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Overcoming Barriers to Effective

Anemia Interventions during

Antenatal Services in Uganda

This is a publication of the Regional Centre for Quality of Health Care (RCQHC) and the MOST project. It was made possible through support provided by the Office of Health, Infectious Diseases and Nutrition, of the Bureau for Global Health, U.S. Agency for International Development (USAID). The International Science and Technology Institute, Inc. (ISTI) manages the MOST project under the terms of Cooperative Agreement No. HRN-A-00-98-0047-00. MOST partners are the Academy for Educational Development (AED), Helen Keller International (HKI), the International Food Policy Research Institute (IFPRI), and Johns Hopkins University (JHU). Resource institutions are CARE, the International Executive Service Corps (IESC), Population Services International (PSI), the Program for Appropriate Technology in Health (PATH), and Save the Children.

The RCQHC is a regional quality of health care capacity development institution that is largely supported by the Regional Economic Development Service Office/East and Southern Africa (REDSO/ESA) in Nairobi, and the Makerere University in Kampala.

The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of USAID, of MOST, or of the RCQHC.

December 2002

For copies of this report, please contact:RCQHC

c/o IPH Makerere, P. O. Box 7072

Kampala, UgandaTel: 256-41-530888, 530321

Fax: 256-41-530876E-mail: [email protected] the file from

www.RCQHC.org or www.MOSTproject.org.

Overcoming Barriers

to Effective Maternal Anemia Interventions

during Antenatal Services in Uganda

D e c e m b e r 2 0 0 2

Robert K. N. Mwadime Nutrition and Child Survival Advisor, AED/Regional Centre for Quality of Health Care, Kampala, Uganda

Philip W. J. HarveyNutritionist, MOST, The USAID Micronutrient Program, Arlington, Virginia, and the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

Sarah Naikoba Child Health Advisor, Regional Centre for Quality of Health Care, Kampala, Uganda

Louise Sserujongi Nutritionist, Child Health Development Project, Makerere, and MOST Coordinator in Uganda

Hanifa BachouMedical Officer Mwanamungimu Nutrition Centre, Mulago Hospital, Kampala, Uganda

Loyce ArinaitweCoordinator of the Anemia Project, Regional Centre for Quality of Health Care, Kampala, Uganda

Wamuyu G. MainaConsultant and Lecturer, Kyambogo University, Kampala, Uganda

Acknowledgements

The research described in this publication was strongly supported by the Reproductive and Child Health Divisions of the Ministry of Health in Uganda. Specifically, we would like to acknowledge the technical and moral support provided by Drs. Florence Ebanyat and Anthony. K. Mbonye from the Reproductive Health Division and Dr. A.L. Abongomera and Ms. Usula Wangwe from the Child Health Division. We also acknowledge the technical inputs that Dr. Alice Mutungi, the RCQHC Reproductive Health Advisor, provided.

A number of districts and people contributed to the development of this publication. We appreciate the technical input and support provided by Dr. Sara Byakiika of Jinja Hospital and the district directors of health services from Apac, Kumi, Mukono, and Ssembabule districts. Specifically, we would like to thank Dr. Felix Ocom, District Director of Health Services in Kumi, for the facilitation he provided in the operations of district activities. We would also like to thank the district staff that participated and contributed in the data collection at various stages of the research. Finally, we appreciate the technical and administrative support that the RCQHC staff provided.

iOvercoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda

Table of Contents

Acronyms ii

Executive Summary iii

Introduction 1

Background 1Effectiveness of National Anemia Programs 1Anemia in Uganda 2Study Objectives 3

Methodology 4

The Study Districts 4Assessment Framework 6Setting a Stakeholder Advisory Group 7Defining the Desired Performance 7Measuring the Actual Performance 7Identifying Performance Gaps and Determining the Root Causes 9Selecting Performance Improvement Interventions 10

Results 11

Characteristics of Study Facilities and Health Workers Interviewed 11Characteristics of Respondents in the Exit Interviews 11Accessibility To and Use of ANC Services 12Iron and Folic Acid Supplementation 18Other Critical Actions to Control Anemia in Pregnancy 22

Discussion and Conclusions 25

Recommendations 27

Systems Level (District and MOH) 27ANC Health Provider Level 28Community Level (client/pregnant woman) 29

Literature Reviewed 30

Appendix: Factors influencing women’s supplementation behavior 30

Table of Contents and Acronyms

ii MOST The USAID Micronutrient Program

Acronyms

Table of Contents and Acronyms

AIDS Acquired immunological deficiency syndrome

ANC Antenatal care

ARV Anti-retrovirals

DDHS District Director of Health Services

DHT District health team

DISH II Delivery of Improved Services Project

FAO Food and Agricultural Organization

FGD Focus group discussion

HIV Human immune deficiency virus

HMIS Health management information System

HSD Health sub-district

IDA Iron deficiency anemia

IEC Information, education and communication

IMCI Integrated management of childhood illness

ITNs Insecticide-treated bed nets

MOH Ministry of Health

MTCT Mother-to-child-transmission of HIV

NGO Non-governmental organization

PMTCT Prevention of mother-to-child-transmission of HIV

QOC-CPI Quality of Care-Client Provider Interaction Study

RCQHC Regional Centre for Quality of Health Care

REDSO USAID Regional Economic Development Support Office for East and Southern Africa

TB Tuberculosis

TBA Traditional birth attendant

TIPs Trials of improved practices

UDHS Uganda Demographic and Health Survey

UGAN Uganda Action for Nutrition

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WHO World Health Organization

VCT Voluntary counseling and testing

iii

Executive Summary

Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda

Executive Summary

Anemia is a widespread problem in Uganda, adversely affecting four out of every ten pregnant women. The main strategies of controlling anemia in pregnancy are provided during facility-based antenatal care (ANC). Previously, iron/folate supplementation was

often seen as the primary approach to anemia control. Over the last few years, however, it has been recognized increasingly that anemia will be controlled more effectively by addressing its major causes, such as malaria and intestinal worms as well as iron deficiency. Furthermore, the effectiveness of a) intermittent preventive treatment (IPT) and insecticide-treated bed nets (ITNs) in controlling malaria and b) using antihelminthics in treating hookworm infections have been firmly established.

The Regional Centre for Quality of Health Care (RCQHC), the Ministry of Health (MOH), and MOST, the USAID Micronutrient Project, collaborated in assessing specific local barriers to integrating the implementation of these three interventions as part of a revised ANC approach to anemia. This formative assessment used the performance improvement framework to determine the district health system’s capacity to implement an integrated approach to anemia and other constraints that limit the effectiveness of anemia control during pregnancy. The first step was defining the desired performance—actions needed to control anemia through ANC contacts—then actual performance was assessed.

The fieldwork to assess actual performance was undertaken in four districts with eight health facilities that were selected to represent both government and non-governmental organization (NGO) services. Qualitative and quantitative data collection methods were used; these included focus group discussions (FGDs) with district health teams (DHTs), in-depth interviews with managers of the health facilities and the officers in charge of ANC services, and interviews with clients immediately after receiving ANC service. Inventory checklists were used to assess supplies in the facilities. All interview guides and checklists were developed from instruments used previously in Uganda. Enumerators and supervisors from each study district were recruited from the health services from each district and given five days of training. After pre-testing the instruments in a district not involved in the study, the enumerators worked in pairs and spent a full day in each facility.

The fieldwork results were validated through meetings held with district health teams and national experts. Together with experts and stakeholders at the district and national levels, the root causes of the barriers to effective anemia programs were identified and solutions to them recommended.

The results were summarized at the health system, health provider, and client levels.

At the health system level

The number of days each week that the facilities provided ANC services varied between districts and also within districts, depending on the facility level concerned. In over 40% of the facilities, ANC services were provided only one or two days a week, in many cases limiting client access to services.

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Executive Summary

MOST The USAID Micronutrient Program

Most facilities had “enough” ferrous sulfate/folic acid (IFA) only 50% of the time over the previous three months. Because of this inconsistent supply, providers tended to “save” supplies by not providing it to all pregnant women and/or dispensing tablets for less than the required number of days.

Although almost all health units reported that they were providing the ANC package recommended in the National Reproductive Health Guidelines, only 9% of the ANC providers interviewed were aware of the existence of the guidelines.

ANC providers considered the number of supervisory visits to be inadequate.

At the ANC provider level

The implementation of the guidelines was inconsistent both between and within districts, e.g., the dose of iron supplements provided solely for prevention varied from one to three tablets per day.

Although most health facilities reported routinely controlling malaria and hookworm, these services were not often observed in this study. 48% of the clients reported receiving antimalarials on the current or the previous ANC visit, and a similar percentage reported being asked about malaria symptoms. Almost two-thirds of the facilities reported conducting routine de-worming, but of the women interviewed in their third trimester, only 14% had ANC cards recording such treatment.

