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Maama project

Evaluation  of the Maama  project:

 report 2016

Home visits
Executive summary 4 3.3
Maama kits
Summary of recommendations 5 3.4
Antenatal care attendance – the women’s perspective
1. Introduction 6 3.5
Antenatal care visits – the clinic perspective
1.1 Context 7 3.6
1.2 Maternal and newborn health
in Uganda
7 a)
Delivery location
and birth attendance
1.3 The Maama Project 7 b) Birth preparedness
and transportation
2. Evaluation methodology 9 c) The role of traditional birth attendants (TBAs) in delivery 23
2.1 Aim and objectives 10 3.7
Newborn health
2.2 Evaluation design, tools
and data collection
10 a)
Newborn care practices
2.3 Study
population and sampling strategy
11 b) Umbilical cord care 25
2.4 Ethics 11 2.8
Male involvement
2.5 Data analysis 11 3.9
Mental health
3. Findings 12 3.10
Family planning
3.1 Characteristics of project beneficiaries 13 References 31

Core evaluation team: Linn Persson Berg, Erika Lejon Flodin, Hedvig
Berntell, Teresa Marie Kreusch, Tania Neuman, Evelina Linnros, Amrita Namasivayam and Marjan Molemans

Graphic designer: César Augusto Ortelan Perri

ANC Antenatal care

CHW Community health worker

NGO Non-governmental Organisation

SOGH- Swedish Organization for Global Health

TBA Traditional birth attendant

WHO World Health Organization

Executive summary

This report documents
the evaluation  of the Maama project following two years of implementation. The project aims at increasing knowledge
of maternal  and newborn
 health  in the community  and the uptake  of health  services such 
as antenatal care visits and  deliveries at health facilities.

The project is a collaboration between Swedish Organization for Global

Health (SOGH) and Uganda Development and Health
Associates (UDHA).

CHWs conducted 1231 home visits during the project year. Of the interviewed women, 80% reported getting at least one prenatal home visit and 84% of women received at least one postnatal visit.

The proportion of women completing four ANC visits increased from 12%

at baseline
to 86% and health facility deliveries increased from 70% to


A total of 246 birth kits were distributed during ANC visits. Out of the women interviewed, 79% reported receiving a birth kit.

The assessment  indicates that 
the birth kit is a strong motivator for pregnant women to complete four antenatal visits and to give birth at a health facility by addressing financial barriers.

The CHWs and the clinic staff have reported an overall empowerment of the community and a decrease in misconceptions
and knowledge gaps.

The community is aware of health
and the health
seeking behavior has increased in the community.

Of the mothers who had received chlorhexidine, 96% used it and 81%
used in within 24 hours. All interviewed women had a positive attitude towards the use of chlorhexidine for umbilical cord care.


Summary of recommendations

Already implemented

The need  to improve  the
delivery of kits to the clinic was met during summer  2016
in two ways. First, instead
 of ordering  kits a couple 
of times per year and waiting
for them to be delivered, the supply of kits
a whole year was ordered at once. Secondly, vouchers
were made in case the stock does run out, so that mothers  can
come and collect the kit later on.

The limited capacity of Maina clinic was remedied
during the evaluation by the purchase of an extra bed where women who have delivered can take rest before making the journey home.

The  CHW have  received
 extra  training
 to  be  explain
 and application of chlorhexidine to
ensure better use in the future. The Maina clinic also has a pictorial on the wall explaining how it should be used.

Short term

SOGH should look
the possibilities to help the CHW create a better
system to identify pregnant woman and give additional aid, for example in form of a card or booklet, to help them remember all topics that need to be covered in the home visits.

Investigate the  possibility to include more  items in the
 kit, especially more plastic gloves. However this is difficult, since the kits are bought in
a sealed bag. Another way to accommodate for the lack
of gloves would be to supply the clinic with extra gloves.

Make the  conditions
 for receiving
 a  Maama
 kit more  clear  for the beneficiaries (i.e. four ANC visits at Maina clinic)

CHWs should encourage the
women  in the villages
to go to the ANC clinic earlier during their pregnancy, so they will have time to complete all four visits.

Educate CHW more on family planning
and encourage them to pass on the knowledge.

Educate husbands on family planning

of a mother’s card with the important information  about
the women’s ANC visits. The card could also be used as a check list at the ANC visits, but also at the home visits by the CHW.

Continue  to
 spread  of information  in the
 communities,  primarily in the  rural areas, with an emphasis  to address
 importance of men in
 understanding and
 taking  full
responsibility  as  fathers,  through
community sensitization taking place monthly.

Long term

Donation of bikes to the CHW to facilitate the home visits.
Increased compensation for the CHW

larger facility with more seating areas and at least one more antenatal/

delivery bed and installation of electricity
and running water.

The workforce should also be increased, preferably with a
midwife. Provision
of items that are currently lacking should be provided
to the

clinic, e.g. blood pressure machine and a
measuring tape.

Extra stock of medicine and rapid malaria tests. Adding
rapid HIV, syphilis tests and more options
of contraceptives to the stock of medicine.

Strengthen and support the group of single mothers.

In the
long term, it should be considered
 if SOGH can
organise a system to make it more easy for mothers  to get 
to the clinic. For example, a
bodaboda that mothers
in need can call.



1.1  Context

Every year
2.7 million infants die during their first month
 of life (1). An
estimated 99% of these  deaths
 take place in low- and middle-income countries
 (2). During the past two decades, neonatal
 death  rates have out of all
low- and middle-income
 regions decreased the least in sub- Saharan Africa (3): 29 neonatal  deaths
 occur for every 1000 live births in the region, compared to 3 per 1000 in high-income
 countries (1). At the current  rate of change, it will be over a century before an African
newborn  has the same chance of survival as a baby born in Europe or North America (4), indicating a pressing need for interventions targeting pregnancy, childbirth and the newborn period.

