Peggy

ACCESS TO ANTENATAL EDUCATION BY PREGNANT WOMEN IN
NKOKONJERU TOWN COUNCIL: A CASE OF
ST. FRANCIS HOSPITAL NKOKONJERU
BY
NABUUFU JOSEPHINE
2012/HD04/1137U
A DISSERTATION SUBMITTED TO THE DIRECTORATE OF RESEARCH AND

GRADUATE TRAINING IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE AWARD OF MASTER DEGREE IN ADULT AND COMMUNITY
EDUCATION OF MAKERERE UNIVERSITY
MAY 2017
DECLARATION
I Nabuufu Josephine, declare that this dissertation is my original work and has never been
submitted to any higher institution of learning for any academic award.
Signature…………………………………………..
Nabuufu Josephine
(Researcher)
Date……………………………………………..
ii
APPROVAL
This dissertation entitled “Access to Antenatal Education by Pregnant Women a case of St.
Francis Hospital Nkokonjeru Town Council, Buikwe District in Central Uganda is an original
work of Miss Nabuufu Josephine Reg. No. 2012/HD04/1137U, done under my supervision and
has been submitted for examination with my approval as a University Supervisor.
Dr. Alex Okot
(Supervisor)
Date……………………………………
Signature………………………………
Prof. George L. Openjuru
(Supervisor)
BA/Ed Hon; M.Ed., (Mak), M.Ed. (Natal) PhD (UKZN)

(Supervisor)
Date……………………………………
Signature………………………………
iii
DEDICATION
This work is dedicated to my husband and children whose love and care have made it possible
for me to go through this study.
iv
ACKNOWLEDGEMENT
I wish to acknowledge the following persons in their capacities who have selflessly contributed
towards my education and the generation of this piece of work; my sincere gratitude goes to my
supervisors; Prof. George L. Openjuru and Dr. Alex Okot, for their open, genuine and
continuous advice and their efforts to transform me intellectually.
I also gratefully acknowledge the contributions of all my lecturers in the School of Distance and
Life Long Learning, Makerere University for their academic support and advice during the
course of this study which has made it possible for me to produce this piece of work.
I extend my heartfelt appreciation to all my respondents who provided data and information I
wanted, during the time I visited and approached you. My thanks go to the staff of St. Francis
Hospital, Nkokonjeru, and the midwives in the antenatal department, may God reward you for
your tireless efforts and fruitful contributions exhibited during my research study.
I forward my appreciation to all those who materially, financially and morally contributed to my
study directly or indirectly. Special thanks go to Mr. Kasasa Jude Kanyike, my daughter, Maria,
my sons; Andrew and Joseph, my sisters; Caroline and Christine and last but not least my dear
parents Mr. and Mrs. Kiwanuka Joseph. May the Almighty God reward you abundantly.
Thanks to my dear course mates (MACE students) for your wonderful cooperation, constructive
comments and academic support which has enabled me produce this work.
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TABLE OF CONTENT
DECLARATION.............................................................................................................................ii
DEDICATION................................................................................................................................iv
ACKNOWLEDGEMENT...............................................................................................................v
List of figures................................................................................................................................xii
List of tables..................................................................................................................................xii
List of abbreviations.....................................................................................................................xiii
CHAPTER ONE..............................................................................................................................1
INTRODUCTION AND BACKGROUND TO THE STUDY.......................................................1
1.0 Introduction................................................................................................................................1
1.1 Background to the study............................................................................................................1
1.1.1 Overview of Antenatal Education in Uganda 3
1.1.3 Problem statement 6
1.2 Purpose of the study...................................................................................................................7
1.2.1 Specific objectives 7
1.2.2 Research questions 7
1.3 Significance of the study...........................................................................................................8
1.4 Justification of the study............................................................................................................8
1.5 Scope of the Study.....................................................................................................................9
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1.6 Definition of Key terms...........................................................................................................10
CHAPTER TWO...........................................................................................................................11
LITERATURE REVIEW..............................................................................................................11
2.0 Introduction..............................................................................................................................11
2.1 Skills and information provided to pregnant women in antenatal education..........................11
2.2 Adult education and provision of antenatal education to pregnant women.............................12
2.2.1 Adult education 12
2.2.2 Antenatal education as a form of non-formal education 15
2.3 Methods of delivering antenatal education in antenatal classes..............................................16
2.4 Participation of pregnant women in antenatal education.........................................................20
2.4.1 Experience based learning and participation of pregnant women in antenatal education
25
2.4.2 Relationships in women’s learning: “Women’s Ways of Knowing” 26
2.5 Utilization of antenatal education by pregnant women to promote maternal health...............27
2.6 Figure 2: Conceptual Framework........................................................................................30
2.6.1 Determinants of Access to Antenatal Education 30
CHAPTER THREE.......................................................................................................................31
METHODOLOGY........................................................................................................................31
3.0 Introduction..............................................................................................................................31
3.1 Research design.......................................................................................................................31
3.2 Study Area...............................................................................................................................31
3.4 Sampling..................................................................................................................................32
3.4.1 Sample size...........................................................................................................................32
3.5.2 Sampling Techniques............................................................................................................33
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3.6 Data Collection Instruments/methods......................................................................................34
3.6.1 Semi-structured interviews 34
3.6.2 Focus group discussions 34
3.7 Data Quality Control................................................................................................................36
3.8 Data Management....................................................................................................................36
3.9 Validity and reliability of the instruments...............................................................................37
3.10 Data Analysis.........................................................................................................................37
3.11 Ethical consideration.............................................................................................................38
PRESENTATION OF RESULTS/FINDINGS.........................................................................40
4.0 Introduction..............................................................................................................................40
4.1 Demographic characteristics of respondents (pregnant women).............................................40
4.2 Skills and information provided to pregnant women in antenatal education..........................41
4.2.1 Good nutrition 45
4.2.2 Care during pregnancy 47
4.2.3 Birth plan 47
4.2.4 Danger signs 48
4.2.5 Immediate care for the newborn 49
4.2.6 Breast feeding 50
4.2.7 Sleeping under a mosquito net 51
4.2.8 General cleanliness 52
4.2.9 Counseling 52
4.3 Methods of delivering antenatal education to pregnant women at St. Francis hospital..........53
4.3.1 Written information 54
4.3.1.1 Printed Materials........................................................................................................54
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4.3.2 Group discussion 55
4.3.2.1 Group size in delivering antenatal education.............................................................56
4.3.3 One to one session 57
4.3.4 Lectures 58
4.4.1 Reasons for participation in antenatal education 58
4.4.2 Attendance as a way of participating in antenatal education 61
4.4.3 Topics 63
4.4.4 Motivation 64
4.4.5 Language 65
4.4.6 Inferiority complex among adolescent pregnant women 66
4.5 How is antenatal education utilized by pregnant women to promote maternal health............67
4.5.1 Decision making 67
4.5.2 Proper nutrition 68
4.5.3 Ability to detect danger signs 69
4.5.4 Compliance to medication 69
4.5.5 Birth plan 70
4.5.6 Care for the new born baby. 71
4.5.7 Family planning 71
CHAPTER FIVE...........................................................................................................................73
ANALYSIS AND DISCUSSION OF FINDINGS.....................................................................73
5.0 Introduction..............................................................................................................................73
5.1 Skills and information provided to pregnant women..............................................................73
5.1.1 Understanding / making a birth plan in antenatal education. 73
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5.1.2 Information on danger signs. 75
5.1.3 Information about good nutrition for pregnant women 76
5.1.4 Counseling sessions in antenatal education 76
5.1.5 Breast feeding education 77
5.1.6 Immediate care for the newborn 77
5.1.7 Family planning information 78
5.1.8 Sleeping under a mosquito net by pregnant women 79
5.1.9 Non-formal education and the provision of antenatal education 80
5.2 Methods of delivering antenatal education to pregnant women..............................................81
5.2.1 Group discussion method 81
5.2.1.1 Group size in delivering antenatal education.............................................................81
5.2.1.2 The role of relationships in discussing antenatal education by pregnant women......82
5.2.2One to one session 83
5.2.3 Written information 83
5.2.3.1 Printed material and teaching aids used to deliver content in antenatal education....84
5.2.4 Lecture method 85
5.3.1 Attendance 88
5.3.2 How motivation promotes participation of pregnant women in antenatal education. 89
5.3.4 How inferiority complex causes low participation of pregnant women in antenatal
education. 90
5.3.5 The effect of Language on pregnant women’s participation in antenatal education 91
5.3.6 Experiential learning and its effects on participation of pregnant women in antenatal
education 91
5.4 Utilization of antenatal education by pregnant women...........................................................92
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5.4.1 Decision making 92
5.4.2 Ability to detect danger signs 93
5.4.3 Compliance to medication 93
5.4.4 Low utilization of family planning 94
5.5 Access and utilization of antenatal education by pregnant women.........................................95
5.5.1 Physical availability of antenatal education 95
5.5.2 Distance to the health center 95
5.5.3 Economic costs associated with utilization of antenatal education 96
5.5.4 Social-cultural factors and utilization of antenatal education. 96
5.6 Limitations of the study...........................................................................................................96
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS.................................................98
6.1 Summary..................................................................................................................................98
6.2 Conclusion (s)..........................................................................................................................99
6.3 Recommendations..................................................................................................................100
6.3.1 Modifying the process of delivering antenatal education 100
6.3.2 Conduct refresher training for health workers. 100
6.3.3 Need to conduct out-reaches of antenatal education services in communities. 100
6.3.4 Developing partnership with TBA’s 101
6.4 Areas for further research......................................................................................................101
REFERENCES............................................................................................................................102
Appendix I: Semi-structured interview guide for pregnant women in St. Francis Hospital
Nkokonjeru 110
Appendix ii: Semi-structured interview guide for antenatal education providers: Health workers
113
Appendix iii: Focus group discussion guiding questions for pregnant women 115
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Appendix IV: Observation Guide................................................................................................117
List of figures
Figure 1: Kolb’s formula on human behaviuor function………………………………….........25
Figure 2: Conceptual framework……………………………………………….. ……………..30
List of tables
Table 1 Demographic characteristics of respondents……………………………………………33
Table 2 Education levels of pregnant women…………………………………………………...41
Table 3 Skills and information provided to pregnant women in antenatal education…………...45
Table 4 Methods of delivering antenatal education to pregnant women…………………….......54
Table 5 Reasons for participation of pregnant women in antenatal education…………………..59
Table 6 Utilization of antenatal education by pregnant by pregnant women……………………67
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List of abbreviations
AIDS Acquired Immunodeficiency Syndrome
ANC Antenatal Care Services
A R V’ S Anti- Retro-Viral Drugs.
CEES College of Education and External Studies
COR Chain of Response Model
DMP Data Management Plan
FGD Focus Group Discussion
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HIV Human Immunodeficiency Syndrome
ITN Insect Treated Net
MOH Ministry of Health
PMTC Prevention of Mother to Child
SoDLL School of Distance and Life-long Learning
TBA Traditional Birth Attendant
UBOS Uganda Bureau of Statistics
UDHS Uganda Demographic Health Survey
UN United Nations
VHT Village Health Team
WHO World Health Organization
Abstract
This study aimed at finding out about access of pregnant women to antenatal education conducted at
St. Francis Hospital, located in Nkokonjeru Town Council Buikwe district. It specifically intended to
identify the skills & information provided to pregnant women in antenatal education, examine the
methods used to deliver content in antenatal classes, determine the participation of pregnant women
in antenatal education, and assess how pregnant women utilize knowledge gained through antenatal
education to improve maternal health.
In trying to understand the above objectives, the researcher employed an exploratory study design in
order to gain an in- depth understanding, of the responses regarding access to antenatal education by
pregnant women at St. Francis Hospital. In-depth interviews, Focus Group Discussions (FGDs) and
observation were the main data collection methods used amongst forty eight (48) pregnant women.
Findings from the study showed that pregnant women were provided with information about good
nutrition, care during pregnancy, making a birth plan, danger signs during pregnancy and labor,
sleeping under a mosquito net, and care for the new born baby, counseling, breast feeding and
personal hygiene. The methods of delivering content were; group discussions, one-to-one sessions,
written information and lecture method. The group discussions allowed participation through sharing
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ideas, experiences and problems related to pregnancy, the discussions covered a larger group of
participants and explored a variety of topics. The content delivered to pregnant women especially in
groups was not thoroughly exhausted due to limited time and many pregnant women reached late due
to long distances and family responsibilities. Written information provided in books and brochures
was not properly understood by pregnant women with low education levels. This could not allow
pregnant women to access and utilize antenatal education effectively considering many challenges
they faced including the long-distance to the hospital, socio- cultural family beliefs and economic
costs associated with utilization of skills and information provided in antenatal education.
This research concludes that access of pregnant women to antenatal education as one of the forms of
non-formal education is influenced by the relevance, depth, focus, flexibility and organization of
information and skills provided to pregnant women. There is need to deliver antenatal education to
pregnant women using methods and materials that best suit them as adults. In this case, group
discussions facilitate experiential learning and participation of pregnant women by sharing
experiences of past pregnancies and pregnancy complications. Therefore access to antenatal
education requires addressing factors that may hinder access and effective utilization of skills and
information acquired in antenatal education, such as education levels of pregnant women, transport
costs, socio –cultural practices and society values.
The research study therefore recommends modifications in the process of delivering antenatal
education by considering variations in education levels and pregnancy stages; conduct refresher
training for health workers and community out-reaches with VHT’s about antenatal education to
pregnant women who cannot come to the hospital; develop partnership with TBA’s because they are
found to be key providers of antenatal services to many pregnant women.
CHAPTER ONE
INTRODUCTION AND BACKGROUND TO THE STUDY
1.0 Introduction
This chapter introduces the background of the study, access to antenatal education, statement of
the problem, study objectives, significance, justification, study scope and the definition of
concepts. The study was about access to antenatal education programs provided by St. Francis
Hospital to pregnant women in Nkokonjeru Town Council. It explored the knowledge, skills and
information provided to pregnant women, the delivery methods of antenatal education, their
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levels of participation and how pregnant women were utilizing the education provided to them
by health workers.
1.1 Background to the study

Historically, knowledge about child birth and parenting has been learnt informally from other
women, mainly family members, and through practical experience of assisting with child rearing
in extended family systems (Renkert & Nutbeam, 2001). However, changes in family structure
and women’s increased participation in higher education and the workforce, combined with the
increasing medicalization of child birth, have meant that women are far more likely to depend
upon informally organized antenatal education as the mechanism through which they develop
their knowledge and skills (Zwelling, 1996; Nolan, 1997). Pregnant women now need to have
access to proper antenatal education so that they are more informed and be able to take
appropriate decisions regarding their health and that of their babies.
The Program for Action of the International Conference on Population and Development, and the
Platform for Action of the Fourth World Conference on Women, encourages governments to
take appropriate measures to reduce maternal mortality, and to ensure women's rights relating to
safe pregnancy and child birth (UN, 2000). These rights include the right to education; and the
right to receive and impart information, including education and information relating to sexual
and reproductive health without any discrimination. Education and information are crucial in
communities to raise awareness about unsafe motherhood as a social injustice issue. Education
and information can help families and communities provide women with the adequate
information about nutrition needed during pregnancy and to identify the signs indicating the
necessity to obtain maternal health care (UN, 2000).
The World Health Organization urges countries all over the World to take deliberate efforts in
ensuring access to adequate antenatal education in order to reap admirable maternal health
outcomes (WHO, 2003). WHO calls for access to antenatal education, where access is
recognized in five different components which include physical availability of services, distance
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to the health center, economic costs as well as cultural and social factors that may impede access
and the quality of antenatal services offered (Tawiah, 2011).
The 5th Millennium Development Goal called for a reduction in maternal mortality by three
quarters by 2015 (UN, 2011). World Health Organization reports and experts in the field of
maternal health consistently highlighted lack of access to local adequately resourced healthcare
facilities as an important reason for the relatively slow rate of progress realized towards,
achieving the fifth Millennium Development Goal. The WHO, (2003) report presented antenatal
education as one of the most important services and hence pregnant women should have full
access to it.
The United Nations Agenda for Sustainable Development Summit (2015) presents sustainable
goal 3 which aims at ensuring healthy lives and promote well- being for all people. It aims at
reducing global maternal mortality death ratio to less than 70% per 100,000 live births, end
preventable deaths of newborns and children below 5 years, ensure universal access to sexual
and reproductive health care services including family planning, information and education as
well as the integration of reproductive health into national strategies and programs by 2030 (UN,
2015).
In Africa, maternal health still remains a major issue since health facilities do not provide a full
range of health services, undermining access to antenatal education as well as comprehensive
emergency obstetric care (Tawiah, 2011). The rate of progress of maternal mortality figures is
slow in Africa although antenatal coverage rates have improved slightly during the last two
decades, but the number of women attending four or more times has remained static at about 44
% (UN, 2011).
According to Kyomuhendo, (2012) many pregnant women do not access antenatal education
because of the deeply held cultural beliefs and tribal traditions, surrounding the nature of
pregnancy and child birth. The patriarchal order of many African societies has also hindered
many pregnant women from accessing antenatal education. This is because the men control the
homes especially in terms of resource allocation; the male partners decide whether the pregnant
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woman will attend antenatal education or not, which compromises pregnant women’s access to
antenatal education (Tawiah, 2011).
1.1.1 Overview of Antenatal Education in Uganda

In developing countries like Uganda, physical or geographical access to health centers are a
major barrier affecting pregnant women, from seeking reproductive health care and accessing
antenatal education (Kasolo & Ampaire, 2000). These come along with other issues like distance
to health centers, lack of transport due to high transport costs, poor road conditions and uneven
distribution of health facilities. These factors increase travel time and the difficulty in accessing
health centers.
The Safe Motherhood program which is the major promotion of maternal health in Uganda
embraces antenatal education; however, it has been hampered with insufficient funding, limited
budget allocations, corruption and also limited skilled personnel to fully educate pregnant
women (Kaviri, 2012).
Practices of health workers in some hospitals also make some pregnant women fail to access
antenatal education. Many pregnant women are required to come with their spouses and also
present antenatal cards usually sold at a fee in many hospitals. This discriminates against
pregnant women whose spouses do not attend and those without money for the antenatal cards
since they are believed to have no record of antenatal attendance (Amooti, 2000) cited in
(Finlayson and Downe, 2013).
The low literacy rate among women in Uganda largely affects birthing outcomes and information
on reproductive health (MOH, 2008). Many women do not utilize health care services because
they do not understand reasons for procedure (Kyomuhendo, 2012). Antenatal education
provided in Uganda is characterized by poor attendance, poor counseling and poor client
provider relationship (Uganda Democratic Health Survey, 2011). Therefore many pregnant
women end up relying on myths, rumors and misconceptions that discourage them from
attending antenatal education.
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1.1.2 Access to Antenatal Education
Access refers to the right or privilege to approach, reach, enter or make use of something
(Kwesiga, 2002). In the context of this study, access is defined as the ability of pregnant women
to have/get involved in antenatal education provided in hospitals to satisfy their education needs
in regard to maternal health.
Access to antenatal education is an important means of ensuring a healthy mother and baby
during pregnancy, delivery and the postpartum period. Pregnant women are given important
information on danger signs during pregnancy, nutrition, breastfeeding, care of the new born
baby, personal hygiene as well as the opportunity to establish a social relationship with the health
care provider during child birth (WHO, 2005).
According to Koehn, (2008) antenatal education can be viewed as one of the steps towards the
goal of becoming a mother, more so Lederman, (1996) Mercer (1999 & 2004) as cited in Koehn,
(2008) suggested that successful completion of pregnancy assists the woman in the mind shift to
motherhood.
Antenatal education carried out in a caring and supportive manner plays an enormous role in
alleviating the fears and anxieties associated with pregnancy, delivery and child parenting. It
promotes confidence to meet the challenge of child birth and early parenting. The overall aim of
such educational programs is to support parents during the process of pregnancy, delivery and
child upbringing; by providing accurate information and other related support services regarding
labor, delivery and parenting (Koehn, 2008).
The World summit for children’s goal calls for access to antenatal education. However, access is
a multi-dimensional concept which is mostly recognized in five different components, they
include; physical availability of antenatal education, distance to the health center, economic and
other costs, cultural and social factors (WHO, 2003), uneven distribution of health care facilities
and lack of independence by pregnant women to make decisions on matters that directly affect
their health (Tawiah, 2011). These continue to frustrate physical access, implementation and
expansion of effective reproductive and sexual health rights.
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Poor access to antenatal education has been identified as an impediment to good maternal health
leading to poor birth outcomes, particularly premature births, small babies and caesarean
sections. A higher proportion of women who make less than three antenatal visits and those that
make the first visit late tend to have premature births: while undernourished women are more
likely to produce babies that are small (Magadi, Zulu and Brocheroff, 2003). It is also noted that
pregnant women who participate in antenatal education programs can still end up with poor birth
outcomes. This can be attributed to poor delivery of content, limited participation and inadequate
utilization of the skills and information provided in antenatal education.
Economic ability to access antenatal education has been posited by recent studies as a major
factor affecting reproductive health in general and antenatal education in particular (Bbaale,
2011; Birungi, Stephanie, & Hughes, 2008; Tawiah, 2011), it is noted that women’s financial
dependence on their husbands affect their decision making, this is because health care options
must be supported by husbands, hence for a woman to access antenatal education in a hospital,
she must seek for money and permission from the husband. Asiimwe, (2010) found out that in
Western Uganda, the ability of a woman to access antenatal education in a health facility has a
significant association to the number of antenatal visits she is likely to make. This is because she
has to take transport fee as well as laboratory, drug and consultation fees in case of private
centers, these costs usually deter pregnant women who may not be able to raise the required fee
hence failing to access antenatal education in hospitals. However, there are also instances where
husbands provide the required funds to pregnant women, but then they decide not to attend
antenatal education and divert the funds to other issues. Hence, they miss vital information and
fail to participate as well as utilize the knowledge provided in antenatal education.
Social cultural belief systems, values and practices also shape pregnant women’s knowledge and
perception of antenatal education. Some pregnant women do not access antenatal education
because of deeply held cultural beliefs and tribal traditions surrounding the nature of pregnancy
and child birth (Kyomuhendo, 2012). These social cultural norms and practices promote self-
care and use of traditional birth attendants among pregnant women, which may contribute to
some un-healthy practices among those who prefer them, to accessing antenatal education from
the rightful health personnel. The Ministry of Health has consistently warned pregnant women
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about non-qualified traditional birth attendants and advised pregnant women to go to qualified
health workers so as to help save their lives in case of emergencies.
In the context of this research, access was measured in terms of persistence, by pregnant women
who managed to attend antenatal sessions and received antenatal education at St. Francis hospital
Nkokonjeru. The study intended to find out how & what pregnant women achieve from
accessing antenatal education. It also sought to determine how they had utilized the knowledge,
skills and information from the facilitators in antenatal education, in order to assess whether they
had put what they had learnt into practice.
1.1.3 Problem statement

Access to antenatal education plays an important role in ensuring a healthy mother and baby
(WHO, 2005). Historically, knowledge about child birth and parenting has been gained
informally from other women, mainly family members, and through practical experience of
assisting with child rearing in extended family systems (Rembert & Nutbeam, 2001).
Observations by Zwelling (1996); Nolan (1997) show that changes in family structure, women’s
increased participation in higher education and the workforce, combined with the increasing
medicalization of child birth, explain why women can no longer depend upon informally
acquired antenatal education as the mechanism through which they develop their knowledge and
skills.
During antenatal education, mothers are supposed to be given important information on danger
signs during pregnancy, preventive and curative information as well as appropriate nutrition and
receive antenatal education and only 42% are attended to by skilled health care breast feeding
skills (Bbaale, 2011). Contrary to this, the Uganda Demographic and Health Survey conducted in
2011 indicates that 48% of pregnant mothers in Uganda personnel. This increases with mother’s
level of education whereby 92% of women with no education received antenatal care from a
skilled provider, compared with 95% of women with primary education and 97 % of women
with secondary and higher education (UDHS, 2011). Similarly, in Uganda women in the highest
wealth quintile were more likely to receive care from a skilled provider with 97 % compared
with 94 %t of the women in the lowest wealth quintile (UDHS, 2011).
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Kyomuhendo, (2012) in her study, argues that pregnant women who attend antenatal classes
acquire very little knowledge of danger signs during pregnancy, with 68% of women who
attended four antenatal visits during pregnancy; only 19% of them could indicate at least three
danger signs. The UDHS (2011) survey indicates an increase in the percentage of women who
were informed of complications during pregnancy from 35% to 51%. This is also influenced by a
mother’s education, wealth, and place of residence, as well as birth order of her infant. This
shows, a considerable share of those who seek professional care are not retaining/receiving vital
information (Kabakyenga, Per- Olof, Turyakira, & Kareen, 2012), thereby implying a risk of
irresponsible parenthood and increased maternal and infant mortality due to poor participation in
antenatal education.
Basing on the information and the background presented, pregnant women seem to be facing a
lot of limitations in their struggle to access antenatal education. This study wanted to find out
why pregnant women may not be getting the right educational outcomes in the antenatal
education provided in hospitals. I hoped to explore and ameliorate the skills and information,
methods and participation based dilemmas that hamper pregnant women from fully accessing
and utilizing the information provided to them in antenatal education.
1.2 Purpose of the study