Counseling provided to ANC clients was of uneven quality. While most were told of the iron dosage to take, fewer than 10% were warned of potential side effects or how to deal with them. Half the women were not told of the benefits of malaria control during pregnancy.

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Group health talks were often given as a component of ANC clinics, but overall, about one-third of women reported not having understood most of what was discussed.

Despite the above findings, most clients reported that the ANC services they received were adequate in quality. Almost 80% complained of long waiting times, but said that they did not mind this as long as they received the services and the “medicines” they expected.

At the client level

On average, there were four ANC visits per pregnancy, but very few women attended ANC in their first trimester.

60% of the women in the exit interviews had attended an ANC clinic previously for their current pregnancy and been given IFA. Of these, two-thirds reported having finished all the tablets given them. It was a little surprising that few clients expressed any concern about taking iron supplements.

Receiving an ANC card was the primary reason for going to the clinic for most women. This card was required if women wanted to access emergency services during the pregnancy or delivery. Delivering in the health facilities was not seen as desirable in some communities. 41% of women reported attending a clinic after experiencing a specific problem rather then for “preventive” reasons.

The root causes of barriers to the effectiveness of anemia services provided through ANC programs concur with what was reported previously. The barriers include: inadequate logistics, late and infrequent use of antenatal services, and a lack of awareness among pregnant women of the benefits of using ANC services and of reducing their anemia. The causes are associated with factors operating at

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Executive Summary

Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda

the health systems, health worker, and client levels. Some other findings may have been less commonly reported. For example, there were huge differences in the dosages of iron provided to women to prevent anemia, and the side effects from taking iron were rarely reported as a major reason for not complying with the daily regimen.

The findings emphasize that urgent actions must be taken to improve logistics and health worker performance (“pull effect”), and to create demand among pregnant women for the ANC services (“push effect”). In the absence of such actions, community-based alternatives to existing facility-based ANC services should be developed as a means of controlling anemia among pregnant women in Uganda.

This report describes the process and results of a study

undertaken to identify barriers to implementation of

effective interventions aimed at addressing anemia

in pregnancy. The study was conducted in four

districts in Uganda in 2001-2002. The study findings

will be used to develop strategies for improving

the implementation of effective interventions for

addressing anemia in pregnancy at the district level.

Introduction

1Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda

Introduction

Background

Anemia is a major public health problem worldwide. It affects mainly preschool children and pregnant women in low-income countries. At the global level, anemia prevalence is over 30%. In sub-Saharan Africa, anemia prevalence levels are not well documented due

to inadequate and insufficient techniques used to estimate anemia in the population. However, according to the World Health Organization (WHO), anemia prevalence among pregnant women in sub-Saharan Africa is estimated at 50%. Most of the anemia is associated with an imbalance between iron intake, utilization and loss that leads to iron deficiency. Malaria, hookworm infestation, deficiency in other nutrients such as vitamin A, folic acid, and B12, and, to some extent, HIV/AIDS, are also important co-factors in sub-Saharan Africa.

The consequences of anemia can be devastating. Anemia reduces the work capacity of individuals and populations through ill health, premature death, and lost physical productivity. Maternal anemia contributes to maternal and peri-natal mortality, pre-term delivery, low birth-weight, and fetal impairment. About 20% of maternal deaths are attributed to anemia (Ross and Horton, 1998).

Effectiveness of National Anemia Programs

For years, sub-Saharan African countries have had national iron supplementation programs for pregnant women; some countries have included folic acid in the programs. Despite these

initiatives, anemia prevalence among women remains high; this indicates that large-scale anemia control programs have had limited effectiveness, mainly because of poor implementation of iron supplementation programs and their failure to address anemia causes other than iron deficiency. The following operational factors have been documented as key constraints that have caused the poor implementation of large-scale iron supplementation programs:

Inefficient and irregular supply, procurement and distribution of supplements.

Low accessibility and utilization of antenatal care by pregnant women.

Inadequate training and motivation of frontline health workers.

Inadequate counseling of mothers on the consequences of anemia and of supplementation’s benefits and side effects.

Low compliance by the intended beneficiaries with the supplementation regimen.

Overcoming these barriers would reduce the overall burden of anemia and significantly contribute to achieving the Millennium Development Goals (MDG).

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Introduction

2 MOST The USAID Micronutrient Program

Anemia in Uganda

Like many African countries, Uganda has committed itself to reduce anemia

by 30% by the year 2010, in line with the MDG. Various strategies have been implemented, among them iron and folic acid supplementation for pregnant women. Although this program has been operational for years, maternal anemia remains high. According to a recent demographic survey, 30% of women in Uganda are anemic (UDHS, 2000). Pregnant women (41%) and breastfeeding mothers (32%) are more likely to be anemic than women who are neither breastfeeding nor pregnant (27%). Data on the causes of anemia are scanty but, given findings elsewhere in Africa and from small studies in Uganda, it is probable that the major causes of anemia are nutritional deficiencies, malaria, and hookworm infections. The Uganda Action for Nutrition Group (UGAN) estimated anemia’s direct and indirect consequences in Uganda as being more than 66,000 maternal deaths and more than US$204 million worth of productivity lost at present values over 10 years, if the current anemia rates do not change (UGAN, 2002). These are huge losses and call for immediate action to identify the potential barriers to providing effective anemia control services during pregnancy.

Pregnant women access anemia control services during the antenatal contact. They must access the services in a timely manner and the services should be of high quality to provide iron/folate supplements and the support needed to comply with the regimen. In Uganda, ANC attendance is high, over 93% made at least one visit and only 6% do not use the services at all. Contrary to general belief, only 10% receive ANC services from traditional birth attendants (TBAs) (UDHS, 2000). Younger women (<20 years) are more likely to use ANC services (96%) than older women (>35 years, 89%). While the use of ANC services is high, timing and frequency are poor—about 44% of mothers go for

their first antenatal visit after six months of gestation. Only 14% go for ANC before the 4th month of pregnancy (UDHS, 2000). Problems of accessibility, continuity, and quality of antenatal services contribute to the low compliance and dissatisfaction with ANC service quality among clients.

Two Ministry of Health policies have been endorsed to guide anemia-related activities: the Anemia Policy (February 2002) and the Sexual and Reproductive Health Minimum Package for Uganda (GOU 2001a). These are supplemented by the guidelines on how the policy should implemented, the Uganda Reproductive Health Policy Guidelines of 2001 (GOU 2001b). Existing policies and guidelines endorse WHO recommendations for supplementation as set out in the document by Stoltzfus and Dreyfus (1998).

Many barriers described above are relevant to program effectiveness in most countries, but their relative importance is likely to vary widely. The variation in importance means that programmers in each country will need to identify the key underlying barriers to the effectiveness of their own anemia programs.

This report describes the process and results of a study undertaken to identify barriers to implementation of effective interventions aimed at addressing anemia in pregnancy. The study was conducted in four districts in Uganda in 2001-2002. The study findings will be used to develop strategies for improving the implementation of effective interventions for addressing anemia in pregnancy at the district level.

Introduction


Study ObjectivesThe study objectives were to:

Assess gaps in the district health system that constrain the effectiveness of the anemia control during ANC.

Determine factors constraining the implementation of recommended actions on anemia control during ANC.

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Identify solutions to the identified gaps and recommend a minimum performance improvement package that can be pre-tested in a few districts before being scaled-up to be implemented in the rest of the country.

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Methodology

Methodology

The Study Districts

The four districts of Apac, Kumi, Mukono and Ssembabule were selected for the study (see map). The MOH and the Regional Centre for Quality of Health Care (RCQHC) jointly selected these districts for the study based on the following criteria:

Geographical representation (at least 4 of the 6 geographic regions were to be represented) to allow diversity in the ethnic groups in Uganda and distances from the central government headquarters in Kampala.

Representation in the operation of a large donor community in health support in the districts.

Implementation of other programs related to anemia in pregnancy (e.g. malaria project).

Each of the four districts was considered fairly similar to the others in its ecology and administration, and thus the four together were representative of the situation in Uganda.

Profile of the districts

The Apac District is found in Uganda’s Northern Region. The Northern Region reported about 30% anemia prevalence among women in the last UDHS. The district is mainly savannah woodland and receives about 1300 mm of rainfall per annum. The district has an estimated population of about 580,000. Subsistence farming is the main source of livelihood. The main food crops are maize, beans, simsim, cassava, potatoes, sunflowers, and groundnuts. Cotton and tobacco are the main cash crops. The district has 37 health facilities and 24% of the population lives within 10 km of a health facility. Most of the Apac health facilities were at the Health Centre II level and were not providing ANC services. Major constraints reported included inadequate staffing levels in all health facilities and a lack of integrated services.

