In this section of the paper we present the main gains, challenges and lessons learnt while supporting community capability for maternal and newborn health. We present our findings by the community stakeholders that were the focus of the project: households, transporters, saving groups and VHTs.
Households
The main gains reported by women and men at household level included increased awareness about birth preparedness, improved newborn care and more male involvement in maternal and newborn health.
Maternal and newborn health awareness and care
Mothers reported that they became more aware of what they themselves could do to prepare for birth through the sensitization from the VHTs during home visits and community dialogue meetings, as illustrated in the following quotes.
I benefited from the VHT’s visits because women have been ignorant. You would be there pregnant but when you don’t know how you will care for the baby after birth. Maybe you would just tear any rug and wrap the baby in it after delivery. But as they taught me, I started preparing birth requirements when my pregnancy was four months. (FGD women)
We were at a village meeting and there was some kind of sensitization. All ladies who were expecting and those with babies of not more than a year were asked to start saving. With the money we had, we were asked to start saving a certain portion to help us meet the childbirth financial costs in addition to what husbands may provide. (FGD women)
The women also reported learning how to care for their babies. In particular key behaviours related to newborn health and survival related to hygiene and cord care were discussed.
I have benefited because we are now informed girls who know what to do, who can practice good hygiene in our homes. These things of coming back from the garden then you just rush to carry the baby are no longer there; you have first of all to clean your hands before carrying the baby. If am in the garden, I make sure that I go with water to wash my hands when I want to breastfeed. (FGD women)
…Before MANIFEST came when I could give birth, my mother- in law would immediately come and say put this and that on the baby’s cord so that it heals very fast but when this program came and they started educating us on how you can take care of the baby’s cord that you just clean it with water and a little soap, we stopped all those things like putting powder and so on. (FGD women)
Male involvement
During the project, men and women were encouraged to participate during home visits, at dialogue meetings and in the saving groups. Overall, women participated more than men. Nevertheless some changes were observed among some of the men. They started to support their partners by procuring more nutritious diets, purchasing birth items, and saving for childbirth, as pointed out by women during FGDs.
My husband is really taking care of me, he feeds me well, he keeps balancing the food I eat for instance if I had kalo (millet bread) for lunch, he will make sure he buys matooke (plantains) for the next meal. But previously if it was a season for beans you would feed on that until the season ends. If you would try to say buy some sauce, he would simply say go and boil beans or get greens from the garden. Through the health education that the VHTs give us, men these days have understood and they really give support. (FGD women)
…They have changed my husband and he can listen to what is being discussed in the meetings and even do it because he can now buy birth items when am pregnant. And when I start getting labor pains I go to the facility and the health workers help me because I will have bought the birth requirements and now it will not be hard for me. (FGD women)
During the qualitative interviews, men themselves noted that they were now more aware of the roles that they needed to play in ensuring mothers and newborns are safe. Men reported that they escorted their wives for antenatal care and delivery, underwent joint HIV testing, and supported birth preparedness by giving money to save for birth items and transport costs.
The VHTs have educated us about health; they say it is not good for a woman to deliver in the village because she can easily die. So that has made us know that it is important to escort our wives to the health facilities early enough so that they can get the required services. (FGD men)
…At least men are also aware that saving is not only for women it’s for both, because these days men can give their women money [and say] that you take this money to the saving group. (KII with community development officer)
Although a positive response was noted with regard to male involvement, in a few instances money saved by women was taken by their husbands and used for non-maternal and newborn issues. In the FGDs it was also noted that a minority of the men did not support their wives because of addiction to alcohol, lack of understanding about maternal and newborn health, polygamy and misunderstandings between the men and women.
What I can say is men who don’t help pregnant and newly delivered women don’t attend meetings so they don’t know what is taking place. (FGD women)
They don’t support their women because they have got addicted to alcohol; they just wake up in the morning and go to bars to drink so the money that would be saved to prepare for birth or to help the newly delivered mother is all spent in drinking. (FGD Women)
The failure of the majority of men to attend community dialogues and home visits clearly illustrated the need for communication channels that can target men more directly and the benefit of using a mix of communication channels.
Saving groups and local transporters
Saving practices
Many families relied on income generating activities like rearing chicken, keeping domestic animals and running small businesses from which they accumulated some funds for saving.
Some of us just do garden work [small scale farming]. Others sit alongside the wards and sell silver fish. So whenever she gets a small profit she adds on her savings. Other women who cannot do that just sell off what they rear at home, that could be a chicken, and then she brings the money to save. (FGD women)
It was noted that in the past when someone had a problem, they would have no where to borrow money from, as a result of which assets were sold off when they needed money for maternal and newborn health. By strengthening saving groups, families were able to save more money than they had previously. This money was used to meet transport costs and to purchase other items needed for birth, as well as meeting other personal needs that families encountered.
Although households were encouraged to save, some of them cited lack of access to cash and low incomes as a constant reason for not saving. In addition, most of these saving group leaders lacked the necessary knowledge and skills in management and record keeping. With time, as the savings groups were strengthened, they accumulated a lot of savings but did not know how to handle these deposits. They did not know what income generating activities to invest in and at the same time feared putting their money in the bank because they had not been exposed to the benefits of using banks to keep money. They also encountered problems related to default in payment. In some cases, this led to the collapse of groups.
These challenges were countered first by encouraging the saving groups that had large sums of money to bank it. Second, we worked with the community development officers to encourage saving groups to identify income-generating activities that were likely to be successful in their community. This was done by promoting exchange visits and sharing of experiences between saving groups and groups that had successful income generating activities. The problem of default in payment was mitigated by encouraging saving groups to develop constitutions with clear criteria for lending and steps for recovering payment.
