Thirteen adolescent (14–19 years) and 18 adult (20–45 years) mothers were interviewed. Twenty-six of the respondents were farming their own land, while five were formally employed and earning a monthly salary. Twenty-two mothers attained primary level education, four secondary education and five had no formal education. Mothers visited on average 3.2 times the health care centre for prenatal care; 22 mothers (9 adolescents and 13 adults) delivered at home and 9 (4 adolescents and 5 adults) delivered in a health facility. One interview was excluded from the analysis because of incomplete data.
Four district level managers and 13 peripheral health workers were included in the interviews with health workers. Among the peripheral health workers, 3 were trained as general nurses and 10 received basic midwifery training. Their years of experience ranged from 5 to 30 years. Three of the 17 respondents were men. Three tutors at the training school and two employers at the district level were interviewed.
In this section we present findings along two broad themes: i) the prenatal care organisation and the views of mothers and health workers and ii) the current newborn care practices from the perspective of the mothers. The existing differences between adolescent and adult mothers are only presented where relevant.
Prenatal care organisation: views of mothers and health workers
Delayed, ad hoc and selective implementation of prenatal care
The health care centre attempted to organise prenatal care on a daily basis. As mothers arrived at different times (starting at 7 am onwards) at the health care centre, health workers generally waited for a ‘quorum’ (a reasonable number) before initiating the prenatal session. This made it difficult to decide when to start the session, but usually they did start around 10 to 11 am. In addition, it took long to offer all the services during prenatal visits; the women came early in the morning and could only leave later in the afternoon. Women who arrived late for the session were not offered another chance to receive the information as sessions were only organised on a “collective” basis, and were never a constitutive part of the individual interaction between the patient and the health worker. Some of the health care workers had to say this:
“But the problem is that the pregnant mothers also come late, some end up coming as late as midday. We try to wait for them up to like about 10–11 a.m., but again we see that this again makes those who come early to wait and really they are complaining. You hear these mothers quarrelling and saying that they have been there since this morning. Others when they arrive late are not attended to anymore and are told to come the next day” (health worker with 25 years of experience);
The late arrival of pregnant mothers suggested by health workers is further supported by a mother making the following comment:
“Nothing, I get there (in the prenatal clinic) when they have finished the teaching, so I don’t get anything. I don’t know what they teach. I don’t get any teaching (adult mother)
In addition, some health workers thought that some mothers deliberately arrived late for the antenatal session in order to avoid the long waiting time and the initial talks that were perceived to be boring and monotonous.
“It is also possible that these people (pregnant mothers) come late because they want to come when the health education part is finished” (health worker with 26 years of experience)
While prenatal care is organised on a daily basis, the health education component is not routinely offered to pregnant women, but only under the form of ad hoc talks when time was available. The peripheral and low value of health education in prenatal sessions was confirmed by this health worker:
“We don’t give health education talks every day, it is organised at least twice in a week so you can see that just vital things are actually left out…the good part is that when health education is not done properly it is not dangerous in the end, it may not contribute to somebody’s death (laughter) (health worker with 11 years of experience )
Almost all women indicated that the topics covered during the prenatal sessions included Malaria, HIV and immunization for which national programmes already exist. In addition, these sessions focused on the message to deliver at the hospital or a health centre with particular attention to what to bring with them at the time of delivery. The disease specific information that prenatal mothers received from the health workers on malaria and HIV/AIDS illustrated that these diseases received more attention compared to more important aspects of prenatal care as was illustrated by this mother:
“No, they don’t teach us anything concerning feeding, what to do during pregnancy or even how to look after the baby. They only tell me that I am negative (that is HIV). That is what they normally tell me” (adult mother)
Mothers most frequently received postnatal information from health workers on childhood immunization; they were advised to do so before they were discharged after delivery.
“At the hospital once you deliver, there is nothing else that they tell you. No, they don’t tell us to go back. They only tell us to take the baby for immunization after delivery that’s it” (adult mother), “Once the baby is out, the rest is your business. They do not tell anything else. And I don’t think they have that time. What are they supposed to tell us? They tell us to take children for immunizations” (adult mother).