The Mukono District is found in the central part of the country. In the last UDHS, anemia prevalence in the Central Region was about 28%. The district headquarters is 30 km from Kampala. The population is estimated at 830,000, with most people living on subsistence agriculture and/or fishing. There are 49 public health units, of which 16 belong to NGOs. Staffing of health facilities was reported to be among the best in the country, but a major complaint was staff absences.

The Kumi District is located in the Eastern Region. Anemia prevalence among women in the Eastern Region was about 37%, according to the latest UDHS. The district has a modified equatorial climate with both heavy rainfall and high temperatures. It has a total population of 293,000, with most living on subsistence agriculture. The district has about 32 health units. In the past, the district received some support for its health system from CARE/International; it currently receives aid from Irish Aid.

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Methodology


The Ssembabule District is a fairly new district found in western Uganda. According to the last UDHS, anemia prevalence in western Uganda was about 28%. The district has a population of about 144,000. The district experiences very high temperatures and long dry periods that can last up to five months. Agriculture cattle rearing and fishing are the main economic activities in the district. The district has very poor and inadequate basic infrastructure with only 11 health units.

Study health units

In each study district, the DHTs and the research team selected a convenience sample of eight health facilities that offer ANC services. They mapped all health facilities and selected a sample to represent all parishes in the district and the various levels of health care within a district.

Within a district, there are four levels of health care:

Health Center II (HC II), which is the lowest level and provides basic outpatient services including ANC services.

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Figure 1: Map of Uganda showing study districts


Methodology

Health Center III (HC III) provides both outpatient and normal delivery services.

Health Center IV (HC IV) provides outpatient, inpatient and theatre and also acts as headquarters for a health sub-district.

Hospital.

These units are owned either by the government or the NGO (not for profit) sector. As much as possible, each service and ownership level was represented among the selected sites in the districts, except where the particular kind of facility (by either ownership or level) did not exist. No sample size calculation or power analysis was used in selecting these sites.

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Assessment Framework

This study was a formative assessment. It was a cross-sectional, facility-based

study that used a descriptive and an analytical approach. The performance improvement framework was used to guide this formative assessment (see figure 2). This framework was developed through the collaborative efforts of representatives of USAID and USAID-funded cooperative agencies.1 The goal of performance improvement is to provide high quality, sustainable health services. Results are achieved through a process that considers the institutional context, describes desired performance, identifies gaps between desired and actual performance, identifies root causes, selects interventions to close the gaps, and measures changes in performance.

Table 1: Number of Health Facilities Selected in Four Districts by Level and Ownership

Apac Kumi Ssembabule Mukono Total

Gov NGO Gov NGO Gov NGO Gov NGO Gov NGO

Hospital 1 1 1 2 0 0 1 1 3 4

HC IV 2 0 1 0 2 0 1 0 6 0

HC III 4 0 4 0 3 1 3 1 14 2

HC II 0 0 0 0 2 0 1 0 3 0

Total 7 1 6 2 7 1 6 2 26 6

1 Performance Improvement Consultative Group, “Improving performance to maximize access and quality for clients,” http://www.reproline.jhu.edu/english/6read/6pi/ppt/maqpipg.htm

Create and Maintain Stakeholder Agreement

Desired Performance

Actual Performance

GapIdentify root

causes of performance

gap

Select and design

interventions

Implement interventions

Monitor and Evaluate

Consider

cultural

religious

political

economic

macro- & micro policy environment

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Performance Improvement Framework

Figure 2: The Performance Improvement Framework (USAID/Performance Improvement Consultative Group, 2001)1

Methodology


Setting a Stakeholder Advisory Group

The study’s key stakeholders were brought together through a series of meetings to

advise the MOH and the research team on the different stages of the research process. In Kampala, the MOH set the study agenda and selected the study districts. Participating districts were visited, informed of the research, and invited to participate. All four study districts agreed in writing to participate in the study. At key stages of the study, the stakeholders were informed of its progress to ensure their consensus and buy-in throughout the process.

Defining the Desired Performance

Drawing from components of the ANC Package in the Reproductive Health

Strategy and the Anemia Policy, the MOH/RH specified the minimum set of services to be provided at the different levels: national, district, ANC contact in a health facility, and the community. A consensus was reached on

the desired actions needed to control anemia in pregnancy through antenatal care (see table 2). These actions are from the antenatal care package in the Uganda Reproductive Health Policy Guidelines of 2001”(GOU 2001).

Measuring the Actual Performance

Measuring the actual performance involved building consensus on the

various data sources needed to measure how well the districts were performing. The next steps were to develop the tools/instruments for collecting the various data and data collection and analysis.

Table 2. Desired Actions to Control Anemia in Pregnancy through the ANC

Desired actions

Provide ANC services according to standard guidelines

Encourage ANC attendance at least four times, i.e., once each in the first and second trimesters and twice during the third semester

Conduct a physical and laboratory examination for anemia

Monitor growth of the pregnancy using standard ANC cards

Provide supplementation of iron and folic acid (throughout pregnancy and postpartum)

Conduct routine de-worming of pregnant women in the second and third trimesters

Provide intermittent preventive treatment (IPT) for malaria in the second and third trimesters

Provide appropriate case management for malaria and other disease complications of pregnancy

Provide health/nutrition education to all pregnant women.

Promote the use of/sleeping under mosquito nets by pregnant women

Education and sensitization about sexually transmitted infections (STIs)/HIV/AIDS/PMTCT

Supervision of community health workers (TBAs, Community Resource Health Workers)

Adequate feeding during pregnancy

Provide voluntary confidential counseling and testing (VCCT) for HIV

Refer complicated cases

Make monitoring and evaluation progress reports


Methodology

Development of research instruments/tools

Six study instruments were developed from instruments used previously in related work in Uganda and the region (see www.rcqhc.org):

District/sub-district interview schedule

Facility inventory

Exit interviews schedules

FGD guides

Observation checklists/guide

A records inventory checklist

A number of existing materials were reviewed to come up with more comprehensive and appropriate tools. The reviewed materials included:

Questionnaires used by the Delivery of Improved Services Project (DISH II Project).

Quality of Care-Client Provider Interaction Study at the RCQHC (QOC-CPI).

WHO Safe Motherhood Needs Assessment tools.

RCQHC/LINKAGES Nutrition Job Aids that were being pre-tested in Kenya.

The draft of findings of the Facility-Based ANC/RH Services Performance Assessment in Tanzania.

Inputs from the initial review of the draft tools were used to improve their quality. The review was conducted by:

District health personnel from non-participating districts, i.e., Kampala and Wakiso districts.

Staff from the RCQHC, MOH (nutrition and RH units), Child Health Development Project, and Mwanamungimu/Mulago Hospital.

The enumerators during their training.

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Selection and training of enumerators

A total of 16 enumerators (four from each district) and four supervisors, selected from the four districts, were recruited for the study. The enumerators were clinical officers, nurses, and midwives with basic knowledge of ANC services in the district/country, and general knowledge of nutrition interventions in the health sector and of record keeping.

The enumerators underwent a five-day training course that included both the theory and practice of using the study tools. As part of the training, the enumerators visited four health facilities to practice using the tools. The training process was designed to enhance standardization in questioning and data recording.

Pre-testing the tools

The tools were pre-tested in four health units in the Jinja District in eastern Uganda, an area that was not part of the study area. The enumerators tested the questionnaires in the health units and discussed the flow and the comprehension of the questionnaires. The study instruments were then adjusted for better flow and comprehension.

Data collection

Five data collection methods were used:

FGDs were held with the district health teams in the four study districts to determine gaps in the district health system that constrain the effectiveness of the anemia control program and factors constraining the implementation of recommended actions on anemia control for mothers in ANC.

In-depth interviews were conducted with 32 managers in charge of the health facilities; 32 providers in charge of ANC services at their respective health facilities were interviewed using a structured interview schedule.

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Methodology


Observations of the provider client interaction. The observed behaviors were checked off against a checklist. On completion of the survey, this methodology was assessed and considered to lack sufficient validity. As a result, the team did not use data from these observations.

Exit interviews: Every third woman who went through the system was interviewed using the exit interview schedule to assess their opinions and satisfaction with the ANC services that the health facility had provided. A total of 256 exit interviews were conducted.

A facility audit was done in all 32 health facilities to assess the availability of basic ANC equipment, logistics/supplies, facilities/equipment, IEC materials and activities, and record keeping and reporting.

During the fieldwork, the enumerators worked in pairs. The enumerators were not allowed to use the instruments in the facilities where they worked. Each pair spent a full day at a health facility. Field supervisors supported the enumerators during the data collection and checked the questionnaires for consistency and completeness. This was to ensure that the data collected was accurate as possible.

Data entry and analysis

The quantitative data were entered and analyzed using the EPI-INFO computer program. However, no formal statistical inferences have been drawn. Qualitative data were categorized according to themes and sub-themes before being analyzed.