Newborn health and survival are closely related to maternal health.
Over half of all maternal
 deaths  in the world are due to preventable causes
such as hemorrhage, hypertensive
and sepsis. These can be addressed with quality antenatal, delivery and postnatal care, including, completion
 of four antenatal visits, skilled care 
during  delivery, and postnatal visits during the first week after birth (5). Research has shown that
 newborn  deaths
 can  be  prevented with already
 available interventions  targeting
 preconception,  antenatal,  intrapartum and postnatal care  (6). Skilled care 
during  labor  is estimated to  reduce
neonatal deaths by 25% and a combination of clean birth and postnatal
care practices can reduce neonatal
 deaths due to sepsis and tetanus by

40% (6). Community-based care that includes
community mobilization, home
visits and improved linkage to health
care services has also been estimated to reduce neonatal  mortality by 40% (6).

1.2 Maternal and newborn
health in Uganda

Even though Uganda achieved the Millennium Development Goal 4 by reducing  under-five mortality to less than  90 per 1000 live births, the neonatal
 mortality rate still remains high at 19/1000
births. Over one- third (35%) of under-five deaths happen during the first
month of

life. Uganda  fell short  of achieving  the  desired
 5.5% reduction  in the maternal mortality rate of Millennium
goal 5. Moreover, the lifetime risk
of death due to pregnancy or childbirth remains high at 1 in 44, with
343 maternal deaths per 100,000 live births (5). The health care coverage of essential interventions remains overall low in the country. Only 44% of
the women meet with the demand for family planning, only 48% of the women 
complete  four ANC visits and only 57% of the women  have a skilled attendant present
 at delivery. Moreover, only 33% of the women receive postnatal care and  63%
of women  breastfeed exclusively for
the first six months  (5). There is an equity gap between the richest and poorest, with large differences in an unmet  need  for family planning, completion  of four  ANC visits and
 presence   of skilled attendant at delivery (5).

Research conducted at
the Iganga-Mayuge  Demographic  Surveillance
Site in southeastern Uganda has contributed significantly to the knowledge on the state of newborn health in rural Uganda. The research
indicates  that
 that  54% of newborn
 deaths  occur away from a health facility and half of all newborn deaths are linked to a delay in the decision to seek care. Most newborn  deaths
 in the area happen during the first week of life: 47% during the first 24 hours, and 78% during the first seven days (7). An additional challenge is the lack of knowledge regarding safe newborn care practices, with coverage ranging from 38% for clean cord care, 42% for optimal thermal care and 57% for exclusive breastfeeding

1.3 The Maama  Project

To address  the  risks mothers  and  newborns
in Uganda,  SOGH developed
 maternal   and  newborn   health  
project  together  with
Uganda  Development
 (UDHA).  The  Maama Project covers Maina
Parish, located in Mayuge District in southeastern

Uganda. The project area consists
of five villages (Mwezi, Kyete, Maina, Girigiri and Bulondo) and a private health center financed by the partner
NGO UDHA. The health
 is classified as level II,  denoting the most basic level of facility health  care out of four possible
levels, with village health teams comprising level I. The Maama Project follows
the recommendations outlined  in a joint statement by WHO and UNICEF that recommends the uptake of a home visit strategy to reduce newborn
deaths (9). The project is based on a community model of two prenatal
and three postnatal home visits that has been tested
 and evaluated  by several studies
(10–16), including the Uganda Newborn Study (UNEST) conducted in Iganga
and Mayuge districts (17,18).

Project activities
carried out by CHWs who have been picked out by local leaders and trained by staff from the Iganga-Mayuge Demographic Surveillance Site. CHW’s main role is to identify pregnant women
 and provide two prenatal and three postnatal home visits (on days 1, 3 and

7 after birth).

During postnatal visits, the CHW counsels the woman on safe newborn
care practices and family planning. The CHWs have also been trained to identify low birth weight babies and provide referrals to health facilities.

Furthermore,  to  promote  hygienic  practices
 during  deliveries,  the project includes the provision
of birth kits (Maama kits), which are pre- prepared, packaged, single-use 
kits that  contain
 a selection
 of items
pivotal to a hygienic delivery. The kit contains two pairs of sterile gloves,
cotton  wool,
 sterile blade,
 a preparation sheet,
 a plastic
sheet,  soap, cord tires and a new child growth and postnatal clinic card. The birth kits are provided
 by the health  facility to pregnant women on their fourth antenatal visit, acting as an incentive for the women to attend ANC four times.

In summary, a pregnant
woman in the project area receives two home visits from a CHW and  visits
a health  facility four times
 during  her pregnancy. On the fourth visit
she receives a Maama kit, which can be used during a facility- or home delivery. After delivery, she receives three postnatal home visits
from the CHW.

2. Evaluation  methodology


2.1 Aim and objectives

The aim of the  evaluation  was to assess
to which extent
 the  Maama Project has been successful
in improving maternal and newborn health in
Maina Parish.

The main objective of the evaluation was to describe the change in the community  regarding
 attitudes and behaviors related to maternal
 and newborn
 following two years of implementation. A
secondary objective  was
 to  identify
 challenges   of 
the  project  and  remaining barriers related to health service uptake, as well as ways to develop and expand the project.

The qualitative and quantitative key indicators investigated were: Completion of four ANC visits

Delivery with a skilled birth attendant

Uptake and knowledge of safe newborn care practices

Number and timing of home visits

Services and education provided during
the home visits

Services and education provided during
at the Maina clinic

The role and use of Maama kits

The role of community health workers in attitude
and behavior change

of the successes
and challenges of the project

The mental health of the women, during
and after pregnancy

Male involvement in maternal health, newborn care and antenatal care

The use of Chlorhexidine, a disinfectant for the umbilical cord stump

Due to the relatively small number of estimated pregnancies and deliveries in the project area and the small sample size in this evaluation,
effect of the project on
maternal or newborn mortality, which are rare outcomes in themselves, could not be investigated.

2.2 Evaluation design, tools and data collection

A mixed-methods design  was used
 to assess the  effectiveness
 of the project. During the evaluation period, both quantitative and qualitative
data  were collected
 through  interviews and a surveys. Data collected at baseline
 and during
 the project  year (2015-2016) were included
 in the  analysis. The interview  tools  were  developed in English
by the evaluation   team   consisting   of  eight   SOGH interns.
 Three  Lusoga- speaking  interpreters  worked  in  the  evaluation.  While two  female interpreters who  were  not
 involved  in 
the  project  interpreted the majority  of  interviews,  the  male
 manager   interpreted the interviews on male involvement, one interview with a CHW and three interviews  with mothers
 during  one  field
day. The evaluation
 group made this decision
because  it was suggested that the husbands would feel more comfortable with a
male interpreter.

