KNOWLEDGE ATTITUDE AND PRACTICE After Birth

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					KNOWLEDGE, ATTITUDES AND PRACTICES
                OF
     WOMEN AND MEN TOWARDS
SAFE MOTHERHOOD IN RURAL SETTINGS




A QUALITATIVE STUDY
December 2000




CONDUCTED BY:
DR. KASOLO JOSEPHINE
AMPAIRE CHRISTINE



On Behalf of:
DELIVERY OF IMPROVED SERVICES FOR HEALTH II
(DISH II) PROJECT

         USAID Cooperative Agreement 617-00-00-00001-00
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TABLE OF CONTENTS:
Acknowledgements.                                                        3

Abbreviations                                                            4

1.0    Introduction                                                      5

1.2    Objectives                                                        7

2.0    Methodology                                                       9

3.0    Results                                                           11

3.1    Key findings and Recommendations                                  11

3.2    Communication During Pregnancy                                    17

3.3    Knowledge about pregnancy and delivery                            19

3.4    Trust among Spouses                                               24

3.5    Reasons for not Attending Antenatal care                          27

3.6    Reasons for Attending ANC in the First Three months               30

3.7    Traditional Practices During Pregnancy                            32

3.8    Traditional practices that may lead to delivering outside the health facility.
                                                                        34

3.9    Reasons for delivering outside the health facility                39

3.10   Rumours and misconceptions                                        43
4.0 Preferred means of reaching the communities with SM Massages 44
Annexes:
Focus Group Discussion Guide                                             45
Key Informant                                                            51
Brief report on the training of researchers.                             52
Researchers                                                              53




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ACKNOWLEDGEMENT

We would like to first of all extend our gratitude and thanks to all those who
provided us with this valuable wealth of information that forms the basis of this
document.

Secondly we acknowledge the staff members of DISH who participated in
different ways, the Research Assistants and Supervisors who collected data, the
district mobilizers who made our work possible.

Special thanks go to DISH II for funding this exercise that will facilitate
improvement as well as re-consolidation of safe motherhood practices.




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ABBREVIATIONS


DISH II   -   Delivery of Improved Services for Health II Project
              (DISH II)

ANC       -   Ante Natal Care

TBA       -   Traditional Birth Attendant

KI        -   Key Informants

FGD       -   Focus Group Discussion

SM        -   Safe Motherhood




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I.0. Introduction.

Since the Nairobi Safe Motherhood Conference of 1987, the government of
Uganda and non-governmental organizations (NGOs) have committed
resources to promote safe motherhood in Uganda. The Delivery of Improved
Services of Health (DISH) II Project is administered by The Johns Hopkins
University, University of Northern Carolina and Management Sciences for
Health. The DISH Project began in 1994. The DISH II Project is a second 3-
year phase which began November 1999. It is a joint project of the Uganda
Ministry of Health and United States Agency for International Development
(USAID). DISH II operates in 12 districts of Kampala, Mbarara, Ntungamo,
Masaka, Masindi, Luwero, Nakasongola, Sembabule, Jinja, Kamuli, Rakai and
Kasese to:

    Make good quality reproductive, maternal and child health services more
     widely available and

    Improve public health attitudes, knowledge and practices through;
     training, supervision and clinical services, health management and
     quality assurance, behaviour change communication,       community
     activities, research and evaluation.

 DISH II project would like to improve safe motherhood practices in Uganda by
concentrating on some maternal indicators that have remained the same since
the DISH Project began 1994.

The maternal mortality rates in Uganda are among the highest in sub Saharan
Africa. The UDHS (1995) put maternal deaths at 506 per 100,000 live births
with the figures in the rural areas being higher than in the urban centres.

Maternal mortality can be reduced by women reporting early for ante natal care
and reporting for delivery at the health facility.

There is positive trend of increase in knowledge of women about ante natal
care, the importance of receiving ante natal care early and the pregnancy
complications during the 1995 to 1999 period. The negative attitude towards
health facility and health workers is slowly changing among women and men in
the DISH districts. The Uganda Quality of Care Survey of Family Planning and
Antenatal Care Services conducted by the DISH Project and the MEASURE
Evaluation Project in 1999, confirmed findings from other studies showing that

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the majority of ante natal care clients initiate ante natal care during the second
or third trimester and that many women attend ante natal care only when they
have developed problems.


From February-December 1998 the DISH Project carried out a maternal
campaign with the main message points of: when and how often to go for ante
natal care, benefits of routine ante natal care, and warning signs of pregnancy
complications. This campaign was evaluated in August 1998. It is interesting to
note that the campaign created a lot of awareness among women attending
antenatal clinics where 62% knew the benefit of attending ANC in the first 3
months and yet only 14% of the respondents were attending ante natal clinic
during the first trimester. The issue of timing for the first antenatal visit proved
a very difficult behavior to tackle. The evaluation did not determine the reasons
for the large gap between knowledge and practice. It was observed that the
campaign messages did not change that behavior.

One year later (1999), the DISH Project conducted a population based survey
on 1,766 women and 1,057 men in 11 districts, and found that about 82% of
women made at least three ante natal visits during their most recent pregnancy.
This remained unchanged since the 1995 UDHS. The first antenatal visit
continued to occur during the second trimester of pregnancy for most women.
Only 17% sought antenatal care (ANC) during the first three months of
pregnancy. There was a slight trend to an increasing proportion of births
occurring at the health facilities from 48% in 1995 to 54% in 1999; but this was
not statistically significant. There was a significant and marked increase
between 1997 and 1999 in the proportion of women who reportedly delivered
with the assistance of a nurse or midwife.

The information above indicates that women continue to report late for ANC
and few women deliver at health facilities with the assistance of qualified health
providers. It is against this background that DISH II planned and executed this
study to investigate and understand the factors that prevent women from early
attendance of ante natal care and delivering at the health facilities.




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1.2      Objectives of the study


1.2.1       General objective.

The main objective of the study was to investigate and understand the factors
that prevent women from early attendance of ANC and delivering at health
facilities.



1.2.2       Specific objectives

      1. To assess the attitudes and practices of women and men related to
         delivery, post natal care,and first attendance of antenatal care.

      2. To identify myths and misconceptions concerning antenatal attendance
         and delivery at health facilities.

      3. To recommend main message points for a safe motherhood campaign
         that will encourage to early attendance of ante natal care and delivery at
         the health facility.


There has been some promise that women who attend ante natal care services at
least three times during pregnancy, starting antenatal care during the first
trimester will be more likely to deliver at the health facility. The question
remains “What hinders women form early attendance of ante natal care”? And
“What prevents women from delivering at health facilities”?

Inspite of health facilities being within a walk-able distance, women having
some income, improvement in quality of care, women continue to report late for
antenatal care and deliver outside health facilities.




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FIG.1. CONCEPTUAL FRAMEWORK:

Factors that may lead to late attendance of antenatal care and delivery
outside health facilities.

                                             Poor Quality of
                                             Care




Negative Attitudes of
Men and Women

                                Late Attendance of
                                Antenatal Care and                 Inaccessible
                                Delivery outside the              Health Facilities
                                Health Facility



Myths and
Misconceptions
                                                         Traditional Beliefs
                                                         And Practices



                                Financial Difficulties

This study concentrated on understanding the knowledge and attitudes of men
and women towards health facilities utilization; myths, misconceptions and
traditional practices that lead to late attendance of ANC and delivering outside
the Health Facilities.