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Identifying Performance Gaps and Determining the Root Causes

The researchers, field supervisors, and enumerators discussed the findings and

the gaps in key desired service performance in anemia control during the ANC contact. Performance gap statements were written. Possible causes of the gaps were also identified from the data and solutions hypothesized. The root cause analysis was conducted during two-day workshops aimed at disseminating and validating the study findings in the four districts.

Six representatives from each of the Apac and Kumi districts met together in Kumi. Although Mukono and Ssembabule representatives planned to meet in Mukono, unfortunately, the Ssembabule representatives were unable to attend. Eight staff from Mukono met in Mukono for the dissemination and validation workshop. In each workshop, the findings and performance gaps statements from the analysis of study findings were presented. With the facilitation of the DDHS and the Kumi and the RCQHC study team, each performance gap was discussed; rewording of the performance gap statements was done where necessary to depict the real situation in the field. For each performance gap, a root cause analysis was undertaken using either the “fish bone” method or the “cause-effect tree” method.2 The challenge was to avoid including perceived causes rather than the real causes of poor performance in the analysis.

The results of the root cause analysis and verification meetings were presented in a way to integrate them into the study findings, either when explaining the findings or in the discussion section, as appropriate.

2 Root cause was defined as the basic cause of the performance gap that either the district of the MOH could do something about.


Methodology

Selecting Performance Improvement Interventions

During the two-day validation workshops, the root causes of the performance

gaps were identified, and possible solutions discussed and categorized at the national, district, or community/household level. The district recommendations were then discussed in a one-day workshop in Kampala with national experts in anemia/antenatal care, MOH personnel, and WHO, UNICEF and university staff. The study methodology and findings were presented. Kumi District representatives presented the recommendations made during the district meetings. The discussions were mainly to

assess if the findings’ were representative of the Ugandan context (given the study districts, the design, and findings), and the feasibility and prioritization of the recommendations by the districts. Modifications to the wording of the report findings were made and, when necessary, additional explanations were given, and recommendations customized to the Uganda context. The final recommendations as discussed by the workshop participants are presented in this paper in the recommendations section.

Results


Results

Characteristics of Study Facilities and Health Workers Interviewed

A total of 32 facilities—8 from each of the 4 study districts (Apac, Kumi, Mukono and Ssembabule)—were included in the assessment. Of the 32 facilities, 7 were hospitals, 3 HCII facilities, 16 HC III, and 6 HC IV. Most facilities were located in rural areas

(84%) and were government owned (81%). The health worker in-charge of ANC services was interviewed from each participating health unit. Most interviewed were in-charges of antenatal clinics, including clinical officers and enrolled nurses (56%) and registered midwives (25%). There were no differences in the responses of the different categories of health worker.

Characteristics of Respondents in the Exit Interviews

Exit interviews were held with ANC clients outside the clinics. Almost half (48%) of the clients were attending for the first time in this pregnancy and 52% were returning clients.

Over 72% of the respondents were from health center levels III and IV. The majority (79%) of the respondents resided in rural areas. Most (97%) were married or staying with their partner; 17% were having their first baby. A third (34%) of the respondents were younger than 20 years of age.

Table 3: Characteristics of Respondents in Exit Interviews

Apac Kumi Mukono Ssembabule All

Number of respondents 64 64 64 64 256

Percent of Respondents in Each District with Selected Characteristics (N=64 per district)

Level of Clinic

HC II 0 0 12 25 9

HC III 47 50 61 50 52

HC IV 29 25 2 25 20

Hospital 24 25 25 0 19

Visits (Reattendees) 46 59 53 50 52

Number of visits >=4 41 26 11 16 23

<=20 yrs (%) 29 34 33 41 34

Married/co-habiting (%) 96 96 92 91 95

Occupation (housewife %) 88 92 84 80 86

Duration of pregnancy (% >3 months)

99 100 98 91 97

Number of pregnancies

First (%) 12 20 16 22 17

2-4 (%) 44 47 60 53 51

4+ (%) 44 33 24 25 32

Had attended clinic due to complication/sickness

37 33 32 59 41


Results

Accessibility To and Use of ANC Services

According to the Ministry of Health Reproductive Guidelines for Uganda,

every pregnant woman should have at least four ANC contacts before delivery. It was reported in the 2000 UDHS that about 94% of women attended at least one ANC visit in their pregnancy: 14% came before the fourth month; 7% were first time visitors after the eighth month of pregnancy; 42% reported attending four or more ANC visits in the last pregnancy.

To “meet the utilization needs of the clients,” the MOH Reproductive Health Policy is to have integrated health services.3 ANC should therefore be provided each day of the week. In addition, the MOH recommends that health facilities implement outreach services to improve accessibility of primary health care services, including ANC. The Reproductive Health Policy Guidelines state that six services should be provided during the antenatal contact to control anemia in pregnancy. These are: i) nutrition education and counseling to increase diversity of foods eaten, ii) control of helminths, iii) IPT to control malaria, iv) supplementation with iron and folic acid together with counseling on compliance and potential side effects, v) voluntary counseling and testing (VCT) of HIV infection and, vi) promotion of child spacing.

Finding 1: A pregnant woman is not guaranteed accessibility to comprehensive ANC services.

District health teams reported all ANC services in the districts as being integrated with other health services and being provided every day of the week. However, less than

half (47%) of the health units reported that they provided services for five days or more per week; 40% reported providing ANC services only one or two days in a week. There was a large variation in the integration of ANC services within and between districts. The average number of days per week for provision of ANC services was highest in Kumi and Mukono (4.4 days per week) and lowest in Apac (1.6 days a week).

Explanation:

The integration strategy of services expects ANC clients to come when it is convenient for them, in terms of the time and weekday. However, even where health workers provided integrated reproductive health services on a daily basis, most pregnant women still preferred to attend the ANC on specific dates. This was either because women would combine the ANC visits (a preventive action) with other social/business activities like market days or, in some cases, women (especially new clients) were not aware of the newly integrated services.

There were situations when health workers preferred specific weekly “ANC days.” For instance, when integration meant too much time with individual

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Figure 3. Average number of days that antenatal services are provided at selected health facilities, by district

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3 Integrated services means that comprehensive care is always available and the antenatal package is one component of this care.

Results


clients and/or it increased the workload for the health workers. Examples given were the sacrifice of group education sessions, which were normally not provided in an integrated system, or where first-time attendees needed specialized attention and education that was not needed by re-attendees. The data actually show that the districts with the highest integration rates of ANC with other services (i.e., in Kumi and Mukono), reported the lowest attendance in group education for ANC mothers.

Finding 2: ANC attendance by pregnant women is poor.

Although pregnant women are advised to seek antenatal care services as soon as they learn they are pregnant, many delayed getting ANC. In a typical clinic, about half (48%) of the attendees were attending clinic for the first time for this pregnancy. Most women (93%) attending the ANC for the first time were in their second trimester; only 5% were in the first trimester, while 41% of women attend because of complication/sickness (see table 3).

Re-attendees had an average of three visits during the current pregnancy (range 1-5). Those who were in their third trimester (according to the ANC cards) attended an average of four ANC clinics (2 to 6).

Explanation

As reported during the FGDs, a pregnancy (especially teenage and first pregnancies) is culturally not something women would like to expose to the public. Coming for ANC services is a confirmation that one is, or suspects being, pregnant.

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The benefits of attending ANC early are unknown, save for getting an ANC card. ANC clients reported that the main reason they had attended ANC was to get the ANC card. Without this card, women facing “pregnancy problems” could not get assistance from the health units readily or without being scolded. In addition to the ANC card, an illness during pregnancy or suspicion of a pregnancy-related complication is another major reason why mothers attended ANC services. On the study day, 41% of the respondents had come for the ANC in search for medical care for a pregnancy-related complication or sickness, such as acute abdominal pain, dizziness, swollen limbs, severe headache or suspected a risky pregnancy such as multiple pregnancy or abnormal lie of the baby. ANC clients also indicated that other women did not know of or see the benefit of attending the clinic, either because they suspected they would not get the drugs or they had apathy towards existing ANC services. Table 4 shows reasons for using ANC clinics that both health workers and clients offered during FGDs. Table 5 gives the perceived and real reasons for not attending ANC clinics. There is a high degree of consistency in the reasons given between both the two districts and the health workers and clients. Most (63%) health workers interviewed associated the delay in/failure to attend ANC to ignorance of the importance of ANC among the general public.

Attending ANC was perceived as likely to lead to delivery in the health facility. For some communities, this is not a desirable

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“ Many pregnant mothers do not come to ANC because they had several normal pregnan-cies and think all will continue to go on well always.”

Health worker, Apac

“ The health worker at the health centre is very rude, she has no time for us; so we fear even asking questions or discussing any issue about our health. So I go all the way to Naguru health clinic and only here if I have no money for transport.”

