Women's experiences of maternal and newborn health care services and support systems in Buikwe District, Uganda: A qualitative study.

BACKGROUND: Uganda continues to have a high neonatal mortality rate, with 20 deaths per 1000 live births reported in 2018. A measure to reverse this trend is to fully implement the Uganda Clinical Guidelines on care for mothers and newborns during pregnancy, delivery and the postnatal period. This study aimed to describe women's experiences of maternal and newborn health care services and support systems, focusing on antenatal care, delivery and the postnatal period.
METHODS: We used triangulation of qualitative methods including participant observations, semi-structured interviews with key informants and focus group discussions with mothers. Audio-recorded data were transcribed word by word in the local language and translated into English. All collected data material were stored using two-level password protection or stored in a locked cabinet. Malterud's Systematic text condensation was used for analysis, and NVivo software was used to structure the data.
FINDINGS: Antenatal care was valued by mothers although not always accessible due to transport cost and distance. Mothers relied on professional health workers and traditional birth attendants for basic maternal services but expressed general discontentment with spousal support in maternal issues. Financial dependency, gender disparities, and lack of autonomy in decision making on maternal issues, prohibited women from receiving optimal help and support. Postnatal follow-ups were found unsatisfactory, with no scheduled follow-ups from professional health workers during the first six weeks.
CONCLUSIONS: Further focus on gender equity, involving women's right to own decision making in maternity issues, higher recognition of male involvement in maternity care and improved postnatal follow-ups are suggestions to policy makers for improved maternal care and newborn health in Buikwe District, Uganda.

Introduction

Uganda continues to have a high neonatal mortality rate, with 20 deaths per 1000 live births reported in 2018. The country is projected to miss the Sustainable Development Goal (SDG) 3.2 of a neonatal mortality rate of 12/1000 live births in 2030, if the current trend continues [1]. Contributing factors to the high number of neonatal deaths in Uganda are the country’s challenges to implementing multi-level policy strategies for enhancing newborn survival. Policy strategies include implementation of The Uganda Clinical Guidelines (UCG) from 2016 with updates, which have detailed descriptions of recommended health care and medical advice in all aspects involving maternal care [2]. Additional obstacles for optimal maternal and newborn health care include informal out-of-pocket payments for health care services, along with shortage of accessible staff, and low quality of care [3]. WHO defines quality of care as:

The extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centred [4].

Quality of care is contextualized within the phenomena of maternal and newborn support systems. It implies that the mothers have someone to trust and rely on during pregnancy, time of childbirth and the following postnatal period, enhancing the chance for an optimal start in life for the newborns [5]. So that in times of need, or if encountering emergencies, the mothers have a security net around them which can provide practical help and emotional support, such as encouraging mothers to seek professional health care [6]. Evidence from other settings show that women with supportive environments and reliable partners have easier births, healthier babies and better postnatal experiences [7].

The term postnatal is defined by WHO as “the time after birth and up to six weeks (42 days)”. The most vulnerable period for a newborn and its mother is the first month after birth, where the first 24 hours are the most critical. Despite this fact, attention and care for the mother and newborn are often neglected after delivery [8]. The national estimate of mothers receiving postnatal care within two days is only 33%, and studies from Uganda show that giving birth in health facilities is the predominant factor for receiving early postnatal care [9, 10].

Assurance of quality of care through the conjugated components of maternal care is important in ensuring optimal outcome for both the mother and her infant. Family and spousal support through each of these stages are paramount for the mothers’ wellbeing [6]. This study aimed to describe women’s experiences of maternal and newborn health care services and support systems in Buikwe District, focusing on antenatal care, delivery and the postnatal period.

Methods

Study design

In an effort to get a deeper and more elaborated understanding of the topic, we used qualitative methods where data was collected through focus group discussions, key informant interviews, and participant observations [11]. The findings presented in this paper are part of a broader study named “Health care and support systems for mothers and newborns around delivery in Buikwe district, Uganda” and the methods have been described earlier [12]. The research was part of the fulfilment of a M.Phil. degree in Global Health at the Centre for International Health, University of Bergen.

Setting and population

We conducted research in 7 villages in Buikwe district, in east central Uganda. Buikwe has a total population of approximately 423,000 (2014), where the majority of the people relies on subsistence farming [13]. Most people travel on foot, or they use bicycles or scooters for transportation. Some villages are remote from the closest health facility and traveling at night can be hazardous on narrow dirt roads. Nyenga town contains Saint Francis Hospital and Saint Francis School of Nursing and Midwifery. Kabizzi village includes a Health Centre III for the public in the area, which provide both in-and out-patient services, including a two bed maternity room [14, 15]. The health care system in Uganda is a referral system, with voluntary village health team members (VHTs) operating as the first contact point for patients. The next contact point is Health Centre II, which refers to Health Centre III or IV (District Hospital) if needed. The highest level of care is the National Referral and Teaching Hospital in the capital Kampala [3].

Based on their occupation and involvement in maternity issues, we recruited professional health workers such as midwives, students and nurses from the maternity ward at St. Francis Hospital and Kabizzi Health Centre. We enrolled mothers from the hospital or the villages, with the inclusion criteria that they had given birth within the past month. Traditional birth attendants (TBAs) were included based on their role as often being the first line contact with pregnant mothers in the villages, together with VHTs, who are the local representatives of the professional health care system in Uganda. We have displayed the data collection process in a flow chart below (Fig 1).

Fig 1

Flow chart of data collection process.

Sampling

The villages were selected by approaching local village leaders, who lingered after conclusion of a village committee meeting in the urban centre of Nyenga town. We gave an introduction about the study and made arrangements to meet in their respective villages. In cooperation with the village leaders, the main researcher and two local research assistants enrolled a total of 57 participants in the study. Fifteen key informants were recruited for interviews, and 42 mothers attended focus group discussions. The key informants consisted of 4 mothers, 4 TBAs, 3 VHTs and 4 health workers. With exception of the professional health workers, all participants were small-scale subsistence farmers with some having additional small businesses. The education level ranged from none to certificate level for the health workers, as displayed in Table 1.

Table 1

Characteristics of participants.

Participants	Key informant interviews	Focus group discussions	Age	Occupation	Education
Health workers (4)	4		19–35	Nurses, midwives, students	Certificate level
Mothers (46)	4	42	16–45	Subsistence farmers, small scale business	Primary to secondary
TBA’s (4)	4		50–80	“	None to primary
VHT’s (3)	3		50–80	“	Primary
Total 57	15	42

Data collection

We used two semi-structured interview guides as instruments for the data collection, where one guide was directed towards mothers, and the other to key informants. The interview guides were locally pre-tested and amended before use in interviews with key informants and in focus group discussions (S1 and S2 Files).

Two local research assistants were trained and educated by the main researcher before initiation of the study. One male assistant was handling logistic organization, recruitment of key informants together with local village leaders and was moderator in focus group discussions. One female assistant was doing translations and transcriptions of recordings in the local language Luganda and had a role as moderator in focus group discussions. Both were fluent in English and Luganda with bachelor’s degrees in social sciences, working within the same field.

The time period for data collection was from January 15th to February 25th, 2019.

