Mama & Family Project
Evaluation Report 2016-2017
Summary 1. Context 4 2. Maternal and newborn health in Uganda 5 3. SOGH and the Mama & Family Project 6 4. The importance of male involvement 7 5. Methods 9 Quantitative evaluation 9 6. Quantitative evaluation 10 6.1 Home visits by Community Health Workers 10 6.2 Clinic visits 11 6.3 Birth kits 12 7. Qualitative evaluation 13 7.1. The male role in contraception 13 7.2. Contraceptives 13 8. Future plans 15 References
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1. Context Approximately 7,000 newborns die every day, accounting for 2.6 million newborn deaths globally in 2016. A decline of under-five mortality was recorded during 1990 and 2016, yet neonatal deaths of all under-five mortalities increased from 41% in 2000 to 46% in 2016 [1]. Low- and middleincome countries (LMIC) account for 99% of neonatal deaths worldwide [2]. The highest mortality risk occurs in the first month of a child’s life. In Sub-Saharan Africa, one child in 36 dies during the first month, in comparison to a one in 333 ratio in high-income countries (HIC). The number of neonatal deaths in Sub-Saharan Africa declined by only one percent during 1990 and 2016 [1]. To achieve an equal survival rate found in Europe and North America, it will take over a century for Sub-Saharan African countries, at the current rate of change [3]. All of which calls for a rapid increase in the access to neonatal care. The health and survival of a newborn is closely related to that of the mother. In 2015, maternal mortality in SubSaharan Africa was 546 per 100 000 live births [4]. This is
due to causes such as hemorrhage, hypertensive disorders and sepsis, which account for over 50% of maternal deaths and could be prevented with access to basic medical care. Access to quality preconception, antenatal, intrapartum and postnatal care has shown to prevent most newborn deaths [5]. An estimated 25% reduction of neonatal deaths due to sepsis and tetanus is achieved by providing skilled care during labor. Further access to clean birth and postnatal care practices account for an additional 40% reduction of neonatal deaths. A further estimated 40% reduction can be achieved when combined with community-based care, along with community mobilization, home visits and improved linkage to health care services, is available [6].
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Evaluation Report 2016-2017
2. Maternal and newborn health in Uganda In 2016, Uganda had 40.4 million inhabitants and a fertility rate of 5.6 [7], slightly over two times the world average of 2.5 in 2015 [8]. The three major causes of neonatal death were, by descending order: preterm births (38%), intrapartum related complications (28%) and severe infections (24%). Furthermore, reliance on official development assistance (ODA) has been increasing. In maternal and newborn health, per live birth, ODA increased 56%, from 13.8 US Dollars in 2003 to 21.47 US Dollars in 2008 [9]. According to the Institute of Health Metrics and Evaluation, observed mortality rates for under-1 and under-5-year age groups are lower than the expected rates. Moreover, when following mortality rates over the past 26 years, it becomes obvious that early childhood mortality has decreased profoundly, which represents a big accomplishment for the Ugandan healthcare system [7]. Despite the considerable progress and increase in newborn and maternal interventions in Uganda, the latter are still of crucial importance, particularly due to the high fertility rates in the country.
Under-5
Expected 1990 2017 243.7 95.7
Under-1
145.9
67.6 5
Observed 1990 2017 169.9 60.1 95.7
42.8
Evaluation Report 2016-2017
3. SOGH and the Mama & Family Project SOGH’s vision for the Mama & Family Project consists of supporting education and research in maternal, newborn, and sexual health for people worldwide via the promotion and implementation of low-cost interventions. Health interventions have demonstrated to improve birth preparedness and newborn care, as well as male involvement [10]. Moreover, a study suggested that young women aged 15–24 had a lower probability of birth preparedness [11]. Several strategies seem necessary to underpin behavior change, thus improving birth preparedness and knowledge of obstetric danger signs [12]. These findings motivate and strengthen the continuity of the Mama & Family Project. Traditionally, community health workers (CHWs) are key players in terms of the delivery of health interventions in LMIC [13]. As vastly published, CHWs training is beneficial due to the fact that they are selected by and trained in the community, that they possess problem-solving skills and respond to local needs, amongst others. Moreover, CHWs use their social networks to identify, not only pregnant and puerperal women, but also men, for health education activities [14]. For these reasons, SOGH has been committed, since its early start, to support the training of CHWs.
However, the management of CHWs is not straightforward. A study interestingly points out that CHWs salary is independent of their level of activity, i.e. number of mothers reached. Therefore, to increase efficiency, innovative management (supervision to guarantee coverage and quality of care are appropriate) is needed. This appears necessary due to the multiple responsibilities that CHWs hold [15]. Looking at different players, district and community level stakeholders support maternal and newborn care interventions, but are not necessarily drivers of these measures. Foreseeable financial constraints and lack of human resources act as an impediment to affordable scaleup. Thus, research to policy translation and dialogue is crucial to successfully implement such interventions [16]. SOGH plans to achieve the endorsement by the Ugandan Ministry of Health in 2018, in order for the Mama & Family Project to receive the required support and visibility.