A pregnant woman, Kojja, Mukono


Results

outcome. Some tribes are reported to discourage their women from attending ANC; instead they prefer that the TBAs and private midwives provide the ANC services and deliveries. This opinion was expressed strongly by respondents from Mukono District. It was reported that women were increasingly giving birth alone or with the help of relatives. While this may be attributed to increased poverty, for some of the health staff interviewed, this was seen as carelessness, stubbornness, or a failure to heed advice on the part of mothers.

Although distance to the health facility was given as a major factor for not (regularly) attending ANC by health workers, it was mentioned, but not as a key factor among women (see tables 4 and 5). For instance, when asked why women did not attend ANC on time or regularly, 31% of the health workers thought it was associated with the long distance to ANC services and/or poor transport to health units. But non-attendees did not rank distance as a

4)

key factor. About 60% of the attendees reported during exit interviews that they used the specific clinic (and not any other) because of its proximity to their homes.

Quality factors were key reasons why pregnant women do not visit ANC clinics. For instance, pregnant women believed that if they visited the clinics they might wait a long time before they were seen, and sometimes a health worker might not see them. And even when they are seen, they may not get the attention/attitude they count as worthy or may not get the medicines they expect.

Finding 3: Women who attended the ANC were not guaranteed the key services needed for anemia control in pregnancy.

The findings indicate that health workers in all the selected health units in the four study districts knew about and were willing to provide the key services for anemia control.

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Table 4. Reasons Why Women Use Antenatal Services as Given by Health Workers and Women by Study Area During FGDs

Reasons given by health workers Reasons given by women

Apac District

To get assistance when sick

To get the ANC card in case there is a need to use the hospital

To know if baby is lying well

To get free service

When sent from another health facility

When a mother is sick and needs treatment

When a mother wants to obtain ANC Card for use in case of emergency

When a mother is close to delivery time

When mother wants to know if her baby is well

If referred by TBAs or lower health unit

When a mother is not sure she is pregnant and wants to confirm.

Mukano District

To get information about the pregnancy, the num-ber of babies, and position

For treatment when sick

To be immunized and get a card

When referred from a lower level health center

To know if the baby is well

Some who want to deliver at the health facility

To get treatment when sick

To get card so that in case of need, they can be attended to in a health facility

To know what they would need during delivery

To confirm a multiple pregnancy

If the service is good and staff are friendly

Encouraged by other relatives/friends

Results


However, there were some gaps in the services:

The nutrition education was not discussed in relation to anemia control; there was no link between anemia and health education on sanitation/hygiene.

Some recommended services were not adequately provided. For instance, hookworm infestation and control in pregnancy were rarely discussed and de-worming was rarely conducted. Health

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workers also did not always provide counseling, VCT, PMTCT, and child spacing after delivery.

Women were not advised of the potential side effects of the supplements provided during pregnancy and how to deal with these if they arose, nor were women provided with any memory aides to assist them in complying with the recommended doses.

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Table 5. Reasons Given For Not Using Antenatal Services Mentioned During FGDs

Health workers Pregnant mothers

Apac District

Long distance from home

Lack of drugs in the ANC

Some think that TBAs are enough

Waste of time, has been delivering uneventful from home

Delay in the ANC (long waiting time)

Elderly pregnant women fear being laughed at by younger women

ANC clients

Long waiting hours (“We wait for too long to be seen.”)

Fear of being asked to pay a fee for the services

Possibility of not receiving the services/ care they expect (When they come and go back without being seen or getting the medicines).

Non-ANC clients

Are not feeling sick enough to warrant going to health facility

Women wait for too long (and may not even get the service).

Many times they do not get the drugs.

Have no wish to deliver in a health unit

Fear of being referred to other health centers away from home with no transport and no assistance

Health workers are rude and no respect at clients (“They shout at us especially when they get tired”).

Transport is a problem. Many mothers walk a long distance to ANC.

Mukano District

A long distance from home to health facility

Have no time to come to the clinic

Have no health problems

They see it as waste of time, has been delivering uneventful from home

No knowledge about the importance of ANC

Some tribes prohibit attendance of ANC

Shyness especially teenage primi-gravidae

ANC clients

See no need to attend ANC since they are not sick

Some are lazy to go for ANC (There is some form of stubbornness).

Problem with transport (especially those who live on the islands)

They prefer to go to TBAs or private clinics.

Non-ANC clients

Are attended by TBAs near or in their homes

No money for transport and drugs

Not sick to need to go to health services

Pregnancy still small (find it too early to need care)

No decent clothes to wear for the clinic

Fear of taking too many medicines including TT


Results

Food and nutrition issues during pregnancy were discussed in all the group talks held during the visits. The kinds of (local) foods providing various micronutrients and macronutrients of energy and protein were discussed in 80% of the facilities. Also discussed were appetite problems during pregnancy (15%) and the need for adequate rest (23%). However, in all the facilities, weight monitoring was done independent of the nutrition/food talks; in other words, the weighing was not used to counsel mothers on nutrition and food intake.

Explanation

Although all health units (97%) indicated that they were providing the ANC package recommended in the national reproductive health guidelines for ANC, only 9% of the health workers interviewed were aware of the existence of the national reproductive health guidelines (table 7). Only one (3%) reported having seen/read a copy of the guidelines,

while two (6%) reported actually having copies of the guidelines.

Finding 4: Most ANC clients received services that they perceived as being of adequate quality.

When asked to rate the quality of services received on that day, 7% perceived the services as excellent, 81% as good, and only 12% as fair/poor. In fact, 88% reported having been physically examined in an environment that was private, and only 8% were concerned with the audio privacy at one stage of the ANC or another. Almost all women (99%) who had attended the ANC felt they would trust the health providers who examined/or counseled them with information confidentiality. Although 78% indicated the waiting time as long, they did not mind it as long as they got the services and the medicines they expected. However, in the FGDs, non-clients considered a long waiting time and the rudeness of health workers as

Table 6. Provision of Selected Nutrition ANC Services at Selected Facilities as Reported by the Officer In-Charge of ANC, by District

Desired action Apac Kumi Mukono SsembabuleTotal

N (%)

Number of facilities in Each District Providing Selected Services (N=8 per district)

Screen for severe anemia [use palm pallor method] 7 [6] 8 [5] 8 [7] 8 [8] 31 (94%)

Provide iron and folic acid supplements 8 8 8 8 32 (100%)

Treat severe anemia 8 8 8 8 32 (100%)

Counsel on compliance, safety and side effects of iron supplements

6 6 6 5 23 (72%)

Provide IPT of malaria 7 6 8 6 27 (84%)

Prescribe/dispense ITNs 7 8 6 5 26 (81%)

Provide treatment for intestinal parasites (hookworm)

4 5 5 4 18 (56%)

Provide education and counseling about: 8 6 6 5 25 (78%)

Eating well and reducing workload 8 6 6 5 25 (78%)

Preparation for immediate and exclusive breastfeeding

8 5 5 5 23 (72%)

Need for and prevention of malaria 7 8 8 6 29 (91%)

The prevention of helminth infestation 5 4 6 3 18 (56%)

PMTCT/HIV 7 6 5 7 25 (78%)

Offer voluntary counseling for HIV testing (If available or within 60 minutes’ walk)

2 3 3 4 12 (38%)

Counsel HIV+ mothers PMTCT/Infant feeding 4 3 4 2 13 (41%)

Discuss the need for family planning (after delivery)

8 7 7 7 29 (91%)

Results


major reasons for not attending the ANC clinics.

Explanation

If most clients felt the quality of services as satisfactory, there is a need to investigate the factors that clients perceived as contributing to quality and whether they would affect future use of services.

Finding 5: The health talks held on the day of the study did not meet the needs of the major-ity of ANC clients.

All women who attended the health talks indicated that the educator had been loud enough for them to hear, and 90% felt the atmosphere was free for them to ask ques-tions in case they had any. However, 32% of the attendees reported not having understood most of what was discussed on the day of the study. In Kumi, specifically, over half of the respondents (56%) did not understand all that was discussed or did not find it relevant.

Table 7. Access to National Reproductive Health Guidelines for ANC, by District

Desired performance related to ANC national standard guidelines

Number of facilities in Each District Providing Selected Services (N=8 per district)

Total (N=32)N (%)Apac Kumi Mukono Ssembabule

Provide services according to the national standard guidelines

2 6 1 0 9 (28%)

Knowledge of national RH/ANC guidelines

2 1 0 0 3 (9%)

Has seen a copy of the RH/ANC guidelines

1 0 0 0 1 (3%)

Have a copy of the national standard guidelines

1 1 0 0 2 (6%)

Knowledge of expected activities 7 8 8 7 30 (97%)

Table 8: Perceived Quality of ANC Service Reported at Exit Interviews, by District

Characteristic Apac Kumi Mukono Ssembabule All

Number of respondents 64 64 64 64 262

Percent of Respondents in Each District Reporting on Selected Aspects of ANC Service Facility (N=64 per district)

Perception of ANC services:

Excellent 4 6 13 4 7

Good 80 92 78 75 81

Fair/poor 16 2 8 21 12

Examined in privacy 69 98 98 89 88

Concerned about audio privacy at any stage of ANC

13 6 2 9 8

Could trust the health worker confidential information

100 97 97 98 98

Considered waiting time as ‘long’ 89 75 64 87 78


Results

However, most participants reported finding the health talks useful and indicated that the talks contributed to influencing their health/nutrition behavior/practices during pregnancy. The proportion that found the talks not useful varied from 19% to 31% as shown in figure 4.