Key informant interviews

We conducted semi-structured key informant interviews with 15 participants in quiet outdoor settings in the villages, or by the Hospital or Health Centre. The interviews were carried out by the main researcher in English (n = 5), or by one of the research assistants in Luganda, if the interviewee was not comfortable with the English language (n = 6). Upon request from the participants, one interview with key informants was a group interview including two TBAs and two VHTs, where each question was answered successively among them. The duration of the interviews ranged from 10 to 30 minutes.

Focus group discussions

Six focus group discussions were held in five villages, where the local leaders had provided outdoor sites in quiet areas under large trees. In one village, two discussions were held simultaneously due to the high number of mothers gathered. One of the local research assistants had the role as moderator in Luganda and gave intermittent brief summaries in English to the main researcher. She was present for observation and note taking during all focus group discussions, which lasted from 40–60 minutes.

Participant observations

The main researcher, who is a nurse by profession, spent six weeks observing daily routines and interactions between staff and mothers and their families in the Hospital and Health Centre. She engaged in unstructured dialogues with mothers and staff as a tool for understanding the dynamics of family and partner engagements, division of responsibilities within the health system and other support systems in maternal issues. Notes were written continuously.

Data management

Transcriptions from audio-recorded interviews were typed into Microsoft Word documents within 2–4 days. If conducted in the local language, we transcribed the interviews first in Luganda, then into English consecutively. Final proofreading was performed by a third assistant, who listened to the audio while reading through the transcripts in both languages. Field notes from observations were typed upon completion of the study period.

All electronic data are kept behind two-level password protection in OneDrive. Notes and hard copies are stored in a locked cabinet and will be destroyed after 5 years from the time of data collection.

Data analysis

The authors analysed the data based on the method called Systematic Text Condensation (STC), developed by Malterud [16]. Following the STC method, we read the transcribed text documents in-depth several times, in order to detect emerging themes from the raw data. After identifying the themes, the authors developed descriptive headlines and created coding trees using the NVIVO 12 pro software program. We pulled extractions from the transcribed documents and placed them under the most fitting code group. Several alterations of the coding structure were done during the process. Ultimately, the authors agreed on three themes created under the topic of “Maternal help and support”, which were identified as: (a) Antenatal care and spousal support, (b) Health care and family support around delivery, (c) Postnatal care and challenges related to gender roles. The contents from the different code groups were further analysed by creating condensed narratives supplemented with “golden quotes” to complete the descriptions.

The main researcher (MBR) was a female nurse from Norway who had visited Uganda several times previously. She was in charge of the primary data collection, coding and analysis of the data. IMSE assisted with co-reading the raw-data and discussion of main themes with the first author. RM contributed with developing the interview guides, acquisition of data and discussion of main themes with the first author. IN collected data materials, discussed findings and interpretations with the first author and helped with critical revision of the final paper.

In November of the same year, the participants in the study were invited for a dissemination meeting where they were presented with the findings and encouraged to modify, comment on, or question the results. The participants did not know the status of the other participants as informants. Feedback from the participants included a request to the local health workers and village leaders of a strategy to include and educate partners and men in maternity issues.

Ethical considerations

The research was approved by the Regional Committee for Medical and Health Research Ethics, Norway (2018/602/REC West), Makerere University Higher Degrees Research and Ethics Committee, Uganda (HDREC/2018/6). Signed consent for internship/research was obtained from St.Francis hospital Nyenga and Kabizzi Health Centre. The study was registered with Uganda National Council for Science and Technology (HS302ES). Study participation was fully voluntary. Information about the study was given both in English and Luganda when necessary, and the participants signed or fingerprinted consent forms. During focus group discussions, each participant was given a number for recognition and was asked not to share private information gained during the sessions outside the group. Snacks and refreshments were offered to the participants before the interviews and focus group discussions, and they were reimbursed for transportation costs up to 15 000 UGS (equals 4 USD). The mothers attending focus group discussions received a piece of locally made baby clothing after the session and no extra money was given for participation.

Results

One of the interesting aspects with conducting qualitative research is the emergence of views and shift in focus during interviews or focus group discussions. In this study, views about the importance of antenatal care and male involvement in maternal issues were given much attention both from mothers and TBAs, although they were not at the centre of the focus group discussion guides. Hence, the authors decided to give these topics augmented attention in this paper. Many women in the study were discontented with spousal support when they endeavoured to attend antenatal classes, which was often related to financial situations and transport challenges. The mothers had mainly positive experiences with professional health workers and TBAs around the time of delivery, where TBAs often played a key role. Postnatal care initiations from the professional health workers were found close to non-existent, except for the six-week check-up combined with the vaccination program. The mothers revealed disappointment with postnatal spousal support, such as unmet expectations of practical help, challenges related to gender roles, poverty, and inhibitions in own decision-making. Observations by the researcher could occasionally deviate from the view of the participants in the study and are conveyed explicitly. In the following section, the authors present the themes extracted from the analysis: (a) Antenatal care and spousal support, (b) Health care and family support around delivery, (c) Postnatal care and challenges related to gender roles.

Antenatal care and spousal support

Among the interviewed mothers, knowledge of the importance of antenatal care was widespread, although many admitted non-attendance at antenatal classes for various reasons like road conditions, distance, and transport cost. Mothers explained how they were dependent on their partners for financial support, and how it could sometimes be difficult to convince them of the importance of antenatal care. Also, the partner could be away from home, which gave them no opportunity for traveling:

Sometimes a woman can request some money for transport from the husband and he tends to refuse to give out the money to the wife hence she ends up not going for antenatal care. That’s why the husbands send their wives to go to these TBAs because for them they will not pay money. (Mother 35–45 years, village 4)

The TBAs and VHTs brought up antenatal care as an important issue, and they stressed the significance of attending antenatal classes to gain information on hygiene and general baby care, referring to some mothers as “totally green about some issues”. (TBA, village 7). They were especially concerned about very young mothers, sometimes only 14–15 years old, who did not have sufficient experience or knowledge about how to care for themselves or their newborns. The TBA’s were advocating for a closer work relationship with professional midwives and health workers in the community, as a way to reach out to all new mothers. Some of the TBA’s confirmed the statements of the mothers, that non-attendance in antenatal classes reflected the total financial situation in the family, where the lack of funds prohibited transportation to facilities.

Health care and family support around delivery

For various reasons like rapid labour onset or going into labour after dark, the mothers did not always reach professional help in time for delivery. In one key informant interview, a mother explained in detail how she admired her husband for taking responsibility in asking a neighbour for assistance with delivering their baby, due to rapid labour combined with difficulties obtaining transport. Reliance on and support from family members in times of need and during vulnerable circumstances contributed to better coping and a sense of well-being.

On several occasions the researcher witnessed very young mothers who arrived with their mothers-in-law in time for delivering, both at the Hospital and the Health Centre. The researcher also witnessed many caring and supportive partners and husbands while present for observations at the Hospital and Health Centre. Men who accompanied their partners could be seen anxiously waiting for hours outside the maternity ward, awaiting the birth of their baby son or daughter, or they travelled long distances to reach the delivery.