The purpose of the study was to assess how access to antenatal education by pregnant women
could help improve maternal health, reduce neonatal deaths and improve the survival of infants.
1.2.1 Specific objectives

1. To identify the skills & information provided to pregnant women in antenatal education
programs by St. Francis Hospital Nkokonjeru.
2. To examine the methods used to deliver antenatal education conducted at St. Francis Hospital
Nkokonjeru.
3. To determine the participation level of pregnant women in antenatal education at St Francis

Hospital Nkokonjeru
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4. To assess how pregnant women utilize knowledge and skills gained through antenatal
education to improve maternal health
1.2.2 Research questions

1. What skills & information are provided to pregnant women in antenatal education programs
by St Francis Hospital Nkokonjeru?
2. What methods are used to deliver antenatal education to pregnant women at St. Francis
Hospital Nkokonjeru?
3. How are pregnant women participating in antenatal education at St. Francis Hospital
Nkokonjeru?
4. How is knowledge and skills gained from antenatal education utilized by pregnant women
attending antenatal classes at St. Francis Hospital Nkokonjeru, to improve maternal health?
1.3 Significance of the study

The study came at a time when Uganda as a country was promoting the safe motherhood
program with emphasis put on promoting maternal health through informed choice, service
accessibility and improving the quality of services as a strategy of achieving the 2015
Millennium Development goal of reducing Maternal mortality and Strategic Development Goal
3 which emphasizes good health and well- being by 2030. The results of the study therefore may;
 Provide midwives, gynecologists and other related medical personnel with appropriate
strategies of delivering antenatal education to pregnant women of various education
levels.
 The study would help improve pregnant women’s capacity to access information
regarding maternal health and their capacity to use it effectively.
 Reveal existing loopholes that may hinder pregnant women from accessing antenatal
education programs despite the availability of antenatal care services in almost every
health center in Uganda.
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1.4 Justification of the study
The maternal health policy framework aims at reducing mortality, morbidity and fertility as well
as disparities that exist in reproductive health (MOH, 1999). The overall aim is to ensure access
to a minimum health care package. In relation to the above, Ministry of Health Uganda (2004)
put forward a strategy during 2005-2010 that can help increase access to goal- oriented antenatal
care, increase in access to skilled attendance at birth emergency obstetric care and increased
access to family planning as a way of improving maternal health.
Sustainable Development Goal 3 focuses on ensuring healthy lives and aims at promoting well-
being for all, at all ages by reducing the global maternal mortality ratio to less than 70 per
100,000 live births by 2030; end preventable deaths of newborns and children under 5 years of
age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live
births and under-5 mortality to at least as low as 25 per 1,000 live births ; reduce by one third
premature mortality from non-communicable diseases through prevention and treatment and
promote mental health and well-being. This can be achieved by ensuring universal access to
sexual and reproductive health-care services, including family planning, information and
education, where antenatal education falls, and the integration of reproductive health into
national strategies and programs (UN, 2015).
According to the Ministry of Health Uganda, (2016) there has been a significant decline of
maternal mortality from 438 deaths per 100,000 live births registered in the 2011 UDHS report
to the current 336 deaths per 100,000 live births in the 2016 UDHS report.
Infant mortality has also declined from 54 deaths per 100,000 live births in 2011 UDHS report to
43 deaths per 100,000 live births in 2016 UDHS report.
In Uganda, 141,000 children die before reaching their 5th birthday; annually 26% of these
children die in their first month of life (Mbonye et al, 2012). The major causes of neonatal deaths
in Uganda like in other Sub Saharan African countries include sepsis, pneumonia, tetanus,
Prematurity and birth asphyxia (Liu et al, 2010). The underlying causes of death are related to
poor access and low utilization of health services during pregnancy and child birth (Pearson et al,
2007) cited in (Kananura et al, 2016).
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To counter these causes of deaths, mothers and newborns need safe and easily accessible care so
as to promote the effective management of any arising complications.
1.5 Scope of the Study

The geographical scope of the study was Nkokonjeru Town Council specifically at catchment
area, St. Francis Hospital Nkokonjeru. It is a private non-profit community hospital located in
Central Uganda, Buikwe district in Nkokonjeru town. It is owned by the Roman Catholic
Diocese of Lugazi and administered by the Little Sisters of St Francis. The hospital was started
in 1926 by Mother Kevin Kearney as a dispensary which later developed into a full hospital with
emphasis on maternal and child health. The hospital serves a population of about 50,000 and it
was started with emphasis placed on educating local people in maternal and infant health where
antenatal education is a branch. Therefore due to its services of maternal and infant health it was
chosen as appropriate for this study.
The study covered mid wives and the pregnant women. I only confined myself to how pregnant
women accessed antenatal education; the information and skills provided to them, methods of
delivering antenatal education, their participation and how pregnant women utilized antenatal
education, of which data collection took only 3 weeks.
1.6 Definition of Key terms

Access: In this study, access is defined as the ability of pregnant women to have/ get involved in
antenatal education provided in hospitals to satisfy their education needs.
Antenatal education: In this research, refers to information and skills provided to pregnant
women in hospitals to prepare them for labor, delivery and basic baby care skills.
Primgravida (e): This refers to a woman carrying her first pregnancy
Multigravida (e): It refers to a woman who has had two or more pregnancies
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CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
This chapter presents the literature review in relation to the research questions which include;
skills and information provided to pregnant women in antenatal education, how antenatal
education is delivered to pregnant women in antenatal classes, participation of pregnant women
in antenatal education and how antenatal education is utilized by Pregnant women to improve
their health.
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2.1 Skills and information provided to pregnant women in antenatal education
Access to antenatal education is an opportunity that helps pregnant women acquire skills and
obtain information about pregnancy, child birth and care for the new born baby. It helps equip
pregnant women with skills and information to make appropriate choices that contribute to
optimum pregnancy outcome (Renkert and Nutbeam, 2001). Non formal education has been
widely adopted as a way through which skills and information is provided to pregnant women
which has made antenatal education a standard component of antenatal care worldwide (Turan &
Sale, 2003) cited in (Anya, Hydara, & Jaiteh, 2008).
According to Renkert & Nutbeam, (2001) primgravidae (mothers carrying their first pregnancy)
are not familiar with pregnancy as well as the responsibilities and complications that come with
it; these require skills and information on a number of issues that can only be provided through
accessing antenatal education. Primgravidae seek advice and assistance (Pell, Menaca, Were,
Afrah, & Chatio, 2013) acquire new nutrition habits for pregnant mothers, breast feeding skills
for the new born baby (Kisuule, Kaye, Najjuka, Ssematimba, Arinda, Nakitende, & Otim,
2013), and general care of the new born baby. However, Renkert and Nutbeam, (2001) note that
antenatal classes do not usually provide pregnant women with skills of gaining confidence and
emotional insight, traditionally gained through informal communication with other women.
There is also much emphasis put on the birthing process and little time is allocated on what
mothers should do after the baby is born, mothers lack sufficient knowledge on caring for the
new born. Important post-delivery practices are commonly neglected during antenatal education
(Carolyn, Kizza, Morison, Mabey, Muwanga, Grosskurth, & Elli1ot, 2013).
Through antenatal education, pregnant mothers are assisted to come up with a birth plan that
constitutes birth preparedness and complication readiness measures for pregnant women, their
spouses and family (Kakaire, Kaye, & Osinde, 2011). The birth plan package includes;
recognition of danger signs a plan for a birth attendant, place of delivery and saving money for
transport and other costs that may arise (JHPIEGO, 2001) cited in (Kakaire et al, 2011) a
potential blood donor and decision maker may also be included (Kaye et al, 2003) because
complications such as hemorrhage are un predictable. The birth plan promotes active preparation
and decision making for delivery by pregnant women and their families (Kakaire et al, 2011)
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hence it acts as a key strategy that can help reduce on the number of women dying from
pregnancy complications.
Antenatal education provides skills and information on how to identify and manage danger signs
and obstetric complications (Tetui, Kiracho, Bua, Mutebi, Twaheyo, & Waisswa, 2012). It
provides an entry for interventions which give health workers the opportunity to detect these
risky conditions and therefore refer them for early management leading to better maternal health
outcomes (Magadi et al, 2003). Pregnant women are also educated about emergencies during
pregnancy and how to deal with them before reaching hospital (WHO, 2003). However, in many
instances the ability of pregnant women to detect danger signs and act appropriately depends on
the skills and depth of information acquired in antenatal education (Carroli, Rooney, and Villar,
2001). Health workers need to further train pregnant women with self-help first aid skills in case
of any danger.
2.2 Adult education and provision of antenatal education to pregnant women
2.2.1 Adult education

There are variations in the perception and use of the term adult education, which arises from the
social, political and cultural conditions of each country (Jarvis, 1990). These variations are
widely considered in defining the scope and purpose of adult education hence the UNESCO
definition below was adopted;
Adult education denotes the entire body of organized education processes, whatever the
content, level and method, whether formal or otherwise, whether they prolong or replace
the schools, colleges and universities, as well as an apprenticeship, whereby persons
regarded as adults by the societies to which they belong develop their abilities, enrich
their knowledge, improve their technical or professional qualifications or turn them in a
new direction and bring about improved changes in their attitudes or behaviors in the
two fold perspective of full personal development and participation in balanced and
cultural development UNESCO, ( 1976) as cited in Oketch, (2004).
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The aims of adult education reflect a high degree of flexibility that characterizes adult education
and which in turn reflects the varied nature of the needs of the target groups in prevailing social,
political and cultural conditions.
According to Oketch, (1984) adult education has been categorized in various forms depending on
the way it is provided. It is classified into formal, informal and non-formal education.
Formal adult education refers to education provided in a hierarchically structured and accredited
setting. This form of adult education is mainly found at the continuing and further education
level (Oketch, 2004).
In line with the above definition, Cross, (2006) defines formal learning as the institutional ladder
that goes from pre-school to graduate studies. This system has the following features: it is highly
institutionalized; it includes a period called 'basic education' which varies from country to
country, which is compulsory, implements a prescribed curriculum approved by the state with
explicit goals and evaluation mechanisms, hires certified teachers, and institutional activities are
highly regulated by the state and that to enter into a certain level it is a prerequisite to
satisfactorily complete the previous level; it is a hierarchical system, usually with ministries of
education at the top and students at the bottom; at the end of each level and grade, graduates are
granted a diploma or certificate that allows them to be accepted into the next grade or level, or
into the formal labour market. Under this conceptualization, adult basic education programs that
follow the prescribed curriculum and employ certified teachers can also be understood as part of
formal education. Antenatal education by pregnant women cannot take formal learning and
therefore, pregnant women have no opportunity to access formal antenatal education in this case.
Informal adult education is learning that takes place without the learner deliberately taking part
in an organized education activity, it is often a by-product of some other activity. however it is
also often the result of an education provision deliberately planned to reach either the public in
general or certain categories of the public ( Oketch, 2004). In this context the learner does not
deliberately go out to participate but finds him/ herself learning.
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According to McGivney (1999), Informal learning is the most source of information for non-
literate community. McGivney defines informal learning as learning that takes place outside a
dedicated learning environment and which arises from the activities and interests of individuals
and groups, but which may not be recognized as learning. It can also be referred to as a non-
course-based learning activities (which might include discussion, talks or presentations,
information, advice and guidance) provided or facilitated in response to interests and needs by
people from a range of sectors and organizations (health, housing, social services, employment
services, education and training services, guidance services).
Informal learning should no longer be regarded as an inferior form of learning whose main
purpose is to act as the precursor of formal learning; it needs to be seen as fundamental,
necessary and valuable in its own right, at times directly relevant to employment and at other
times not relevant at all (Coffield, 2000). We cannot therefore ignore informal learning as an
avenue for information regarding antenatal education especially for non-literate pregnant women
/ pregnant women with low education levels who may receive antenatal education information
from friends or peers incidentally.
Non-formal education according to Cross, (2006) refers to all organized learning programs that
take place outside the formal school system, and are usually short-term and voluntary. This
includes a wide variety of programs such as tennis courses, second language programs, driving
lessons, cooking classes, yoga classes, rehabilitation programs, painting courses, training
programs, workshops, etc. As in formal education, there are teachers (instructors, facilitators)
and a curriculum with various degrees of rigidity or flexibility. Unlike formal education, these
programs do not normally demand prerequisites in terms of previous schooling.
According to Fordman, (1993) the following characteristics are associated with non-formal
education; relevance to the needs of disadvantaged groups; concern with specific categories of
person; a focus on clearly defined purposes; flexibility in organization and method.
The most enduring theme in non-formal education according to Fordman, (1993) is that the
education provided should be in the interests of the learners and that the organization and
curriculum planning should preferably be undertaken by the learners that is bottom-up approach.
xxx
It is also urged that this approach should empower learners to understand and if necessary
change the social structure around them.
Non-formal education is usually directed to adults, but children and adolescents may also
participate in this sector (for instance, children going to Sunday school; boy-scout and girl-scout
programs, second language courses, music lessons during the weekend, etc.). I support the view
that non-formal learning can be the best learning design for pregnant women to receive/acquire
2.2.2 Antenatal education as a form of non-formal education

Antenatal education as a form of non- formal education provides pregnant women with skills and
information that are empowering such that they can be more responsible and able to take
decisions that affect them as pregnant women. The education interventions provide expecting
mothers with information that enable them to identify potential warning signs of malfunctions or
abnormalities during pregnancy as well as strategies to adhere to prescribed treatment and
referral (Otaiby, Jradi, & Bawazir, 2013).
Antenatal education is a structured form of education provision. The highly structured antenatal
education program may have greater impact on the effectiveness of antenatal education, the
health outcomes of new and expectant mothers and eventually on the overall health of the next
generations in any nation (Otaiby et al, 2013).
In many cases each hospital designs antenatal classes as they see it as appropriate. This is
because there are no widely applied guidelines or standards for antenatal education, these classes
vary widely in length, instructor training, sponsorship, goals focus, and content (Shearer, 1996).
Antenatal classes are conducted most often by trained midwives but may be nurses or
physiotherapists. However findings indicate that in many instances, these clinicians have good
content knowledge, but are not necessarily trained and competent in teaching adult learners
(Nolan, 1997).
The methods used in delivering antenatal education vary widely to include participatory and non-
participatory methods. These include written material, group education, one-to-one sessions,
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lectures, role-plays, demonstrations and audio-visuals among others. However scholars have
noted that antenatal education in groups produces the most useful and cost effective outcome for
pregnant women. Antenatal group programs are more successful in terms of long term change in
parental behaviors as well as problem solving and creating social networks, among pregnant
women (Nolan, 1997; Otaiby et al, 2013). Similarly, Renkert & Nutbeam, (2001) indicate that
even within a single hospital, there is variability in the goals and educational methods in
delivering antenatal education
The purpose of antenatal education is to improve maternal health where women need to leave
classes with the skills and confidence to take a range of actions that contribute to a successful
pregnancy, child birth and early parenting (Renkert & Nutbeam, 2001). Antenatal education
should offer us the opportunity to shift from a simple transfer of knowledge, to a more active
process of empowering women for parenthood (Nolan, 1997).
2.3 Methods of delivering antenatal education in antenatal classes.

Most adult education programs in Uganda today encourage the use of participatory methods for
both facilitation and learning. The approaches and methods encourage creative and active
involvement of the participants and building on their knowledge and experiences (Nandago,
1998).
Antenatal education provided to pregnant women by health workers employs a number of

participatory methods but in many instances non participatory methods are also used in antenatal
classes.
Svensson, Barclay, & Cooke, (2008) describe the group discussion method as one that permits
open interaction between learners and the facilitator as well as among learners themselves. It
involves free flowing conversation, giving learners an opportunity to express their opinions and
ideas, hear those of their peers and facilitator. The facilitator does not take the leadership role but
rather participates as a member of the group.
Group education is considered an adult education strategy in the modern era and professional
literature reports that parenting education in groups produces the most useful and cost effective
xxxii
outcome for both parents (Ghate, 2002). A study of group antenatal education concluded that
support and feedback from other parents is a primary method that makes parenting education
programs more successful (Barlow, Parsons, Stewart-Brown, 2005). Other studies have shown
that group antenatal education programs are more successful in terms of long term change in
parental behaviors and the behaviors of their children in future compared to one to one programs
(Wellington, White and Liossis, 2006).
According to Nolan, (2009) pregnant women want to learn about labor, birth and motherhood in
peer groups made up of a small number of pregnant women, with a facilitator who is able to
identify how much information to give, has skills to promote discussions, gives plenty of
opportunities for practicing skills and encourages them to get to know and support each other.
Large groups in which it is difficult to ask questions, and facilitators who present themselves as
experts and who do not interact with pregnant women render education in the antenatal period
ineffective (Abrahamson et al, 2005). Sevensson et al, (2008) explain that large groups inhibit
contributions from less confident pregnant women. There is a danger that some voices will not
be heard when more extrovert participants dominate the discussion.
The lecture method is a one way communication of prepared talk where the facilitator talks to
learners in an autocratic way, and in its pure form. The learners have no opportunity to ask
questions or offer comments during the lesson. Even though lectures appear to be an efficient
teaching or training method as little or no time is spent discussing, learning is not guaranteed.
This is because the lecture method does not take into account the individuals needs feelings or
interests of learners as no feedback from learners is required (Otaiby et al, 2013).
In order to make the lecture method more effective, avoid falling into the trap of talking a lot and
hoping the learners are not only listening but absorbing too, the checklist by Cross, (2006)
encourages facilitators to use lectures for occasions when other techniques are less useful to
learners; limit the lecture to not more than 20 minutes; the talk should have a clear beginning,
middle and end; always keep to key points; support your talk with a clear hand out; support the
lecture with pictures, diagrams or models; know your body language and mannerisms and how
they affect your lecture.
xxxiii
Question and answer is defined by Mtunda and Saffuli, (1997) as a method both for teaching and
oral testing based on the use of the questions to be answered by the learners. When conducting a
class or group discussion, facilitators should be aware of the impact of turning down learner’s
response. By not accepting a response in a positive way, the facilitator may discourage learners
from answering further questions.
According to the IIED trainer’s guide, (2000) learners’ should be given enough time to think
about a response. The questions should come rapidly enough to keep the pace of the class lively.
Facilitators are encouraged not to ask questions which require a one word answer for example;
yes or no. Instead, open and clarifying questions should be asked to encourage learners to
express themselves.
The questions also help the facilitator to assess his/her teaching and learners` learning. It is
therefore necessary that facilitators also formulate higher order questions which require the
learners to apply, synthesize and evaluate knowledge or information (Cross, 2006).
Otaiby et al, (2013) in one to one session, it is common knowledge that individuals prefer
hearing about their health concerns from their physician, feeling that a physician is a trusted
source of information. Pregnant women like to receive emotionally demanding information from
a health care provider in person. They want to be able to ask questions, seek clarification, and
relate information to their own circumstances (Nolan, 2009). In such a case antenatal educators
should be competent, non-judgmental, up to date, unbiased, flexible and approachable when
conducting one-to one sessions with pregnant women (Svensson et al, 2008).
According to (Cross, 2006) in role play, learners use their own experience and creativity to
imitate a real life situation. When done well, role play increases learners` self-confidence, gives
them the opportunity to understand or feel empathy for other people’s view-points or roles, and
usually encourages them to come up with practical answers, solutions or guidelines on various
issues. Learners act out what they would say or do in a given situation. The acting can last 5 to
10 minutes. Other learners watch and listen carefully. After the role play, they discuss the
performance and the situation is then discussed. Learners may raise and discuss questions such
xxxiv
as: Does this happen in our community? Who or what causes this problem, how can it be solved
and who can solve it?
Stamler, (1998) notes that role-plays can only be effective in antenatal education when the
classes are small. This allows for free questioning and discussion among pregnant women and
for the educators to seek appropriate feedback from their clients.
Although there is a genuine intent to use participatory methods, it has been observed that adult
education instructors and facilitators tend to fall back on more familiar and less challenging
methods. The language, concepts, illustrations and other pedagogical techniques they use tend to
reinforce learner’s dependence on the instructor or facilitator. They do not encourage the active
participation of learners in the learning process and more especially in decision making. They
usually do not alter existing roles and un-equal relationships. Such methods are not
transformative and empowering (Oketch, 2004).
According to Nolan, (1997), antenatal class teachers are most often trained as midwives, but may
be nurses or physiotherapists; these clinicians have good content and knowledge but are not
necessarily competent and trained in teaching adults. Svensson et al, (2008) explain that the
actual process used is mainly that of a large group teaching where the educator has control of the
learning. There should be refresher need-based training for health workers to help link
appropriate information with clinical examinations, laboratory tests and drug distribution
(Conrad, Manuel, Arinaitwe, Olaf, & Malabika, 2012).
Active learning requires a shift from simply delivering instruction to setting conditions for the
process of engagement, application and authentic understanding. Active learning can occur in
any delivery format like classrooms and the common denominator is that learners are interacting
with their peers about real problems and issues as they are constructing knowledge and
understanding in their learning area of choice.
Jennings, Muzi, Megan, Michelle, Britta and Saifuddin, (2014) describe empowerment as the
expansion in people’s ability to make strategic life choices, in a context where this ability was
previously denied to them. This encompasses a process of change in which an individual
xxxv
acquires both resources and agency, to make and act upon decisions that affect her well-being or
that of others. Pregnant women need to be engaged in problem posing, solving and recognize
that they can collectively change their circumstances.
Empowered pregnant women particularly those who are more autonomous have increased
pregnancy health care seeking, are more likely to have skilled delivery attendance ,utilize
modern contraceptive use and have lower infant mortality (Kabeer, 2014). Women are more
empowered if they have the mandate to decide on when to go for antenatal education, how often
and whom to see about their health care in case they are sick, consequently improving their
health status. Svensson et al, (2008) explains that information transfer by itself should no longer
be the focus of antenatal education; rather, it should provide opportunities for people to learn
skills in order to practice desired behaviors.
In order to bring about empowerment, the methods and techniques used in the learning process
should be aimed at developing learner’s capacity to be creative and analytical. This calls for a
departure from the orientation type of training to a more systematically conceptualized,
organized and regular training and follow-up of facilitators. The training should also endeavor to
clarify the theoretical aspects surrounding participatory methods and their practical implication
for learning outcomes (Oketch, 2004).
Nutbeam, (2000) explains that providing pregnant women with written information to take home
is helpful because although they might not be interested in it at that time, they can always refer to
it later. In order for pregnant women to access, understand and utilize written information, the
concepts of literacy: reading, writing and numeracy should be at play whereby pregnant women
are able to read write and do some simple arithmetic (Renkert & Nutbeam, 2001).
However a study conducted by Stapleton, (2002) exploring the effectiveness and accessibility of
leaflets in promoting women’s choice around key areas of pregnancy, labor and postnatal care.
The leaflets were unsuccessful in promoting informed choice in child bearing women. Pregnant
women wanted to discuss the content of leaflets with mid wives, but these had insufficient time
to do so which made the method of giving written information to pregnant women not
successful.
xxxvi
According to Renkert & Nutbeam, (2001) health literacy represents the cognitive and social
skills which determine the motivation and ability of individuals to gain access to, understand,
and use information in ways which promote and maintain good health. By using the concept of
healthy literacy to guide the content and delivery of health education, attention is focused on the
development of the skills and confidence to make choice that improve individual health
outcome, rather than being limited to the transmission of information.
2.4 Participation of pregnant women in antenatal education.

