swedish organization for global health : the maama...

Swedish Organization for Global Health : The Maama Project – Annual Report 2014 2

“Every year, 438 women per 100,000 live births die in Uganda due to

birth related problems… However, many of these can be prevented by

simple, evidence based interventions.”

Maternal mortality in Uganda is 68.5 times higher than in Sweden.

Every year, 438 women per 100,000 live births die in Uganda due

to birth related problems and complications1, with infections

responsible for 15% of the deaths.2 Moreover, Uganda has the

fifth highest newborn mortality in Sub-Saharan Africa with 29

deaths per 1,000 live births for infants under 28 days of age.3 The

most common causes of neonatal deaths in Uganda are

complications due to preterm births, asphyxia and infections.4 An

unclean delivery environment is one of the main factors that

contribute to the high rate of infections in both mothers and their

newborns.5 One third of all infant deaths (deaths during the first

year of life), happen during the first month. Even though infant

mortality and under-five mortality are decreasing in Uganda,

newborn mortality has remained constant for the past twenty

years.6

Many maternal and newborn deaths can be prevented by simple,

evidence-based interventions. Evidence shows that 15-32% of

neonatal deaths can be prevented through clean delivery

environment, hygienic cord care, thermal care, early and exclusive

breastfeeding and community-based care for low birth weight.7

Many complications can be prevented by monitoring the health of

the mother and the baby during antenatal and postnatal visits and

through safe motherhood training that can be conducted by

community health workers; health knowledge plays a large role in

newborn survival, with an estimate of 50% of newborn deaths in

rural Uganda being caused to delays in recognizing problems or

making the decision to seek care.8

Increasing attention has been drawn to women's and newborns'

health in view of the post-2015 sustainable development agenda

with the launch of United Nation's Global Strategy for Women's

and Children's Health (2010), the Commission on Life Saving

Commodities for Women and Children (2012) and the Every

Newborn Action Plan by WHO and Unicef. Increased efforts must

be made especially in countries like Uganda that have not

achieved the Millennium Development Goals 4 and 5.

In light of these circumstances, the Swedish Organization for

Global Health, in partnership with the Uganda Development and

Health Associates (UDHA), established the Maama Project, a

scheme to educate expectant and new mothers in rural Uganda

about safe and hygienic childbirth methods and newborn care

with the aim of improving maternal health outcomes and reducing

infant mortality.

The Maama Project: Background The Maama Project was established in 2014 by the Swedish

Organization for Global Health (SOGH) and aims to improve health

outcomes for mothers and children in rural Uganda through

education and advice. Here is why the project was established…


Mayuge district is a region in southeastern Uganda. It consists of

12 sub-counties and 385 villages. 58.9% of the population is under

18, whereas 4.4% are over 60. The district has an annual

population growth rate of 3.5%. The most recent literacy level

from 2002 was 63%. The fertility rate is 7 children per woman,

higher than the national average. 72% of the rural population

depends on subsistence farming.9

Uganda Development and Health Associates (UDHA), a local NGO,

has been financing a rural health clinic in Maina village, in Buwaya

sub-county of Mayuge district. The health clinic covers Maina

Parish, consisting of four villages with an estimated population of

3,312, of which 900 are women of childbearing age (15-49 years

old)10

. The health clinic is entirely financed by UDHA with the

exception of the salaries for the two nurses, which are covered by

the Ugandan government. The healthcare center provides free

antenatal and postnatal care to all pregnant women in the area.

Currently, only 12% of the women who attend the antenatal clinic

complete all four recommended visits and 64% give birth in health

facilities.11

An estimated 20 women give birth in Maina parish every month.

Most women who access the health facilities for delivery face a

lack of basic materials such as sterile gauze, cotton wool, sterile

cloths, blades and gloves needed to conduct safe deliveries. The

situation has led to general frustration, because pregnant women

are asked to purchase and bring delivery materials with them.

Most women in Maina Parish lack the means and access to

purchase these items, leading the women to avoid going to the

health facility or bringing with them the bare minimum of items

that may not be sterile or suitable.

Consequently, Mayuge district was identified as an area that could

significantly benefit from the Maama Project’s aim to improve

access to education and resources that promote and facilitate a

safer birth environment.

