twin. The risks of early discharge after vaginal delivery increased: among older women compared with younger women, women living with a partner compared with married women, being from middle and rich income households compared with those coming from poor households, giving birth in private health facilities compared with government facilities, access to media/radio compared with no access to media/radio, giving birth to big-sized children compared with small and average-sized children, child health not checked before discharge compared with child health checked, and giving birth to one child compared with multiple children. Thus, further investigations are needed to ascertain how these characteristics can be addressed through healthcare programs.

Acknowledgements. The authors extend their appreciation to ICF International for allowing them to access the 2016 Uganda Demographic and Health Survey data.

Funding. This study received no specific grant from any funding agency, commercial entity, or not-for-profit organization.

Conflict of Interest. The authors have no conflicts of interest to declare.

Ethical Approval. Employing authorized secondary data obtained from ICF International and DHS, the study obtained approval from the DHS Ethics Committee during the original survey.This study used secondary data and the authors affirm that all procedures contributing to this work conform with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Availability of Data and Materials: The dataset is available for access after request to DHS (Demographic and Health Surveys) and ICF International website, via https://dhsprogram.com/data/Access-Instructions.cfm.

Author Contribution

Author Contributions Statement: Each author’s contribution is outlined below;Kayera Brian (K.B.): K.B. conducted a background literature review, developed a research topic, conceptualized the study by formulating objectives, and performed data analysis and reporting. K.B. additionally drafted the manuscript, coordinated inputs from various co-authors, and identified the journal for publication.Charles Lwanga (C.L.): C.L. contributed to the study design, performed data analysis, participated in the interpretation of findings, reviewed, and edited the manuscript offering valuable feedback to enhance its clarity and coherence.Kudzaishe Mangombe (K.M.): K.M. contributed to the reporting of results, meticulously edited the manuscript, and ensured alignment of the writing with BMC standards.Lutendo Malisha (L.M.): L.M. added a valuable dimension to the manuscript, bringing insights from a different statistical landscape. His contribution strengthened the methodological rigor and the broader applicability of the study.Namawejje Hellen (N.H.): N.H. significantly contributed to the development of the methodology, guided data analysis, and interpretation. Additionally, N.H. performed final edits on the manuscript before it was considered for publication.

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No competing interests reported.

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Discharge time following natural birth in Uganda: Do non-clinical factors explain the trend?

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Abstract

Background

Theoretical Consideration

Methods

Measures of Outcome Variable

Measures of Explanatory Variables

Statistical Analysis

Results

Distribution of Respondents by Social-Economic, Obstetric, and Child Characteristics

LoS = Length of Stay

Multivariate Results

Ref = Reference Category; Cl = Confidence Interval

Discussion

Declarations

Author Contribution

References

Additional Declarations

Supplementary Files

Status:

Version 1