Participation generally involves sharing or taking part in something, when applied to adult
education, participation means enrolment and involvement in an adult education program or
class (Mejai, 2008).
Jarvis (1990) defines participation in adult education simply as 'the attendance at adult education
courses. A survey of available literature however reveals that participation – generally – and
especially in adult education is not as simple as Jarvis’s definition.
According to Merriam, Caffarella and Baumgartner (2007) participation is one of the more
thoroughly studied areas in adult education. Participation is complex, contested and weaves into
issues of context, barrier, learning, motivation, enrolment, retention/attrition, ideology and social
stratification.
Long (1991) cited in Mejai, (2008) noted, the nature of adult education as a voluntary, need-
oriented endeavor, imposes a need to understand the undercurrents of why adults participate in
any form of learning in spite their regular social commitments. Long also indicates that the initial
efforts in the study of participation have revolved around ‘motive’. In addition to looking at
motivations for adults’ participation, he also identified several barriers to participation. Citing
other sources, he lists barriers to participation to include, among others, ‘lack of interest’, being
too old, having poor health, lack of time and costs. Other barriers include; socio-economic
condition and location of the educational opportunity.
A detailed study of participation in adult education is Cross’s, (1981) Chain of Response (COR)
model. Her model was the outcome of her analysis and critique of previous models of
xxxvii
participation on one hand and her study of adult learners as lifelong learners. The (COR) model
as presented by Cross, (1981) identifies 3 main barriers to adult participation; Situational- those
that arise from one’s situation or environment at a given point; Institutional-those practices and
procedures that exclude or discourage adults from participating in organized learning activities
and Dispositional-those related to the attitudes and self-perceptions about ones-self as a learner.
According to Cross, (1981) the chain of response model asserts that adult participation in
learning is not an isolated act but results from a complex chain of personal responses to internal
and external variables that either encourage or discourage participation in learning.
In spite of her model, she admits the complexity and contentious nature of participation. She
insists that, the question why adults participate will probably never be answered by any simple
formula. Motives differ for different groups of learners, at different stages of life, and most
individuals have not one but multiple reasons for learning.
Merriam et al, (2007) in their chapter entitled ‘adult learners: who participate and why?' did a
fine analysis of participation almost from all its ramifications including several schools of
thought on the concept. Their subtitle that ‘problematized’ participation especially underlines the
fact that participation is a contested concept as it weaves into issues of context, barrier, learning,
motivation, enrolment, retention/attrition, ideology and social stratification. In spite of the
complex and contested nature of the concept participation, it must have a minimum level of
universal application in adult education.
In reference to the social context is instructive. Rubenson, (1989) concludes that participation
has to be understood in relation to the processes that govern the social construction of attitudes
towards adult education and in relation to the social functions that adult education is allocated in
society.
According to Mejai, (2008) participation in adult education and learning in, most communities of
the world revolved around the need to make the community better through individual
empowerment and education. Participation in adult education empowers women to provide
financial, material and moral support to their children. It brings about attitudinal changes that
xxxviii
result in long-term psychosocial and economic benefits such as the capacity to analyze and solve
problems, increased participation in local settings and community decision making, better self-
image, increased independent thought and many other aspects of personal development
(Oxenham et al, 2002; Oketch 1999).
Adult education programs in Uganda still have inherent weaknesses and face many challenges as
they work towards the empowerment of women as a marginalized group. Studies indicate that
the majority of marginalized groups like women do not enroll in adult education programs. The
few who enroll exhibit high levels of irregular attendance, absenteeism and dropout (Oketch,
2004).
Oketch, 2004 highlights those barriers to access and participation which include absence of a
comprehensive adult education policy that focuses on creating inclusive cultures and practices at
all levels of education system. The education inclusion of women cannot proceed very far
without developing the capacity of learning centers to respond to learner diversity. More so the
learning environment is equally insensitive to special needs of many female learners. Other
barriers are social and cultural, such as division of labour and resources by gender at all levels,
negative attitudes towards the marginalized groups and inadequate capacity among planners and
program designers to design relevant and accessible programs.
In relation to antenatal education pregnant women participate in antenatal education in group

sessions using adult learning strategies and one to one sessions between a health professional and
a pregnant woman, (Otaiby et al, 2013). One to one sessions usually cover counseling and very
sensitive issues between the pregnant woman and health worker. Small peer groups encourage
pregnant women to get to know and support each other, while larger groups make it harder for
pregnant women to ask questions (Nolan, 2009). Pregnant women prefer groups to be less formal
where rather than having an expert lecturing, the educator gives information and teaches skills
which are discussed and practiced (Nolan, 2009). In antenatal education there is need to create an
environment that enables participants to discuss feelings and concerns which may enhance
awareness of their own resource and provide them with strategies of how to cope with birth and
parenthood (Illeris, 2009).
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A study conducted by Fraser, (2004) as cited in Nolan, (2009) shows that the language used in
antenatal education at certain instances limits pregnant women from fully participating in
antenatal education, this is because many do not understand some medical terms and information
provided. The language used in screening and diagnosing becomes more complex and
challenging for lay people, midwives need to undertake interaction work by talking to pregnant
women about procedures in a language that they understand to enable them participate and make
decisions in the context of their culture and lifestyle (Svensson et, al 2008). Interviews and
discussions conducted by midwives to pregnant women are usually based on their medical
discourse rather than the lay pregnant woman’s discourse (Nolan, 2009). However,
Abrahamsson et al, (2005) urges midwives to discover and adopt “the lay perspective of a
pregnant woman so that her thoughts are given space to grow while she talks”pg. 334.
Despite the differences in age and education level, pregnant women are positive about
participating in antenatal education, indicating that this activity meets their needs. Younger
participants are noted as more positive than older ones (Alden, Ahlehgen & Josefeson, 2012).
Similarly participants with a lower level of education are more positive than participants with a
higher level of education. This might be explained in a way that older participants, who also had
a higher education level, might have developed a more critical way of thinking as regards birth
and care of the baby because they have more knowledge from previous pregnancies (Alden et al,
2012). In the same way younger participants would want to know and explore more about birth
hence they should also be motivated.
It is noted that in many instances, majority of antenatal classes cover the birthing process and a
small proportion of time is left to focus on what to do after the baby is born (Renkert &
Nutbeam, 2001). Birth is a one day event as parenthood is an experience for the entire life; this
explains why the highest reason for participating in antenatal education is to feel more secure as
a parent (Alden et al, 2012). Pregnant women who attend antenatal education have no realistic
understanding of the burden of parenthood or the changes in lifestyle and relationships that come
with it (Hillan, 1992). In these circumstances women are leaving antenatal classes with a good
knowledge of birthing options but feel insufficiently prepared for what lies ahead (Renkert and
Nutbeam, 2001) after the baby is born.
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The knowledge given to pregnant women in many hospitals is always projected and may not fit
the education needs of many pregnant women as well as their experiences which totally limits
their participation in such classes, (Nolan, 2009). The fact that pregnant women have some prior
knowledge and experiences especially multigravida this can be built on by health workers and
used to benefit them by actively involving them in the learning (Svensson et al, 2008). There is a
suggestion that educators in antenatal education need to become facilitators and adopt an
outcomes based education approach which shifts the emphasis from the educator to the learner,
Svensson et al, (2008). This is because outcomes based education approach is a flexible, and an
empowerment oriented approach to learning, which aims at equipping learners with the
knowledge needed for success on completion of their training (Cross, 2006). The facilitator
should therefore aim at promoting the outcomes essential for learning such as skills and values
among learners to help them think, solve problems, collect, organize and analyze information as
well as working in groups or independently to communicate effectively and make responsible
decisions.
Adult education is concerned not only with preparing people for life but rather with helping
people to live more successfully (Rubenson,1989) thus if there is to be an overarching function
of the adult education enterprise, it is to assist adults to increase competence by helping them
participate actively in any learning /training activities. This will help them gain greater
fulfillment in their personal lives and to assist them in solving greater personal and community
problems (Merriam et al, 2007).
However, in many instances adult education has remained insufficient in its inclusion and
promotion of active participation of women and their experiences in theoretical and practical
learning experiences, this is because the work of adult educators concerning how women learn
and know what they know has largely been ignored (Svensson et al, 2008). Therefore health
workers need to put in mind the different ways of women’s learning as well as trying to
eliminate some of the barriers to learning so as to enhance active participation of pregnant
women as discussed by adult education scholars.
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2.4.1 Experience based learning and participation of pregnant women in antenatal
education
Experience-based learning is regarded as the earliest approach to learning, the significance and
potential of it has not been fully recognized until relatively recently. In the formal education
system it has been developed and regarded as somehow fundamentally inferior to those
organized forms of knowledge which have been constructed as subjects or disciplines. Scholars
from outside of youth education often have a more sanguine contribution to make in defining
how people learn. Adult education scholars ( Rogers, 1951;Chickering, 1977; Jarvis, 1987; Kolb,
1993; Merriam & Clark, 1993, for example, have found out that it is constructive to document
the learning process for adults as experiential. What these authors do is provide alternative ways
of looking at the question of how people learn, resulting in a productive view of the learning
process among humans, both young and old, about which there is a reasonable degree of
consensus.
Kolb (1984) argued that defining learning in terms of the change in behavior is limiting and
poorly characterizes the learning process. Kolb defined learning as a human adaptation process,
whereby knowledge is created through the transformation of experience. Kolb (1984) work as
the empirical evidence for supporting a learning cycle theory begins with the experiences of the
learner. Kolb’s formula for learning describes human behavior as a function of a person and the
environment as presented in figure 1
Figure 1: Kolb’s formula on human behavior as a function
Concrete experience
Reflective
Active observation
experimentation
Abstract
. conceptualization
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In the experiential model, Kolb (1984) described two different ways of grasping experience:
Concrete Experience and Abstract Conceptualization. He identified two ways of transforming
experience: Reflective Observation and Active Experimentation. These four modes of learning
are often portrayed as a cycle.
According to; Kolb, Boyatzis & Mainemelis, (2000) concrete experience provides the
information that serves as a basis for reflection. From these reflections, we assimilate the
information and form abstract concepts. We then use these concepts to develop new theories
about the world, which we then actively test. Through the testing of our ideas, we once again
gather information through experience, cycling back to the beginning of the process. The process
does not necessarily begin with experience; however, instead, each person must choose which
learning mode will work best based upon the specific situation.
Stamler, (1998) notes that in antenatal education, pregnant women attending antenatal classes
like to feel welcome to ask questions and want to receive answers. This calls for small informal
classes using role-play, problem solving activities which can promote interaction and experience
sharing. Pregnant women enjoy learning from each other, respect and value the input of other
pregnant women who have recently been through the experiences they are about to face
themselves.
It is thus worth finding out how pregnant women use their experience they acquire from different
sources and how this experience determine their choice of methods in accessing antenatal
education.
2.4.2 Relationships in women’s learning: “Women’s Ways of Knowing”

Belenky, Clinchy, Goldberger, & Tarule, (1986) in their theory; “women’s ways of knowing”
described the role of relationships linked to connected knowing in women’s ways of learning.
Connected knowers seek to understand others' ideas and points of view, emphasizing the
relevance of context in the development of knowledge and the fundamental value of experience.
Connected knowers develop procedures for gaining access to other peoples’ experiential
xliii
knowledge through resonance and empathy. It involves seeing the other not in their own terms
but in others terms. In connected knowing you suspend your dis- belief, put your own views
aside, and try to see the logic in the idea (Belenky et al, 1986).
Connected knowing is marked by really listening, it involves the capacity to attend to another
person and to feel related to that person in spite of what may be enormous difference, (Belenky
et al, 1986). Connected knowing was described as embracing new ideas and seeking to
understand different points of view. The authors identify a variety of ways of knowing used by
women and asserted that connected learning was preferred by the largest number hence they
proposed connected teaching to support this way of knowing.
Connected teaching is concerned with bringing the feminine principle into the educational
learning relationship. Women need to be heard, therefore in antenatal education, the facilitator as
a midwife should help pregnant women draw out and give birth to their own ideas. The
facilitators should believe and trust in their learners’ thinking as well as encouraging them to
expand it.
In summary, relationships in the theory of “women’s ways of knowing” as developed by

Belenky et al, (1986) shows that women are more oriented towards sharing feelings and
communicating empathy if they are to participate fully in any learning /training activity as they
also prefer solving problems in groups (Hales, 1999).
Relationships in women’s learning have a great significance for the presumed preferences for
subjective and affective ways of learning. This centrality of relationships has led to
recommendations that educational programs for women should emphasize collaboration, support
and affiliation as well as critiques of gender bias, in the emphasis on autonomy and self-direction
in much of adult learning practice, as it helps enhance and promote women’s participation.
2.5 Utilization of antenatal education by pregnant women to promote maternal health.

Antenatal education plays an important role in ensuring a healthy mother and baby during
pregnancy and after delivery (Awusi, Anyanwu, & Okeleke, (2009). Mothers are given important
information during pregnancy; appropriate information on nutrition, breastfeeding, preparation
xliv
for labor and various options for management of prolonged labor. Usually such information is
given in a form that is easy to understand such that it can be utilized by pregnant women.
However, pregnant women with additional needs such as physical or sensory learning disabilities
as well as those who do not speak or read English, cannot clearly understand and fully utilize
such information (Birungi et al, 2008).
Antenatal education offers pregnant women an opportunity to develop a birth and emergency
preparedness plan. A birth and emergency preparedness plan includes identification of the
following elements: the desired place of birth; the preferred birth attendant; funds for birth-
related and emergency expenses; a birth companion; support in looking after the home and
children while the woman is away; transport to a health facility; transport in case of an obstetric
emergency; and identification of compatible blood donors in case of emergency (Birungi et al,
2008).
WHO, (2005) recommends that all pregnant women have a written plan for dealing with birth
and any unexpected adverse events, such as complications or emergencies that may occur during
pregnancy, child birth, or the immediate postnatal period. Women discuss and review this plan
with a skilled attendant at every attendance in antenatal education. Although little evidence exists
to show the direct correlation between birth preparedness and reducing morbidity or mortality for
mothers and babies, small-scale studies show that there is a considerable benefit gained from this
intervention (Pell et al, 2013).
Antenatal education prepares pregnant women to manage decisions during pregnancy and at
child birth. It orients women towards making informed decisions about their health and that of
their babies (Renkert & Nutbeam, 2001). Pregnant women are informed about the purpose of
any tests before they are done, health care professionals ensure women understand any necessary
information to give them sufficient time to make an informed decision (Birungi et al, 2008).
Through antenatal education health workers explain the use of medications distributed to
pregnant women such as ant malaria drugs, folic iron tablets (Carroli et al, 2001) as well as
various tests run such as HIV test, blood group, blood sugar and anemia among others. The
explanations help them understand the procedures they undergo as well as the purpose and
xlv
prescription modalities of the drugs they receive. Lack of explanations from health workers on
clinical procedures as well as drugs and tests leaves uninformed pregnant women, with little
chance to understand the importance of such services, possibly leading to poor compliance
(Conrad et al, 2012).
Counseling sessions are carried out especially to pregnant women who have life threatening
complications (Kisuule et al, 2013). Counseling prepares pregnant women emotionally and
physically for birth, care for the new born and early exclusive breastfeeding (Birungi, 2008).
Antenatal education can be a privileged entry point for counseling to prevent mother to child
transmission of HIV (WHO, 2003) and feeding options for HIV positive mothers (UN, 2011).
Conducting individualized and group counseling on the physiological processes of pregnancy
and child birth, recognizing pregnancy risk factors, personal hygiene, sexually transmitted
infections and HIV are all discussed in antenatal education (Birungi et al, 2008).
The education provided during the antenatal period provides an opportunity to supply
information on birth spacing which is recognized as an important factor in improving infant
survival (WHO, 2003).Active promotion of family planning is a means of preventing maternal
mortality in high-parity women (Birungi et al, 2008). The education received assists pregnant
women in deciding on future pregnancies in order to improve pregnancy outcomes (WHO,
2003).
Research, provides some evidence that women who are prepared for child birth tend to require
less medication, report less pain during labor and birth, have shorter labors, and have a more
positive attitude about the child birth experience (Riedmann, 2008). Pregnant women who elect
child birth preparation are often advantaged over other women and are able to utilize antenatal
education in many ways: this is because they are better educated, of a higher socio-economic
xlvi
status, more positive and less anxious about their pregnancies. Generally, they are older and plan
to breastfeed their babies for a longer period (exclusively for the first six months). The benefits
that come with the utilization of antenatal education have been demonstrated to various degrees,
even when motivation to take classes has been carefully controlled (Koehn, 2008). These
benefits include reduction of pain during labor and delivery, decreased use of analgesics and
anesthetics during labor, reduction of anxiety or tension during labor, decreased incidence of
forceps use, and a more positive birth experience (Finlayson and Downe, 2013).
2.6 Figure 2: Conceptual Framework
2.6.1 Determinants of Access to Antenatal Education

Dependent Variables Independent
Intervening Variables Variables

Information& skills Education levels of pregnant
provided in antenatal women
education.
Language used in antenatal
Methods of delivering classes
antenatal education to Improve maternal
pregnant. Awareness level of pregnant health.
women regarding the
Participation of pregnant importance of antenatal Promote infant &
women in antenatal education neonatal health
education
Social cultural values
Utilization of antenatal
Time and distance to the
education by pregnant
health center.
women to address
maternal health Economic factors
By Nabuufu Josephine
xlvii
The conceptual framework was built on a basis that access to antenatal education provides
different skills and information to pregnant women. Antenatal education content should be
delivered in a way that pregnant women understand and be able to fully participate such that they
could put into practice the skills and knowledge gained during antenatal education. It was thus
assumed that if various skills and information regarding pregnancy are provided to pregnant
women, they could be able to participate and utilize, it such that they could improve their health.
However there are intermediary factors that may hinder access, participation and utilization of
antenatal education among pregnant women and therefore leading to poor maternal health. These
are; the education levels of pregnant women, language used in antenatal classes awareness level
of pregnant women regarding the importance of antenatal education, social, cultural and
economic factors among others.
CHAPTER THREE
METHODOLOGY
3.0 Introduction
This section presents the research design; research approach; the study area, study population,
sampling, sample size, sampling techniques, instruments for data collection, data analysis and
quality control, as well as ethical considerations strategies that were employed during the study.
3.1 Research design

This study used a qualitative approach and an exploratory research design to assess access of
pregnant women to antenatal education programs. However, some elements of quantitative data
were adopted like tabulating findings using numbers and frequency counts. Exploratory research,
as the name states, intends merely to explore the research questions and does not intend to offer
final and conclusive solutions to existing problems (Singh, 2009; Adler, 2011). However,
Saunders, Lewis & Thornhill, (2007) earlier warned that when conducting exploratory research,
the researcher ought to be willing to change his/her direction as a result of revelation of new data
and new insights.
xlviii
3.2 Study Area
The study location was Nkokonjeru Town Council specifically the catchment area, of St. Francis
Hospital Nkokonjeru. The hospital was started as a dispensary which later developed into a full
hospital, with emphasis placed on educating local people in maternal and infant health where
antenatal education is a branch. Therefore due to its services of maternal and infant health it was
chosen as appropriate for this study. The researcher was also familiar with the place; she could
speak and understand the local language and also had an understanding of the local culture. The
study was based at the hospital and focused on pregnant women who came from different areas
to attend antenatal education programs conducted at the hospital.
3.3 Study Population
Yount, (2006) views a study population to comprise all the possible cases (persons, objects,
events) that constitute a known whole whereas Burns, (2000) defines study population as the
entire group of people or objects or events which all have at least one common characteristic.
Pregnant women attending antenatal education at St. Francis Hospital Nkokonjeru were the key
participants of the study. Majority of the pregnant women were primgravidae (women carrying
their first pregnancy) (30) and the rest (18) were multigravidae (women carrying their second or
more pregnancy. They fell within the age bracket of (16-47) whereby primgravidae fell within
age bracket (16-22) and multigravidae (20-47) years.
Antenatal education providers/ midwives of St. Francis Hospital Nkokonjeru were also engaged
in the study since their services directly determined access of antenatal education by pregnant
women. These included (1) registered midwife and (2) enrolled midwives working in the
antenatal department of St. Francis hospital Nkokonjeru.
3.4 Sampling
Polit, Beck, & Hungler, (2001) define sampling as a process of selecting a group of people,
events, behaviours or other elements in the study that is to be conducted while Yount (2006)
views sampling as a process of selecting a group of subjects for a study in such a way that the
xlix
individuals represent the larger group from which they were selected. The representative portion
of a population is called a sample.
3.4.1 Sample size

According to Baker and Rosalind (2012) is the number of people required to make an adequate
sample for a qualitative research project. This can vary from one to a hundred or more. However,
when considering the length of time this type of research often takes, the difficulty of gaining
entire or even the most mundane group or setting, the difficulty in transcribing thousands of
hours of interviews, and to publish, the best bet is to advise in the broad range of between a
dozen and 60, with 30 being the mean.
On the other hand, Miles and Huberman, (1994) define saturation as the point in data collection
when no new or relevant information emerges with respect to the newly constructed theory.
Hence, a researcher looks at this as the point at which no more data needs to be collected.
Saturation may be achieved more quickly if the sample is cohesive (e.g., if all participants are
members of a particular demographic group).
Combining the ideas of Baker and Rosalind (2012), my saturation point reached a total of fifty
one respondents (51) where pregnant women included; multigravidae were (18) primgravidae
were (30) aged between 16-47 years and Health workers were (3). They were recruited using
purposive sampling technique. Study participants included pregnant women who came for
antenatal education at St, Francis Hospital during the study. The 3 Midwives at the hospital also
provided information about access to antenatal education and were very critical in mobilizing
pregnant women for the two focus group discussions. This made the sample size come to 51.
Table: 1 Characteristic Features of Respondents
Research Participants Number

Pregnant
women
Primgravidae 30
Multigravidae 18
l
Health 3
workers
TOTAL 51
3.5.2 Sampling Techniques

Convenient and purposive sampling strategies were adopted. Victor, (2006) defines purposive
sampling as a form of non-probability sampling in which decisions concerning the individuals to
be included in the sample are taken by the researcher, based upon a variety of criteria which may
include specialist knowledge of the research issue, or capacity and willingness to participate in
the research. Some types of research design necessitate researchers taking a decision about the
individual participants who would be most likely to contribute appropriate data, both in terms of
relevance and depth.
Further, to say you will engage in purposive sampling signifies that you see sampling as a series
of strategic choices about with whom, where and how to do your research, that there is no one
best sampling strategy because which is best will depend on the context in which you are
working and the nature of your research objectives (Victor, 2006).
I purposively involved three (03) health workers/ midwives who were providing antenatal
education to pregnant women at St. Francis Hospital. They discussed access to antenatal
education by pregnant women, the skills and information provided, methods of delivering
antenatal education, participation and it’s utilization by pregnant women. All other related
challenges in handling pregnant women during the provision of antenatal education were also
discussed. These were chosen because they had all the necessary information about the provision
of antenatal education to pregnant women. In addition, I purposively engaged cases or
individuals who met a certain criterion, in this case pregnant women who came for antenatal care
services provided at St. Francis Hospital Nkokonjeru.
Convenient sampling on the other hand was employed on pregnant women who came to the
hospital for general services such as pregnancy checkups in case of danger signs or related
complications. I requested them to provide information to the study. Those who came in groups
of two and above were involved in focus group discussions.
li
3.6 Data Collection Instruments/methods
According to Polit, Beck, & Hungler, (2001) data collection methods include steps, procedures
and strategies for collecting and analyzing the data in a research study. I used focus group
discussions (focus group discussion guide) semi-structured interviews (interview guide) and
observation (observation schedule/check list as the main data collection methods for this study
3.6.1 Semi-structured interviews