Project Area:

Mayuge District,

Uganda

Ugandan mothers-to-be face a number of

challenges, including insufficient access

to healthcare facilities and professionals,

inability to procure resources required to

have a safe and hygienic birth and lack of

educational opportunities. These

problems are particularly acute in more

rural areas of the country. One such

community is Mayuge district in the

south-east of the country, which chosen

as the first area to roll out the Maama

Project…


The project consists of the provision of birth kits to pregnant

women, and health training and home visits provided by

community health workers. The community health workers' task is

to identify pregnant women and conduct two home visits where

the woman will be provided information on birth preparedness,

safe motherhood and newborn care. The CHWs also stress the

importance of attending antenatal visits at the health clinic. As an

incentive, a birth kit will be offered free of charge to all women on

their fourth visit. After birth, the community health workers will

visit the mother for three postnatal checkups after 24 hours, 3

days and 7 days.

The Birth Kits

The birth kit contains two pairs of sterile gloves, cotton wool, sterile

blade, a preparation sheet, a plastic sheet, soap, cord ties and a new

child growth and postnatal clinic card. The kits are purchased from

PACE at a price of 13,500 Ugandan shillings each (US$5; SEK 35).

The sterile equipment in birth kits reduces the risk of infections for

both the mother and the baby.

The community health workers have been trained according to the

guidelines of the Uganda Newborn Survival Study (UNEST), a

cluster randomized study funded by BIll and Melinda Gates

Foundation in the Iganga/Mayuge Demographic Surveillance Site.

The aim of UNEST is to develop and evaluate a maternal-newborn

care package linking community and facility care in order to

improve maternal and newborn health outcomes.11

The activities target maternal and newborn health throughout the

continuum of care, maximizing the impact of the intervention:

1) During pregnancy Two home visits by community health workers

Training on pregnancy care and birth preparedness

Encouraging women to attend four antenatal visits at a

health facility

Encouraging women to give birth at a health facility

2) During birth Ensuring a sterile delivery environment with the birth kit

3) After birth Three home visits by community health workers during

the first week after birth (days 1, 3 and 7)

Training on newborn care and family planning

Recognizing and referring underweight newborns for

treatment

Referrals to health facility in case of health issues

An earlier Maama kit project established by WHO and the

Ugandan government in Luwero and Lira districts reported the

outcomes of the project on two levels:

Improved reproductive health service delivery: a

decrease in sepsis and tetanus rates in mothers and an

improvement in the previously strained relationship

between the women and the health care personnel.

Improved utilization of the kit and related services by

expectant mothers: no reported refusals of Maama kit

use, an increase in antenatal visit attendance and an

increased number of deliveries at health facilities.

“Overall, all health providers and partners agree that the gains

expected of Maama Kit initiative have largely been achieved.

Demand for the kit across the districts is high – an indicator of

both perceived benefit of the kit by expectant mothers, and

increase in the utilization of the health services."12

How The Project Works

The Maama Project was rolled out in Mayuge District in August 2014 by the Swedish Organization for Global Health

(SOGH) in collaboration with the Uganda Development and Health Associates (UDHA). Here is how the project works

and how the local communities have benefitted from the services that it has offered…


The Maama Project aims to build a community-based

approach to improving healthcare outcomes for

expectant and new mothers and their infants.

The project has five main objectives that it seeks to

achieve…

Project Objectives

1. Strengthen and invest in care during labor,

birth and the first day and week of life

The birth kits will enable the women to have a hygienic delivery,

reducing the risk of infection for the mother and the baby. The

services offered by the clinic will be complemented by CHW home

visits during pregnancy and after birth.

2. Improve the quality of maternal and newborn

care

Birth kits are a cost-effective way to make a delivery safer when

the health facility suffers from a lack of resources and equipment.

The availability of local CHWs will enable women to access

information on issues related to health and pregnancy and receive

advice on when and where to seek help for health issues. The

CHWs encourage the women to attend antenatal visits, making it

possible to monitor the health of the woman and her baby.

3. Reach every woman and newborn to reduce

inequities

The community health worker visits and birth kits are free and the

birth kits are offered to every pregnant woman on their fourth

antenatal visit. Women living further away from the clinic are also

reached as the CHWs conduct home visits at every house in their

home villages.

4. Harness the power of parents, families and

communities

The local community leaders are working closely with the project

and have given it their full approval. All community health workers

have been recruited from the local villages and are respected by

their community. The training of the CHWs, interactions with

beneficiaries and monitoring of the project are all conducted

entirely in Lusoga, the local language in the area.

