The survey was conducted over a six-week period commencing on the 15th March 2004. The study design predicted that 640 households would be visited, but some of the selected segments contained less than 4 inhabited homes; thus data were collected for 610 households only. Within these households 410 had one woman who had been pregnant in the last 5 years; 15 had two such women. Of these 440 women, 413 (94%) were available and gave information. The median time from interview to delivery date was 2.25 years. Complete data sets in each area were difficult to obtain as at times women were unable to recall, or gave no responses with regard to occasional variables, however the relevant missing data are indicated in the following results.
Among the 413 women who responded to questions about their most recent pregnancy the mean age was 26 years; the majority (78%) were married or living as married and 71% were housewives with no formal occupation; 12% had received no formal education, 49% some primary education and 39% some secondary or tertiary education. Most were poor, with low scores for socioeconomic parameters such as items owned in the family (64% none of the items listed or a bed only; 30% a mobile phone, motorbike or car). Of these 413 women, 28 were unable to recall, or gave no response regarding frequency of antenatal clinic attendance, providing 385 respondents (88% of all women in the household sample). Of these, 369 (96%) had attended antenatal clinic at least once and 355 (92%) at least twice. Of those who attended for antenatal care, 14 were unable to recall, or gave no response with regard to antenatal services received, meaning that complete reports were available for 355 women. Complete reports on delivery and perinatal practices were available for 339 live births. The median antenatal quality score was five (range 0–7) out of seven possible points. The median postnatal quality score was 4 (range 1–6) out of a possible maximum score of six. These binary variables were used to relate services and practices reported to the care setting and to demographic and socioeconomic variables. A considerable number of mothers gave incomplete responses regarding socioeconomic variables and two had missing data regarding their ward, only those with complete information were used in the multivariate the analyses (294 were included for analysis of antenatal care and 270 for analysis of delivery and perinatal practices; 83% and 82% of all mothers respectively).
Table shows the type of facility attended and the services received. Antenatal services were variable with the provision of HIV voluntary counselling and testing, haematinics and IPTp being least frequently reported. Coverage of blood pressure monitoring and tetanus toxoid vaccination was good throughout. For antenatal care, the strongest associations were observed with care setting and year of pregnancy: low scores were observed among mothers attending public clinics rather than hospitals, and a highly significant improvement in services was observed by year (Table ). Neither effect was explained by adjusting for potentially confounding socioeconomic factors. There was a tendency for younger mothers and better-educated mothers to report better services. These effects were reduced after adjusting for care setting, in part possibly because better-educated mothers were aware that quality of services differed in different settings. All antenatal services listed, except IPTp and haematinics, were significantly less likely to have been given at clinics than at hospitals.
Factors associated with reported antenatal services during the most recent pregnancy
The improvements observed in antenatal care by year were largely explained by improvements over time in care at Entebbe Hospital, the main hospital in the area (Figure ) and by an increase over time in the proportion of mothers who sought care at Entebbe Hospital (p = 0.038; Figure ). At Entebbe Hospital, improvements in provision of IPTp, haematinics, counselling and HIV testing and syphilis testing were particularly marked (Figure ). The provision of tetanus immunisation slightly declined, but not among primigravidae where rates remained at 90% or above (data not shown); tetanus immunisation is not required among multigravidae who have received five doses during previous pregnancies. At other facilities there was no statistically significant trend in overall score with year (Figure ). There were moderate increases in the provision of IPTp and of counselling and HIV testing but neither was statistically significant (Figure ). There was no significant change over time in the proportion of women booking by trimester.
Figure 2 Trends by year in proportion of mothers. (a) reporting a high score for antenatal services at Entebbe Hospital compared with other facilities. (b) attending Entebbe Hospital compared with other facilities. P values for a test for trend were obtained using (more ...)
Trends by year in proportion of mothers reporting receipt of specific antenatal care services. (a) at Entebbe Hospital. (b) at other facilities. P values for a test for trend were obtained using complex survey commands (svylogit).
For both antenatal and delivery care there were associations between personal and socioeconomic characteristics and care setting. For antenatal care, multigravidae were more likely to attend Entebbe Hospital, compared to other facilities (OR 1.85, 95%Confidence Interval (CI) 1.13–3.00) and better-educated mothers were more likely to go to a private hospital (OR 3.32, 95%CI 1.84–6.00). At delivery, primigravidae were more likely to attend another government hospital (outside the Entebbe area) (OR 2.24, 95%CI 1.12–4.46) and less educated, poorer mothers were more likely to have a TBA or no trained assistant (for less education: OR 3.07, 95%CI 1.49–6.31; for measures of household wealth: lack of electricity OR 3.60, 95%CI 2.04–6.37; ownership of fewer items OR 3.47, 95%CI 1.51–7.97; crowded household OR 2.71, 95%CI 1.42–5.16).
A high proportion of women delivered their infant at a hospital or public clinic but one in 10 women still delivered their infant at home with no trained assistance (table ). Of these 44 women who delivered at home: 34% (15) stated that this was due to financial limitations, 23% (10) due to transport limitations, and 27% (12) due to 'other reasons' which were most commonly stated as to be due to the delivery occurring too quickly or too late at night to attend the facility of choice. Of the women who reported that financial and transport limitations were the most important factor in where they delivered, 40% (17/42) and 37% (10/27) respectively delivered at home with no trained assistance.
Hygiene practices and cord care at the time of delivery were generally reported as very good but, in the immediate aftermath, delay in wrapping was common and babies were frequently bathed too soon. Untrained assistants were less likely to be reported to have washed their hands with soap and water or used gloves and often delayed the first feeding beyond one hour. Both untrained assistants and traditional birth attendants were less likely to be reported to have used a clean surface for the delivery or to have tied the cord with a clean or new thread; together with clinics, they were reported to have bathed the baby early. Traditional birth attendants were more likely to have applied material other than spirit/antiseptic to the cord stump. Offering the breast was often delayed beyond one hour, and only 78% of infants had been put to the breast within 4 hours of delivery. Forty percent of babies were given something other than breast milk for their first feed, including water, glucose, salt solution or tea (28%); ghee (3%); mushroom soup (2%) or herbs (1%).
For postnatal practices, the strongest association was again with care setting: lower scores were reported by mothers who delivered at public clinics rather than hospitals, and, in addition, by those who delivered with a traditional birth attendant or without trained assistance (Table ). There was no association between reported delivery practices and year of delivery, but there was a stronger suggestion of an association between good practices and higher socioeconomic status than observed for antenatal care, and multigravidae reported better practices than primigravidae.
Factors associated with reported postnatal practices following the most recent pregnancy