Contrary to the mentioned statements and observations, many women who participated in focus group discussions showed resentment and anger towards negligent husbands and fathers, regarding unmet expectations of help and support in time of labour, as well as on economic issues:

A very big number of women from this village give birth from their homes just because they lack money and even the husbands do not fulfil their responsibilities, which sometimes leads to both infant and maternal mortality. (Mother 35–45 years, village 4)

Being at a health centre with marginal resources and equipment when complications occurred, was described as a huge challenge for the health workers, and they often found themselves alone on duty. When there was need for referrals, it was the family’s responsibility to arrange for transport, but that was often described as difficult and unreliable. One midwife interviewed had a traumatic experience freshly in mind of how she struggled to find transport for referral of a mother who faced complications during labour, implicitly also describing her own support to the mother and her family:

I was alone, and the baby was at the outlet, I was seeing the head actually. I tried several bodaboda names (scooter driver’s names), but their phones were off…before reaching (village 1) we got in an accident around the house near N. Then we reached the road, it was raining, totally raining, and the petrol got finished. And she was fitting (having seizures) with heavy rain. We stayed in (village 1) up to morning. They had to give magnesium, but it took long for her to give birth. She delivered when she was still fitting. They did episiotomy when she was still fitting. (Midwife 19–35 years)

Postnatal care and challenges related to gender roles

Due to the various components of postnatal care, the theme will be presented with sub-topics as follows; postnatal follow-ups, breastfeeding and nutrition, family planning, and gender inequality. The sub-topics will be combined in the discussion.

Postnatal follow-ups

Pre-scheduled or planned postnatal follow-ups before vaccination of newborns at six weeks was not common or recognized among the professional health workers. When inquiring from the health workers about postnatal follow-ups or home visits, the general answer was that they told the mothers to return to the facility if they should face any challenges, but they also confirmed that this seldom occurred. Newborn vaccinations against polio and BCG were normally given at the Hospital or Health Centre before discharge.

For women giving birth at home, the TBAs or VHTs could offer advice to go to the hospital for vaccinations and measurements, but it was the mothers’ responsibility to follow up. Some of the TBAs interviewed took extra measures to follow up on the mothers they had helped with deliveries:

Yes, I do visit them after some time from the day I discharged them to find out how they are doing, if they are in good condition both the mother and the baby. (TBA 50–80 years, village 1)

Others explained how they recommended them to seek postnatal care and go for vaccinations at various health facilities.

Breastfeeding and nutrition

The midwives were often alone on duty, and due to hectic work environments and sometimes attending to several mothers in labour simultaneously, the information and support for breastfeeding were thus neglected. Sometimes the mothers were fortunate to have gained experiences through family ties.

Making sure that the mothers initiated breastfeeding early were important to the TBAs, and when mothers faced challenges of sore nipples, they would sometimes go to extreme measures to make the mothers breastfeed:

There are some mothers when you tell her to breastfeed the baby, she can hesitate [saying] that she feels nipple pain, me I even slap some of them for hesitating. (TBA 50–80 years, village 1)

Family planning

Women’s autonomy and own decision-making were challenged in reproductive health issues. Recurrent topics raised by women attending focus group discussions were sexual activity after birth and family planning, where the discord between the various needs of men and women were repeatedly proclaimed, and, as the following quote shows, it could prove a risky affair for the women:

If a woman goes for family planning on her own and the man gets to know it, it will just become a fight or even he can kill the wife. (Mother 35–45 years, village 4)

From observations at the Hospital, the researcher witnessed a young mother who had requested tubal legation after having had four Caesarean sections. The procedure had been recommended and approved by the doctors for the health of the mother and her husband had signed the consent papers. On the day of the procedure the husband withdrew his approval, and the mother was not allowed to go through with the surgery.

Unstructured dialogue with mothers during observations revealed that many were aware of other contraceptives like intra-uterus devices (IUDs), but intimidating stories of painful insertions and side-effects of infertility prohibited usage.

Gender inequality

Whether one was a first-time mother or had other children, women described the early postnatal period as challenging due to sleep deprivation, breastfeeding problems, daily chores, and uncertainties about motherhood. Unmet expectations from their partners resulted in exposure of underlying feelings of being neglected and betrayed, which became transparent in this quotation from a focus group discussion:

Me, sometimes after giving birth I feel like eating posho (local dish from maize), but my husband tends to run away from his responsibilities and goes and marries other women, me I even fetch water for myself. (Mother, 25–35 years, village 4)

During the observation period, the researcher witnessed supportive husbands or other family members who cared for the mothers after they had given birth. Single mothers would often be accompanied by a sibling of the mother, who would assist her in caring for the newborn, or fetching food and water for washing. However, the negative experiences did influence the interview data.

Discussion

The initial platform to ensure safe quality care for pregnant women and their unborn babies is antenatal care visits. The presented results indicate that antenatal care was not always accessible for all mothers in Buikwe district, due to distance and transport costs as the biggest obstacles. The women relied heavily on their partners and their support to access the services. WHO/UNICEF Uganda recommends eight antenatal visits during pregnancy, whereas the UCG aim for at least 4 visits [2, 4]. Studies from sub-Saharan Africa have shown clear associations with attending antenatal care and reduction in neonatal mortality [17], even though timing and frequency for antenatal visits vary among regions and socioeconomic status [18]. Studies from Uganda concerning availability and quality of antenatal care provision in rural settings show lack of qualified staff and inadequate check-ups and provision of necessary information as key areas for improvements [19]. One study found that sampling of urine and receiving drugs for intestinal parasites were components most often neglected during antenatal visits, and that the overall quality of antenatal care has been found to be higher in private sector facilities than in public ones [20]. Intervention programs on improving quality of care show promising results, but reveal the need for systemic improvements in infrastructure and education of health care providers [19]. Statements from TBAs and VHTs in this study, reveal concerns about some young women’s low knowledge about issues like hygiene and how to care for newborns. This indicates a need for closer cooperation between TBAs/VHTs and professional health workers in rural Uganda.

Both mothers and TBAs referred to poverty as the key reason why women were not able to attend antenatal care. The same factor can possibly also explain low male involvement in maternity care, since the transport cost would double if two people were to travel instead of one, in addition to income and working time lost. The importance of supportive environments and recognition of partner involvement interventions in maternal health, has gained increased attention since the introduction of WHO’s Maternal and Child Health Care Program (MCH) in the mid 1990’s [21]. The multi-lateral global movement Every Woman Every Child includes strategies of male involvement in maternal health programmes as one of its action areas towards achieving the SDGs before 2030 [22]. Focus on male involvement in maternal care is further strengthened in the national strategy for Sexual and Reproductive Health and Rights (SRHR), which was launched by the Ugandan Government in 2014 [23]. Male involvement in maternal care is also implemented in the UCG by recommending bringing the partner or a family member to at least one antenatal visit [2]. Previous studies from Uganda have confirmed that the spouse often remains at home looking after the household and other children, which allows the woman to go for antenatal care [24]. A documented cost-effective way to increase male attendance is to give a personal invitation letter to the women’s spouses, as an alternative to a general information pamphlet. This intervention has proven to raise the attendance by up to 10% [25], although it does not solve the underlying economic problem.

Traditional and cultural customs of men being unwelcome in the delivery rooms could contribute to signals of men not being wanted or needed in situations around childbirth [26]. Looking at the situation from another angle, the men might not always have a choice of attending to their wives based on work conditions and availability. Given time off work to tend to one’s wife and child around the time of childbirth is constituted in the Employment Act of Uganda from 2006, which gives fathers four days paid leave from work to spend with the family [27]. However, many men do not have regular work conditions to effectuate that. Obstacles to male involvement in maternity care are grounded in both culture and religion, as shown in studies within Nigerian and Ugandan settings, where women tend to share similar views as men when it comes to what is considered appropriate and expected, although it varies within the socioeconomic strata [28, 29]. Many mothers in the study did not have safe environments around the time of childbirth. Challenges related to logistics and economy were explained as reasons for suboptimal birthing experiences, both from the user and provider perspectives. Weather and road conditions reflect the vulnerability of the health system in rural Uganda and add to the challenges of transport costs and low staffed health facilities. Hence, many women must succumb to the environment and give birth in the villages with help from TBAs.