While using semi structured interviews, the same questions were asked in each interview
conducted with the different participants. Dawson, (2009) cautions the need to remain flexible so
that other important information can still arise. In this way therefore, a list of questions or topics
were prepared for discussion for each interview to ensure uniformity. To obtain the required
information on access to antenatal education by pregnant women at St. Francis Hospital
Nkokonjeru, pregnant women were interviewed until the required saturation point was reached at
48. The interviews were conducted with different respondents in a separate room after the mid
wife had finished checking the pregnant woman. The antenatal education providers /midwives
were also interviewed with the main focus being placed on the skills and information provided to
pregnant women in antenatal education, methods of delivery, participation and utilization of
antenatal education by pregnant women.
3.6.2 Focus group discussions
A number of pregnant women were asked to come together in a group to discuss some issues
identified using the Focus Discussion Guide (Dawson, 2009). The discussion led by a moderator
or facilitator introduced the topic, asked specific questions, controlled digression and stopped
break- away conversations (Dawson, 2009). The moderator made sure that no one person
dominated the discussion whilst trying to ensure that each of the participants made a
contribution. Focus groups may be recorded using audio or visual recording equipment. Peek
(2010) clarifies this when he says under conditions of plentiful participants; researchers are
encouraged to use data-gathering techniques such as focus groups. Peek adds that these are
balanced by the ability to get subjects to tackle problematic or difficult issues with each other,
raising opposing viewpoints and resolving conflicting perceptions. During this study specifically,
lii
two main focus group discussions were conducted with pregnant women who were categorized
into two; primgravidae (women carrying their first pregnancy) (30) and multigravidae (women
carrying their second or more pregnancy (18). Again small groups of 3-4 pregnant women were
split from the two main focus group discussions at a later stage and these were according to the
pregnancy stages of different women. These shared responses on skills and information provided
in antenatal education, delivery methods, participation and utilization of antenatal education. The
method purposely catered for those pregnant women with limited time to wait for the one-on-
one interviews as well as those feeling shy to speak when approached individually.
3.6.3 Observation
The term “observation” means “looking at something without influencing it and simultaneously
recording it for later analysis.” In observational research, we do not deal with what people want
us to know (self-report measures) or with what some test writer believes he knows (tests and
scales). Rather, we deal with actual people in real situations. People are seen in action (Yount,
2006). Chilisa & Preece (2005) also expressed that, researchers do not only hear what the
researched say but also see, smell and touch as they interact with the participants. In the same
way, Denscombe, (2007) contends that when observation as a data collection method is used, it
doesn’t rely on what people say, do, or what they think but also draws on the direct evidence of
the eye to witness events at hand. It is based on a premise that, for certain purposes, it is best to
observe what actually happens.
In this study, observations were conducted to enhance an elaborate discussion of a specific issue,
to corroborate findings, and triangulate or complement data gathered through focus group
discussions and individual interviews. During semi-structured interviews and focus group
discussions held with pregnant women, I observed their participation levels and how the methods
were used to deliver antenatal education as well as utilization depending on the way pregnant
women presented themselves at the hospital. I also observed materials and activities which were
used during the provision of antenatal education.
liii
3.7 Data Quality Control
A pre-test of the interview guide was conducted with five pregnant women who met the
inclusion criteria and attended antenatal education at St. Francis Hospital Nkokonjeru, where the
study was conducted during the pilot study phase. The purpose of the pilot was to test the clarity
and relevance of data collection instruments and to familiarize myself with the instrument. The
responses from the pilot study were checked for completeness and consistency by the principal
investigator. After the pilot study, the researcher identified some missing gaps in the interview
guide. New ideas were included while irrelevant ones were eliminated. This made the subsequent
data collection process easier. In order to avoid response biases, the participants in the pilot study
were not included in the main study.
3.8 Data Management
Saunders et al, (2007) describe data management to include all actions needed to make research
data discoverable, accessible and understandable in the long term: organization, documentation,
storage, sharing and archiving. Data management is most efficient if it is planned at the start of
the research process. Data Management Plan (DMP) helps to identify the needs and barriers of
dealing with data in a research project in advance. Saunders et al, (2007) emphasizes that the
DMP should always be written before the start of the data collection. The (principal) investigator
describes the kind of data to be collected, the estimated size and formats, details on how and
where the data will be stored.
During this study, data collection included hand written notes and recorded interviews using the
researcher’s smart phone recordings. Field notes were expanded and written up in detail
immediately after leaving the research site. I also transcribed the recorded interviews. Data was
then coded like interview 1, Focus Group Discussion 1, 2. The transcriptions were done
precisely word for word. I then translated the complete interviews together with the field notes
processed and filed in preparation for analysis.
liv
3.9 Validity and reliability of the instruments
Reliability is when your measurement is consistent. It means if you are using a certain kind of
instrument for a test and the results on the subjects you are testing is the same for the first and
second try, then it is considered reliable (Miles & Huberman, 1994). If reliability is more on
consistency, validity is more on how strong the outcomes of the hypothesis are. It answers the
question ‘are we right?’ According to Denscombe, (2007) validity refers to the accuracy and
precision of the data. It also concerns appropriateness of the data in terms of the research
question being investigated.
The instruments for data collection were first prepared in English and two University supervisors
assessed their content validity. Qualitative research is also characterized by multiple realities and
therefore multiple truths. Research evidence is therefore credible if it represents as adequately as
possible the multiple realities revealed by participants. In this study, reliability and validity of the
study was reached by using more than one method for data collection. Semi-structured
interviews, focus group discussions and observations were used co-concurrently.
3.10 Data Analysis

According to Denscombe, (2007) analysis means the separation of something into its component
parts, to do this, the researcher needs to first identify what those parts might be by tracing things
back to their underlying source. Analysis involves probing beneath the surface appearance of
something to discover the component elements which have come together to produce it.
The researcher familiarized herself with data by repeatedly listening to the smart phone-
recordings and passed through transcriptions many times in comparison to the field notes. The
researcher made effort to accurately represent the integrity of respondents’ narratives. To
organize and prepare the data, the researcher first transcribed interview data by listening to the
audio files recorded to confirm meaning. This was followed by reading through the data to make
sense out of it. Then the transcribed data was codified by putting them under the already
identified themes in line with the research objectives.
lv
In developing the codes, effort was made to find any new themes that might be arising from the
interviews and the FGDs such as the demographic background of research participants. Also
attempt was made to identify possible differences in life events based on age and category of
pregnant woman (primgravida/ multigravida) and some differences were noticed among pregnant
women at St. Francis Hospital. The additional different codes were then used to form detailed
description of information about participants and the events in their pregnancies. The researcher
then used quotations from participants, which the researcher directly translated into the English
language. During these direct quotations, the researcher used pseudonyms which replaced the
participants’ real names to ensure privacy.
I ensured and checked the data collected for completeness and consistency, and then categorized
all the items before coding, examining, and tabulating.
All audio discussions from the Focused Group Discussions were transcribed. I transcribed the
data into written notes. The written data was then edited and coded.
I analyzed data in narrative form, interpretive summaries and presentation of verbatim quotes of
some respondents depending on the issue addressed. Data was presented in line with research
questions of the study.
I also ensured and checked the data collected for completeness and consistency, and then
categorized
3.11 Ethical consideration

Comstock & Gary, (2013) define research ethics as the moral principles guiding research from
its inception through to completion and publication of results and beyond. It could be contended
that as an applied ethic, research ethics seeks to ensure a convergence between the right and
wrong.
In fulfilling the ethical issues of this research, permission to conduct the study was obtained from
Makerere University School of Distance and Lifelong Learning (SoDLL) College of Education
and External Studies (CEES). Before carrying out the study, the researcher sought informed
lvi
consent from the respondents and clearly explained to them the purpose of the study. All
participants’ right to self-determination and autonomy was respected. They were given any
information they needed, verbally. Participation in the study was voluntary and they were
allowed to withdraw from the study at any time if they wished without explanation and without
being penalized. Confidentiality was assured and no personal details were recorded or produced
on any documentation related to the study. The researcher used pseudonyms to explain the exact
words of different respondents. This was intended to protect the privacy of the respondents from
the general public especially during information dissemination.
After the analysis, data was handled in a way that, there was indexing of raw data (instruments)
with a reference code that was used to store and relocate data so as to retain confidentiality and
anonymity. In this case, audio files were labelled with details of when and where they were
recorded rather than names of respondents.
lvii
CHAPTER FOUR
PRESENTATION OF RESULTS/FINDINGS
4.0 Introduction
This chapter presents the study findings, presenting skills and information provided to pregnant
women, methods of delivering of antenatal education, participation of pregnant women in
antenatal education and utilization of antenatal education by pregnant women. The presentation
in this chapter is guided by research objectives.
4.1 Demographic characteristics of respondents (pregnant women)

The respondents included; pregnant women of which majority depended on subsistence farming
as a source of livelihood, out of the 48 interviewed, only 3 were teachers (primary) 5 were
business ladies operating small restaurants and the rest 40 depended on subsistence agriculture.
Majority of the pregnant women were primgravidae (women carrying their first pregnancy) (30)
and the rest (18) were multigravidae (women carrying their second or more pregnancy. All the
respondents belonged to age range of (16-47) but primgravidae fell within age bracket (16-22)
and multigravidae (20-47) years.
Majority were married living with their husbands (28 out of 48) and (20) living with their parents
or a relative having conceived while still at home, many said their partners had ran away due to
lviii
fear of responsibility and being imprisoned by the girls’ parents for those who were still in
school.
Pregnant women were of mixed religions including Protestants 12, Muslims 4, Catholics 24 and
Pentecostal faith 8. The tribes included; Baganda 36, Basoga 6, Banyarwanda 2, Bagisu 3, and
Jhapadhola 1.
The education level of pregnant women varied from primary two to diploma level as presented
below
Table: 2 Education levels of pregnant women
Level of education Number

No education 4
Primary Lower (1-4) 18
Upper (5-7) 12
Secondary O- level 8
A-level 3
Certificate 2
Diploma 1
TOTAL 48
The education levels of pregnant women in the study are indicated in table 1 above; with 4
having no education at all, 18 had lower primary from primary one –four, 12 had upper primary,
five- seven. Secondary level had 8 for O-level and 3 for A-level. Certificate holders were 2 and
there was only 1 with an ordinary diploma.
lix
The study also included 3 health workers providing antenatal education to pregnant women
where by (1) was a registered mid wife and (2) were enrolled midwives.
4.2 Skills and information provided to pregnant women in antenatal education.

In the general study, pregnant women who visited the hospital were aware that accessing
antenatal education availed them with skills and information which helped them during the
course of pregnancy. All the 48 pregnant women in the study had some information and skills
provided to them in antenatal education by health workers. Each of them was able to mention at
least 3 or more skills and some information provided to them in antenatal education by health
workers.
Pregnant women had various interests and preferences about skills and information provided to
them in antenatal education. This is because there are a lot of myths, rumors and misconceptions
surrounding child birth. Primgravidae (first time mothers) in the first trimester showed anxiety
for more information about pregnancy as they were anxious to know how to manage
complications like excessive vomiting, nausea, loss of appetite, the common problems among
pregnant women in the first three months. In a FGD held with primgravidae, they expressed this;
“Olubuto olusooka luleeta enkyukakyuka nyingi mu mubiri nga okusesema, obutalya,

emmeeme embi naddala mu myezi esatu egisooka. N’olwekyo bwoba osooka busoosi
okuzaala olina okujja n’osoma osobole okufuna amagezi amatuufu okuva mu basawo
agakuyamba okuyita mu buzibu, okusinga okukozesa eddagala lyekinnansi n’amagezi
agatuwebwa mu byalo.”
These pregnant women meant that;
The first pregnancy brings a lot of body changes like vomiting, loss of appetite and
nausea especially in the first three months. Therefore if you’re carrying your first
pregnancy you have to come and get the right information from skilled people to help
you manage such complications other than using only local herbs and knowledge
provided in our villages, Focus group discussion held with pregnant women on 6 th June
2016.
lx
Pregnant women in the second trimester (4-6) months desired information about feeding for the
mother and baby, when and what to prepare for labor as well as breastfeeding. These covered the
continuing and first time mothers.
In a FGD with pregnant women in the second trimester about what they wanted to learn in
antenatal education, this is what they said;
“Twaliyagadde okusoma ku ndya entuufu ey’omukyala w’olubuto n’omwana ali mu

lubuto. Mu myezi (4-6) gino, omukyala yetaaga okumannya ebintu byalina okukozesa
mu kuzaala asobole okubitegeka. Enyonsa y’abaana entuufu erina okutusomesebwa nga
bukyali ne twetegeka okusinga okulinda mu myezi egisembayo nga tuzitoye nnyo.”
Pregnant women in of the second trimester meant that;
We would like to learn about proper feeding for a pregnant woman and the baby in the
womb. During these months (4-6) a pregnant woman needs to know what she has to use
during delivery such that she can start preparing. We also need to be taught proper breast
feeding earlier such that we prepare other than waiting in the final months when we are
overburdened by the pregnancy, Focus group discussion held with pregnant women on 6 th
June 2016.
Pregnant women in the third trimester (7-9) months desired information about what happens in
the labor ward, breastfeeding, care of the mother after birth and the baby. Exercise for the body,
management of pain and complications that come with the excessive size and weight in the last
three months as they approach giving birth, these were expressed in a FGD held with pregnant
women as presented below;
“Bwoba mu myezi gino egisembayo esatu oyagala okumanya ebibeera mu leeba, naddala
nga osooka busoosi okuzaala. Okuyonsa omwana wamu n’endabirira ya maama
n’omwana nga azaaliddwa. Okukola ‘exercise’ wamu n’okwasaganya obulumi n’obuzibu
obuva mu mugejjo oguletebwa olubuto mu myezi essatu egisembayo.”
Pregnant women meant that;
lxi
If you are in the last three months, you need to be briefed on what happens in the labor
ward especially if you’re carrying the first pregnancy. Breast feeding for the baby, care
for the mother and baby at birth. Exercise for the body and management of complications
that come with excessive body size and weight in the last three months as we approach
birth, Focus group discussion held with pregnant women on 6th June 2016
Generally pregnant women were aware that accessing antenatal education is good as it helped
them acquire skills about pregnancy, child birth and care of the new born baby as well as
information to make appropriate choices that contribute to optimum pregnancy outcome, but
access was still lacking as many pregnant women had irregular attendance. In an interview with
Saudha, she had this to say when asked about the benefits of accessing antenatal education.
“Okujja mu kusoma nga oli lubuto kirungi kubanga kikuyambako okufuna obukugu ku
by’embuto n’okulabirira omwana azaaliddwa. Bwoba osomeseddwa osobola okukola
okusalawo okutuufu eri gwe n’omwana ali mu lubuto. Naye okwetanira okusoma
tekunajumbirwa bulungi bakyala ba mbuto kubanga twosa mu nnaku eziba zituwereddwa
okukomawo.”
This is what Saudha meant;
Accessing antenatal education is good because it helps us acquire skills about pregnancy
and caring for the new born baby. The information provided helps us make the right
choice for you as a pregnant mother and the un born baby. However pregnant women do
not fully access antenatal education due to irregular attendance, many miss out on the
return days allocated to them, an in-depth interview conducted with Saudha on 23rd May
2016.
The packaging and order of presentation of topics was also another problem with pregnant
women. The facilitators always moved forward and backward, so as to catch up with late comers
lxii
and those of irregular attendance. It was observed that the forward and backward movements in
the presentation of topics made the facilitators fail to exhaust all the topics due to limited time.
The views of pregnant women on information and skills provided to them in antenatal education
are presented in the following table;
Table 3: Skills and information provided to pregnant women in antenatal education.
ITEM RESPONSE FREQUENCY
Good nutrition 46
lxiii
Care during pregnancy 38
Skills and Birth plan 18

information
Danger signs 38
provided to
pregnant women Immediate care for the new 32
in antenatal born
education
Counseling on issues of 38
HIV/AIDS and family planning
Sleeping under a mosquito net 42
Breastfeeding 36
Personal hygiene 28
Source: Primary data from responses of pregnant women during semi- structured interviews.
4.2.1 Good nutrition

In a focus group discussion, held with multigravida pregnant women (12) accessed information
about good nutrition from antenatal education provided at the hospital. They were able to point
out the types of food encouraged for pregnant women such as proteins vitamins and
carbohydrates among other foods. However, despite the information received about good
nutrition, many pregnant women still held on to the myths of women not eating certain foods like
chicken and eggs. In the same way they complained about eating certain fruits like pineapples
and sugarcane as it makes babies pour out saliva as they grow. In an in-depth interview with 47
year old Nalongo who was carrying her seventh pregnancy, she revealed this;
“Abasawo batusomesa ku ndya ennungi omuli okulya ebibala nga ennannansi n’ebikajjo
wamu n’ebyennyanja naye ffe mukyalo bagamba bwobirya omwana gwozaala ayiika
endusu.”
lxiv
Nalongo’s words meant;
Health workers teach us about proper feeding which includes so many foods like fish and
fruits, however, for us in the villages they say; when you eat fish and certain fruits
(pineapples and sugarcane) your baby pours out a lot of saliva, an in-depth interview
conducted with a 47 year old Nalongo on 27th May 2016.
Another issue raised by pregnant women as causing failure to adhere to good nutrition as
presented in antenatal education by pregnant women is poverty. They complained that they could
not afford to buy such food to balance up their diet as pregnant women. This was challenged by a
midwife who advised pregnant women that since they are rural women, where majority are
subsistence farmers; they should be able to grow some of this food like greens and fruits around
their homes to cut down on their food expenses.
In her words, Sr. Jane Francis Namatovu, a registered mid wife advised pregnant women as
follows;
“Okusinga okwekwasa nti temulina ssente zigula mmere eyo musobole okulya obulungi
nga omukyala w’olubuto bwasanidde okulya”. Abakyala abasinga muli balimi, mutegeke
obulimiro bw’enva n’okusimba ebibala awaka musobole okukendeeza ku nsasaanya
egenda ku mmere mu maka.”
Her advice meant;
Instead of saying that you don’t have money to buy food and adhere to proper feeding as
required by a pregnant woman, majority of pregnant women here are farmers, organize
small gardens of greens and plant fruits around your homes to enable you reduce on the
food expenses at home, advice to pregnant women by Sr. Jane Francis Namatovu on 9 th
June 2016.
4.2.2 Care during pregnancy

This consists of advice about the dos and don’ts of a pregnant woman during the period of
pregnancy. In an interview with a midwife she had this to share about how they advise pregnant
lxv
women to take care of themselves and the un- born babies.
Sr. Namatovu Jane Francis, a registered midwife explained that;
Pregnant women are advised to come and check their pregnancy with health workers as
soon as they realize they are pregnant. We also check their pregnancy on every visit since
the womb gets bigger as the pregnancy progresses.
Pregnant women are given 1 iron tablet every day for at least 90 days; they are advised to
take them because they help in the formation of blood and have no harm to the baby.
They are also given 3 fansidar tablets (ant-malaria drug) once every three months starting
at 3 months of pregnancy. This prevents them and their babies from getting malaria. A
tetanus toxoid vaccine is also given to pregnant women to vaccinate them against tetanus.
Blood pressure is also checked and weight measured on every visit because weight
increases as the pregnancy advances.
We also advise pregnant women to avoid heavy workload and take enough rest. This
prevents lower abdominal pain, backache, and other complications that may lead to
miscarriages among pregnant women.
The most disturbing issue is that pregnant women report late for antenatal services and
miss out on the required medication and tests as well as advice provided in the early
stages, this interferes with their health and that of the growing baby, an in depth interview
with Sr. Jane Francis Namatovu on 9th June 2016.
4.2.3 Birth plan

Findings from the respondents about what they understand by a birth plan were varying
depending on each pregnant woman. Among the 48 pregnant women interviewed 18 had a view
that a birth plan meant having a mama kit which constitutes; four pairs of gloves; plastic sheet 3
pieces of string and a razorblade. Pregnant women had a view that when you have a mama kit
One has already planned for the birth of the baby.
lxvi
In an interview with Kisaakye a primgravida of 18 years this is what she had to say when asked
about what she learnt about a birth plan.
“Okwetegekera okuzaala kwekubeera nti olina “mama kit” era tujja n’ogula wano mu
ddwaliro ku mitwalo ebiri (20,000/=). “Mama Kit” eno y’erimu ebikozesebwa mu
kuzaala.”
Kisaakye was explaining that;
A birth plan means having a “mama kit” ready; we come and buy it from the hospital at a
fee of 20,000. It contains what you need when giving birth, an in depth interview with
kisaakye about a birth plan on 13th June 2016.
In another interview with Grace, a multigravida of 3 children, she had this to say when asked
about a birth plan.
“Okwetegekera okuzaala olina okubeera nga otegese eby’okukozesa mu dwaliro nga

ozaala. Olina okubeera ne “mama kit” mulimu ebikozesebwa mu leeba nga ozaala
omwana. Okw’otekako ebyetaago ebirala nga engoye z’omwana; ebbaafu; engoyezo;
sabbuni; sukaali; amajani; emmere ne caayi wamu ne sente ez’okwekuumisa.”
Grace was explaining that;
In a birth plan, you have to organize and prepare what to use in the hospital while giving
birth. You should have a “mama kit” which contains what is used in the labor ward. In
addition you need other necessities like baby’s clothes; basin; your own clothing; soap;
sugar; tea leaves and food plus some money for emergency necessities, an in-depth
interview conducted with Grace on 27th May 2016.
4.2.4 Danger signs

Respondents were also informed and educated about danger signs during pregnancy. In different
FGDs held on 6th June 2016 at least 38 out of the 48 participants had been informed about danger
signs and could detect them which included any vaginal bleeding, fever, and malaria, severe
abdominal pain especially in the lower abdomen, severe headache and excessive vomiting.
lxvii
Pregnant women were also able to tell that health workers advise them to rush to hospital in case
they experienced any of the above signs and symptoms.
During the discussion it was noticed that pregnant women did not recognize and take serious
some symptoms of danger signs say swelling of the face, legs and feet, to many it was normal to
experience such especially in the third trimester. In a FGD held on 6 thJune 2016 this was also
revealed by some respondents;
“Abasawo batusomesa obubonero bungi obw’obubenje naye obumu tebuba bwa maanyi
nga okuzimba mu maaso, ebigere, n’amagulu. Bino byo bituuka nnyo ku bakyala
naddala mu myezi essatu egisembayo.”
The respondents meant;
Health workers educate us about many danger signs but some of them are normal like
swelling of the face, legs and feet. This is normal and mainly happens to pregnant women
in the final 3 months of pregnancy, Focus group discussion held with pregnant women
about danger signs on 6th June 2016.
4.2.5 Immediate care for the newborn

In an interview with Leticia, a multigravida of 26 years she had this to explain when asked about
immediate care for the new born;
“Sisita yatugamba nti omwana omuzinga mu ngoye enyonjo nga nkalu era nga zibuguma,
omutwe n’ebigere obibulizamu wabula ennyindo wegendereza obutagibika. Batukubiriza
obutateeka kintu kyonna ku kundi, lirina okuyonjebwa n’amazzi agalimu omunnyo nga
gabuguma, olireke likale okusobola okwewala obuwuka obuleeta enddwadde. Abasawo
batusomesa okunaaba mu ngalo nga tugenda okwata omwana, kubanga obuwuka obuva
mu ngalo buyinza okulwaza omwana nga buyita mu kkundi oba omumwa. Omwana alina
okunaazibwa ne ssabuni n’amazzi amayonjo”.
Leticia annyonyola nti;
lxviii
“Ebyogeddwa wagulu tetusobola kubitukiriza byonna nga abasawo bwe balagira,
okugeza batukubiriza okukuuma akalira nga kayonjo naye nyazaala wange ateeka
eddagala essekule ku kalira kasobole okuwona amangu.”
Leticia was explaining;
The sister (midwife) told us, we should wrap the baby in dry, clean and warm clothes
including head and feet but without blocking the nose. We are advised not to apply
anything on the cord; it should be cleaned with warm salty water, left dry and open to
prevent germs that can cause illness. Health workers encourage us to wash hands before
handling the baby; this is because germs from the hands can cause infection to the baby
through the cord, skin and mouth. The baby should also be bathed with soap and clean
water.
Leticia also explained that
We cannot meet the above conditions like the health workers say, for example we are
advised to keep the cord clean but my mother in law normally applies some powdered
herbs on the cords to help it heal faster, an in-depth interview conducted with Leticia
about immediate care for the new born on 26th May 2016.
4.2.6 Breast feeding

Among the respondents, 36 had been informed on when to start breast feeding and this was to be
done immediately after birth. Pregnant women were advised to breast feed their babies
exclusively on breast milk on demand at least 8 times a day.
Skills of how to position the baby properly, by attaching it on the breast to help improve the
amount of milk produced were also availed to pregnant women. In a FGD held on 6 th June 2016
about breast feeding, this was also revealed by some respondents;
Abasawo batunyonyola nti omwana alina kuyonka amabere gokka, okutuusa ku myezi
mukaaga, era tulina okuyonsa omwana buli lwaba yetaaze, wakiiri emirundi munaana
olunaku. Wabula olusi tulemererwa okukola nga abasawo bwebagamba kubanga amabere
lxix
gabula, olw’obutafuna mere eyamba okuleeta amata agamala omwana, ate oluusi emirimu
gitulemessa okuyonsa kubanga oyinza okuba nga oli mu nimiro ate nga omwana ali waka.
Ekirara omwana omuwere aba tasobola kunyweza bbere nga ayonka, nolwekyo maama
alina okumukwatirako ku bbere nga ayonka. Kino kimuyamba nasobola okunyweza
enywanto asike amata okuva mu bbere. Maama alina okulaba nti tabikka nnyindo ya
mwana asobole okussa obulungi nga taziyira.
They meant;
Health workers explain to us that a baby has to breast feed exclusively on breast milk for
a period of six months, we have to breast feed the babies whenever they are in need at
least 8 times a day. However, sometimes we fail to do like the health workers say
because we lack enough breast milk to feed the baby. This is because we are not able to
get the proper and enough food that helps in the stimulation of breast milk to feed the
baby. Sometimes the family chores are too many especially work in the gardens and little
time is left for breast feeding especially when the baby was left at home.
Next, new born babies cannot hold the breast firmly; therefore as mothers, we are advised
to hold the breast for the baby to help position the teat of the breast in the mouth of the
baby. This helps stimulate on the flow of milk as the baby suckles. Here, the mother has
to ensure that the breast does not block the nose of the baby to ease breathing and avoid
suffocating the baby. Focus group discussion held with pregnant women about breast
feeding on 6th June 2016.
4.2.7 Sleeping under a mosquito net

