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This study examines the challenges of maternal healthcare in Bugiri District, Eastern Uganda, highlighting systemic barriers such as inadequate infrastructure, staffing shortages, cultural stigma, and logistical issues. Using a mixed-methods approach, data from 394 participants, including mothers, healthcare workers, TBAs, and officials, revealed critical obstacles like geographical inaccessibility, insufficient TBA training, and stigma, particularly for adolescent mothers. TBAs, vital in rural care, face limited recognition and resources. Key recommendations include integrating traditional and modern healthcare, enhancing TBA capacity, improving infrastructure, and addressing socio-cultural barriers through government policies and community leadership. These steps are crucial for reducing maternal mortality and advancing sustainable health development.
ROBINAH NAMULINDWA
LIGS University, UNITED STATES OF AMERICA, PRACTICAL EDUCATIONAL MANAGEMENT
1. Introduction
Maternal mortality remains high in Uganda, with rural areas such as Bugiri facing significant challenges due to systemic barriers in healthcare infrastructure, education, and management practices. Women in these regions encounter infrastructural, socioeconomic, and logistical obstacles that critically limit access to prenatal and postnatal care, leading to adverse outcomes for mothers and children.
Previous studies have highlighted systemic barriers to maternal healthcare access across sub-Saharan Africa, including Uganda. For example, Jaeger et al. (2018) noted shortages of healthcare facilities and trained professionals in rural areas, while Dowhaniuk (2021) emphasized how infrastructural deficits exacerbate health disparities. However, existing research often relies on national-level data or general healthcare challenges, offering limited insights into localized contexts like Bugiri. Furthermore, while the role of Traditional Birth Attendants (TBAs) has been explored in other regions, little is known about their impact in districts where they frequently act as primary caregivers in the absence of formal health services (Medard et al., 2023).
In Bugiri District, these challenges manifest differently for various stakeholders. Healthcare workers face resource constraints and high workloads, compromising their ability to provide quality care. Administrative officers grapple with limited funding and infrastructural deficits, hindering the implementation of community-based health initiatives. Maternal mothers face diverse challenges: adolescent mothers deal with unemployment, lack of partner support, and inadequate healthcare education, while older mothers face physical challenges such as traveling long distances to access care.
This study addresses these issues by exploring the perspectives of key stakeholders, including healthcare providers, TBAs, community leaders, administrative officers, and maternal mothers. By capturing these viewpoints, the research aims to identify actionable strategies to improve maternal health outcomes, strengthen healthcare delivery, and enhance education and management approaches. These efforts align with broader goals of achieving health equity and sustainable community development.
This research aims to fill critical knowledge gaps by examining factors affecting maternal healthcare access, education, and management in rural Bugiri. Its dual objectives are: (a) Identifying key challenges that maternal mothers face in accessing healthcare services and (b) explore stakeholder recommendations to improve maternal healthcare in the district.
The significance of this research lies in three key aspects:
- Localized Insights: It provides targeted analysis of maternal healthcare challenges specific to Bugiri, a region often underrepresented in existing studies.
- Comprehensive Perspectives: By incorporating the experiences of healthcare providers, TBAs, administrative officers, and maternal mothers, it offers a holistic understanding of barriers to maternal healthcare.
- Policy Implications: The study aims to inform evidence-based policies and programs by presenting practical recommendations for improving maternal healthcare services. These findings contribute to ongoing national and global efforts to reduce maternal mortality and enhance health outcomes for mothers and children (Sarikhani et al., 2024; Milku et al., 2024).
2. Methods
2.1. Description of the study site
This field study was conducted in August and September 2024 in Bugiri District within the framework of a PHD study on the subject matter in a predominantly rural region in Eastern Uganda characterized by limited access to maternal healthcare. The district's economy is a blend of agricultural and trading activities, with many residents’ dependent on subsistence farming. However, underdeveloped road infrastructure poses significant challenges, hindering timely access to health facilities for much of the population.
