Facilitators and barriers to cesarean section delivery in south western Uganda: A qualitative study

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Cesarean section rates are unacceptably high and reasons for this remain unclear. In an attempt to understand this, we aimed at assessing facilitators and barriers of cesarean section among mothers that experience and health workers that take part in the cesarean section delivery in South-western Uganda in order to improve on knowledge and health practices in line with cesarean section delivery and its services. Objective To determine the facilitators and barriers of cesarean section among mothers and health workers in South-western Uganda. Methods We had 36 participants; 18 in-depth interviews and 2 focus-group-discussions with mothers and 6 key-informant interviews with health workers. Analysis Data collected was transcribed verbatim, coded using NVivo 20.2 and analyzed considering the health belief model and content thematic approach. Results Facilitators were maternal preference after previous cesarean section, maternal perception of importance of cesarean section to her and baby, health workers advise, health workers perception of benefit of cesarean section to mother and baby, traditional birth attendants, community and religious perception of benefits of cesarean section, high knowledge about cesarean section by health workers, family perception about importance of cesarean section to mother and baby, friend’s recommendation of cesarean section, health workers’ good communication skills during consenting process, maternal awareness about their condition and how it prevents vaginal delivery. Barriers included; rude health workers, high expenditures like buying expensive drugs and transport to and from the facility especially for referred mothers, delay by health workers to perform cesarean section on referred mothers, presence of medical students in the theatre, community, traditional birth attendants and church’s negative perception, limited staff on maternity ward, stock-outs, maternal preference for vaginal delivery, low maternal education status, bad previous experience with cesarean section, uncomfortable procedures like catheterization and spinal anesthesia injections and perception of having limited number of children due to cesarean section. Conclusion With this information, we were able to understand why cesarean section was done/ preferred or not done/ not preferred, this provides a basis for implementation of working evidence based interventions for proper use of cesarean section like strengthening health education talks in the communities to increase knowledge about cesarean section among community members. facilitators barriers cesarean section mothers health workers Kabale Regional Referral Hospital South-western Uganda 1. Background Cesarean section (C/S) is a fetal delivery through an open abdominal incision and an incision on the uterus( 1 ). C/S is the most common surgery done globally ( 2 ) There are two classifications of C/S according to time of operation, that is; elective cesarean (where a time is scheduled during pregnancy to undergo the C/S as advised by doctor or on maternal request to ensure the best quality of obstetric care, anesthesia, neonatal resuscitation and nursing services) ( 3 ). Whereas emergency cesarean section (EmC/S) is a surgical procedure that is performed when there is an immediate threat to the life of a fetus and/or woman ( 4 ). Some indications for C/S include; 2 previous scars, fresh scar (less than 2 years old), labor dystocia, malpresentation of fetus, multiple pregnancy, abnormal fetal heart rate pattern and macrosomia, central placenta previa, contracted pelvis or cephalo-pelvic disproportion, pelvic mass obstruction, advanced carcinoma cervix and vaginal obstruction. ( 3 ) C/S is part of the comprehensive emergency obstetric care and is important to save maternal and fetal life if kept below the recommended 15% rate by WHO. C/S rates higher than 15% can be disastrous this is because it is associated with both maternal and fetal complications including hemorrhage, sepsis, placenta accreta, fetal respiratory infections. These complication s result into maternal and fetal deaths. According to the World Health Organization (WHO), the recommended rate of C/S is 10–15%. However, there is an increasing rate of C/S over time worldwide ( 1 ). Evidence from 154 countries covering 94.5% of world live births has shown that from 2010 to 2018, C/S accounts for 21.1% deliveries, averages ranging from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean ( 5 ) In a study done in the eastern world based on nine South Asian and South-East Asian countries, cesarean section rates ranged from 1.51–31.78% ( 6 ). In Sub-Saharan Africa, C/S rates in Rwanda, Nigeria and Ethiopia range from 15.6% to as high as 38.3% ( 7 – 9 ). In East Africa, a study showed that the overall prevalence was 24.0%( 10 ). A study done in eastern Uganda showed a prevalence of 14% and Uganda’s facility-based C/S rate was projected to increase by 36% in 2021, while the population-based C/S rate was estimated to double in the same period from the baseline in 2016 ( 11 ). Evidence shows that increased C/S rates are associated with increase in elective C/S, advanced maternal age, high maternal educational background and maternal urban residence ( 12 – 14 ). Conversely, fear for C/S, high costs of C/S, Improper informed consent, religious beliefs were some of the barriers for undertaking C/S among mothers ( 15 , 16 ) All health care practitioners especially nurses who mostly interact with pregnant women and their families play an important role in the cesarean delivery rates and use ( 17 ). Nurses take part in preparing the mother for C/S by obtaining consent, placing urinary catheters, obtaining IV access, administering IV fluids and wheeling the patients to theatre. During C/S, a nurse can assist the surgeon by prepare the instruments and act as patient advocate during the procedure. Nurses play a vital role at all stages of a C/C delivery including the preoperative, intraoperative, and post-operative care of the mother. These roles can include; obtaining consent, placing urinary catheters, obtaining IV access, administering IV fluids and wheeling the patients to theatre. Intraoperative, nurses assist in instrument preparation and act as advocates during the procedure. Post operatively, they receives the baby, admits the mother on post-natal ward, regularly monitors the mother and health educates the mother about post-natal care of herself and the baby ( 18 ). Nurses therefore play a pivotal role in overall experience of the patient care during C/S delivery. Poor management of C/S at any stage of care can result in significant increase in complications and contribute to a bad patient experience of the procedure. To enable better delivery of this essential service, it is important to understand facilitators and barriers associated of C/S utilization among mothers receiving it and healthcare workers. 2. Methods 2.1 Study site and setting The study was carried out at Kabale Regional Referral Hospital (KRRH). It is a 280 bed capacityand serves a population of about 2 million people in the districts of Kabale, Kisoro, Rukungiri, Kanungu, and some parts of Ntungamo as well as people from neighboring countries of Rwanda and the Democratic Republic of Congo. Mission of the hospital is to provide quality and sustainable, general and specialized, health services to all people in Kigezi region. (Ministry of Health Uganda, 2019) This Hospital is located on Makanga Hill in Kabale town, Kabale district found in South-western Uganda. It is about 1.3km from the main Kabale-Kisoro road and approximately 426 Kilometers from Kampala. KRRH provides comprehensive primary and secondary care services ranging from basic and comprehensive obstetric, pediatric and medical care services to its local communities, services such as family planning, HIV/AIDS prevention and treatment, and infectious diseases management, wide range of laboratory services such as X-ray, Ultrasound, CT-scan, and MRI, emergencies and surgeries like C/S delivery. These C/S deliveries are carried out in a general theatre by a specialist Obstetrician or Obstetrics senior house officer (SHO) assisted by a midwife or medical student and anesthesia is given by an anesthesiologist. The hospital has no designated obstetric theater and C/S deliveries are carried out in the main operating theater where other surgical procedures are done. The hospital also houses other units like neonatal unit, laboratory, pharmacy, obstetrics and gynecology units, pediatric unit, maternity, maternal and child health (MCH), outpatient and inpatient services, accidents and emergency unit, radiology unit, dental clinic, ear, nose, throat clinic (ENT), tuberculosis unit and mental unit. Each ward has about four staff per duty that is; In-charge nurse, two nurses, and two doctors and intern doctors, intern nurses and midwives, plus the nursing, midwifery and medical students from nearby institutions that work and learn clinical skills from the hospital. The maternity ward was the specific site for the interviews, it had two obstetricians, three senior medical officers, 6 midwives and five intern doctors. The hospital is affiliated with the Ministry of Health in Uganda and is a World Bank–approved institution. This study setting was chosen because it is a regional referral where the lower cadre facilities also refer high risk women for C/S delivery making it a suitable site for the study. 2.2 Study design This study employed a qualitative study design with a theoretical approach. This study relied on the Health Belief Model (19,20) in the designing of the data collection tools, the analysis, reporting and interpretation of findings. Data collection took place from January 2024 to February 2024 and analysis took place from February 2024 to the month of March 2024. 2.3 Study population and size The study consisted of 36 participants that is; 30 mothers and 6 health workers. We had 18 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with the mothers. These focus group discussions had 6 participants in each. We had 6 key informant interviews (KIIs) with the health workers consisting of: 1 senior obstetrics and gynecology consultant, 1 senior medical officer, 2 intern doctors and 2 midwives (Table 1) 2.4 Participant selection In this study, convenience sampling was used to select mothers who met the inclusion criteria. We considered mothers who are 0 days to 6 weeks postpartum who delivered by C/S at Kabale Regional Referral Hospital (KRRH) and consented to participate in the study. We considered 6 weeks postpartum and below because in this time frame the mother is able to recall events surrounding the C/S delivery. Purposive sampling was used to select the health workers because they had the technical knowledge and experience in performing C/S delivery. 2.5 Data collection procedures and methods The study got ethical approval from the Department of Nursing Sciences, KRRH Research Ethics Committee and administrative clearance from KRRH. Approvals were presented to the ward in-charge before data collection was undertaken. The In-charges helped the researcher in identifying willing participants for the various data collection methods 1 . Mothers Each mother was approached individually and their voluntary written informed consent sought before proceeding to data collection. The participants were informed of the aims of the study and the interviewer established rapport with the participants prior to the interviews. The mother with her baby were then escorted to the designated place. The face-to-face in-depth interviews and focus group discussions were conducted in a private, free and quiet room on maternity ward. Each mother was interviewed individually using an in-depth interview guide for the IDI and a focus group discussion guide for the FGD, each containing topics of discussion, guiding questions and probes. The interviews and discussions were conducted in English and the local language Rukiga . For interviews conducted in Rukiga , a translator was used. The participants were identified using codes to keep their identity anonymous. Each IDI lasted approximately 20 to 30 minutes whereas the FGD lasted 50 minutes to 1 hour. Additional information collected included participant demographic data. For covid-19 precautions, the interviewer and the participants wore facial masks and kept social distance was kept between them. An alcohol-based hand sanitizer was used by all participants and interviewers before, during and after each interview or FGD session. 2. Health workers We approached each health worker one at a time. To each health worker, we introduced herself, explained the details of the study and sought for their voluntary informed consent. We established rapport with the health workers and sought for consent to audio record the interviews. The health worker was then escorted to a designated place for the interview process to take place. The face-to-face key informant interviews were conducted in a private, free and quiet room on maternity ward. Before proceeding with the interview, the participants were given information about the study and aims clearly communicated. Each health worker was interviewed individually using a topic guide containing topics of discussion, guiding questions and probes. The interviews were conducted in English. The participants were identified using codes to keep their identity anonymous. The sessions took approximately 15 to 20 minutes. Additional information collected included participant demographic data. For covid-19 precautions, the interviewer made sure that participants were wearing facial masks and kept social distance between the interviewer and participants during interviews. An alcohol-based hand sanitizer was used before, during and after each interview for all participants and the interviewer. TABLE 1: TABLE SHOWING THE NUMBER OF PARTICIPANTS PER DATA COLLECTION METHOD Data collection method Senior obstetrics and gynecology consultant Senior medical officer Interns doctors Midwives Mothers who had undergone C/S FGDs 2 groups each consisting of 6 mothers; n=12 KIIs 1 1 2 2 IDIs 18 mothers n= 18 TOTAL 1 1 2 2 36 GRAND TOTAL (N) is 2+2+2+31 = 36 2.6 Data management and analysis We transferred the audio recordings of the interviews from the audio recorder to the laptop. We then listened and re-listened to each audio recording while transcribing the interviews verbatim in English into Microsoft word 2016 while saving each transcript with the client code name. We created an analytical framework to extract potential themes from the text data as per each objective of the study (Table 3). We then read and re-read through all transcripts while extracting codes and typing them into Microsoft word 2016 to create a code book. The transcripts were exported into a qualitative data analysis software, NVivo 20.2 (https://qsr-nvivo.software.informer.com/download/). Within the analytical software, the codes that had been created in the code book were generated and the process of attaching corresponding reference text to each generated code was done. Two data coders and analysts (PA and AN) Two researchers (PA and AN) carried out the coding and analysis at each level. The codes and corresponding reference texts were then exported back to Microsoft Word 2016 and saved. The reference texts and their codes were then tabulated and the analytical framework was aligned to the Health Belief Model (19) and were then inserted in the table to make it complete. The health belief model was used because it helped to better present the results of experiences and perceptions of the mothers and health workers. This was the process of content thematic analysis. The most appropriate reference texts were selected under each code and aligned under the themes in the health belief model. Consolidated criteria for reporting qualitative research (COREQ) were closely followed during the reporting of study findings. 2.7 Reflexivity Being qualitative researchers, we know that our prejudices, ideas, perceptions and assumptions could have influenced the study. During the entire research process, all members of the research team made sure to be aware of and address these influences through frequent self-refection. We tried to bracket our biases and assumptions, while recognizing that complete objectivity was unattainable. So, in order to enhance the trustworthiness of the findings, every member of the research team had a journal where each one documented their thoughts, feelings, and decisions during each interview or discussion. We also had on going self-critique of our own positionality and biases. 