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Evaluation Report 2016-2017
4. The importance of male involvement In many countries of Sub-Saharan Africa, pregnancy is considered a “women’s issue”. However, at the same time, men are still the main decision makers in the family, deciding e.g. on the number of children a woman should have, the use of contraceptives, the attendance to ANC, etc. The 2011 survey of the Ugandan Bureau of Statistics shows that only 23% of Ugandan women independently decide on their own health care with no recorded improvement in the last 5 years (22% in 2006) [17]. Decision making is a solely male responsibility, in most cases, the financial manager of the family, deciding upon the resources that women need in order to access health care. Therefore, male involvement in family planning and reproductive health is a key factor to improve maternal and child health, as several studies have shown over the years [18-20]. However, even if the benefits of male involvement have been highlighted by the scientific data, it remains a challenging goal to achieve due to several factors. Those factors, also called determinants of male involvement, are divided in 4 levels, as reported in the table below [21, 22]. This multi-level system explains all the barriers at different levels that we need to overcome in order to improve male engagement in women’s and children’s health. Identifying and understanding the factors behind poor male involvement in the Ugandan villages involved in the Mama & Family Project is fundamental to advance the positive impact that our project has on these communities.
Table 1. Determinants of male involvement.
Level
Factor
Individual
• Limited or incorrect knowledge and myths about contraceptives • Women feel controlled if men are involved • Preference for large family size (due to high child mortality) • Fear of being tested for HIV (i.e. stigma) • Men think they are not allowed to go to the clinic
Interpersonal
• Preference to gain knowledge about reproductive health from other people in the community (whom they consider to be more trustworthy) • Men may not want to discuss family planning with their partners • Multi-partner/affairs (both men and women do not want to be seen with a specific partner) •Shame/embarrassment to be seen in public with the partner (e.g. due to arranged marriages)
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Evaluation Report 2016-2017
Community/ Cultural
• Religion
Structural/ Health System
• No time to go to the clinic with their partner (e.g. due to work) • High costs related to clinic visit and transportation •Poor quality of care (e.g. long waiting times, no privacy, unfriendly staff)
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Evaluation Report 2016-2017
5. Methods Quantitative evaluation CHWs and the Maina clinic staff collected quantitative data on prenatal and postnatal home and clinic visits and the number of distributed birth kits for monitoring purposes between August 2016 and July 2017. The data were retrieved from medical records and transferred to Excel in order to calculate total numbers of ANC visits and distributed birth kits and compare the results to the previous project periods. Qualitative evaluation Study design An exploratory qualitative study was conducted to assess the perceptions of men regarding family planning, following an inductive approach. Data collection The focus group was conducted and recorded by a local researcher. A semi-structured interview guide, mainly composed of open-ended questions, was used. The focus group interview lasted for approximately two and a half hours. Questions focused on exploring the knowledge on contraceptives, applied birth control measures and importance of the clinic’s services. A brief explanation on the purpose of the study was provided, as well as assurance of confidentiality. A verbal informed consent was obtained. Data analysis The focus group was translated and transcribed verbatim and the recording was deleted. Data were extracted to a Word sheet using an iterative process of coding. An open search of codes was performed, independently from the chronological order of the interview. Four researchers were involved in data synthesis and analysis, and final validation was accomplished. Ethical considerations A verbal informed consent was obtained from the interviewees, prior to the interview. Since the interview did not focus on gathering information that might be sensitive and/or confidential, no additional measures had to be taken.
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Evaluation Report 2016-2017
6. Quantitative evaluation 6.1 Home visits by Community Health Workers Twelve CHWs conducted prenatal and postnatal home visits to six villages, namely Girigiri, Kyete, Maina, Bulondo, Mwezi A and Mwezi B. Monitoring tools indicated that the CHWs conducted a total of 817 home visits during the project period between August 2016 and July 2017. Each of the CHW completed 68 visits on average. This project period indicated a 34% decrease in the number of home visits in comparison to the previous project year. Due to missing information on individual ANC visits in the project monitoring records, the total number of prenatal and postnatal visits, gestational age at visit, and the number of visits per individual mother could not be determined. Hence, monitoring tools were adapted accordingly to ensure higher quality of future CHW monitoring data.
