(Revamon) Katakwi District, Eastern Uganda

2018 - 2020

REACHING VULNERABLE ADOLESCENT MOTHERS AND NEWBORNS (REVAMON)

KATAKWI DISTRICT, EASTERN UGANDA

BIRTHING KIT FOUNDATION AUSTRALIA JUNE 2018 OVERVIEW

Birthing Kit Foundation Australia (BKFA) 4

Implementing Partner—Teso Women Peace Activists (TEWPA) 5

Country Context 6

Uganda is a landlocked country in East Africa, bordered by Kenya, South Sudan, DR Congo, Rwanda and Tanzania. Most Ugandans live in rural areas and the majority are employed in agriculture. Since independence in 1960 the country has experienced multiple conflicts, and remains a heavily indebted country relying on international aid for primary services. Refugees fleeing South Sudan remain a critical issue in the north of the country. Maternal and newborn health outcomes remain poor due to issues with health service provision and access in rural areas which impacts on antenatal care coverage and skilled birth attendance.

Situation in the Teso Region 9

Throughout Uganda, the Teso sub-region has the highest proportion of adolescents who have begun childbearing. It is known that adolescents—particularly in the early years—are at much higher risk than other age groups of childbirth-related death and disability. While physically undeveloped, adolescent girls who become pregnant are also more likely than their peers to be poor; with poorer nutrition and general health. The region continues to recover after decades of conflict—deeply affecting the lives of women and girls. Project Overview 11

The goal is to improve the maternal and newborn outcomes for adolescents in 3 sub-counties of Katakwi District in Eastern Uganda. This will be achieved by improving adolescents’ pregnancy, childbirth and postnatal experience, and reproductive health; engaging boys and men and gaining support from leaders within the community on adolescent reproductive health issues and rights.

Project Components 13

The core elements of this project include establishing adolescent health groups in schools and communities; production of hygiene, clean birth and newborn packs by adolescents; adolescent- friendly care provision using a group antenatal care model; and awareness-raising at all levels of the community using workshops, radio programming and district-level engagement.

Overview of Activities 14

Activities have been designed to achieve project outcomes and have been planned over a timeframe of 3 years. BIRTHING KIT FOUNDATION AUSTRALIA (BKFA)

BKFA is an Australian non-profit organisation BKFA PLAYS A SUPPORTIVE working to improve reproductive wellbeing and CAPACITY-BUILDING, childbirth survival for mothers and newborns in developing countries. For more than a decade, BKFA COMMUNICATIONS AND has worked with partner organisations in Ethiopia, MANAGEMENT ROLE IN DR Congo, Nigeria and India to develop and implement community development projects. PROJECT PARTNERSHIPS Our projects are community-centred, focused on achieving outcomes, evidence-based, value for money and integrate quality monitoring and evaluation processes. We are committed to ‘leaving no-one behind’ and work to reduce the disparity in health care for vulnerable populations. We stand to progress the health and rights of childbearing mothers and their families. Our investment in research, collaboration and learning provides a foundation for our program and advocacy strategies.

04 IMPLEMENTING PARTNER TESO WOMEN PEACE ACTIVISTS (TEWPA)

TEWPA is a rural women’s organisation founded TEWPA MANAGES ALL in 2001 to respond to the challenges of unrest of ASPECTS OF PROJECT armed conflicts manifested in different forms in Teso. TEWPA builds the capacity of rural women in conflict IMPLEMENTATION WITH resolution and transformation processes and stimulate THEIR TEAM OF LOCAL dialogue through active involvement and participation of women, youth and selected strategic stakeholders. STAFF AND NETWORKS TEWPA envisions an environment where both women and men fully participate in enabling a peacefully co-existence in Teso-Karamoja. TEWPA’s mission is to strengthen women and girl child and youth in Teso and Karamoja regions to be able to access and demand services through capacity building lobby advocacy and information sharing capacity.

05 COUNTRY CONTEXT

UGANDA

The Republic of Uganda is a landlocked country in East Africa, bordered by Kenya, South Sudan, the Democratic Republic of the Congo, Rwanda and Tanzania. It is in the African Great Lakes region and the southern part of the country includes a substantial portion of Lake Victoria. Most Ugandans live in rural areas, and the majority of the labour force are employed in agriculture12. The country has experienced multiple conflicts since gaining independence in 1962, including violent regimes, military coups, and civil war. The current president, Yoweri Museveni, and his National Resistance Movement, have been in power since 19863. Stability and economic growth have improved under President Museveni, but economic growth is slowing, and by 2017, public debt had increased to 40% of the country’s GDP. The World Bank lists Uganda as a Heavily Indebted Poor Country4. In Uganda, economic growth has not always led to the reduction of poverty, and the country relies heavily on foreign aid for health and education5. Currently, Uganda is also experiencing an influx of refugees, with more than 1 million refugees fleeing civil war in South Sudan67. Human Rights Watch (HRW) advises of harsh political repression in Uganda; government opposition and journalists have been subject to arrest and detention, and vague legal provisions have seen NGOs charged with politically motivated offences8.