3. Results 3.1 Participant characteristics Participant characteristics/ demographic data is presented in table 2. The mean age of health workers was 32 years, all of them had tertiary level of education, two were married, four were single, three were Bakiga, one was a Muganda, one was a Mufumbira and one was foreign (Somali). (Table 2) 3.2 Mothers The study included mothers who had a cesarean section delivery at Kabale Regional Referral Hospital between 0 days to 6 weeks and agreed to consent to be part of the study. We considered 6 weeks postpartum and below because in this time frame the mother is able to recall events surrounding the cesarean section delivery. The mean age of mothers was 26.8. 57% of the mothers had primary education, 37% of them had secondary education, and 7% had tertiary education. 93% of the mothers were married and 7% were single, twenty-eight were Bakiga and two were Banyankole. Thirteen of them were Anglican, thirteen were Catholic, three were born again and one was Pentecostal (Table 2). 3.3 Health workers The study included health workers who were rotating on maternity ward and consented to be part of the study and these included: gynecologist consultant, senior medical officer, midwives and intern doctors. The mean age of health workers was 32 years, all of them had tertiary level of education, two were married, four were single, three were Bakiga, one was a Muganda, one was a Mufumbira and one was foreign (Somali). (Table 2) TABLE 2: A TABLE SHOWING THE DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS Code Age Educational status Marital status Tribe Religion/cadre Data collection method IDI01 22 Primary seven Married Mukiga Catholic In-depth interview IDI02 43 Primary three Married Mukiga Pentecost In-depth interview IDI03 20 Primary seven Single Mukiga Anglican In-depth interview IDI04 20 Senior three Married Mukiga Anglican In-depth interview IDI05 27 Senior four Married Mukiga Anglican In-depth interview IDI06 24 Senior four Married Mukiga Anglican In-depth interview IDI07 22 Primary seven Married Mukiga Catholic In-depth interview IDI08 21 Primary seven Married Mukiga Catholic In-depth interview IDI09 32 Primary seven Single Mukiga Anglican In-depth interview IDI10 23 Senior four Married Mukiga Anglican In-depth interview IDI11 34 Primary seven Married Mukiga Catholic In-depth interview IDI12 26 Primary five Married Mukiga Catholic In-depth interview IDI13 30 Primary five Single Mukiga Born again In-depth interview IDI14 30 Diploma Married Mukiga Catholic In-depth interview IDI15 35 Primary seven Married Mukiga Catholic In-depth interview IDI16 25 Senior four Married Mukiga Anglican In-depth interview IDI17 36 Primary seven Married Munyankole Born again In-depth interview IDI18 24 Primary seven Married Mukiga Catholic In -depth interview FDG1.1 23 Primary seven Married Mukiga Anglican Focus group discussion FDG1.2 21 Senior four Married Mukiga Catholic Focus group discussion FDG1.3 27 Senior four Married Mukiga Catholic Focus group discussion FDG1.4 19 Senior one Married Mukiga Anglican Focus group discussion FDG1.5 23 Senior three Married Mukiga Catholic Focus group discussion FDG1.6 24 Primary seven Married Mukiga Anglican Focus group discussion FDG2.1 30 Senior four Married Mukiga Anglican Focus group discussion FDG2.2 20 Primary seven Married Mukiga Anglican Focus group discussion FDG2.3 39 Primary four Married Mukiga Born again Focus group discussion FDG2.4 29 Primary seven Married Munyankole Catholic Focus group discussion FDG2.5 24 Senior two Married Mukiga Anglican Focus group discussion FDG2.6 31 Diploma Married Mukiga Catholic Focus group discussion KII01 29 Diploma Married Mukiga Midwife Key informant interview KII02 27 Bachelors Single Muganda Intern doctor Key informant interview KII03 38 Diploma Married Mukiga Midwife Key informant interview KII04 25 Bachelors Single Somali Intern doctor Key informant interview KII05 35 Bachelors Single Mufumbira Senior medical officer Key informant interview KII06 40 Bachelors Single Mukiga Senior gynecology and obstetrics Consultant Key informant interview 3.4 Presentation of results The results were presented according to the objectives and themes of the health belief model as shown in table 3 below. TABLE 3: A TABLE SHOWING THE RESULTS; THEMES, CORRESPONDING CODES AND QUOTES ACCORDING TO THE OBJECTIVES AND THE HEALTH BELIEF MODEL FACILITATORS OF CESAREAN SECTION AT KABALE REGIONAL REFERRAL HOSPITAL BARRIERS OF CESAREAN SECTION AT KABALE REGIONAL REFERRAL HOSPITAL Perceived self-efficacy Theme: Maternal preference Codes: Preferred delivery mode at admission Preferred mode of delivery on next pregnancy Perceived barriers Theme: Care Codes: Recommendations from mothers to health workers Care by health workers Theme: Health worker related barriers Code: Challenges faced by health workers Theme: Maternal preference Codes: Preferred delivery mode at admission Preferred mode of delivery on next pregnancy Theme: Maternal attitude Code: Recommendations from mothers to health workers Theme: Community perceptions Codes: Perception of village members Religious perception TBAs perception Perceived susceptibility Theme: Maternal preference Code: Preferred mode of delivery on next pregnancy Perceived severity Theme: Maternal experience with cesarean section as a barrier Codes: Changes on body after cesarean section Complications of cesarean section Disadvantages of cesarean section Perceived benefits Theme: Benefits of cesarean section Codes: Importance of cesarean section sReasons for accepting/doing cesarean section Theme: Community perceptions Codes: Religious perception Perception of village members TBAs perception 3.5 Narrative of results in table 3 Facilitators of cesarean section among mothers and health workers at Kabale Regional Referral Hospital 1. Perceived self-efficacy: According to the HBM, perceived self-efficacy is the belief in one’s ability to successfully perform a behavior, in this study that behavior is cesarean section. Theme: Maternal preference: this refers to what the mode of delivery the mother prefers Code: Preferred delivery mode at admission: Some mothers, who had a previous cesarean section in the past had believed that they had the ability to successfully have another and preferred it while those who had it for the first time accepted C/S due to failed vaginal delivery and had cesarean section. “I wanted a cesarean section because 2 weeks ago I went to a health center to deliver but the contractions later left and I was referred here so by the time I reached I was tired and was put on oxygen and I wanted a cesarean section as fast as possible.” IDI05, 27-year-old female “ Yes, but I came in labour but being cut is easier.” IDI12, 26-year-old female Code: Preferred mode of delivery on next pregnancy: Some mothers who had cesarean section at the time of data collection wanted a cesarean section on the next birth because they believed they could successfully undergo the procedure. “ I have always had cesarean section because the babies are big and don’t descend towards birth so of course I want to do a cesarean section.” FGD2.4, 29-year-old female 2. Perceived susceptibility: This refers to the mother’s belief that they will undergo the procedure again. Theme: Maternal preference Code: Preferred mode of delivery on next pregnancy: Some mothers believed that after the cesarean section, that they will automatically have it again. Mothers believed having a C/S delivery automatically resulted in subsquent delivery by the same. “ I have always had cesarean section because the babies are big and don’t descend towards birth so of course I want to do a cesarean section.” FGD2.4, 29-year-old female 3. Perceived benefits: This refers to the belief that cesarean section is beneficial Theme: Benefits of cesarean section: this refers to the importance of cesarean section to the mother Code: Importance of cesarean section: Mothers perceived C/S delivery as helpful in relieving the contractions associated with vaginal delivery. They perceived it to be faster and easier than a vaginal delivery. “ The truth is cesarean section is less painful, and its faster and the suture pains you later, it’s like u were in a lot of pain and someone says let me help you, u feel good.” FGD2.1, 30-year-old female Code: Reasons for accepting/doing cesarean section: when mothers where asked why they accepted to do cesarean section, they gave indications or reasons the doctors had given them as to why they couldn’t push and therefore cesarean section saved their babies and themselves. The health workers also gave indications for conducting cesarean section and they said it helps when the mother has failed to push. Mothers identified stated the indications offered by health workers for C/S delivery as the reason for accepting the C/S. There was coherence in the responses given by both mothers and healthcare workers indicating the information shared by the HCW influenced decisions made by the mothers to undergo C/S. “They told me that after I will not be able to deliver normally because the placenta was the first and was covering the outlet.” IDI14, 30-year-old female “ They checked me and they saw that I was sick down and my uterus will not push the baby then they said I should proceed and the children were sick and I was also sick. And I used to fall sick frequently during pregnancy, so, they said they should do cesarean section to save the children. That’s how I got a cesarean section.” FGD2.1, 30-year-old female Theme: Community perceptions: This refers to the thoughts of the church and village members as well as the TBAs Code: Church members’ perception: Some mothers said that the church members and leaders think that cesarean section is good and beneficial to the mother and the baby. “They give testimonies that cesarean section helped them” IDI04, 20-year-old female Code: Perception of village members: Some mothers said that some of the village members supported cesarean section. “They say that it is okay as long as it saves the baby and you” IDI09, 32-year-old female Code: TBAs perception: Some mothers said that TBAs supported cesarean section because it saves the mother and baby. “They do not want you to deliver from the village if the mother is not able to deliver normally, they send then to the hospital” IDI10, 23-year-old female Barriers of cesarean section among mothers and health workers at Kabale Regional Referral Hospital 1. Perceived barriers : According to the Health Belief Model, perceived barriers are perceptions or experiences that prevent mothers from accepting cesarean section or they hinder health workers from performing cesarean section. Theme: Care: this refers to the care given to the mothers by the health workers Code: Care by health workers: Some mothers said that some health workers were rude like FGD2.3 said that some heath workers who talked badly might have not been in a good mood. Mothers complained of painful procedures like anesthesia injections while other mothers complained of being ignored by the nurses. “We are suffering because we can tell the nurses our problems and they ignore us, there are only 2 good nurses. That’s what I’ve seen. Because you can get overwhelmed and you call a nurse and she will just leave you when her shift is done and you suffer. I think nurses should change the way they talk to us; some nurses are truly rude.” IDI07, a 22-year-old female Theme: Health worker related barriers: these are hospital factors that prevent use or cause delay of cesarean section for example hospital setting Code: Challenges faced by health workers: Health workers said that they had things that cause delay or failure to perform cesarean section and these included, stock-outs, limited staff on maternity ward, community perception of cesarean section making mothers disabled discouraged them from accepting, skills of health workers and low level of education status of mothers, limited theatre rooms. “Out of stock of things to use, staffing has been a challenge because we are few compared to other hospitals, but staffing is not enough really like your seeing now, I’m alone on labour suit and that is not okay, but besides that we are okay.” KII03, a 38-year-old female midwife . Theme: Maternal preference: this refers to the mother’s preferred mode of delivery Code: Preferred delivery mode at admission: some mothers wanted to push on arrival at the hospital but failed. Others were told to have a cesarean section earlier but they still preferred to push their babies. “ Yes, everyone wants to push.” FGD1.3, 27-year-old female Code: Preferred mode of delivery on next pregnancy: some mothers including those who had two previous cesarean sections and above also desired to push on the next delivery. “I would have wanted to push but it is impossible according to the health workers.” IDI15, 35-year-old female Theme: Maternal attitude: this refers to the way the mother reacts or thinks towards cesarean section Code: Recommendations from mothers to health workers: Mothers wanted heath workers to improve on the care they give like some mothers said that some health workers should improve on the way they talk to the mothers. They were therefor not satisfied with the care given by the health workers. “We are suffering because we can tell the nurses our problems and they ignore us, there are only 2 good nurses. That’s what I’ve seen. Because you can get overwhelmed and you call a nurse and she will just leave you when her shift is done and you suffer. I think nurses should change the way they talk to us; some nurses are truly rude.” IDI07, 27-year-old female Theme: Community perceptions: This refers to the thoughts and ideas of the community members that may prevent mothers from using or accepting cesarean section. Code: Perception of village members: Mothers said that village members had negative ideas about cesarean section. “ They take you as if you are not normal, like your lame and they take you as a disabled. Also, they regard as one who can’t do work. Generally, u seen to be disabled before them.” FGD2.6, 31-year-old female Code: Church members’ perception: Mothers said that church members said bad things about cesarean section, like some believed that cesarean section is Satan and Satan enters your body after having it. “ They say bad things like cesarean section is Satan. Satan comes into your body when you do cesarean section” FGD1.2, 21-year-old female Code: TBAs perception: Mothers said that some Traditional birth attendants had bad ideas about cesarean section and that they don’t believe that a woman can fail to push. “ They don’t believe that someone can fail to push, so they think if you’ve been going to them and they attend to you as someone that has been pregnant, they devise means for you to push. So, they don’t believe that someone can be pregnant and fail to push.” FGD2.1, 30-year-old female 2. Perceived severity : These are the maternal perceptions that cesarean section is harmful. Theme: Maternal experience with cesarean section as a barrier: This refers to the experiences of the mother regarding cesarean section that might make her not accept/prefer cesarean section delivery. Code: Changes on body after cesarean section: Mothers reported that they had issues on their bodies after or related to cesarean section like the painful incision, body weakness and failure to walk properly for a while. “ On my body, I feel weak, I can’t walk well.” FGD1.3, 27-year-old female Code: Complications of cesarean section: Mothers said that cesarean section had complications like falling sick, long healing time, headache, unconsciousness, paralysis around the waist and thighs, back ache, pain at the incision site, unbearable pain, death of the baby and bursting of the previous scar. “ Our bodies are not the same, some people heal faster after theatre compared to others like me I’ve been here for a week and I've been sickly with headaches and medication wasn’t working, bodies are not the same, but the others I underwent the procedure with on the same day were discharged when they were well” FGD2.3, 39-year-old female “ The wound healed within a month