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2.0 Methodology

The study was conducted as a descriptive cross-sectional one using qualitative
methods of information gathering including Key Informant Interviews (KI) and
Focus Group Discussions (FGD). Both men and women of 18-22 years and
those above 40 years participated. This was preceded by a literature review of
related materials on the subject. The study process started with a 3 day detailed
training of research team followed by pre-testing of the instruments and
translations of the tools. A five day data collection activity was undertaken in
each of the 5 districts with transcribing of the information as part of the process.
The themes for the FGD and KI concentrated on knowledge, traditional
practices, myths, and misconceptions related to relationships, pregnancy, child
birth and immediate post natal practices that lead to late reporting for ante natal
care and deliveries outside health facilities.




   2.1 Method of data collection

   2.1.1 Study districts and participants.

Five districts were purposely selected for the study to represent DISH II
districts. These included: Mbarara, Masaka, Masindi, Kasese, and Kamuli.


Focus Group Discussion:

Each group comprised of fathers and mothers with a low education level
(illiterate or just completed primary), who were willing to discuss openly
traditional issues concerning pregnancy, child birth and immediate post partum
practices and were not related by law or blood.




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Key Informants:

These were Traditional Birth Attendants (TBAs) and Traditional Healers or
Herbalists who handle pregnant women.


Table 1.     Study Participants:

Category                                           Number of people
                              Masaka        Kasese Mbarara Masindi Kamuli

a). FGD
 Young men (18-22yrs)        12            12     12      12      12
 Young women (18-22yrs)      12            12     12      12      13
 Old men above 40 yrs        12            12     13      12      12
 Old women above 40 yrs      11            12     13      13      12
b). Key informants
 TBAs (mainly women)         2             2      5       2       2
 Herbalist (men)             2             2      2       2       2

Note:        Those who got more KI were allowed to interview them since a
             qualitative study uses purposive sampling.




2.2     Data analysis

The data was analyzed by the principal investigator, co-
investigator, and two researcher assistants, who had
participated in the data collection. analysis was done manually
along the major themes. Broad categories were developed to
describe the ideas and views expressed by the participants. The
ideas, opinions and attitudes that emerged were noted and
related to the objectives. Comparison and critical analysis of the
ideas led to the findings and interpretations.




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3.0 RESULTS:


There was a lot of information collected about traditional beliefs and
practices that surround pregnancy, child-birth and the immediate post natal
period. The study only concentrated on those that influence the health
seeking behavior of women and those that affect the woman’s early
attendance of antenatal care and her delivery at a health facility. The poor
knowledge of what is done at the health facility, coupled with poor
communication among spouses, lack of trust between spouses and the low
status of women in the community greatly affect woman’s utilization of health
facilities.



3.1   KEY FINDINGS AND RECOMMENDATIONS.



 There is little communication between couples during pregnancy in
relation to antenatal care, especially on when to start and where to have it,
the place of delivery and who would assist her.

Recommendation: Encourage and provide a forum where pregnant women and
their spouses can exchange ideas on pregnancy, child birth and post natal care.



 There are rumours and misconceptions on what is done at the health
facility when a woman attends antenatal care or delivers her baby from
there. This scares women in the rural areas from using these services.

Recommendation: Develop massages that will correct these rumours and
misconceptions.




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 People have poor knowledge about conception, fetal development in the
womb, antenatal care and delivery services offered at a health facility.

Recommendation: Develop simple materials that can educate people about child
development in the womb, antenatal and delivery care services at the health
facility.



 There are many traditional practices surrounding pregnancy and child –
birth which prevent women from attending antenatal care or delivering at
health facilities. There are many myths attached to these practices that
leave women no room to think positively about their health.

Recommendation: Messages should be developed to demystify those myths.
They should be helped to realize the fact that those practices when not done
cause no harm to the baby or to the mother.



 Men and women strongly believe in local herbs which they bathe in,
drink or sit in during pregnancy, child birth and immediately after birth.
These herbs have been found useful . They are used by women in addition
to attending antenatal care in health facilities.

Recommendation: Doctors should study these compounds and find out the
active agents in them, and to determine whether or not they are harmful.



 Both men and women recognize the fact that a woman who may have
had a normal pregnancy can develop problems and die during labour or
immediately after birth. They also recognize the fact that every woman
must be assisted during delivery. Because of this women attend antenatal
care at least once so as to book the health facility in case problems arise.




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Recommendation: Messages should be developed to seek support for women so
that they can go to the health facility early and be assisted by a trained health
worker instead of first waiting for problems to arise.

 Women produce children not for themselves but for the clan. It is very
important to every woman that she produces a child in good health that
has a father and will be a wealthy responsible citizen. This forces women to
accept whatever the husband or in-laws say because she does not want to
be accused of carrying another man’s child.

Recommendation: Messages should build on the desire by men and women
that their children will be born healthy if they go for antenatal and deliver in a
health facility with assistance of a qualified health provider.



 While many women do not go to the health facility during pregnancy
unless they have a problem, many of those who go in the first trimester
want to find out if they are really pregnant. Early during pregnancy health
workers are unable to confirm pregnancy at most health facilities. This
forces the women to seek confirmation from the TBAs and mothers-in-law.

Recommendation: Health facilities should be provided with pregnancy testing
equipment and people be informed of their availability.



 Men and women believe that health workers have a negative attitude
towards women who go for antenatal care within the first three months.
They believe women will not be treated with respect and in many instances
they will be abused.

Recommendation: Men and women should be reassured that health workers
have changed their attitudes. They now welcome clients during early
pregnancy.




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 There is a general belief that pregnant women have sex with other men
who are not their husbands, and that men have sex with pregnant women
who are not their wives. This causes mistrust between couples and many
men do not allow their wives to go for antenatal especially before the
abdomen is very bulky and can be noticed from a distance because it is
believed that women are less likely to have sex late in pregnancy.

Recommendation: Messages to create trust among couples should be developed
so that pregnant women can access antenatal care services early and do not have
to wait until they develop a problem. Men should also be encouraged to
accompany their women to the antenatal clinic.



 Pregnant women work in the fields until they get labour pains. When
labour starts they do not have enough time to prepare. They need to get
someone to stay with the older children, and cook for the husband before
they go to the health facility to deliver. They find it more convenient to
deliver at home.

Recommendation: Messages should be developed to encourage pregnant
women to have enough rest and encourage men and women to prepare for
delivery well in advance.



 There is great fear that at the health facilities, not enough care is taken
to protect the new born babies from diseases, yet babies born in the
community are protected with herbs and rituals.

Recommendation: Messages should be developed to reassure the public that
great care is given to the mother and the baby at the health facility and that the
baby is immunized at birth against tuberculosis and polio.



 Women who get miscarriages are looked at with scorn in the community,
because this is a sign of infidelity. They are labeled all sorts of names and
they are cursed. This creates fear in the women to announce that they are


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pregnant or to attend antenatal care until they have passed the first three
months period when most miscarriages occur.

Recommendation: Information on causes of miscarriage should be provided to
the public.



  Husbands and mothers in-law play a key role in whether a woman seeks
antenatal care early or delivers at a health facility because they are the first
to be told about the pregnancy and they are responsible for providing
antenatal and postnatal care.