In the FGD and Interviews held with both primgravidae and multigravidae 42 out of 48
respondents had been informed about sleeping under a mosquito net and accepted being given
free mosquito nets at their first antenatal visit. During the FGD, many respondents pointed out
that the nets were weak, of poor quality and the chemicals applied to nets suffocated them
causing nausea. Much as the nets helped prevent mosquitoes that caused malaria, the smell of the
chemical was a problem to some pregnant mothers especially those in the first trimester, a stage
lxx
characterized with nausea and excessive vomiting and a number of pregnant women revealed to
have stopped sleeping in the mosquito nets.
In an interview with Flora about sleeping in a mosquito net, she had this to say;
“Abasawo batusomesa ku migaso gyokusula mu katimba k’ensiri okwetangira omusujja

ogusasanyizibwa ensiri, naye obutimba obutuwebwa bulimu eddagala eriwunnya ennyo
era lituyisa bubi naddala nga olubuto luto (emyezi; 1-3). Lino lituletera okusesema
n’emeeme embi era nze akange nakatereka.”
The respondent was saying;
Health workers educate us about the benefits of sleeping under the mosquito net to
prevent malaria spread by mosquitoes. However, the nets given to us contain a smelling
chemical that suffocates us especially with a young pregnancy of 1-3 months. The smell
of the chemical causes excessive vomiting and nausea so that is why I stopped using my
mosquito net and kept it, an in-depth interview conducted with Flora about sleeping in a
mosquito net on 9th June -2016.
4.2.8 General cleanliness

In finding out about information provided to pregnant women about general cleanliness or
personal hygiene, a 47-year-old Nalongo had this to say;
“Abasawo batukubiriza okweyonja ng’abakyala naddala nga tuli bazito. Kino kiyamba
okubanguyiza omulimu gwabwe kubanga nabo kibakalubirira okukwata ku muntu
omucaafu. Abakyala tulina okusaba kubuyambi bw’abaami bwe tuba tetwesobola mu
bigambo by’okweyonja.”
Nalongo’s words meant that,
The health workers encourage us as pregnant women to be clean especially when we are
pregnant. This helps ease their work as midwives because they also find it hard to handle
a dirty person. They encourage us to ask our husbands for help in case we cannot manage
lxxi
cleaning ourselves, Nalongo’s expression about general cleanliness in FGD held on 16 th
June 2016.
4.2.9 Counseling
Pregnant women are counseled mainly on issues relating to HIV/AIDS in a bid to promote
prevention of mother to child transmission and family planning
Pregnant mothers were tested for HIV/AIDS. Those found negative were advised to stay
negative by sticking to one partner as well as continue HIV tests every after 3 months. Those
found HIV positive were advised to start ARV’s to help save their babies and were oriented into
the Prevention of Mother to Child Transmission (P M T C) club.
However, in an interview with Sr. Nantale Prosy an enrolled midwife she revealed that
“Some pregnant women withdraw from accessing antenatal services where education is
inclusive, whenever they are tested positive. Health workers endeavor to give adequate
counseling to such pregnant women to make them accept positive living but due to
stigma, these pregnant women shun away from the hospital services and resort to small
clinics and traditional birth attendants”, an in-depth interview conducted with Sr. Nantale
Prossy about counseling on 30th May 2016.
In counseling sessions, family planning was also discussed with 32 out of 48 informed about
family planning. Respondents understood family planning as child spacing or giving birth to few
children.
In a FGD held with pregnant women, they expressed negative experiences about family
planning, which included;
“Family planning” ereeta okuvaamu omusaayi omungi, obugumba, omugejjo oba

okukogga ennyo, emalawo n’obwagazi. Abakyala abasinga tetugyetanira yadde eyamba
obutazaalira kumukumu naye tetugikozesa kubanga etuletera ebizibu bingi. Wakiri ofuna
olubuto okusinga okubonabona n’ebizibu byereeta.
They meant;
lxxii
Family planning causes excessive bleeding barrenness, weight gain\ loss and also loss of
libido. Majority of pregnant women don’t use it although it helps in birth spacing but we
don’t use it because it causes a lot of problems to us. We rather get pregnant, than suffer
with the problems it causes, FGD held on 16th June 2016 with pregnant women at St.
Francis Hospital about family planning.
In summary, the responses on the skills and information provided in antenatal education were
positive, pregnant women were educated on many issues however; many respondents had not
clearly understood certain topics exhaustively. They showed an information gap in the way they
responded about certain areas that appear crucial to them such as birth plan, nutrition and baby
care skills. It was also recognized that, primgravidae had little to share and explain on the skills
and information as compared to multigravidae who had been exposed to child birth and baby
care skills.
4.3 Methods of delivering antenatal education to pregnant women at St. Francis hospital
Antenatal education was mainly delivered to pregnant women by mid wives in-group and
individual sessions with pregnant women. The midwife took the role of the facilitator/instructor.
One to one sessions, group discussion, lectures and giving written information were methods
employed. The language of communication was mainly Luganda.
Table: 4 Methods of delivering antenatal education to pregnant women at St. Francis

Hospital Nkokonjeru.
No. Method frequency Percentage
(1) Written information 6 12.5%
(2) Group discussion 30 62.5%
(3) One to one session 12 25%
(4) Lectures 0 0%
lxxiii
Source: Primary data collected from interviews conducted with pregnant women about the
methods they preferred.
4.3.1 Written information

Findings from the study indicate that although several methods were used (6) out of (48)
pregnant women preferred antenatal education to be delivered using written information in
antenatal classes. This represented only 12.5 % of pregnant women in the study; written
information helped them revise at home during their free time. However, it was realized, the six
women were educated with better occupations compared to their fellow pregnant women.
4.3.1.1 Printed Materials

Pregnant women in the study were able to tell printed learning materials given to them by
midwives these included brochures and other printed materials distributed to pregnant women
especially on their first visits like the Mother Child Health Passport. However with the majority
being primary level dropouts with 18 in the category of lower primary level (P.1-P.4), 12 in the
upper primary (P.5-P.7) and 4 of them with no education, they could not understand them given
the fact that no clarifications were regularly made at the time of materials distribution. These
reading materials never created any impact concerning antenatal education provided to pregnant
women.
In an in-depth interview with 36-year-old Susan over the printed materials she had this to
say;
“Nafuna ekitabo mu ddwaliro, naye ekibi simanyi kusoma, era nakitereka mu kisenge.
Bwenakikomyawo olulala okulaba omusawo, yeyangamba nti mulimu ebikwata ku
mukazi w’olubuto n’omwana.”
The respondent meant that,
I received a book from Health Centre but unfortunately I am unable to read it. I just kept
it at home in my bedroom. I then returned it back to the hospital on the next antenatal
lxxiv
visit and presented it to the mid wife. It was then the midwife who told me that it
contained some information about pregnancy and child birth, an in-depth interview with
36 year old Susan over the printed materials about access to antenatal education held on
27thMay 2016
That was an expression of a 36 year old Susan with no education expressing how lack of reading
skills made her fail to understand antenatal education information in the brochure she was given
from the hospital.
4.3.2 Group discussion

Study findings indicate that pregnant women were more comfortable with group discussion as a
method of delivering antenatal education, 30 out of 48 pregnant women were in favor of group
discussion.
In a FGD held with pregnant women about the group discussions, they said;
“Okusoma awamu mu “group” kuwa emirembe ate mukekereza n’obudde kubanga

babanyonyolera wamu. Tuwebwa n’omukisa okunyonyola ebizibu byaffe nga tewali
kutya, kituyambako n’okuyiga okuva mu banaffe naddala abazaddeko abayiseko mu
mbeera y’okuzaala n’okulabirira omwana.”
The respondents meant that;
Group discussions are more comfortable and time saving because information is given to
a larger group. We are also given chance to explain our problems without fear, they also
help us learn from each other especially primgravidae learning from the multigravidae
who have been through the experience of pregnancy and child birth, a FGD held on 16th
June 2016 with pregnant women about the group discussions.
The discussion method also enabled pregnant women to share experiences amongst themselves
with the help of health workers who were facilitating the discussion. However, respondents
reported, discussions were not allocated enough time to allow every pregnant woman share her
experience and concerns. In the same way, their complaints varied depending on the stage of the
lxxv
pregnancy with different experiences hence in such a case the discussion could not flow to allow
every pregnant woman raise her concerns.
In an in- depth interview with Grace about group discussion method she explained;
“During discussions midwives are always in a rush to catch up with time and exhaust the
topics prepared for the day. They do not give ample time to the already tired pregnant
woman, who has walked to the hospital on foot, when it comes to discussing, such a
pregnant woman cannot contribute because she is not prepared by a facilitator. In most
cases midwives do not adopt the lay perspective of such a pregnant woman, her thoughts
are not given space to grow to enable her talk out what may be running in her mind”. An
in-depth interview conducted with grace about group discussion method on 27th May
2016.
4.3.2.1 Group size in delivering antenatal education

In an interview with pregnant women about how antenatal education is delivered to them, group
method was mainly used by midwives, in delivering content. The groups normally started with 5-
7 pregnant women who came early and the rest joined as they arrived at the hospital. This made
the groups larger as more pregnant women continued to join, this made pregnant women at the
extreme end divert their attention. In the same case, the midwife as the facilitator lost full control
of the large group and focus was placed on the ones at the front. It was observed that pregnant
women shared a lot of information and experiences that were really helpful in groups but none of
them took trouble to note down anything hence there is a possibility of forgetting some vital
content.
Respondents from the FGDs showed that groups had some negative issues; this is because
pregnant mothers were neither categorized according to education levels nor pregnancy periods
(trimesters) among other emerging categories but just mixed, yet they required different
information depending on their education levels and the period of their pregnancies. In many
instances discussions could not flow as they required different methods and content to meet their
concerns hence pregnant women could not come to a common point.
lxxvi
This was expressed by Khamida about groups and pregnancy stages, she said;
“Okusoma okwawamu tekwandibadde kubi naye embuto zaffe ziri mu biseera byawufu
era n’ebizibu byawuka, nolwekyo nsuubira okusomesebwa ebintu ebyawufu ku buli
mutendera olubuto gwe luyitamu okusinga okutugatika awamu.”
Khamida meant that
Group discussions wouldn’t be bad but our pregnancies are at different stages, with
different complications so I think we need to be taught different content at every stage of
the pregnancy other than putting us together in one group, an expression of Khamida over
groups in a FGD held on 16th June 2016.
4.3.3 One to one session

Findings of this study show that; a relative percentage of pregnant women 12 out of 48 which
makes 25% preferred one to one discussion with a midwife. This is mostly used when dealing
with sensitive information about pregnancy and maternal health.
These involved a lot of counseling especially on the physical condition of the growing baby and
pregnant woman. In the same way after running tests like HIV syphilis, urinary tract infections
and ultra sound scans, counseling is done depending on the results. However respondents
reported that one to one discussions subject them to a lot of fear and pressure as they are always
on tension, waiting to receive either bad or good results. In most cases they lack concentration
making it hard for them to conceptualize the information provided by the health worker.
In an interview with Miss Rose (not real names) an HIV multigravida of 6 children in the PMTC
club this is what she had to say;
“Omusawo bwakukebera nakugamba otuule kulayini y’akasenge otyamu, era ne

by’akunyonyola oyinza obutabitegera nga olinda mawulire agavudde mu kukebera”.
She meant that;
lxxvii
When a health worker checks you and tells you to sit on the line going to the room you
develop some fear, you might even fail to understand what is being explained to you
because you are just waiting for the results, an expression of Rose about her concerns of
one to one sessions in an interview conducted on 9th June 2016.
4.3.4 Lectures
In lectures, the facilitator (midwife) takes control of the learning process, determines what is to
be taught and learnt when and how. In an interview with pregnant women, lectures covered little
time and always started very early in the morning when most of them had not yet reached the
hospital. Pregnant women reported that, lectures denied them chance to share their experience
which is a rich resource for learning in adults; hence they miss out some vital content which
would have been important.
Respondents reported that during lectures they just sit and receive what has been prepared for
them. Although some may have questions to ask, the answers provided are not thorough to fully
exhaust the question due to the limited time allocated.
In an interview with Grace a multigravida of two children and teacher by profession she
explained,
“In most cases the information provided using the lecture method is projected and at times does
not meet the education needs of some pregnant women because their personal experiences are
not given serious attention to maybe correct mistakes that might have occurred with the past
pregnancies” (an in-depth interview with Grace about using the lecture method in antenatal
education held on 27thMay 2016).
4.4 Participation of pregnant women in antenatal education
4.4.1 Reasons for participation in antenatal education

Pregnant women in the study conducted at St. Francis Hospital Nkokonjeru had various reasons
for participating in antenatal education which included; the need to interact with fellow pregnant
women and the hospital environment so as to obtain new competencies as pregnant women;
acquire knowledge and be able to cope with birth and parenthood; but the most pronounced
lxxviii
reasons were that pregnant women participated in antenatal education because they wanted to
feel more secure as parents and be able to acquire skills of taking care of their new born baby.
Table: 5 Reasons for participation of pregnant women in antenatal education.
No. REASON/RESPONSE FREQUENCY
1. To manage child birth 48
2. Learn skills of taking care of new born 46
3. Identify problems during pregnancy 38
4. Ensure healthy of pregnancy and development of baby 34
5. Obtaining a birth / antenatal card 26
6. Take medicine provided in the hospital 24
7. Normal part of pregnancy 8
8. Compulsory as required by hospital staff 16
Total Number of respondents: 48
Source: Primary data from responses of pregnant women in a focus group discussion conducted
with pregnant women on 6th June- 2016
Pregnant women in the study gave various reasons for participating in antenatal education. Study
findings show that managing child birth with 48 and learning skills of caring for the new born
were given by majority pregnant women 46 as the main reasons for their participation in
antenatal education. This could be attributed to the fact that the transition to parenthood includes
lxxix
a radical change in the lives of pregnant women, which requires them to make significant
adjustments, in order to deal with the changes during pregnancy. In a focus group discussion
conducted with pregnant women on 6th June 2016, they reported;
“Ekisinga okutuleeta okwenyigira mu musomo gw’embuto kwe kumanya ku by’okuzaala

omwana n’okufuna obukugu mu ndabirira y’abaana abawere.”
These pregnant women meant;
The reason for us to participate in antenatal education is to know about child birth and
acquiring skills of caring for new born babies, an expression of pregnant women in a
FGD held with pregnant women on 6th June-2016.
During the study, 38 out of the 48 pregnant women participated in antenatal education to be able
to identify problems during pregnancy. This involved discussion of the danger signs they
experienced with health workers. It also helped them ensure the health of the pregnancy and the
development of the baby; this was mentioned by 34 out 48 pregnant women.
“Twenyigira mu musomo gw’embuto kubanga twagala kuyiga bubonero bwakabenje nga

oli lubuto. Abasawo babutunyonyola ne tusobola okubwewala tubabulira n’obuzibu
bwetulina n’embuto zaffe.”
Literally meaning,
We participate in antenatal education because we want to learn about danger signs during
pregnancy. Health workers explain them to us and how we can avoid them, we too
explain to them complications we have with our pregnancies, an expression of pregnant
women in a FGD held on 6th June -2016.
Findings indicate that 26 out of 48 pregnant women participated in antenatal education because
they wanted to get a birth/antenatal card. The cards contain information about pregnant women’s
identity and their health history. The motive behind obtaining a birth /antenatal card as one of the
reasons for participating in antenatal education is that “without a card, pregnant women would
lxxx
encounter problems if they attended a health center to deliver”, in most cases without the cards,
they would be denied care. Norah explained that;
“Bwojja mu ddwaliro nga ogenda okutandika okusoma bakuwa ekipande okubeera

amannya go nebikwatako byonna. Kino kyowa abasawo nga ozze okuzaala era oluusi
bwoba tokirina osanga obuzibu, bayinza okulwawo okukolako oba nebaganira ddala
okuzalisa kuba oba tolina kiraga nti obadde onywa eddagala”.
Norah’s words,
When you come to the hospital to start attending antenatal, an antenatal card is issued to
you. This contains your name and personal information. The card is presented to health
workers during the time of birth and if you don’t have it, you encounter some problems.
Health workers tend to delay attending to you or even refuse to help you deliver because
you have no record of attending antenatal services, an expression of Norah during a FGD
held with pregnant women on 6th June-2016.
Out of the 48 pregnant women 24 highlighted the need to take medicine provided in hospitals as
another reason for participating in antenatal education. This medicine is free and it is swallowed /
injected in the hospital, as it was said by Zainab and Kisaakye,
“Tujja mu ddwaliro okusoma kubanga tulina okunywa eddagala eriweebwa ab’embuto.

Eddagala lino liba lya bwerere era olimirira mu dwaliro, n’empisso bagikuba.”
These meant,
We come to the hospital for antenatal education because we also have to take medicine
given to pregnant women. This medicine is free and it is swallowed /injected in the
hospital, views expressed by Zainab and Kisaakye during a FGD held with pregnant
women on 6thJune-2016.
Study findings also indicated that 16 out of 48 pregnant women viewed participation of pregnant
women in antenatal education as a normal and compulsory requirement by hospital staff. These
pregnant women reported that it is a requirement for every pregnant woman to visit a health unit
lxxxi
just as the government encourages them to at least visit the health Centre four times. They
explained,
“Okujja muddwaliro kya bulijjo era teeka ku buli mukyala ali olubuto nga abasawo bwe
batulagira. Gavumenti ekubiriza abakyala abali embuto okugenda mu ddwaliro
okeberebwa wakiri emirundi ena”.
Meaning,
Coming to the hospital during pregnancy is a normal and compulsory requirement for
every pregnant woman. The government also encourages pregnant women to attend
antenatal at least four times, an expression of pregnant women about participating in
antenatal education in a FGD held with pregnant women on 6thJune-2016.
4.4.2 Attendance as a way of participating in antenatal education

Participation of pregnant women in antenatal education was characterized by their attendance.
The fact that pregnant women attended the antenatal classes singled out clearly that they
participated in antenatal education. Pregnant women were issued with an antenatal card/ book,
where health workers indicated their personal information and medical history as well as the
days for attending antenatal sessions.
However, many respondents came late due to family responsibilities and gender roles and many
only came when they had problems with their pregnancies.
According to Miss Namuzibwa Florence an enrolled mid wife, she explained that,
“Pregnant women usually attend and participate in antenatal education whenever they
experience some complications at home, without such they stay in villages and go to
traditional birth attendants (TBA’S). She also noted that many pregnant women
participated in antenatal sessions and missed classes by coming late, these always found
when classes were done. Therefore much as pregnant women were encouraged to attend
antenatal education, many came late and normally found the group study sessions done.”
An interview conducted with Miss Namuzibwa Florence an enrolled midwife about
lxxxii
attendance as a way of participating in antenatal education by pregnant women on 9th
June-2016.
In a focus group discussion held with pregnant women on 6 th June 2016, it was realized that
many of them attended antenatal education late. This is because they had no money to buy the
antenatal book required in the hospital for recording information about their health history and
the progress of the pregnancy.
Bwoba onotandika okusoma wetaaga okugula ekitabo, kya silingi 6,000/= eza Uganda.
N’olwekyo tulwawo okujja mu musomo gw’embuto nga tukyanoonya ssente ezo
tusobole okusoma.
The respondent meant,
If you are to start attending antenatal education you need to buy a book (Mother Child
Health Passport) at a fee of 6,000 Uganda shillings. Therefore we come late because we
are still looking for that money to be able to come in antenatal education, an expression
of Meeme about lack of money to access antenatal education in time during a FGD held
on 6th June 2016
4.4.3 Topics
Antenatal education has a wide range of topics like birth, care of the new born and breastfeeding
among others. In most cases these topics are explored by health workers to help pregnant women
understand what lies ahead of them mainly in theory. Respondents reported that in most cases it
is the health worker who chooses the topic(s) of study for the day, whereby it is mainly
theoretical. However in a focus group discussion held with pregnant women, they preferred
active participation where many especially primgravidae (first time mothers) would wish to have
some practical or a video show on some sensitive topics like how to push out a baby. This is
because they just imagine what it looks like, especially those carrying their first child. More to
that, they wanted to at least watch a video about the theory being explained to them about child
birth and care for the new born which the hospital could not afford because they had no such
teaching aids.
lxxxiii
The topics presented were according to the category of mothers in the class. Primgravidae
normally covered topics like danger signs, good nutrition, birth plan, family planning and HIV
counseling whereas multigravidae dwelt so much on baby care skills breast feeding and birth
plan. It was observed that the facilitator tried to look at all the topics briefly, because pregnant
mothers had varying education needs yet the time allocated was always short to exhaust all the
topics.
Responses from the pregnant women in the two focus group discussions showed that respondents
had varying education needs that could not be exhausted in the short period allocated for the
antenatal class. Therefore they always had to ask health workers during one to one sessions of
counseling, especially in cases where it was so sensitive requiring a lot of privacy.
In an interview with Rose, an HIV multigravida carrying her second pregnancy, she had this to
say;
“Bwe nzijja mu musomo gw’embuto nga nina byenjagala okuyiga nze nga omuntu wamu
n’ebibuuzo by’enjagala okuddibwamu mu bulambulukufu bwabyo, ebiseera ebisinga
tekisoboka kubanga abasawo baba bategese eby’okusomesa ebyabwe n’olwekyo mba
nzibuwalirwa okubatataganya nange nsobole okunyonyolwa ebiba bindeese.
Nebwomubuuza akuddamu naye takulambululira byonna olwobufunda bw’ebiseera.
N’olwekyo mba nina kumulinda mu kasenge nga akebera kyoka ate oluusi layini ebeera
mpanvu”.
Rose meant;
There are times I come for antenatal education with issues that I want to learn about
personally. There are also questions where I need thorough answers but in most cases this
is impossible because health workers have already prepared what is to be taught that
particular day, this becomes hard for me to actively participate and air out my concerns.
Also where answers are provided, the information is brief due to the limited time
allocated for the classes. Therefore I have to wait for the health worker in a room during
lxxxiv
check-ups and have a one to one discussion however; this takes a lot of time due to the
long line, an expression of Rose in an interview conducted about topics on 9th June-2016.
It was also observed that pregnant women wanted to learn about topics where they had personal
problems. In many instances when a health worker asked if there was anything more they wanted
to know, they always participated and cited their personal health problems like excessive
vomiting, backache, loss of appetite and general body weakness. Pregnant women usually
wanted to know the causes and how to manage such conditions but in most cases, their concerns
were not always exhausted because they were many and the time allocated was little.
4.4.4 Motivation
Motivation of pregnant women in antenatal education was also noted as an outstanding factor as
regards participation in antenatal education, this is because these women are always weak and
exhausted by the heavy weight of the babies they are carrying.
When asked what motivates and demotivates pregnant women from participating in antenatal
education;
Bugonzi a 32 year old multigravida of 4 children had this to say
“Nze setanira byakusoma lwansonga baabitusomesadda okuva ku baana abasooka nakati

byebasomesa teri bipya byeboogerako nze njagala nensanga nga biwedde”.
She meant that,
I am not motivated any more to attend because the same information is given to me ever
since my first child. I think there is no new information that motivates me to attend; I just
come a bit late for only checkups, an expression of Bugonzi about motivation in an in-
depth interview conducted on 10th June 2016.
Sr. Jane Francis Namatovu explained that they try so much to motivate pregnant women by
rewards like giving out mosquito nets to pregnant women and their babies such that that they
don’t contract malaria but still many only come for the first time to receive the nets and
disappear without coming back for the next visits.
lxxxv
4.4.5 Language
The language of communication in the classes was mainly Luganda, this was because majority of
pregnant women were Baganda with 36 in number, the rest included; 6 Basoga, 2 Banyarwanda,
3 Bagisu, and 1 was a Jhaphadola, these too could understand and speak Luganda
Pregnant women were well conversant with the use of Luganda in the classes. However it was
realized that much as majority of pregnant women knew the language well, there were some
terms which pregnant mothers had not heard of especially primgravidae who were new to the
field of pregnancy and child birth. In many cases they seemed not to understand those terms
which limited their participation, therefore the midwife had to explain to them in the simplest
terms possible to enable them catch up and freely participate in antenatal sessions.
During a discussion facilitated by a mid-wife about signs of birth, a pregnant mother raised a
question about what the midwife meant by these terms,
“Ensundwe okwabika”
Meaning;
Opening / rapturing of the uterus membranes.
“Omwana owemabega”
Meaning;
A sack that carries a baby, in the womb.
The language used in antenatal education also at times limits pregnant women from fully
participating in antenatal education. In a focus group discussion conducted with pregnant
women, they emphasized that some medical terms are so complicated for them to understand as
lay people. Terms used in screening and diagnosing are usually hard for them to understand
hence limiting their participation because they cannot exchange ideas and talk about issues
beyond their understanding hence they are left with only one choice of accepting what health
workers are saying.
lxxxvi
In an interview with Tusabe, this is what she had to say,
“Ebigambo abasawo bye bawandiika oluusi bikaluba n’otabitegeera naddala bwaba

takunyonyodde. Eddagala n’okukebera obulwadde obumu byetaagisa sente naye, tutuuka
n’osaba omwami sente n’akubuuza kyebitegeeza nga tosobola kubinyonyola”.
This is what Tusabe meant,
The words health workers write for us are sometimes hard to understand especially when
they do not explain to us. For example names of certain medications and tests for some
illnesses where you have to get money from the husband and he asks you the meaning of
the words written and you can’t tell, an in-depth interview conducted with Tusabe about
language used by health workers on 10th June 2016.
Another Namakula said,
“Nze omusawo yangamba okugenda mu ‘Scan’ naye bwenamubuuza kyeki? Nangamba

ka T.V wabula teyanyinyonyola lwaki, nabiki ebikolebwayo era sigendangayo”.
Literally Namakula meant,
The health worker told me to go for ultra sound scan but when I asked what it is, she told
me it’s a small television. She never explained to me why I should go there and what is
done there so I haven’t also gone in the Television.
This was an expression of Namakula about the language used by health workers during a focus
group discussion conducted on 16th June 2016
4.4.6 Inferiority complex among adolescent pregnant women