5. Count every newborn through measurement,

program tracking and accountability

Monitoring and evaluation is conducted on CHW training,

activities, and services to mothers including monitoring of

deliveries and birth outcomes. Baseline data has been collected in

order to measure program success.


2014 Project Outcomes to Date Monthly data and reports are collected to ensure that the impact of the project in Mayuge district can be evaluated.

The first five months of the project from August 2014 to December 2014 have already demonstrated the impact that

the project has had…

0

5

10

15

20

25

Visit 1 Visit 2 Visit 3 Visit 4

Av

erg

ae

Mo

nth

ly V

isit

s

Antenatal Visits

Pre-Project (May 13 -

Jun 14)

Project (Aug 14 - Dec

14)

0

20

40

60

80

100

120

140

Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Nu

mb

er

of

Vis

its

Women Reached by CHWs by

District

Mwezi

Maina

Kyete

Girigiri

CHWs in the four subregions of

Mayuge district have been responsible

for 531 visits to women who are either

expecting or of child-rearing age. As

well as their role in educating mothers,

CHWs have also been able to reach out

to fathers within the community and

encourage them to support their wives

by helping them with transport

arrangements or procurement of items

to help with a hygienic and safe

delivery.

The Maama Project has contributed to a

significant increase in expectant

mothers in the project areas attending

antenatal appointments. This has been

particularly remarkable in respect of

fourth visit attendances, which have

increased by 760%. Expectant mothers

attending a fourth antenatal visit not

only benefit from critical checks on both

their own and their child’s health, but

are also able to take advantage of the

free clean birth kit.


0%

20%

40%

60%

80%

100%

% o

f B

irth

s

Birth Locations

Non-Health Facility

Births

Health Facility Births

2014 Project Outcomes to Date

(continued)

0

5

10

15

20

25

30

Aug-14 Sep-14 Oct-14 Nov-14 Dec-14Nu

mb

er

of

Bir

th K

its

Dis

trib

ute

d

Birth Kit Distribution

One of the main goals of the Maama Project

is to encourage women to give birth in a

healthcare facility where they can benefit

from medical professionals and avoid the

risks associated with home births. Although

transportation issues often present

problems in more rural parts of the

community, 63% of births in the project

duration took place in healthcare facilities, in

line with the national average. This is an

area, therefore, that CHW will continue to

target as they seek to encourage women to

give birth in the safest possible

environment.

A total of 87 birth kits have been

distributed to expectant mothers,

relieving them of the financial burden of

buying their own sanitary birth

materials. In turn, this has helped those

mothers minimize the risk of infection

during birth and help rebalance some of

the financial inequalities that exist

between the different communities

within the project area.


The training of Community Healthcare Workers (CHWs) is a key cornerstone of

the Maama Project. To date, ten CHWs have been trained to deliver advice to

new and expectant mothers. Here is what they have to say about their

experiences….

‘’The best part of being a CHW is being known as a helper. I learnt that health centers contribute a

lot to the well being of the community’. Mothers have no bad reactions on the visits and birth kits

but call for the project to continue running.’’

Naigoma Zam, CHW, Mwezi B

‘’The best part of being a CHW is that you learn to solve your own problems because of the

different training you get from different organizations. I learnt that human health at home is

everyone’s responsibility. Mothers have appreciated the visits and birth kits and there is also

increased male involvement in child birth planning in some homes.’’

Naigaga Zaina, CHW, Girigiri

“The best part of being a CHW is that you act as a role model to the community so there is a lot of

respect if you also work well. I learnt to maintain sanitation and hygiene at home through the

training I got from different people. Mothers are so happy with the home visits and the birth kits

given to them. The information passed out to the community has helped both mother and father

to be involved in birth preparedness.”

Namalero Tabisa, CHW, Mwezi A

“The best part of being a CHW is that you acquire some knowledge that you didn’t have and you

are always informed about all health policies. I learnt basic techniques of counseling and gained

confidence to talk in public. Mothers are positive to both home visits and the birth kits, they also

give thanks to UDHA for remembering their community and giving them that type of help. The

community has benefited a lot. Before this project, fathers could not be bothered helping mothers

to prepare for birth but as of now fathers even fetch water for their pregnant wives and also buy

most of the necessary materials for birth.”