but the tingling pain took about 2 and a half months.” IDI17, 36-year-old female Code: Disadvantages of cesarean section: Mothers said that cesarean section was associated with problems like lack of energy, inability to do work because of the pain, it is more expensive, high expenditure on drugs and transport, inability to deliver many children, failure to use family planning, failure to have more than five children and uncomfortability with the catheter. “ If you had planned to have more than 5 children and they tell us that with cesarean section, you cannot exceed 5 children. So, that can cause your husband look for another wife if he wants to make the number of children he wants or you yourself you feel guilty that why can’t I deliver more than 5 children. But with the Uganda of nowadays, no one wants to have more than 5 children. So cesar is of more good than harm.” FGD2.6, 31-year-old female “I have headache and the catheter makes me uncomfortable” IDI04, 20-year-old female Other facilitators of cesarean section that are not in the health belief model Theme: Health worker attitude towards caesarean section rate: This refers to the way health workers react or relate to the cesarean section rates at Kabale Regional Referral Hospital. Code: Attitude towards Kabale Regional Referral Hospital cesarean section rates: The health workers had a positive attitude towards the high rates of cesarean section at Kabale Regional Referral Hospital. They said that Kabale Regional Referral Hospital being a regional referral, therefore the high rates were inevitable as most referrals came specifically for cesarean section. “ Since it is a referral most of the mothers are done cesarean section, according total number of admissions, total deliveries, I think cesarean section deliveries are higher than normal deliveries. But it is a referral and we receive most mothers from lower health facilities who are specifically for C/S, so I think its fine ” KIIO1, a 29-year-old midwife Code: Awareness of Kabale Regional Referral Hospital cesarean section rates: the health workers were aware that the rates of cesarean section at Kabale Regional Referral Hospital were high. However, they were not aware of the exact rate of cesarean section at the facility. “I've gotten chance of listening to the in-charge and the rates are between 30-41%.” KII02, a 27-year-old male intern doctor Theme: Key decision makers in consenting for cesarean section: this refers to the people other than the mother that influenced her decision to accept cesarean section Code: Other decision makers in cesarean section: many mothers said that they just followed the health workers advise while some mothers said that their mothers, mothers-in law and especially their husbands helped them decide. “My husband and my mum helped to make a decision during the consent.” IDI01, 22-year-old female . Some mothers said that the decision was entirely theirs for example; FGD2.3: “ I decide, even my husband can’t stop me, unless he refuses to sign, but I decide for myself because I want to be well.” FGD2.3, 39-year-old female Theme: Maternal attitude: this refers to the way the mother reacts towards cesarean section Code: Recommending cesarean section to someone else: Most mothers said that they would recommend cesarean section to a friend or someone who has been advised by the doctor to have it. Others said that the mode of delivery is the mother’s choice and others said that they would tell them to follow the doctor’s advice. “ I’d tell her to accept” FGD1.2, 21-year-old female Theme: Consenting: This refers to the process by which health workers convince mothers to have a cesarean section. Code: Creating rapport: Health workers showed that they had the skills of creating rapport with the mothers and they said that they are usually able to convince them to have the cesarean section and those who may refuse are given time to think and are explained to more and in a language they understood better. They make sure the mother has understood. “When they come, we just welcome them, we greet them, you show them a smile so that they can’t fear you, then you talk to them, they tell you why they have come, so if you want information from them, they can tell you. So, you talk to them as long as you know the language, you talk to them. You show them a nice face so; you talk to them.” KII03, 38-year-old female midwife Code: Details given for consenting: Health workers knew the information to give mothers to convince them to accept. They said that as long as you explained the mother’s problem to her and the complications of pushing the baby with such problems, they most of the times accept. The information given included, indications for cesarean section and complications of vaginal delivery. “The indication, why we go to do cesarean section, that is the main information we give” KII01, 29-year-old female midwife 4. Discussion FACILITATORS OF CESAREAN SECTION AMONG MOTHERS AND HEALTH WORKERS AT KABALE REGIONAL REFERRAL HOSPITAL PERCEIVED SELF-EFFICACY Mothers perceived that cesarean section as a mode of delivery was the best option for them probably because it was easier and faster. One mother said; “ Yes, but I came in labour but being cut is easier.” IDI12, 26-year-old female. This perception was probably because these mothers feared vaginal birth as it takes longer hours to go through all the stages of labour till delivery and this long period also involves pain of labour contractions. Therefore, C/S was seen as a better alternative since labour pains aren’t necessary and the procedure usually takes a shorter time. These findings in this theme relate with findings in a research where it was found out that women preferred C/S because it was the most convenient way to deliver ( 20 ). PERCEIVED SUSCEPTIBILITY Mothers who had C/S before perceived that they were susceptible to having it again. For example, a mother said; “ I have always had C/S because the babies are big and don’t descend towards birth so of course I want to do a C/S,” said FGD2.4, 29-year-old female. These mothers probably believed that once one has a C/S, then they would always have it. This could also be because of the health workers advice, where they encourage C/S to mothers who have had two C/S and those with fresh scars. These findings correlate with findings in a study where it was revealed that mothers believed that once a C/S, then always a C/S ( 16 ). PERCEIVED BENEFITS Mothers perceived C/S to be important to save the life of the baby and the mother especially after the mother failed to push. The mothers also perceived that some village members and religious members also perceived C/S as a procedure that helped to save the baby and the mother. For example, a mother said, “They say that it is okay as long as it saves the baby and you” IDI09, 32-year-old female. These mothers, the village and religious members actually understood the indications for C/S after being explained to by the health workers and they understood that if they insisted on pushing either they would lose their lives or the babies’. Health workers were aware of the importance of C/S and perceived it as an important procedure to save the mother and bay’s life especially when the mother presented with failure to push and an indication for C/S such as obstructed labour, 2 previous scars, fetal distress, breach fetal position, cord prolapse, severe gestational hypertension and big fetus. For example, a health worker said, “When the mother is sick and can’t push.” KII05, 35-year-old male medical student. These findings in this theme are in line with the findings in a research were it was found that women had positive views on C/S, that it was safer for the baby ( 21 ). BARRIERS OF C/S AMONG MOTHERS AND HEALTH WORKERS AT KABALE REGIONAL REFERRAL HOSPITAL PERCEIVED BARRIERS Some mothers that had C/S from the facility preferred SVD. For example, a mother said, “ Yes, everyone wants to push.” FGD1.3, 27-year-old female. This was probably because these mothers had faced challenges or complications with C/S and therefore wanted to push. These findings correlated with a research study where it was found out that most women preferred vaginal delivery to C/S ( 20 ) . Some mothers perceived the health workers to be rude. “We are suffering because we can tell the nurses our problems and they ignore us, there are only 2 good nurses. That’s what I’ve seen. Because you can get overwhelmed and you call a nurse and she will just leave you when her shift is done and you suffer. I think nurses should change the way they talk to us; some nurses are truly rude.” IDI07, 27-year-old female. Since these mothers were in pain and needed help, this attitude of health workers could have discouraged them from wanting a C/S again. The findings correlate with the study where it was found out that health workers were rude but the cadre was not specified ( 22 ). Some mothers also perceived that some village and religious members perceived C/S to make the mothers disabled and unable to do work. For example, a mother said, “ They take you as if you are not normal, like your lame and they take you as a disabled. Also, they regard as one who can’t do work. Generally, u seen to be disabled before them.” FGD2.6, 31-year-old female. This community perception probably discouraged mothers from preferring C/S because of the stigma or fear of being considered disabled. Some religious members also perceived C/S to be Satanic. For example, a mother said, “ They say bad things like cesarean section is Satan. Satan comes into your body when you do cesarean section” FGD1.2, 21-year-old female. This perception also probably made the mothers from those religious affiliations hesitant to accept the procedure even on doctor’s advice. The findings in this theme relate with the findings two studies where it was found out that religion and community influenced maternal choice ( 16 , 21 ). Health workers perceived that stock-outs, limited staff assigned to maternity ward, negative community perceptions about C/S and low maternal education level were the barriers to C/S. For example, a health worker said, “Out of stock of things to use, staffing has been a challenge because we are few compared to other hospitals, but staffing is not enough really like you’re seeing now, I’m alone on labour suit and that is not okay, but besides that we are okay.” KII03, a 38-year-old female midwife. These factors probably cause delays in decision making due to the community perceptions and low maternal education level and delays in performing the C/S due to limited work force and stock-outs. These findings correlate with a study where it was found out that the number of seniors less than two had lower odds of C/S delivery ( 23 ). PERCEIVED SEVERITY Mothers that had bad experiences with C/S perceived it to be harmful to them. Mothers mentioned bad experiences like falling ill after C/S, having severe pain after the procedure, headaches, general body weaknesses, long healing time for the C/S, uncomfortable indwelling catheter, long hospital stay and painful anesthesia injections. For example, a mother said, “I have headache and the catheter makes me uncomfortable” IDI04, 20-year-old female. The findings in this theme rate to the study where it was found out that women feared the adverse outcomes related anesthesia and complications of cesarean delivery ( 20 ). 5. Conclusions and recommendations The findings showed that according to the health belief model, the facilitators of cesarean section among mothers and health workers at Kabale Regional Referral Hospital were perceived self-efficacy, perceived susceptibility and perceived benefits. Whereas the barriers of cesarean section among mothers and health workers at Kabale Regional Referral Hospital were perceived barriers and perceived severity According to the results, the major facilitators of cesarean section among mothers and health workers at Kabale Regional Referral Hospital were maternal preference for cesarean section after previous cesarean section, maternal perception of importance of cesarean section to her and the baby, health workers advise, health workers perception of benefit of cesarean section to the mother and baby, traditional birth attendants, community and religious perception of benefits of cesarean section, high knowledge about cesarean section by the health workers, family perception about importance of cesarean section to the mother and baby, friend’s recommendation of cesarean section, health workers’ good communication skills during the consenting process and maternal awareness about their condition and how it prevents vaginal delivery. Also the study findings show that the barriers of cesarean section among mothers and health workers at Kabale Regional Referral Hospital included; rude health workers on maternity ward, high expenditures associated with cesarean section like buying expensive drugs and transport to and from the facility especially for referred mothers, delay by health workers to perform cesarean section on referred mothers, presence of medical students in the theatre during the procedure, community, traditional birth attendants and church’s negative perception of cesarean section, limited staff on maternity ward, stock-outs, maternal preference for vaginal delivery, low education status of mothers, bad previous experience with cesarean section, uncomfortable procedures associated with cesarean section like catheterization and spinal anesthesia injections and perception of having limited number of children due to cesarean section. The researcher recommends the next researchers to study the experience and perception of health workers in line with cesarean section delivery to explore their challenges and personal experiences deeper as this study was majorly focusing on the maternal experience and perception and very little of the health workers experience and perception was explored. The researcher also recommends the next researchers to conduct a similar study in the community in-order to directly acquire the community perceptions about cesarean section since it wasn’t possible to do it in this study. The researcher recommends the government of Uganda and the Ministry of health to perform health education talks in the communities and health facilities to increase knowledge about cesarean section among the mothers and the members of the community. The researcher also recommends the administrator of Kabale Regional Referral Hospital to increase on the number of staff assigned to maternity ward. The researcher recommends the staff on maternity ward to strengthen their audit systems for referred cases for cesarean section in-order to reduce on the rates of cesarean section at Kabale Regional Referral hospital. The researcher recommends the Ministry of Health and the administrative office of Kabale Regional Referral Hospital to put measures that ensure continuous supply of materials and drugs specifically used for cesarean section delivery. Limitations Since the study was hospital based, the researcher was not able to collect community perspectives from the community members like the care givers of cesarean section mothers, traditional birth attendants, village health teams and religious leaders. Abbreviations KRRH- Kabale Regional Referral Hospital CSD- Cesarean section delivery CS- Cesarean section WHO- World Health Organization MOH- Ministry of Health HOD- Head of Department IDIs- In-depth interviews KIIs- Key informant interviews FGDs- Focus Group Discussions Declarations Ethical approval and consent to participate: Approval to conduct the study was granted by the Kabale Research and Ethics Committee: Ethical approval number: KABREC-2023-89 Date of approval: 08- April-2024. The administrative clearance was granted by the Hospital Director of Kabale Regional Referral Hospital in South western Uganda. The In-charge of Maternity ward gave us permission to collect data in her ward and she introduced the data collectors to the eligible mothers and staff on ward. Participants received verbal and written information detailing the purpose and process of the study. All participants gave written informed consent confirming their voluntary participation in the study. Confidentiality and privacy of all data collected were observed during the course of the study through restricted access. This research was carried out in accordance with the Declaration of Helsinki. Consent for publication: Not applicable. Data availability: The raw data supporting the conclusions of this article will be made available by the authors. Competing interests: All authors declare that they don’t have any competing interests regarding this work, be it financial or personal. Funding: This research has not received any funding yet. Author contributions: Conceptualization by P.A and A.N., Data curation by P.A and A.N., Formal analysis by P.A, A.N., Funding acquisition by P. A and A.N., Methodology by P.A and AN, Project administration by P.A and A.N., Resources by P. A and A.N, Supervision by A.N., Writing of original draft by P.A, A.N, E.A and M.M., Review and editing by P.A, A.N, E.A, V.M and M.M. Acknowledgements: We thank the participants for accepting to participate in this study and giving us rich information that was beneficial to the study. Open Access: Article not yet licensed. Contributions to literature: This study assesses the facilitators and barriers of cesarean section and this will provide more literature and knowledge about why cesarean section is done or not done. Although many studies have been done regarding cesarean section and they show that the rates are increasing worldwide, however the reasons for this remains unclear. Different studies to assess these factors in various countries has been done but none in south western Uganda therefore prompting this study in order to contribute to the already existing literature. References WHO. WHO Statement on Caesarean Section Rates. 