Maternal health services in Bugiri are often inadequate, with women encountering barriers such as long travel distances, financial constraints, and a lack of awareness about available healthcare services. The district grapples with numerous systemic issues, including insufficient healthcare facilities, a shortage of trained health professionals, and logistical challenges. These factors have led many community members to depend on Traditional Birth Attendants (TBAs) and community-based resources for maternal care.
The population of Bugiri includes both adolescent and mature mothers, each facing distinct challenges. Adolescent mothers often experience stigmatization and health risks due to socioeconomic and cultural pressures, while mature mothers contend with the physical demands of accessing distant healthcare services. These circumstances make Bugiri a critical region for studying maternal healthcare access and understanding the perspectives of various stakeholders.
2.2. Ethical approval
Ethical approval for the study was obtained from the district health in-charge. All participants provided informed consent, and for adolescent participants under 18 years of age, consent was additionally obtained from their guardians. Confidentiality and anonymity were strictly maintained throughout the study, and participants were assured of their right to withdraw at any time without facing any consequences.
2.3. Description of data collection process
The study engaged a diverse group of stakeholders to gain comprehensive insights into maternal healthcare access in Bugiri. Structured interviews were conducted with healthcare workers, Traditional Birth Attendants (TBAs), adolescent and mature mothers, and administrative officers. These interviews featured open-ended questions designed to explore participants' experiences with maternal healthcare, the barriers they faced, their perceptions of the current system, and their recommendations for improvement.
2.4. Data collection
Semi-structured questionnaires were administered in 5% of the total 466 villages in the district, equating to approximately 24 villages. In each selected village, 15 mothers (10 maternal and 5 adolescent) were targeted, resulting in a total of 360 participants. Similarly, 5% of the health facilities in the district were included in the study.
Data on maternal healthcare access were collected from both primary and secondary sources. Primary data were gathered through face-to-face interviews, while secondary data were obtained from healthcare facility records and reports from the district health office. To ensure content validity, all data collection tools were reviewed by an expert panel before their implementation.
2.5. Data analysis
Data was cleaned and analysed using STATA software. Univariate, bivariate, and multivariate analyses were conducted to describe the significant characteristics of the respondents. Chi-square tests and logistic regression analyses were employed to examine associations and correlations among the variables.
2.6. Limitations
While the study provides valuable insights, several limitations should be acknowledged. First, the research relied on self-reported data from stakeholders, which may be subject to bias or inaccuracies. For example, responses from healthcare workers and TBAs could reflect personal perceptions rather than objective realities. Additionally, the geographic focus on Bugiri District means the findings may not be fully generalizable to other regions with different socio-economic and cultural dynamics.
3. Results
3.1. Perception of traditional birth attendants
Traditional Birth Attendants (TBAs) in Uganda face numerous challenges that significantly hinder their ability to provide safe and effective maternal care. A key issue is the lack of formal training, with 77.78% of TBAs reporting insufficient knowledge in critical areas such as obstetric skills and infection control. While some have undergone basic training, the majority express an urgent need for further education, particularly in infection prevention, emergency preparedness, and hygiene practices.
Another critical challenge is the limited availability of medical supplies. Approximately 88.89% of TBAs lack access to essential materials and clean instruments, significantly increasing the risk of infections during childbirth and posing serious threats to maternal and neonatal health. Additionally, TBAs often face concerns about personal safety and receive minimal support from the government and formal healthcare systems, leaving them without the resources necessary to provide optimal care.
Cultural beliefs and practices further complicate the situation. Many TBAs (77.78%) report difficulties in persuading pregnant women to seek care at formal healthcare facilities. Cultural influences, trust in the TBAs’ experience, and privacy concerns often lead women to prefer traditional birth services. Limited collaboration with the formal health system exacerbates these challenges, with only 77.78% of TBAs reporting the existence of referral or coordination mechanisms.