Postnatal check-ups are recommended in the UCG at 6 hours after birth, after 2–7 days and after six weeks, and include counselling on emergency issues, hygiene and general baby care [2]. Neither the health workers nor the mothers were familiar with the UCG recommendation of 2–7-day check-ups [2], which would give the mothers a good platform for expression of concerns around breastfeeding issues or other postnatal conditions. Some of the health workers interviewed recommended mothers to come back if they faced any trouble post-partum, but that was not routine. The recommended level of professional support in the postnatal period has changed over the years, but recent WHO guidelines give higher attention to this vulnerable time in a mother’s and her baby’s life. The new guidelines include postnatal care on the first day, third day, between 7–14 days and six weeks [8], but these recent recommendations are not yet included in the UCG. Postnatal contact between mothers and TBAs was more common, and a study from Nigeria show that both monetary and non-monetary payments to TBAs gave incentives for referral of mothers to health facilities [30].

A feeling of security and supportive surroundings are requirements for a good bonding- and early breastfeeding experience, and the lack of such may lead to post-partum depression and trouble with, or discontinuation of, exclusive breastfeeding [31]. Emotional wellbeing and family support is equally important [8]. Midwives reported challenges with time constraints as factors for not providing sufficient information and support in breastfeeding issues for the mothers. This study points towards shortcomings both in frequency and quality of postnatal encounters between health workers and mothers.

Some mothers showed resentment towards their spouses for not assisting them during and after birth and uttered disappointment with spousal neglect in providing them with nutritious food and support with household chores they normally were doing. Stories told with anger and bitterness reflected the hopelessness and despair many women found themselves to be in. Some of the mothers mentioned sharing concerns and advice with neighbours and friends, but when it came to provision of physical help it often seemed to be each woman for herself. The resentment was coupled with aversion against early sexual demands. In the Ugandan culture, many women are subjected to the wants and decisions of men, as described clearly in an article in The Observer by Kiiza and Akumu [32]. Although the Uganda Children’s Act deems the parents equal [33], culturally the children are seen as the property of the father, and the mother of the child cannot deny the father sexual favours [32]. In addition to the feeling of lack of support and care, women also face the problem of being economically dependent on their partners, enhanced by legislative regulations that favour males [34].

The mothers interviewed in this study complained about unreliable financial support from their husbands and made them partly responsible for the poverty. This study did not capture fathers’ views on the situation, however, other studies from Uganda describe gender disparities as the causal factor of poor access to sexual and reproductive services [24]. Additionally, men’s lack of financial support in maternal health could often be justified by the overall lack of financial resources at home [26]. The women’s discontent with support from their partners could be an indication of alterations of traditional gender roles in view of recent years’ access to internet services and influences from social media [35].

Findings from the presented study, related to women’s autonomy in reproductive health issues mirror similar findings concerning maternal health and support systems in Uganda [26]. Maternal and newborn health research could continue with gender sensitive perspectives, taking into account disparities that may arise from the presence or lack of family support in vulnerable pregnant and delivering women, and for the mother and baby in the postnatal period.

Study strengths and limitations

The authors sought to obtain reliability by using local translators and trained interviewers of both sexes. Possible bias includes that the main researcher and primary analyst was a foreign person and holds an etic, meaning subjective, view of the situation witnessed in Uganda during the research period. Alternatively, sometimes being from a different country or culture can have a positive effect on the interviewees as it is seen as less threatening, as someone from the same culture may be more prone to criticize local practices. Also, the supportive statements and validation of data from local women give extra strength to the observations from the study. A majority of the negative statements about partners’ support on maternal issues were from the same focus group discussion, where many women were gathered. Being many may have encouraged others who otherwise would have kept silent. The study did not include interviews with fathers or partners, which could be seen as limitations to the study. Including the voice of partners could have given a more nuanced picture of the situation reflected in the study, and a better understanding of their situation. Proofreading of transcriptions added credibility to the study. Issues with electric power and technical difficulties resulted in written notes only, from one focus group discussion and one in-depth interview. Dependability of the study was sought obtained through triangulation of qualitative methods, although no participant observations were done outside of the health facilities. Previous research results from rural settings in Uganda makes the study transferable to settings with similar context and clienteles.

Conclusions

Maternal support and care were highly sought and valued by the mothers in the study, but not always accessible due to logistic and financial problems. Resources were scarce both in the homes and within the health system. Further focus on gender equity on all policy making levels, involving women’s right to own decision making in maternity issues and higher recognition of male involvement in maternity care, are suggestions to policy makers for improved maternal health and newborn survivals in rural Uganda. This study highlights a continued need for higher awareness and incentives for implementation of recent WHO recommendations on postnatal care in the combat against infant mortality.

Interview guide for key informants.

(DOCX)

Click here for additional data file.

Interview guide for focus group discussions and mothers.

(DOCX)

Click here for additional data file.

4 Aug 2021

PONE-D-21-14606

Women’s access to and use of maternal health care and home support systems to reduce neonatal deaths in Buikwe district, Uganda: a qualitative study

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for inviting me to review this manuscript on women’s access to and use of maternal health care and home support systems in Uganda. I have enjoyed reading the paper as it speaks to a topic close to my own scholarly interests and has numerous quotes that point to some original and important qualitative data.

Some of my major comments and constructive criticisms relate to 1) the structure, organization, and language of the paper, 2) coverage of appropriate literature, and 3) adequacy of analysis, interpretation, and definition of key concepts, terms. For example, in the title of the manuscript it says, “to reduce neonatal deaths,” but the qualitative data and discussion is less about neonatal deaths and more about structural barriers to accessing biomedical, facility-based health care such as expenses, transport, social and economic support from spouse. I would encourage the authors to think a little more about the main ideas that they would like to put forth in the paper and restructure/organize the data to support 1-2 main arguments instead of summarizing the findings. There are a lot of great data and analysis in the discussion but some of the this gets lost in the way the paper is currently organized. Overall, there are too many quotes used throughout the paper. PLOS One has a wide audience and readership and you need to be able to walk each reader through your paper by providing enough background, context, and utilizing only the quotes that speak directly to your main argument. We do not know how or why a quote is important if you do not articulate your main argument and relate the quote back to this idea. Perhaps restructuring the data and discussion sections so that the discussion comes after each of the different thematic data sections. You could also use the perspectives of mothers, TBS, and health workers as the main data sections to try to show the variation in the themes that were important to each group. Or if you keep the current structure there needs to be more specific analysis in each data section as right now seems to be a grouping of quotes that do not all seem to fit under the thematic heading. I also put “I don’t know” in regards to the question about the statistical analysis because the way the data is currently structured I cannot say if the Nvivo analysis was performed appropriately and rigorously.

I would also encourage the authors to go through and try to make writing more active throughout the manuscript by getting rid of passive voice and reducing the number of words that end with “-ing.” For example, in the Introduction, line 45, it says, “Uganda is a country struggling with reducing” and this could become “Uganda is a country which has struggled to reduce…” Same thing in the abstract, line 28 could become “This study aimed to describe…” instead of “aimed at describing.”