2015. Vega ES. Rising Trends of Cesarean Section Worldwide: A Systematic Review. Obstet Gynecol Int J. 2015 Nov 6;3(2). Maktha V, Ghatam A, Padamata H, Ravulakol A. Prevalence and factors associated with caesarean section: a community based cross sectional study in rural parts of Rangareddy district, Telangana, India. Int J Community Med Public Heal. 2016;2054–7. Kitaw TM, Limenh SK, Chekole FA, Getie SA, Gemeda BN, Engda AS. Decision to delivery interval and associated factors for emergency cesarean section: a cross-sectional study. BMC Pregnancy Childbirth. 2021 Dec 1;21(1). Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: Global and regional estimates. BMJ Glob Heal. 2021;6(6):1–8. Verma V, Vishwakarma RK, Nath DC, Khan HTA, Prakash R, Abid O. Prevalence and determinants of caesarean section in South and South-East Asian women. PLoS One. 2020;15(3). Kibe PM, Mbuthia GW, Shikuku DN, Akoth C, Oguta JO, Ng’ang’a L, et al. Prevalence and factors associated with caesarean section in Rwanda: a trend analysis of Rwanda demographic and health survey 2000 to 2019–20. BMC Pregnancy Childbirth. 2022 Dec 1;22(1). AD I, N A, J Z. A five-year survey of cesarean delivery at a Nigerian tertiary hospital. Trop J Obstet Gynaecol. 2018;35(1):14. Tsegaye H, Desalegne B, Wassihun B, Bante A, Fikadu K, Debalkie M, et al. Prevalence and associated factors of caesarean section in Addis Ababa hospitals, Ethiopia. Pan Afr Med J. 2019;34. Habteyes AT, Mekuria MD, Negeri HA, Kassa RT, Deribe LK, Sendo EG. Prevalence and associated factors of caesarean section among mothers who gave birth across Eastern Africa countries: Systematic review and meta-analysis study. Heliyon [Internet]. 2024;10(12):e32511. Available from: https://doi.org/10.1016/j.heliyon.2024.e32511 Waniala I, Nakiseka S, Nambi W, Naminya I, Osuban Ajeni M, Iramiot J, et al. Prevalence, Indications, and Community Perceptions of Caesarean Section Delivery in Ngora District, Eastern Uganda: Mixed Method Study. Obstet Gynecol Int. 2020;2020. Adewuyi EO, Auta A, Khanal V, Tapshak SJ, Zhao Y. Cesarean delivery in Nigeria: Prevalence and associated factors •a population-based cross-sectional study. BMJ Open. 2019 Jun 1;9(6). Hailegebreal S, Gilano G, Seboka BT, Ahmed MH, Simegn AE, Tesfa GA, et al. Prevalence and associated factors of caesarian section in Ethiopia: a multilevel analysis of the 2019 Ethiopia Mini Demographic Health Survey. BMC Pregnancy Childbirth. 2021 Dec 1;21(1). Hathout HM, A Elsaid NB, Gabr HM. Prevalence of Cesarean Section Delivery and Associated Risk Factors [Internet]. Available from: http://creativecommons.org/licenses/by/4.0/ Richard F, Zongo S, Ouattara F. Fear, guilt, and debt: An exploration of women’s experience and perception of cesarean birth in Burkina Faso, West Africa. Int J Womens Health. 2014 May 5;6 .(1):469–78. Litorp H, Mgaya A, Kidanto HL, Johnsdotter S, Essén B. “What about the mother?” Women’s and caregivers’ perspectives on caesarean birth in a low-resource setting with rising caesarean section rates. Midwifery. 2015 Jul 1;31(7):713–20. Gagnon AJ, Meier KM, Waghorn K. Continuity of nursing care and its link to cesarean birth rate. Birth. 2007 Mar;34(1):26–31. Rice Simpson K, Lyndon A. CESAREAN BIRTH LABOR NURSES’ VIEWS OF THEIR INFLUENCE ON. 2017. Abraham C, Sheeran P. The health belief model. Cambridge Handb Psychol Heal Med Second Ed. 2014;(June 2015):97–102. Loke AY, Davies L, Li SF. Factors influencing the decision that women make on their mode of delivery: The Health Belief Model. BMC Health Serv Res. 2015 Jul 20;15(1). Colomar M, Opiyo N, Kingdon C, Long Q, Nion S, Bohren MA, et al. Do women prefer caesarean sections? A qualitative evidence synthesis of their views and experiences. PLoS One. 2021 May 1;16(5 May). Mannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and behaviours of maternal health care providers in interactions with clients: A systematic review. Global Health [Internet]. 2015;11(1):1–17. Available from: http://dx.doi.org/10.1186/s12992-015-0117-9 Tenaw Z, Yohannes Z, Bekele G, Kahsaye Z. Prevalence, indications and associated factors of cesarean section delivery at public hospitals in Wolayta Zone Southern, Ethiopia. 2020; Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 24 May, 2026 Reviewers agreed at journal 23 May, 2026 Reviews received at journal 17 Aug, 2025 Reviewers agreed at journal 12 Aug, 2025 Reviewers invited by journal 04 Aug, 2025 Editor invited by journal 09 Jul, 2025 Editor assigned by journal 09 Jul, 2025 Submission checks completed at journal 09 Jul, 2025 First submitted to journal 02 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7029339","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495545191,"identity":"5d5ad75e-ca42-4129-9a14-732c43fb7b28","order_by":0,"name":"Paula Mary Amito","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYFACxgYwxQfhSciByAMP8GtpBOthg/AsjMFaEoixBqqlIhHMw6eFf9rh9gcfd9gltrGfTvxc2SaRPj/s8EOgLXZyug3YtUjcTmxsnHkmObGNJ3ez5Nk2idyNt9MMgFqSjc0O4LAGqKWZt405sY0hd4NkI0jL7ASQlgOJ23BokYdoqU9s43+7+SdQS7rh7PQPeLUYQLQcTgSavw1kS4K8dA5+WwyBWmbOPHPcuE3i7TbLhnMShhukcwoOJBjg9ovc7fQHHz7uqJbt58/dfLOhrE5efnb65g8fKuzkcHofBKAJAMgAxo4BWKUBHuUoWhj+AAOkAbfCUTAKRsEoGJkAABZJaQJhbNVPAAAAAElFTkSuQmCC","orcid":"","institution":"Kabale University","correspondingAuthor":true,"prefix":"","firstName":"Paula","middleName":"Mary","lastName":"Amito","suffix":""},{"id":495545192,"identity":"5c820bd1-4792-40bd-be04-a6b995a2f7c6","order_by":1,"name":"Martha Muduwa","email":"","orcid":"","institution":"Mbale Clinical Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Martha","middleName":"","lastName":"Muduwa","suffix":""},{"id":495545193,"identity":"718eade1-d301-4534-8192-8c7ef94beffd","order_by":2,"name":"Emmanuel Ategeka","email":"","orcid":"","institution":"Kabale University","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Ategeka","suffix":""},{"id":495545194,"identity":"62595417-59c9-48d1-b1ed-9cfaef12f96a","order_by":3,"name":"Valence Mfitumukiza","email":"","orcid":"","institution":"Kabale University","correspondingAuthor":false,"prefix":"","firstName":"Valence","middleName":"","lastName":"Mfitumukiza","suffix":""},{"id":495545195,"identity":"ea1a46c5-d1da-44d6-95dc-4f88853791df","order_by":4,"name":"Agnes Napyo","email":"","orcid":"","institution":"Kabale University","correspondingAuthor":false,"prefix":"","firstName":"Agnes","middleName":"","lastName":"Napyo","suffix":""}],"badges":[],"createdAt":"2025-07-02 12:23:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7029339/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7029339/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88439732,"identity":"d0f521ba-84f4-4569-86dc-979e61028f36","added_by":"auto","created_at":"2025-08-06 12:26:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2177235,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7029339/v1/2b833613-77bd-495e-baca-4b8e6dc88484.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Facilitators and barriers to cesarean section delivery in south western Uganda: A qualitative study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eCesarean section (C/S) is a fetal delivery through an open abdominal incision and an incision on the uterus(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). C/S is the most common surgery done globally (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThere are two classifications of C/S according to time of operation, that is; elective cesarean (where a time is scheduled during pregnancy to undergo the C/S as advised by doctor or on maternal request to ensure the best quality of obstetric care, anesthesia, neonatal resuscitation and nursing services) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Whereas emergency cesarean section (EmC/S) is a surgical procedure that is performed when there is an immediate threat to the life of a fetus and/or woman (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Some indications for C/S include; 2 previous scars, fresh scar (less than 2 years old), labor dystocia, malpresentation of fetus, multiple pregnancy, abnormal fetal heart rate pattern and macrosomia, central placenta previa, contracted pelvis or cephalo-pelvic disproportion, pelvic mass obstruction, advanced carcinoma cervix and vaginal obstruction. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eC/S is part of the comprehensive emergency obstetric care and is important to save maternal and fetal life if kept below the recommended 15% rate by WHO. C/S rates higher than 15% can be disastrous this is because it is associated with both maternal and fetal complications including hemorrhage, sepsis, placenta accreta, fetal respiratory infections. These complication s result into maternal and fetal deaths.\u003c/p\u003e\u003cp\u003eAccording to the World Health Organization (WHO), the recommended rate of C/S is 10\u0026ndash;15%. However, there is an increasing rate of C/S over time worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Evidence from 154 countries covering 94.5% of world live births has shown that from 2010 to 2018, C/S accounts for 21.1% deliveries, averages ranging from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIn a study done in the eastern world based on nine South Asian and South-East Asian countries, cesarean section rates ranged from 1.51\u0026ndash;31.78% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Sub-Saharan Africa, C/S rates in Rwanda, Nigeria and Ethiopia range from 15.6% to as high as 38.3% (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In East Africa, a study showed that the overall prevalence was 24.0%(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A study done in eastern Uganda showed a prevalence of 14% and Uganda\u0026rsquo;s facility-based C/S rate was projected to increase by 36% in 2021, while the population-based C/S rate was estimated to double in the same period from the baseline in 2016 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEvidence shows that increased C/S rates are associated with increase in elective C/S, advanced maternal age, high maternal educational background and maternal urban residence (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConversely, fear for C/S, high costs of C/S, Improper informed consent, religious beliefs were some of the barriers for undertaking C/S among mothers (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eAll health care practitioners especially nurses who mostly interact with pregnant women and their families play an important role in the cesarean delivery rates and use (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Nurses take part in preparing the mother for C/S by obtaining consent, placing urinary catheters, obtaining IV access, administering IV fluids and wheeling the patients to theatre. During C/S, a nurse can assist the surgeon by prepare the instruments and act as patient advocate during the procedure.\u003c/p\u003e\u003cp\u003eNurses play a vital role at all stages of a C/C delivery including the preoperative, intraoperative, and post-operative care of the mother. These roles can include; obtaining consent, placing urinary catheters, obtaining IV access, administering IV fluids and wheeling the patients to theatre. Intraoperative, nurses assist in instrument preparation and act as advocates during the procedure. Post operatively, they receives the baby, admits the mother on post-natal ward, regularly monitors the mother and health educates the mother about post-natal care of herself and the baby (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Nurses therefore play a pivotal role in overall experience of the patient care during C/S delivery. Poor management of C/S at any stage of care can result in significant increase in complications and contribute to a bad patient experience of the procedure. To enable better delivery of this essential service, it is important to understand facilitators and barriers associated of C/S utilization among mothers receiving it and healthcare workers.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003ch2\u003e2.1 Study site and setting\u003c/h2\u003e\n\u003cp\u003eThe study was carried out at Kabale Regional Referral Hospital (KRRH).\u0026nbsp;It is a 280 bed capacityand serves a population of about 2 million people in the districts of Kabale, Kisoro, Rukungiri, Kanungu, and some parts of Ntungamo as well as people from neighboring countries of Rwanda and the Democratic Republic of Congo. Mission of the hospital is to provide quality and sustainable, general and specialized, health services to all people in Kigezi region. \u0026nbsp;(Ministry of Health Uganda, 2019)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This Hospital is located on Makanga Hill in Kabale town, Kabale district found in South-western Uganda. It is about 1.3km from the main Kabale-Kisoro road and approximately 426 Kilometers from Kampala.\u003c/p\u003e\n\u003cp\u003eKRRH provides comprehensive primary and secondary care services ranging from basic and comprehensive obstetric, pediatric and medical care services to its local communities, services such as family planning, HIV/AIDS prevention and treatment, and infectious diseases management, wide range of laboratory services such as X-ray, Ultrasound, CT-scan, and MRI, emergencies and surgeries like C/S delivery. These C/S deliveries are carried out in a general theatre by a specialist Obstetrician or Obstetrics senior house officer (SHO) assisted by a midwife or medical student and anesthesia is given by an anesthesiologist. The hospital has no designated obstetric theater and C/S deliveries are carried out in the main operating theater where other surgical procedures are done. The hospital also houses other units like neonatal unit, laboratory, pharmacy, obstetrics and gynecology units, pediatric unit, maternity, maternal and child health (MCH), outpatient and inpatient services, accidents and emergency unit, radiology unit, dental clinic, ear, nose, throat clinic (ENT), tuberculosis unit and mental unit. Each ward has about four staff per duty that is; In-charge nurse, two nurses, and two doctors and intern doctors, intern nurses and midwives, plus the nursing, midwifery and medical students from nearby institutions that work and learn clinical skills from the hospital. The maternity ward was the specific site for the interviews, it had two obstetricians, three senior medical officers, 6 midwives and five intern doctors. The hospital is affiliated with the Ministry of Health in Uganda and is a World Bank\u0026ndash;approved institution. This study setting was chosen because it is a regional referral where the lower cadre facilities also refer high risk women for C/S delivery making it a suitable site for the study.\u003c/p\u003e\n\u003ch2\u003e2.2 Study design\u003c/h2\u003e\n\u003cp\u003eThis study employed a qualitative study design with a theoretical approach. This study relied on the Health Belief Model (19,20) in the designing of the data collection tools, the analysis, reporting and interpretation of findings. Data collection took place from January 2024 to February 2024 and analysis took place from February 2024 to the month of March 2024.