Tracing pathways to adverse pregnancy outcomes in eastern Uganda: A retrospective analysis of contributing factors

Pregnancy and childbirth are natural processes that, in an ideal world, result in a healthy mother and a healthy baby. Yet, across much of the world, this expectation is frequently shattered by adverse pregnancy outcomes. These are the tragic events where a pregnancy ends in a miscarriage, a baby is stillborn, or a newborn dies shortly after birth. While global health programs and national governments have worked hard to create guidelines and run programs to prevent these losses, the numbers remain stubbornly high in many places. In Uganda, for instance, the rate of newborn deaths and stillbirths remains significant, suggesting that simply having rules on paper is not enough. The real question is not just whether care exists, but how families actually experience the journey from pregnancy to birth, and where the system fails them along the way.

To answer this, researchers in eastern Uganda decided to look beyond hospital records and statistics. They turned to the stories of the people who lived through the loss. Between 2025 and 2026, a team of analysts re-examined interviews conducted in 2021 with 51 parents—mostly mothers, but also some fathers—who had experienced a miscarriage, stillbirth, or newborn death. Instead of just counting the losses, the researchers listened to the detailed narratives of these families to trace their entire journey. They wanted to see the path a family took: where they went for help, how many times they moved between different clinics or hospitals, what happened when they arrived, and what barriers stood in their way. By mapping these stories against international standards for quality care, the team uncovered a complex web of missed opportunities, broken links, and human errors that contributed to these tragedies.

The most striking finding was that the path to care was rarely a straight line. Very few families went to a single hospital and stayed there. Instead, their journeys were often a chaotic shuffle between different places. Some families never reached a formal health facility at all, giving birth at home or with a traditional birth attendant. Others started at a small local clinic, were told to go to a bigger hospital, struggled to find transport, and then ended up moving between public and private clinics as their condition worsened. In many cases, a mother or baby would be sent from one place to another, sometimes three or four times, while their health deteriorated. This "hopping" between facilities often happened because the first place could not handle the problem, or because the family lost trust in the care they were receiving.

When the researchers looked closely at what happened inside these facilities, they found that the care was often far from the standard expected. During pregnancy checkups, health workers frequently missed warning signs. Mothers reported bleeding, fevers, or high blood pressure, yet these conditions were sometimes ignored or treated with simple remedies without further investigation. In some cases, a mother was told her baby was in the wrong position, but no one explained how to fix it or offered a scan to confirm. When labor began, the situation often grew more desperate. Women described waiting for long periods without being checked, or being told they were not in labor yet, only to deliver alone or in a panic when the baby was already in distress.

The care for newborns was particularly lacking. Even when babies were born in hospitals, they often did not receive the specialized help they needed. The study found that no one mentioned using "kangaroo mother care," a simple but life-saving practice where a parent holds a premature baby against their skin to keep them warm. Instead, sick or premature babies were often given vague treatments, sent home too soon, or left without oxygen when it was needed. In several instances, parents described being told their baby had swallowed "dirty stuff" or had a fever, only to watch the child get worse. The lack of basic supplies, such as oxygen or essential medicines, meant that families sometimes had to buy drugs from outside the hospital while their baby waited, a delay that often proved fatal.

Beyond the lack of equipment, the human element of care was deeply flawed. Many parents recounted feeling disrespected, ignored, or even abused by health workers. Some described being shouted at, while others felt their cries for help were met with silence. In a few heartbreaking cases, health workers were so inexperienced or overwhelmed that they could not perform basic tasks, like fixing an oxygen machine for a struggling baby. The communication gap was also severe; when a baby died, parents were often given no clear explanation of why, leaving them to bury their child with unanswered questions and confusion. This lack of dignity and clarity added a heavy emotional burden to the physical loss.

The problems were not limited to the hospitals. The study also highlighted how social and cultural factors played a role. Many families delayed seeking help because they did not recognize the danger signs of a sick baby or a complicated pregnancy. Some relied on traditional medicines or herbs, hoping they would cure the illness, only to lose precious time. Poverty was another major barrier; families often could not afford the transport to get to a better hospital, or they could not pay for the scans and tests that were required. In some cases, husbands refused to provide money for care, or the family simply had no resources left. These external pressures meant that even when a family wanted to get help, they were often blocked by circumstances beyond their control.

When the researchers compared these findings to the global standards for quality care, a clear picture emerged. The biggest gaps were in the actual medical practices and the skills of the health workers. The system failed to provide evidence-based care, meaning that the treatments given were not always what the medical guidelines said they should be. There was also a severe shortage of competent and motivated staff, particularly in smaller, rural clinics. The referral system, which is supposed to move patients from small clinics to bigger hospitals when things go wrong, was broken. Transport was unreliable, and the hospitals that were supposed to receive the referrals were often unprepared to handle the emergencies.

The study concludes that fixing these tragedies requires more than just better guidelines. It demands a complete overhaul of how care is delivered, starting with the very first visit to a clinic. Health workers need better training and support to recognize danger signs early and to treat them correctly. The system needs to ensure that every facility has the basic supplies it needs, like oxygen and medicine, and that there is a reliable way to get a sick mother or baby to a higher-level hospital quickly. Most importantly, care must be respectful. Mothers and fathers need to be treated with dignity, given clear information, and supported emotionally, especially when the outcome is tragic.

Ultimately, the researchers found that many of these losses could have been prevented if the problems had been caught and managed earlier, during the pregnancy. The journey to a healthy birth is fragile, and it breaks down at many points. By listening to the stories of those who suffered, the study shows that the solution lies in strengthening the entire chain of care, from the community to the hospital, and ensuring that every mother and baby receives the safe, skilled, and compassionate care they deserve.