Welcome to the world, S.O.U.L. Antenatal Education Center!

By Andrea Koris

Operations, Monitoring and Eval. Officer

It’s 9:00am on Monday morning. I start down the red dirt path to the S.O.U.L. office, eyes to the ground in effort to keep my shoes reasonably dust-free. The twinkling of women’s laughter drifts through the banana trees to my ears. “What day is it?” I think to myself. As the answer hits me, I abandon my careful trek and tear off wildly towards the sound. I turn right at the sweet potato garden, scurry down the trail between the maize fields, and with a flourishing swipe of the matooke fronds in my path, I land among the most beautiful sight: 60 Ugandan women, bedecked in their brightest kitenge, patiently awaiting for the opening of the S.O.U.L. Antenatal Education Center.

Today is not just any other Monday in the sleepy town of Bujagali where S.O.U.L. is located; it is the official opening of S.O.U.L. Foundation’s Maternal Health Network. It’s a labor of love that has gestated and grown over the years. The idea of building a program to address rural maternal health issues in this region, originally conceived around a table between S.O.U.L. and community leaders, has been tended to with collaborative care ever since. And as I walk into the S.O.U.L. schoolyard this morning, wading through the women’s excited hugs and morning greetings, the love and hard work of everyone who molded the foundations of this program is abundantly evident.

 

In the past 5 years, substantial progress has been made across the world to meet the Millennium Development Goals (MDGs); and while significant improvements have been made on accounts to global health and education, progress is far from sufficient in regards to global maternal and infant mortality rates. The Sustainable Development Goals (SDGs) as a result demand a more exacting requirement of the global community, to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

 

Here in Uganda, 360 women die per 100,000 live births. And that statistic only accounts for women who decide to give birth in public health facilities. Considering that only 42% of births in Uganda are attended to by a qualified health professional, maternal morbidity statistics fall short in capturing mortality rates and health indicators for women and newborns who cannot access public care. S.O.U.L. wanted to know how this overwhelming statistic played out in the lives of the mamas that make up the lifeblood of our beneficiary communities, many of whom decide to deliver with Traditional Birthing Attendants instead of qualified midwives. To answer these questions, S.O.U.L. conducted a year long research assessment investigating the barriers that influence women’s maternal health choices and behaviors, and the challenges government health workers face in trying to provide quality care in rural settings.

 

The Maternal Health Network is a result of the findings of this groundbreaking research. The program houses several interventions, each of which attack a different ‘delay’ that contributes to maternal mortality in rural settings: 1) Delay in decision to seek care; 2) Delay in reaching care; and 3) Delay in receiving adequate health care at facility. The Antenatal Education Center, housed within the Maternal Health Network, aims to reduce maternal mortality by disseminating Safe Motherhood and Birth Preparedness education and encouraging male involvement in maternal health for women and their male partners.

 

As I follow the line of mamas into the sunny colored classroom, being pulled along in the tide of excitement, I can’t help but feel a wellspring of joy. The opportunity to walk with the women and men of this community as they invest in their right for health for themselves and their families is a gift; to witness the birth of this program, a blessing; and to be part of its creation, the highest honor.

It’s not that simple…

by Devin Faris
S.O.U.L. Foundation Global Health Corps Fellow

There are few tools more powerful in development work than the art of listening. However, moving one step further and channeling this tool through rigorous research offers us the unique opportunity to see inside high complex sets of issues. Through our research, we are able to capture reality in a way that no amount of informal observation allows us to do. My co-fellow Viola and I live and work in a situation that allows us to appreciate this contrast in quite a striking way. We wake up each morning in our simple, sleepy house in the middle of our village near Jinja, Uganda, greeting the families outside and walking the muddy roads to our offices at S.O.U.L. Foundation, and are able to observe each family’s struggles, innovations and unique realities. While we can engage deeply with each of these families who continue to accept us into their homes and lives, we cannot adequately compare their stories or experiences in any kind of meaningful and measurable way that can be responsibly manifested into community-based programming. So we turn to our research…

