Maternal Health Services for Adolescent Urban Refugees in Urban Settings in Uganda; Access, Utilization and Health Facility Readiness.

Abstract

Background; Uganda hosts an estimated 1.7 million refugees, 12.5% of these live in urban areas mainly in Kampala city. Uganda is implementing an integrated healthcare model where both refugees and host population utilize the same health care services. Yet, in Kampala, adolescents generally find it hard to access maternal health services because of difficulty in reaching the facility, lack of financial support, discrimination and disrespect by health workers, and lack of privacy. Whereas there are several studies on maternal health among the general population, little is known on what is the level of access and utilization of maternal health services among urban refugee adolescents in Kampala? and what is the readiness of the government health facilities to offer maternal health services to this population? The study investigated access, utilization, and the readiness of the government health facilities to offer maternal health services to urban refugee adolescents in Kampala, Uganda.Methods; This was an explanatory sequential mixed methods study conducted between November 2023 and August 2024 in Kampala Uganda. Quantitative and qualitative methods of data collection were used. The qualitative component explained the findings from the quantitative component of the study. First, validation of the tool that measured access to antenatal and delivery services adapted from (Hoseini-Esfidarjani et al., 2021) was undertaken. This came first to allow measurement of access using a validated tool. Second, a quantitative study, which was the biggest part of the study, was conducted to assess access and utilization of antenatal and delivery care services among 637 urban refugees who became pregnant aged 10 -19 years. A semi-structured questionnaire uploaded in ODK software was used and analysis was conducted using STATA version 17. Uni-variate, bi-variate and multivariate analyses were performed. Third, a facility-based cross-sectional study was conducted to assess health facility readiness in all the six government lower level III & IV health facilities in Kampala City, Uganda. Data were collected using a health facility checklist that was adapted from African Youth Alliance, Path Finder and WHO. Finally, a qualitative study was conducted to assess the readiness of health workers to offer maternal health services to refugee adolescents among 12 health workers from the six government health centers using an in-depth interview guide. This component of the study explained the findings from the first, second and third component of the study that were qualitative focused on the access and utilization of maternal health services by adolescents and the readiness of the facilities. Interviews were audio recorded and transcribed verbatim. Qualitative data were analysed using thematic and content analysis and findings are presented in themes and supported with typical quotes. The results from the quantitative and the qualitative study were integrated during reporting. Findings highlighting the level and correlates of access and utilization of antenatal and delivery care services were presented first, then readiness of the government health facilites to offer adolescent friendly maternal health services and later the qualitative findings were presented to explain how they offer the services, why the utilization and access was at that level, the challenges they face and the reccomendations to improve access and utilization .Results; This study reflected consistently high levels of perceived access of antenatal and delivery care services among the adolescent urban refugees with the overall perceived access score having a median of 4.0 (IQR 3.9–4.4). The correlates of access to antenatal care services were age, marital status and distance to the facility. Utilisation of antenatal care services was sub-optimal with less than half (41.5%) of the participants attending antenatal care within the first trimester and only 12.2% attending eight or more antenatal care visits recommended by WHO. Utilisation of health facility deliveries was high at 98.3% with 81.6% delivering at public health facilities. The utilization of ANC and delivery services among adolescent refugee mothers in Kampala was influenced by age, marital status, distance to health facilities, and type of facility attended. The readiness of all the six lower-level health facilities in Kampala city to offer general adolescent friendly services was high at 92.5%. The readiness of the health providers to offer adolescent friendly services was 77.7%. The readiness of the facilities to offer antenatal care was higher at 87.2% compared to delivery services 65.8%. Factors that significantly affected readiness include untrained non-provider staff 33.3% (95% CI: 4.3, 77.7), not having essential medicines and supplies 16.6% (95% CI: 0.4, 64.1) and not having essential equipment 33.3% (95% CI 4.3, 77.7) for antenatal and delivery care. The qualitative study revealed that the health workers felt sympathy for the adolescent urban refugees and were willing to offer services to them. They reported that peer educators and village health teams or community health workers enabled them to provide the services. However, health workers had inadequate knowledge about adolescent friendly services and they faced challenges like language barrier, lack of essential drugs, supplies and equipment. The health workers recommended training of healthcare workers, separate space for antenatal care and delivery for adolescents and young people, translators for refugees, and improvement in the availability of essential drugs, supplies and equipment. Conclusions; Perceived access to antenatal and delivery care services among the adolescent urban refugees is high. Utilization of ANC by urban refugee adolescents is sub-optimal, but high for delivery services. The readiness of the lower-level government health facilities to provide general adolescent-friendly services was high. However, the readiness to provide antenatal and delivery care services to refugee adolescents was sub-optimal. Health workers in government lower-level facilities are willing to provide maternal health services to adolescent urban refugees. However, they face several challenges including inadequate knowledge about adolescent friendly services, language barrier and inadequate supplies that limit their readiness to offer the services. There is therefore need for targeted interventions that include community outreaches and home visits to encourage adolescent refugees to utilize antenatal care and delivery care services optimally. There is also an urgent need to improve the readiness of health facilities and health workers to offer adolescent friendly maternal health services to urban refugee adolescents. This research provides a validated tool to measure perceived access to antenatal and delivery care services in similar settings. It provides evidence on the access and utilization of antenatal and delivery care services by urban refugee adolescents and the readinees of the health facilities and health workers to offer maternal health services to adolescent refugees