I think there also could be additional inclusion of other social science and qualitative literature. There has been a lot of anthropological literature published on this topic in Uganda and other countries in sub-Saharan Africa that could be useful for adding context. Helle Max Martin (Nursing Contradictions) has written about maternal health in Uganda and also look at recent publications in BMC pregnancy and birth, Social Science & Medicine, Health Policy & Planning.

Here are some additional comments and questions:

Lines 49-50, Can you be more specific about what you mean as “good quality maternal health care and professional support systems”? Perhaps offer some citations here. What constitutes good quality—how is this being defined, etc.?

Lines 76-78, Can you describe this more? I am not sure how giving a written letter to a spouse would increase male attendance by 10%. Who writes the letters? Are their fines or sanctions for not attending if one receives a written letter?

Line 100, Can you offer a definition for how you are conceptualizing/defining support? There are lots of types of support—such as economic, social, emotional, etc. I think offering a brief definition about how you define/use maternal support as a concept would be helpful here.

Line 130, Passive voice—try to rephrase. Also making it active would allow reader to see who was doing this recruitment which is a question I have. Who recruited participants for the study? The authors, village leaders, etc?

Line 132, You are using acronyms, but have you already defined them? Need to spell them out first and add additional context about who these people are and the roles the perform.

Line 142, Okay here I see there were local researchers helping with recruitment and data collection. This may be helpful to bring up with the previous section or mention this earlier.

Lines 157-158, How did you determine whether to interview someone in English or Luganda? By their wishes, proficiencies? Who made that call? Perhaps you could explain more briefly.

Lines 179-198, this section, “Data analysis” seems to be entirely in passive voice. I think switching into active voice enables clearer, stronger writing. Is there a way you can rewrite, even if it brings you into this more? You can say, “Authors analyzed data using the STC method developed by Malterud.

Lines 226-227, What about other non-biomedical forms of postnatal care? I work in Tanzania, where women access many different forms of care, from family members, TBAs, etc. Perhaps if you are going to state that postnatal care was non-existent specify what type of postnatal care, such as facility-based/biomedical, you are referring to here.

Lines 308-310, This quote from data does not seem to be analyzed or unpacked, overall, I would cut down on quotes and only include the ones that directly relate to your argument about maternal support, which you also should clearly state more thoroughly. You are offering a summary of findings but I as a reader am starting to get a little lost about what you are doing with this summary—where you are going and the significance, meaning of it all. I think cutting back on quotes would help and you need to offer analysis, context, for each quote you use, relating it back to your main ideas or arguments.

Reviewer #2: Review assignment for PONE-D-21-14606

TITLE: Women’s access to and use of maternal health care and home support systems to

reduce neonatal deaths in Buikwe district, Uganda: a qualitative study

Summary

This is a good study that provides interesting qualitative findings of the access and use of women of maternal support systems to reduce neonatal mortality. Key themes emerged from this study highlighting financial and logistical problems that led to inadequate maternal support and care. However, the excerpts from the interviews highlight how important these voices are in amplifying and highlighting key issues emerging from this research.

Key issues to consider

'

Introduction

There is a lot of focus on antenatal care in the background section but the relevance of all the information provided is not coming out clear in the paper

Would be good to have a description of what the home support systems entail in the background so that one can be able to know what the study is all about such that each component is unpacked in a way that flows in the background of the paper

It would have been good to see how these support systems have worked or been implemented in different contexts besides the African context as has been presented based on evidence from the literature

The Ugandan clinical guidelines are mentioned in the background line 75. Some brief descriptions of what they are and how relevant they are for this study.

This section could also incorporate aspects that come up in the discussion including gender, culture and socioeconomic disparities that would

Methods

These have been well described although some sections could be summarized to give information that would be important to report in a paper rather than the full details of the specific steps taken. This can be done with guidance from the editors.

There is a need to describe the context a bit more so that one can be able to understand and relate some of the specific findings of these populations that could be linked to the culture and available systems within this context to support maternal care and postnatal care.

Results

The themes have been summarized well, although one who has more experience in reviewing qualitative research could provide more insight into the statistical analyses and results that have been described.

The key themes are supported by the reported findings from the participants.

“the importance of antenatal care and expectations to fathers were given much attention both from mothers and traditional birth attendants, although not being a key focus of the topic guide” – There is a lot of discussion in the background about ANC so why did the authors choose that it is not a key focus of the topic guide. I also wonder about spousal support which is very key when it comes to maternal care and pregnancy.

“Many women in the study were discontent with spousal and family contributions related to help and support in maternal issues, often related to pecuniary difficulties” Not clear what this sentence means

The issue of gender comes out in the results but is not well described in the background section of the paper

Line 306 and 307 could be moved to the health worker section as it is not linked to the gender roles section

The section on Postnatal care and challenges related to gender roles. Could be reorganized to bring out key themes to improve flow for example i. gender inequality ii. breastfeeding and nutrition, iii. Family planning iv. Postnatal care etc.

The discussion on spousal support this section could also be moved to the relevant section

Discussion

This statement in line 361 needs to be re-written as it comes out as a strong statement likely just due to the wording “not a well-established practice for all mothers in Buikwe district.”

This comes out in the discussions but is not adequately discussed in the results “young women’s low knowledge about issues like 381 hygiene and how to care for newborns”

“Challenges related to logistics and economy were explained as reasons for suboptimal experiences both from the user and provider perspective.”- This needs to be further explained as it is not clear and also a strong statement

The UGC comes up again in the discussion but is not well discussed in the background/ methods so that one can be able to relate to it in the discussion

Minor comments

Some terminologies that come out as a bit strong making some statements difficult to interpret

“In acquiring to understand” change wording here

Line 132 “TBAs, 3 VHTs” write in full

Discrepancies in the use of abbreviations throughout the document for example as above and in the results and discussion sections

Reviewer #3: Overall comments:

This is an important piece of work that is addressing a key global health priority. However, the themes reported on maternal experiences of health care are very similar to what has been found in other contexts in sub-Saharan Africa, so it is ever so important that the authors draw out what their key messages are and what this adds to the literature. They also need to link it better to neonatal outcomes as they have stated in the title. Unfortunately, most sections are not written at the level required for a publishable manuscript. Some of the sections are very long and lack focus (e.g. Introduction and Results). The Methods section needs to be reorganised and, in some sections, explained in more depth. The whole manuscript would benefit from a review of the grammar.

Title: Women’s access to and use of maternal health care and home support systems to

reduce neonatal deaths in Buikwe district, Uganda: a qualitative study

I appreciate the complexity of what was being explore in this study but suggest the title captures this work more succinctly. For example:

Women’s experiences of maternal and newborn health care services in Buikwe district, Uganda: a qualitative study

Abstract

Background: This study aimed at describing maternal support systems – revise to This study aimed to describe….

Methods and findings:

Data Management is missing.

Line 73…prohibited women in receiving optimal – replace in with from.

Line 38 Unclear how “ Postnatal follow-ups were found unsatisfactory.” This needs to be explained a bit more in the Abstract as it is linked to a recommendation in the Conclusion.

Please review the grammar in the Abstract.

Introduction

This section needs to be a lot more succinct and linked to the aims of the study. As written, it is too long. Some of this content can be moved to the Discussion.