We interview mothers and pregnant women, some as young as 14, about what deters women in the community from delivering their newborns in Uganda’s health centers, what drives them to continue to deliver with traditional midwives (known more commonly by the increasingly taboo label of Traditional Birthing Attendants, or TBAs) and put themselves at risk (granted some of the most skilled and talented midwives I have met are among these traditional midwives – they are miracle workers), and what they wish would change about the Ugandan health system. They say the nurses abuse them, shout at them, even slap them, often failing to serve mothers who have just spent an hour and a half on the back of a boda driving up a muddy road through littered trading centers for their ANC visits, only to have to return home to come back the next day, having not received the care they needed. The mothers are chastised for not bringing the materials they need to deliver in the health center can even be sent to the back of the line while those with the requisite ANC book, kitenge, plastic sheets and gloves get pushed to the front. So we say to ourselves, “the main problem is the attitude and behavior of the health workers.”

But it’s not that simple…

We visit each of the 16 health centers throughout the health sub-district to listen to their workers, the midwives who work tirelessly, short-staffed and overburdened, to meet the explosive maternity needs of this country. They say that when mothers come without the supplies they need and the health center lacks the provisions, they just can’t help them. They say they do everything they can, but they simply do not have the supplies to be able to give to the mothers themselves. They lack the staff to provide care to the dozens of mothers that come for ANC every day, lack adequate supplies of immunizations to offer the women who bring their children for PNC visits, and must break the news to these mothers that they all need to come at once on a designated day when the medicines are available so that everyone can receive these services at the same time. The mothers, they say, are not well enough informed or mobilized to be able to interface with the health system. So we say to ourselves, “the main problem is that women lack the proper information and mobilization to make the most of their health center visits.”

But it’s not that simple…

We hold focus group discussions with the Village Health Teams in each of our 11 sample villages across the health sub-district. These are the community health workers – the first level of the Ugandan health system – charged with the task of mobilizing women to attend ANC visits, to bring their newborns in for postnatal care and immunizations 6 weeks after delivery, and for supplementing the information given to them at the health centers. The VHTs express how they are supposed to be coordinating for these women to come to the health facilities on the designated days in order to be properly served, but since the inception of the VHT program in 2010, in-service training for each team has been minimal at best. The required 10 VHT members in each village has dwindled to the 2 most active, known as Community Medicine Distributors, leaving the rest of the VHTs out from any trainings or continuing medical education opportunities from the Ministry of Health or NGOs like Marie Stopes or TASO Uganda. Without training, without means of transport, without any sort of compensation or incentives to keep working in the community, the VHTs are barely able to do the work that they are intended to do. So we say to ourselves, “the main problem is that every level of the health system lacks the appropriate training, supplies and resources to be able to adequately assist the women in the community.”

But it’s not that simple…

We go to the District Health Officials and ask them about how they are addressing the issue of limited supplies, poor attitudes of the health workers, low staff attendance, and limited training opportunities for VHTs. They tell us that each district only gets a certain lump sum each quarter from the Ministry of Health, and that it is in no way enough to meet all the needs expressed by the health workers throughout the health sub-district. They tell us that the amount they receive depends on the needs conveyed through district reports, but these reports have to come from the lower rungs of the health center and have to be submitted in a timely manner in order for any action to be taken. Reporting mechanisms throughout the district are weak, and their ability to properly advocate for what the district needs remains limited. So we finally say to ourselves, “Clearly there is no main problem, but rather a complex set of interwoven issues that are holding women in Uganda back from accessing the care that they need.”

It’s never that simple.

