Background Reduction of maternal and child mortality is universally accepted as a desirable goal. However, the same is not true for family planning. In Uganda, a developing country with high maternal and child deaths, 12% of pregnancies are unwanted, 44% unplanned and 32% mistimed.
We used confidential enquiry to identify avoidable factors, without blaming anyone. In the UK, confidential enquiries have helped to address avoidable factors in the health system and beyond which have contributed to deaths. This paper examines whether promotion of family planning would be accepted as an intervention to prevent maternal and child deaths.
Methods We adapted the UK-developed ‘confidential enquiry’ methodology to the context in Uganda. Verbal autopsy interviews of family members and health workers were used to investigate all maternal and under-5 deaths in selected sub-counties. Cases were reviewed by multidisciplinary panels to assign cause of death, to identify avoidable factors, and to make recommendations for avoiding similar future deaths. Results were fed back to communities and cases were discussed to raise awareness of different avoidable factors, including lack of family planning.
Findings Over 50 maternal and over 300 child deaths were investigated. This interim report covers 219 child and 51 maternal deaths. Almost all deaths had at least one avoidable factor. There could be missed opportunities to prevent illness or get treatment right from conception, birth, infancy, weaning and childhood. This could be in form of failure to use or get appropriate family planning, antenatal care, safe delivery, neonatal care, use of vaccines and bed nets, appropriate nutrition, safe water, etcetera.
How many deaths could have been prevented by using appropriate family-planning services? There are challenges in answering this. A question like “Was this pregnancy desired?” is not an evident one after a mother or child has died. Father and mother may have differing answers. Besides, it is difficult to know whether family planning was being used adequately.
However, the review panel was able to identify the contribution of lack of family planning in these deaths. The minimum (low estimate) – family planning being identified by the case review panel as an avoidable factor – was 19.6 % and 21.6% for under-five and maternal deaths respectively. The maximum (high estimate) – with family planning being identified by the case review panel as an avoidable factor, plus any of the following: maternal age <18, maternal age >40, birth order of the child >5 – was 30.6% and 23.5% for under-five and maternal deaths respectively.
There were cases of inadequate contraception such as missed pills, failure of method, poor advice from friends as well as health workers, fear of side effects and myths. There were cases of unwanted pregnancies but no contraception used.
In most communities family planning was recognised as an important intervention for preventing maternal and child deaths, and barriers to its use were discussed.
Discussion & conclusion Lack of appropriate use of family planning was an avoidable factor in 19.6%–30.6% of child deaths and 21.6%–23.5% of maternal deaths in Uganda. Most communities accept the need to use family planning in order to reduce maternal and child deaths. However, there is still resistance to modern methods of family planning from some religious leaders.
There is a vicious cycle of high child mortality and lack of family planning leading to high fertility rates and maternal deaths. High child mortality is not only a cause but also a consequence of lack of family planning. This vicious cycle can be broken by lowering child mortality and using family planning. When mothers have faith that all children born are likely to survive, then only will they deliver the number of children they desire to have. Promoting and using family planning will lead to low child and maternal deaths.
There are gaps in the literature on mortality data, as the data available are facility-based. There has been no evaluation of community-based confidential enquiries.
An adaptation of the confidential enquiry methodology to the context in sub-Saharan Africa, involving local stakeholders in a participatory discussion identified avoidable factors not only in health facilities but also in the community, generated recommendations for improving the health care of critically ill women and children. Improved understanding of the benefits of family planning, and how to overcome barriers, may significantly contribute to a much-needed reduction in mortality.
The confidential enquiry methodology can be adapted to the context of the developing countries. This tool could help reducing under-five and maternal mortality, by identifying avoidable factors, making and implementing recommendations and prioritising possible interventions.
No conflict of interest.
- confidential enquiry
- family planning
- maternal mortality
- child mortality
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