Despite their critical role in maternal healthcare, TBAs remain largely unsupported by the government and lack formal recognition. This lack of institutional support hinders their integration into the broader healthcare system. Combined with inadequate training, scarce resources, and weak referral networks, these factors severely constrain TBAs’ ability to contribute meaningfully to improving maternal health outcomes in Uganda.
3.2. Perception of midwives and other healthcare workers
Health workers in Bugiri District, Eastern Uganda, face numerous challenges that hinder their ability to deliver effective healthcare services. Over half (50%) of healthcare facilities report shortages of medical supplies and inadequate training, significantly affecting service quality. Additionally, 68% of health workers struggle with high patient loads, while 86% identify insufficient staffing as a major issue. These challenges highlight critical gaps in resources and professional development, with over 75% of health workers stressing the need for better medical supplies and enhanced training opportunities.
Infrastructure deficiencies further exacerbate these problems, with 40% of health workers reporting poor facility conditions that impede efficient healthcare delivery. Transportation challenges are equally pressing, as 82% of health workers emphasize the need for improved emergency transportation services. Alarmingly, only 31% of health facilities are adequately equipped to handle maternal health emergencies, leaving many facilities ill-prepared for the high patient volumes they face.
Low staff motivation is another critical concern, cited by 72% of health workers. This issue stems from factors such as insufficient staffing, heavy workloads, and delayed salary payments, with only 13.64% of workers receiving timely compensation. Despite widespread acknowledgment of the need for increased staffing and comprehensive training—reported by 86% of health workers—systemic constraints often undermine improvement efforts.
Community engagement also requires attention. Only 59% of health workers participate in community meetings, limiting opportunities to raise awareness and improve access to healthcare services. Together, these challenges underscore the urgent need for investments in infrastructure, resources, training, and workforce motivation to strengthen healthcare delivery in Bugiri District.
3.3. Perception of mature and adolescent mothers
The table below highlights the challenges faced by adolescent and mature mothers in rural Bugiri and outlines the direct consequences of these barriers on their maternal health.
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| Table 1: Challenges and their consequences on maternal health in Rural Bugiri |
3.4. Perceptions of district health officer and management of healthcare in Bugiri
Bugiri District has 57 healthcare facilities, including one government hospital and various health centres, yet faces significant staffing challenges, with only 356 healthcare and administrative officers available. Although antenatal care attendance is relatively high, indicating improved healthcare-seeking behaviour, access to maternal health services is hindered by several obstacles. These include funding gaps, cultural barriers, and limited awareness of available services.
Additional challenges, such as long distances to healthcare facilities, low education levels, shortages of medical supplies, and reliance on untrained volunteers, further complicate healthcare delivery. While government initiatives, such as the Adolescent Health Policy, aim to improve maternal and adolescent health, persistent issues like insufficient funding highlight the need for targeted interventions. Addressing these barriers is essential to enhancing healthcare access and quality for vulnerable populations in the district.
3.5. Challenges experienced in the healthcare sector as perceived by government officials in Bugiri
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| Table 2: Challenges experienced by healthcare officials |
3.6. Comparison of proposed solutions for improving access to healthcare across stakeholders
3.6.1. Traditional birth attendants
TBAs emphasize the need for formal training, particularly in infection prevention, emergency preparedness, and obstetric skills. They advocate for better access to essential medical supplies and equipment and support in building referral networks with formal healthcare facilities. Additionally, TBAs call for greater recognition and integration into the formal healthcare system to legitimize their role and improve collaboration with healthcare workers.
Healthcare workers
Healthcare workers propose improved infrastructure, including better staffing levels, increased availability of medical supplies, and enhanced transport options to reduce delays and improve patient care. They stress the importance of professional development and ongoing training in maternal health, emergency response, and infection control. Furthermore, they advocate for better community engagement and awareness programs to educate the public on the benefits of formal healthcare.
