Obstructed labour and Birth preparedness: Community studies from Uganda

Abstract

Labour is said to be obstructed when the presenting part fails to descend through the birth canal despite strong uterine contractions. The condition is mostly prevalent in low-income countries where the main causes are cephalopelvic disproportion and malpresentation. The overall aim of this thesis was to investigate the individual, community and health system factors associated with obstructed labour and birth preparedness practices in south-western Uganda.

Analysis of 11,180 obstetric records was conducted to determine factors associated with obstructed labour (Study I). Grounded Theory (GT) was used to analyse data from 20 focus group discussions (FGDs) (Study II). 764 recently delivered women were questionnaire Interviewed to assess knowledge of key danger signs, birth preparedness and assistance by skilled birth attendants (Studies III & IV).

The risk of obstructed labour was statistically significantly associated with being resident of a particular district [Isingiro], with nulliparous status, having delivered once before and age group 15-19 years. The risk for perinatal death as an adverse outcome was statistically significantly associated with districts other than five comprising the study area and grand multiparous status. Analysis of FGDs resulted into a conceptual model, which is presented as a pathway initiated by women’s desire to “protect own integrity” (core category), which was closely linked to 6 other categories; taking control of own birth process, ‘reaching the limit - failing to give birth, exhausting traditional options, partner taking charge, facing challenging referral conditions, and enduring a non-responsive health care system. The relationship between knowledge of key danger signs during pregnancy and postpartum and birth preparedness showed statistical significance. Furthermore the relationship between women’s decision-making on location of birth in consultation with spouse/friends/relatives and assistance by skilled birth attendants also showed statistical significance. Education, household assets and birth preparedness showed clear synergistic effect on the said relationships.

Individual and health system factors are strongly associated with obstructed labour and its adverse outcomes in south-western Uganda. There is a need for health care providers to understand and acknowledge women’s reluctance to involve others during childbirth. Community empowerment and developing capacities of health care providers and health care facilities will increase skilled attendance. A continuum of care needs to be developed between communities and health care facilities. Antenatal care could be used for promoting birth preparedness. Universal primary and secondary education programmes ought to be promoted so as to enhance skilled delivery. Improved maternal health will require multi-sectoral interventions.

Abstract (Swedish)

Popular Abstract in English

Labour is said to be obstructed when the baby’s presenting part fails to descend through the birth canal despite strong uterine contractions. Obstructed labour is one of the major causes of maternal and neonatal mortality and morbidity in low-income countries. It is mostly caused by disproportion between the baby’s head and mother’s pelvis but also abnormal presentation of the baby such as brow/shoulder during labour. Delayed treatment of obstructed labour may result in rupture of the uterus, injury of the bladder, haemorrhage and fistulas, which may cause both urine and faeces leakage.

Birth preparedness is an intervention that involves women, their partners and families as well as communities to prepare in advance for seeking skilled care of both normal and complicated births. Women’s knowledge of obstetric danger signs during pregnancy and childbirth is crucial for them to seek care from skilled birth attendants in time. The overall aim of this thesis was to investigate the individual, community and health system factors associated with obstructed labour and birth preparedness practices in south-western Uganda in order to provide policy makers and implementers with evidence-based information for designing appropriate interventions.

The thesis is based on four studies: (Study I) Analysis of 11,180 maternal records from 6 hospitals in order to determine factors associated with obstructed labour. (Study II) Analysis of 20 focus group discussions (10 groups of women and 10 groups of men) to explore community members understanding and management of cases of obstructed labour was conducted. (Study III & IV) Analysis of Data collected through a questionnaire to assess 764 recently delivered women’s knowledge of key danger signs and birth preparedness practices. Further, the effect of decision-making on seeking assistance by skilled birth attendants was also investigated.

The risk for obstructed labour was highest in younger women, women who were delivering their first or second child and women who lived in a district with no hospital. Likewise, women who lived in districts far away from hospitals or had given birth to several children were at a higher risk of losing their babies as a result of obstructed labour (Study I). Analysis of the focus group discussions revealed that women’s desire to protect their own integrity resulted in a preference for unassisted or assisted home deliveries. Women tried to control the birth process on their own, and in case obstructed labour occurred reached a point where they needed to ask for assistance. The partner and/or the family would usually be asked for support at this stage. After making a decision to seek care was made, the partners and/or families had to struggle with difficulties in arranging transport, bad roads, communication and an inadequate health system.

In general, women’s knowledge of obstetric danger signs and birth preparedness was very low. Women with knowledge of key obstetric danger signs were more birth prepared than those without such knowledge. Women who consulted others (partners/friends/relatives) regarding location to give birth were more likely to deliver under the care of skilled birth attendants than those who did not involve others in that decision. High education was associated with knowledge of key danger signs, birth preparedness and assistance by skilled birth attendants.

Individual, infrastructural and health system factors are strongly associated with obstructed labour in south-western Uganda. Women prefer to have childbirths in locations where their integrity is protected. Health system should be responsive to the community’s expressed needs by providing skilled care at birth closer to the populations. Community mobilization and empowerment supported by a functional and responsive health system may lead to a continuum of care, which in turn may increase deliveries under the assistance of skilled birth attendants, thereby reducing maternal-newborn morbidity and mortality.

• author: Kabakyenga, Jerome
• supervisor: Per-Olof Östergren; Karen Odberg Pettersson
• opponent: Professor van Roosmalen, Jos, University of Leiden
• organization: Social Medicine and Global Health (research group)
• publishing date: 2012
• type: Thesis
• publication status: published
• subject: Clinical Medicine
• keywords: obstructed labour, individual factors, health system factors, protecting own integrity, adverse outcomes, knowledge of danger signs, birth preparedness, assistance by skilled birth attendants, Uganda
• categories: Higher Education
• in: Lund University Faculty of Medicine Doctoral Dissertation Series
• volume: 2012:6
• pages: 139 pages
• defense location: Jubileumsaulan’, MFC, Entrance 59, SUS Malmö
• defense date: 2012-02-03 13:00:00
• ISSN: 1652-8220
• ISBN: 978-91-86871-68-0
• language: English
• LU publication?: yes
• additional info: Kabakyenga JK, Östergren PO, Turyakira E, Odberg Pettersson K. The effect of birth preparedness and women’s decision-making on location of birth and assistance by skilled birth attendants among women in south-western Uganda. Manuscript submitted for publication.
• id: a7492755-ccf6-4ee7-9b1e-298156c7aea4 (old id 2293071)
• date added to LUP: 2016-04-01 14:07:30
• date last changed: 2019-11-19 13:49:02