Table 2: Total number of community health worker home visits per month between August 2016 and July 2017 200
160 140 120 100
100 82
79
80
67
73
68
64
60
62
60
60
63
39
40 20
10
17 l/ ju
17 ju n/
m
ay
/1
7
17 r/ ap
m
ar
/1 7
17 b/ fe
7 /1 ja n
16 c/ de
16 v/ no
16 t/ oc
6 /1 se pt
16
0
au g/
Total number of CHW home visits
180
Evaluation Report 2016-2017
6.2 Clinic visits Medical records obtained from the Maina clinic stated a total of 1,371 ANC visits to the clinic between August 2016 and July 2017. The number of ANC visits to the clinic constitutes a similar number to the last project year when 1,301 visits were reported. On average, 114 ANC visits were registered per month. The clinic records indicate that 71% of women complete the aspired four ANC visits. Table 3. Total number of antenatal visits to the clinic stratified by first, second, third and fourth visit during the project periods 2014-15, 2015-16 and 2016-17. 500 444
Total number of ANC clinic visits
450 400
379
369 350
360
326
300
267
263
244
250
269
200
196
200 150
137
100 50 0
First visit
Second visit
Third visit
2014-15
2015-16
Fourth visit
2016-17
Table 4. Total number of antenatal visits to the clinic per month between August 2016 and July 2017. 500
400 350 300 250 195
200 153
150
152
151 125
116
97
100
120
87
67
51
50
57
11
17 ju l/
17 ju n/
m
ay
/1
7
17 r/ ap
/1 7 m
ar
17 b/ fe
17 ja n/
16 c/ de
16 v/ no
16 t/ oc
16 t/ se p
/1
6
0
au g
Total number of ANC clinic visits
450
Evaluation Report 2016-2017
6.3 Birth kits Birth kits are being distributed to expecting mothers after completion of the fourth ANC visit and are therefore an incentive for mothers to attend the recommended number of ANC visits prior to childbirth. Each birth kit includes two pairs of sterile gloves, cotton wool, a sterile blade, a preparation sheet, sopa, cord tires and a newborn growths and postnatal clinic card. Medical staff at Maina clinic distributed 197 birth kits to expecting mothers between August 2016 and July 2017. The number of distributed kits ranged from 5 to 43 kits per month. This number constitutes a 20% decrease compared to the previous study period, though an increase in recorded ANC visits at the clinic during the project period 2016-17 compared to 2015-16. The reason for this finding is yet to be determined. Table 5. Total number of distributed birth kits per month between August 2016 to July 2017. 50 45
43
35 30 25
25
25 19
20
17
16
15
14 11
9
10
7
5
5
6
12
17 l/ ju
17 n/ ju
m
ay
/1
7
17 r/ ap
7 m
ar
/1
17 b/ fe
17 n/ ja
16 c/ de
16 v/ no
16 t/ oc
6 /1 pt se
g/
16
0
au
Number of distributed kits
40
Evaluation Report 2016-2017
7. Qualitative evaluation 7.1. The male role in contraception Participants in the focus group discussion revealed an acceptable knowledge on the different contraceptive methods, mentioning the "pill", "injection", "coil", "condoms", "female condoms" and "traditional methods". Two important notes, we have found that condoms were associated to a possible sign of infidelity and traditional methods were believed to be ineffective. In general, the interviewed men were not in favor of family planning. Notably, reasons that were pointed out related to the concern of contraceptives’ side-effects experienced by their wives. Stated examples of adverse effects of contraceptives were, by decreasing order of importance, "extensive bleeding", "anemia", "difficulties during labor", "decreased fertility after discontinuation of contraceptive" and "causing cervical cancer". Some participants feared that contraceptives might affect fertility and that they could delay the return of the woman's fertility. No relevant association was found in the literature. Minimal association between the use of oral contraceptives and complications of delivery has been found, though no association was found between the use of contraceptives and an increase in birth defects [23]. Despite a reported increase in the risk for cervical cancer amongst women with HPV who take oral contraceptives, evidence has found a potential decrease of other kinds of cancers, e.g. in the uterus, colon and rectum, in women using oral contraceptives [24]. The type of birth control most often used was, by decreasing order of importance, the pill, injections and the coil. All men who reported experiences with adverse effects of contraceptive use by their wives, associated that event with a high financial burden for the family. Whenever this was mentioned, men offered expressions like "we wish we had not used them [contraceptives] initially" and "scared of using them [contraceptives]". Finally, another reason presented was the fear of a decrease in the wife's libido and the fear of side effects acquired from word of mouth. As an important remark, SOGH does support community sensitization for family planning, however does not provide the different types of contraceptives offered at the clinic we support. The injectable in use at the clinic is Depo-Provera and the implant is Norplant. Remarkably, both Depo-Provera and Norplant are not frequently used in HIC due to its severe adverse effects [25]. However, the reported fear of side effects suggests that exploring
this problem is a pressing issue, alongside with a careful review of the therapeutic guidelines in place at Maina clinic. Thereby, SOGH can plan a future intervention to restore the community's trust in the contraceptive options offered at the healthcare facility. Traditional contraceptive methods were mentioned during the focus group interview. Some of the men reported the use of methods like "moon beads" and the “calendar method”. Furthermore, they mentioned a religious individual who provides educational training on traditional family planning methods. The men did not place much confidence in these methods, however they are used for child spacing due to the markedly lower risk of side effects. When asked about their reaction if their wives were to use contraceptives, expressions offered were often negative, e.g. "send her back to her parent's house", "doubt my wife would want to" or "only listen to her if a new method without complications is available". However, some men mentioned that they accompany their wife to the health center to discuss family planning. When talking about healthy pregnancy, men generally perceived this term as encompassing "antenatal visits", "attendance of antenatal visits with their wife", "eating well/ healthy diet", "support of wife" and "visit to a government gynecologist".