Linkages with transport providers
Saving groups were supported to work closely with transporters and VHTs to identify pregnant mothers and transport them to health facilities to deliver when the time came. Some of the saving groups where able to make formal and informal agreements with transporters to provide transport services to the women in the saving groups. These agreements stipulated the transport charges from specific villages to the health facilities that serve the villages.
They also indicated that the transporter was obliged to provide transport as and when required by the client (woman). This protected the women from having to pay unfair prices it also assured them of transport whenever it was required. Furthermore the women could be transported on credit and then the saving group pays later. This was critical especially in the case of referral because mobilising sufficient cash to meet the high referral costs previously led to delays in referral, sometimes with fatal outcomes for either the mother or the newborn.
The feedback received during group meetings with the transporters and VHT’s showed that saving groups that had transporters as members where more successful in convincing the transporters to provide transport services than those that did not have transporters within the group. Some of the saving groups purchased their own motorcycles and contracted transporters to ride them, in such cases members from the group were charged a lower fee.
I really benefited. We had transporters as part of the group. So in case you belonged to that group, transport was provided at half price by the boda bodas. (FGD women)
For me the issue of transportation is very good because it saves lives. These transporters are paid after they – bodas have transported our women to the health facility through their savings unlike those days when they used to deliver in banana plantations. (KII with community development officer)
Although some saving groups were able to work with the transporters as illustrated above, many saving groups were not able to identify a transporter to work with. Women from such saving groups that had no transporters resorted to using any transporter who was available in the community and this arrangement also worked well especially for routine trips to the health facility for antenatal care or delivery (not emergency referrals).
Several reasons were proposed as explanations for the difficulties encountered in working with transporters. They included difficulty in sensitizing transporters since in some cases they did not have associations and so were difficult to reach, lack of trust between transporters and saving groups, inadequate number of transporters who did not wish to be committed to only one saving group, preference for immediate payment, and fear of signing agreements (often because of high illiteracy).
When the program was designed it was assumed that after having an orientation meeting for saving group leaders and transporters, they would link up in the community and start providing the required services. However the groups were not able to organise themselves as required. Thereafter it was decided that the CDOs would be encouraged to provide more support to the saving groups. CDOs were asked to support saving groups to develop constitutions and register at the sub county and district level. In addition, CDOs were to encourage saving groups to link up with transporters. Each CDO was to ensure that he had at least one model saving group in every parish.
When the project decided to work with the CDOs to support the saving groups, it was assumed that the CDOs would be able to provide the support as they went about their other duties. However later it emerged that although the government expects CDOs to support the saving groups in their day-to-day duties, most of them had no means of transportation to the communities and no transport allowance. Some of them had motorcycles but they did not have fuel. When they were given transport allowances by the project they were able to perform their work. This illustrates that without adequate resources community level cadres may not be able to carry out their duties satisfactorily.
Village health teams
As mentioned earlier, the VHTs were a key resource for community mobilization and sharing information with households. The home visits were conducted twice during pregnancy and two times in the first week after delivery. The VHTs visited all the homes every three months to identify new pregnancies. During the home visits the VHTs provided health education about danger signs during pregnancy, delivery and after birth, and birth preparedness.
The community dialogues were done every quarter at village level and they were facilitated by VHTs. During the dialogues the community discussed issues that were relevant and important for guiding appropriate decision making regarding improved access to MNH. They also developed suggestions of how they could solve local problems related to seeking MNH care. Women were highly appreciative of the information and guidance provided by VHTs as noted in the following quotes.
The first time the VHT came to my home I was four months pregnant. He asked me how old my pregnancy was and I told him it was four months and he told me that if it reaches eight months, I should have already bought all the requirements. So he advised me to start saving money. He told me to buy gloves, razorblade, baby shawl, and cotton. Everything, including a basin. (FGD women)
You may be pregnant and at the same time have many complications in your body like swelling of legs and hands and also feeling weak all the time. So VHTs have helped us a lot to make sure that they send us to health facilities to get treatment and become well. (FGD women)
While being valued as key community resources, VHTs faced barriers in terms of their low levels of education. Although the selection criteria for VHTs specify that a VHT should be able to read and write, some of them were not able to do so. This decreased their ability to comprehend key concepts and to keep good records. A key lesson was recognising the need for close supervision and reinforcement of knowledge, particularly in the initial stages of the project.
Another challenge that VHTs faced was that despite VHTs being volunteers, they put in a lot of time to visit homes and cover large areas in terms of distance. VHT’s received 10,000 sh (Approximately $3 USD) only as a transportation refund for conducting dialogue meetings and attending VHT group meetings every quarter (total of $6 USD). VHTs preferred more regular payments and expressed the desire to be included on the government payroll. They also expressed the need for bicycles to be able to move easily within the communities. Broader community members also felt that VHTs should be given better transportation support:
Now these VHTs walk on foot all day, they would ease on their mobility by providing them with transport that can motivate them to work. (FGD women)
On several occasions VHTs requested equipment, such as umbrellas for use during rainy and hot seasons. However, the project was only able to provide a t-shirt for identification purposes and bags to carry and protect their health education materials, which they appreciated.
Although under the Government system, the Health Assistants and health workers from the catchment areas are supposed to supervise VHTs, the study revealed that this does not always happen due to challenges in facilitation and workload. The project therefore provided some monetary facilitation to enable these cadres to do their work. During the first year of the program, health workers were supported on a quarterly basis to provide directly observed supervision during home visits for every VHT and quarterly supportive supervision meetings to motivate and reinforce knowledge and skills of the VHTs and VHT trainers.
The work with the VHTs also illustrated the importance of high-level participation and engagement of trainers/supervisors in creating ownership. It was observed that the VHT trainers/supervisors who were involved right from the beginning were more knowledgeable, committed, and exhibited a greater sense of responsibility than the supervisors who were brought on board later.