Beneficiary interviews served as the main source of quantitative data.
A modified questionnaire based on the Demographic
Health Survey (1) was used to interview program beneficiaries, i.e. mothers in the project
area. The final questionnaire consisted
 of the 
following components: respondent’s background, reproduction, pregnancy  and
postnatal care, use of chlorhexidine, contraception, occupation and family economy. Additional questions  concerning
 antenatal care attendance, CHW visits
and birth kit use were included. In addition, data from monitoring tools that were filled in monthly by CHWs and clinic staff from August 2015 to July 2016 have been included
in the quantitative analysis.

 data  on  newborn   and  maternal 
were  obtained
through  semi-structured interviews 
with CHWs and  health  care staff from Mayuge health  centre
 and  Maina clinic. In addition,  qualitative interviews with mothers  and fathers participating
the project during
the last year and traditional birth attendants (TBAs) were conducted. All
interviews were recorded and transcribed.

2.3 Study population and sampling strategy

criteria for the  mothers  for both  qualitative  interviews and quantitative surveys were i) living in the project area, ii) having given birth during the past 12 months  and
iii) being available
for interviews during  the 
evaluation  period. Random sampling  in the  form of pre- selecting households based  on geographical location was trialled, but turned
 out to be impossible
 to implement  in the  local setting, partly because
many women worked outside
the home and could not be found with
this method. Participants were thus identified through convenience sampling. Some were approached with the help of CHWs, who located mothers willing to be interviewed. Others were interviewed during their visit
to the weekly immunisation  day at the Maina Clinic. A
total of 70 mothers  were interviewed, nine of which were excluded in the analysis due to their children being older than 1 year. The final sample size was

61 women.

Five further  parties
 interviewed   qualitatively.  These  included eleven CHWs from the five villages, the two nursing assistants working at the Maina Clinic, one midwife from the nearby Mayuge Health Centre, one traditional birth attendant (TBA) and four husbands of
women  in the Maama project.

2.4 Ethics

Informed consent was obtained
orally before commencing the interview. The  participants   were  assured
 that  i) their
 answers  would
 remain anonymous ii) that
 they had  the  right to refuse the
 interview, refuse to answer specific questions  or stop at any time without  providing an explanation
 and iii) that  their
responses  would not affect their future
health  care. Additionally, permission to audio-record  was obtained for
the qualitative interviews.

2.5 Data analysis

The quantitative survey results were entered into a database in SPSS version 23. New
summary variables
were created
 from the data, e.g. a binary ‘completion of 4 ANC visits’ variable. Analyses were performed in  SPSS
to  obtain  descriptive
the  outcome variables. Associations and differences between groups were tested  for statistical
significance with Chi-square and t-tests.

The qualitative data from interviews with the CHW, health care staff at Maina clinic and Mayuge, TBA and the husbands involved in the project was content analysed to identify patterns. Furthermore, content analysis
was made on the data from
the interviews with the mothers to provide more  insight
 topics  covered
 quantitative  survey.
Lastly, the qualitative question
 items from the quantitative survey were

3. Findings


3.1 Characteristics of
project beneficiaries

Table 1
presents the characteristics
of the study population. The average age of mothers
interviewed was 27.7 years. Close to all women were married and most lived together with their husband. The majority worked as farmers and more than half had completed between 6-10 years of schooling. More








than half of the mothers wanted more children, the average desired number of children being 5.5 (SD1 = 1.4) children.

Mean Age at last

27.7 years

Percentage (%)   Number/ Total N


Bulondo Giri Giri Kyete Maina Mwezi



Married/living together with a man as if married






















Married  and
living with husband
Married  but
not living with husband Separated/divorced

Husband has other wives

Never married














Other (Born again)



1-5 years

6-10 years














11 or more





















Seller of agricultural products


1. SD = standard
 deviation from the mean

Mean Age at last

27.7 years

Percentage (%)   Number/ Total N


















Woman and partner together






















































Woman and partner together


Mean number of pregnancies during  lifetime
Mean number of births during  lifetime
  Has lost one
or more  children in the first month
of life
Has had a stillbirth, abortion or miscarriage
PLANNING   Currently using a contraceptive method
(excl. breastfeeding)
    Wants more  children
    Desired number of children*
Most recent birth was a live birth
from most  recent birth is still alive

Table 1. Characteristics of the respondents of the quantitative survey.

*calculated among
 mothers who wanted more  children as current number of
living children plus number of desired children.

3.2 CHW Home visits

The project monitoring  tools indicated
 that the CHWs conducted 1,231 home visits during the project year 2015-16;
each CHW made 103 visits on average. The visits are composed of
862 prenatal visits
and 369 postnatal visits. This is
more than the 1,021
visits in the previous year, which can partly be explained
by the addition of one village
to the project area.

Out of the 61 mothers in the evaluation survey, 49 women (80%) received at least one prenatal CHW home visit. That 20% of interviewed women did not receive prenatal visits indicates the need to improve the project’s reach. At the first visit women were on average 4.13 months (SD= 1.65) pregnant, ideally
it should occur when being 8-12 weeks pregnant (18). The mean number  of prenatal visits
was 3.5 (SD=2.0 visits), which exceeds the desired number
of 3 visits.

Eighty-four percent
 (51 women) received at least one postnatal home visit
from a CHW. The median
number  of postnatal visits were 2 (SD= 1,9). The reach thus needs to be improved but the number of visits to those who receive visits
meets the desired target.

Forty-seven percent  (29 women) reported that they had been referred to a health
facility for something else than antenatal care. The most common reason for being referred was malaria. Other reasons
were stomach pain, headache or bleeding, which are possible danger signs for pregnant women. The frequent use of referrals is a positive outcome.

