Antenatal Couples' Counselling in Uganda (ACCU)

在这个项目中，我们希望制定和评估一项复杂的干预措施，通过改善乌干达的计划生育和分娩后避孕措施的使用，减少母婴死亡。乌干达每年有数千名妇女和儿童死于怀孕和分娩期间的问题。我们在2011-2015年的研究表明，这些死亡中约有20%可以通过使用避孕措施来避免意外怀孕。另外25%左右可以通过确保母亲前往最合适的卫生设施分娩来预防。在乌干达，许多妇女在没有丈夫的同意和支持的情况下不会做出这些决定; 43%的妇女仍然不在卫生机构分娩。即使在保健设施分娩的妇女中，许多高危妇女也是在小型保健中心分娩，而该中心在必要时无法提供紧急手术。如果妇女确实在保健设施分娩，尽管她可能永远不会回来进行产后检查，但有一个关键的机会在分娩后立即提供避孕措施。虽然有几个项目培训保健工作者在分娩后立即提供避孕线圈，但在乌干达，很少有妇女带着计划生育方法回家。为了了解原因，我们的团队在2015年采访了乌干达的80名女性、男性和卫生工作者。许多妇女希望有时间与丈夫讨论避孕问题（分娩时丈夫往往不在），并从分娩中恢复过来。女性担心出血等副作用，以及这些副作用对婚姻的影响;男性也担心副作用和管理这些副作用的成本。我们采访的许多人建议，需要提高对计划生育的认识。一些人还建议，男子应陪同妻子到产前诊所（这在乌干达很少发生），与卫生工作者讨论未来的计划生育问题。这也是一个理想的机会，与夫妇讨论生育计划，并获得丈夫的理解和合作，以决定最安全的分娩地点。由于红十字委员会-澳大利亚人权委员会的伙伴关系发展奖，我们现在已经用两种乌干达当地语言制作了关于避孕的卫生教育纪录片和戏剧。这些影片经过编辑，纳入了当地观众的反馈意见，现在准备进行更大规模的评价。然而，如果不对夫妇进行后续辅导，解决他们的具体问题和关切，那么，光靠电影可能影响有限。我们在乌干达中部和南部的妇女、男子和保健工作者组成的18个重点小组中征求了对产前夫妇咨询概念的反馈意见。几乎每个人都喜欢这个概念，但仍然存在一些后勤挑战。首先，由于交通费用、地点和时间的原因，男子往往不愿意去产前诊所。他们建议，在远离卫生设施的村庄开设“外展”产前诊所，以及在周末开设产前诊所，可以提高妇女的就诊率。第二，有些男子不愿意与其伴侣一起接受艾滋病毒检测。第三，一些保健工作者认为，除了现有的工作量外，他们没有时间为夫妇提供深入的咨询。在这个项目中，我们希望在现有研究的基础上，制定和试行一项复杂的干预措施，在乌干达的产前诊所提供夫妻咨询，以增加适当的分娩地点，并增加产后避孕药具的使用。这将包括（a）培训乡村保健小组，为产前夫妇提供咨询，并鼓励他们一起到产前诊所就诊;（B）制作关于计划生育的保健教育影片;（c）培训产前诊所的保健工作人员，为夫妇提供有效的计划生育和产后计划生育咨询。

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.