\u003c/p\u003e\n\u003ch2\u003e2.3 Study population and size\u003c/h2\u003e\n\u003cp\u003eThe study consisted of 36 participants that is; 30 mothers and 6 health workers. We had 18 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with the mothers. These focus group discussions had 6 participants in each. We had 6 key informant interviews (KIIs) with the health workers consisting of: 1 senior obstetrics and gynecology consultant, 1 senior medical officer, 2 intern doctors and 2 midwives (Table 1)\u003c/p\u003e\n\u003ch2\u003e2.4 Participant selection \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eIn this study, convenience sampling was used to select mothers who met the inclusion criteria. We considered mothers who are 0 days to 6 weeks postpartum who delivered by C/S at Kabale Regional Referral Hospital (KRRH) and consented to participate in the study. We considered 6 weeks postpartum and below because in this time frame the mother is able to recall events surrounding the C/S delivery. Purposive sampling was used to select the health workers because they had the technical knowledge and experience in performing C/S delivery.\u003c/p\u003e\n\u003ch2\u003e2.5 Data collection procedures and methods\u003c/h2\u003e\n\u003cp\u003eThe study got ethical approval from the Department of Nursing Sciences, KRRH Research Ethics Committee and administrative clearance from KRRH. Approvals were presented to the ward in-charge before data collection was undertaken. The In-charges helped the researcher in identifying willing participants for the various data collection methods\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e. Mothers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach mother was approached individually and their voluntary written informed consent sought before proceeding to data collection. The participants were informed of the aims of the study and the interviewer established rapport with the participants prior to the interviews. The mother with her baby were then escorted to the designated place.\u003c/p\u003e\n\u003cp\u003eThe face-to-face in-depth interviews and focus group discussions were conducted in a private, free and quiet room on maternity ward. Each mother was interviewed individually using an in-depth interview guide for the IDI and a focus group discussion guide for the FGD, each containing topics of discussion, guiding questions and probes. The interviews and discussions were conducted in English and the local language \u003cem\u003eRukiga\u003c/em\u003e. For interviews conducted in \u003cem\u003eRukiga\u003c/em\u003e, a translator was used. The participants were identified using codes to keep their identity anonymous. Each IDI lasted approximately 20 to 30 minutes whereas the FGD lasted 50 minutes to 1 hour. Additional information collected included participant demographic data. For covid-19 precautions, the interviewer and the participants wore facial masks and kept social distance was kept between them. An alcohol-based hand sanitizer was used by all participants and interviewers before, during and after each interview or FGD session.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Health workers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe approached each health worker one at a time. To each health worker, we introduced herself, explained the details of the study and sought for their voluntary informed consent. We established rapport with the health workers and sought for consent to audio record the interviews. The health worker was then escorted to a designated place for the interview process to take place.\u003c/p\u003e\n\u003cp\u003eThe face-to-face key informant interviews were conducted in a private, free and quiet room on maternity ward. Before proceeding with the interview, the participants were given information about the study and aims clearly communicated. Each health worker was interviewed individually using a topic guide containing topics of discussion, guiding questions and probes. The interviews were conducted in English. The participants were identified using codes to keep their identity anonymous. The sessions took approximately 15 to 20 minutes. Additional information collected included participant demographic data. For covid-19 precautions, the interviewer made sure that participants were wearing facial masks and kept social distance between the interviewer and participants during interviews. An alcohol-based hand sanitizer was used before, during and after each interview for all participants and the interviewer.\u003c/p\u003e\n\u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:8.0pt;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTABLE 1: TABLE SHOWING THE NUMBER OF PARTICIPANTS PER DATA COLLECTION METHOD\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;border: none;width: 639px;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81.7pt;border: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eData collection method\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64.45pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eSenior obstetrics and gynecology consultant\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eSenior medical officer\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76.6pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eInterns doctors\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eMidwives\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82.2pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eMothers who had undergone C/S\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81.7pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eFGDs\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64.45pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e2 groups each consisting of 6 mothers; n=12\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81.7pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eKIIs\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64.45pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81.7pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eIDIs\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64.45pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;background: rgb(89, 89, 89);padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e18 mothers\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003en= 18\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 81.7pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTOTAL\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64.45pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74.85pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76.6pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82.2pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0cm 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:0cm;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e36\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin-top:0cm;margin-right:0cm;margin-bottom:8.0pt;margin-left:0cm;font-size:11.0pt;font-family:\"Calibri\",sans-serif;text-align:justify;line-height:115%;'\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eGRAND TOTAL (N) is 2+2+2+31 = 36\u003c/span\u003e\u003c/p\u003e\n\u003ch2\u003e2.6 Data management and analysis\u003c/h2\u003e\n\u003cp\u003eWe transferred the audio recordings of the interviews from the audio recorder to the laptop. We then listened and re-listened to each audio recording while transcribing the interviews verbatim in English into Microsoft word 2016 while saving each transcript with the client code name. We created an analytical framework to extract potential themes from the text data as per each objective of the study (Table 3). We then read and re-read through all transcripts while extracting codes and typing them into Microsoft word 2016 to create a code book. The transcripts were exported into a qualitative data analysis software, NVivo 20.2 (https://qsr-nvivo.software.informer.com/download/). Within the analytical software, the codes that had been created in the code book were generated and the process of attaching corresponding reference text to each generated code was done. Two data coders and analysts (PA and AN) Two researchers (PA and AN) carried out the coding and analysis at each level. The codes and corresponding reference texts were then exported back to Microsoft Word 2016 and saved. The reference texts and their codes were then tabulated and the analytical framework was aligned to the Health Belief Model (19) \u0026nbsp;and were then inserted in the table to make it complete. The health belief model was used because it helped to better present the results of experiences and perceptions of the mothers and health workers. \u0026nbsp;This was the process of content thematic analysis. The most appropriate reference texts were selected under each code and aligned under the themes in the health belief model. Consolidated criteria for reporting qualitative research (COREQ) were closely followed during the reporting of study findings.\u003c/p\u003e\n\u003ch2\u003e2.7 Reflexivity\u003c/h2\u003e\n\u003cp\u003eBeing qualitative researchers, we know that our prejudices, ideas, perceptions and assumptions could have influenced the study. During the entire research process, all members of the research team made sure to be aware of and address these influences through frequent self-refection. We tried to bracket our biases and assumptions, while recognizing that complete objectivity was unattainable. So, in order to enhance the trustworthiness of the findings, every member of the research team had a journal where each one documented their thoughts, feelings, and decisions during each interview or discussion. We also had on going self-critique of our own positionality and biases.\u003c/p\u003e"},{"header":"3. Results","content":"\u003ch2\u003e3.1 Participant characteristics\u003c/h2\u003e\n\u003cp\u003eParticipant characteristics/ demographic data is presented in table 2.\u003c/p\u003e\n\u003cp\u003eThe mean age of health workers was 32 years, all of them had tertiary level of education, two were married, four were single, three were Bakiga, one was a Muganda, one was a Mufumbira and one was foreign (Somali). (Table 2)\u003c/p\u003e\n\u003ch2\u003e3.2 Mothers\u003c/h2\u003e\n\u003cp\u003eThe study included mothers who had a cesarean section delivery at Kabale Regional Referral Hospital between 0 days to 6 weeks and agreed to consent to be part of the study. We considered 6 weeks postpartum and below because in this time frame the mother is able to recall events surrounding the cesarean section delivery. The mean age of mothers was 26.8. 57% of the mothers had primary education, 37% of them had secondary education, and 7% had tertiary education. 93% of the mothers were married and 7% were single, twenty-eight were Bakiga and two were Banyankole. Thirteen of them were Anglican, thirteen were Catholic, three were born again and one was Pentecostal (Table 2).\u003c/p\u003e\n\u003ch2\u003e3.3 Health workers\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe study included health workers who were rotating on maternity ward and consented to be part of the study and these included: gynecologist consultant, senior medical officer, midwives and intern doctors. The mean age of health workers was 32 years, all of them had tertiary level of education, two were married, four were single, three were Bakiga, one was a Muganda, one was a Mufumbira and one was foreign (Somali). (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 2: A TABLE SHOWING THE DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCode\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTribe\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion/cadre\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eData collection method\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary three\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003ePentecost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior three\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI06\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI07\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI08\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI09\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary five\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary five\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eBorn again\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMunyankole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eBorn again\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIDI18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eIn\u003c/p\u003e\n \u003cp\u003e-depth interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG1.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG1.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG1.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG1.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior one\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG1.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior three\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG1.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG2.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG2.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG2.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary four\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eBorn again\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG2.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003ePrimary seven\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMunyankole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG2.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eSenior two\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eAnglican\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFDG2.