In Uganda, maternal and neonatal mortality rates at 438/100,000 live births and 27/1000 live births respectively have barely changed during the past decade [1]. Although over 90 % of mothers attend one antenatal care visit, less than half complete the four recommended antenatal visits, and only 57 % deliver in health facilities [1]. Critical resources such as qualified health workers, drugs, equipment and supplies are needed to improve the delivery of quality health services. Community capacities and resources must also be harnessed to support maternal and neonatal health, which is the focus of this paper.

The Alma Ata declaration emphasised the importance of community participation in the planning, organization, operation and control of primary health care services [2]. Community participation and empowerment can improve access to health services and health service outcomes [3], however the literature also shows significant variations regarding the interventions implemented, the nature of the communities involved and inputs provided and how participation is defined [4], with implications for effectiveness [5]. When community participation is minimal and focused only on raising awareness of health issues, this may not necessarily improve access to skilled care services [6, 7].

Factors that can facilitate increased community participation include pre-existing intrinsic motivation among individuals in the community, community-level trust, strong external linkages, and supportive institutional processes such as decentralization reforms and engagement with social movements [4]. Conversely, community participation can be hindered by a lack of training, interest and information, along with weak financial sustainability and low community accountability [4]. Rassekh and Segeran [8] found that the most successful community engagement strategies were those that provide feedback through sharing results with communities; foster local adaptive learning; harness community resources and promote equity. These processes and factors when brought together strengthen community capability.

Community capability has been defined as “a set of dynamic community traits, resources, and associational patterns that can be brought to bear for community building and community health improvement” [9]. We followed a participatory action research approach [10], which emphasises community participation in the collaborative identification and resolution of community problems, as a key way of strengthening community capability, program relevance and effectiveness. While not comprehensively covering all domains of community capability [11], this paper provides insights into the gains realized, challenges faced and lessons learnt in supporting community efforts to improve maternal and newborn health.

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.

Through a participatory action research process, district teams accompanied by a research team at Makerere University, strengthened the capacity of a diverse group of stakeholders to improve maternal and newborn health. Positive results included increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. While women and project stakeholders stressed the value of male engagement, more direct communication strategies were required to reach additional men beyond the minority who attended community dialogues and home visits.

Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and meet other personal needs. Some households however cited lack of access to cash and low incomes as a constant reason for not saving and savings groups required significant support to improve their income generation, management skills and interpersonal trust among members. Linkages between savings groups and transport providers improved women’s access to health facilities at reduced cost.

VHT’s were a key resource for providing information, however their efforts were constrained by their low levels of education, inadequate financial compensation and transportation challenges. To ensure VHT and savings groups functioning, support mechanisms in terms of regular supervision, review meetings and payment for supervisors to visit was critical.

Our experience of working with communities on improving maternal and newborn health is comparable to studies elsewhere. Other efforts to improve community-facility linkages found that, in addition to high levels of active community participation, programs that were most effective had: contextualized newborn problems in the local customs/culture; the involvement of a broad range of key community stakeholders; and home visitation and peer counselling [7].

With regards to efforts related to savings groups, communities have been known to contribute funds through loan schemes, insurance groups or other financial social networks [12–15]. These funds are used either to meet the medical (drugs, supplies, consultation fees) or nonmedical costs (transport, food etc.) of health care and have been successful in increasing the utilization of MNH services [13, 14, 16].

Community initiatives that use CHWs have led to improved maternal and newborn care practices, birth preparedness, and a decline in maternal and neonatal mortality especially in South East Asia [17–20]. The success of these CHWs depended on several factors which included community ownership and mobilization, their selection processes, training, supportive supervision, monetary incentives, their management and their link with the health system [21–24].

However, the use of CHWs has not always led to positive effects in reduction in mortality [3, 25, 26]. Positive impacts were registered where community participation interventions were part of supply side improvement packages, male partner involvement and involvement of significant others in the households. The scaling up and sustainability of these interventions should be given considerable attention during the designing of programs. Interventions that involve community mobilization and empowerment, that have been institutionalized within local structures and that meet an identified need in the community are more likely to be sustained [16, 27].