Baby’s foot measured with foot length card

Family planning





Topics covered during  CHW home  visits (N=61)

2014 – 2015

2015 – 2016

Clean cord care
Benefits of breastfeeding
Thermal care for baby Newborn danger

Receipt of Maama kit at 4th ANC visit

Birth preparation














Figure 4 shows the
 topics  covered
 by the
 CHWs during  home  visits,
as reported by our sample. Overall, slightly less mothers  reported the different topics
to have been covered compared to year 2014-15
(Fig. 1).
Last year’s sample was however 
more strongly selected  for compliant
mothers  than  it is the  case  in the
 which  might
explain the difference. A positive change was observed in the proportion of women  who reported that the CHW had
measured the
baby’s foot,
a method to identify low birth weight. This indicates an improvement thanks to the specific training on how to use the foot length
 card that the CHWs received in summer 2015.


A part of our
sample was obtained through the CHWs leading us to the women
 and the CHWs were sometimes  present during the interviews,
which may have affected the answers the
women gave. No
CHWs were present during
the interviews conducted at Maina

There might be cultural factors, such as a tendency towards answering
“yes” rather than “no” on questions, that could have an impact on the answers (social desirability bias).


For the next evaluation it might be of value to find another
way to ask for
what information the mothers received from
the CHWs, instead of asking closed yes-or-no questions. In this
evaluation they were asked whether or not they remembered being told about this
topic. Another way of asking
might give more information about the content of what they remembered.

Some  CHW indicated  that  the  workload 
was  heavy,  and  that  they sometimes  had to go very far to visit a mother. Therefore, they asked
SOGH if it would be possible
to donate bikes to them. In the long term, an increased compensation should also be considered.

Some mothers did not receive any home visits because the CHW did
not know them or were not aware of the pregnancy. A better system to find
pregnant mothers could be considered.

The slight
decrease in percentage of topics covered by the CHW, might be due to the heavy workload. An extra aid for the CHW to remember them which
topics should be considered, could be useful.

3.3 Maama

The Maama kit is intended to  grant  the  beneficiaries  in the
 Maama project the items required for a hygienic delivery. It is distributed to the beneficiaries at the fourth ANC visit and thus works as an incentive for the
mothers to seek the recommended amount  of antenatal care.

The Maama kit includes
two pairs of sterile gloves, cotton wool, a
sterile blade,
a preparation sheet, a plastic sheet,
soap, cord tires and a new child growth and postnatal clinic card. A total of 246 Maama kits were
distributed during the project year 2015-2016. This is an increase with 47 kits compared to the previous year. According to the monitoring

68% of beneficiaries reported using the kit during 
delivery. For those who did not use the kit the monitoring data does not inform on whether mothers  had not received it or chose not to use it. Since none  of the interviewed mothers
chose not to use the Maama kit, there is reason to assume that it is the first reason.

Out  of the
 women  interviewed, 79% (48 women)  reported having received the kit. Among the 13 women  who did not receive a kit, the reported reasons
 that  (i) ANC visits took
 place  at  the  Mayuge district hospital
and not at the project
 clinic (38%) (ii) four ANC visits
were not completed (31%) and (iii) the kit was out of stock at the Maina
clinic (23%). One woman completed four ANC visits at the Maina clinic, yet as she was referred to undergo cesarean section at a larger hospital
in an early stage of her pregnancy, she did not need the kit.

CHWs and health
personnel  alike
reported that the Maama kit works as an effective incentive for the women to complete four ANC visits.

“It is easier for the mothers
since they receive the Maama kit now. Before it was more difficult
for them economically
buy the things
they needed for delivery which are in the Maama kit now.”

Peninah, nursing assistant at Maina clinic

At the Mayuge district hospital, the healthcare staff explained that since
the hospital is frequently understocked with cotton, clean razor blades, cord ties and other items required for a
clean delivery, it is helpful when Maama project beneficiaries bring these items themselves.

Generally, the view among mothers, CHWs and health personnel
is that all items in the kit are essential. Some beneficiaries and CHWs reported that
the kit should include
baby clothes. Healthcare staff at both the Maina project 
clinic and the Mayuge district hospital as well as some CHWs, emphasized that  the  kit could  be  improved
 by including
 additional plastic gloves. Another
suggestion from the nursing assistants at Maina
clinic was to include gauze pads.

In the in-depth  interviews, the
women  who had received a kit agreed with the view expressed by the health personnel
and the CHWs, namely
that  the kit is an important incentive  for them  to complete  four ANC visits and that it helps them save money.

Furthermore, the  women  expressed  that
in the  kit were useful, but also stated that the kit could be improved by including more items such as soap, baby clothes,
sheets and a towel for
the baby. One woman who reported not receiving
a kit as she did not complete  four ANC visits, explained
that she made one herself by buying
the following
items: cotton, gloves, clothes,
sheets and a razor for
the umbilical cord. One interview was conducted with a woman who, due to a quick onset of delivery, was not able to reach the clinic. The family members  who assisted  at her delivery made  use
of the  gloves and  the  razor blade, showing how the kit also can be used to make home deliveries safer.


The Maama kits sometimes ran out of stock, then women had to come back later to get it or did not receive it. If this happens too often the incentive for
completing four ANC visits is taken away.

Mothers and CHWs ask for more items to be included in the kit. However,
the Maama kits are bought in a sealed
bag and the manufacturer can not provide more items in the kit.


Improve delivery of kits to the clinic to avoid running low in stock. This was done during summer 2016 in two ways. First, instead of ordering kits a couple
of times per year and waiting for them to be delivered, the supply
of kits for a whole year was ordered at once. Secondly, vouchers were made in case the stock does run out, so that mothers can come and collect the kit
later on.

Investigate the possibility to include more items in the kit, especially
more plastic gloves. However this is difficult, since the
are bought in a sealed
bag. Another way to accommodate
the lack of gloves would be to supply the clinic with extra gloves.