Recommendation:             Include men and women above 49 years in the
target audience of safe motherhood campaigns. They need to understand and be
able to appreciate the importance of early attendance of antenatal care and
delivery at a health facility.



  The low status of women in society and the marginalization of women
puts women in a difficult position. They are battered if they do something
contrary to the orders of the husband or to that of the in-laws. These
women cannot make a decision on their own. Even when she has the
money she cannot go to attend antenatal care without permission.

Recommendation: Messages should be developed to address the equal
partnership in safe motherhood.



 There are some practices which are done to babies and mothers who
deliver in the community that are not done in the health facilities. They
include: bathing the baby with warm local herbs ( Kyogelo) immediately
after birth, feeding the baby with warm herbs(Lusoggo) because the
mother has no breast milk, massaging the mother with warm herbs
immediately after birth so that all the clotted blood comes out.

Recommendation: Messages should inform the public why babies are not
washed immediately, why except the mother‟s breast milk no other feed should

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be given to the baby, and why a mothers uterus is usually not compressed
immediately after birth when women deliver at health facilities.




 Women are shy beings, who do not want people to look at their genitals.
They love privacy and comfort. They prefer to deliver when squatting or
kneeling, with the people they are used to in attendance. Such a condition
is offered to them when they deliver in the community.

Recommendation: Conduction of delivery at the health facility should be
revised to put into consideration the unmet needs of women and their
expectations.




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3.2   COMMUNICATION DURING PREGNANCY:


There is poor communication between spouses during pregnancy. It is a
taboo in some cultures to talk or prepare for an unborn child. Once a woman
suspects that she is pregnant she tells her husband first so that he does not
deny paternity. The mother-in-law or a TBA may also be told so that she can
have the pregnancy confirmed, receive the herbs and be told the traditional
practices they have to conform to during pregnancy. The first person told
about the pregnancy has a major role to play as to when to start attending
antenatal care. Their advise is taken very seriously by the pregnant woman.
They advise on the foods to eat and those not to be eaten, how to sit and how
to take good care of herself throughout pregnancy. The poor communication
between pregnant women and their spouses makes it difficult for the pregnant
women to ask for money to attend antenatal care and to prepare for delivery.
Due to inadequate preparation for the baby, deliveries in rural settings are
always emergencies.



3.2.1 What spouses talk about during pregnancy:

Men do not want to discuss antenatal attendance with their spouses
because the pregnant women nag a lot. They want much attention and are
always asking for money. This creates a communication gap that may lead
to late attendance of antenatal care.

“My husband stopped talking to me the day I told him I was expecting our third
born.” Young woman-Kamuli.

“Traditionally, it is a taboo to talk about a child before it is born.” Old woman-
Masindi.

“I only talk to my husband during pregnancy if I am asking for something or
seeking permission to go for antenatal care.” Young woman- Masaka.

“Every time I would ask him to buy clothes for me to attend antenatal care he
would just quarrel.” Old woman –Kasese


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“Why talk to him about pregnancy doesn‟t he see that it is growing ?” Old
woman –Kamuli.

“It is difficult to discuss a sensible thing with a pregnant woman. They are too
moody.” Old man Kamuli.


3.2.2. The first person to be told about pregnancy and reason:

Most of the women tell their husbands first about the pregnancy at 2-3
months because he is the one responsible for the expected child. It is also
very important to tell the husband immediately the woman confirms
pregnancy so that he does not deny paternity. Others do so in order to
attract his attention to start saving for ANC and delivery. He can assist in
case the woman develops a medical problem.

“Husbands of course especially when it is the first pregnancy, because they
have to count the days and prove that they are the real fathers.” Young woman-
Masindi.

“The husband is told first because pregnancy comes out of a secret shared
between husband and wife.” Old woman-Masaka.

“She tells her husband first because he owns the woman.” old woman-Mbarara.

Some women first tell their mothers-in-law because:

“It is culturally supposed to be done like that.” Old woman-Mbarara

“To confirm pregnancy.” Old woman - Mbarara

“To be introduced to local herbs for treating syphilis, maintaining blood and
getting strength.” Old woman Mbarara.

She would tell the TBA first because she wants to:

“Get local herbs.” TBA-Mbarara

“Confirm pregnancy,”. Old woman-Masindi.



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“They first consult me . If they have a problem I send them to the health
facility. They have to keep on coming to me until they deliver.” TBA- Mbarara


3.3   KNOWLEDGE ABOUT PREGNANCY AND DELIVERY.


Most people know very little about what is done at the health facility during
antenatal care and at delivery. Although they have good knowledge about
signs of early pregnancy and on the onset of labour, they do not appreciate
the reasons why miscarriages occur during the first trimester. They have very
scanty knowledge on child development in the womb. They believe that the
baby is a clot of blood until 4-6 months. They do not see the reason why
women should go for antenatal care early before the baby is developed.



3.3.1. Conception

 Men and women knew that one conceives after having sexual intercourse
between a man and a woman. The egg from the woman and that of the
man unite. It was interesting to note that the men as well as women are
convinced that a man can know when he has had a successful intercourse
that results into pregnancy.

“When I get very excited and my husband gets very excited during sexual
intercourse then we both know that he has made me pregnant” Young woman-
Kamuli.

“My husband is able to detect that I have conceived during sexual intercourse.
The gift of being able to detect was given to him by God.” Old woman-
Masindi

“Having sexual intercourse with a woman I can feel that I have scored and
know that I have made her pregnancy.” Old man - Masaka




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3.3.2. Signs of early pregnancy.


Early pregnancy is recognized by both men and women. It is identified by
having missed a monthly period for two consecutive months, nausea,
vomiting, preference to some foods, becoming more attractive and warm.
Although they may not confirm that a woman is pregnant, they suspect her
being pregnant.

“Once I miss two periods I know that I may have become pregnant.” Old
Woman –Masindi.

“When my wife becomes warm and I enjoy sex very much with her, then I
know that she is pregnant.” Old man- Masaka.

“When a woman becomes very attractive and becomes fatter and her skin
lighter, Mmmm. She is pregnant.” Young man Kamuli.

“When a woman starts rejecting some foods and craves for others, then she is
pregnant”. Old Man –Masindi.

“When a woman has been good to you and she starts quarreling and nagging
then she is pregnant.” Young Man-Kasese.

“When I feel lumps and fullness in the breasts, vomiting and nausea, makes me
suspect that I an pregnant”. Young woman-Mbarara.



3.3.3. Child Development in the Womb:


Knowledge of child development is very scanty and inaccurate. They all
state that after conception, what develops in the womb is a clot of blood.
This blood keeps on increasing in size until four months when the body
parts start to grow. It is a recognizable child at 6 months when it has

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physical baby parts with hair, legs, arms and can easily swim in the womb.
At 8 months it turns to face downwards and this time it mainly kicks. It is
a mature baby at 9 months and that is when it is delivered.

“From the 1st to 4th month the head of the baby faces upwards then from there
on to the 8th month it develops while facing downwards.” Young man-Kamuli

“The baby starts developing when a man plays sex with a woman, the eggs
meet and at 1st month the egg which was fertilized moves to the womb and at
3rd month the thing is shapeless. From 4 th-6th month the different parts of the
body starts to develop and at 7 months the baby turns upside down . The baby is
mature at 9th month and is ready to be born.” Young man - Masaka.

