The following section will display results extracted from the final code group labelled pregnancy and birth which emerged during the analysis using Malterud’s Systematic Text Condensation where facilitators and barriers in adherence to guidelines were focalized (27). The study found discrepancies between performed hands-on-procedures and the UCG related to neonatal care practices. The results are thematically presented in the table below based on the predominate responses from participants and main observation findings.
Table 2: Overview of results from various respondents’ perspectives
|
Parto-
gram use
|
Timing for cord clamping
|
Suction/wiping of newborns
|
Skin-to-skin care
|
Initiation of breastfeeding
|
Complications
|
Mothers
|
N/A
|
Uncertain
|
Not mentioned
|
Various experiences
|
Mostly as recommended
|
Deviant from UCG
|
Health workers
|
Rarely used
|
Deviant from UCG
|
Against UCG recommendations
|
Limited
skin-to-skin contact
|
As recommended
|
Marginal resources and infra-structure
|
TBAs/
VHTs
|
N/A
|
Various procedures
|
As recommended
|
Uncertain
|
As recommended
|
Hospital referrals
|
None of the respondents confirmed knowledge about UCG, but the researcher found the printed guidelines present in both the Health Centre and the Hospital. When asked to describe what happens during labour and after birth, the respondents talked of procedures related to vital examinations of the mother, baby’s body warmth, hygiene, cord clamping, resuscitation and necessary injections and medicines. These procedures were also closely observed by the researcher when present during and after deliveries. Initiation of breastfeeding was found to be according to guidelines both from observations and interviews, although with a few exceptions.
Monitoring of delivery
Health workers perspective
In-depth interview with health workers about monitoring of women in labour showed knowledge about vital observations. They would check the heartbeat, is it present? Is the baby still alive? They would listen to the heartbeat of the baby through the fetoscope: Is the heart beating weak or faint? Or is it maybe beating too fast? They explained about taking the fundal height and procedures for vaginal examination:
“Did she take the circumcision, you see some people have, is she having a normal vulva? So, I do the cleaning, after that I go inside, I must check - is the vagina hot? If it is hot it is also an alarming thing. So, it has to just be warm and moist. Because if she’s in labour and the vagina is actually dry, it is also a problem”. (Midwife 25-35 years)
Observations in the Hospital and Health Centre found common use of freehand journal writing as documentation of delivery. Although charts and partograms were available, they were rarely or unsystematically used which could sometimes cause difficulties or delays when searching for specific vital data or monitoring of a patient’s delivery progression.
TBAs’ and VHTs’ perspective
Both VHTs and TBAs assisted women who came to ask for help in labour. They would check the mother for signs of diseases and had low thresholds for referrals to hospitals if the mothers were showing signs of complications.
“A woman when she produces, and you check her that she`s ok, you get a flask of warm water and mix it with tea leaves because it helps her to produce well. When a mother is in labor pain and when there is no one to help her, I do give a hand to her to help her deliver well” (VHT 50-80 years, village 1)
Cord clamping – timing
Mothers’ perspective
A number of the mothers told stories of how they were unable to reach qualified help when the time for delivery was near. Reason could be transport cost, unsafe environments, darkness, or long distance. Nevertheless, home births could have the advantage of facilitating delayed cord clamping:
“I produced outside the house, so they took the baby inside. When I was done with giving birth, I knelt down for the remaining’s of the placenta to come out. They got the baby to cut the cord, after they covered the baby and they took the baby inside”. (Mother 25-35 years, village 3)
Health workers’ perspective
Optimally, from the health workers’ perspective, clamping of the umbilical cord was done using forceps, but from observations done by the researcher, the cut-off ends of surgical gloves were frequently used for cord clamping in cases where the forceps had not been sterilized or were unavailable. The clamping and cutting of the baby’s umbilical cord was normally performed on the mother’s abdomen immediately after birth. Further shortening of the cord was then done in the infant warmer, or sometimes also on the abdomen of the mother:
“The baby is placed on the stomach of the mother, then you get two forceps, then you use them to attach to the umbilical cord, then you cut ”. (Nursing student 19-21 years)
The “warmer” is an electrically heated machine where the newborn was placed after birth while the health workers cleaned the mother and where procedures on the baby were performed, thus creating a barrier for skin-to-skin contact.
TBAs’ perspective
Traditional birth attendants naturally did not have the equipment and resources available at the health facilities, but several of them had attended training with medical doctors and had been taught what steps and measurements to take after attending to a delivery. The procedure of cord-clamping varied from village to village as described by two different attendants below:
“I shorten the cord before the remaining of the placenta comes out because that’s how the doctors told us”. (TBA 50-80 years, village 1)
“I help the mother to remove the remains of a placenta from the mother’s womb then after removing it I cut it off”. (TBA 50-80 years, village 5)
Oronasopharyngeal suction
Health workers’ perspective
Routine suction of the nose and mouth was performed various places. Sometimes it happened on the abdomen or chest of the mother, whereas other times it could be performed on a separate bed or in the infant warmer. Students interviewed also confirmed being taught how to routinely suction newborns.