Make the
 conditions  for receiving  a
more  clear for the beneficiaries (i.e. four ANC visits at Maina

3.4 Antenatal care  attendance –
the women’s perspective

One of the aims of the Maama Project is to increase ANC attendance among pregnant women. Both the CHWs and the health care staff reported an
increase in the number
of ANC visits and a rise in the number
of women who completed four ANC visits since the project started. These reports were confirmed by an analysis of baseline 
data, data from monitoring tools  and  information   collected   during   the 

Attending four visits to receive the Maama kit

Cleaning the baby’s umbilical cord using either chlorhexidine or water and salt

Preparing baby clothes

Breastfeeding for 6 months

Preparing money for transport and emergencies

Going to the hospital or clinic for delivery or if they
were not feeling well

Exercising and avoiding hard work during

Women in the sample (n=61) who attended at least one ANC visit


Baseline data from May 2013 to June 2014 obtained from the records at
 Maina clinic indicated
 that  on  average,
 35 women
 for an ANC visit per  month,  with
12% of women  completing  all four visits.
During  the  first  project  year
 (2014-2015), the  average  
number   of visits increased
 by  122%
to  78  visits per
 month,  according  to
 the monthly
 tools and  cross-checked  with
clinic records. The clinic records
 indicated  that
 82% of women  completed all four visits.

In our  study
 for the
2015-2016, 98.6% of the
 women reported attending antenatal
care at least once during the pregnancy, comparable to 100% in the  previous
 year and
 figure of

94% (Figure 2). A total of 85.7% of women interviewed had completed

four  antenatal  visits,  significantly
 than   the 
 baseline   figure

Project Year


2014-2015          2015-2016






























of 12% and
 also  higher  compared to  the  estimate
 from  interviews with
 women  in the
 previous  year,
 was 76% (Figure 3). Most of the  women
 (82.9%) attended
ANC sessions  at  the  Maina Clinic.

When asked to recall five things that
 they learned
 from the antenatal
care advice they received, most women mentioned:

Preparing themselves for birth

Eating well

tested for HIV

Women in the sample (n=61) who completed 4 ANC visits








Sleeping under a
mosquito net during pregnancy to avoid being infected with malaria

Project Year


2014-2015          2015-2016

3.5 Antenatal care
 visits –

the clinic perspective

The interviews with the nursing assistants and the clinical
records gave information  about  the 
content of the 
ANC visits in Maina which was compared to the WHO guidelines (19).

The nursing assistants always included
the following information in the clinical records: woman’s age, which ANC visit they attend, number
and deliveries, gestational  age, expected date  of delivery and other  diagnoses. There are no free pregnancy  tests
 at the  Maina
clinic; the  women  have to buy their own. An insecticide
 bed net is provided by the government and, if in stock, are handed out for
during the first ANC visit. Other preventive  measures
 provided  by the clinic include intermittent preventive  treatment of malaria, tetanus toxoid immunization,
de-worming, iron and folic acid substitution.

The only
laboratory test that can be routinely
performed  at the Maina
clinic is the rapid Malaria test. Women are consulted  and
referred to the Mayuge health
 clinic for HIV and syphilis testing. There is no machine to measure
 haemoglobin levels at Maina, and
the only way to assess anemia  is by looking under  the  woman’s eyelids and  at  her  skin. A pregnant woman’s blood
 should  be controlled  during
 every visit in order  to recognize  pre-eclampsia
 early, yet the  clinic’s blood
pressure  machine  is currently  broken.
 for malnutrition  is performed by weighing the pregnant woman during every visit. The mid upper
arm circumference cannot be measured as
there is no measuring
tape at the Maina clinic.

The nursing assistants
 give the expectant mothers
about pregnancy  danger  signs, breastfeeding and how to eat healthily.
They also advise the pregnant women about  which
items they should bring
for delivery and to plan arrange transportation to the delivery facility in


It is positive that more women are coming to the Maina clinic for ANC visits and delivery, but it is challenging  for the small clinic to keep up with the increasing
demand. The clinic is only open  during weekdays and at daytime, which was mentioned as
a problem also by the mothers in
the interviews.

Some respondents further noted  that there are too few beds in Maina,
the rooms are too small and the clinic needs more health care personnel. Currently there  are not enough seats and only one antenatal/delivery bed at the clinic. Before the summer
2016 there was only one postnatal bed, but SOGH has managed to provide one more. Another
challenge is the  shortage of personnel;  there  are
 currently  only 
two  nursing
assistants, who mentioned
that they would appreciate more help.

The clinic has  no  electricity  or  running  water  and  lacks
important medical
equipment, e.g. blood pressure machine, measuring
 tape, bag and resuscitation mask. Mosquito nets and medicines
(e.g. Lumartem for treating  malaria) that are provided by the government
are often out of stock. Two women said during their interviews that they did not receive mosquito
 nets as promised
and three other women said that there was not enough free medicine. Three mothers
 reported that 
they did not receive the Maama kit due to it being out of stock.

One of the nursing
assistants also raised the issue that the women are too young when they have children, which
can lead to more complications
during  pregnancy   and  delivery.  It  can  also  give  rise
 to  social 
and economic  problems
 in the 
long-term.  Five women  in the  survey said that they wanted more information about family planning.

According to the nursing assistants, the major reason
 why women  do not complete  all four ANC visits is starting  the first ANC visit too late in their pregnancy. On average the women went to their first
ANC visit
when  they were four months  pregnant, which is later than
 the WHO recommendation of
8-12 weeks.
 Eleven out
 of 61 women  attended
their first ANC visit when  they 
were 6 months
 pregnant. There is no standardized plan  for what
 ANC visits should  include  and  what information
 receive. The nursing  assistants
 only have the headlines in the ANC clinical records book, which is provided by the government, and their own memory to follow.


Larger facilities with more seating areas and at least one more antenatal/ delivery bed are needed. Electricity and running
water should if possible be
installed. The workforce should also be increased, preferably with a midwife. Critical items that are currently lacking should be provided to the clinic, e.g. blood
pressure machine and a measuring tape. Increasing
the number of Maama kits stored at the clinic would also reduce the risk
of them running out of stock.

According  to  the  nursing  assistants,  it would  be  desirable
 to  have an extra stock of medicine
 and rapid malaria tests  in addition
 to the governmental provision.
The nursing
 assistants  also 
suggested that providing the Maina clinic with rapid HIV and syphilis
tests could possibly increase 
the  proportion of women  taking the
 tests. The possibility to control haemoglobin levels and perform urine analyses would further add to the quality of the ANC care provided 
at the clinic. The nursing
assistants also suggested that the CHWs should encourage the
women in the
villages to go to the ANC clinic earlier during their pregnancy, so they will have time to complete all four visits.