This assertion was supported by responses from the health workers. In addition to this information and the distribution of a mosquito net, ‘mama kits’ (containing disposable materials necessary for conducting a normal delivery) were also distributed.
“When they come here we talk to them about HIV/AIDS, to sleep under a mosquito net…they even get free nets those who are coming for the first time, these days we also have mama kits from NMS [National Medical Stores which is the central national store responsible for procurement, storage and distribution of essential medicines] ” (health worker 29 years of experience)
During the prenatal sessions, health workers advised mothers to acquire the necessary requirements for delivery. Mothers were required to buy items such as surgical gloves, polythene papers (commonly referred to as kaveera) and to carry them along at the time of labour.
“The health workers tell us to come with razorblade, basin, gloves, kaveera and thread. I even bought the medicine that stops bleeding (meaning ergometrine), needle and syringes” (adolescent mother)
Mothers as passive recipients of prenatal services
Health workers did not consider mothers as active recipients of antenatal care. They rather approached them as passive recipients, largely ignoring mothers’ views regarding pregnancy, delivery and neonatal care. Health education sessions were basically a one-way process in which health workers assumed they know the mothers’ needs and they should simply conform to what is being told. A health worker reported:
“because health education is where all mothers are supposed to listen and pick things, what they are told,…so people don’t take things [the educational information offered] seriously, but they get the information”(health worker 26 years of experience)
Mothers were not informed on the results of laboratory tests such as haemoglobin/anaemia analysis. At the time of delivery mothers were never updated on the progress of labour, for example on the descent of the presenting part. Women were worried that nurses would treat patients without explaining which procedures they were about to perform. One mother, still indignant, had this to say:
“Ha, I was in the hospital, the nurse came and injected a patient without even touching her. It was like she was injecting a cow” (adult mother)
Source of prenatal information
For education on pregnancy and newborn care, family networks were a prominent source of information among mothers, while none of them mentioned health workers as an information source. During prenatal visits to the health centre or hospital, no specific advice was offered on maternal nutrition.
“Nothing, I never heard anything like that (teaching on caring for the newborn baby). Perhaps they teach other mothers what to eat but me I never heard anything. Nothing about how to nurse the baby or feed the baby. Nothing!” (adult mother)
Hence, practices depended on individual decisions and preferences largely influenced by advice obtained from family members, relatives and peers. Unfortunately, this advice was not based on any scientific evidence, but rather on myths and traditional cultural beliefs. Both adolescent and adult lactating women expressed similar sentiments:
“When it was almost time to deliver, I was told by my mother-in law to sit on the potato leaves so that I could soften and dilate easily the birth canal” (adolescent mother)
“When it comes to breastfeeding I would observe the wives of my husband’s brothers and my brother’s wife so I could see what to do, I just learnt by myself (laughter)” (adult mother)
In particular, mothers were concerned about foods that might make the baby in the womb grow too big which may lead to a surgery and the chance of dying during this procedure was believed to be very high. In addition to the advice about certain foods, women received the recommendation from their close relatives to abstain from sexual intercourse as it was believed to cause a white cheesy coating (vernix caseosa) on the skin of the newborn. As such some mothers had this to say:
“It depends on how you feel. Some people fear maize porridge, it makes the baby too big, they (relatives) tell us to eat green vegetables, not to eat things that make the baby too big, that when the baby becomes big, it will be hard to deliver the baby and then you can get operated or die” (adolescent mother)
“I was told by my mother that I should stop (having sexual intercourse) when I was seven months pregnant, that when you sleep with a man in late pregnancy you will deliver a baby which is dirty with a bad skin” (adolescent mother)
Similarly, the care and advises regarding newborn care offered in the health centre and at the hospital after delivery, were perceived to be poor. These were some of the comments from adolescent women:
“Ooh oh, can the nurse at Kiryandongo touch your baby. Their job is to get the baby out of your womb. Once that is done, they are finished. They do not tell you when to breastfeed, when to bathe, nothing Eeh! Nothing! Do you think those nurses tell you anything? Nothing, their job is to help you deliver and that’s it, nurses should be like mothers who know what childbirth means!”(adolescent mother)
These concerns about the baby having vernix caseosa at birth, a big-size baby and fear of being operated were reported among both adolescent and adult mothers. However the prenatal intake of waragi (potent gin, locally brewed from ripe bananas), which was believed to help in cleansing the baby’s cheesy skin while in the womb, was only reported among adolescent mothers:
“Yes I was taking a little waragi; I took about a full glass once a week. I started when I got pregnant. I was told that a little waragi is good for the baby, it helps the skin of the baby to remain clean” (adolescent mother)
Newborn care practices: mothers’ perceptions
Data on current newborn care practices is presented along three specific thematic areas: cord care, thermal care and initiation of breastfeeding.
