Perinatal death in northern Uganda: risk factors, associated postpartum depression, lived experiences and the cultural perspective

Abstract

Uganda’s institutional perinatal mortality estimated at 17.8 deaths per 1,000 births (FY 2022/2023), is associated with negative emotional and psychosocial outcomes among families. However, it has received insufficient attention. Northern Uganda has marginal data on perinatal deaths, as well as the associated emotional and psychosocial outcomes. This thesis estimated the incidence of and risk factors for perinatal deaths in Northern Uganda. It also examined the associated postpartum depression, and explored the lived experiences, as well as the cultural perspective, on the perinatal death of the Lango community in Northern Uganda. This thesis employed both qualitative and quantitative research methods in Lira District, Northern Uganda. Pregnant women were identified from 30 clusters within the community, and consecutively recruited at ≥28 weeks of gestation, between January 2018, and March 2019. Baseline characteristics were collected at recruitment, and the participants were then followed up, until 50 days postpartum. Neonatal survival was assessed on the day of birth, and 7 days postpartum. Women were screened for postpartum depression at 50 days postpartum. Quantitative data were analysed using STATA version 14. A generalized estimating equation of the Poisson family was used to compute the measures of association between determinants and outcomes. Parents who experienced perinatal death and clan leaders were purposively selected and interviewed, using in-depth interviews and focused group discussions as appropriate, to explore their lived experiences, cultural beliefs and practices surrounding perinatal death. Qualitative data were analysed using a thematiccontent approach. Ethical approval was granted by SOMREC and UNCST, and written informed consent was obtained from participants. Results: Perinatal mortality was 43 deaths per 1,000 pregnancies (95% CI: 35, 53) with death risks being higher among nulliparous women at baseline (adjusted IRR: 2.7 [95% CI 1.3, 5.6]), and those over 30 years (aIRR: 2.5 [95% CI: 1.1, 5.8]). The prevalence of postpartum depression was three times higher among mothers who experienced perinatal death, than those with live infants (aPR: 3.45[2.67, 4.48]). Bereaved parents experienced immediate and delayed reactions, such as pain, confusion, blame, guilt, financial losses, challenging roles, and mixed reactions from health workers. The community viewed perinatal deaths as child deaths, and thus performed the typical rituals for memory and connection. They also associated perinatal death with biomedical explanations and preferred health system care over traditional practices for perinatal death prevention. Conclusion: Perinatal mortality in the study area was higher than the national estimate, with the risk greatest among the nulliparous women at baseline, and those over 30 years. This calls for improvement in intrapartum care of high-risk women, to reduce perinatal deaths. Postpartum depression among women with perinatal death was three times higher than those with live infants. Similarly, perinatal death negatively affected both parents. Thus, there is a need for institutionalising bereavement care counselling in maternal child health and depression screening, and management of bereaved postnatal women. The community offers bereavement care to parents who experience perinatal deaths, therefore, healthcare providers need to provide culturally sensitive support to parents, after perinatal death. The community’s belief in biomedical explanations for perinatal death and advocacy for health system care allow for designing health programs for improving perinatal health in this community.