Ugandan health workers' and mothers' views and experiences of the quality of maternity care and the use of informal solutions: A qualitative study

PLoS One. 2019 Mar 11;14(3):e0213511. doi: 10.1371/journal.pone.0213511. eCollection 2019.


Introduction: Although the coverage of maternity services in some low and middle-income countries (LMIC) has greatly improved, the quality of maternity care remains poor, and maternal mortality rates are high. In this study, we describe the meaning and determinants of maternity care quality from the perspective of health workers and mothers in Uganda, the informal solutions used by health workers to manage their daily challenges, and we suggest ways in which maternal care quality can be improved.

Methods: We conducted a qualitative study in the Mpigi and Rukungiri districts of Uganda. Twenty-eight health workers based at selected health centres participated in structured interviews. Thirty-six mothers, half of whom had delivered at health facilities, participated in focus group discussions. Data were analysed thematically, and informed by the WHO framework on quality of care for maternal and newborn health and by Lipsky's street level bureaucracy concept.

Results: According to health workers, knowledge of clinical standards and processes, timeliness, and women's choice during labour, as well as resources, physical infrastructure; collaboration with mothers, professionals and community health workers; were important aspects of good quality care. Mothers' perceptions of good quality care were largely similar to health workers' views, though mothers were more concerned about health workers' interaction skills. Structural challenges sometimes led health workers to develop informal solutions such as asking mothers to purchase their own supplies with variable implications on the quality of care. While several of these informal solutions were useful in addressing bottlenecks in the health system, they sometimes placed additional burdens and personal costs on health workers, created mistrust, inequity in care and negative experiences among mothers who could not afford the extra costs.

Conclusions: Health system structural factors; including technical, interpersonal, resource and infrastructural factors; impede the provision and experience of good quality maternity care at health centres in Uganda. Improving the quality of care will require strategies that address these core problems in the health system structure. Such structural reforms will require political support to commit resources, skilful management and leadership that seek to change organisational behaviour and build trust through good quality, woman-centred maternity care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Attitude of Health Personnel
  • Female
  • Focus Groups
  • Health Knowledge, Attitudes, Practice
  • Health Workforce
  • Humans
  • Infant, Newborn
  • Maternal Health Services* / organization & administration
  • Mothers
  • Obstetrics
  • Pregnancy
  • Professional-Patient Relations
  • Quality of Health Care* / organization & administration
  • Uganda

Grants and funding

The Research Council of Norway ( through the Global Health and Vaccination Programme (GLOBVAC), project number 220851 funded this study and part of SMB time. The funders had no role in the design of this study, data collection and analysis, decision to publish, or preparation of the manuscript. The Norwegian Public Health Institute Funded part of SMB and CG’s time on the project, the University of Southampton funded MW’s time, and the Makerere University College of Health Sciences that previously employed HN, funded her time on the project.