The information given to the women about family planning by the CHWs and Maina clinic needs to be to improved. Currently, the only available family planning methods are injectables, implants and condoms.

If given resources, the  interviewed
 midwife in Mayuge said that
 she could  arrange  family
planning  training
 sessions. However, additional family planning methods should be implemented.

Additionally, the  distribution  of a mother’s card  with 
the  important
information about the women’s ANC visits might increase the pregnant women’s involvement. The card could also be used as a check list at the ANC visits. The nursing assistants gave positive feedback
about this idea.

3.6 Deliveries

a) Delivery location and birth attendance

According to the 
quantitative survey, 89% of mothers  delivered  their most recent child in a health facility, which is a marginal increase from

86% in the previous project year.  Slightly different numbers show in the monitoring data, which includes
all mothers who were visited by a CHW
after birth. The monitoring files state that 78% of mothers
delivered at a health facility in
the project year 2015-2016,
compared to 67% in 2014-

2015. In any case there is a
positive trend towards more facility deliveries.

The quantitative survey recorded that 46% of facility deliveries occurred in Maina clinic, where the two nursing assistants work as birth attendants,

41% in the larger health centre in Mayuge with more midwifes and 13%

in a
referral hospital
(see figure 5).



Health  Facility                                                            

The choice  of facility differs from 
the  evaluation  2015,
where  40% delivered in Maina clinic and 60% in Mayuge health centre. The fact that
more mothers delivered in hospitals might indicate a better functioning of
the referral system in case of birth complications. While mothers were giving mixed accounts of the treatment in
Mayuge, all respondents were
very positive about the care provided
by the nursing assistants in Maina. The nurses  can only offer basic obstetric  services, however  they 
also provide ergometrine injections to stop 
excessive bleeding
 after birth.
This service is also used by home-delivering mothers, as they sent family member  to get ergometrine
injections from the clinic after delivery, for
example when the delivery happened during the night.

Eleven percent
 of mothers  delivered at home (Fig. 5), slightly less than last
year (14%). Home deliveries often go hand in
hand with unskilled birth attendance, delay in referrals in case of complications
and unclean environments. Home
deliveries can thus present a danger to the health of mother
and newborn (2). The qualitative interviews revealed that while all
women prefer a hospital
delivery, it is not always possible.
Common reasons
 for home
 birth were sudden  delivery onset
 and thus 
trouble reaching the facility. At home women were assisted by a TBA, a relative or a friend. The qualitative interviews revealed that in two cases the TBAs
were a mother or a mother-in-law and were paid in cash or in kind. Both of them  had planned  to deliver at a facility, but the circumstances
 did not allow it. One of the mothers used a Maama kit during home delivery.

Overall, positive trends
 in delivery location  were observed. A
greater proportion of
deliveries occurred  in health
with skilled attendance and the referral system is possibly
functioning better. Even though home  deliveries have 
become  less common,
 a considerable
portion  of women  still delivered  at
 home,  often  despite

deliver in a facility. It is important to tackle the remaining
barriers, some of which are known from similar research (20), so
that every mother
can deliver in the safest possible setting.

b) Birth preparedness
and transportation

Data on birth preparedness
and transportation to the delivery facility
(Fig. 6) were newly added  to the  survey this year. 95% out  of the  42 women who used motorcycles had arranged
 the transportation before the onset of labour pains. Around 80% of mothers recalled that the CHW
had actively encouraged them  to save money  for transportation. The message seems to be passed on and can be seen as a project success.


Birth preparedness further includes packing a bag with essential items for delivery that  are not provided  in the  facilities. Almost
all mothers brought a
basin to wash the baby, baby clothes 
and a jerry can with water. Almost
everyone  who received  a Maama kit brought it to the delivery. Moreover, many brought clean cloths, soap, a baby blanket, tea  and  sugar. The above
 indicators  were not
 measured in
the  2015 evaluation,  hence
 no comparisons  can
be drawn. The overall state  of birth- and transportation preparedness appears to be positive.







The transportation to the facility took on an average
 32 minutes
confidence  interval: 23-41 minutes). This number  is
only a rough approximation,
 as there were doubts
 about the time estimations
 given by several respondents. Moreover, 94% of women were accompanied to the delivery, most commonly
by the husband, a close relative or a friend.

96% of these mothers
had also previously arranged transportation back home in advance.

c) The role of traditional birth attendants (TBAs) in delivery

This year we were also able to interview a traditional 
birth attendant (TBA) in the village of Bulondo to find out more about
the role of TBAs in maternal health care, particularly around home births. Since 2010, TBAs have officially been banned in Uganda, though they continue
to practice
given the poor implementation of the ban (27). The TBA perceived that
since the community
 knows of and trusts them,  they
are still seen  as relevant people in the community, though many TBAs increasingly
refer women to health care centres for delivery.

The TBA further explained  that
 she had been
 in this role for about
 15 years; she 
had  only
recently  moved  to Bulondo, but  in her previous location  she saw on average  100
mothers  in a month.
 The common practice was that the expectant mothers
 would come to her (unless
it was an emergency, in which case she would go to their houses) and this happened most often in situations where they could not access care at a health 
facility, due to time or geographical
constraints. Items for the delivery (gloves,
razor blade, sheet,
thread  for cord, basin, soap, sugar,
pads, clothing for baby, diapers)
as well as food are usually brought by the mother; in some cases the TBA would provide food as well.

Before the delivery, the TBA would initially assess the mother’s condition to determine if
the birth could take place at home, or if a referral was needed to  the  nearest
 facility.   If  the
 TBA  could  handle  the situation, she would assess the approximate time when to expect  the baby, and make the mother
 feel comfortable  and
provide tea and food until the time of delivery. The TBA would then  assist
with the delivery and monitor the health 
of the mother  and baby for the following four hours. If the delivery takes place at night, the mother usually stays over and leaves in the morning. In terms of post natal care, the TBA follows up with check
ups on the mother  one day and again one week after birth
and also gives advice on family planning.