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eCatholic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eFocus group discussion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKII01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eKey informant interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKII02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eBachelors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMuganda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eIntern doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eKey informant interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKII03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eMidwife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eKey informant interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKII04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eBachelors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eSomali\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eIntern doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eKey informant interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKII05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eBachelors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMufumbira\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eSenior medical officer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eKey informant interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKII06\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eBachelors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eMukiga\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003eSenior gynecology and obstetrics Consultant\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eKey informant interview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e3.4 Presentation of results\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe results were presented according to the objectives and themes of the health belief model as shown in table 3 below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 3: A TABLE SHOWING THE RESULTS; THEMES, CORRESPONDING CODES AND QUOTES ACCORDING TO THE OBJECTIVES AND THE HEALTH BELIEF MODEL\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFACILITATORS OF CESAREAN SECTION AT KABALE REGIONAL REFERRAL HOSPITAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBARRIERS OF CESAREAN SECTION AT KABALE REGIONAL REFERRAL HOSPITAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePerceived self-efficacy\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Maternal preference\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCodes:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePreferred delivery mode at admission\u003c/p\u003e\n \u003cp\u003ePreferred mode of delivery on next pregnancy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePerceived barriers\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Care\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCodes:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eRecommendations from mothers to health workers\u003c/p\u003e\n \u003cp\u003eCare by health workers\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Health worker related barriers\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCode: Challenges faced by health workers\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Maternal preference\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCodes:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePreferred delivery mode at admission\u003c/p\u003e\n \u003cp\u003ePreferred mode of delivery on next pregnancy\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Maternal attitude\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCode:\u0026nbsp;\u003c/strong\u003eRecommendations from mothers to health workers\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Community perceptions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCodes:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePerception of village members\u003c/p\u003e\n \u003cp\u003eReligious perception\u003c/p\u003e\n \u003cp\u003eTBAs perception\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePerceived susceptibility\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Maternal preference\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCode:\u0026nbsp;\u003c/strong\u003ePreferred mode of delivery on next pregnancy\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePerceived severity\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Maternal experience with cesarean section as a barrier\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCodes:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eChanges on body after cesarean section\u003c/p\u003e\n \u003cp\u003eComplications of cesarean section\u003c/p\u003e\n \u003cp\u003eDisadvantages of cesarean section\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003ePerceived benefits\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Benefits of cesarean section\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCodes:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eImportance of cesarean section\u003c/p\u003e\n \u003cp\u003esReasons for accepting/doing cesarean section\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTheme: Community perceptions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCodes:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eReligious perception\u003c/p\u003e\n \u003cp\u003ePerception of village members\u003c/p\u003e\n \u003cp\u003eTBAs perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e3.5 Narrative of results in table 3\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFacilitators of cesarean section among mothers and health workers at Kabale Regional Referral Hospital\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e1. Perceived self-efficacy:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003eAccording to the HBM, perceived self-efficacy is the belief in one\u0026rsquo;s ability to successfully perform a behavior, in this study that behavior is cesarean section.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Maternal preference:\u003c/strong\u003e this refers to what the mode of delivery the mother prefers\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Preferred delivery mode at admission:\u0026nbsp;\u003c/strong\u003eSome mothers, who had a previous cesarean section in the past had believed that they had the ability to successfully have another and preferred it while those who had it for the first time accepted C/S due to failed vaginal delivery and had cesarean section.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I wanted a cesarean section because 2 weeks ago I went to a health center to deliver but the contractions later left and I was referred here so by the time I reached I was tired and was put on oxygen and I wanted a cesarean section as fast as possible.\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI05, 27-year-old female\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;\u003cem\u003eYes, but I came in labour but being cut is easier.\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI12, 26-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Preferred mode of delivery on next pregnancy:\u0026nbsp;\u003c/strong\u003eSome\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003emothers who had cesarean section at the time of data collection wanted a cesarean section on the next birth because they believed they could successfully undergo the procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eI have always had cesarean section because the babies are big and don\u0026rsquo;t descend towards birth so of course I want to do a cesarean section.\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD2.4, 29-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e2. Perceived susceptibility:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003eThis refers to the mother\u0026rsquo;s belief that they will undergo the procedure again.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Maternal preference\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Preferred mode of delivery on next pregnancy:\u0026nbsp;\u003c/strong\u003eSome mothers believed that after the cesarean section, that they will automatically have it again. Mothers believed having a C/S delivery automatically resulted in subsquent delivery by the same.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eI have always had cesarean section because the babies are big and don\u0026rsquo;t descend towards birth so of course I want to do a cesarean section.\u0026rdquo;\u003c/em\u003e FGD2.4, 29-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e3. Perceived benefits:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003eThis refers to the belief that cesarean section is beneficial\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Benefits of cesarean section:\u003c/strong\u003e this refers to the importance of cesarean section to the mother\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Importance of cesarean section:\u003c/strong\u003e Mothers perceived C/S delivery as helpful in relieving the contractions associated with vaginal delivery. They perceived it to be faster and easier than a vaginal delivery. \u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eThe truth is cesarean section is less painful, and its faster and the suture pains you later, it\u0026rsquo;s like u were in a lot of pain and someone says let me help you, u feel good.\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD2.1, 30-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Reasons for accepting/doing cesarean section:\u0026nbsp;\u003c/strong\u003ewhen mothers where asked why they accepted to do cesarean section, they gave indications or reasons the doctors had given them as to why they couldn\u0026rsquo;t push and therefore cesarean section saved their babies and themselves. The health workers also gave indications for conducting cesarean section and they said it helps when the mother has failed to push.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMothers identified stated the indications offered by health workers for C/S delivery as the reason for accepting the C/S. There was coherence in the responses given by both mothers and healthcare workers indicating the information shared by the HCW influenced decisions made by the mothers to undergo C/S.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They told me that after I will not be able to deliver normally because the placenta was the first and was covering the outlet.\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI14, 30-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eThey checked me and they saw that I was sick down and my uterus will not push the baby then they said I should proceed and the children were sick and I was also sick. And I used to fall sick frequently during pregnancy, so, they said they should do cesarean section to save the children. That\u0026rsquo;s how I got a cesarean section.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFGD2.1, 30-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Community perceptions:\u003c/strong\u003e This refers to the thoughts of the church and village members as well as the TBAs\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Church members\u0026rsquo; perception:\u0026nbsp;\u003c/strong\u003eSome mothers said that the church members and leaders think that cesarean section is good and beneficial to the mother and the baby.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They give testimonies that cesarean section helped them\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI04, 20-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Perception of village members:\u0026nbsp;\u003c/strong\u003eSome mothers said that some of the village members supported cesarean section.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They say that it is okay as long as it saves the baby and you\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI09, 32-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: TBAs perception:\u0026nbsp;\u003c/strong\u003eSome mothers said that TBAs supported cesarean section because it saves the mother and baby.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They do not want you to deliver from the village if the mother is not able to deliver normally, they send then to the hospital\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI10, 23-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eBarriers of cesarean section among mothers and health workers at Kabale Regional Referral Hospital\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e1. Perceived barriers\u003c/u\u003e\u003c/strong\u003e: According to the Health Belief Model, perceived barriers are perceptions or experiences that prevent mothers from accepting cesarean section or they hinder health workers from performing cesarean section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Care:\u0026nbsp;\u003c/strong\u003ethis refers to the care given to the mothers by the health workers\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Care by health workers:\u0026nbsp;\u003c/strong\u003eSome mothers said that some health workers were rude like FGD2.3 said that some heath workers who talked badly might have not been in a good mood. Mothers complained of painful procedures like anesthesia injections while other mothers complained of being ignored by the nurses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026ldquo;We are suffering because we can tell the nurses our problems and they ignore us, there are only 2 good nurses. That\u0026rsquo;s what I\u0026rsquo;ve seen. Because you can get overwhelmed and you call a nurse and she will just leave you when her shift is done and you suffer. I think nurses should change the way they talk to us; some nurses are truly rude.\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI07, a 22-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Health worker related barriers:\u0026nbsp;\u003c/strong\u003ethese are hospital factors that prevent use or cause delay of cesarean section for example hospital setting\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Challenges faced by health workers:\u0026nbsp;\u003c/strong\u003eHealth workers said that they had things that cause delay or failure to perform cesarean section and these included, stock-outs, limited staff on maternity ward, community perception of cesarean section making mothers disabled discouraged them from accepting, skills of health workers and low level of education status of mothers, limited theatre rooms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Out of stock of things to use, staffing has been a challenge because we are few compared to other hospitals, but staffing is not enough really like your seeing now, I\u0026rsquo;m alone on labour suit and that is not okay, but besides that we are okay.\u0026rdquo;\u0026nbsp;\u003c/em\u003eKII03, a 38-year-old female midwife\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Maternal preference:\u003c/strong\u003e this refers to the mother\u0026rsquo;s preferred mode of delivery\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Preferred delivery mode at admission:\u0026nbsp;\u003c/strong\u003esome mothers wanted to push on arrival at the hospital but failed. Others were told to have a cesarean section earlier but they still preferred to push their babies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eYes, everyone wants to push.\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD1.3, 27-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Preferred mode of delivery on next pregnancy:\u0026nbsp;\u003c/strong\u003esome mothers including those who had two previous cesarean sections and above also desired to push on the next delivery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I would have wanted to push but it is impossible according to the health workers.\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI15, 35-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Maternal attitude:\u003c/strong\u003e this refers to the way the mother reacts or thinks towards cesarean section\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Recommendations from mothers to health workers:\u0026nbsp;\u003c/strong\u003eMothers wanted heath workers to improve on the care they give like some mothers said that some health workers should improve on the way they talk to the mothers. They were therefor not satisfied with the care given by the health workers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026ldquo;We are suffering because we can tell the nurses our problems and they ignore us, there are only 2 good nurses. That\u0026rsquo;s what I\u0026rsquo;ve seen. Because you can get overwhelmed and you call a nurse and she will just leave you when her shift is done and you suffer. I think nurses should change the way they talk to us; some nurses are truly rude.\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI07, 27-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Community perceptions:\u0026nbsp;\u003c/strong\u003eThis refers to the thoughts and ideas of the community members that may prevent mothers from using or accepting cesarean section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Perception of village members:\u0026nbsp;\u003c/strong\u003eMothers said that village members had negative ideas about cesarean section.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eThey take you as if you are not normal, like your lame and they take you as a disabled. Also, they regard as one who can\u0026rsquo;t do work. Generally, u seen to be disabled before them.\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD2.6, 31-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Church members\u0026rsquo; perception:\u0026nbsp;\u003c/strong\u003eMothers said that church members said bad things about cesarean section, like some believed that cesarean section is Satan and Satan enters your body after having it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eThey say bad things like cesarean section is Satan. Satan comes into your body when you do cesarean section\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD1.2, 21-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: TBAs perception:\u0026nbsp;\u003c/strong\u003eMothers said that some Traditional birth attendants had bad ideas about cesarean section and that they don\u0026rsquo;t believe that a woman can fail to push.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eThey don\u0026rsquo;t believe that someone can fail to push, so they think if you\u0026rsquo;ve been going to them and they attend to you as someone that has been pregnant, they devise means for you to push. So, they don\u0026rsquo;t believe that someone can be pregnant and fail to push.