3.6.2. Government officials and health managers
Government officials emphasize strengthening policies and frameworks to support maternal health, such as increasing funding for healthcare facilities and implementing programs like the Adolescent Health Policy. They propose addressing socio-economic barriers by improving education and economic opportunities for women and building more accessible healthcare infrastructure, particularly in remote areas. Additionally, the government highlights the need for heightened community awareness about the benefits of formal healthcare to reduce reliance on TBAs and address cultural barriers.
3.6.3. Community members (adolescent and mature mothers)
Community members, particularly adolescent mothers, advocate for improvements in transportation and healthcare facility conditions. They emphasize the importance of awareness programs to educate them on maternal health services and combat the stigma surrounding adolescent and mature motherhood. Mothers also seek increased access to skilled healthcare providers and education to understand the risks of relying solely on TBAs and the importance of seeking professional care.
Key similarities
- Training and Education: All stakeholders agree on the necessity of increased training for TBAs, healthcare workers, and the community to enhance maternal health outcomes.
- Medical Supplies and Equipment: There is broad consensus on the need for adequate medical supplies and equipment to improve maternal healthcare.
- Community Education: All stakeholders recognize the importance of community education programs to dispel myths, reduce stigma, and encourage timely healthcare-seeking behaviour.
- Transport and Accessibility: Improving transportation options is widely recognized as critical to ensuring timely access to maternal healthcare, particularly in rural areas.
Key differences
· Integration with the formal healthcare system:
o TBAs strongly support formal integration and recognition.
o Healthcare workers and government officials are more cautious, focusing on regulation and safety concerns.
o Mothers, particularly adolescents, often prefer TBAs due to trust and cultural preferences.
· Cultural barriers and stigma:
o Adolescent mothers prioritize addressing stigma and cultural barriers to healthcare access.
o Mature mothers focus more on improving the quality and availability of healthcare services.
· Government support and recognition:
o TBAs advocate for formal government recognition and integration into the healthcare system.
o Healthcare workers and government officials prioritize policy and regulatory frameworks to ensure safety standards.
4. Discussion and implications for policy and practice
4.1. The perspective of traditional birth attendants
TBAs in Uganda face substantial challenges, particularly in effectively providing the necessary services of healthcare to maternal mothers. A lack of formal training, reported by 77.78% of TBAs, significantly affects their ability to manage obstetric complications and ensure infection control. This underscores the critical need for targeted education in these areas, as supported by Medard et al. (2023), who highlighted significant training gaps among TBAs in rural Uganda. Furthermore, limited access to medical supplies and clean instruments—reported by 88.89% of TBAs—reflects broader infrastructural and resource deficiencies, a challenge also identified by Jaeger et al. (2018) in rural healthcare systems. These systemic issues underline the urgent necessity of equipping TBAs with adequate knowledge and tools to improve maternal health outcomes, addressing a key objective of this study.
The study also identifies cultural and systemic barriers impeding TBAs’ collaboration with formal healthcare systems. Only 77.78% of TBAs reported the presence of referral mechanisms, mirroring findings by Titaley et al. (2010), which pointed to traditional beliefs and preferences for home-based care as significant obstacles to accessing formal healthcare. Additionally, the lack of government support and formal recognition—a recurring theme in this study—aligns with Dowhaniuk (2021), who noted that systemic neglect severely limits TBAs' capacity to deliver quality care. By situating these challenges within the broader literature, the study underscores the pressing need for policy interventions to integrate TBAs into the formal health sector, improve their training, and foster effective collaboration. These findings highlight the importance of addressing both resource constraints and cultural dynamics to achieve sustainable improvements in maternal health.