“The baby starts as a clotted blood; then later at 4 months turns into a lizard and
slowly it develops other parts. It is mature at nine months.” Young woman-
Masindi.


3.3.4. Causes of Miscarriage :

Because miscarriage is believed to be caused by infidelity, society looks at
women who get miscarriages with scorn. Others knew that untreated
STDs and trauna can cause miscarriages.

“If the woman has many men or has sex with a man who did not make her
pregnant, she miscarries.” Young Man -Masaka.

“The woman may have been raped. Rough sex with a pregnant woman can
cause miscarriage.” Young Man- Kamuli.

“If my wife got pregnant from another man, she will automatically get a
miscarriage .”Old man – Mbarara.

“Some pregnant women annoy their husbands, they get beaten and get a
miscarriage”. Old woman- Masindi.

“Jumping witchcraft at cross roads can cause miscarriage”. Old woman-Kasese.

“If you do not pay bride wealth, and your wife conceives before you have fully
paid, that can cause miscarriage.” Young man - Mbarara.

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“A pregnant woman can have a miscarriage if she does not perform some
traditional rituals to protect the pregnancy or does not use local herbs.” Old
woman- Masindi.

“She is a promiscuous woman who had multiple sex with different men while
pregnant”. Young woman - Kasese.

“The woman may have had an STD and did not seek treatment”. Young men-
Masaka.

“Some women abort especially when their intentions are only to enjoy life”.
Old woman - Kasese.



3.3.5 What is Done during Antenatal Care at a Health Facility:

Knowledge about what is done during the ANC conducted at the health
facility is very poor. It mainly focused on the behavior of health workers
and little on what they do. It is full of rumours and misconceptions. The
young and old women from Mbarara who participated in FGD had never
attended ANC or delivered at a health unit.

“For us we don‟t know what they do in the hospital because we have never
gone there”. Young woman - Mbarara.

“You are weighed and told to lie on the bed. The baby is checked and treated
if you have syphilis”. Young woman - Masaka.

“When I went to hospital at three months the nurse taught us how to feed,
weighed me and if found sick got tablets and a white liquid which was very
useful.” Old woman - Masaka.



3.3.6 Labour:

The most known sign of labour is labour pains. In most cases it comes
unexpected. It finds women in all sorts of places like gardens, church,

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market or on the way from the garden. An older woman is called to assist
to prepare for delivery. In many instances a TBA is consulted. Having
confirmed labour, she advises the woman to go to a health facility only
when she realizes that the labour is complicated and unmanageable .

“When I get labour pains and contractions, I go to the TBA to check and it will
depend on her advise to either go to deliver at a health facility or at the TBA‟s
place”. Old Woman -Mbarara

“When I see my wife in a lot of pain from the abdomen I call an older woman
and I go to meet with friends. By the time I come back she has delivered”. Old
man-Kamuli.



3.3.7. Delivery at the health Facility.

There is poor knowledge on what is done at the health facility during
delivery which scares women from venturing into it. The participants had
little experience as to what happens there. They relied on rumours and
hear say.

“I hear women saying that the nurse gives orders and has laws to be followed.
She tells the women to lie down on their backs and hold their legs. She calls
her friends to watch the baby come out”. Old woman Kamuli.

“If a woman delivers in hospital the placenta remains in the hospital. For me I
pick my wife and baby and we go home”. Old man - Kamuli.

“I saw a mother who delivered in the hospital compound before the midwives
could come” Old woman - Kamuli.

“I hear women say that in a health facility nobody holds your back and you are
left alone in the room. When you call the nurse when the pain increases, she
tells you to shut up”. Young woman –Masindi.




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3.4   TRUST AMONG SPOUSES:

Generally there is a lot of mistrust between men and women in the
community. The marital relationships are constrained during pregnancy.
Because women cannot become pregnant during this period, men think that
they can go with other men. Most of the traditional practices attached to
pregnancy are geared towards preventing pregnant women from meeting
other men and in the long run they are also prevented women from early
attendance of antenatal care.


3.4.1. Test for paternity

In all the groups studied, a child’s paternity and belonging to a clan is
given priority. No clan would like to accept a child that does not belong to
it. This child should not share their property--especially land. Even when
the father has accepted paternity of the child, the clan leaders perform
rituals to confirm that the child belongs to that clan. If the child does not
belong to that family and the woman refuses to tell the real father, it is
adopted in the family using local herbs. This child is segregated, works
harder than other children, eats less and may have less education. He does
not share the clan property.

Different clans in a tribe may have similar or different tests and because of
the above reason women’s health seeking behaviors are controlled by the
husband, and her in- laws. Slight doubt of paternity causes great distress
to the mother and the child. She will not move out of the house to attend
ANC if the husband or in-laws have a contrary view. The child or the
pregnancy will be disowned and the women asked to look for the father of
the child. She would get no financial or moral support from the husband
or the in- laws.




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3.4.2 Ways of proving paternity

“Checking the baby by the in-laws for resemblances with the man‟s family and
relatives. They mainly check the face, nails and head.” Young man- Masindi.

“Putting the baby in the doorway of domestic animals, if the child does not
belong to that family it is trampled on and it dies.” Old woman- Kamuli.

“The umbilical cord smeared with ghee is put at the bottom of a basket full of
water and released. If it floats then the child belongs to that clan and if it sinks
the child does not belong to that clan.” Young man – Masaka.

“Children born in a year are taken to the lake. The woman hands over the
children to the men who take them into the water. The children are thrown into
the water and the children who sink do not belong to that clan.” Old woman –
Kamuli.

“If the child who does not belong to that clan is given a clan name, it will cry
endlessly.”
Old woman – Kasese.

“During the first sexual intercourse after child birth, the woman gives the cord
to the man who is the father of the baby. If she does not give it to you then the
baby is not yours.” Young man-Kamuli.



3.4.3 Men refuse their spouses permission to attend antenatal care during
the first three months:

Some men refuse their wives to attend ANC before 5 months because they
believe that women in early pregnancy are promiscuous.

“Women enjoy sex during pregnancy especially early pregnancy” Young
woman -Masaka.

“Women befriend men when pregnant because they do not fear to get a child
from another man”. All men and women FGD.




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                                      26


“Few women loose interest in sex when pregnant.” Old woman-Kamuli and
Kasese.

“Men befriend pregnant women who are not their wives because they are warm,
attractive and sweet.” Young man -Mbarara

“Boys of these days are terrible. They run after other men‟s pregnant women.”
old woman- Mbarara.

“It is believed that some pregnant women lack something in their body that
makes them crave for sex.” Old man - Masaka.



3.4.4 Attitude towards women whose children are denied paternity.

It is important to note that society has a negative attitude towards women
whose pregnancy or child has been denied paternity. Such a woman loses
respect and the child she produces does not have equal status like other
children in that family. This is emphasized by some of the responses from
the focus group discussions.

“Such women are promiscous and a prostitute and cannot be trusted by the
husband.” Old woman-Kamuli.

“The child will grow up with bad behavior and will disorganize the family and
clan.” Old man-Masaka.

“The disowned child is taken to his mothers parents and grows from there. He
is not part of the family.” Old woman-Mbarara.




