Obstructed labour and Birth preparedness: Community studies from Uganda

Sammanfattning: 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.