7.2. Contraceptives During the focus group discussions women reported that they had experienced severe side effects to the contraceptives they used. These side effects included lower abdominal pain, severe bleeding and even blindness. Women reported to have preferred injectable contraceptives and this finding was similar to previous studies carried out by the Uganda Bureau of Statistics that had showed an increase in the use of injectable contraceptives [26]. In addition, injectables had been shown to be effective and have fewer side effects compared to oral contraceptives [27]. Some of the contraceptives that were reported to be administered at the Maina clinic included Microgynon, a contraceptive pill, Depo-Provera (DMPA, a progestin-only 13
Evaluation Report 2016-2017
contraceptive) an injectable, Implanon (etonogestrel) and Jadelle/Norplant II (progestin levonorgestrel) which are contraceptive implants, and lastly Sayana press, a selfinjectable contraceptive. The most notable side effects reported by previous studies demonstrated that DMPA was associated with more side effects including irregular menstruation, abdominal pain and weight gain [28]. Further evidence may be needed to investigate the prevalence of DMPA use among women who visited the clinic, in addition we hope to ascertain its associated risks. In previous studies in Sub-Saharan Africa, the increased use of Norplant II was also reported to lead to adverse menstrual symptoms such as amenorrhea, intermenstrual bleeding and intermenstrual spotting and vision-related problems [29]. We therefore aim in subsequent reports to establish the incidence of side effects among women who used implants. Some key issues that may need to be explored further include the drug procurement and storage process, whether there is overuse or multiple use of two or more contraceptives at a time, and whether the community health workers are well-trained to administer the injectable contraceptives.
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Evaluation Report 2016-2017
8. Future plans According to the quantitative evaluation of medical records from Maina clinic, we noted that the number of distributed kits ranged from 5 to 43 kits per month in the year 2017. This number constitutes a 20% decrease compared the previous study period, despite there being an increase in recorded ANC visits at the clinic during the project period 2016-17 compared to 2015-16. Based on this discrepancy we sought to find out if there were any birth kits available and if we should reduce the budgetary allocation for the kits in the future. The UDHA team reported that the reduced number of ANC visits to the clinic may have been due to a similar United States Agency for international AID (USAID) project that had begun within the same area addressing maternal and newborn health problems. Due to that, most mothers may have completed their ANC attendance at the nearby clinic and did therefore not receive the kits. The USAID project was a one year pilot project implemented in the area and was due to be completed. Thus, UDHA staff assumes that mothers will resume seeking health services at the Maina Clinic in the next financial year. Due to the fact that the total number of pregnant women in the villages included in the project has not been determined in the quantitative records, we plan to implement a newly
created electronic recording tool to collect the total number of mothers included in the project to increase the quality of the quantitative project data. On a broader note, essentially, by 2040, reliance on foreign help (development assistance for health) will have more than doubled [7]. Therefore, SOGH continuously works to ensure the sustainability of the Mama & Family Project. Despite its efforts, access and utilization, challenges are present. Different reasons have been pointed out contributing to poor access and utilization of maternal and newborn services. Within these, long distances and lack of transport, inadequate information, poverty and poor services at the health facilities play an important role that need to be overcome in order to increase access and utilization of the project’s resources [30]. Despite previous barriers to contraceptive such as access to facilities having been addressed, there has remained poor uptake of contraceptives by women in the area. We plan to assess potential causes for poor contraceptive use and related aspects through qualitative interviews with midwives and nurse at the clinic. In the upcoming year, SOGH plans to collect data on side-effects experienced after using contraceptives to better understand the fear of severe side effects conveyed by some participants in the focus group.
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Evaluation Report 2016-2017
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C O T T ON
C O T T ON
C O T T ON
C O T T ON
C O T T ON
C O T T ON
C O T T ON
C O T T ON
C O T T ON
C O T T ON