Obstructed labour and Birth preparedness: Community studies from Uganda

Sammanfattning: 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.