This was especially noted by the researcher among primgravidae and young pregnant girls
possibly who had dropped out of school. These feel ashamed and fear to open up in society
something that hinders their participation.
In an interview with Miss Nantale Prosy a midwife she explained that;
lxxxvii
“Girls who become pregnant and drop out of school are seen by society as a
disappointment to their parents and the way society talks about them subjects them to
inferiority. In many instances, these fail to express themselves even when attending
antenatal education. They are always silent and usually do not fully participate, like their
fellow pregnant women”, an expression of Miss Nantale Prosy a midwife, during an
interview conducted on 13th June 2016.
4.5 How is antenatal education utilized by pregnant women to promote maternal health
Different skills and information were identified in interviews and focus group discussions where
respondents thought that if given serious attention, pregnant women would utilize them to
promote maternal health. Among the issues raised by respondents, the following were more
pronounced as presented in the table below;
Table: 6 Utilization of antenatal education by pregnant women
ITEM RESPONSE FREQUENCY
Promotes decision making 26
Utilization of Proper nutrition 38

antenatal
education by Ability to detect danger signs 32
pregnant Compliance to medication 28
women
Personal hygiene 32
Able to make a birth plan 36
Care for the new born 38
Family planning 24
Source: Primary data from responses of interviews conducted with pregnant women.
4.5.1 Decision making

Access to antenatal education exposes pregnant to information about pregnancy and how to
manage such a period. It orients them on what to do and how to act responsibly during
lxxxviii
pregnancy. Antenatal education equips pregnant women with decision making skills of
sustaining themselves such that they can easily decide on the right thing to do at the right time
other than depending on husbands.
During an interview with Veronica on challenges encountered in decision making she was able
to tell that,
“Ebiseera ebimu oyinza okusalawo nti ojja kuzaalira mu ddwaliro nga abasawo
bwebatusomesa naye omwami nagaana ate obeera tosobola bisale bya ddwaliro awatali
buyambi bwa mwami”.
Veronica meant,
Sometimes you may decide that I will give birth in the hospital like the health workers
teach us, but instead your partner deliberately refuses and you cannot afford the hospital
bills without the help of the husband, an in-depth interview conducted with Veronica
about decision making on 9th June 2016.
4.5.2 Proper nutrition

Pregnant women did not understand clearly what proper nutrition for a pregnant woman meant
and did not fully utilize the information provided to them about nutrition. In a FGD held with
pregnant women, many understood it as eating some meat and matooke.
Meeme a multigravida of two children had this to say,
Nze bwendya ku tooke n’ennyama oba ekintu kyonna kye njoya mba ndide bulungi.
Meaning,
When I eat meat and matooke plus anything I crave for, is good feeding to me, as
expressed by Meeme in a FGD held on 16th June 2016.
In a focus group discussion where respondents were explaining how they utilize antenatal
education. They had mixed reactions and views about proper nutrition; to some it meant eating a
balanced diet whereas to others it was eating 3 meals in a day.
lxxxix
Serina explained that,
“Nze endya ennungi ntegeera okulya emmere erimu ebiriisa ebyenjawulo”.
Meaning,
I understand proper nutrition as eating food that has a variety of food values. An
expression of Serina about proper nutrition, in a FGD held on16th June 2016.
Whereas Nyadoi said,
“Endya ennungi etegeeza nga osobola okulya wakiri emirundi essatu olunaku, ekyenkya,
ekyemisana n’ekyegulo”.
She meant,
Proper nutrition means being able to eat 3 meals in a day; breakfast, lunch and supper, as
explained by Nyadoi, in a FGD about proper nutrition held on16th June 2016.
4.5.3 Ability to detect danger signs

Pregnant women reported to have been educated about danger signs during pregnancy, when
asked about how they utilized the information given to them, Nantayi, a multigravida of 4
children said,
“Bwetufuna obubonero obw’obubenje, abasawo batukubiriza okugenda mu dwaliro naye

oluusi tulemesebwa olw’obutaba nantambula yamangu. Naye ate waliwo n’ebintu nga
ndaba tebisaana ddwaliro byabulijjo nga okuzimba ebigere”.
Nantayi was reporting that;
When I experience danger signs, health workers encourage us to rush to hospital, but in
many cases we fail due to lack of immediate transport. She adds that, sometimes the
danger signs we experience are minor and normal to us like swelling of face and feet,
views expressed by Nantayi about detecting danger signs in a FGD held with pregnant
women on 16th June 2016.
xc
It was noted that pregnant women did not receive adequate information regarding all danger
signs that is why they even refer to some danger signs like swelling of foot and feet as nor mal
and minor where they did not require to rush to hospital as informed by the health workers.
4.5.4 Compliance to medication

In antenatal education, pregnant women are given medication in form of tablets and injections
for certain sicknesses and pregnancy complications. Health workers usually explain and inform
pregnant women why they are given such medication. However, in cases where health workers
do not give thorough information and explanations to pregnant women, utilization and adherence
to this medication is always inadequate.
A 29 year old Nankinga, who is a multigravida stated;
“Nze eddagala linkalubiriza naddala amakerenda era simira mangi kugamalawo

bwempuliramu obulungi nga mbivaako.”
She meant
I always find it hard to take tablets so I don’t take many, when I feel better I stop an
expression of Nankinga about compliance to medication, an in-depth interview conducted on 10 th
June 2016.
It was realized that much as pregnant women had been educated and informed about the need to
take medication during pregnancy. They revealed that many did not finish the required dose as
given by the health worker and were not informed about the need to finish the given dose as
many withdrew from the medication whenever they felt better.
4.5.5 Birth plan

A birth plan was mainly understood by pregnant women as supplies needed in a hospital during
birth. Pregnant women took the trouble to buy the required necessities when going to the hospital
for delivery as informed by the midwives. However when asked about issues like someone to
accompany them to the hospital when labor starts, a person to stay with at the hospital, and
someone to live home when going for delivery in case there are other children to look after,
xci
many had no immediate answer for those questions, meaning their birth plan was not yet
complete as they still needed to plan and get those people to help them when labor starts.
In a FGD held with pregnant women about preparing what constitutes a birth plan, they had this
to say;
“Abasawo batunyonyola ku by’okukola entekateka tusobole okwetegekera okuzaala naye

oluusi olw’ebbula ly’ensimbi ebimu tulemererwa okubiteekateeka mu budde. Olubuto
tomannya ddi lwe lunakuluma, oyinza okuba nga wagamba omuntu okuwerekerako mu
ddwaliro kyokka n’olumwa nga taliwo era abeerawo yenna yakuyamba nakubeerako mu
kuzaala”.
They meant
Health workers explain to us about making a birth plan such that we can prepare for birth
but sometimes we lack enough money and fail to buy and prepare all the required
necessities in time. It is also hard to know when labor will start, you might have booked
someone to escort you to hospital, but the labor pains start when that person is not
around, in such a case you have no option but to go with who-ever is around to help you
during labor and delivery. Views expressed about utilizing a birth plan in a FGD held
with pregnant women on 16th June 2016.
4.5.6 Care for the new born baby.

All respondents reported to have been educated about care for the new born baby by the health
worker such as wrapping the baby in dry warm clothes and starting to breast feed immediately
after birth. In many instances these are done in hospital with the help of a midwife, however
what lies ahead for the mother as she left the hospital was more challenging to pregnant women.
In an interview with Nabateesa a multigravida, this is how she narrated her experience with her
first child;
“Bwenazaala omwana wange eyasooka, buli kimu kyali kipya gyendi. Nali ntya
okunaaza omwana naddala awali ekirira yadde omusawo yakyogerangako nnyo nga
xcii
tusoma. Nali sisobola kukwata bulungi mwana mutereeza nga ndowoza ajja kumenyeka
amagumba. Maama wa bba wange yeyannalizanga omwana okutuusa lwe yavaako
ekirira.”
Nabateesa meant,
When I gave birth to my first child, everything was new to me; I feared bathing the baby
most especially the cord though the midwives were talking about it regularly in antenatal
class. I could not properly position the baby because I thought the bones would break. It
was my mother in law bathing the baby until the cord got off, an in-depth interview with
Nabateesa about care for the new born baby conducted on 9th June 2016.
It was realized that much as Nabateesa had been educated, she could not utilize the skills because
she was still fearful of practicing what she had been taught and not ready to handle and care for
the baby.
4.5.7 Family planning

In antenatal education pregnant women were introduced to the concept of family planning. All
respondents had been educated about family planning in general where some understood it as
child spacing while to others it was producing few children one can manage to look after. In a
focus group discussion, pregnant women were asked how they utilized family planning and
many had a bias against it. They complained on the side effects about it among them were
causing excessive weight, loss of libido, failure to have normal periods, prolonged bleeding
among others. It was realized that basing on the complications raised many had stopped using
family planning
In an in-depth interview with Agatha this is what she said
“Nasala kilo 10 mu myezi ena nga mira amakerenda ga famire ne ndowoza nafunye
mukenenya. Nagenda ne nekebeza omusawo nangamba sirina bulwadde. Bakyala
banange bangamba nti amakerenda ga famire gegandetede okukendeera omubiri.
Nakyusa nenzira ku mpisso ne ngejja ne kilo 9 mu myezi ebiri ekyampitirirako.
Nasalawo ne mbivako byombi era kati ndi lubuto.”
xciii
Agatha meant;
“I lost 10kg in the fourth month I swallowed pills and I thought I had contracted
HIV/AIDS. Later when I tested thinking I was sick, the doctor told me I wasn’t. My
friends advised me that pills were the cause of this huge weight loss. Then later changed
to injector plan and gained nine kilograms in 2 months which appeared abnormal. I
decided to leave both methods and now I am pregnant. An expression of Agatha about
family planning, an in-depth interview held on10th June 2016.
The presentation above shows that pregnant women access antenatal education however the
skills and information provided, the methods of delivery, content, participation of pregnant
women and how they are utilizing the antenatal education provided, is still wanting if we are to
improve maternal and infant health.
CHAPTER FIVE
ANALYSIS AND DISCUSSION OF FINDINGS
5.0 Introduction
This chapter gives the analysis and discussion of findings of the study. The study investigated the
skills and information provided to pregnant women, methods of delivering antenatal education,
participation and utilization of antenatal education by pregnant women. The whole discussion is
guided by research objectives.
5.1 Skills and information provided to pregnant women.

Antenatal education provides pregnant women with skills and information on birth preparedness,
health information, counseling, advice on appropriate nutrition and rest, promotion of early and
exclusive breastfeeding, parenting skills as well as family planning are all discussed in antenatal
education. Collins, (2007) cited in Pell et al, (2013) emphasizes that in antenatal education, the
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focus should be shifted to providing opportunities for pregnant women to learn skills in order to
practice desired behaviors in their favored way of learning.
According to the findings, all pregnant women received skills and information about pregnancy
in antenatal education. They responded to have acquired at least 3 or more skills like; breast
feeding, caring for the new born, and detecting danger signs as well as some information about
pregnancy as presented in the previous chapter, table 3.
However, it was noticed that the skills and information presented to pregnant women were
lacking. In many instances pregnant women held to myths and misconceptions as well as cultural
and social practices other than adopting the skills and information provided to them in antenatal
education as presented below:
5.1.1 Understanding / making a birth plan in antenatal education.

Research indicates that making a birth plan is seen as a key strategy that can reduce the number
of pregnant women dying from complications. This is because; it constitutes birth preparedness
and complication readiness measures for pregnant women, their spouses and family (Kaye et al,
2003).
However, study findings about what pregnant women understood by a birth plan were varying
depending on each pregnant woman. Among the 48 pregnant women interviewed 18 had a view
that a birth plan meant having a mama kit which constitutes; four pairs of gloves, plastic sheet, 3
pieces of string and a razorblade. Pregnant women had a view that when you have a mama kit
you have already planned for your birth.
In this study, education level, the income or occupation of pregnant women as well as the
presence of pregnancy complications and the anticipated mode of delivery, were associated with
making a birth plan. In this case pregnant women with better education were in a better position
to plan for what they would need during birth, compared to those with low or no education at all.
This is because they clearly understand what lies ahead as told by the health workers and can
adjust and take deliberate decisions.
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Similar to the above is the occupation or income status of a particular pregnant woman, in the
same way educated women may have a better job and earn more money, which improves their
access to economic resources and adequate information. This helps them to make a birth plan
and have the necessary requirements at birth as told by the health workers during antenatal
education. This is in line with UDHS, (2011) findings where educated women had better
pregnancy outcome compared with un educated women, possibly because they were better
informed, and likely to make better choices, and more likely to develop and make a birth plan.
Pregnant women with low or no education usually fail to understand clearly what health workers
say especially where further assistance is not given to them. Health workers do not clearly
elaborate and remind pregnant women what they need to do from the first visit throughout the
course of pregnancy to help them plan. This explains why 18 pregnant women in the study
understood a birth plan in terms of a mama kit. In most cases such pregnant women have low
levels of awareness and poor access to economic resources which makes planning for labor a
problem, even when complications arise because they cannot meet all that is required in the birth
plan.
There is need for health workers to further explain in the simplest terms possible to the low
educated pregnant women on what should constitute a birth plan other than only purchasing a
mama kit. These may include; the expected date for delivery. where she intends to deliver from,
a person to accompany/ stay with her at the health Centre, a person to live at home while away,
HIV status, placenta disposal, a mama kit, sanitary pads, gauze, baby clothing, basin, soap, clean
clothing for the mother, sugar and tea leaves as well as money for emergencies such as transport
and other needs. In such a case pregnant women should be encouraged to start saving early so as
to at least have the basic items needed at birth in case of emergency complications.
5.1.2 Information on danger signs.

In a FGD held on 16 th June 2016, majority of pregnant women 38 out of the 48 had been
informed about danger signs which included any vaginal bleeding, fever, malaria, mother fitting
or having convulsions, severe abdominal pain especially in the lower abdomen, severe headache
and excessive vomiting, swelling of face, legs and hands.
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The (UDHS, 2011) survey indicates that more than half (51%) of mothers were informed of
possible complications (danger signs). The detection of these complications helps to treat
problems during pregnancy which reduces the morbidity risk for the mother and child during
pregnancy and delivery.
Pregnant women in the study were able to tell that health workers advised them to rush to
hospital in case they experienced any of the above signs and symptoms. During the discussion it
was noticed that pregnant women did not recognize and take serious some symptoms of danger
signs say swelling of the face, legs and feet, to many it was normal to experience such, especially
in the first and third trimester. In many cases pregnant women associate swelling of legs, face
and feet to myths like carrying twins, or being almost due especially those in the third trimester.
This can be attributed to the fact that health workers may not have explored the causes of these
danger signs so pregnant women tend to take them as light yet the inner effects to the baby may
be worse to even cause threatening abortion.
In line with the above, a study conducted by (Kabakyenga et al, 2012) found that pregnant
women attending antenatal classes had very little knowledge of danger signs during pregnancy.
While only 68% of pregnant women in the study had attended at least four antenatal visits during
pregnancy, only 19% of them could indicate at least three danger signs. This shows that in many
cases, pregnant women seek professional care but they receive inadequate information as well as
failing to retain the vital information as regards danger signs during pregnancy.
The low levels of awareness on danger signs contribute to failure to obtain adequate care in time.
This usually leads to very dangerous circumstances which sometimes cost the life of the mother
and baby.
5.1.3 Information about good nutrition for pregnant women

In a focus group discussion held with multigravidae on (16th June 2016), 12 pregnant women
accessed information about good nutrition from antenatal education provided at the hospital.
They were able to point out the types of food encouraged for pregnant women such as proteins
vitamins and carbohydrates among other foods. Providing pregnant women with specific
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nutritional guidelines to enhance fetal and maternal health is recommended (Banta, 2003) to
prevent low birth weights and preterm births.
However, despite the information received about good nutrition, many pregnant women still held
on to the myths of women not eating certain foods like chicken and eggs. They complained about
eating certain fruits like pineapples and sugarcane as it makes babies pour out saliva.
The social, family and community context beliefs affect health during pregnancy, either
positively or negatively by either promoting or denying the intake of certain foods by pregnant
women. A study conducted by Birungi et al, (2008) asserts that, nutritional taboos may deprive
pregnant women of essential nutrients adding to nutritional deficiencies particularly iron,
proteins and certain vitamins. This adversely affects pregnant women because they tend to give
birth to yellowing and under weighted babies due to poor nutrition during pregnancy.
5.1.4 Counseling sessions in antenatal education

Pregnant women were counseled mainly on issues relating to HIV/AIDS in order to promote
prevention of mother to child transmission. Pregnant women in the study were tested for
HIV/AIDS. Those found negative were advised to stay negative by sticking to one partner as
well as continue HIV tests, after every three months. Those found HIV positive were advised to
start ARV’s to help save their babies and were oriented into the Prevention of Mother to Child
Transmission (P M T C) club.
However in a one to one discussion with Sr. Nantale Prossy an enrolled midwife she revealed
that some pregnant women withdraw from accessing antenatal services where education is
inclusive, whenever they are tested positive. Health workers endeavor to give adequate
counseling to such pregnant women, to make them accept positive living. However, due to
stigma these women shun away from the hospital services, and resort to small clinics and
traditional birth attendants.
The researcher observed that counseling was in one direction from the health worker to the
pregnant woman, in such instances a pregnant woman is denied chance to express her concerns
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amidst the shortest time provided. This in many cases renders counseling inadequate due to
failure to exchange ideas and concerns.
Findings from (WHO, 2003) agree that, antenatal education represents an important opportunity
and an entry point for counseling; more attention is directed to the HIV/AIDS epidemic to
prevent mother-to-child transmission. Increasing knowledge of ways in which HIV can be
transmitted from mother to child and reducing the risk of transmission using antiretroviral drugs
are critical to reducing mother-to-child transmission of HIV. However, the opportunity currently
appears to be under exploited due to the short time frame allocated for individual counseling and
shortage of health workers in hospitals. In relation to the above, Anya et al, (2008) reveals a
strategy of clearly identifying the barriers to individual counseling at the hospital level and
institute appropriate interventions to ensure that the peculiar circumstance of each pregnant
woman is dealt with.
5.1.5 Breast feeding education

According to the study findings, 38 out of 48 respondents had been informed when to start breast
feeding and this was to be done immediately after birth. Pregnant women were advised to breast
feed their babies exclusively on breast milk on demand at least 8 times a day.
Skills of how to position the baby by properly attaching it on the breast to help stimulate the
amount of milk produced were also provided to pregnant women as properly illustrated in the
(Mother Child Health Passport, 2012 pg.12).
Research by Riedman, (2008) shows that providing information on breast feeding has a
significant effect in increasing early breast feeding among mothers. Similarly, research
conducted shows that there is evidence between initiation of breast feeding and improving the
duration of breast feeding among women who attend antenatal education (Clinical Guideline,
2008). This explains why a considerable number of pregnant women in the study 38 had been
informed about early and exclusive breast feeding despite the complaints of failing to have
proper foods that can help mothers stimulate the production of milk to breast feed the babies
exclusively and on demand.
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5.1.6 Immediate care for the newborn
Newborn care is essential to reduce neonatal problems and death, identify, manage, and prevent
complications soon after delivery.
According to the information provided by (Mother Child Health Passport, 2012) as presented by
Ministry of Health, information provided on immediate care for the newborn mainly involved;
Immediate breastfeeding at birth exclusively on breast milk, on demand at least 8 times a day.
Position the baby properly and attach the baby well on the breast, to improve the amount of milk
produced; wrapping the baby in dry, warm cloth including head and feet and putting the baby in
in skin to skin contact with the mother; do not apply anything on the cord, leave it dry and open
to prevent any germs from entering to cause illness to the baby and always wash hands before
handling the baby.
Contrary to the above, research indicates that majority of antenatal classes cover the birthing
process itself, and only a relatively small proportion of time available is used to focus on what to
do after the baby is born. In these circumstances, pregnant women are leaving antenatal classes
with a good knowledge of child birth options, but feel insufficiently prepared for what lies ahead
(Hillan, 1992).
Omeara, (1993) in her evaluation of consumer perspectives of child birth and parenting
education, found a high level of dissatisfaction among women attending child birth education
classes in Austria. She notes that women lacked timely knowledge for the caring of their new
born, and did not have confidence to make decisions for the family’s care. This explains why
mothers in-law continue interfering with new born care by promoting traditional practices which
may even be unhealthy to the new born.
On the side of health workers, these feel that their clients (pregnant women) are not interested in
new born care and parenting topics before child birth, and simply want to get though labor and
pain. However, research by Nolan, (1997) concludes that couples desire a balance between labor,
delivery and postnatal issues, both prenatally and postnatal, fear of labor pain was only a minor
part of a woman’s motivation for child birth education.
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5.1.7 Family planning information
In a group discussion with pregnant women during antenatal education, they received
information about their family planning methods from the health service provider but expressed
negative experiences about family planning which included; causing excessive bleeding; fertility
loss; unnecessary weight gain /loss and severe headache among others. According to Tupange,
(2013) a medical practitioner asserts that in the pharmaceutical world, no drug is minus side
effects, even painkillers. Women need to make intelligent decisions when choosing a family
planning method and to tolerate the minor side effects that come with it. He agrees that there is a
lot of misinformation on the side effects of contraceptives.
Tupange, (2013) confirms that service delivery is one of the major impediments in the use of
modern family planning, whereby some understood it as child spacing while to others it was
producing few children one can manage to look after. Tupange suggests that there is need for
training and updating health workers, on proper use of family planning as he believes some
health workers fuel misconceptions about family planning or even do not take initiative to
disseminate family planning information properly.
5.1.8 Sleeping under a mosquito net by pregnant women