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3.5 REASONS FOR NOT ATTENDING ANTENATAL CARE
IN THE FIRST THREE MONTHS.


The participants in the FGD had reasons which prevent women from
attending antenatal care in the first three months.

There was a general feeling in the focus group discussions that women
should use local herbs which they can use to help with minor problems
during early pregnancy. This prevents them from attending antenatal care
during that period. These herbs treat syphilis which is greatly feared by all
communities because it is known that it affects both the mother and the baby.
These herbs give them strength when bathed in cold water early in the
morning. They felt that none of the drugs given to them in the health facility
give them strength. Such feeling may greatly influence ANC attendance
within 3 months.

Women’s low status in society whereby they cannot make independent
decisions about their health even when they have money and are aware of the
advantages of attending ANC early. Heavy work load makes it impossible for
pregnant women to start ANC before 5 months. It is a common practice that
women go to the health facility if they have a problem that requires medical
attention. There is poor knowledge about ANC in the communities and the
benefits are not easily appreciated.

Pregnancy before three months is not confirmed at most health facilities.
Most women go to attend ANC in the first three months to be assured of the
fact they are pregnant. In most cases, health workers cannot confirm early
pregnancy due to lack of pregnancy test kits. This frustrates both the men
and women who may want to confirm pregnancy. Lack of money to pay for
transport and user fees was mentioned, but this is not a serious reason. User
fees go as low as 500/= an amount which is affordable. Similarly, transport
to most health units ranges from 500-3,000 shillings which is not a
prohibitive cost.


“If your husband sees that you are fine he may not allow you to go for ANC.
Husbands may also think that you are going to other men especially when you
take long to go back home.” Old woman –Mbarara.


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                                        28




“Some primitive men also refuse their wives to go for ANC because to them
pregnancy is not a sickness, that it is laziness. It is only when their mother-in-
laws get concerned they bring them to me” Trained TBA Mbarara.

“When I went to a health facility at three months pregnant, the nurse could not
tell me that I was pregnant. She told me to go back after one month”. Old
woman-Masaka.

“The doctor told me to remove my pants and put his fingers inside my private
parts when I asked him if I were pregnant. He told that he was not sure and told
me to go back after 6 weeks.” Young woman - Kasese.

“If women go early to attend ANC, they will get tired because they will be
required to go there more times. They wait and go in late months of pregnancy
although others may go on the same day they will give birth.” Old woman-
Kamuli.

“Some women fear tablets and injections which may be recommended by the
medical personnel.” Old woman-Kasese.

“Sometimes pregnant women may lack money to transport them to the health
facilities and that to be paid as fees.” Young woman-Kasese.

“If your husbands sees that you are fine he may not allow you go for ANC.
Husbands may also think you are going for other men especially if you take
long to come back home.” Young woman-Masaka

“Sometimes there is hardly any problem with the pregnancy so there is no need
to go to the hospital.” Young men-Masaka.

“Lack of knowledge about the importance of attending ANC among pregnant
women and husbands”. Old man-Kamuli.

“Health facilities are sometimes located in long distances which discourage
pregnant mothers”. Young man-Kamuli.

“Beliefs in traditional medicine (herbs) which are eaten, drank, sat in by women
discourage ANC attendance because they feel well”. Old woman-Masaka



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“Normally before 3 months elapse, pregnant women are not so sure of the
pregnancy and fear to attend ANC.” Young woman-Masindi.

“There is a tendency to hide the pregnancy until it can no longer be hidden
especially for the newly married and school girls.” Young woman-Masindi.

“Even the women who have money may be prevented from attending ANC by
their husbands”. Old woman-Kamuli.

“A pregnant woman may fail to get someone to leave with the older children
when she wants to attend ANC.” Old woman-Masaka.

“ Women here in the house are overworked and do not have time to visit the
health facility for antenatal care.” Old man - Kamuli.




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3.6. REASONS FOR ATTENDING ANTENATAL CARE IN
THE FIRST THREE MONTHS:


The participants expressed the reasons why women should attend antenatal
care in the first trimester which could be exploited to strengthen antenatal
care attendance.

“Women go to the health facility to confirm pregnancy.” Young man –
Mbarara.

“I think it is to get set for the days ahead by getting an antenatal card so that in
case a woman fails to deliver properly and she goes to hospital, a health worker
will know that she tried her best.” TBA – Mbarara.

“Pregnancy is a sickness. Women feel nausea and abdominal pains. They
should get treated.” TBA –Masindi.

“These are modern days when a pregnant woman has to go to hospital.” Old
man- Mbarara.

“Women these days should go for antenatal care early because pregnancies
these days are complicated by many diseases in existence today.” Old Woman
Mbarara.

“Yaah! In fact it is a rule that every woman has to follow. Once she finds out
that she is pregnant, she goes there to get an antenatal card so that in case of any
complication at a later time, she will find no problem with the midwives at the
hospital. Even though they tell them to keep going back after every month, most
of them really do not go back as long as they feel no pain or are not bleeding.”
Old man - Mbarara.

“I go to be told that I am okay.” Young woman – Masaka.

“TBAs fear to handle short women. They send us to hospital.” Old Woman-
Kasese.




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                                         31


“For me I say that as soon as a woman gets to know that she is pregnant she
should go to a health facility where there is a yellow flower.” Young man-
Kamuli.

“Before three months, it is the best time to go to the health facility in case you
need an abortion” Young woman –Masaka.




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3.7. TRADITIONAL PRACTICES DURING PREGNANCY:


There were a number of traditional beliefs and practices that, if religiously
followed, would prevent women from attending antenatal care. Although
most of the practices are fading away, there are those that still have a
strong hold on women’s health seeking behaviors.


 Although some traditional practices and beliefs are fading away, most
women believe in traditional herbs which are given to them by the mothers-
in-law, TBAs and older women in the community. These herbs which are
drunk and bathed in give them strength, increase appetite, treat syphilis,
prevent ante-partum hemorrhage and prevent sexually transmitted diseases.
The women and men do not see the need for going to ANC early when it is
made safe by the herbs.

 In all the cultures pregnant women are not supposed to cross roads. In
Kasese, they can only cross in the afternoon or else the mother and child
would carry away the evils thrown at the junctions which may interfere with
the mother and babies health. This is a practice that is likely to make women
fear to walk to the ante natal clinic. Otherwise evil will follow them. Most
antenatal clinics are conducted in the mornings. In Buganda and Busoga it
pregnant women were told not to cross roads in order to protect pregnant
women from walking long distances because they may get a miscarriage.
They also feared witch craft which could be placed at cross roads.

 Pregnant women should not sit on chairs or stools where other people
have been sitting or else she can contract STDs or develop eclampsia. It is
important to note that when women go to attend ANC they sit in taxis or on
bicycles or motor cycles where other people have been sitting. At the health
facility they sit in a queue one after the other. That fear may prevent them
from going to attend ANC. The fewer times she is exposed to catching STDs
the better.




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 Pregnant women should not stand in the doorway or else the evil spirits
can enter her and harm the baby as reported by old men in Masindi. At the
health facility women stand in the door way waiting for their turn. This can
be an explanation for women not going to the ANC early.

 A pregnant woman should not meet a dead animal. In most rural areas
dead animals are thrown by the road side. These include dogs, rats and cats.
There is a tendency of women fearing to meet them on their way to ANC.
Therefore they are likely to try to reduce on the risks by moving out less often
including going to attend ANC.