4.2. The perspective of healthcare workers
Standard healthcare workers in Bugiri District face significant challenges, particularly in provisioning maternal healthcare services. Insufficient medical supplies and inadequate training, reported by over 50% of healthcare facilities, critically impede service provision. These findings echo Jaeger et al. (2018), who noted the pervasive resource shortages in rural Uganda. Additionally, staffing shortages, cited by 86% of health workers, exacerbate high patient loads (68%), ultimately compromising the quality of care. This aligns with Dowhaniuk (2021), who highlighted the strain on rural health systems caused by inadequate human resources and limited professional development opportunities. The emphasis by 75% of health workers on the need for better training and supplies underscores the urgency of addressing these systemic deficiencies to improve healthcare outcomes.
Further compounding these challenges are inadequate infrastructure and transportation, with 82% of health workers identifying the need for improved emergency transport services. These barriers are consistent with Titaley et al. (2010), who emphasized the critical role of infrastructure in ensuring timely maternal healthcare access. Low staff motivation, reported by 72%, and delayed salary payments (13.64%) reflect systemic issues that undermine service quality, as highlighted by Medard et al. (2023). Moreover, limited community engagement—evidenced by only 59% of health workers participating in community outreach—weakens efforts to enhance maternal health awareness and access.
These findings underscore the urgent need for strategic investments in infrastructure, staffing, and community health initiatives to overcome healthcare delivery challenges in Bugiri. Addressing these systemic gaps aligns with broader strategies to promote health equity and improve maternal health outcomes in rural Uganda.
4.3. The perspective of maternal mothers
The perceptions of adolescent and mature mothers in Bugiri District highlight critical barriers that provide insight into maternal health challenges and their impacts. Distance to healthcare facilities and the time required to access them emerge as significant issues, with 31.43% of adolescent mothers and 22.22% of mature mothers living more than 5 km away. This distance results in delays and physical strain, reflecting findings by Medard et al. (2023), who noted that geographic barriers disproportionately affect rural healthcare access. Similarly, transport challenges—reported by 75.86% of adolescent mothers and 61.92% of mature mothers—further exacerbate delays and costs. These challenges align with Titaley et al. (2010), who identified poor transportation infrastructure as a major impediment to timely maternal healthcare. The reliance on walking or motorbikes underscores the urgent need for improved transportation systems to mitigate delays in accessing care.
Cultural barriers and stigma also significantly limit maternal healthcare access. Stigma is a major challenge for 90% of adolescent mothers, compared to 50% of mature mothers, highlighting the heightened vulnerability of adolescents to societal judgment. This finding supports Dowhaniuk (2021), who emphasized the role of stigma in deterring marginalized groups from seeking care. Additionally, a high reliance on Traditional Birth Attendants (TBAs)—70% among adolescent mothers and 63.80% among mature mothers—reflects patterns documented in existing literature, such as Medard et al. (2023), which noted the preference for TBAs due to their accessibility and cultural trust. However, this dependence raises concerns about the quality of care, as TBAs often lack adequate training, increasing risks of maternal and neonatal complications.
By integrating these findings with existing research, this study underscores the multifaceted nature of maternal health challenges. Addressing issues such as transportation, facility accessibility, stigma, and cultural practices is essential to improving health outcomes for both adolescent and mature mothers in Bugiri District.
4.4. Structural challenges and policy Implications.
The perspectives of the District Health Officer and healthcare management in Bugiri District highlight critical systemic challenges that impede maternal healthcare delivery. Staffing shortages—evidenced by only 356 healthcare and administrative offices serving 57 facilities—underscore the strain on human resources. This aligns with Jaeger et al. (2018), who identified staffing constraints as a pervasive issue in rural Uganda. Additionally, the lack of essential medical supplies and reliance on untrained volunteers exacerbate risks to maternal health, echoing Medard et al. (2023), who noted resource limitations as a critical barrier. While increased antenatal care attendance suggests improvements in healthcare-seeking behavior, persistent gaps in funding, awareness, and accessibility underscore the urgent need for comprehensive strategies to address these systemic shortcomings.