Sleeping under a mosquito net is one of the measures taken to prevent malaria caused by
mosquitoes. Study findings indicate that 36 pregnant women out of 48 had been informed about
sleeping under a mosquito net and accepted being given free mosquito nets at their first antenatal
visit. During the FGD, many respondents pointed out that the nets were weak, of poor quality
and the chemicals applied to nets suffocated them causing nausea. Much as the nets helped
prevent mosquitoes that caused malaria, the smell of the chemical was a problem to many
pregnant women especially those in the first trimester. This stage is characterized with nausea
and excessive vomiting, therefore some pregnant women revealed to have stopped sleeping
under the mosquito nets because the chemical affected them. This is in relation to Mpungu,
Mufubenga, (2008) findings in Luwero district where; only (31.3%) of women stated that they
used a bed net during their previous pregnancy, and only (48.5%) reported a net re-treatment
with an insecticide within the last 6 months.
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However, Hawley et al (2003) cited in Mpungu et al, (2008) asserts that sleeping under an
insecticide treated bed net (ITN) can reduce the risk of a pregnant woman being infected with
malaria and reduce the risks of maternal anemia and low birth weight .
Therefore I conclude by saying, health workers need to raise massive awareness during antenatal
education, about the rampant threat of malaria in Uganda as well as its effects on pregnant
women. These include spontaneous abortions and fetal deaths; therefore, pregnant women need
to be encouraged to continue using mosquito nets for the sake of their health and that of their
babies.
5.1.9 Non-formal education and the provision of antenatal education

In relation to skills and information provided to pregnant women, non-formal education played a
big part towards disseminating skills and acquisition of information by pregnant women in
Pregnant women accessed antenatal education at St. Francis Hospital non- formally. This was
organized by health workers focusing on information, skills and knowledge aimed at preparing
pregnant women for child birth parenting and being able to take proper decisions regarding their
health and that of their babies.
According to Cross, (2006) non-formal education refers to all organized learning programs that
take place outside the formal school system, they are usually short-term and voluntary. It is any
organized education activity outside the established formal system whether operating separately
or as an important feature of some broader activity that is intended to serve identifiable learning
clienteles and learning objectives.
Non –formal education is about acknowledging the impotence of education, learning and training
which takes place outside recognized educational institutions, it is basically linked with
community groups and other organizations.
In agreement with Cross, (2006) antenatal education provided to pregnant women at St. Francis
hospital Nkokonjeru aimed at meeting the education needs of pregnant women, focusing on facts
surrounding pregnancy, labor and baby care skills. The education was conducted using group
study, lectures and one to one sessions as well as providing some written information in form of
leaflets and brochures.
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Antenatal education varies widely in terms of focus and content, each hospital designs the
education according to appropriateness and education needs of pregnant women. Zwelling,
(1996) urges that antenatal education should be informative and beneficial due to the
socialization with fellow pregnant women rather than the knowledge and skills transferred. This
is in agreement with Fordman, (1993) whereby, the most enduring theme in non-formal
education is that the education provided should be in the interests of the learners and that the
organization and curriculum planning should preferably be undertaken by the learners that is
bottom–up approach. Therefore emphasis should be directed at allowing pregnant women to
identify skills and information they would wish to learn about during antenatal education.
It is also urged that this approach should empower learners to understand and if necessary
change the social structure around them. In the same way, antenatal education as a form of non-
formal education ought to provide pregnant women with skills and information that are
empowering such that they can be more responsible and able to take decisions that affect them as
pregnant women as well as preparing for child birth and parenting.
5.2 Methods of delivering antenatal education to pregnant women

Antenatal education was delivered to pregnant women by mid wives using a number of methods
like: written information, group discussion, one to one sessions and the lecture method as
presented in chapter four. The midwife took the role of the facilitator/instructor. The study
indicates that respondents were more comfortable with the group method which had 30, followed
by one to one sessions with 12, next was written information with 6 and though the lecture
method was used, none of the pregnant women was comfortable with it in delivering antenatal
education.
5.2.1 Group discussion method

Study findings indicate that pregnant women were more comfortable with group discussion as a
method of delivering antenatal education whereby 30 out of 48 pregnant women were in favor of
group discussion as presented in table 3 chapter four. This can be attributed to the fact that
groups were more comfortable and time saving because the information was given to a larger
group. Pregnant women freely shared information and discussed ideas for a common cause,
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which enabled free interaction among pregnant women. They shared experiences and thoughts
by comparing their contributions to what others had said about a particular topic. This is in line
with a study of group antenatal education which concluded that support and feedback from other
parents is a primary method that makes parenting education programs successful (Barlow et al,
2005).
According to Otaiby et al, (2013) in antenatal education, group education is considered as an
adult education strategy in modern era and literature reports that, parenting education in groups
produces the most useful and cost effective outcome for parents. This compels health workers to
largely consider the work of adult education theories when delivering antenatal education to
pregnant women.
5.2.1.1 Group size in delivering antenatal education

In an interview with pregnant women about how antenatal education is delivered to them, the
group method was mainly used by midwives. The respondents stated that; groups normally
started with 5-7 pregnant women who came early and the rest joined on arrival at the hospital,
which made the groups larger as more pregnant women continued to join. Studies conducted by
Stamler, (1998) note that pregnant women who attend antenatal classes like to feel welcome, ask
questions and receive answers. This can only be reached with a particular group size of pregnant
women in any antenatal class. Large groups can become hard to control because the big numbers
cause fragmentation within the group, this causes splinter groups which start to talk among
themselves. This makes the group lose focus with multiple groups and discussions breaking out
spontaneously. A smaller group can easily engage in questioning and discussion, have their
personal problems addressed and educators can easily seek appropriate feedback from their
clients. On the other side large groups can inhibit contributions from less confident pregnant
women; there is a danger that some voices will not be heard as more extrovert pregnant women
might dominate the group discussion. Stamler, (1998) concludes that small informal classes
using role-play, problem solving activities and experience sharing sessions promote interaction
among pregnant women as learners in antenatal classes.
This conclusion supports the literature on adult education, in Danes, Daines and Grahams (1993)
seminal work, Adult teaching, Adult learning as cited in Nolan, (2009), authors noted that most
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sessional classes in adult, community or further education comprise between 12-20 adults in
order to allow facilitators create a climate where interaction can flourish, people can participate
in safety and learn both with and from others.
In relation with the group discussion method is the theory of “Women’s Ways of Knowing”
which looks at connected knowers who seek to understand others’ ideas and points of view,
emphasizing the relevance of context in the development of knowledge and the fundamental
value of experience.
5.2.1.2 The role of relationships in discussing antenatal education by pregnant women

Women’s distinctive characteristics as learners are discussed in the theory of women as learners,
developed by Belenky et al, (1986); here women’s learning is associated to “connected
knowing”, popularly characterized as collaborative and empathetic.
Connected knowers develop procedures for gaining access to other people’s experiential
knowledge through resonance and empathy. Connected knowing is marked by listening, it
involves the capacity to attend to another person and feel related to that person in spite of
enormous differences (Belenky et al, 1986). The development of these relationships has been
promoted as more effective and an appropriate way of learning in many education programs
targeted for women. In this particular aspect, pregnant women who participated in antenatal
education at St. Francis hospital Nkokonjeru exhibited collaboration and empathy.
Linked to connected knowing is connected teaching which is concerned with bringing the
feminine principle into the educational learning relationship .Women need to be heard, therefore
in antenatal education, the facilitator as a midwife should help pregnant women draw out and
give birth to their own ideas (Hayes, 2001). The facilitators should believe and trust in their
learners’ thinking as well as encouraging them to expand it.
5.2.2One to one session

Findings of this study show that; a relative percentage of pregnant women (12) out of (48) which
makes 25% as presented in table: 4, chapter four, preferred one to one discussion with a health
worker mostly when dealing with sensitive information about pregnancy and maternal health.
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Otaiby et al, (2013) explain that if pregnant women are to receive verbal instruction, they had a
preference of one to one instruction with a physician. It is common knowledge that individuals
prefer hearing about their concerns from a health worker feeling that he/she is a trusted source of
information. This calls for cooperation between the health worker and pregnant woman, when
dealing with individual concerns of pregnant women. In such a situation, learning should be
organized around the experiences, concerns and life situations of pregnant women rather than
according to subject matter.
5.2.3 Written information

Findings from the study indicate that (6) out of (48) pregnant women preferred antenatal
education to be delivered using written information in antenatal classes. This represented only
12.5 % of pregnant women in the study; to them they argued that written information can help
them revise at home during their free time however it was realized that the six women were
educated with better occupations compared to their fellow pregnant women.
The above findings correlate with studies where higher education is associated with higher
income and better occupation (professional), this ideally determines one’s ability to afford and
access basic and comprehensive health information (Kisuule et al, 2013). This can be attributed
to the fact that a well-educated woman may have a better job and earn more money, which
improves her economic access to resources and reinforces the effect of access to adequate written
information. This is similar to what Benefo, (2006), and Awusi et al, (2009) found in Ghana and
Nigeria respectively, indicating that education has a strong positive impact on the choice of the
method of delivering antenatal education to pregnant women.
The study also revealed that pregnant women with low or no education who were given written
information in form of leaflets wanted to discuss the content with mid wives but midwives had
insufficient time to do so. This explains why written information had low scores of 12.5 % in the
study and it was not widely welcomed by pregnant women.
5.2.3.1 Printed material and teaching aids used to deliver content in antenatal education
Pregnant women in the study were able to tell learning materials given to them by midwives
these included; brochures, health charts and other printed materials distributed to pregnant
women especially on their first visits like the Mother Child Health Passport. However with the
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majority being primary level dropouts and non-literate, they could not understand them
especially in case where no clarifications were made at the time of materials distribution. These
reading materials usually never created any impact in regard to delivering content in antenatal
education. This is because some of them depicted western culture with white pregnant women.
Usually these created low awareness levels among pregnant women because they objected to
some of them especially brochures showing white women displaying skills of early parenting.
Studies by Nolan, (2009) highlight the subject of teaching aids whereby in most cases, teaching
aids depict western contexts of child birth and early parenting. Usually many of these have
photographs and pictures of white women and babies hence, pregnant women tend to think that
the information contained is meant for whites like those who appear in the materials. In most
cases, pregnant women object to materials that have been developed for another culture and
articulated the need to approach child birth from a culturally specific perspective. There is need
to raise awareness among the developers of teaching materials in antenatal education, about the
need to ensure a multicultural approach in antenatal classes other than using white dolls to
represent babies and pictures of white women in labor for African pregnant women attending
antenatal education (Nolan, 2009).
It is noted that the lack of multicultural representation in developing printed materials and
teaching aids used to deliver antenatal education, can be largely blamed on the difficulty to
access ethnically and culturally sensitive teaching aids and materials by health workers. In most
cases many health workers tend to use whatever is available, to pass on information due to the
costs associated with developing suitable teaching materials. Usually they use donations from
western countries to curb the costs which in most cases fails to meet the education needs of
African pregnant since they have been developed for another culture.
5.2.4 Lecture method

Pregnant women in the study were not in favor of the lecture method although the health
workers used it. Lectures covered little time and always started very early in the morning when
most of them had not yet reached the hospital. Pregnant women reported that, lectures denied
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them chance to share their experience which is a rich resource for learning in adults; hence they
miss out some vital content which would have been important.
Respondents reported that during lectures they just sat and received what had been prepared for
them by the health workers. Although some had questions to ask, the answers provided were not
thorough to fully exhaust the questions due to the limited time allocated.
“In most cases the information provided using the lecture method is projected and at times does
not meet the education needs of some pregnant women. This is because their personal
experiences are not given serious attention, to may be correct mistakes that might have occurred
with the past pregnancies”. An in-depth interview with Grace about using the lecture method in
antenatal education held on 27thMay 2016
Pregnant women involved in antenatal education reported that the lecture method denies them
chance to engage in questioning and discussing to have their personal problems addressed and
for the educators to seek appropriate feedback from pregnant women. Nolan (2009) explains that
facilitators who present themselves as experts, with no interaction with pregnant women render
education in the antenatal period ineffective. This might be the reason why pregnant women in
the study did not choose lectures as suitable for delivering antenatal education.
5.3 Participation of pregnant women in antenatal education

Pregnant women in the study had various reasons for participating in antenatal education which
included; the need to interact with fellow pregnant women and the hospital environment; acquire
knowledge and be able to cope with birth and parenthood; but the most pronounced reasons were
that pregnant women participated in antenatal education because they wanted to feel more secure
as parents and acquire skills of taking care of their new born baby.
The respondents gave various reasons for participating in antenatal education as seen in table: 5
of the previous chapter; whereby managing child birth and learning skills of caring for the new
born had 48 and 46 respondents respectively. This can be attributed to the fact that the transition
to parenthood includes a radical change in the lives of pregnant women. This requires them to
cviii
participate in antenatal education, acquire skills of managing child birth and caring for the new
born baby, to make significant adjustments, and deal with these changes during pregnancy.
This is in agreement with a study conducted by Alden et al, (2012) about parents expectations of
participating in antenatal education, the top two reasons that both the women and the men gave
for participating in antenatal education classes were; to help them feel more secure as parents
and more secure in taking care of their newborn. Therefore antenatal educators should develop
more content on managing child birth and caring for the new born baby. This should be designed
using participatory approaches to allow free interaction among pregnant women.
Identifying problems during pregnancy had 38 pregnant women. This involved discussing danger
signs and pregnant women actively participated, by mentioning and discussing danger signs they
experienced with their pregnancies to health workers. Ensuring the health of the pregnancy and
development of the baby followed with 34 pregnant women.
These resonate with a study conducted by Pell et al, (2013) in Kenya where pregnant women
revealed that they participated in antenatal education to identify problems during pregnancy by
consulting midwives on how to handle them to avoid miscarriages and low birth weight. Kakaire
et al, (2011) asserts that education provided during the antenatal period has the potential to
reduce delivery and pregnancy complications and improve birth outcomes in resource poor
settings. Participation in antenatal education improves the survival and health of the babies and
their mothers. They cover information on counseling and advice on the causes on maternal and
new born deaths like malaria, anemia, malnutrition, tetanus and STD’S among others. The
effectiveness in managing danger signs and pregnancy complications depends on how best
pregnant women have been involved in addressing these challenges.
Obtaining a birth / antenatal card had 26 pregnant women; this is because a pregnant woman
cannot participate in any antenatal class without a record card at St. Francis hospital Nkokonjeru.
The cards contain information about pregnant women’s identity and their health history. The
motive behind obtaining a birth /antenatal card as one of the reasons for participating in antenatal
education is; without a card, pregnant women would encounter problems with health workers if
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they attended a health center to deliver, in most cases without the cards, they would be delayed/
denied services.
This is similar to a study conducted by Finlayson and Downe, (2013) in Sub Saharan Africa,
whereby the practice of giving antenatal cards to pregnant women attending antenatal services is
poorly managed, and having a detrimental effect on continued access. Some health workers use
the antenatal card as a passport and refuse to enroll pregnant women who cannot afford to buy
the cards in antenatal classes (Kyomuhendo, 2003), even admitting laboring women without a
card is a problem in some health centers (Atuyambe, Mirembe, Johansson, Kirumira, &
Faxelid, 2009). This has created a situation where pregnant women participate in antenatal
education only once, to get an antenatal card despite the required four times as recommended by
the champions of maternal health in the World Health Organizations
Pregnant women, 24 highlighted the need to take medicine provided in hospitals as another
reason for participating in antenatal education. This correlates with findings by Pell et al, (2013)
where pregnant women in Kenya participated in antenatal education conducted at health centers
with the aim of taking medicine provided to ensure the health of the pregnancy and the mother. I
agree with the above findings because lay people understand antenatal attendance as a condition
where pregnant women go to the hospital to take medicine.
The study revealed that 8 pregnant women viewed participation of pregnant women in antenatal
education as a compulsory requirement by hospital staff and 16 of them, as a normal part of
pregnancy. It was noted that these were adolescent primagravidae reporting on their first visit in
antenatal education. In my view I believe these respondents lacked adequate knowledge why
they had to participate in antenatal education therefore antenatal educators should endeavor to
explain to them the benefits of participating in antenatal education.
In summary I agree with pregnant women’s reasons that had high scores: learning skills of taking
care of new born and coping with child birth. This is because many pregnant women have a lot
of fear about child birth however their participation in antenatal educations enlightens them and
prepares them on what to expect in the labor ward. From a historical perspective, antenatal
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education has focused on preparation for child birth because of a belief that the childbirth
experience is the main interest among parents-to-be.
Secondly it is noted that birth is a one day event, whereas parenthood is an experience for an
entire life; understanding this notion may explain why taking care of the new born was highly
ranked among the reasons for participating in antenatal education by pregnant women. This is
because antenatal education gives them light on what to expect in the new world of parenting and
how to overcome the challenges that come with it by taking deliberate decisions and acting in the
right manner.
5.3.1 Attendance
Participation of pregnant women in antenatal education is characterized by their attendance. The
fact that pregnant women attended the antenatal classes singled out clearly that they participated
in antenatal education. However, pregnant women’s attendance was affected positively by
several factors which enhanced their participation in antenatal education programs.
Previous or ongoing pregnancy related problems prompted pregnant women to attend antenatal
services and participate in antenatal education. However, pregnant women in a healthy condition
do not feel the need to participate in antenatal education and seek professional care when there is
nothing wrong with their pregnancy (Anya et al, 2008).
Findings by Pell et al, (2013) reveal that pregnancy related health problems prompted pregnant
women to seek advice and attention from health workers. In such a case antenatal education
should be conducted in a problem focused manner, with health workers paying attention to
complaints of pregnant women participating in antenatal education, to jointly come up with
solutions to their complaints and problems.
Study findings show that the number of primgravidae was more with 30 pregnant women
compared to multigravidae who were 18 in number participating in antenatal education.
Parity had a complex impact upon pregnant women’s communication and participation in
antenatal education. Primgravidae were unaccustomed to the experience of pregnancy, the
cxi
associated signs and symptoms hence were more likely to seek advice and assistance from health
workers by participating in antenatal education.
In relation to the above, findings by Finlayson and Downe, (2013) explain that interaction of
pregnant women with health workers, about the myths and misconceptions surrounding
pregnancy and child birth, raises awareness and confidence among primgravidae. This is because
health workers’ advice is generally trusted and pregnant women usually follow the instructions.
Therefore communication between pregnant women and health workers in health education
should provide opportunities for dialogue, to promote active participation of pregnant women in
Pell et al, (2013) notes that in Kenya, interaction between pregnant women and health workers
were influenced by social factors whereby at a health facility, communication tended to be more
two-way if a woman was comparatively wealthy or well educated or had a familiar relationship
with the health worker. Contrary to the above, majority of pregnant women at St. Francis
hospital were typically quiet and reserved with the head down demeanor of some pregnant
women when interacting with health workers in antenatal education. Pregnant women reported
discrimination at health facilities in terms of social status, education level and where a woman’s
birth spacing was deemed inadequate, pregnant women with young children did not pay adequate
attention which limited their participation in antenatal education.
Transport costs associated with attendance and participation of pregnant women was also
revealed by pregnant women in the study as limiting their participation in antenatal education.
Transport costs varied according to the means of transport to be used by a pregnant woman and
her area of residence. In Nkokonjeru town council, vehicles providing public transport within the
area were scarce, pregnant women mainly walked to the hospital to minimize transport costs.
However, in light of their pregnancy related tiredness minority pregnant women used motor bike
taxis because of their greater comfort.
In relation to a study conducted by Finlayson and Downe, (2013) pregnant women living in
villages without health Centres journey to distant locations for professional care which presents
with travelling difficulties that they are unable to overcome. Transport limitations are a major
cxii
factor in hampering the ability of pregnant women to participate in antenatal education. Health
centers should endeavor to conduct outreaches at least once a week to cater for those hampered
with transport costs. Health workers also need to open the antenatal clinic full day other than
working half day to allow late comers a chance to participate in antenatal education.
5.3.2 How motivation promotes participation of pregnant women in antenatal education.

Motivation of pregnant women in antenatal education was also noted as an outstanding factor
during their participation in antenatal education. This is because these women were always weak
and exhausted by the heavy weight of the babies they were carrying.
When asked what motivates and demotivates pregnant women from participating in antenatal
education; Bugonzi a 32 year multigravida of 4 children had this to say
“I am not motivated any more to attend because the same information is given to me ever since
my first child so I think there is no new information that motivates me to attend, I just come a bit
late for only checkups. This is in agreement with Anya et al, (2008) findings whereby the limited
information received by pregnant women during health talks and one to one consultations has
been described as a missed opportunity to inform pregnant women about pregnancy
complications which demotivates them from participating in antenatal education. This is
supported by findings by Conrad et al, (2012) where Midwives confirmed that no systematic
procedure was in place to ensure that women attending ANC received all the relevant basic
information on safe pregnancy. One midwife reported, “We ask them to return after one month;
in between, we do not follow it up. So when they come, the topic they find is the one they shall
listen.
5.3.4 How inferiority complex causes low participation of pregnant women in antenatal
education.
Inferiority complex was noted by the researcher among primgravidae and young pregnant girls
possibly who had dropped out of school. These felt ashamed and could not easily open up when
asked by health workers, something that hindered their effective participation in antenatal
education.
In an interview with Miss Nantale Prosy a midwife she explained that;
cxiii
“Girls who become pregnant and drop out of school are seen by society as a disappointment to
their parents and the way society talks about them, subjects them to inferiority and they also fail
to express themselves even when attending antenatal education. These are normally silent and
usually do not fully participate, like their fellow pregnant women”, an expression of Miss
Nantale Prosy a midwife, during an interview conducted on 13th June 2016.
In relation to the above findings, studies conducted by Pell et al, (2013) argue that in light of the
social ramifications of pregnancy at the adolescent stage, mostly expulsion from school and the
shame in society these pregnant women cannot freely participate in antenatal education.
Health workers and parents of adolescent girls need to develop strategies that enable pregnant
adolescents to access antenatal services and participate in antenatal education in hospitals.
5.3.5 The effect of Language on pregnant women’s participation in antenatal education

The language used in antenatal education also at times limits pregnant women from fully
participating in antenatal education. In a Focus group discussion conducted with pregnant
women, they emphasized that some medical terms are so complicated for them to understand as
lay people. Terms used in screening and diagnosing are usually hard for them to understand
which limits their participation because they cannot exchange ideas and talk about issues beyond
their understanding. They are left with only one choice of accepting what health workers are
saying.
According to Nolan, (2009) as the extent and complexity of prenatal screening and diagnosis
becomes more challenging to lay people. There is need for health workers to undertake
interactional work by talking to women about procedures in a language that they understand and
helping them to make decisions in the context of their culture and lifestyle. This will become
vital in increasing participation of pregnant women in antenatal education.
It was also noted that midwives try to explain medical terms to pregnant women however due to
the low education levels among pregnant women and the different languages spoken .This makes
it hard for health workers to meet the concerns of each pregnant woman such that they can fully
participate in antenatal education.
cxiv
5.3.6 Experiential learning and its effects on participation of pregnant women in antenatal
education
Multigravidae participated in antenatal education basing on the experience they had with
previous pregnancy complications. Experiential learning therefore played an important role in
determining topics to be discussed with pregnant women. This is in agreement with the
experiential theory proposed by Kolb which takes a more holistic approach and emphasizes how
experiences, including cognitions, environmental factors, and emotions, influence the learning
process (Kolb 1984).
According to Kolb et al, (2000) concrete experience provides the information that serves as a
basis for reflection. From these reflections, we assimilate the information and form abstract
concepts. We then use these concepts to develop new theories about the world, which we then
actively test. Through the testing of our ideas, we once again gather information through
experience, cycling back to the beginning of the process. The process does not necessarily begin
with experience, however. Instead, each person must choose which learning mode will work best
based upon the specific situation.
I therefore agree with Kolb’s experiential theory that pregnant women use their prior birth
experience acquired from previous pregnancy complications and society to participate and share
views, ideas and information with fellow pregnant women in antenatal education. The role of
antenatal educators should therefore be to allow free interaction among pregnant women such
that they can freely share experiences and use it in the process to promote participation of
pregnant women in antenatal education.
5.4 Utilization of antenatal education by pregnant women

Research findings suggest that utilization of information and skills provided to pregnant women
in antenatal education lies within conservative social-cultural, economic, religious and political
forces which frustrate the implementation and expansion of effective antenatal education. In the
same way the study identified a number of factors such as maternal education, husband of low
education, maternal employment, long distance to the hospital and late attendance as factors
affecting access and utilization of antenatal education by pregnant women (Finlayson and
cxv
Downe, 2013). These had an effect on the utilization of antenatal education presented in table 6
(chapter four) by pregnant women as discussed below;
5.4.1 Decision making

