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Background: Maternal morbidity and mortality remains high in Uganda; largely due to inadequate antenatal care (ANC), low skilled deliveries and poor quality of other maternal health services. In order to address both the demand and quality of ANC and skilled deliveries, we introduced community mobilization and health facility capacity strengthening interventions. Methods: Interventions were introduced between January 2010 and September 2011. These included: training health workers, provision of medical supplies, community mobilization using village health teams, music dance and drama groups and male partner access clubs. These activities were implemented at Kitgum Matidi health center III and its catchment area. Routinely collected health facility data on selected outcomes in the year preceding the interventions and after 21 months of implementation of the interventions was reviewed. Trend analysis was performed using excel and statistical significance testing was performed using EPINFO StatCal option. Results: The number of pregnant women attending the first ANC visit significantly increased from 114 to 150 in the first and fourth quarter of 2010 (OR 1.72; 95% CI 1.39-2.12) and to 202 in the third quarter of 2011(OR 11.41; 95% CI 7.97-16.34). The number of pregnant women counselled, tested and given results for HIV during the first ANC attendance significantly rose from 92 (80.7%) to 146 (97.3%) in the first and fourth quarter of 2010 and then to 201 (99.5%) in the third quarter of 2011. The number of male partners counseled, tested and given results together with their wives at first ANC visit rose from 13 (16.7%) in the fourth quarter of 2009 to 130 (89%) in the fourth quarter of 2010 and to 180 (89.6%) in the third quarter of 2011. There was a significant rise in the number of pregnant women delivering in the health facility with provision of mama-kits (delivery kits), from 74 (55.2%) to 149 (99.3%) in the second and fourth quarter of 2010. Conclusions: Combined community and facility systems strengthening interventions led to increased first ANC visits by women and their partners, and health facility deliveries. Interventions aimed at increasing uptake of maternal health services should address both the demand and availability of quality services. © 2013 Ediau et al.; licensee BioMed Central Ltd.
The interventions were conducted in Kitgum Matidi Sub County in Kitgum District, Northern Uganda. Kitgum Matidi (HC) III serves as the highest level health facility providing health care services in Kitgum Matidi Sub County. The facility serves an estimated population of about 15,000 people. The health facility provides a range of preventive and curative health services including: ANC, skilled attended delivery, other outpatient and inpatient services. The project interventions focused on strengthening both the community and health facility systems in order to increase demand and quality of services, and ultimately utilization of ANC and skilled delivery services at the health facility. The project interventions were implemented between January, 2010 and September, 2011. The interventions mainly targeted pregnant women and their male partners. Details of the program interventions are described below. The key components of the interventions are also summarized in Table 1. Summary of selected program interventions implemented Health facility capacity building was done through training of health workers with ongoing mentorship, and provision of basic supplies such as delivery kits (also known as mama-kits), drugs, and HIV test kits. The mama-kit includes basic delivery supplies: cotton wool (200 g), hydrophilic gauze, sterile surgical gloves, mackintosh (rubber/polythene sheet), washing soap (600 g), surgical blades, umbilical-cord tie and tetracycline eye ointment (for the new born baby). These kits were also supplied to facilities by Ministry of Health (MoH) but stock outs were experienced by the health centre. Stock out of delivery supplies and the requirement for “poor” mothers to buy these supplies has been documented as one of the hindrances to health facility deliveries. In order to attract mothers to deliver at the health facility; baby soap, a baby towel and shawl were also added into the mama-kit. The modified delivery kits (with additional baby items) were given to pregnant women when they turned up to deliver at the health facility since anecdotal information suggested that some mothers used these kits to deliver elsewhere, within the communities, and their distribution at ANC may be viewed as encouraging women to deliver at home. Mama-kits were given free of charge. The community interventions included activities such as music, dance and drama (MDD), use of village health teams (VHT) for community sensitization, and establishment of male partner access clubs to sensitize and mobilize communities. The key messages to the community included benefits of ANC and skilled delivery attendance as well as male partner involvement in ANC. Community mobilization and sensitization was carried out using existing community structures; VHT are the frontline community workers and are recommended by the MoH for community education and health promotion for all diseases and have been used to delivery other health interventions in Uganda [23]. Sixty VHT members were identified and trained. These included both males