Maama project

Evaluation of the Maama project:

Evaluation
report 2016

Abbreviations	3	3.2 CHW Home visits	15
Executive summary	4	3.3 Maama kits	17
Summary of recommendations	5	3.4 Antenatal care attendance – the women’s perspective	19
1. Introduction	6	3.5 Antenatal care visits – the clinic perspective	20
1.1 Context	7	3.6 Deliveries	22
1.2 Maternal and newborn health in Uganda	7	a) Delivery location and birth attendance	22
1.3 The Maama Project	7	b) Birth preparedness and transportation	23
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	25
2.2 Evaluation design, tools and data collection	10	a) Newborn care practices	25
2.3 Study population and sampling strategy	11	b) Umbilical cord care	25
2.4 Ethics	11	2.8 Male involvement	26
2.5 Data analysis	11	3.9 Mental health	28
3. Findings	12	3.10 Family planning	28
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).

The
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

89%.

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
issues
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
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.

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
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.

Short term

SOGH should look
at
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

Distribution
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
the
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

A
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.Introduction

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
disorders
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
most
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
(8).

1.3 The Maama Project

To address the risks mothers and newborns
face
in Uganda, SOGH developed
a
maternal and newborn health
project together with
Uganda Development
and
Health
Associates
(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
center
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
are
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
health
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
visits
at the Maina clinic

The role and use of Maama kits

The role of community health workers in attitude
and behavior change

Perceptions
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,
any
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
project
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.

Qualitative
data on newborn and maternal
health
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
in
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

Inclusion
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
were
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
estimates
of
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
in
specific
topics covered
in
the
quantitative survey.
Lastly, the qualitative question
items from the quantitative survey were
analysed.

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
birthday

27.7 years

Percentage (%) Number/ Total N

VILLAGE

Bulondo Giri Giri Kyete Maina Mwezi

MARITAL STATUS

AND LIVING SITUATION

Married/living together with a man as if married

16
18
12
15
39

53/61
45/61
15/61

5/61
18/61

3/61

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

Husband has other wives

Never married

RELIGION

Christian

Muslim

34/61

24/61

3/61

Other (Born again)

EDUCATION

None

1-5 years

6-10 years

7/61

10/61

38/61

6/61

11 or more

EMPLOYMENT

Farmer

10/61
11/61
7/61

9/61
24

46/61

2/61

13/61

Seller of agricultural products

Other

1. SD = standard
deviation from the mean

Mean Age at last
birthday

27.7 years

Percentage (%) Number/ Total N

DECISION
MAKER FOR HEALTHCARE

Woman
herself

Husband/Partner

24/61
22/61
8/61

7/61

Woman and partner together

Other

DECISION MAKER

FOR MAJOR HOUSEHOLD
PURCHASES

Woman
herself

Husband/Partner

6/61
30/61

20/61

5/61

4.82

4.52

5.5

15/61

11/61

12/61

36/61

61/61

Woman and partner together

Other

	Mean number of pregnancies during lifetime Mean number of births during lifetime
FERTILITY AND FAMILY		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		Most recent birth was a live birth	100
BIRTH		Baby from most recent birth is still alive	100

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

28%

49%

50%

72%

Topics covered during CHW home visits (N=61)

2014 – 2015

2015 – 2016

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

Receipt of Maama kit at 4th ANC visit

Birth preparation

54%

69%

59%

69%

76%

80%

84%

79%

54%

100%

97%

0%
20%
40%
60%
80%
100%
120%

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
present
evaluation,
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.

Challenges

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
clinic.

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).

Suggestions

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
kits

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
data,

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
were
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
to
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
the
items
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.

Challenges

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.

Suggestions

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
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)

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
evaluation
interviews.

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
pregnancy

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

100%

Baseline data from May 2013 to June 2014 obtained from the records at
Maina clinic indicated
that on average,
35 women
came
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
monitoring
tools and cross-checked with
clinic records. The clinic records
indicated that
82% of women completed all four visits.