Some specific points:

Line 47 … 2030 if today’s trend continues- revise to: if the current trend continues.

Line 51-53…. For the mothers it is also important to have someone to trust and rely on during pregnancy, time of childbirth and the following post-partum period, and by such providing an optimal start in life for the newborns (3). So that…please expand on this.

Methods

Line 108 …individual interviews – I am not clear what individual interviews are because in qualitative research, interviews are conducted between a researcher and a participant and not a group. Please clarify.

Line 108…key-informants- do you mean key informant interviews?

Line 113- A summary of methods is given below: please delete this as it doesn’t provide any additional

Line 127- Participants were selected purposefully – based on what characteristics? Please expand. (mentioned in line 149-150)

Line 129- Sample – This subtitle should be “Sampling”. It would be useful to have a Table linked to this section to summarise the sampling strategy.

Line 176 Instruments This should be incorporated at the beginning of the sub-section: Data Collection.

Data Management is missing.

Results

Introductory paragraph needs to be revised as it doesn’t lead the reader well into the content of the results. This section is also long so the authors need to decide what the key messages are and re-write this in a logical manner that brings out the key messages.

Discussion

This section of the manuscript is more structured with clearer messages of the relevance of this work in the context of existing literature on the topic and context. However, the focus on maternal experiences doesn’t link adequately to neonatal outcomes as stated in the title so I wonder whether the paper should focus on maternal experiences of accessing health care.

Conclusion

No comments

**********

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Submitted filename: Peer review_PONE-D-21-14606.pdf

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13 Sep 2021

PONE-D-21-14606

Women’s access to and use of maternal health care and home support systems to reduce neonatal deaths in Buikwe district, Uganda: a qualitative study

PLOS ONE

Dear Editors and Reviewers at PLOS ONE,

The authors thank you for considering the manuscript for publication in your journal, and for your thorough and constructive feedback. We have made our best effort to adhere to your recommendations and hope the manuscript is now further qualified and organized in line with the requirements of PLOS ONE. A point-by-point response to the editor and reviewers’ comments is given below.

Sincerely, on behalf of the authors,

Marte Bodil Roed.

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Line 221: Ethics statement has been included in the manuscript

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Reviewers' comments:

Reviewer's Responses to Questions

Reviewer #1: Thank you for inviting me to review this manuscript on women’s access to and use of maternal health care and home support systems in Uganda. I have enjoyed reading the paper as it speaks to a topic close to my own scholarly interests and has numerous quotes that point to some original and important qualitative data.

Some of my major comments and constructive criticisms relate to 1) the structure, organization, and language of the paper, 2) coverage of appropriate literature, and 3) adequacy of analysis, interpretation, and definition of key concepts, terms. For example, in the title of the manuscript it says, “to reduce neonatal deaths,” but the qualitative data and discussion is less about neonatal deaths and more about structural barriers to accessing biomedical, facility-based health care such as expenses, transport, social and economic support from spouse. I would encourage the authors to think a little more about the main ideas that they would like to put forth in the paper and restructure/organize the data to support 1-2 main arguments instead of summarizing the findings.

The authors agree and appreciate the feedback. The title and aim of the paper have been altered to focus more specifically on women’s experience on maternal and newborn health care services. Also, the data has been more compressed and hopefully more focused.

There are a lot of great data and analysis in the discussion but some of the this gets lost in the way the paper is currently organized. Overall, there are too many quotes used throughout the paper. PLOS One has a wide audience and readership and you need to be able to walk each reader through your paper by providing enough background, context, and utilizing only the quotes that speak directly to your main argument. We do not know how or why a quote is important if you do not articulate your main argument and relate the quote back to this idea. Perhaps restructuring the data and discussion sections so that the discussion comes after each of the different thematic data sections. You could also use the perspectives of mothers, TBS, and health workers as the main data sections to try to show the variation in the themes that were important to each group. Or if you keep the current structure there needs to be more specific analysis in each data section as right now seems to be a grouping of quotes that do not all seem to fit under the thematic heading. I also put “I don’t know” in regards to the question about the statistical analysis because the way the data is currently structured I cannot say if the Nvivo analysis was performed appropriately and rigorously.

Thank you for this useful advice. We have restructured the data- and discussion section so that the discussion follows directly after each thematic data section. The quotes have been reduced. We hope that the manuscript now has a better flow and structure, and that the method of analysis is easier recognized in the paper.

I would also encourage the authors to go through and try to make writing more active throughout the manuscript by getting rid of passive voice and reducing the number of words that end with “-ing.” For example, in the Introduction, line 45, it says, “Uganda is a country struggling with reducing” and this could become “Uganda is a country which has struggled to reduce…” Same thing in the abstract, line 28 could become “This study aimed to describe…” instead of “aimed at describing.”

Thank you for this suggestion. We have reduced on the use of passive voice and words ending with -ing.

I think there also could be additional inclusion of other social science and qualitative literature. There has been a lot of anthropological literature published on this topic in Uganda and other countries in sub-Saharan Africa that could be useful for adding context. Helle Max Martin (Nursing Contradictions) has written about maternal health in Uganda and also look at recent publications in BMC pregnancy and birth, Social Science & Medicine, Health Policy & Planning.

Line 53: A deeper understanding of the underlying factors of neonatal mortality in Uganda have been added in the introduction section.

Here are some additional comments and questions:

Lines 49-50, Can you be more specific about what you mean as “good quality maternal health care and professional support systems”? Perhaps offer some citations here. What constitutes good quality—how is this being defined, etc.?

Line 56: WHO’s definition has been implemented and cited here.

Lines 76-78, Can you describe this more? I am not sure how giving a written letter to a spouse would increase male attendance by 10%. Who writes the letters? Are their fines or sanctions for not attending if one receives a written letter?

Line 299: This paragraph has been moved to discussion under “Antenatal care and spousal support”, and explained in more details.

Line 100, Can you offer a definition for how you are conceptualizing/defining support? There are lots of types of support—such as economic, social, emotional, etc. I think offering a brief definition about how you define/use maternal support as a concept would be helpful here.

Line 65: We have further clarified and defined our use of the maternal support concept in introduction

Line 130, Passive voice—try to rephrase. Also making it active would allow reader to see who was doing this recruitment which is a question I have. Who recruited participants for the study? The authors, village leaders, etc?

Line 140: It was the main researcher and two local assistants. The information has been specified and inserted here, and also rephrased to active voice.

Line 132, You are using acronyms, but have you already defined them? Need to spell them out first and add additional context about who these people are and the roles the perform.

Acronyms and context of TBAs and VHTs have been spelled out and elaborated.

Line 142, Okay here I see there were local researchers helping with recruitment and data collection. This may be helpful to bring up with the previous section or mention this earlier.

Has now been mentioned earlier.

Lines 157-158, How did you determine whether to interview someone in English or Luganda? By their wishes, proficiencies? Who made that call? Perhaps you could explain more briefly.

Line 166: They were interviewed in Luganda if they were not comfortable with English language (have been specified).

Lines 179-198, this section, “Data analysis” seems to be entirely in passive voice. I think switching into active voice enables clearer, stronger writing. Is there a way you can rewrite, even if it brings you into this more? You can say, “Authors analyzed data using the STC method developed by Malterud.

Thank you for pointing this out. The section is now more active.