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3.8 TRADITIONAL PRACTICES THAT MAY LEAD TO
DELIVERING OUTSIDE THE HEALTH FACILITY.


Due to the fact that traditional practices are not catered for at the health
facility and that women and men strongly believe in them, most women
deliver outside the health facility where they can easily practice them. The
practices that are done to the mother, the baby and to the placenta
immediately after birth are necessary to preserve the mother’s fertility, to
protect her from people who do not wish her well and treatment of any illness
that may have arisen from pregnancy and child birth. They also protect the
child from evil spirits, and childhood illness, and models the baby into a
responsible human being who will be wealthy and prosperous in adulthood.



3.8.1. Local Herbs:

Herbs are used during pregnancy, labour and the post partum period.
Herbs are used to: induce and quicken labour; stop the after pains and
bleeding after delivery; massage the mother to remove blood clots and
quicken healing; wash both the mother and the baby; and to treat diseases
which the baby might have been born with. Yet medicines are not routinely
give to mothers and babies who deliver or are delivered in a health facility.

“Immediately after birth, herbs are boiled and put in a basin to bathe the child”.
Non trained TBA – Mbarara.

“After birth, boil the herbs, put them on banana leaves and do massage on all
body parts of the mother. The blood clots will come out and make the bones
come together “ Non –trained TBA - Mbarara.

“After birth, different herbs with different uses are collected and boiled together
and the child washed so as to get luck, be protected from enemies and also be
protected from various misfortunes.” Old women - Mbarara.

“I wash the child with warm water mixed with some herbs called Kyogero”
TBA - Masaka.


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“Local herbs are drank and bathed by an expectant woman to induce labour
contractions to quicken delivery.” Old men – Kamuli.

“I give women herbs to stop bleeding after birth and also I give those herbs that
cure after pains.” Herbalist – Masindi.

“After birth the women are washed and massaged with warm water containing
herbs.” Young women – Masindi.

“Herbs are prepared and taken by the woman, her husband and relatives after
delivery of twins.” - TBA - Mbarara district.

“Women are bathed in herbs to prevent and treat eclampsia .” Young woman –
Kamuli.

“Millet flour is mixed with water, sieved and fed to the baby immediately after
birth. This is done to remove the white mucus on the throat of the baby .” Old
man- Mbarara.

“The baby stays indoors for 3 days if it is a girl and 4 days for a boy. The baby
is then taken out and given a name.” Old women- Masindi.

“One day after delivery sunflower and millet cereals are prepared. Some are
eaten and others sprinkled on the boy child saying „Produce every night and
many children‟.” Young women- Masindi.



3.8.2 Placenta Disposal:

The placenta is regarded as the second child and is carefully handled at
birth and properly disposed of. There are many rituals regarding the
placenta so that the woman continues to have children and delivers well
during subsequent pregnancies. The placenta disposal is also believed to
determine the child’s luck and misfortunes and its growth into a
responsible citizen. The placenta is buried in the house, or on a banana
plantation depending on the sex of the child or in the forest under a
particular tree, depending on the clan. In all cases its disposal is done by


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someone who is close to the woman and has ever delivered a baby. Proof
that it has been buried is essential. This is to guard against any malicious
person who can get access to it and use it to bewitch or harm the mother or
the baby.

“Every clan has its own way of disposing of the placenta and every sex has its
own plantain. The placenta of the girl is put on the female plantain and for the
boy the placenta is buried on the male plantain.” Young woman – Kamuli.

“When a woman has delivered a baby, the placenta is disposed of in either the
banana plantation or buried in the forest depending on the clan.” Old man -
Kamuli

“If the baby is a girl, a small pit is dug on the left side of the door way. Leaves
of „Omuko‟ are placed in the pit first to form a carpet, a piece of a broken pot is
put in and the placenta is placed upright and covered on the left side of the door
way. For the a boy all the above is done but put on the right side of the door
way.” Old woman – Masindi.

“The placenta is placed on a piece of an old broken pot and buried facing
upwards and in case of a problem one would visit the place where it was buried.
If one placed it facing downwards it implies that ones‟ chances of ever giving
birth again is limited. If not buried and is thrown away the child may become
dormant or may die.” Young woman – Masindi.

“After delivery the woman stays indoors and comes out after four days and goes
out with the placenta and she disposes of it.” Old woman – Mbarara.

“The placenta is mixed with sorghum, millet and green vegetables so that the
woman can continue to deliver well.” Un- trained TBA – Mbarara.

“It is the husband, mother or sister-in-law who buries the placenta because if
the woman buries the placenta, she may fail to deliver again because it is
presumed that she has buried all the children in the womb.” Non trained TBA –
Masindi.

3.8.3 Positioning at delivery:

Positioning at delivery varies from place to place but the ones identified are
squatting and kneeling while holding either a house pole or a banana tree

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and not lying on the back as commonly practiced in hospitals. The one to
be used depends on circumstances and the intentions include: not to expose
one’s private parts to the people assisting in the delivery; using the
position one is accustomed to; and having enough support during child
birth.

“During delivery a woman is supposed to kneel down or squat. If she does not,
the baby will not come out properly” Non-trained TBA - Mbarara.

“The woman should not remove her clothes but kneel or squat gracefully and
deliver. It really depends on which position gives her energy.” Young men –
Mbarara.

“I hear women saying that the nurse gives orders and has laws to be followed
and tells the woman to lie down on her back and hold her legs. She calls her
friends to watch the baby come out “ old woman - Kamuli.

“For us we prefer to deliver at the TBAs. A woman remains dressed in her
clothes and is covered. She squats and the TBA only checks with her hand to
receive the baby without looking there.” Old woman - Kamuli.

“Some women kneel when in labour but they are few because it makes them
tired and can kill the baby. Most women prefer to squat with their backs
supported by the midwife.” Old women – Masindi.

“You squat and spread the legs so that the baby can come out properly. Usually
some one sits behind you to offer support. The way you squat will determine
how quickly you will deliver and how relaxed you will be.” Old women -
Kasese.



3.8.4. Massaging of the mother after birth:

Massaging as a means of quick healing of the physical and after pains as
well as useful means of removal of blood clots from the woman is widely
and commonly practiced. Herbs are boiled in water and a piece of cloth or
banana leaves which have been used to cover food are used to press on all
parts of the woman’s body concentrating mainly on the abdomen.



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“An attendant is responsible for massaging the woman who has delivered. She
lies on banana leaves and is massaged immediately after delivery. In case there
is nobody to do it, the woman herself does it or her husband or any other old
member in the family. In the hospital, massage is not done.” Old woman –
Kamuli.

“The mother is massaged with warm water using banana leaves so that blood is
removed from the womb and her back is strengthened.” Old woman - Masindi.

“After birth, the woman is bathed and massaged with warm water containing
herbs. Offals are prepared and the soup drank by the mother for replacing the
lost blood.” Young women - Masindi.

“Immediately after birth, if the baby is born with some complications certain
rituals are performed. For example if a woman saw a dead dog she produces a
child who will be sickly all the time and very tiny. They have to look for the
bone of a dead dog and tie it on a string around its neck and the child heals.”
Young man” - Mbarara.