Expecting mothers
usually know about and plan to deliver at a health facility. However, practical problems such
as transport to the health facility can not be overcome in the current project and lead to that some mothers decide to deliver with a TBA.

Limited capacity of Maina clinic. At the start of the evaluation there was one bed for delivery and one bed for resting afterwards. This meant that if two women had to rest after delivery, one had to rest on a mat on the ground. both mothers and health care staff brought this up.


In the long term, it should be considered if SOGH can organise
a system to make it more easy
for mothers to get to the clinic. For example, a bodaboda that mothers in need can call.

The limited capacity of Maina clinic was remedied
during the evaluation by the purchase of an extra bed where women who have delivered can take rest before making the journey home.

3.7 Newborn  health

half of the newborns  (44%) had
no health problems during the neonatal  period of 28 days. The reported problems
 for the rest of the newborns
 included malaria (36%), colds and coughs (11%), skin rashes (8%), problems with the umbilical cord (7%) or a combination of these.

a) Newborn care practices

We recorded
 the  prevalence
 of several good
 newborn  care practices
which are recommended by WHO (25). 92% of mothers  had the baby put on the bare skin of their chest directly after delivery. Close to  all mothers  breastfed  their children. Ninety-three 
percent  started
 within one
hour from birth, which is more than in the 2015 evaluation
Exclusive breastfeeding
in the  first three
 days of life was reported by

83% of mothers, compared to 79% in 2015. The ten mothers
 who gave their babies
something else to drink than breastmilk used warm water, sometimes
with sugar. Four women did not produce enough breastmilk
and thus needed to supplement. All mothers
 except for two were still
when being interviewed, when over 30% of the children were older than 6 months. Long-lasting
appears to be the norm in the project area and may contribute to birth spacing.

Overall, direct skin contact with the baby and immediate, exclusive and long-term
 breastfeeding appear
 to be strong  social norms within the surveyed  population.
 This was seemingly
 already the  case before
 the project start in 2014. Yet, this evaluation  revealed a further increase in immediate and exclusive breastfeeding compared to 2015. Emphasizing
the importance of good care practices during CHW home visits and ANC has likely contributed to this positive development. In contrast, other reports on newborn care in Uganda suggest a more problematic situation (8). The next evaluation could benefit from measuring
 a wider range of
safe newborn  practices to identify the areas that  need  improvements also in the project area.

b) Umbilical cord care

Of the  mothers  in the  project  area, 36% received 
the  umbilical cord disinfectant
 chlorhexidine at their fourth antenatal visit. The low proportion could be explained 
by that  the chlorhexidine  intervention
was initiated in March 2016 and by then many of the mothers
 already had their fourth ANC visit or their delivery.

Out of the
 women  who 
received  chlorhexidine, 96% (21 out
 of 22) applied it. The mother who did not apply it explained
that she forgot to use it. Out of the women who received and applied chlorhexidine, 81% (17
out of 21) applied it within 24 hours. An important note is that many
mothers explained
that they applied chlorhexidine
multiple times, while they
were given a tube
 for a single
time application.
This could thus mean
that the chlorhexidine is not optimally
used. Mothers who did not receive chlorhexidine
reported no specific method of umbilical care, or that they washed the stump  with
water or warm water, in many cases with added soap or salt.

Due to a small sample
study, no conclusions can be made if the newborns
receiving  chlorhexidine  experienced fewer  infections. However, it is known that chlorhexidine effectively decreases umbilical cord infections in
low-income settings
(26). The finding of one infection and three slowly
healing cords in our small sample suggests 
a need for intervention. The qualitative  interviews  revealed  that
 a positive  attitude towards
 and said they would like to use it, if
available. Thus, SOGH currently discusses how chlorhexidine  provision might be permanently incorporated into the Maama project. Ensuring the gel’s correct application will be
a further challenge.


Stock of chlorhexidine: At the time of the evaluation the Maina clinic had
no stock of chlorhexidine. Because of a miscommunication with the field
project manager, the rest of
the stock had not been delivered to Maina

Six of  the  women
 reported  having
 received  chlorhexidine had delivered before the intervention was started. Two of them delivered at Mayuge health center, where it may have been possible that they received chlorhexidine. The other four delivered at Maina, where we have  no knowledge of available
chlorhexidine at that time. These answers might be due to a social desirability answer in some cases, in other cases these women 
talked about when and how they applied it, so there possible
explanation is that these women are not always fully informed about what they

Use of chlorhexidine: The chlorhexidine is supposed to be used as a one time
 application. However, some
 of  the  mothers  reported that  they used it multiple times during multiple days. Multiple
use of the received chlorhexidine makes it doubtful that a sufficient
amount is used. One
of the mothers used the chlorhexidine three times a day for one week, but reported that her child’s cord healed slowly,which
could be an indication of unsatisfying results resulting
from misuse of chlorhexidine. The misuse could in some cases be explained
by that the pictorial instruction was not given to all mothers.


The CHW have received extra training to be explain the use and application of chlorhexidine to ensure better use in the future. The Maina
clinic also
has a pictorial on
the wall explaining how it should be used.

3.8 Male involvement

In order to improve the results and to sustain the Maama Project in
the long run, both mothers
and fathers need to be involved. An exploratory investigation was conducted by interviewing
four husbands to mothers who took part in the Maama project. The respondents were accessible during daytime, which may contribute to selection bias since the men who stay at home for work, in
comparison to men who work away from
home, are likely to be more positive to the project due to a higher degree of information and involvement.

As the  communities
 have  become
 sensitized  to
Project, CHWs have reported that  men 
are increasingly positive towards  ANC visits and  the  work of the
 CHWs. One important reason
 the positive attitude is
that  the project and the Maama kits not only help the women, their unborn and newborn babies, but also decrease men’s work that otherwise would include retrieving
items for the birth which is
a costly and time-consuming

With sensitization, the men stated
 that they are more concerned about
women’s and
 newborn’s health
 they  expressed  support
 of the CHWs, ANC and the project
 overall. One stated
 reason  for supporting the project was that several fathers now feel less worried when working out of the home as they know that the CHW will be there supporting the wives.

