title: A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming.
abstract: BACKGROUND
  Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda.
  
  
  METHODS
  Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified.
  
  
  RESULTS
  The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery.
  
  
  CONCLUSIONS
  A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.
authors.affiliation: Doctors with Africa CUAMM, via san Francesco 126, Padua, Italy. c.wilunda@cuamm.org.
authors.forename: Calistus
authors.initials: C
authors.lastname: Wilunda
authors.forename: Gianluca
authors.initials: G
authors.lastname: Quaglio
authors.forename: Giovanni
authors.initials: G
authors.lastname: Putoto
authors.forename: Peter
authors.initials: P
authors.lastname: Lochoro
authors.forename: Giovanni
authors.initials: G
authors.lastname: Dall'Oglio
authors.forename: Fabio
authors.initials: F
authors.lastname: Manenti
authors.forename: Andrea
authors.initials: A
authors.lastname: Atzori
authors.forename: Rose Miligan
authors.initials: RM
authors.lastname: Lochiam
authors.forename: Risa
authors.initials: R
authors.lastname: Takahashi
authors.forename: Aline
authors.initials: A
authors.lastname: Mukundwa
authors.forename: Koyejo
authors.initials: K
authors.lastname: Oyerinde
mesh_terms: D001291:Attitude of Health Personnel; D003469:Culture; D036861:Delivery, Obstetric / Q000191:economics / Q000706:statistics & numerical data*; D003906:Developing Countries; D005260:Female; D005523:Food Supply; D006268:Health Facilities / Q000191:economics / Q000706:statistics & numerical data*; D006295:Health Resources / Q000600:supply & distribution; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D010358:Patient Participation; D011203:Poverty; D036301:Qualitative Research; D019035:Rural Health Services / Q000191:economics / Q000706:statistics & numerical data*; D014454:Uganda
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