Explanation

The talks were useful if they addressed the cli-ents’ immediate needs and if the clients could understand the recommendations being made during the talks. There was a need for more interaction between the health workers and the clients during the health/nutrition group talks.

Iron and Folic Acid Supplementation

All women are supposed to receive and consume daily iron and folate supple-

ments for six months during pregnancy and continue with the supplements after deliv-ery if they had not finished the 180 days. Unfortunately, most of the time health units do not have enough supplies of ferrous sul-phate. In a study of health facilities in 11 DISH-supported districts in Uganda, 75% had iron/folate supplements (Katende, et al. 2000). In the 2000 UDHS, about 54% of the women with live births in the previous five years had received iron tablets before delivery, and

only 35% had received antimalarials. According to the WHO and INACG rec-ommendations, the dosages should be 60 mg of elemental iron (200 mg of fer-rous sulphate) and 400 µg of folic acid. Women should be given (or prescribed) enough supplies to last to the next visit, usually a month. They should also be counseled on compliance issues such as how to manage potential side effects.

Finding 6: Not all women were assured of enough supplies of iron folic acid to last up to the next ANC visit.

All health units provided iron supplements to pregnant women, starting with the mother’s first visit. Most facilities had ferrous sulphate and folic acid supplies during the month of the study. But most reported that there were insufficient supplies. The iron supplements were found in different colors and often a choice of colors was available at each facility.

Table 9: Reporting to Selected Aspects of Facility Group Talks, by District


Number of Respondents 64 64 64 64 262

Percent of Respondents in Each District Reporting on Selected Features of Health Talks (N=64 per district)

Attended group health talks 60 57 35 62 54

Health worker was loud enough for them to hear*

100 100 100 100 100

Felt free to ask questions* 95 88 88 87 90

Understood most of what was being discussed in the talks*

85 44 79 62 68

*Percent of respondents who had attended the group health talks that day

Figure 4. Reported usefulness of the facility-based ANC group talk by district

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Not useful

Fairly useful

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Results


The common colors were red (78%), green (38%), brown (19%), and pink (6%). The majority of the health units (66%) sourced their supply of iron supplements through the ANC-kit from the Ministry of Health. Half of the facilities also supplemented the supplies from the ANC-kits with purchases from the local private market.

On average, facilities reported as not having “enough” ferrous sulphate/folic acid supplies for 45 days in the last three months or 50% of the time.

Due to the inadequate supply, most women could not be provided with enough tablets to last to the next visit. Preference was given to “saving available supplies” for anemic women and children. On average, about 50% of the exit interview respondents had received iron and folic acid. The proportion prescribed the tablets was higher (figure 5). Almost half (48%) of the respondents in the Kumi sample reported receiving neither iron supplements nor a prescription for the supplements during their visit.

All the health units provided folic acid in dosages of one tablet daily for a week. All clients who received ferrous sulphate also received folic acid. Clients without supplements were meant to be given a prescription to buy folic acid from the local drug stores.

The iron supplements were given only during pregnancy and not postpartum, even though most women did not complete the recommended 180 days of intake of the supplements during pregnancy.

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Other related supplies were also lacking in most facilities. For instance, ANC cards were available only in 44% of observed facilities; IEC materials in local languages related to ANC were available in 56% of the facilities.

Explanation

Districts have been highly dependent on the MOH National Medical Stores for the supply of the supplements. However, the MOH sometimes provides insufficient supplies through the drug kit. That notwithstanding, recently a large consignment of supplements was found expired in the MOH stores, sadly not having reached the districts.

Some districts have not used their PHC funds to supplement the iron/folic acid supplements provided through the MOH drug kits.

There is a problem of estimating the amount of supplements that the facility needs. This may be related to fluctuations in ANC attendance, but is also due to failure to attempt estimating the supplement needs (both for

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Figure 5. Reported receipt of iron/folic acid supplements or a prescription by women exit interviews, by district

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Results

prevention and treatment among children and women) at the health unit level.

Health workers did not know that the recommendation was to continue supplementing women even postpartum. One main concern was supplies: “If the supplies were not adequate even to be given during antenatal, where would they get the ones for postpartum?”

Finding 7: ANC attendees were not assured of getting the correct dosage of the supplements.

As noted above, it was reported that all women categorized as “anemic” were given ferrous sulphate and that the dosage varied from 200 mg to 600 mg daily for two to four weeks. Some women in Apac reported dosages of as high as 1200 mg per day.

About 88% of the clients were not “anemic” according to the criteria/ methodology being used in the assessment and categorization. The dosage of the iron supplements provided for preventive purposes varied widely within and between districts. The range was 200 mg to 600 mg. In Apac and Kumi, more than 50% of the facilities provided the recommended 200 mg of ferrous sulphate per day for non-anemic women (figure 6). Over 60% of exit interview respondents from Mukono and

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Ssembabule had been advised to take 400 mg or more of ferrous sulphate (2-3 times the dosage recommended for non-anemic patients).

Not all women had received folic acid. Only slightly over half (56%) of the ANC clients were provided folic acid before exiting. The folic acid dosage was 400 µg (for 90% of the respondents); nine percent were advised to take 800 µg per day.

Explanation

Health workers reported frequent and recurrent shortages of iron/folic acid supplements, which made them prescribe and dispense tablets for fewer days than intended. According to health workers, this is not because the supplements were totally out of stock, but more because they wanted to “save the limited supply for more serious cases.” For instance, due to a supply shortage, faith-based health facilities had a policy to provide supplements to last no longer than a week. This implied women would need to come for supplies every week or they would have to take the supplements for fewer days.

The findings of the FGDs point to the fact that generally, health workers did not consider preventive supplementation with iron supplements as important and necessary as other components of ANC and postnatal care.

Health workers were implementing dosage recommendations inherited from their predecessors and most were not aware of the “new” WHO or MOH guidelines.

Finding 8: Most ANC clients took their iron/folic acid supplements, but not consistently.

Although most women who were given the supplements took them, they did not

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400 mg

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Figure 6. Dosage of ferrous sulphate prescribed to respondents by district

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Results


comply with the daily regimen. During the FGD with the ANC clients, it was reported that the desire to take the tablets was there but that the daily regimen was difficult to adhere to. Of the 79 ANC re-attendees (60% of all re-attendees) who had received iron/folic acid supplements in the last visit, about 67% reported having finished all the iron/folic acid tablets provided from the previous visit, of whom 43% reported taking them consistently on the recommended daily regimen. Ten percent of the re-attendees had misplaced some of the tablets before finishing them and 16% had not finished all the tablets, although they reported to have taken “most of them” (figure 7).

Respondents identified a number of benefits that they derived from taking iron/folic acid supplements. Most benefits identified included experiences of increased strength, improved appetite and reduced feeling of dizziness. They also mentioned benefits like “getting a healthier child who had more strength.” Even non-attendees to ANC indicated that they had heard of benefits like improved appetite, reduced dizziness, and increased strength.

Explanation

When asked why most women did not comply with taking their iron supplements, the ANC attendees’ responses can be grouped into seven categories, as follows:

Fear of side effects like nausea, vomiting, abdominal discomfort, and shivering.

Fear of taking drugs when pregnant because of perceived negative effects on the mother’s or baby’s health, including body itch.

Ignorance as to the benefits of taking the supplements.

A bad taste or smell associated with the tablets.

“Laziness” to take tablets, mainly because they are not sick or too many tablets to take.

Mothers who just forgot to take the tablets because “there were too many tablets to take” over a very long period.

Mothers who misplaced the supplements.

Some women attributed the side effects to the iron tablets’ color. Green or black iron tablets were reported to give more side effects than red or brown colored tablets. All the tablets were 200 mg ferrous sulphate tablets, but were from different manufacturers. Most women preferred the red iron tablets; a few did not mind the brown ones. In all study areas, women detested the green and gray

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Figure 7: Response by ANC re-attendees on use of iron/folic acid supplements

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“ I think these tablets for blood should be given only to pregnant women who have no blood. It may cause a high blood level and lead to high blood pressure.”

TBAs, Kyampisi

“ Women with increased blood should not take these tablets (iron and folic acids) because their heartbeats will increase and they will sweat very much.”

