title: Losing women along the path to safe motherhood: why is there such a gap between women's use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda.
abstract: BACKGROUND
  Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Delivery with a skilled birth attendant is a vital intervention for saving lives. Yet many women, particularly where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. In Uganda, only 58 % of women deliver in a health facility, despite approximately 95 % of women attending antenatal care (ANC). This study aimed to (1) identify key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery; (2) examine the association between advice during antenatal care to deliver at a health facility and actual place of delivery; (3) investigate whether antenatal care services in a post-conflict district of Northern Uganda actively link women to skilled birth attendant services; and (4) make recommendations for policy- and program-relevant implementation research to enhance use of skilled birth attendance services.
  
  
  METHODS
  This study was carried out in Gulu District in 2009. Quantitative and qualitative methods used included: structured antenatal care client entry and exit interviews [n = 139]; semi-structured interviews with women in their homes [n = 36], with health workers [n = 10], and with policymakers [n = 10]; and focus group discussions with women [n = 20], men [n = 20], and traditional birth attendants [n = 20].
  
  
  RESULTS
  Seventy-five percent of antenatal care clients currently pregnant reported they received advice during their last pregnancy to deliver in a health facility, and 58 % of these reported having delivered in a health facility. After adjustment for confounding, women who reported they received advice at antenatal care to deliver at a health facility were significantly more likely (aOR = 2.83 [95 % CI: 1.19-6.75], p = 0.02) to report giving birth in a facility. Despite high antenatal care coverage, a number of demand and supply side barriers deter use of skilled birth attendance services. Primary barriers were: fear of being neglected or maltreated by health workers; long distance and other difficulties in access; poverty, and material requirements for delivery; lack of support from husband/partner; health systems deficiencies such as inadequate staffing/training, work environment, and referral systems; and socio-cultural and gender issues such as preferred birthing position and preference for traditional birth attendants.
  
  
  CONCLUSIONS
  Initiatives to improve quality of client-provider interaction and respect for women are essential. Financial barriers must be abolished and emergency transport for referrals improved. Simultaneously, supply-side barriers must be addressed, notably ensuring a sufficient number of health workers providing skilled obstetric care in health facilities and creating habitable conditions and enabling environments for them.
authors.affiliation: United Nations Population Fund (UNFPA), 605 Third Avenue, New York, NY, 10158, USA. anastasi@unfpa.org.
authors.forename: Erin
authors.initials: E
authors.lastname: Anastasi
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK. Matthias.Borchert@charite.de.|Institutes of Tropical Medicine and International Health, Charité-Universitätsmedizin Berlin, Berlin, Germany. Matthias.Borchert@charite.de.
authors.forename: Matthias
authors.initials: M
authors.lastname: Borchert
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK. oona.campbell@lshtm.ac.uk.
authors.forename: Oona M R
authors.initials: OM
authors.lastname: Campbell
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK. Egbert.sondorp@lshtm.ac.uk.
authors.forename: Egbert
authors.initials: E
authors.lastname: Sondorp
authors.affiliation: Gulu University Faculty of Medicine, Gulu, Uganda. fkaducu@gmail.com.
authors.forename: Felix
authors.initials: F
authors.lastname: Kaducu
authors.affiliation: Medicos sin Fronteras (MSF/Doctors Without Borders) - Spain/OCBA, Barcelona, Spain. oliviahill2010@gmail.com.
authors.forename: Olivia
authors.initials: O
authors.lastname: Hill
authors.affiliation: Apac Hospital, Apac, Uganda. okenggdennis@gmail.com.
authors.forename: Dennis
authors.initials: D
authors.lastname: Okeng
authors.affiliation: Apac Hospital, Apac, Uganda. odvinolaker@yahoo.com.
authors.forename: Vicki Norah
authors.initials: VN
authors.lastname: Odong
authors.affiliation: London School of Hygiene & Tropical Medicine, London, UK. isabelle.lange@lshtm.ac.uk.
authors.forename: Isabelle L
authors.initials: IL
authors.lastname: Lange
mesh_terms: D000293:Adolescent; D000328:Adult; D036861:Delivery, Obstetric / Q000379:methods / Q000523:psychology / Q000706:statistics & numerical data*; D005239:Fear; D005260:Female; D017144:Focus Groups; D006268:Health Facilities / Q000706:statistics & numerical data*; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006700:Home Childbirth / Q000523:psychology / Q000706:statistics & numerical data; D006801:Humans; D008428:Maternal Mortality; D008880:Midwifery / Q000706:statistics & numerical data*; D010342:Patient Acceptance of Health Care / Q000523:psychology / Q000706:statistics & numerical data*; D011247:Pregnancy; D011295:Prenatal Care / Q000523:psychology / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012959:Socioeconomic Factors; D018454:Spouses; D014454:Uganda