Access to antenatal education exposes pregnant women to information about pregnancy and how
to manage such a period. It orients them on what to do and how to act responsibly during
pregnancy. Antenatal education equips pregnant women with decision making skills of
sustaining themselves such that they can easily decide on the right thing to do at the right time
other than depending on husbands.
During an interview with Veronica on challenges encountered in decision making she was able
to tell that;
“Sometimes you may decide that I will give birth in the hospital like the health workers
teach us, but instead your partner deliberately refuses and you cannot afford the hospital
bills without the help of the husband.’’
Although antenatal education equips pregnant women with decision making skills, decision
making in homes especially on child birth is between husband and wife and very few pregnant
women can implement decisions without the help of the husband. This is supported by
Atuyambe et al, (2009) and Kasolo et al, (2000) findings that in some patriarchal societies the
decision to engage with antenatal services and women’s choices is influenced by husbands or
mothers in law rather than pregnant women themselves. Women need to be mentored in income
generating skills to help them implement decisions especially where money is required instead of
being dominated by husbands because they control resource allocation in most homes.
5.4.2 Ability to detect danger signs

Pregnant women reported to have been educated about danger signs during pregnancy, when
asked about how they utilized the information given to them, Nantayi, a continuing mother of 4
children said
“When I experience danger signs, health workers encourage us to rush to hospital, but in many
cases we fail due to lack of immediate transport.
cxvi
Many pregnant women in the study lived in rural areas with relatively basic transport networks,
journeying to the hospital in case of the emergency of danger signs to receive adequate attention
as advised by health workers was problematic. These lacked transport due to the long distances
and some bad road conditions especially during the rainy season.
This correlates with studies conducted by Finlayson and Downe, (2013) about women’s use of
antenatal services, in this regard, populations affected by poverty have limited resources and
these are directed towards immediate survival needs rather than pregnancy related concerns.
Even when services are free, the cost of transport and the possibility of having to pay additional
medicine makes a pregnant woman’s efforts to rush to hospital in case of danger signs futile.
5.4.3 Compliance to medication

In antenatal education, pregnant women were given medication in form of tablets and injections
for certain sicknesses and pregnancy complications. Health workers usually explained and
informed pregnant women why they were given such medication. However in cases where health
workers did not give thorough information and explanations to pregnant women, utilization and
adherence to this medication was always inadequate.
It was realized that much as pregnant women had been educated and informed about the need to
take medication during pregnancy. They revealed that many did not finish the required dose as
given by the health worker and were not informed about the need to finish the given dose as
many withdrew from the medication whenever they felt better.
This resonates with a study by Conrad et al, (2013) where pregnant women frankly admitted not
understanding the functions of the drugs received or their prescription modalities due to the
insufficient information received on medication. In such instances efforts should be made to
influence the provider – patient encounter such that pregnant women can freely ask questions
and additional explanations.
It was also observed that some pregnant women did not comply with medication because
pregnancy to them was a normal life event rather than a medical condition. Multiparous pregnant
women objected medicine because they always delivered well and did not see the need for
cxvii
medication. They depended on herbs provided to them by mothers in law and traditional birth
attendants in their communities (Kasolo et al, 2000).
5.4.4 Low utilization of family planning

In antenatal education pregnant women were introduced to the concept of family planning. All
respondents had been educated about family planning in general where; some understood it as
child spacing while to others it was producing few children one can manage to look after. In a
focus group discussion, pregnant women were asked how they utilized family planning and
many had a bias against it. They complained on the side effects about it among them were
causing excessive weight, loss of libido, failure to have normal periods, prolonged bleeding
among others. It was realized that basing on the complications raised many had stopped using
family planning and were now pregnant.
Pregnant women attributed their irregular use to lack of medical support and adequate advice on
how to handle side effects, resistance from their spouses especially those women whose
husbands were not in agreement with a particular family planning method and the information
inflow from peers, friends and relatives explaining the negative side of different family planning
methods.
The irregular use of family planning and the fear of side effects by pregnant women attending
antenatal education at St. Francis hospital in Nkokonjeru were in line with the findings of
Beekle, (2006) who found that the fear of side effects was one of the major reasons for the
discontinuation and non-use of contraception among the study participants; therefore, the
potential side effects of contraceptives and how to overcome them should be incorporated into
family planning education and counseling. To Beekle, (2006) these messages should be
reinforced by using different communication channels, including the media that are available and
accessible to most women and men.
5.5 Access and utilization of antenatal education by pregnant women

WHO calls for access to antenatal education, where access is recognized in five different
components which include physical availability of services, distance to the health center,
cxviii
economic costs as well as cultural and social factors that may impede access and the utilization
of antenatal education provided in hospitals (Tawiah et al, 2011). In relation to this study the
above factors were seen to be affecting access and utilization of antenatal education by pregnant
women
5.5.1 Physical availability of antenatal education

Physical availability of antenatal education in hospitals is lacking because health workers
allocate limited time for antenatal health education talks concentrating more on checkups and
diagnosing. Research findings by Pell et al, (2013) attributed this to the transition of hospitals to
focused antenatal care where information is no longer provided to pregnant women during health
talks. Findings by the study clearly show that pregnant women receive insufficient information
with no systematic procedures in place to ensure that pregnant women receive all the relevant
information on pregnancy. This makes it somehow difficult for pregnant women to recall certain
information and knowledge which could be important during pregnancy.
5.5.2 Distance to the health center

Pregnant women accessing antenatal education at St. Francis hospital in Nkokonjeru town came
from surrounding rural areas with relatively basic transport networks. The fact that their areas
had no health care facility that meets required standards, they had to journey the long distance to
St. Francis hospital in town to receive adequate antenatal information and antenatal care services
as informed by health workers. These lengthy journeys where pregnant women walked for two
or three hours were associated with risks and the related tiredness, could not allow pregnant
women to concentrate in class hence they missed out some vital information, which meant
inadequate utilization of such information in the course of their pregnancy.
5.5.3 Economic costs associated with utilization of antenatal education

Charges levied for antenatal procedures add to a range of several costs that pregnant women
have to meet when attending antenatal services reducing utilization of the education provided in
hospital. Pregnant women had to incur transport costs to the hospital so as to attend antenatal
education; they had to pay antenatal fees in case of those coming for the first visit; purchase a
Mother to Child Health Passport and laboratory fees for women with certain complications.
cxix
It was observed that the mother to child health passport was used as a reference in antenatal
education and contained information about the pregnant woman and her pregnancy health
history, therefore failure to have it a pregnant woman could not fully understand and utilize
antenatal education provided.
This was also observed by (Chapman, 2003) as cited in ( Finlayson et al, 2013) in a number of
cases the practice of giving antenatal cards to pregnant women is poorly managed and has
detrimental effect on the continued access and utilization of antenatal services. Some health care
providers use the clinic card as a passport and refuse to admit laboring women to a hospital if
they don’t have one. This kind of negative reinforcement has created a situation in which
pregnant women visit an antenatal facility only once –to get a clinic card.
5.5.4 Social-cultural factors and utilization of antenatal education.

Socio-cultural belief systems, values, and practices also shape pregnant women’s knowledge and
perception of health and illness/disease, and health care seeking practices and behaviors (MOH,
2004). These shared norms guide self-care practices, access and utilization of antenatal education
by pregnant women (MOH, 1999).
The dominant patriarchal culture in Uganda where men play an important role in determining
what counts as a health care need for pregnant women; men are in control of almost all the
resources in the family (Kasolo et al, 2000). Men and women, who are often inclined to
customary beliefs, object to their wives going for antenatal care services and education especially
under skilled health providers. According to Kasolo et al, (2000), perception of men and women
depict their agitation to deny their wives or for that matter daughters in law from seeking and
utilizing antenatal education.
5.6 Limitations of the study

Time keeping among the respondents was poor, pregnant women always reached late yet the
antenatal section was only open from 8:00 am to 2:00 pm. This was attributed to long distances
coupled with high transport costs, family responsibilities and the tiredness associated with heavy
burden of pregnancy. I had to reduce on the time allocated for interviews and sort out vital
cxx
questions for late comers who were not able to exhaust the interview guiding questions like their
counter parts who managed to keep time.
I did not have enough information about the utilization of antenatal education by pregnant
women. This is because in most cases this is better observed when a mother is due for birth, the
way she prepares herself with or without the necessary requirements shows that she utilized the
education received in antenatal education.
Silence among some pregnant women left the researcher with no idea of what was running in
their minds. Silence was observed among adolescent pregnant women mainly caused by stigma,
some first time mothers and pregnant women in the first trimester due to nausea and early
pregnancy disturbing signs and symptoms caused by body changes. I had to wait and also adjust
where necessary which consumed some time leading to failure to exhaust the questions as earlier
planned.
cxxi
CHAPTER SIX
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
6.1 Summary
Access to antenatal education by pregnant women acquaints them with information about;
pregnancy, birth, baby care and parenting skills. The education level of pregnant women,
occupation, and anticipated mode of delivery as well as presence of pregnancy complications
were associated with seeking appropriate information and skills by pregnant women in antenatal
education.
It is noted that antenatal education was delivered to pregnant women who attended ANC services
conducted at St. Francis hospital, Nkokonjeru. There were several methods used, but the group
discussion method was more comfortable to pregnant women, this is because groups facilitated
participation whereby pregnant women shared experience with the help of the facilitators. This
can be attributed to the support and feedback from fellow pregnant women during the provision
of antenatal education. Groups were also time saving and cost effective to the side of facilitators.
Learning materials and teaching aids used to deliver antenatal education to pregnant women did
not create much impact because of the varying education levels of pregnant women. This is
because pregnant women with limited education and no education at all, could not understand
them especially where no clarifications were made by health workers. Teaching aids used for
demonstrations in antenatal classes sometimes depict western culture and pregnant women
usually objected to materials and teaching aids developed for another culture.
The reasons for participation of pregnant women in antenatal education were varying however
managing child birth and learning skills of caring for the new born enlightens pregnant women
on what to expect in the labor ward and parenting or caring for babies is a challenging
experience for many women.
Previous and on-going pregnancy complications prompt women to attend and participate in
antenatal education to seek advice and correct past mistakes as well as solving current pregnancy
cxxii
problems. In the same way parity had an impact on pregnant women’s attendance and
participation in antenatal education to seek advice from health workers.
The utilization of antenatal education provided to pregnant women depends on several factors;
the education level of pregnant women whereby, highly educated pregnant women are able to
access and utilize education provided in antenatal education compared to those with low
education or completely non literate.
Economic costs, social and cultural values commanded by the dominant patriarchal culture
where men control resources and decision making in homes interferes with adequate utilization
of antenatal education by pregnant women.
If access to antenatal education by pregnant women is to be more effective, there is need to

derive information and skills that meet the education needs of pregnant women to enable them
address their concerns. Methods of delivering antenatal education to pregnant women need to be
appropriate so as to allow for participation of pregnant women in classes. This can enable
pregnant women acquire knowledge about child birth such that they know what to expect and do
when labor starts, as well as ensuring proper care for their babies. Failure to design appropriate
information and delivering antenatal education in a way preferred by pregnant women will not
create any impact in promoting maternal and infant health. They will not be able to make proper
birth plans, detect danger signs and care for their babies, which can adversely affect their health
and the un born-baby. When antenatal education is accessed in the right way, it can protect
pregnant women from the risks and danger signs associated with pregnancies, hence reducing on
maternal and infant mortality rates.
6.2 Conclusion (s)

Results from the study show that access of pregnant women to antenatal education as one of the
forms of non-formal education is influenced by the relevance, focus, flexibility and organization
of information and skills provided to pregnant women in antenatal education. There is a
suggestion that effective antenatal education is delivered to pregnant women using methods and
materials that best suit them as adults. In this case, group discussions facilitate experiential
cxxiii
learning whereby, pregnant women share experiences of their past pregnancies and pregnancy
complications in learning sessions which also promotes their participation in antenatal education.
It is therefore worthy to note that access to antenatal education by pregnant women requires
addressing factors that may hinder effective utilization of the skills and information acquired in
antenatal education by pregnant women such as low levels of education of pregnant women,
transport costs, negative socio –cultural practices and society values. If properly organized, by
addressing gaps identified in the study, access to antenatal education can help reduce on maternal
and infant mortality rates through creating awareness among pregnant women about child birth
and how to care for new born babies.
6.3 Recommendations
The study at St. Francis hospital, Nkokonjeru Town Council, Buikwe district about access to
antenatal education by pregnant women recommends the following;
6.3.1 Modifying the process of delivering antenatal education
Providers of antenatal education should be aware that pregnant women attending antenatal
education have varying education levels and their pregnancy stages differ as well as their
personal pregnancy problems. Although the group study was widely welcomed by pregnant
women and midwives, there is need to put in mind what group size is manageable in terms of
learning because larger numbers are difficult to control, cost more and can inhibit contributions
from less confident pregnant women. Providers of antenatal education need to be aware that
handling rural pregnant women with written materials like the Mother Child Passport alone may
not be useful. When written materials are used, they need to be written at a simpler level than
they are now and should be tested as to whether they actually communicate the information in a
comprehensible way.
6.3.2 Conduct refresher training for health workers.

Pregnant women are adults that require particular methods of handling them as provided by the
tenets of adult education. Health workers should undertake refresher training and acquire skills
of handling adult learners. Training should also be undertaken by health workers to help them
cxxiv
draw appropriate time tables that can allow them exhaust all the information required by
pregnant women. The language used in disseminating antenatal education should also be
simplified and information should be linked appropriately with clinical examinations, laboratory
tests, drug distribution as well as supervision when conducting antenatal classes.
6.3.3 Need to conduct out-reaches of antenatal education services in communities.

Findings indicate that pregnant women lacked economic capacity in terms of transport costs to
fully access antenatal education at St. Francis Hospital Nkokonjeru, many missed out on the
return days allocated to them by health workers on their cards. This calls for community
outreaches of antenatal education services to be conducted and expanded in nearby communities
of Nkokonjeru so as to disseminate information and skills on child birth and baby care, to the
unreached and underserved rural pregnant women through Village Health Teams (VHTs). By
bringing antenatal education closer to pregnant women, it improves accessibility and availability
of antenatal education services. The absence of VHTs and enough staff at St. Francis hospital to
conduct out-reaches created poor access to antenatal education by most pregnant women as most
of them made irregular attendances due to failure to get transport to the hospital and the busy
schedule of domestic work at home especially in the morning hours during seasons of planting
and harvesting. Extending antenatal education services nearer to pregnant women in their areas
means that pregnant women will be able to access rightful information from qualified health
workers who can disseminate information on antenatal education with scientific evidence.
6.3.4 Developing partnership with TBA’s

There is a need for mid wives at St. Francis hospital to develop partnership with Traditional
Birth Attendants in Nkokonjeru. These were found still providing antenatal services to many
pregnant women as many revealed to have visited them for pregnancy check-ups and provision
of herbs. TBAs were trusted by pregnant women because the information received from them
was considered true. Creating a linkage between TBAs and trained health workers means that
TBAs can be trained as VHTs to disseminate information on modern antenatal education and
rightful child birth practices to pregnant women who approach them for their services.
cxxv
6.4 Areas for further research
Additional research is needed to find out how antenatal education can be evaluated so that it is
possible to know whether and how antenatal classes impact pregnant women’s ability to access
services and mold them to their particular needs, child birth and parenting experiences.
Concerns were also expressed in terms of curriculum, content and standards of practice with
respect to timing of antenatal classes offered in terms of length and size.
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APPENDICES
Appendix I: Semi-structured interview guide for pregnant women in St. Francis Hospital
Nkokonjeru
Dear respondent,
I am a graduate student from Makerere University undertaking a study entitled ‘access to

antenatal education by pregnant women at St Francis Hospital, Nkokonjeru. The aim of this
study is to find out how best pregnant women can access antenatal education.
Kindly give your honest opinion without reservation on the topic under study. The information
provided is for academic purpose and it will be treated with utmost confidentiality and
professionalism. Thank you in advance.
Village_______________________________Age________________________________
Religion_____________________________Tribe________________________________
Level of Education____________________ Marital status________________________
No. of births_________________________________________________________
Section A: Skills and information provided to pregnant women
1. What skills are provided in antenatal education and which ones are more beneficial to
you?
2. What information is mainly provided, how and about what?
3. How deep is the information provided, explain
4. Is the information provided mainly practical/theory?
5. Which of the above would you prefer and why?
6. Does the information provided satisfy your information needs as a pregnant mother?
7. Do you always understand the skills and information provided in antenatal education?
8. How do you think information and skills development should be provided during
antenatal education?
cxxxv
9. What challenges do you face while accessing the skills and information provided in
antenatal education?
10. What concerns do you have as regards skills and information provided in antenatal
education?
Section B: Delivery of content in antenatal education
1. Who delivers antenatal education to you?

2. Which methods do they mostly use when delivering content to you?
3. What methods do you prefer and why?
4. In which language is antenatal education disseminated?
5. What language / culture are the materials developed?
6. How is content organized in terms of topics presented in antenatal education?
7. Does the content meet your needs and preferences?
8. If yes why
9. If No why
10. Which topics do you think need more time and why?
11. Do you have access to brochures and books or any antenatal education printed
information?
12. Are you able to read and understand them fully on your own?
13. How long do you take when to receiving antenatal education?
14. Do you always understand all the antenatal education information that you
receive?
15. What Challenges do you face while accessing antenatal education?
Section c: Participation of pregnant women in antenatal education
1. What motivates you to attend antenatal education?

2. What demotivates you from attending antenatal education?
3. Do you ask questions about topics of your choice?
4. Do you discuss freely and share information with peers about pregnancy?
5. How often do you attend antenatal education?
cxxxvi
6. What are some of the challenges encountered in participating in antenatal
education?
7. What can be done to enable pregnant women participate fully in antenatal
education?
Section D Utilization of antenatal education by pregnant women
1. How has antenatal education changed your attitude towards birth and care of the
baby?
2. How has your interaction with health workers helped you during pregnancy?
3. Are you as a pregnant woman able to use antenatal education for self-awareness
or sustenance such as taking decisions as regards pregnancy?
4. What are the challenges that you meet in trying to put into practice the knowledge
gained from antenatal education?
5. How does a pregnant woman accessing antenatal education differ from one who
does not?
6. What do you think can be done to enable pregnant women fully utilize antenatal
education they receive?
cxxxvii
Appendix ii: Semi-structured interview guide for antenatal education providers: Health
workers
Dear respondent,
I am a graduate student from Makerere University undertaking a study entitled “access to

antenatal education programs by pregnant women at St Francis Hospital Nkokonjeru”. The aim
of this study is to find out how best pregnant women can access antenatal education.
cxxxviii
Honestly give your opinion without reservation on the topic under study. The information
professionalism. I thank you for being part of this study.
Position held_____________________________Age_________________________________
Education level___________________________Sex_________________________________
1. Do you conduct antenatal education for pregnant women?

2. Do you provide them with reading materials?
3. If yes, what type of reading materials do you provide them?
4. In what language/ culture are materials developed?
5. How do you disseminate antenatal education to pregnant women?
6. In which language is antenatal education disseminated?
7. Are there any challenges you face while providing antenatal education to
pregnant women? Mention them
8. What do you think are the major challenges facing pregnant women while
utilizing the skills and information provided in antenatal education?
9. Are there indicators that approve that women are utilizing antenatal
education?
10. What have pregnant women done with the knowledge gained?
11. As antenatal education providers, what are you doing to address these
challenges?
12. Do you think all pregnant women benefit from antenatal education?
13. Give an account of your answer
14. What is your view to antenatal education utilization in regard to pregnant
women?
15. Do you know any other barriers that stop women from accessing antenatal
education?
16. What have you done to address these challenges?
cxxxix
17. Any other comment
Appendix iii: Focus group discussion guiding questions for pregnant women
Dear participants,
cxl
I am a graduate student from Makerere University undertaking a study entitled ‘access of
pregnant women to antenatal education programs. The aim of this study is to find out how best
pregnant women can access antenatal education.
Honestly give your opinion without reservation on the topic under study. The information
professionalism. I thank you for being part of this study.
1. Do you attend antenatal education?
2. What is it all about?
3. Is antenatal education good or bad? Support your answer.
4. Do you like antenatal education?
5. If yes why do you like it?
6. If no, why don’t you like it?
7. How do you access antenatal education?
8. If you are attending antenatal education, what motivates you to attend?
9. If not what de-motivates you?
11. Do you have access to brochures or any antenatal education printed information?
12. Are you able to read and understand them fully on your own?
13. Are there any meetings or classes you attend to acquire antenatal education?
14. If you attend antenatal education, how is it conducted?
16. Which concerns and education needs do you have as regard to attending antenatal
education?
cxli
17. In the above antenatal education needs and concerns, which of those are the antenatal
education providers addressing and not addressing?
18. What can be done to enable pregnant women to effectively access and utilize skill and
information provided in antenatal education?
cxlii
Appendix IV: Observation Guide
Introduction:
This Observation Guide will be used for observing skills and information, materials, delivery
methods participation levels and antenatal education utilization among pregnant women
attending antenatal education conducted at St. Francis Hospital Nkokonjeru. Date.
……………………
Time…………………………
Location…………………………
Who is involved…………..
1 Skills and information provided in antenatal education
 The methods used
 Duration of the classes
 Composition of pregnant women in class, (multigravida/ prim gravida)
 The level of participation for pregnant women
2 Teaching materials
 Types of teaching materials
 Language in which materials are written
 Visibility
3 Facilitation methods
 Methods used in delivering antenatal education content
cxliii
 Favourable/unfavorable to pregnant women
4 Antenatal education utilization
 How antenatal education information is used to promote maternal health.
 Relevance of the antenatal education materials distributed
cxliv

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ACCESS TO ANTENATAL EDUCATION BY PREGNANT WOMEN IN

NKOKONJERU TOWN COUNCIL: A CASE OF

ST. FRANCIS HOSPITAL NKOKONJERU

A DISSERTATION SUBMITTED TO THE DIRECTORATE OF RESEARCH AND

Dr. Alex Okot

Prof. George L. Openjuru

BA/Ed Hon; M.Ed., (Mak), M.Ed. (Natal) PhD (UKZN)

INTRODUCTION AND BACKGROUND TO THE STUDY.......................................................1

1.1 Background to the study............................................................................................................1

1.1.1 Overview of Antenatal Education in Uganda 3

1.1.3 Problem statement 6

1.2 Purpose of the study...................................................................................................................7

1.2.1 Specific objectives 7

1.2.2 Research questions 7

1.3 Significance of the study...........................................................................................................8

1.4 Justification of the study............................................................................................................8

1.5 Scope of the Study.....................................................................................................................9

2.1 Skills and information provided to pregnant women in antenatal education..........................11

2.2 Adult education and provision of antenatal education to pregnant women.............................12

2.2.1 Adult education 12

2.2.2 Antenatal education as a form of non-formal education 15

2.3 Methods of delivering antenatal education in antenatal classes..............................................16

2.4 Participation of pregnant women in antenatal education.........................................................20

2.4.2 Relationships in women’s learning: “Women’s Ways of Knowing” 26

2.5 Utilization of antenatal education by pregnant women to promote maternal health...............27

2.6 Figure 2: Conceptual Framework........................................................................................30

2.6.1 Determinants of Access to Antenatal Education 30

3.1 Research design.......................................................................................................................31

3.2 Study Area...............................................................................................................................31

3.4.1 Sample size...........................................................................................................................32

3.5.2 Sampling Techniques............................................................................................................33

3.6.1 Semi-structured interviews 34

3.6.2 Focus group discussions 34

3.7 Data Quality Control................................................................................................................36

3.8 Data Management....................................................................................................................36

3.9 Validity and reliability of the instruments...............................................................................37

3.10 Data Analysis.........................................................................................................................37

3.11 Ethical consideration.............................................................................................................38

4.1 Demographic characteristics of respondents (pregnant women).............................................40

4.2 Skills and information provided to pregnant women in antenatal education..........................41

4.2.1 Good nutrition 45

4.2.2 Care during pregnancy 47

4.2.3 Birth plan 47

4.2.4 Danger signs 48

4.2.5 Immediate care for the newborn 49

4.2.6 Breast feeding 50

4.2.7 Sleeping under a mosquito net 51

4.2.8 General cleanliness 52

4.3.1 Written information 54

4.3.1.1 Printed Materials........................................................................................................54

4.3.2.1 Group size in delivering antenatal education.............................................................56

4.3.3 One to one session 57

4.4 Participation of pregnant women in antenatal education.........................................................58

4.4.1 Reasons for participation in antenatal education 58

4.4.2 Attendance as a way of participating in antenatal education 61

4.4.6 Inferiority complex among adolescent pregnant women 66

4.5.1 Decision making 67

4.5.2 Proper nutrition 68