TBAs, Seeta Nazigo

“ Some mothers say it smells and they throw away the tablets soon after the clinic.”

Pregnant mothers, Kojja

“ Some mothers do not like taking tablets when they are pregnant.”

Pregnant mothers, Seeta Nazigo


Results

iron tablets; they associated them with more side effects, a bad smell and taste.

Finding 9: ANC clients were not regularly counseled on compliance, the potential side effects of the supplements, or on how to store them.

Most of the clients who were given iron supplements before they left the facilities were told of the dosage that they should take (i.e., 96% of those given the tablets). However, only 10% of the respondents reported being counseled on the potential side effects of ferrous sulphate supplements, although very few (12%) respondents reported having had any concerns in taking the iron supplements.

Findings from the discussions with health workers indicate that they understood the need to counsel mothers to improve their compliance in taking iron and folate supplementation daily during pregnancy. Some limitations reported included: the lack of adequate staff to conduct individualized counseling and inadequate knowledge and skills in counseling, but also the disappointment from an inconsistent and inadequate supply of iron and folate tablets.

Explanation

Health workers reported being too busy to “counsel individual clients on everything.” Their suggestion was to include this information in the health/nutrition group education sessions.

Health workers expected counseling on compliance and potential side effects to be conducted during the dispensing of the supplements/drugs.

Inadequate knowledge and skills in counseling and management of anemia in pregnancy and lack of counseling/teaching aids were mentioned as factors for not putting emphasis on counseling.

There was a possibility that health providers did not place a priority on the

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delivery of iron supplements to women. The health workers also might have had a misconception regarding women’s reasons for non-compliance to the supplementation schedule.

Other Critical Actions to Control Anemia in Pregnancy

Finding 10: Although most ANC clients attended health units that reportedly provided the adjunct actions to reduce anemia, few women actually received these services.

Hookworm control: Although two-thirds (69%) of the units reported conducting routine de-worming, few (18%) actually provided the services to pregnant women or prescribed it. Even during the health talks, the control of hookworm (or any other worms for that matter) was rarely discussed. Only 21% of the clients had been counseled on worm infestation, either in the group talks, by the pharmacists as they received their drugs, or by the health worker during examinations. Only 14% of women in their third trimester had recorded in their ANC cards information as having received antihelminths.

Malaria control: Less than half (47%) of the women reported being asked about symptoms of fever (malaria) in the past month. Most who had this history taken were from Kumi and Mukono districts (62% and 69%, respectively). Almost all the health units (91%) claimed to provide IPT for malaria during ANC. Most facilities (90%) reported using a combination of Fansidar and Septrin. Only 10% of the facilities reported using Chloroquine as the main drug in the ANC. Chloroquine was often used only when the supply of Fansidar was inadequate. However, as shown in table 10, contrary to the reports from health units, 47% of the mothers left the health facility without having being told the benefits of controlling malaria while pregnant. Only 48% of the clients

Results


had received antimalarials on the current or previous visit to the ANC; the percentage was as low as 27% in Kumi district. In Mukono and Ssembabule, clients had prescriptions to purchase antimalarials (either Choloquine or Fansidar). None of the clients among the

Apac respondents were given prescriptions to purchase antimalarials outside the health units. Fewer than one in five women (16%) reported concerns about taking antimalarials as long as health workers provided them, but they indicated that they were not prepared to buy them.

Most facilities reported that they gave advice routinely on the use of ITNs (91%), although rarely was the use assessed (only in 1%) and mothers were rarely advised as to where they could get the nets (6%). Only a quarter (26%) had ever been counseled on the need/benefits of sleeping under ITNs: less than 10% had ever been advised on where to get the ITNs or the insecticide to treat their nets. Only one-third of the women (33%) reported owning and sleeping under mosquito nets, irrespective of whether they were treated.

Birth spacing: Almost all facilities (92%) discussed the need for child spacing with

pregnant women during ANC. This was introduced in connection of the health of the child and the mother, although anemia (or iron deficiency) was rarely mentioned as a major reason to use family planning to space pregnancies.

Explanation

Most of the health workers interviewed (except in the hospitals) were aware of the recent inclusion of IPT of malaria and anti-helminths into the ANC package.

However, no provision had been made for effective implementation of the package. For instance, the supply of Fansidar (SP) and mebendazole had not been provided for, nor had the health committees at sub-district levels been sensitized. The committees are responsible for approval and purchasing of drugs; the alternative, the Reproductive Health Kit, was delivered irregularly. Consequently, some health centers still prescribed weekly Chloroquine to women as prophylaxis and also as treatment of “big spleen disease.”

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Table 10. Women’s Response to Indicators Related to Malaria Control


Number of Respondents 64 64 64 64 262

Percentage of respondents

Told of benefits of controlling malaria in pregnancy

36 75 64 37 53

Antimalarials received before exit from ANC

63 27 48 55 48

Prescribed to get antimalarials outside the health facility

0 21 25 17 16

Have concerns in taking malaria drugs in pregnancy

13 22 6 21 16

Sleep under mosquito nets 53 52 9 17 33

Sleep under treated mosquito net (treated in last 6 months)

22 34 7 12 19

Counseled on sleeping under ITN

17 42 25 20 26

Advised where to get mosquito nets/have them treated

6 14 11 5 9


Results

Finding 11: Health workers have not had enough supportive supervision.

Although the DHTs reported that health sub-districts (HSDs) conducted ANC supervision every month, only 31% of the health units had been supervised by a DHT in the last four months. More than half (53%) of the facilities had been visited at least once by the HSD in the four months prior to the study, and only 19% had been visited at least every month or every other month.

Explanation

Most of the restructuring (to have the sub-dis-tricts conduct supervision of the lower level units) had just been finished in the study dis-tricts. As a result, there were still limitations in terms of staff and the logistics needed for periodic supervision.

Discussion and Conclusions



This study was conducted to assess the gaps in the district health system that constrain the effectiveness of the anemia control program during ANC; the root causes of any gaps were identified as were potential solutions to address the causes of the identified gaps.

The study has several strengths that lend credibility to the findings:

Staff from district and health facilities were involved at all stages of the assessment, including developing the recommendations, so there is ownership of the assessment in the districts.

Staff received rigorous training, and this provides a spin-off benefit of enhancing the capacity of district staff to conduct formative evaluations.

The district staff viewed positively the standard structure of the performance improvement framework.

The variety of data collection methods used allowed internal validity of the findings to be assessed through triangulation.

The facilities and ANC services assessed were considered by the national experts to be representative of the ANC services provided throughout the country.

The study’s debriefing and validation stages were found to be very educational. However, there was a feeling among health workers that the study should also have captured the community’s motivation to be more involved and be more supportive of ANC services. Particularly, gender roles and how they affect accessibility to services and compliance should have been investigated. This is particularly important in districts where seasonal farm activities (planting and harvesting seasons) are likely to affect a woman’s ability to access ANC services. In addition, staffing levels and capacity to provide quality ANC/anemia services were not addressed. Some of these concerns were addressed in a study on trials of improved practices (TIPs) that ran concurrently with the study reported here.

The study found a number of gaps; most of them were associated with the adequacy in utilization of the antenatal care services by pregnant women, but also with the inability of ANC services to provide support to pregnant women in anemia control. During the validation meetings, district and MOH staff considered the study results as representative of the situation/performance in the majority of the health facilities in the district. The authors interpret these findings within this background, i.e. that: i) the data are of good quality and represent the actual situation in the districts, and ii) the results and conclusions are applicable to the rest of Uganda.

Most of the study findings concur with what has been reported elsewhere (Gillespie, 1998; Yip, 1994; Galloway and McGuire, 1994). The main barriers to the iron/folate supplementation during pregnancy were related to logistics and the supply of iron/folic acid supplements, and the late and inadequate (in terms of frequency) use of antenatal services (Galloway and McGuire, 1994). Poor compliance by pregnant women with the recommended daily regimen of taking the supplements and, to some extent, the use of ANC services, were associated with factors operating at the health worker and client levels.

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Some special study findings were as follows:

There was a huge difference between and within districts in the dosage of preventive ferrous sulphate and folic acid provided to pregnant women. The differences were purely based on the health worker’s lack of updated standardized guidelines/protocols on the dosages and not just because there were insufficient supplies.

Complaints on the side effects from taking ferrous sulphate were rarely reported as a major reason for not complying with the daily regimen. More serious reasons were that the women did not realize the benefits of taking the daily dosage, the women forgot to take the supplements, or the health workers did not adequately address the fears that women had in taking the supplements.

Contrary to what was expected, ANC clients rated ANC services as above average in quality, while in the FGDs, non-clients complained of poor health worker attitude and long waiting times as barriers to attending the ANC clinic. Of course for the ANC clients to use the ANC services their perceived (or actual) marginal benefits must be higher than the perceived marginal costs. Although they considered the waiting times to be long, they still used the services. The ANC clients must have had higher understanding and/or esteem for the benefits of using ANC services than non-ANC clients. As long as they received the “expected” service and/or the expected “drugs,” they were satisfied with the services.