Cord care: The majority of mothers used strings from old household materials, such as sacks for tying the cord. Razorblades and other sharp objects available at home, were mostly used for cutting the cord. Only a few mothers used newly bought strings and razorblades for tying and cutting the cord. All interviewed mothers applied substances to the cord to facilitate the healing process. Some applied ashes which were obtained from burning specific shrubs whilst others applied baby powder, cooking oil, local herbal substances and animal dung.
“We use thread from the sacks [sacks of sugar]” (adolescent mother), “I used reeds. The dry reeds are very sharp and they can cut. I have used these since my first born. That is what we use” (adult mother)
Some mothers primarily applied substances like salty water and baby powder, but reported that in case these did not have the desired effect, they chose other options as suggested by this mother:
“I used powder for about three days but it didn’t help, then I asked people and they told me ekiyondo (locally mixed herb) that’s what I used and the cord got dry” (adult mother)
Mothers generally used bed sheets or their own clothes for the provision of warmth immediately after delivery, while some mothers used bitenge (piece of cotton cloth measuring about two-by-two and a half metre, usually wrapped around their waists as part of their dress cord). After delivery, mothers shared the same bed and blanket with their baby while sleeping. Almost all bathed their newborn babies immediately or within 24 hrs after giving birth. Some mothers bathed their baby in the cold night.
“I bathe the baby immediately. Once I finished cleaning myself, I put some water on fire and when it was ready, I bathe the baby. Even if it is night, I always bathe the babies immediately” (adult mother);
This practice of immediate bathing was the same for those who delivered in a health facility or at home. Those mothers who delivered unassisted at home, bathed their babies earlier than those who delivered at the health facility, were assisted by Traditional Birth Attendants (TBA) or by relatives.
A dirty skin at birth had a strong bearing on how soon the baby will be bathed. If the baby was born with the vernix caseosa, then he/she was bathed immediately, while bathing of a ‘clean’ baby could be delayed by a few hours:
“When the baby is born dirty (with the white coating) we bathe immediately. Some children are born when they’re clean, but when they are dirty we have to bathe immediately, because a visitor who comes to see the baby cannot carry a dirty baby” (adult mother).
A delay in bathing the baby was found among adolescent mothers. This decision was driven by fear and inexperience rather than based on evidence as suggested by an adolescent mother:
“The baby was bathed the next day when we got home I did not know how to do it (bathing). I also never wanted to look at the cord. It is scary” (adolescent mother)
Initiation of breastfeeding and pre-lacteal feeds
Generally, early crying of the baby prompted women to initiate breastfeeding early:
“You wait; bathe the baby and when the baby cries then you breastfeed” (adult mother), “I normally breastfeed once the baby cries. If it does not cry, I breastfeed the next day” (adult mother)
However, initiation of breastfeeding was often delayed for a few hours up to two days due to the fact that the baby was sleeping or there was no let-down of breast milk yet.