Lines 226-227, What about other non-biomedical forms of postnatal care? I work in Tanzania, where women access many different forms of care, from family members, TBAs, etc. Perhaps if you are going to state that postnatal care was non-existent specify what type of postnatal care, such as facility-based/biomedical, you are referring to here.

Line 246: Yes, this is true. It is now specified.

Lines 308-310, This quote from data does not seem to be analyzed or unpacked, overall, I would cut down on quotes and only include the ones that directly relate to your argument about maternal support, which you also should clearly state more thoroughly.

Thank you. This quote has been removed from the manuscript

You are offering a summary of findings but I as a reader am starting to get a little lost about what you are doing with this summary—where you are going and the significance, meaning of it all. I think cutting back on quotes would help and you need to offer analysis, context, for each quote you use, relating it back to your main ideas or arguments.

Thank you for this observation. The quotes have been reduced and the summary of findings has been re-written as is hopefully more focused and organized now.

Reviewer #2: Review assignment for PONE-D-21-14606

TITLE: Women’s access to and use of maternal health care and home support systems to

reduce neonatal deaths in Buikwe district, Uganda: a qualitative study

Summary

This is a good study that provides interesting qualitative findings of the access and use of women of maternal support systems to reduce neonatal mortality. Key themes emerged from this study highlighting financial and logistical problems that led to inadequate maternal support and care. However, the excerpts from the interviews highlight how important these voices are in amplifying and highlighting key issues emerging from this research.

Thank you for appreciating the study and for helpful corrections and revisions of the paper.

Key issues to consider

Introduction

There is a lot of focus on antenatal care in the background section but the relevance of all the information provided is not coming out clear in the paper

Lines 257-302: The importance and relevance of antenatal care has been elaborated under the topic of “Antenatal care and spousal support”.

Would be good to have a description of what the home support systems entail in the background so that one can be able to know what the study is all about such that each component is unpacked in a way that flows in the background of the paper

Lines 65-86: We have defined a clearer view on what is understood by maternal support systems, both professional, and community- and home based.

It would have been good to see how these support systems have worked or been implemented in different contexts besides the African context as has been presented based on evidence from the literature.

Line 84: A study on maternal support benefits for both mother and child in a European setting has been added to the context.

The Ugandan clinical guidelines are mentioned in the background line 75. Some brief descriptions of what they are and how relevant they are for this study.

Line 51-53: We have added more details about the guidelines.

This section could also incorporate aspects that come up in the discussion including gender, culture and socioeconomic disparities that would

Lines 80-84: More background and references on gender disparities and socioeconomic aspects have been added.

Methods

These have been well described although some sections could be summarized to give information that would be important to report in a paper rather than the full details of the specific steps taken. This can be done with guidance from the editors.

This section has been shortened and restructured. If the section is still too specific, your guidance will be appreciated.

There is a need to describe the context a bit more so that one can be able to understand and relate some of the specific findings of these populations that could be linked to the culture and available systems within this context to support maternal care and postnatal care.

Lines 113- 125: A paragraph about demographics of Uganda/Buikwe is now added. We also elaborated on the Ugandan health care system.

Results

The themes have been summarized well, although one who has more experience in reviewing qualitative research could provide more insight into the statistical analyses and results that have been described.

The key themes are supported by the reported findings from the participants.

“the importance of antenatal care and expectations to fathers were given much attention both from mothers and traditional birth attendants, although not being a key focus of the topic guide” – There is a lot of discussion in the background about ANC so why did the authors choose that it is not a key focus of the topic guide.

The topic guide was made beforehand as a tool included in the study proposal which focused more on delivery, breastfeeding and postnatal maternal support systems. Discussions around antenatal care arose in connection with questions related to place of birth, where women talked about giving birth where they had gone for antenatal classes due to reduced payments for services. The unexpected turns a qualitative study can take during data collection have been tried to explain in the result section. (Lines 237-242).

I also wonder about spousal support which is very key when it comes to maternal care and pregnancy.

“Many women in the study were discontent with spousal and family contributions related to help and support in maternal issues, often related to pecuniary difficulties” Not clear what this sentence means

Line 242: The sentence has been rewritten and is hopefully clearer.

The issue of gender comes out in the results but is not well described in the background section of the paper

Lines 70-86: We have inserted a paragraph relating to previous research about gender aspects in the background.

Line 306 and 307 could be moved to the health worker section as it is not linked to the gender roles section

After some consideration, this paragraph is now omitted from the paper.

The section on Postnatal care and challenges related to gender roles. Could be reorganized to bring out key themes to improve flow for example i. gender inequality ii. breastfeeding and nutrition, iii. Family planning iv. Postnatal care etc.

The discussion on spousal support this section could also be moved to the relevant section

Lines 353-414: Thank you for this advice. The section on postnatal care and challenges related to gender roles has been reorganized accordingly.

Discussion

This statement in line 361 needs to be re-written as it comes out as a strong statement likely just due to the wording “not a well-established practice for all mothers in Buikwe district.”

Line 278: The sentence has been re-written.

This comes out in the discussions but is not adequately discussed in the results “young women’s low knowledge about issues like 381 hygiene and how to care for newborns”

Line 267-274: The mentioned concern is now explained more extensively in the result section.

“Challenges related to logistics and economy were explained as reasons for suboptimal experiences both from the user and provider perspective.”- This needs to be further explained as it is not clear and also a strong statement

Line 248: The sentence has been slightly re-written and further explained.

The UGC comes up again in the discussion but is not well discussed in the background/ methods so that one can be able to relate to it in the discussion

Line 51: UCG is now more extensively mentioned in the background

Minor comments

Some terminologies that come out as a bit strong making some statements difficult to interpret

“In acquiring to understand” change wording here

Line 214: This sentence has been replaced

Line 132 “TBAs, 3 VHTs” write in full

Acronyms have been spelled out when first used and late as abbreviations.

Discrepancies in the use of abbreviations throughout the document for example as above and in the results and discussion sections

Thank you for noticing and pointing it out.

Reviewer #3:

Overall comments:

This is an important piece of work that is addressing a key global health priority. However, the themes reported on maternal experiences of health care are very similar to what has been found in other contexts in sub-Saharan Africa, so it is ever so important that the authors draw out what their key messages are and what this adds to the literature. They also need to link it better to neonatal outcomes as they have stated in the title. Unfortunately, most sections are not written at the level required for a publishable manuscript. Some of the sections are very long and lack focus (e.g. Introduction and Results). The Methods section needs to be reorganised and, in some sections, explained in more depth. The whole manuscript would benefit from a review of the grammar.

Thank you for appreciating the importance of this topic and for your detailed and constructive review. The key-messages have been more clarified and the whole manuscript has been carefully revised and re-structured. The grammar has been revised.

Title: Women’s access to and use of maternal health care and home support systems to

reduce neonatal deaths in Buikwe district, Uganda: a qualitative study

I appreciate the complexity of what was being explore in this study but suggest the title captures this work more succinctly. For example:

Women’s experiences of maternal and newborn health care services in Buikwe district, Uganda: a qualitative study

Thank you for clarifying the title to be more specific, the suggested title has replaced the former, with some adjustment. We included “and support systems”, as this has a big focus in the paper.

New title: Women’s experiences of maternal and newborn health care services and support systems in Buikwe district, Uganda: a qualitative study.

Abstract

Background: This study aimed at describing maternal support systems – revise to This study aimed to describe….

This is now corrected

Methods and findings:

Data Management is missing.