“After clamping, if the child is OK, you resuscitate, you first suck out the secretion from the noise and the mouth to open the air to breath, you have to resuscitate with the barb syringe, and you remove the mucus here in the mouth. If you don’t, that’s when you find some babies having fever, then flu at an early age”. (Midwife 25-35 years)
TBAs’ perspective
As a variation to oronasopharyngeal suction by bulb syringes mentioned by the health workers, another method used by the TBAs, facilitating guideline recommendation, was described as follows:
“If the baby has been born, immediately you clean the baby very well with a clean cloth because they (health workers) provided us with them, so I use those clean clothes to clean the baby in the ears and mouth for the baby to breath well”. (TBA 50-80 years, village 1)
Skin-to-skin care
Placing the newborn baby on the mother’s abdomen or in her arms immediately after birth is often referred to as kangaroo care, skin-to-skin contact or kulubutu in Luganda.
Mothers’ perspective
Many mothers confirmed having the baby put on their chest after birth and they spoke of the importance related to hygiene and warmth. Others had experiences of being separated from their newborns for unknown reasons.
“after birth they cut the cord, they covered the baby and placed the baby on the bed”. (Mother 15-25, village 3)
Health workers’ perspective
From observations, the newborn was routinely put on the mother’s abdomen immediately after being born, but there were often only a few minutes of contact before the baby was moved to the infant warmer for further procedures, then wrapped in several layers of blankets before returned to the mother.
“After shorten the cord you wrap the baby….remember you do all that (procedures) when you put the baby in the warmer. At least you maintain the temperature that was in the uterus. Then you wrap the baby in warm clothes and give it to the mother for breastfeeding.” (Midwife student 19-21 years)
In the Health Centre, where there was no warmer, the baby was more likely to be placed in the arms of the mother during the cleaning process or given to a family member or attendant for safekeeping.
“when the baby is born you have to get a cloth and put on the abdomen of the mother, as we did it yesterday… and then the baby has to cry, and you place it on the abdomen”. (Midwife 25-35 years)
TBAs’ perspective
When someone gives birth from home with the help of a TBA, the option of putting the baby somewhere other than on the mother’s body was limited. Even so, the practices varied:
“… you clean up the baby and place the baby somewhere and then clean up the mother”. (TBA 50-80 years, village 2)
Initiation of breastfeeding
Overall knowledge about the usefulness of breastfeeding was found among all the participants in the study, and the option of not breastfeeding seemed none-existent, or even unheard of. Time of initiation was found in accordance with the UCG in most of the observed cases and no adverse knowledge or recommendation were detected on this subject. Mothers who had faced complications during or after birth, were naturally more likely to initiate breastfeeding later than the recommendations.
Complicated births
Mothers’ perspective
Some mothers had experienced complications that lead to emergency Caesarean section surgeries, and this could be a challenge. They lost control of the situation and the initiation of breastfeeding was delayed. Sometimes it was the baby who faced complications, and a mother of three who delivered in a hospital explained how she was separated from her baby for three days before the initial breastfeeding occurred:
“I remained in the ward for the mothers. This one they took him in the room. Special care room, for these children, and they worked on him for three days before I saw him, yeah (…) for three days, after there, they give me to breastfeed, to start breastfeeding him”. (Mother 25-35 years, village 7)
TBAs’ perspective
The traditional birth attendants interviewed were aware of the risks connected with childbirth, and when asked about how they dealt with complications, most of them said that they refer the mothers to the hospital.
“…When you first bleed with blood when about to give birth that’s a bad sign and it is not good, when I notice that, immediately I refer them to the hospital, when still in labor pain I am the one to escort them to the hospital…”. (TBA 50-80 years, village 5)
One traditional birth attendant said she used her herbal medicine to help with complications and one respondent described how she dealt with retained placenta:
“When the placenta refuses to come out quickly, I have to place the baby on the mother’s breast when I have cleaned it well, and when the baby sucks the breast it helps the placenta to come out quickly”. ( TBA 50-80 years, village 5)
During the dissemination meeting which took place in November the same year, the participants’ feedback about the study was unanimously positive. Many expressed gratitude for receiving information about updated research and guidelines and gave constructive feedback to the researchers with suggestions for improving quality of maternal health care in Uganda. One recommendation suggested was structured interchanging of knowledge and practices between TBAs and midwives. Another suggestion was to focus more on breastfeeding routines and -problems during antenatal classes.