Cultural and socio-economic barriers further compound these challenges, reflecting broader trends in maternal healthcare access. Cultural beliefs and family influences frequently discourage women from seeking modern medical care, consistent with findings by Titaley et al. (2010), who emphasized the role of traditional practices in healthcare decisions. Low education levels and socio-economic constraints—such as poverty and transportation costs—further hinder women’s ability to make informed choices or access necessary services. Delays in seeking, reaching, and receiving care, as noted by the District Health Officer, align with the "three delays model" discussed in global maternal health literature, illustrating the interplay between individual, transport, and facility-level barriers.
These findings emphasize the need for targeted interventions to enhance maternal health outcomes in Bugiri District. Recommended strategies include community education campaigns to address cultural misconceptions, increased funding for essential supplies, and policies aimed at improving healthcare infrastructure. By tackling these structural and socio-economic barriers, sustainable improvements in maternal healthcare delivery can be achieved.
4.5. Proposed actions for improving access to healthcare for maternal mothers in the Region
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| Table 3: Summary of proposed actions to improve healthcare for maternal mothers from multiple stakeholders |
4.6. Implications for practice
The findings from this study provide critical insights to guide policy reforms and practical interventions aimed at improving maternal healthcare in Bugiri District. Addressing systemic resource shortages, including staffing, medical supplies, and transportation, should be a top priority. Policies must focus on increasing healthcare funding, enhancing emergency transport services, and recruiting and retaining qualified healthcare workers. Institutionalizing training programs for healthcare providers, including TBAs, is essential to ensure standardized, high-quality care. Awareness campaigns targeting cultural barriers and stigma—particularly for adolescent mothers—could promote greater utilization of formal healthcare services. Strengthening referral mechanisms between TBAs and formal healthcare systems can further improve maternal health outcomes by fostering integration between traditional and modern care practices.
If these recommendations are implemented, the potential impact on maternal health outcomes in Bugiri District could be transformative. Improved transportation and infrastructure would reduce delays in accessing care, addressing a key factor contributing to maternal and neonatal complications. Enhanced education and awareness initiatives would empower mothers to make informed health decisions, reducing reliance on untrained caregivers. Additionally, integrating TBAs into the formal health system and improving the conditions of healthcare facilities would create a more robust and inclusive maternal healthcare framework, significantly lowering maternal mortality rates and improving overall maternal and neonatal well-being.
Future research should explore the long-term effects of such interventions on maternal health outcomes through longitudinal studies. Expanding the geographic scope of research could provide a more comprehensive understanding of maternal healthcare challenges across Uganda. Incorporating quantitative data from health records and observational studies would complement qualitative insights, offering a holistic perspective. Furthermore, examining the role of emerging technologies, such as telemedicine and mobile health solutions, in overcoming access barriers could reveal innovative pathways for improving maternal health in rural settings.
5. Conclusion
This study investigated, from the perspective of TBAs, adolescent, and mature mothers, and district health officials, the multidimensional challenges related to maternal healthcare in Bugiri District, Eastern Uganda. The study revealed that key barriers impeding access to healthcare for maternal mother include shortage of medical supplies, personnel shortfall, and lack of formal training for healthcare providers and TBAs.
The most critical challenges were those of geographic and transportation barriers, with many mothers living very far from the health facilities and having to pay a great deal of money for transport. Cultural obstacles, stigma, and low community awareness have further aggravated the underutilization of healthcare services among the mothers, especially adolescent mothers.
These findings point to systemic deficiencies in the health infrastructure and services and indicate a need for urgent attention to improved transport and referral systems, along with capacity-building programs for healthcare workers. Further, increased collaboration between the government and TBAs, and community outreach programs, would greatly enhance the state of maternal health in rural Bugiri District, Uganda.
6. References
Medard, A., et al. (2023). Traditional birth attendants in Uganda: Evaluating their role in rural maternal healthcare. Journal of Global Health, 13(1), 12458.