Mirembe Agness, CHW, Maina

Community Healthcare Workers (CHWs)


As well as dispensing valuable advice,

CHWs can also perform a wider role

within their communities. Here is a story

about how one CHW went beyond the call

of duty…

Scovia Wandera is one of the Community Health Workers trained by the

Maama Project in Mwezi village to give advice to expectant mothers about

accessing antenatal services, preparing for childbirth, giving birth in a formal

health center and caring for infants and young children.

One of the women impacted by the Maama Project in Mwezi was Monica

Kagoya, who first met Scovia when she was five months pregnant with her

fourth child. Monica had recently moved to a more remote area in the region

and was concerned that she wouldn’t be able to access healthcare facilities

due to a lack of transportation. However, through Scovia’s advice and

incentive of the free clean birth kit, Monica was encouraged to attend her

remaining antenatal visits during her pregnancy to ensure that she was

prepared adequately for the birth.

However, one night between her third and fourth antenatal visits, Monica

began the onset of early labor. Her family was too far away from the health

center to be transported there, so Monica called upon her trusted neighbor

Scovia to give her some assistance. Scovia was able to use her training to

support Monica and help her give birth successfully to a boy that she called

Kirabo or ‘gift’. Monica said that she felt that Scovia’s assistance was

invaluable and felt that the experience was like giving birth in a hospital.

Although Scovia’s role is as a local educator rather than a midwife, Kirabo’s

birth demonstrates the trusted position that CHWs hold within their

communities and the invaluable role that they can play in supplementing

existing healthcare resources in areas where demand often outstrips supply.

- Attribution

’The best part of being a CHW is that you gain respect from the community if you help the people. I

learnt that all people offering help to the community need appropriate training before helping because

you deal with different people, cases and problems. Mothers are always positive to the visits and feel

they are being helped a lot when we give them the birth kits. The community has benefited from the

project, especially mothers because before they had no access to information or encouragement to go

to health care facilities. However, now that they have got CHWs, they get informed on everything and

move some distances to go for antenatal classes at Maina or Mayuge.”

Scovia Wandera, CHW, Mwezi

Swedish Organization for Global Health (SOGH)

Address: Katarina Västra Kyrkogata 4, 116 25 Stockholm, Sweden

Email: [email protected]

Website: http://www.sogh.se

Organization-No. 802490-6664

Report compiled by Chris Barstow

References:

1 gapminder.org

2 World Health Organization (WHO). “Making Pregnancy Safer: A health sector strategy for

reducing maternal and perinatal morbidity and mortality.” (Unpublished) (2000). 3 Ministry of Health, Government of Uganda (2008). Situation analysis of newborn health in Uganda.

4 Ministry of Health. Situation analysis of newborn health in Uganda: current status and opportunities to improve care and survival. Kampala: Government of Uganda.

Save the Children, UNICEF,WHO; 2008. 5 WHO. “Care of the Umbilical Cord: A Review of the Evidence.” http://www.who/int.rht/

documents/MSM98-4/MSM-98-4.htm (1 June 2000). 6 Ministry of Health. Situation analysis of newborn health in Uganda: current status and opportunities to improve care and survival. Kampala: Government of Uganda.

Save the Children, UNICEF,WHO; 2008. 7 Bhutta, Z. A., Darmstadt, G. L., Hasan, B. S., & Haws, R. A. (2005). Community-based interventions for improving perinatal and neonatal health outcomes in

developing countries: a review of the evidence. Pediatrics,115(Supplement 2), 519-617. 8 Waiswa P, Källander K, Peterson S et al. Using the three delays model to understand why newborn babies die in eastern Uganda. Trop Med and Int Health, 2010, 15:

964-972. 9 Mayuge District (2009). Higher Local Government Statistical Abstract. http://www.ubos.org/onlinefiles/uploads/ubos/2009_HLG_%20Abstract_printed/Mayuge.pdf

10 Mayuge District (2009). Higher Local Government Statistical Abstract. http://www.ubos.org/onlinefiles/uploads/ubos/2009_HLG_%20Abstract_printed/Mayuge.pdf

11Baseline data collected in June 2014.

12 Information brief about the Uganda newborn survival study (UNEST).

http://www.healthynewbornnetwork.org/sites/default/files/resources/WHAT%20IS%20UNEST.pdf

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