Line 30: Data management has been described.

Line 43…prohibited women in receiving optimal – replace in with from.

Has been corrected

Line 38 Unclear how “ Postnatal follow-ups were found unsatisfactory.” This needs to be explained a bit more in the Abstract as it is linked to a recommendation in the Conclusion.

Line 39: Additional clarifying information has been added.

Please review the grammar in the Abstract.

A review of the grammar has been conducted.

Introduction

This section needs to be a lot more succinct and linked to the aims of the study. As written, it is too long. Some of this content can be moved to the Discussion.

The introduction section has been modified and shortened.

Some specific points:

Line 47 … 2030 if today’s trend continues- revise to: if the current trend continues.

This point has been revised.

Line 51-53…. For the mothers it is also important to have someone to trust and rely on during pregnancy, time of childbirth and the following post-partum period, and by such providing an optimal start in life for the newborns (3). So that…please expand on this.

Lines 67-70: Further elaboration has been implemented.

------------------------------------------------------

Methods

Line 108 …individual interviews – I am not clear what individual interviews are because in qualitative research, interviews are conducted between a researcher and a participant and not a group. Please clarify.

Sorry about the confusion. Key informant interviews is correct.

Line 108…key-informants- do you mean key informant interviews?

Yes, key informant interviews. This is now altered.

Line 113- A summary of methods is given below: please delete this as it doesn’t provide any additional

This sentence is now deleted

Line 127- Participants were selected purposefully – based on what characteristics? Please expand. (mentioned in line 149-150)

Lines 143-147: Characteristics and a table have been included, both for key-informants and mothers.

Line 129- Sample – This subtitle should be “Sampling”. It would be useful to have a Table linked to this section to summarise the sampling strategy.

A table describing characteristics of participants has been created and included (line 147), as well as a flow chart displaying an overview of the distribution of participants (line 135).

Line 176 Instruments This should be incorporated at the beginning of the sub-section: Data Collection.

Lines 150-153:Instruments are now incorporated under Data collection

Data Management is missing.

Line 184: A paragraph about data management has been added.

Results

Introductory paragraph needs to be revised as it doesn’t lead the reader well into the content of the results. This section is also long so the authors need to decide what the key messages are and re-write this in a logical manner that brings out the key messages.

The Introduction has been revised and shortened and more context and focus have been given to key points in the paper.

Discussion

This section of the manuscript is more structured with clearer messages of the relevance of this work in the context of existing literature on the topic and context. However, the focus on maternal experiences doesn’t link adequately to neonatal outcomes as stated in the title so I wonder whether the paper should focus on maternal experiences of accessing health care.

The title and aim of the study have been altered to focus more on women’s experiences with the health care system as suggested.

Conclusion

No comments

Submitted filename: Response to Reviewers.docx

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22 Oct 2021

PONE-D-21-14606R1Women’s experiences of maternal and newborn health care services and support systems in Buikwe district, Uganda: a qualitative studyPLOS ONE

Dear Dr. Rød,

Thank you for submitting your manuscript to PLOS ONE. Peer review of your manuscript is now complete but as pointed out by the third reviewer, there are grammatical errors in all sections that need to be addressed. The reviewer has also commented on the length and focus of the Introduction section. Although the reviewer is concerned about the combined "Results and discussion" section, this format, though not popular, is acceptable by the Journal. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised by the third reviewer, especially the English grammar issue. For example, the first part of the opening sentence of the Introduction is not clear.

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Calistus Wilunda, DrPH

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

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Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: N/A

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

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Reviewer #2: Yes

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**********

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for inviting me to review this paper again and great job on your edits and addressing my previous comments and concerns. I enjoyed your paper and research.

Reviewer #2: (No Response)

Reviewer #3: Overall comments:

Thank you for addressing most of my comments. This manuscript reads much better but there are grammatical errors in all sections that need to be addressed, as it cannot be published like this. Other aspects that need to be addressed:

Introduction:

This remains very long and lacks focus. Please limit this to 3-4 paragraphs that really draw the reader to the aims/objectives of the study. Some of the content here can be moved to the Discussion.

Results

The sub-title is now “Results and discussion” which is incorrect. This should just be Results.

The current format that combines results and the discussion for a specific result is not one that I am familiar with. I think this should use the standard format of a Results section then Discussion.

The content in the Results and Discussion seems appropriate. I would like to see how the Discussion is written in one section and not combined with the Results.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Submitted filename: Peer review_PONE-D-21-14606_R1.pdf

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18 Nov 2021

PONE-D-21-14606R2

Women’s experiences of maternal and newborn health care services and support systems in Buikwe District, Uganda: A qualitative study

Dear Editor and Reviewers at PLOS ONE,

The authors appreciate the constructive and thorough reviews. We have adhered to the suggestion of the third reviewer and the manuscript is now in standard format with Discussion following Results. The manuscript has been professionally proofread to improve the grammar. A point-by-point response letter to the comments suggested by the editors and reviewer is given below. As requested, we have updated the information in the Data Availability statement to comply with PLOS ONE submission guidelines.

Sincerely, on behalf of the authors,

Marte Bodil Roed.

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

The Reference list has been updated and is complete. Some citations and references have been omitted due to editing and reduced length of the paper.

A) Please provide non-author contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

The Data Availability statement now includes the name and e-mail address to the Centre for International Health, University of Bergen, Norway. Reasonable requests for data access may be sent to post@cih.uib.no.

Reviewers' comments:

(Peer review: PONE-D-21-14606_R1)

Thank you for addressing most of my comments. This manuscript reads much better but there are grammatical errors in all sections that need to be addressed, as it cannot be published like this.

The manuscript has undergone academic proofreading by a professional company approved and affiliated by the University of Bergen (Semantix). Suggestions and changes have been discussed among the authors and implemented accordingly.

Other aspects that need to be addressed:

Introduction:

This remains very long and lacks focus. Please limit this to 3-4 paragraphs that really draw the reader to the aims/objectives of the study. Some of the content here can be moved to the Discussion.

The first sentence in the abstract and introduction has been re-written.

The introduction section has been reduced to 4 paragraphs and several components have been moved to discussion or omitted. It should now point more clearly towards the objectives of the study.

Results

The sub-title is now “Results and discussion” which is incorrect. This should just be Results.

The sub-titles Results and Discussion are now separated.

The current format that combines results and the discussion for a specific result is not one that I am familiar with. I think this should use the standard format of a Results section then Discussion.

The authors agree that the format used in this paper is unusual. We have considered the various formats and the Results and Discussion sections are now again written in standard format in separate sections. The discussion has been edited and elaborated with contents added from the Introduction section.

The content in the Results and Discussion seems appropriate. I would like to see how the Discussion is written in one section and not combined with the Results.

Thank you for your clear views and frank suggestions. The Result and Discussion sections are now separated.

Submitted filename: Response to Reviewers .docx

Click here for additional data file.

2 Dec 2021

Women's experiences of maternal and newborn health care services and support systems in Buikwe District, Uganda: A qualitative study

PONE-D-21-14606R2

Dear Dr. Rød,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Calistus Wilunda, DrPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

6 Dec 2021

PONE-D-21-14606R2

Women’s experiences of maternal and newborn health care services and support systems in Buikwe District, Uganda: A qualitative study

Dear Dr. Roed:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Calistus Wilunda

Academic Editor

PLOS ONE