The findings emphasize that, unless urgent actions are taken to improve supplies and health worker performance (pull effect) and to create demand among pregnant women for the service (push effect), facility-based ANC might not be the best means to control anemia among pregnant women in Uganda.

1)

2)

The conclusions are as follows:

Efforts should be made to “pull” more pregnant women to visit the ANC servi-ces. Pregnant women must be confident that they will get the services and drugs they expect when they visit an ANC clinic, that the health workers will be accessible (and not too busy or too few to provide the quality services expected from them). For health workers to provi-de the quality services needed to attract and maintain clients they will need continuous support in terms of supplies, materials, knowledge/skills and supervi-sion.

More should also be done to “push women to attend ANC and to take the supplements.” ANC services should be brought closer to more pregnant women, and pregnant women should be educa-ted and counseled on the importance of attending ANC early and frequently and on the importance of complying with the daily regimen of taking the supplements, including being followed and supported to ensure compliance.

The interventions creating the pull and the push effects can be provided at vario-us levels of health systems (MOH and district), health provider (health faci-lity) and community (or client) levels. Interventions at each level are essential and no intervention at one level, by itself, would be enough to produce effec-tive and sustainable results.

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Recommendations


Recommendations

The study goal was to recommend a minimum performance improvement package to be pre-tested in a few districts of Uganda before being scaled-up to be used in the rest of the country. The recommendations to include in the package are provided at the systems,

health provider, and client (pregnant woman) levels. However, it should be noted that ANC interventions such as safe motherhood and anemia, HIV/AIDS and malaria control in pregnancy should not be introduced in isolation but as a package. Health workers note that operation of individual interventions created confusion and it was a challenge to implement the different actions in an integrated fashion. Some interventions are given priority over others, depending on funds available, and many times different stakeholders promote the interventions in parallel. The recommendations suggested here should be part of a comprehensive ANC improvement strategy.

Systems Level (District and MOH)

The MOH should develop (or facilitate the development of) anemia control guidelines that specify:

The services that should be provided at each level (community, health center and district levels) to control anemia, including distribution of and counseling on compliance with taking iron/folate supplements, malaria IPT, hookworm prevention, and birth spacing promotion.

The planning and timely acquisition of adequate health supplies (iron/folate supplements, antimalarials, de-wormers, packaging materials, recording materials, ANC cards, IEC materials, etc).

The dispensing dosages and length of treatment.

Monitoring and follow-up recommendations.

Revise reproductive health policies so that they address issues of drug procurement and supply to reflect district needs and remove procurement bureaucracies.

Revise the maternal ANC card to accommodate monitoring for compliance in taking the iron/folate supplements and the duration for taking the supplements. Together with this should be the memory aids such as a calendar, which could also go into (or with) a revised ANC card.

Develop a health worker’s kit on anemia control among pregnant women (antenatal and postpartum). The kit should include:

Protocols for recognition of the condition, treatment and prevention methods, e.g., iron supplementation, IPT and de-worming, and dietary and public health approaches to improved iron status. The kit will be more comprehensive if it includes childhood anemia.

1)

a.

b.

c.

d.

2)

3)

4)

a.

Recommendations


Self-assessment tools for health units to conduct periodic self-assessments on providing anemia control actions according to agreed performance standards, analysis of performance gaps, and actions to improve their performance.

Counseling cards/education charts that include counseling on compliance (not just its importance), discussions on potential side effects and how to counteract them, and on “best practices” in handling the supplements at home.

Education tools (e.g. education charts) for educating women on the desirable benefits of taking supplements and having diversified diets to meet the iron needs for themselves and their infants.

In the district comprehensive health plan, districts should include a district anemia control strategy, which includes:

An advocacy strategy to reach the various decision makers (district leaders and other stakeholders, including NGOs and agencies operating in the district) that need to invest in anemia control.

A resource mobilization plan (from different district funding sources) to purchase supplements to subsidize the supply that the MOH provides.

An action plan on training of ANC health providers on counseling skills and anemia (recognition, causes, control, counseling on compliance, etc).

A logistics strategy to ensure adequacy of supplies at the health facility level.

A supportive supervision schedule to ensure service providers are facilitated to provide quality services

b.

c.

d.

5)

a.

b.

c.

d.

e.

on anemia control (including dissemination of the anemia and other RH guidelines).

Train facility health workers:

On how to estimate supply needs—enough to cover preventive and curative aspects of anemia among women and children.

To provide supplements (including recommended daily and total dosages, supplement storage, and safety protocols) and counseling appropriately.

Prepare outlines of health education talks to address the key issues of anemia and compliance.

ANC Health Provider Level

Health workers need to improve strategies to ensure that each ANC client receives individualized counseling when she comes for ANC. Among the issues to be addressed are compliance with the supplements, potential side effects and fears, and storage of the supplements.

If possible, health units should supply the same type and quality of supplements to avoid confusing mothers. Preferably, they should have the kind that most women prefer, i.e., the red or brown tablets. But in addition, they should always educate clients on the types (by color) of iron supplements available in the health facility.

Train community delivery units on counseling on compliance, recognition and counteracting any side effects, and handling the supplements. Also train TBAs/village midwives on communicating the importance of iron for mothers (and their babies) and help women to surmount behavioral, cultural and other barriers to compliance.

6)

a.

b.

c.

1)

2)

3)

Recommendations


Community Level (client/pregnant woman)

Train and support TBAs as channels for providing basic ANC services including distribution of iron/folic acid supplements.

Implement information, education and communication (IEC) practices in the community to promote the benefits of ANC services for pregnant women. Emphasize the services that have benefits for the health of the baby and the mother and on the birth outcome. More work is needed to identify localized messages and appropriate channels to effectively reach these women.

1)

2)

Develop community interventions that focus on women prior to their first pregnancy, targeting also non-pregnant women and adolescents.

3)


Literature Reviewed

Literature Reviewed

Ekstrom, E-C, Kavishe, F.P., Habicht, J-P., et al. “Adherence to Iron Supplementation During Pregnancy in Tanzania: Determinants and Hematologic Consequences.” American Journal of Clinical Nutrition 64 (1996): pages 368-74.

Elder, L. “Issues in Maternal Anemia Programming.” MotherCare, JSI, Arlington, Virginia, September 2000.

Galloway, R., McGuire, J. “Determinants of Compliance with Iron Supplements: Supplies, Side Effects, or Psychology?” Social Science in Medicine. 39 (3) (1994): pages 381-389.

Gillespie, S.R.; Mason, J.B.; Kevany, J. “Controlling Iron Deficiency.” State of the Art Series Nutrition Policy Discussion Paper 9. United Nations Administrative Committee on Coordination/Sub Committee on Nutrition, WHO, Geneva, 1991.

GoU a. The National Anemia Policy. Ministry of Health, Government of Uganda. Kampala, February 2002.

GoU b. Sexual and Reproductive Health Minimum Package for Uganda. Ministry of Health, Government of Uganda. Kampala, 2001.

GOU c, Uganda Reproductive Health Policy Guidelines. Ministry of Health, Government of Uganda. Kampala, 2001.

Huffman, S.L., Zehner, E.R., Harvey, P., Martin, L., et al. “Essential health sector actions to improve maternal nutrition in Africa.” Regional Centre of Quality of Health Care, Kampala, and Linkages/AED, Washington, DC, 2001.

Kakande, C., Bessinger, R., Gupta N., et al. “Uganda Delivery of Improved Services for Health (DISH) Evaluation Surveys, 1999.” Measure Evaluation Project and DISH, Pathfinder International, Kampala, Uganda, 2000.

MotherCare. “Reproductive Health Focus: Report on Projects for Reduction of Maternal Anemia.” MotherCare Project, JSI, Virginia, 2000.

Ross, J. and Horton, S. “Economic Consequences of Iron Deficiency.” The Micronutrient Initiative, 1998: page 26

UGAN. “PROFILES: The cost of and actions to reduce malnutrition in Uganda.” The Uganda Action for Nutrition (UGAN), Kampala, May 2002.

UDHS. “Uganda Demographic Health Survey 2000-2001.” Uganda Bureau of Statistics, Entebbe, and ORC Macro Calverton, Maryland, December 2001.

WHO. “Global Database on Anemia 1998.” WHO, Geneva, 1998.

WHO. “National Strategies for Overcoming Micronutrient Malnutrition, Document A45/3.” WHO, Geneva, 1992.

Yip, R. “Iron Supplementation During Pregnancy: Is It Effective?” American Journal of Clinical Nutrition 63 (1996): page 835.

A-31

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overcoming barriers to effective anemia interventions …a2zproject.org/~a2zorg/pdf/overcoming...

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