She Failed, We Failed, They Failed: Using Qualitative Social Autopsy to Understand Why Women Die During Pregnancy in Iganga District, Uganda. Open Access

Leavitt, Rachel Ann (2016)

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Maternal mortality is a complex issue that is disproportionately found in developing countries, like Uganda. Previous research in Uganda has mostly focused on barriers to maternal health and maternal cause of death studies conducted in hospital settings. This omits information on important barriers in the community and at lower level health facilities that contribute to maternal deaths, as well as, social and behavioral contributors to deaths. This study aimed to identify the individual and community level factors that contributed to maternal death in Iganga district, Uganda to assist in the expansion of services for a local NGO, SAFE Mothers SAFE Babies. Qualitative social autopsies, using the Three Delays framework, were used to gain insights into the social, behavioral, and health systems contributors to maternal deaths in Iganga district, Uganda. Qualitative in-depth interviews were conducted with twelve family members of recent maternal deaths. Information was collected on the woman's care seeking behavior and the barriers to care during pregnancy and the obstetric emergency that led to her death. The study found that the initial decision to seek care was not a barrier in these cases. Lack of knowledge about danger signs, cost of treatment and transportation, community perceptions of health facilities, the availability of transportation, and women's status emerged as common social and behavioral contributors to death. Health system contributors such as poor provider training, low availability of emergency obstetric care and essential medicines, and a poorly functioning referral system all proved to be insurmountable obstacles for women. Interventions should focus on improving the referral system, achieving quality emergency obstetric care at lower level health facilities, increasing quality of care at all health facilities, expanding access to transportation, and increasing community knowledge of obstetric danger signs. Adjustments to the Three Delays framework to better account for changes in care seeking behavior and the referral system is necessary. Resolving issues of transportation and disorganization of the health care system could reduce maternal death in this setting.

Table of Contents

List of Abbreviations X

Chapter 1: Introduction 1-6

Introduction and Rationale 1

Problem 4

Purpose 4

Significance 5

Definition of Terms 5

Chapter 2: Background and Literature Review 7-31

Background 7

Uganda and East Central Region 7

Recent History 8

The Health Care System 10

Literature Review 12

Estimating Maternal Mortality 13

Biomedical Cause of Death Studies 16

Contributors to Maternal Mortality 21

Social Autopsy 25

The Three Delays 27

Social Autopsy and the Three Delays in Iganga, Uganda 31

Chapter 3: Methods 32-39

Introduction 32

Iganga District 32

Study Population 33

Data Collection 34

Recruitment 34

Training 34

In-Depth Interviews 35

Data Analysis 37

Sample 37

Data Analysis 37

Ethical Considerations 39

Chapter 4: Results 40-61

Demographic Characteristics 40

Types of Pathways to Death 40

Case Descriptions 42

Key Themes and Barriers 46

Community Knowledge 46

Transportation 49

Recognition of Danger Signs 53

Health Facility Knowledge 55

Health System 56

Seeking Care at Multiple Health Facilities 61

Chapter 5: Discussion 62-86

Introduction 62

Changes in Care Seeking Behaviors 63

Understanding Illness in the Community 65

Transportation 69

The Health Care System 73

The First Point of Care 73

Referral System 76

District Hospital 78

Limitations 82

Conclusions 84

References 87-92

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