“An old woman who curses out evil spirits is invited immediately after birth
and she utters all sorts of curses to the child. The intention is to guard the child
from curses of malicious people in future” Old man - Mbarara.




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3.9   REASONS FOR DELIVERING OUTSIDE THE HEALTH
      FACILITY:


A wide range of reasons were pointed out that lead to delivering outside a
health facility. These include economic, distance (accessibility) availability of
TBAS, trust in herbs, traditional practices, misconceptions about delivery in
health units, mistrust of the health workers and lack of knowledge on what
happens at the health facility during delivery.



3.9.1 Privacy.

A pregnant woman feels shy and does not want anybody else to look at her
private parts. They will deliver outside a health facility since they have
heard or experienced the fact that health workers look at and touch their
private parts when they go to deliver. In the focus group discussions it was
found out that there are very few times when women’s genitals are looked
at either by herself or by other people during her life time.


“Private parts should only be looked at by your husband when having sexual
intercourse” Young women -Masaka.

“The husband is the rightful person to view his wife‟s private parts. I for one
feel it is permissible to two people and that is the husband and the doctor and
this should be during sexual intercourse and during medical examination
respectively.” Old man – Masaka.

“At birth the TBAs do not look at the private parts. They just feel them.” Old
woman – Kamuli.

“At birth in the hospital you lie down and open your legs. All the health
workers come to see and even uses very bright lights.” Young woman –
Masaka.




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“I would think that it must be during sexual intercourse because the excessive
love and pleasure takes away the expected shyness such that two parties can
freely view and even touch each other while they are purely naked” ” Young
women – Masaka.

“At the age of twelve, as a mother of the child it is difficult to talk to your own
child. The auntie talks to her about the cleanliness of the private parts and the
pulling of the labia minora. She makes her look at hers and know how big hers
has to be.” Old women -Masaka.

“For us men, we are not supposed to see. It is very shameful. How do you look
at a woman‟s genitals?” Old man – Masindi.

“The doctor can see when he or she is treating her. ” Young men -Masindi.



3.9.2. Traditional Birth Attendants’ Services:

TBAs are appreciated in the community. They adhere to the norm of
deliveries always being an emergency in the community. They act quickly
and are always available. They offer support and reassure women during
delivery. The TBAs accompany women to the greatly feared place ( health
facility) when they develop problems during delivery.

“ A TBA can be called upon at any time of the day to assist in delivery and they
do not ask for fancy clothes in which to put the baby. They also give you herbs
to quicken labour pains and delivery.” Young woman –Mbarara.

“ The TBA services are „cheap‟ ranging from 3,000-10,000/= which can be paid
in installments. Some prefer to wait for gifts from the spouses like goat or
chicken, others charge nothing but only leave the choice of rewarding her to the
family.” Non trained TBA-Kasese.

“The TBAs in Mbarara charge 10,000/= or a goat.” Old man –Mbarara.

“The TBAs are close to the people they are near. You can call them anytime of
the night and they will come to help you. They even follow up the child to see
how it is growing and the mothers‟ health.” Old woman – Mbarara.



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“It is very costly to go to hospital in terms of transport due to distance and also
in terms of buying the required medical materials needed in clinics for safe
delivery, so women prefer to go to the TBAs who are relatively cheap.” Old
man – Masaka.

“TBAs have some herbs which induce quick delivery of the baby and placenta.”
Young women - Masindi.

“I do not think that the health facilities are expensive!. They charge 500/= as
user fee and 3000-5000/- for a normal delivery. The TBAs Charge 3000-
10,000/= or a goat . To me TBAs are very expensive.” Young woman –Masaka.

“I deliver the mothers without gloves.” TBA – Mbarara.

“We resort to hospital only when there is a problem after the mother has failed
to deliver from the village”. Untrained TBA - Mbarara.

“If there are no problems and herbs to take are available, then why waste
money? But those who know that they usually get problems are the ones who
rush to hospitals as soon as labour starts.” Old woman - Mbarara

“Yes, if he knows his wife always delivers well, he does not find a reason for
going to hospital.” Young man – Mbarara.

The baby is bathed to remove the white stuff and the head is pressed
immediately after birth. It is bathed with local herbs known as “ekyogero”
which is practiced in all the districts. It is known as “okufubira” in Masindi
or “eshabiko” in Mbarara. The ‘kyogero’ is meant for cleaning the baby
and feeding for the mother who has no breast milk as yet and stop
abdominal pain.

“The baby is washed in a mixture of milk and alcohol. It is believed that the
child dies if you don‟t do it ” Old woman-Kamuli.

“In case the baby fails to cry, the TBA puts water in the mouth and then spits it
on the baby‟s forehead little by little until the baby cries.” Old woman - Kasese.




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3.9.3. Medical Personnel:

Health workers were cited as being responsible for women not delivering at
the health facility.

“The health workers usually do not give enough time to the expecting mothers
to deliver naturally. The moment a woman hesitates a bit during delivery, they
straight away recommend for an operation.” Young woman- Masaka.

“You see now in Mbarara we have got a problem. Immediately a woman
reaches the hospital the students of Mbarara University rush to operate. Now
tell me how can I take there my wife to be operated by learners?” Young man –
Mbarara.

“There is swapping of the children in big hospitals like Mbarara and Mulago”.
Trained TBA-Mbarara.

“The nurses bark at pregnant women using abusive language. „It is not my fault
that you slept with your man and now you are pregnant. Don‟t waste my time
after all I‟m not your husband!‟” Old woman – Masaka.

“If you go to hospital when you are dirty especially when you have not shaved
they call others to see „Mabira forest‟.” Old woman – Kamuli.



3.9.4. Gender Issues:

The gender relations--particularly the issue of decision-making within the
household--was also pointed out as a factor. A woman is not likely to go to
deliver from a health facility or attend antenatal care unless her husband
has given her permission.

“Women can‟t deliver from the hospital if the man has not given her
permission, even if she has the money.” Trained TBA -Mbarara.

“Conflicts in the homes especially with abusive husbands who are jealous and
suspicious can prevent women from delivering at the health facility.” Old
woman- Kasese.



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3.10 RUMOURS AND MISCONCEPTIONS THAT MAY
PREVENT WOMEN FROM ATTENDING ANTENATAL
EARLY OR DELIVERING AT THE HEALTH FACILITY.


“The „polio‟ (tetanus) injection given to pregnant women can kill the baby
inside. Because of that husbands refuse them to go for antenatal care.” Old
man- Mbarara.

“Others fear tablets and injections. Yes we fear in chorus. In fact some throw
them away because some say that they can extend days of pregnancy and
prolong delivery.” Old woman- Kasese.

“We were told with our wives that medicine from hospitals enlarges the baby
in the womb and this leads to caesarean section”. Old men Kamuli.

“Diseases of children like „false teeth, Ebiino’, „ Maize disease Bicori’ and’
Millet disease oburo’ are contracted on the way as pregnant mothers travel
across road junctions to attend antenatal care .” Old woman- Masindi.

“Nurses order pregnant women around, undress them completely, insert hands
in a painful manner into their private parts and even invite other fellow nurses
to come and watch.” Young woman – Masaka.

“When the woman gets a tear in a health facility she is beaten.” Old man-
Kasese.