We conclude with reflections on three cross-cutting issues that were important in our efforts to work with communities to improve maternal and newborn health in rural Uganda. These include the use of a diverse group of stakeholders, provision of support to enable these stakeholders to play their roles satisfactorily and the use of a participatory approach.

Solving maternal health problems requires networking and collaboration among diverse stakeholders at multiple levels of the health systems. In our experience, local leaders (chairpersons, sub county chiefs, council members) were the entry point into the communities and they played key roles in the mobilisation of communities for community dialogues and sensitisation of the communities about the advantages of saving as a means of birth preparedness. They also played key roles in holding providers such as the district health officers and facility managers accountable.

At the household level, the involvement of men in maternal health related issues was very crucial because they hold the economic power and are the decision makers in the family and so they influence the actions taken by their wives [3, 28–31]. Some of the factors that have stopped women from accessing health services, such as heavy workload, lack of access to cash and lack of decision making power, are a result of existing gender inequalities [31].

Interventions therefore need to be designed to be gender sensitive and to promote shared responsibilities between men and women in all these areas, so that women are empowered in all these different dimensions. This intervention provided an opportunity for women to generate income by participating in saving groups, while at the same time encouraging joint decision making by providing health education about danger signs and the importance of skilled attendance to both women and their husbands. It also stressed the importance of male involvement in maternal health, for example through sharing household chores and ensuring adequate nutrition. Some of these roles had been previously seen as the responsibility of only women [31].

Indeed there is evidence that provision of education about maternal health to men and women and increased male involvement in maternal health improves birth planning and skilled attendance [32–35]. Linkages and trust between community members through saving groups and transport providers proved essential to overcome financial and geographic barriers to accessing health facilities. Programs that integrate multiple interventions for maternal health are likely to succeed, as no one intervention on its own is likely to have effect in low resource settings [16, 36].

A significant amount of human resources were needed to execute the community mobilization and empowerment activities. The project worked with existing local human resources such as VHTs, health workers and community development officers. Nonetheless, significant capacity building was required, with continuous support for problem solving and identification of feasible solutions. It was also noted that one of the reasons why these structures failed to function is because of a lack of resources and unrealistic workloads. For example, one CDO was responsible for providing support to over 80 groups with no transport support.

Similarly health assistants and health workers were expected to support VHT’s without sufficient facilitation. In addition, to supporting transport funds, the project also promoted a system of peer support with super VHT’s supporting their colleagues.

The use of community health workers, volunteers and other community resources have been seen as a way of doing things cheaply however it is important to note that for these structures to function appropriately, significant financial and human resources are required [37].

Lastly, the participatory design of the project promoted the participation of local stakeholders. It empowered them to make decisions that they felt were appropriate [37–40]. The flexibility of the design also allowed the implementation of the program to be modified in response to feedback from local stakeholders. For example when things were not working, the team was able to identify the problem and suggest a local solution that could be used to address the problem.

This paper provides valuable lessons about the contribution of communities to improving maternal and newborn health. However the data presented relied mainly on qualitative research which although useful for providing in-depth explanations was not able to show a cause and effect relationship. Another limitation of our work is that we focused on only a few domains of community capability. Lastly the intervention comprised of a package of interventions and so it was not possible to separate the different components of the intervention.

Our experience demonstrates that it is possible to support existing community stakeholders and harness community resources for improving maternal and newborn health. Significant gains were realized despite the challenges faced due to a number of cross-cutting factors: the engagement of a diverse set of stakeholders, collaborative problem solving around maternal health issues, a multi-sectorial approach, the provision of continuous support and facilitation, capacity building to ensure implementers had the skills to do what was required of them, and lastly a participatory study design that allowed flexibility and change in response to feedback from the stakeholders.

We therefore recommend that similar programs work with existing local resources that meet pre-specified criteria. In addition project plans should include resources for strengthening the capacity of local structures so as to ensure that they have the capacity required to implement their responsibilities.