and females. Selection of the VHT members to support these program interventions was done in close consultation with the district and health facility workers. The trained VHTs were involved in community sensitization and mobilization of pregnant mothers (and their male partners) for ANC attendance and health facility deliveries under the care of skilled birth attendants. The training was based on the national (MoH) 5-day training curriculum. Each VHT member was given a bicycle to facilitate movement within the community. Information Education and Communication (IEC) materials (charts) were designed and provided to VHTs to act as job aides. In addition to community sensitization and mobilization, VHTs were involved in tracking mothers who missed ANC visits and encouraging them to deliver in the health facility. Monthly performance review meetings attended by VHTs and health workers were conducted to improve performance and the relationship between VHTs and health workers, and also acted as supervisory encounter by health workers. Two male partner PMTCT access clubs were formed and engaged. These clubs comprised selected men from the community, who were viewed as role models in participating in ANC with their pregnant wives and ensuring that their wives delivered in the health facility. Male partner access clubs were facilitated to conduct two ‘male dialogue’ meetings in each month with other men in the communities. The aim of these meetings was to promote male partner involvement in ANC and skilled attended deliveries by their pregnant wives. Two MDD groups were established, trained and provided with the necessary costumes. Each of the two groups was facilitated to conduct two community mobilization and sensitization performances monthly. These groups focused on promoting ANC and skilled deliveries attendance as well as PMTCT services. Pregnant women and their husbands who turned up at health facility for ANC were counseled, tested and they received their HIV results together (as couples) on their first ANC visit. Pregnant women who turned up for ANC without their husbands were also counseled, tested and received their HIV results as individuals and encouraged to come with their partners on subsequent visits. All data which also included the estimated (expected) number of pregnant women in the first trimester were abstracted from the Health Information Management System (HIMS) data collection and reporting tools as well as registers of MOH that are used routinely by the health workers to capture patient care and treatment data. These included: the ANC register, delivery and birth register as well as quarterly and annual HMIS reports. Based on the population demographics, the health facility with technical support from the district health office and MoH set the annual targets on expected pregnancies. These facility level targets contributed to the district and national annual targets [24,25]. The data that was used for this paper was collected over a period of 21 months (from January, 2010 to September, 2011); during implementation of interventions. In order to evaluate the outcomes of the project, data for the same indicators was collected for the year preceding the interventions (January to December, 2009). The data was abstracted from the registers using a standardized tool and entered into an excel sheet for storage and analysis. Data was analyzed using Excel and Epi Info soft ware. Although data was collected on a monthly basis, during analysis data was collapsed into quarters and years (annually). The variables of interest included: total number of pregnant women attending first ANC visit and this was compared with the estimated annual number of pregnant women in the first trimester who were expected to attend ANC. Other measures included; total number of women attending the fourth ANC, number of pregnant women attending the first ANC visit who were counseled, tested for HIV and received their results (this was compared with the total number of pregnant women attending the first ANC visit rather than the total number of pregnancies in the community), number of male partners of pregnant women attending the first ANC and counseled, tested for HIV and received their results together with their wives (this was compared with number of pregnant women attending the first ANC visit who were counseled, tested for HIV and received their results);first-time ANC pregnant women were expected to be counseled, tested for HIV and given their HIV status results together with their husbands, as couples. The other variable was total number of skilled attended (health facility) deliveries recorded in the facility registers. Pregnant women who attended ANC but did not return to deliver in the health facility were considered to have delivered in the community/at home with the help of unskilled personnel. Using EPINFO StatCal option, we performed a Chi square test for trend and generated Odds Ratios (OR), 95%CI and p-Values to check whether the trends in these indicators were statistically significant. The Confidence Intervals (CI) were computed using the usual Chi-square in EPINFO. This manuscript was based on routine program data analysis for purposes of program monitoring and evaluation. The data that were analyzed had no identifiers for any of the individuals that were served and was exempt from ethical approval.
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