In our study
sample
for the
year
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
the
baseline
figure of

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

four antenatal visits, significantly
higher
than the
baseline figure

Project Year

Baseline

2014-2015 2015-2016

100%

98%

96%

94%

92%

98,6%

94%

90%

of 12% and
also higher compared to the estimate
from interviews with
women in the
previous year,
which
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

Getting
tested for HIV

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

100%

85,7%

76%

60%

40%

20%

12%

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

Project Year

Baseline

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
of
pregnancies
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
treated
bed net is provided by the government and, if in stock, are handed out for
free
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
pressure
should be controlled during
every visit in order to recognize pre-eclampsia
early, yet the clinic’s blood
pressure machine is currently broken.
Screening
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
information
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
advance.

Challenges

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
the
ANC visits should include and what information
the
mothers
should
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.

Suggestions

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).

BIRTH LOCATION

Home
7

Health Facility
54

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
facilities
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
wishing
to

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.

TRANSPORTATION TO PLACE OF DELIVERY

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.

Motorcycle

78%

Walk

18%

Bicycle

The transportation to the facility took on an average
32 minutes
(95%
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
health
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.

Challenges

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.

Recommendations

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

Almost
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
(59%).
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
breastfeeding
when being interviewed, when over 30% of the children were older than 6 months. Long-lasting
breastfeeding
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
mothers
had
a positive attitude towards
chlorhexidine
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.

Challenges

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
clinic.

Six of the women
who
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
receive.

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.

Recommendations

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
the
Maama
Project, CHWs have reported that men
are increasingly positive towards ANC visits and the work of the
CHWs. One important reason
behind
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
venture.

With sensitization, the men stated
that they are more concerned about
women’s and
newborn’s health
and
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
participating
in the survey, 41%

reported that their husband had accompanied them to the delivery.

Challenges

Potential
challenges
for male involvement include strong norms
of
household
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
the
mother
or that men encourage their wife
to
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.

Suggestions

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
the
existence of maternal mental
health
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
aimed
at
the mothers. Both tools were loosely
based on the Edinburgh scale. After
trial in the field and consulting
the
UDHA staff the tools were modified towards focusing mainly on
behaviours as symptoms
of mental
health
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.

3.10
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
who
were
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
breastfeeding
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
expressed
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.

Challenges

The findings clearly indicates
that most women
were
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].

Recommendations

More knowledge
about
family
planning methods was requested by some of the CHW. Continuous
sensitizing of the community about family
planning methods, including the men,
and
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

References

1. World Health
Organization, World Bank Group, United Nations (2015). Levels & trends in child mortality 2015. New York: UNICEF.

2. Lawn JE, Cousens S, Zupan J. 4
million neonatal deaths: When? Where?
Why? Lancet. 2005 Mar 11;365(9462):891–900.

3. Lawn JE, Kinney MV, Black RE, Pitt C, Cousens S, Kerber K, et al. Newborn
survival: a multi-country analysis of a decade of change. Health Policy Plan. 2012;27(suppl 3):iii6–28.

4. Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every

Newborn: progress,
priorities,
and
potential
beyond survival. Lancet.

2014 Jul 18;384(9938):189–205.

5. UNICEF, World Health Organization.
A decade of tracking progress for
maternal, newborn and child survival. The 2015 report. Geneva: World Health
Organization; 2015.

6. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available
interventions
end preventable deaths
in mothers, newborn
babies, and stillbirths, and at what cost? Lancet. 2014;384(9940):347–70.

7. Waiswa P, Kallander K, Peterson
S, Tomson G, Pariyo GW. Using the three
delays model to understand why newborn
babies die in eastern
Uganda. Trop Med Int Health TM IH. 2010 Aug;15(8):964–72.

8. Waiswa P, Peterson S, Tomson G, Pariyo GW. Poor newborn care
practices-a population based survey in eastern Uganda. BMC Pregnancy Childbirth. 2010; 10(1):9.

9. WHO, UNICEF. Home visits for the newborn child: a strategy to
improve newborn survival. 2009.

10. Kirkwood BR, Manu A, ten Asbroek AH, Soremekun S, Weobong
B, Gyan T, et
al. Effect of the Newhints home-visits intervention on neonatal
mortality rate and care practices in Ghana: a cluster randomised controlled trial. The Lancet. 2013 Jun;381(9884):2184–92.

11. Hanson C, Manzi F, Mkumbo E, Shirima K, Penfold S, Hill Z, et al.

Effectiveness of
a Home-Based Counselling Strategy on Neonatal Care
and Survival: A Cluster-Randomised
Trial in Six Districts of Rural Southern Tanzania. PLoS Med. 2015 Sep 29;12(9):e1001881.

12. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis
on neonatal
mortality: field trial in rural India. The Lancet. 1999
Dec;354(9194):1955–

61.

13. Bang AT, Reddy HM, Deshmukh MD, Baitule SB, Bang RA. Neonatal and Infant Mortality in the Ten Years (1993 to 2003)
of the Gadchiroli Field Trial: Effect of Home-Based Neonatal Care. J
Perinatol. 2005;25(S1):S92–107.

14. Kumar V, Mohanty S, Kumar A, Misra RP, Santosham M, Awasthi S, et al. Effect of community-based
behaviour change
management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. The Lancet. 2008 Sep;372(9644):1151–62.

15. Baqui AH, El-Arifeen S,
Darmstadt
GL, Ahmed S, Williams EK, Seraji HR,
et al. Effect
of community-based newborn-care intervention package
implemented through two service-delivery strategies in Sylhet district, Bangladesh:
a
cluster-randomised
controlled trial. The Lancet. 2008

Jun;371(9628):1936–44.

16. Bhutta ZA, Memon ZA,
Soofi S, Salat MS, Cousens S, Martines J. Implementing community-based perinatal care: results from
a pilot study in rural Pakistan.
Bull World Health Organ. 2008 Jun;86(6):452–9.

17. Waiswa P, Pariyo G, Kallander K, Akuze J, Namazzi G, Ekirapa-Kiracho E, et
al. Effect of the Uganda Newborn Study on care-seeking and care
practices: a cluster-randomised controlled trial. Glob Health Action. 2015

Mar 31;8:5–15.

18. Waiswa P, Namazzi G, Kerber K, Peterson S. Designing
for action: adapting and implementing a community-based newborn care package to
affect national
change
in Uganda. Glob
Health Action. 2015 Mar

31;8(0).

19. Lincetto O, Mothebesoane-Anoh S, Gomez P, Munjanja S. WHO 2006, Opportunities for Africa’s newborn, chapter 2 Antenatal care.

20. Mrisho M, Schellenberg
JA, Mushi AK, Obrist B, Mshinda H, Tanner M, Schellenberg
D. Factors affecting
home
delivery in rural Tanzania. Tropical Medicine & International Health. 2007 Jul 1;12(7):862-72.

21. Baron E, Hanlon C, Mall S, Honikman S, Breuer E, Kathree T, Luitel N, Nakku J, Lund C, Medhin G, Patel V, Petersen
I, Shrivastava S, Tomlinson M. Maternal mental health in primary care in

five low- and middle-income
countries:
a
situational analysis. BMC Health Services Research. 2016; 16:53.

22. World Health Organization (2015). Family Planning/ Contraception
Fact Sheet N°351.
Retrieved from: http://www.who.int/mediacentre/ factsheets/fs351/en [06/12/2016]

23. Sanogo, D., RamaRao S. , Jones H., N’diaye P., M’bow B., Bamba Diop C. (2003). Improving Quality of Care and Use of Contraceptives in Senegal. Source: African Journal of Reproductive Health / La Revue Africaine
de la Santé Reproductive. 2003 Aug; 7(2):57-73.

24. Sileo, K.M., Wanyenze, R.K., Lule, H. , Kiene, S.M. (2015).
Determinants of
family planning service uptake and use of contraceptives among
postpartum women in rural Uganda. Int J Public Health (2015) 60:987–

997.

25. World Health Organisation, 2010. Essential Newborn case Practice, Clinical Practice guide. Geneva. Retrieved from: http://apps.who.int/iris/ bitstream/10665/70540/4/WHO_MPS_10.1_Clinical_practice_eng.pdf

26. World Health Organisation, Second Meeting of the Subcommittee of
the Expert Committee on the Selection and Use of Essential Medicines Geneva, 2008. Review of
the available evidence
on 4% chlorhexidine solution for umbilical cord care. Retrieved from: http://www.who.int/ selection_medicines/committees/subcommittee/2/chlorhexidine.pdf

27. Alanna Shaikh, 2010. UNIDISPATCH. Traditional
birth attendants in

Uganda. Retrieved from: http://www.undispatch.com/traditional-birth-

attendants-persist-in-uganda/
Pictures taken by the Maama-project evaluation team 2016