\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD2.1, 30-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003e2. Perceived severity\u003c/u\u003e\u003c/strong\u003e: These are the maternal perceptions that cesarean section is harmful.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Maternal experience with cesarean section as a barrier:\u0026nbsp;\u003c/strong\u003eThis refers to the experiences of the mother regarding cesarean section that might make her not accept/prefer cesarean section delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Changes on body after cesarean section:\u0026nbsp;\u003c/strong\u003eMothers reported that they had issues on their bodies after or related to cesarean section like the painful incision, body weakness and failure to walk properly for a while.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eOn my body, I feel weak, I can\u0026rsquo;t walk well.\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD1.3, 27-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Complications of cesarean section:\u0026nbsp;\u003c/strong\u003eMothers said that cesarean section had complications like falling sick, long healing time, headache, unconsciousness, paralysis around the waist and thighs, back ache, pain at the incision site, unbearable pain, death of the baby and bursting of the previous scar.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eOur bodies are not the same, some people heal faster after theatre compared to others like me I\u0026rsquo;ve been here for a week and I\u0026apos;ve been sickly with headaches and medication wasn\u0026rsquo;t working, bodies are not the same, but the others I underwent the procedure with on the same day were discharged when they were well\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD2.3, 39-year-old female\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eThe wound healed within a month but the tingling pain took about 2 and a half months.\u0026rdquo;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eIDI17, 36-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Disadvantages of cesarean section:\u0026nbsp;\u003c/strong\u003eMothers said that cesarean section was associated with problems like lack of energy, inability to do work because of the pain, it is more expensive, high expenditure on drugs and transport, inability to deliver many children, failure to use family planning, failure to have more than five children and uncomfortability with the catheter.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eIf you had planned to have more than 5 children and they tell us that with cesarean section, you cannot exceed 5 children. So, that can cause your husband look for another wife if he wants to make the number of children he wants or you yourself you feel guilty that why can\u0026rsquo;t I deliver more than 5 children. But with the Uganda of nowadays, no one wants to have more than 5 children. So cesar is of more good than harm.\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD2.6, 31-year-old female\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026ldquo;I have headache and the catheter makes me uncomfortable\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI04, 20-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eOther facilitators of cesarean section that are not in the health belief model\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Health worker attitude towards caesarean section rate:\u0026nbsp;\u003c/strong\u003eThis refers to the way health workers react or relate to the cesarean section rates at Kabale Regional Referral Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Attitude towards Kabale Regional Referral Hospital cesarean section rates:\u0026nbsp;\u003c/strong\u003eThe health workers had a positive attitude towards the high rates of cesarean section at Kabale Regional Referral Hospital. They said that Kabale Regional Referral Hospital being a regional referral, therefore the high rates were inevitable as most referrals came specifically for cesarean section.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eSince it is a referral most of the mothers are done cesarean section, according total number of admissions, total deliveries, I think cesarean section deliveries are higher than normal deliveries. But it is a referral and we receive most mothers from lower health facilities who are specifically for C/S, so I think its fine\u003c/em\u003e\u0026rdquo; KIIO1, a 29-year-old midwife\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Awareness of Kabale Regional Referral Hospital cesarean section rates:\u0026nbsp;\u003c/strong\u003ethe health workers were aware that the rates of cesarean section at Kabale Regional Referral Hospital were high. However, they were not aware of the exact rate of cesarean section at the facility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026ldquo;I\u0026apos;ve gotten chance of listening to the in-charge and the rates are between 30-41%.\u0026rdquo;\u0026nbsp;\u003c/em\u003eKII02, a 27-year-old male intern doctor\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Key decision makers in consenting for cesarean section:\u0026nbsp;\u003c/strong\u003ethis refers to the people other than the mother that influenced her decision to accept cesarean section\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Other decision makers in cesarean section:\u0026nbsp;\u003c/strong\u003emany mothers said that they just followed the health workers advise while some mothers said that their mothers, mothers-in law and especially their husbands helped them decide.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My husband and my mum helped to make a decision during the consent.\u0026rdquo;\u0026nbsp;\u003c/em\u003eIDI01, 22-year-old female\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome mothers said that the decision was entirely theirs for example; \u003cstrong\u003e\u003cem\u003eFGD2.3: \u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eI decide, even my husband can\u0026rsquo;t stop me, unless he refuses to sign, but I decide for myself because I want to be well.\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD2.3, 39-year-old female\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Maternal attitude:\u0026nbsp;\u003c/strong\u003ethis refers to the way the mother reacts towards cesarean section\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Recommending cesarean section to someone else:\u0026nbsp;\u003c/strong\u003eMost mothers said that they would recommend cesarean section to a friend or someone who has been advised by the doctor to have it. Others said that the mode of delivery is the mother\u0026rsquo;s choice and others said that they would tell them to follow the doctor\u0026rsquo;s advice. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eI\u0026rsquo;d tell her to accept\u0026rdquo;\u0026nbsp;\u003c/em\u003eFGD1.2, 21-year-old female\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme: Consenting:\u0026nbsp;\u003c/strong\u003eThis refers to the process by which health workers convince mothers to have a cesarean section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Creating rapport:\u0026nbsp;\u003c/strong\u003eHealth workers showed that they had the skills of creating rapport with the mothers and they said that they are usually able to convince them to have the cesarean section and those who may refuse are given time to think and are explained to more and in a language they understood better. They make sure the mother has understood. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When they come, we just welcome them, we greet them, you show them a smile so that they can\u0026rsquo;t fear you, then you talk to them, they tell you why they have come, so if you want information from them, they can tell you. So, you talk to them as long as you know the language, you talk to them. You show them a nice face so; you talk to them.\u0026rdquo;\u0026nbsp;\u003c/em\u003eKII03, 38-year-old female midwife\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode: Details given for consenting:\u0026nbsp;\u003c/strong\u003eHealth workers knew the information to give mothers to convince them to accept. They said that as long as you explained the mother\u0026rsquo;s problem to her and the complications of pushing the baby with such problems, they most of the times accept. The information given included, indications for cesarean section and complications of vaginal delivery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The indication, why we go to do cesarean section, that is the main information we give\u0026rdquo;\u0026nbsp;\u003c/em\u003eKII01, 29-year-old female midwife\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFACILITATORS OF CESAREAN SECTION AMONG MOTHERS AND HEALTH WORKERS AT KABALE REGIONAL REFERRAL HOSPITAL\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePERCEIVED SELF-EFFICACY\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMothers perceived that cesarean section as a mode of delivery was the best option for them probably because it was easier and faster. One mother said; \u0026ldquo;\u003cem\u003eYes, but I came in labour but being cut is easier.\u0026rdquo;\u003c/em\u003e IDI12, 26-year-old female. This perception was probably because these mothers feared vaginal birth as it takes longer hours to go through all the stages of labour till delivery and this long period also involves pain of labour contractions. Therefore, C/S was seen as a better alternative since labour pains aren\u0026rsquo;t necessary and the procedure usually takes a shorter time.\u003c/p\u003e\u003cp\u003eThese findings in this theme relate with findings in a research where it was found out that women preferred C/S because it was the most convenient way to deliver (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePERCEIVED SUSCEPTIBILITY\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMothers who had C/S before perceived that they were susceptible to having it again. For example, a mother said; \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eI have always had C/S because the babies are big and don\u0026rsquo;t descend towards birth so of course I want to do a C/S,\u0026rdquo;\u003c/em\u003e said FGD2.4, 29-year-old female. These mothers probably believed that once one has a C/S, then they would always have it. This could also be because of the health workers advice, where they encourage C/S to mothers who have had two C/S and those with fresh scars.\u003c/p\u003e\u003cp\u003eThese findings correlate with findings in a study where it was revealed that mothers believed that once a C/S, then always a C/S (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePERCEIVED BENEFITS\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMothers perceived C/S to be important to save the life of the baby and the mother especially after the mother failed to push. The mothers also perceived that some village members and religious members also perceived C/S as a procedure that helped to save the baby and the mother. For example, a mother said, \u003cem\u003e\u0026ldquo;They say that it is okay as long as it saves the baby and you\u0026rdquo;\u003c/em\u003e IDI09, 32-year-old female. These mothers, the village and religious members actually understood the indications for C/S after being explained to by the health workers and they understood that if they insisted on pushing either they would lose their lives or the babies\u0026rsquo;. Health workers were aware of the importance of C/S and perceived it as an important procedure to save the mother and bay\u0026rsquo;s life especially when the mother presented with failure to push and an indication for C/S such as obstructed labour, 2 previous scars, fetal distress, breach fetal position, cord prolapse, severe gestational hypertension and big fetus. For example, a health worker said, \u003cem\u003e\u0026ldquo;When the mother is sick and can\u0026rsquo;t push.\u0026rdquo;\u003c/em\u003e KII05, 35-year-old male medical student.\u003c/p\u003e\u003cp\u003eThese findings in this theme are in line with the findings in a research were it was found that women had positive views on C/S, that it was safer for the baby (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eBARRIERS OF C/S AMONG MOTHERS AND HEALTH WORKERS AT KABALE REGIONAL REFERRAL HOSPITAL\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePERCEIVED BARRIERS\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome mothers that had C/S from the facility preferred SVD. For example, a mother said, \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eYes, everyone wants to push.\u0026rdquo;\u003c/em\u003e FGD1.3, 27-year-old female. This was probably because these mothers had faced challenges or complications with C/S and therefore wanted to push. These findings correlated with a research study where it was found out that most women preferred vaginal delivery to C/S (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003eSome mothers perceived the health workers to be rude. \u003cem\u003e\u0026ldquo;We are suffering because we can tell the nurses our problems and they ignore us, there are only 2 good nurses. That\u0026rsquo;s what I\u0026rsquo;ve seen. Because you can get overwhelmed and you call a nurse and she will just leave you when her shift is done and you suffer. I think nurses should change the way they talk to us; some nurses are truly rude.\u0026rdquo;\u003c/em\u003e IDI07, 27-year-old female. Since these mothers were in pain and needed help, this attitude of health workers could have discouraged them from wanting a C/S again. The findings correlate with the study where it was found out that health workers were rude but the cadre was not specified (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSome mothers also perceived that some village and religious members perceived C/S to make the mothers disabled and unable to do work. For example, a mother said, \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eThey take you as if you are not normal, like your lame and they take you as a disabled. Also, they regard as one who can\u0026rsquo;t do work. Generally, u seen to be disabled before them.\u0026rdquo;\u003c/em\u003e FGD2.6, 31-year-old female. This community perception probably discouraged mothers from preferring C/S because of the stigma or fear of being considered disabled. Some religious members also perceived C/S to be Satanic. For example, a mother said, \u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eThey say bad things like cesarean section is Satan. Satan comes into your body when you do cesarean section\u0026rdquo;\u003c/em\u003e FGD1.2, 21-year-old female. This perception also probably made the mothers from those religious affiliations hesitant to accept the procedure even on doctor\u0026rsquo;s advice. The findings in this theme relate with the findings two studies where it was found out that religion and community influenced maternal choice (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHealth workers perceived that stock-outs, limited staff assigned to maternity ward, negative community perceptions about C/S and low maternal education level were the barriers to C/S. For example, a health worker said, \u003cem\u003e\u0026ldquo;Out of stock of things to use, staffing has been a challenge because we are few compared to other hospitals, but staffing is not enough really like you\u0026rsquo;re seeing now, I\u0026rsquo;m alone on labour suit and that is not okay, but besides that we are okay.