Simply talking to women, or merely listening to health workers, or observing the work of VHTs, or reading reports of the performance of the district health system will never offer the full picture that such comprehensive data collection can provide. Each challenge leads to recognition of a new challenge altogether. This is the driving reason why data must be the first step in quality programmatic efforts in any context. Without such a robust study, we would never be able to provide S.O.U.L. Foundation with the full picture of what women are up against in the health system in eastern Uganda. And of course, it’s still not that simple…

While our data measures these various maternal health indices, it does not measure the sheer breadth of the myriad challenges and epidemics that women face all over this country: domestic and gender-based violence, sexual abuse, workplace discrimination, sex work, trafficking. These are hurdles that women continue to confront the whole world over, and we know our research is only the tip of the iceberg. For now, for what we cannot measure, we know that all we can do is observe, and observe deeply, as these women open their doors, their hearts and their worlds to us each and every day. We believe that our conversations with them empower them to speak their stories, their truths, their voice. All we can hope, through programming or through that very simple act of listening, is that those voices are amplified. The more we listen, the more we learn, and the more we learn, the more we can work together to change this country, and this world.

It all started with one village...

By Devin Faris
S.O.U.L. Foundation Global Health Corps Fellow

It all started with one village.

When we arrived in Bujagali as S.O.U.L.’s new Global Health Corps (GHC) Fellows, we were welcomed with open arms and open hearts for the important work we were about to embark upon. S.O.U.L.’s vision for a new partnership with GHC was to engage the village in in-depth discussions about the maternal health needs of the community in an effort to inform future programming through S.O.U.L.’s Maternal Health Network. We arrived with the humility to recognize that we lacked the knowledge required to properly inform such a program.

So, we started by doing what S.O.U.L. does best: we listened.

We listened to local women leaders like Maama Ali and Maama Muganda about the lives and needs of women in this corner of Uganda. We listened to trusted midwives like Lillian and Rose working in government health centers, as well as traditional midwives like Celementina delivering from their homes, about what it is really like to respond to these needs with the limited resources available to them. We listened to government officials in Jinja about how much power they have to enable these maternal health services to exist within an overburdened and under resourced health system.

The more we listened, the more we learned that listening to just one village was not enough. Nearly 2/3 of women in Bujagali deliver their newborns with Celementina, but what about elsewhere in the Jinja District where Celementina is not the nearest birthing option? What role does proximity to a health center play in maternal health decision-making? What role do health officials play in addressing challenges to access, and what barriers do male partners create for women in seeking appropriate care? In order for S.O.U.L. to truly make an impact, we realized we needed to think bigger.

With clearance from TASO Uganda’s Institutional Review Committee and the Office of the President for our research, we worked with local women, midwives, and health workers to design a comprehensive needs assessment that incorporated the viewpoints of women, husbands, health workers, traditional midwives, health officials, and Village Health Teams through a series of interview and focus group questionnaires. We trained three young and passionate enumerators to help us collect our data and expanded the scope of the research from one village to 11 villages across the Kiira Health Sub-District, comprised of Budondo and Butagaya Sub-Counties. With data from the whole health sub-district, S.O.U.L. will not only have representative information to inform our own programming, but we will have data that has never been collected before in rural Jinja. Since health statistics in Uganda come from health center reports, our data will account for the thousands of women who do not regularly visit health centers and are consequently not included in the formulation of district health priorities. With this data, we will be able to advocate for the needs of women whose voices have never been heard.

S.O.U.L. is firmly dedicated to making all of its programming sustainable, scalable, and replicable. This approach would not be possible without investing the time to truly listen and learn what the women of our community need. In our first six months here in Uganda, we have already learned from these women that while S.O.U.L. is “supporting opportunities for Ugandans to learn,” it is really these Ugandans who are allowing us to learn more than we thought we could. Each and every one of these women has a unique story to tell. Each has their unique struggles, their unique triumphs, and their unique voice. At S.O.U.L., it is our job to ensure the voices of these women are amplified. These are the women whose stories we wish to tell over the coming months as our Maternal Health Network takes flight, as they are the women whose resilience, compassion and wisdom inspire us to do the very work we do here in Uganda.