“I delivered at about 6.00 p.m. and he was breastfed the next day in the evening” (adolescent mother), “I breastfeed after the breast milk has come this can be one or two days after” (adult mother)
Before initiating breastfeeding, women gave pre-lacteal drinks to the baby such as plain boiled water, boiled water with sugar or with glucose or some tea without sugar. Nonetheless, very few mothers did not provide pre-lacteal feeds but waited for the let-down of breast milk.
“I didn’t give the baby anything until the breast milk came. I just kept on putting him (the baby) on the breast” (adult mother),
There was a difference in preference for the type of pre-lacteal feeds offered by the two age-groups of mothers when breastfeeding was not initiated. The adolescent mothers appeared to have a preference for a combination of water and glucose, whilst adult mothers seemed to have a preference for water, sugar, salt or tea:
“We give glucose. We put it in water and give it to the baby with a spoon”
“There was no breast milk so we gave the baby glucose”
“When there’s no breast milk, I boil water and add sugar then I give it to her with a spoon”
“I boil water and add sugar and salt then give it to the baby for about 2 days. In two days the breast milk comes”
Insights from trainers and employers regarding newborn care
According to the trainers at the nurse training school, enrolled and registered nurses/midwives have similar curriculums regarding prenatal and newborn care; but important differences exist. Enrolled nurses/midwives together with the registered nurses mainly received a theoretically oriented training with minimal practical sessions while registered midwives in addition to their training regarding domiciliary care, devote two-thirds of their training to practical interactions with the mothers and babies. Domiciliary training is mandatory and prerequisite for sitting hospital final exams and receiving a certificate of registration as a practising midwife. After completion of domiciliary training a trainee midwife is issued with a certificate of successful completion:
“Domiciliary care is a compulsory training for all registered midwives. During domiciliary care a trainee midwife should be able to confirm established labour; manage all the four stages of labour; after delivery, assess the mother for discharge; and follow-up the mother in her home for seven days after birth”
(tutor training school).
“Most participants enrolled for the basic midwifery training are young high school graduates with no prior experience in newborn care, whereas students of the advanced training in midwifery did, and yet they (enrolled midwives) are expected to provide all the required information and treatment to pregnant mothers ”
(tutor training school)
The employers at the district noted that the Ministry of health together with the Ministry of public service publish job specifications, structures and job requirements for various Ministries of Health (MOH) institutions including health centres at the district. These documents spell out job titles, key outputs and activities related to the job, and person’s specifications. This is what one employer had to say:
“These guidelines are centrally formulated for strict and rigid implementation at the district level. The ministry of public service ensures its strict implementation by scrutinizing staffs’ monthly payrolls and any irregular deployment will lead to suspension of such a payment. Rigid deployment rules do not allow individual health managers of the district to exercise flexibility in the deployment process. For example a District Health Officer cannot deploy registered midwives to a health centre of level 3 even if assessment of the local need requires the presence of such a highly qualified midwife” (employer at the district).
In regard to the inadequate information offered at the prenatal clinics, employers at the district suggested that the few health workers could not attend the high number of patients who are seeking care, hence increasing the workload:
“Apart from antenatal care being labour-intensive, the number of health workers are few compared to the number of mothers who come for antenatal care. Health workers cannot give all the necessary information required during antenatal. They can skip other activities in order to try and serve all the mothers who have reported to the health centre” (
employer at the district
Tutors at the training school referred to the lack of adequate training for enrolled nurses/midwives and registered nurses to offer the entire information package. Instead, the scope of work designated for enrolled nurses/midwives and registered/nurses are limited to conducting a normal delivery (for example a cephalic presentation, delivering a mother who is having her second or third baby) but not attending to a complicated labour like a breach presentation or removal of a retained placenta. Moreover enrolled nurses/midwives and registered nurses do not get training in domiciliary care, as suggested by one tutor:
“That is not what they (enrolled nurses/midwives and registered nurses) were trained to do (providing information on newborn care). They were trained to manage normal labour and recognise any complication and be able to refer to the next level of care or where there is a registered midwife or doctor. That is the reason why enrolled midwives or nurses do not waste time in giving detailed information to prenatal or immediate postnatal mothers” (tutor in training school)