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4.0   MEANS OF COMMUNICATION TO REACH THE
      RURAL POPULATION:

The participants in all the FGD and KI were asked to identify the
best channels of communication that can be used to reach them
with information about Safe Motherhood. They included:

1.    Radio especially the local FM stations.
2.    Workshops and seminars.
3.    Home visiting.
4.    Using Local Council Meetings.

Although Music Dance and Drama was mentioned, both men and
women expressed the fear that most women will be refused
permission to attend those functions. Such gatherings are attended
by people with different characters and intentions. It was dismissed
as a means of reaching married women but can be used to reach the
youth.




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                                           ANNEX: I

SMIU/DISH:                KAP STUDY ON SAFE MOTHERHOOD

KI AND FOCUS DISCUSSION THEME LIST November 2000
                                                                    Date of conduction:

Section 1: Location Data                                            Names of conductors:



 District

 County

 Sub-county

 parish




Name        Sex and/Age    Education level No. of children Marital Status
Section 2: Profiles of members in FGD

Name




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A.   COMMUNICATION


1.   What issues do spouses discuss during the period of pregnancy and
     at birth?

Probes     -     where to attend ANC and deliver from and why
           -     when to start ANC attendance and how often
           -     maternal nutrition
           -     traditions surrounding pregnancy
           -     preparation for the baby



2.   Who is the first person to be told about pregnancy

Probes     -     husband, mother, mother in law or boy friend
           -     At what month/time of the pregnancy
           -     maternal nutrition
           -     reasons for telling that particular person and why at that
                 particular time
           -

B.       ATTENDANCE OF ANTENATAL CARE AND DELIVERY


3. Why should a woman go for ANC in the first 3 months?

Probes    -    confirmation of pregnancy
          -    Advice from health workers
          -    Check whether she is okay
          -
3 Why do you think most women don't attend ANC within the first 3
  months?

Probes     -     not sure of the pregnancy
           -     Lack of trust by husband
           -     May meet other men




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5.  Who dictates/influences the health seeking behaviour of a pregnant
woman?

Probes       -     husband, mother in law, woman herself.
             -     Advice from health workers


6.     Why do most women deliver outside the health facility?

Probes       -     traditional practices that are not catered for at
                   health unit and which are those?
             -     Lack of trust between health workers and spouses/husband
                   not trusting health workers.




C:     PRACTICES, BELIEFS, RITUALS


     7. What are the beliefs and practices attached to pregnancy and birth
        in this community?

Probes       -     food taboos
             -     People not supposed to mix with
             -     Sitting position
             -     Delivery form where
             -     What would happen if she did that?

8. When is sex resumed after delivery?

9. We would like to know from you the birth practices in your community

a) How is the placenta disposed off and the rituals involved?

b) What is the preferred position of a woman during labour (how does a woman
   position herself during labour)?

c) What position is comfortable for them?



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c) What is done immediately after birth to the baby, mother and father?

d) For those who deliver from hospital/health unit: how do they go about the
   birth practices and what are the implications?

e) What are the things needed by the father from the mother and baby at birth
   that would ascertain that he is the father?
            -      blood
            -      piece of article from which mother has delivered

D:    Trust:


10. What is your opinion/view on the assertion that "during pregnancy
women tend to be promiscus" and why that comment/opinion?

      a) Do pregnant women go in for sex with men other than their husbands?

      b) Do men go in for sex with other pregnant women other than their
      wives?

11. In this community, how do you regard or what is the opinion on
   women who tell their husbands that they are pregnant and later finds
   out that they are not?

Probes      -      scheming for/wanting property
            -      Want care
            -      Wants to be recognized and married
            -      Show that she is fertile/not barren


12.   What is your opinion of women who get miscarriage?

  Probes    -      she was promiscuous
            -      Did not do some rituals
            -      Battered by husband
            -      Not cared for
            -      Has VD/sick/STD/HI
            -      Bewitched
            -      Trying to abort/interfering

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               -     Traditions not done


13.What is your opinion of the women whose children are denied
   paternity?

     Probe- Reasons why children are denied paternity

c)       When does a pregnant woman stop working ?



E:       KNOWLEDGE ABOUT PREGNANCY AND CHILD BIRTH

14.How does a woman/husband know that:
     a. She is pregnant and at what month/period?

b)    That she is in labour?
c)    How does conception take place?
d)    How does the baby development in the womb?
e)    When do you think a woman's genitals should be seen/looked at and by
      who?

Probes         -     from where, when
               -     For what reasons
               -     How often



F:       BEHAVIOUR CHANGE

15.Which of the above mentioned rituals, beliefs and practices during
   pregnancy and delivery you feel should be abolished and why?

16.Which of the above mentioned rituals, beliefs and practices during
   delivery and pregnancy you feel should promoted/strengthened and
   why?




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                                     50


17.What do traditional birth attendants (TBAs) offer/provide during
   pregnancy and delivery and after birth that is not offered at the health
   facility to:

      a)    mother
      b)    baby
      c)    father


18.What method should be used to reach you to:

            -     Give you information/Communication channels


Suggestions:

What are your suggestions to address late ANC attendance and delivery
outside the health unit?

Any comment or questions from the participants can be raised



                     THANK YOU !




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ANNEX: II

                         TOPIC GUIDE FOR KI

Biodata for KI

Age                           Education

Sex                           Training

Marital status

Age of last child

Cases handled during last month

Service ANC and delivery cases referred to her records

Maternal death during beginning of this year

Cases they handle.

 What are TBA and healers’ practices during pregnancy, child birth and
  immediate post natal?

 Have you ever assisted a woman in labour?

 What do you do if you find the case is difficult?

 What problems occur to women that may call for the expertise of a
  traditional healer?

 When that problem was presented to you then what did you do?

 What problems do they encounter?




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                                 ANNEX : III

     BRIEF REPORT ON TRAINING OF THE RESEARCH TEAM

The training was conducted by 2 consultants assisted by DISH staff for 3 days.
It included the following:

 Introduction to DISH Project

 Introduction to Safe Motherhood

 Introduction to the study and discussion of literature review

 Group work to define major concepts (rituals, myths, misconceptions,
  practices, beliefs and rumours) and presentation.

 Discussion of tools

 Translation of tools

 Pre-testing of tools in Kamwokya

 Feedback on the pre testing exercise regarding suitability of tools. Changes
  were effected.

 Field work instructions regarding expected output and assembling the field
  tool kit.




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ANNEX IV: Research Team.

Dr. Kasolo Josephine            Principal Investigator
M/S. Ampirwe Christine          Co-Investigator.

The Mbarara team :
Ampairwe Christine               Supervisor
Butamanya Rose,
Twianmasiko Constance
Tuheirwe Inocent,
 Mugisha Samuel.


The Masaka and Kamuli:
Dr. Kasolo Josephine             Supervisor
Kabanga Margaret
Gonza Nabirye Bibiana
Mbaziira Paulo Hudson
Kalulu Bob.

The Masindi team:
Kambaliikye Peter               Supervisor
Tushabe Allen,
Akatukwasa Rita,
Twesigye David
Bigirenkya Jude.

The Kasese team:
Mutesi Rossete                   Supervisor
Nyangoma Anne
Centenary Edson,
Mainuka Paddy,
Nuwayebare Agnes




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Description: KNOWLEDGE ATTITUDE AND PRACTICE After Birth