Antenatal Couples' Counselling in Uganda (ACCU)

In this project, we would like to develop and evaluate a complex intervention for reducing deaths in mothers and babies, by improving birth planning and uptake of contraception after delivery in Uganda.
Every year, thousands of women and children in Uganda die as a result of problems during pregnancy and childbirth. Our research in 2011-2015 showed that about 20% of these deaths could have been avoided by use of contraception, to prevent unwanted pregnancies. Another 25% or so could be prevented by ensuring mothers go to the most appropriate health facility for their delivery. In Uganda, many women will not take these decisions without the approval and support of their husband; 43% of women still do not give birth in a health facility. Even of those who do deliver in a health facility, many high-risk women deliver in a small health centre which is unable to offer emergency surgery if needed.
If a woman does deliver in a health facility, although she may never return for postnatal check-ups, there is a key opportunity to provide contraception immediately after delivery. Although several projects have trained health workers to provide the contraceptive coil immediately after delivery, few women go home with a method of family planning in Uganda.
To understand why, our team interviewed 80 women, men and health workers in Uganda in 2015. Many women wanted time to discuss contraception with their husband (who was often absent at the time of delivery) and to recover from the birth. Women feared side-effects such as bleeding, and the impact these would have on their marriage; men were also concerned about side-effects and the cost of managing these.
Many people we interviewed suggested that more awareness-raising on family planning was needed. Several people also suggested that men should accompany their wives to antenatal clinics (which rarely happens in Uganda) to discuss future family planning with a health worker. This would also be an ideal opportunity to discuss the birth plan with the couple, and to gain the husband's understanding and cooperation in deciding on the safest place for the delivery.
Thanks to a MRC-AHRC partnership development award, we have now developed health education documentaries and dramas on contraception, in two local Ugandan languages. The films have been edited to incorporate feedback from local audiences, and are now ready to be evaluated on a larger scale. However, it is likely that films alone would have a limited impact, unless they are followed up with counselling of couples to address their specific questions and concerns.
We have sought feedback on the concept of antenatal couples' counselling in 18 focus groups with women, men and health workers in central and southern Uganda. Almost everyone liked this concept, but there remain several logistical challenges. Firstly, men are often reluctant to attend antenatal clinics, because of transport costs, location and timing. They suggested that their attendance could be increased by holding "outreach" antenatal clinics in villages which are far from health facilities, and by holding antenatal clinics at weekends. Secondly, some men are reluctant to be tested for HIV together with their partners. Thirdly, some health workers felt that they would not have time to provide in-depth couples' counselling in addition to their existing workload.
In this project, we would like to build on our existing research to develop and pilot a complex intervention to deliver couples' counselling in antenatal clinics in Uganda, in order to increase appropriate place of delivery, and increase uptake of post-partum contraception. This would include (a) training of village health teams to counsel antenatal couples and encourage them to attend antenatal clinic together; (b) health education films on family planning; (c) training of health workers in antenatal clinics to provide effective couples' counselling on birth planning and post-partum family planning.

About 28% of married women and 32% of unmarried women in Uganda have an unmet need for family planning; 43% do not deliver in a health facility. This is linked to high rates of maternal, perinatal and neonatal mortality. Delivery in a health facility is a window of opportunity for providing long-acting reversible contraception (LARC), specifically the contraceptive implant or intra-uterine device (IUD), in the immediate post-partum period prior to discharge. Although health workers have been trained to provide the post-partum IUD, uptake remains low because women need to get the approval of their husbands, who are usually absent at the time of delivery. Men also need to agree the place of delivery as women rely on them for transport and/or money to access a health facility. Yet men rarely accompany their partners to antenatal clinics so couples do not often discuss these issues.
Qualitative interviews with Ugandans suggested that antenatal couples' counselling could be a possible solution. Focus groups agreed with this idea, an explained that men do not often attend antenatal clinics because they work during the week and feel treated rudely.
Our proposed intervention aims to overcome these barriers by providing initial counselling in couples' homes by community health workers, known as village health teams (VHTs), who will encourage couples to attend antenatal clinics together. The clinics will screen health education films, incorporating feedback from local focus groups. Health workers will be trained in communication skills and couples' counselling, as well as refresher training on providing postpartum contraception. We will pilot this intervention to see how well it can be delivered.
We will also test the feasibility of conducting a cluster-randomised trial of the intervention. In particular we will evaluate whether VHTs can recruit and follow up pregnant women in their villages, and whether they are able to use smartphones to collect and enter data.

This intervention has the potential to be highly impactful and cost-effective, by addressing two key avoidable factors in maternal and neonatal deaths (lack of family planning, and inappropriate place of delivery). Progress has been slow on both of these because routine antenatal care has focussed only on women. Yet in much of sub-Saharan Africa, many women are powerless to take important decisions (such as place of delivery, and use of contraception) without involving their husbands or partners. Our intervention would address this barrier, firstly by providing basic counselling to couples at home, encouraging men to accompany their wives to an antenatal clinic; secondly by providing information and counselling to couples at antenatal clinics, to facilitate shared decision-making on the most appropriate place of delivery, and post-partum contraception. This in turn should improve rates of delivery in an appropriate facility, and improve uptake of postpartum contraception. The full logic model is shown in the Pathways to Impact attachment.
If we are granted the opportunity to deliver this project, we will develop and pilot a complex intervention which will be ready to evaluate in a full-scale clinical trial. As MRC guidance states, development, piloting and feasibility testing are crucial for a complex intervention, before conducting a full-scale trial. We will follow MRC guidance on development of complex interventions. Through extensive involvement of potential clients, village health teams and health workers, as well as district health teams and the Ministry of Health, we will improve the intervention package into something which can be scaled up and delivered within the existing health system. We will pay particular attention to cost-effectiveness. We will also assess the feasibility of evaluating this intervention in a full-scale clinical trial.
If our results are positive, we hope to apply for subsequent funding to test the impact and cost-effectiveness of the intervention in a cluster-randomised controlled trial. If the subsequent trial takes place and demonstrates that the intervention is cost-effective, the intervention could be rolled out in Uganda, and also adapted for most other countries in sub-Saharan Africa. It could therefore help to avoid 20-40% of maternal and neonatal deaths. The full trial would provide evidence both to the Ministry of Health in Uganda (and other countries) and to Non-Governmental Organisations (such as private health providers, and providers of family planning such as the Marie Stopes International) who could fund the roll-out of such a programme. Two of our team are involved in the implementation of the USHAPE health partnership funded by the Tropical Health and Education Trust and recently validated as highly cost-effective by DFID.
The results of the scientific research, particularly the development and piloting of the intervention, will be written up and submitted for publication in a peer-reviewed scientific journal (such as Studies in Family Planning). We will also submit abstracts to relevant conferences such as the Uganda National Family Planning Conference.