\u0026rdquo;\u003c/em\u003e KII03, a 38-year-old female midwife. These factors probably cause delays in decision making due to the community perceptions and low maternal education level and delays in performing the C/S due to limited work force and stock-outs. These findings correlate with a study where it was found out that the number of seniors less than two had lower odds of C/S delivery (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePERCEIVED SEVERITY\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMothers that had bad experiences with C/S perceived it to be harmful to them. Mothers mentioned bad experiences like falling ill after C/S, having severe pain after the procedure, headaches, general body weaknesses, long healing time for the C/S, uncomfortable indwelling catheter, long hospital stay and painful anesthesia injections. For example, a mother said, \u003cem\u003e\u0026ldquo;I have headache and the catheter makes me uncomfortable\u0026rdquo;\u003c/em\u003e IDI04, 20-year-old female. The findings in this theme rate to the study where it was found out that women feared the adverse outcomes related anesthesia and complications of cesarean delivery (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e"},{"header":"5. Conclusions and recommendations","content":"\u003cp\u003eThe findings showed that according to the health belief model, the facilitators of cesarean section among mothers and health workers at Kabale Regional Referral Hospital were perceived self-efficacy, perceived susceptibility and perceived benefits. Whereas the barriers of cesarean section among mothers and health workers at Kabale Regional Referral Hospital were perceived barriers and perceived severity\u003c/p\u003e\u003cp\u003e According to the results, the major facilitators of cesarean section among mothers and health workers at Kabale Regional Referral Hospital were maternal preference for cesarean section after previous cesarean section, maternal perception of importance of cesarean section to her and the baby, health workers advise, health workers perception of benefit of cesarean section to the mother and baby, traditional birth attendants, community and religious perception of benefits of cesarean section, high knowledge about cesarean section by the health workers, family perception about importance of cesarean section to the mother and baby, friend\u0026rsquo;s recommendation of cesarean section, health workers\u0026rsquo; good communication skills during the consenting process and maternal awareness about their condition and how it prevents vaginal delivery.\u003c/p\u003e\u003cp\u003eAlso the study findings show that the barriers of cesarean section among mothers and health workers at Kabale Regional Referral Hospital included; rude health workers on maternity ward, high expenditures associated with cesarean section like buying expensive drugs and transport to and from the facility especially for referred mothers, delay by health workers to perform cesarean section on referred mothers, presence of medical students in the theatre during the procedure, community, traditional birth attendants and church\u0026rsquo;s negative perception of cesarean section, limited staff on maternity ward, stock-outs, maternal preference for vaginal delivery, low education status of mothers, bad previous experience with cesarean section, uncomfortable procedures associated with cesarean section like catheterization and spinal anesthesia injections and perception of having limited number of children due to cesarean section.\u003c/p\u003e\u003cp\u003eThe researcher recommends the next researchers to study the experience and perception of health workers in line with cesarean section delivery to explore their challenges and personal experiences deeper as this study was majorly focusing on the maternal experience and perception and very little of the health workers experience and perception was explored.\u003c/p\u003e\u003cp\u003eThe researcher also recommends the next researchers to conduct a similar study in the community in-order to directly acquire the community perceptions about cesarean section since it wasn\u0026rsquo;t possible to do it in this study.\u003c/p\u003e\u003cp\u003eThe researcher recommends the government of Uganda and the Ministry of health to perform health education talks in the communities and health facilities to increase knowledge about cesarean section among the mothers and the members of the community.\u003c/p\u003e\u003cp\u003eThe researcher also recommends the administrator of Kabale Regional Referral Hospital to increase on the number of staff assigned to maternity ward.\u003c/p\u003e\u003cp\u003eThe researcher recommends the staff on maternity ward to strengthen their audit systems for referred cases for cesarean section in-order to reduce on the rates of cesarean section at Kabale Regional Referral hospital.\u003c/p\u003e\u003cp\u003eThe researcher recommends the Ministry of Health and the administrative office of Kabale Regional Referral Hospital to put measures that ensure continuous supply of materials and drugs specifically used for cesarean section delivery.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eSince the study was hospital based, the researcher was not able to collect community perspectives from the community members like the care givers of cesarean section mothers, traditional birth attendants, village health teams and religious leaders.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eKRRH-\u0026nbsp;\u003c/strong\u003eKabale Regional Referral Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCSD-\u0026nbsp;\u003c/strong\u003eCesarean section delivery\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCS-\u003c/strong\u003eCesarean section\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO-\u0026nbsp;\u003c/strong\u003eWorld Health Organization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMOH-\u0026nbsp;\u003c/strong\u003eMinistry of Health\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHOD-\u0026nbsp;\u003c/strong\u003eHead of Department\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIDIs-\u0026nbsp;\u003c/strong\u003eIn-depth interviews\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKIIs-\u0026nbsp;\u003c/strong\u003eKey informant interviews\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFGDs-\u0026nbsp;\u003c/strong\u003eFocus Group Discussions\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u0026nbsp;\u003c/strong\u003eApproval to conduct the study was granted by the Kabale Research and Ethics Committee: Ethical approval number: KABREC-2023-89 Date of approval: 08- April-2024. The administrative clearance was granted by the Hospital Director of Kabale Regional Referral Hospital in South western Uganda. The In-charge of Maternity ward gave us permission to collect data in her ward and she introduced the data collectors to the eligible mothers and staff on ward. Participants received verbal and written information detailing the purpose and process of the study. All participants gave written informed consent confirming their voluntary participation in the study. Confidentiality and privacy of all data collected were observed during the course of the study through restricted access. This research was carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe raw data supporting the conclusions of this article will be made available by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e All authors declare that they don\u0026rsquo;t have any competing interests regarding this work, be it financial or personal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research has not received any funding yet.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eConceptualization by P.A and A.N., Data curation by P.A and A.N., Formal analysis by P.A, A.N., Funding acquisition by P. A and A.N., Methodology by P.A and AN, Project administration by P.A and A.N., Resources by P. A and A.N, Supervision by A.N., Writing of original draft by P.A, A.N, E.A and M.M., Review and editing by P.A, A.N, E.A, V.M and M.M.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe thank the participants for accepting to participate in this study and giving us rich information that was beneficial to the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOpen Access:\u003c/strong\u003e Article not yet licensed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions to literature:\u0026nbsp;\u003c/strong\u003eThis study assesses the facilitators and barriers of cesarean section and this will provide more literature and knowledge about why cesarean section is done or not done. Although many studies have been done regarding cesarean section and they show that the rates are increasing worldwide, however the reasons for this remains unclear. Different studies to assess these factors in various countries has been done but none in south western Uganda therefore prompting this study in order to contribute to the already existing literature.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. WHO Statement on Caesarean Section Rates. 2015. \u003c/li\u003e\n\u003cli\u003eVega ES. Rising Trends of Cesarean Section Worldwide: A Systematic Review. Obstet Gynecol Int J. 2015 Nov 6;3(2). \u003c/li\u003e\n\u003cli\u003eMaktha V, Ghatam A, Padamata H, Ravulakol A. Prevalence and factors associated with caesarean section: a community based cross sectional study in rural parts of Rangareddy district, Telangana, India. Int J Community Med Public Heal. 2016;2054\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eKitaw TM, Limenh SK, Chekole FA, Getie SA, Gemeda BN, Engda AS. Decision to delivery interval and associated factors for emergency cesarean section: a cross-sectional study. BMC Pregnancy Childbirth. 2021 Dec 1;21(1). \u003c/li\u003e\n\u003cli\u003eBetran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: Global and regional estimates. BMJ Glob Heal. 2021;6(6):1\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eVerma V, Vishwakarma RK, Nath DC, Khan HTA, Prakash R, Abid O. Prevalence and determinants of caesarean section in South and South-East Asian women. PLoS One. 2020;15(3). \u003c/li\u003e\n\u003cli\u003eKibe PM, Mbuthia GW, Shikuku DN, Akoth C, Oguta JO, Ng\u0026rsquo;ang\u0026rsquo;a L, et al. Prevalence and factors associated with caesarean section in Rwanda: a trend analysis of Rwanda demographic and health survey 2000 to 2019\u0026ndash;20. BMC Pregnancy Childbirth. 2022 Dec 1;22(1). \u003c/li\u003e\n\u003cli\u003eAD I, N A, J Z. A five-year survey of cesarean delivery at a Nigerian tertiary hospital. Trop J Obstet Gynaecol. 2018;35(1):14. \u003c/li\u003e\n\u003cli\u003eTsegaye H, Desalegne B, Wassihun B, Bante A, Fikadu K, Debalkie M, et al. Prevalence and associated factors of caesarean section in Addis Ababa hospitals, Ethiopia. Pan Afr Med J. 2019;34. \u003c/li\u003e\n\u003cli\u003eHabteyes AT, Mekuria MD, Negeri HA, Kassa RT, Deribe LK, Sendo EG. Prevalence and associated factors of caesarean section among mothers who gave birth across Eastern Africa countries: Systematic review and meta-analysis study. Heliyon [Internet]. 2024;10(12):e32511. Available from: https://doi.org/10.1016/j.heliyon.2024.e32511\u003c/li\u003e\n\u003cli\u003eWaniala I, Nakiseka S, Nambi W, Naminya I, Osuban Ajeni M, Iramiot J, et al. Prevalence, Indications, and Community Perceptions of Caesarean Section Delivery in Ngora District, Eastern Uganda: Mixed Method Study. Obstet Gynecol Int. 2020;2020. \u003c/li\u003e\n\u003cli\u003eAdewuyi EO, Auta A, Khanal V, Tapshak SJ, Zhao Y. Cesarean delivery in Nigeria: Prevalence and associated factors \u0026bull;a population-based cross-sectional study. BMJ Open. 2019 Jun 1;9(6). \u003c/li\u003e\n\u003cli\u003eHailegebreal S, Gilano G, Seboka BT, Ahmed MH, Simegn AE, Tesfa GA, et al. Prevalence and associated factors of caesarian section in Ethiopia: a multilevel analysis of the 2019 Ethiopia Mini Demographic Health Survey. BMC Pregnancy Childbirth. 2021 Dec 1;21(1). \u003c/li\u003e\n\u003cli\u003eHathout HM, A Elsaid NB, Gabr HM. Prevalence of Cesarean Section Delivery and Associated Risk Factors [Internet]. Available from: http://creativecommons.org/licenses/by/4.0/\u003c/li\u003e\n\u003cli\u003eRichard F, Zongo S, Ouattara F. 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Prevalence, indications and associated factors of cesarean section delivery at public hospitals in Wolayta Zone Southern, Ethiopia. 2020; \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"facilitators, barriers, cesarean section, mothers, health workers, Kabale Regional Referral Hospital, South-western Uganda","lastPublishedDoi":"10.21203/rs.3.rs-7029339/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7029339/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCesarean section is an important emergency obstetric care service; however, it loses its relevance of reducing maternal and neonatal mortality rates when the rates are above the recommended 15% by WHO. Cesarean section rates are unacceptably high and reasons for this remain unclear. In an attempt to understand this, we aimed at assessing facilitators and barriers of cesarean section among mothers that experience and health workers that take part in the cesarean section delivery in South-western Uganda in order to improve on knowledge and health practices in line with cesarean section delivery and its services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine the facilitators and barriers of cesarean section among mothers and health workers in South-western Uganda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe had 36 participants; 18 in-depth interviews and 2 focus-group-discussions with mothers and 6 key-informant interviews with health workers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collected was transcribed verbatim, coded using NVivo 20.2 and analyzed considering the health belief model and content thematic approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFacilitators were maternal preference after previous cesarean section, maternal perception of importance of cesarean section to her and baby, health workers advise, health workers perception of benefit of cesarean section to mother and baby, traditional birth attendants, community and religious perception of benefits of cesarean section, high knowledge about cesarean section by health workers, family perception about importance of cesarean section to mother and baby, friend’s recommendation of cesarean section, health workers’ good communication skills during consenting process, maternal awareness about their condition and how it prevents vaginal delivery.\u003c/p\u003e\n\u003cp\u003eBarriers included; rude health workers, high expenditures like buying expensive drugs and transport to and from the facility especially for referred mothers, delay by health workers to perform cesarean section on referred mothers, presence of medical students in the theatre, community, traditional birth attendants and church’s negative perception, limited staff on maternity ward, stock-outs, maternal preference for vaginal delivery, low maternal education status, bad previous experience with cesarean section, uncomfortable procedures like catheterization and spinal anesthesia injections and perception of having limited number of children due to cesarean section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWith this information, we were able to understand why cesarean section was done/ preferred or not done/ not preferred, this provides a basis for implementation of working evidence based interventions for proper use of cesarean section like strengthening health education talks in the communities to increase knowledge about cesarean section among community members.\u003c/p\u003e","manuscriptTitle":"Facilitators and barriers to cesarean section delivery in south western Uganda: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 12:09:58","doi":"10.21203/rs.3.rs-7029339/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-24T05:23:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127688261582712345755405871332790426160","date":"2026-05-24T02:56:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-17T20:36:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1022952000504159607748890300668474830","date":"2025-08-12T19:10:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-04T05:18:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-09T12:04:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-09T08:02:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-09T08:00:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-07-02T12:19:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b41bbec-ac65-4f3e-9dff-c0d4a58a0db6","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-24T05:23:59+00:00","index":89,"fulltext":""},{"type":"reviewerAgreed","content":"127688261582712345755405871332790426160","date":"2026-05-24T02:56:39+00:00","index":88,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-06T12:09:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 12:09:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7029339","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7029339","identity":"rs-7029339","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}