All male respondents stated that they participated in birth preparedness with a CHW and/or
 at ANC visits at a clinic and could elaborate  on and specify
the ways in which
they and their families had benefited from
the visits. Examples of new insights included additional ways to support their wife
during pregnancy
 and after giving birth, encouragement of mothers to attend ANC and to give birth at a health facility and additional knowledge about child care. Three out of four fathers had attended ANC

visits with the mother. Of the mothers
 in the survey, 41%

reported that their husband had accompanied them to the delivery.


 for male  involvement  include  strong  norms
responsibilities and family roles within the communities. One challenge  brought up in some CHW interviews is that men sometimes
have  had  a bad  attitude when  the  CHW goes  to see
 or that men encourage their wife
go to a TBA. Lack of information and understanding of the purpose of the project was suggested to contribute
to the men’s behaviour. In addition,  there  have been  occasions when the mother  hides
the Maama kit from the husband in order to sell the
items or to get additional money from her husband (to buy items for the child birth) although she already has gotten a Maama kit for free from
Maina clinic. Traditional power 
structures  and
lack of communication between
the parents  and the CHW can thus be a cause of disruption within families. CHWs have also reported that some men need  to take more  responsibility  during  the  pregnancy
 period  by obtaining  items such
as clothes for the baby as well as providing
transportation money for the mothers
to the health facilities.


Recommendations forward for the
Maama Project include
continuous spread
 of information  in the communities, primarily in the rural areas, with an emphasis
to address the importance of men in understanding
and  taking full responsibility  as fathers  and 
not  perceiving  initiatives such as the 
Maama project  as a way to avoid responsibility. It is also important  to  discuss  how  the  family 
and  the  community   overall benefit
from increased male involvement. An identified
opportunity to strengthen
male involvement is to increase incentives for the fathers to be more engaged in their wife’s pregnancy. Finally, it is of importance to strengthen
and support the group of single mothers.

3.9 Mental health

Research conducted in Uganda  indicates
 existence  of maternal mental
 issues  and  postpartum depression
(21).   In order  to investigate whether mental health was a field of interest for the Maama Project we created
 a qualitative tool aimed at CHWs as well
as adding
questions  in the
 quantitative tool
the  mothers. Both tools were loosely
based  on the Edinburgh scale. After
trial in the field and consulting
 UDHA staff the  tools were modified  towards  focusing mainly on 
behaviours  as symptoms
 of mental
 problems. Our findings indicate that 16% (10 women) reported that they experienced one or several signs of maternal mental health problems or postpartum depression.

However, out of these women 50% reported that this was due to physical problems such as malaria or pains after the delivery. Of the women who had experienced at least one sign of postpartum
depression 70% (7 out of 10 women) did not desire more children which is considerably higher than, 35% among
 the women  who had not experienced any signs of
postpartum depression.

Only one of the CHWs said that
 she had met a woman  suffering from postpartum depression,  one 
other  CHW said that  the  women
 would talk to her if they were sad after a miscarriage or a stillbirth. This result should be interpreted with precaution;
 several factors could have had an effect on the validity of the study, such as stigma related to mental health
problems (21) and the tool not being culturally sensitive enough, causing a failure in screening
for maternal mental health problems.

Family planning

According to WHO, the
 promotion of family planning, and  ensuring
access to preferred  contraceptive methods
for women
 and couples, is essential to securing the well-being
and autonomy of women. Further, WHO claims that the use of family-planning can improve both maternal
and infant health as it can prevent closely spaced, high-risk and ill-timed pregnancies and births (22).

According to the quantitative study carried out, 23% (14 women) of the women interviewed reported
that they were currently using a modern
contraceptive method (breastfeeding not included).
Out of these women the most commonly
used contraceptive methods
were injectables (8.2

%) or condoms  (6.6%). Out of the women who did not currently use a family planning  method, 52% (24 women) clearly expressed
 that  they intended to use a
family planning method later on.

This result is in line with the findings from the qualitative
 interviews with the  fathers
 who,  despite
 of desiring
 more  children, either  used or intended
to use a contraceptive method
in order to delay the next pregnancy. Among the  women
 who intended
to use a contraceptive
method later, the most common methods mentioned were injectables, male condoms
or female sterilisation.

Out  of  the  women
 currently  not  using  a  contraceptive
method 10% (5 women) expressed that they were not planning to use a contraceptive-method
at all.

Many women replied that they did not use a contraceptive method as it was too soon after the delivery; they either
expressed that they were
using postpartum abstinence, that they needed to heal, that they were
or that they were waiting
for their period to come back.

Out of the women who intended to use a family
planning method later on, five women
 that  they
had concerns  regarding  the
side effects of certain family planning  methods or that
 they needed more
information. This made 
them  delay their use of or reluctant
 to find a method that they thought suited them.

Half of the women (31 women) in our survey reported that the CHW had talked
to them  about  family
planning. Most women (16) were advised to use family
planning  or to go to the clinic/hospital for contraceptive
counselling in order to find a suitable contraceptive
method. Furthermore, most of the
women were also given general information about family planning methods and that they could be used in order to avoid getting pregnant.


The findings  clearly indicates
 that  most  women
 aware  of the existence
 of different  family planning
 methods. Using the
 data  we acquired from our survey it is hard to know whether
 the women were
able to space or limit their fertility in accordance with their own wishes. A suggestion is to
further investigate the existence of unmet
contraceptive needs among the beneficians of the Maama Project. Education, receiving information about the contraceptive method of choice, communication
with one’s partner, and finding a suiting contraceptive method has
been proven to lead to a continuous
contraceptive use [23,24].


More knowledge
planning  methods was requested by some of the CHW. Continuous
sensitizing of the community about family
planning  methods, including  the  men,
 possibly  the  CHWs,
 can therefore
 be suggested. As certain women experienced negative
 side- effects from their previous contraceptive method
(notably injectables), it
is recommended
that other contraceptive methods, for example
non- hormonal contraceptives, should be made available
at Maina clinic.

The Maama-project evaluation team 2016



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 Pictures taken by the Maama-project evaluation team 2016