HEALTH IN UGANDA Uganda’s healthcare performance outreach and disseminate health is still ranked as one of the worst information. HCII are required to have in the world by the World Health a physical facility including an enrolled Organisation (186 out of 191 nurse and midwife, HCIII a clinical nations). The healthcare system is a officer and laboratory, and HCIV a combination of the public and private doctor and operating theatre11. sectors, with 44% of health services Access to healthcare in Uganda is delivered by the public sector. The impacted by various factors, including Ministry of Health (MoH) oversees a lack of operational health facilities, health services, which are delivered poor roads and infrastructure. 75% by local government and managed at of Uganda’s population are within the sub-district level9. Health service 5 km of a health facility, but those provision is based on a tier system of living in rural areas lack physical health centres (HC) ranging from the access to adequate facilities12. As village level (HCI) to the district level a consequence of longstanding (HCIV), and hospitals (HCV-HCVII)10. conflict in the north of Uganda, HCI consist of volunteer community health outcomes in the region are members who coordinate health inequitable.

1. World Vision, “Uganda Country Profile,” https://www.worldvision.com.au/docs/default-source/school-resources/uganda-country-profile.pdf?sfvrsn=0. 2. CIA, “Uganda,” https://www.cia.gov/library/publications/the-world-factbook/geos/ug.html. 3. Peace Insight, “Uganda,” https://www.peaceinsight. org/conflicts/uganda/. 4. World Bank, “Heavily Indebted Poor Country (Hipc) Initiative,” http://www.worldbank.org/en/topic/debt/brief/hipc. 5. CIA. 06 6. J.Patinkin, “Uganda Struggles to Cope as 1 Mln South Sudanese Refugees Pour In,” Reuters 2017. 7. Peace Insight. 8. Human Rights Watch, “Uganda,” https://www.hrw.org/africa/uganda. 9. World Health Organization, “Who Country Cooperation Strategy, 2016-2020, Uganda,” (2016). 10. The Repub- lic of Uganda, “Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda, 2007-2015,” (2007). 11. S. Rudrum, “Traditional Birth Attendants in Rural Northern Uganda: Policy, Practice, and Ethics,” Health Care Women Int 37, no. 2 (2016).12. World Health Organization, “Who Country Cooperation Strategy, 2016-2020, Uganda.” COUNTRY CONTEXT

MATERNAL NEWBORN HEALTH

Uganda has a young and rapidly treatment in hospitals, a shortage of growing population, and one of the skilled staff at the primary level, and highest fertility rates in the world. a lack of understanding of biomedical Factors like short birth intervals and treatment18. Traditional beliefs also early childbearing age contribute to a play a role in a woman’s choice to high maternal mortality rate13. The deliver outside of a health facility, Ugandan government maintains that including beliefs that “pregnancy is a all women should deliver at health test of endurance and maternal death facilities where they can access skilled a sad but normal event”19. care14. However, despite growing Uganda’s Ministry of Health has set emphasis on skilled birth attendants out a Road Map for Accelerating the (those who have received formal Reduction of Maternal and Neonatal training), traditional birth attendants Mortality and Morbidity20. It defines (TBAs) continue to play an important a vision by the government and key role in maternity health care stakeholders with 3 objectives: provision15. Some women reveal a 1. Increase accessibility and preference for TBAs over skilled birth utilisation of skilled care during attendants, as skilled birth attendants pregnancy, child birth and the may be regarded as “outsiders” who post-natal period. are not part of local birth culture16. 2. Encourage appropriate health A 2003 study in rural Western seeking behaviour Uganda found that 58% of women 3. Strengthen family planning had given birth away from health information and provision to facilities17. Unwillingness of women prevent ‘unwanted’ or ‘untimely’ to deliver in health facilities can be pregnancies. attributed to factors including poor

1. World Vision, “Uganda Country Profile,” https://www.worldvision.com.au/docs/default-source/school-resources/uganda-country-profile.pdf?sfvrsn=0. 2. CIA, “Uganda,” https://www.cia.gov/library/publications/the-world-factbook/geos/ug.html. 3. Peace Insight, “Uganda,” https://www.peaceinsight. org/conflicts/uganda/. 4. World Bank, “Heavily Indebted Poor Country (Hipc) Initiative,” http://www.worldbank.org/en/topic/debt/brief/hipc. 5. CIA. 07 6. J.Patinkin, “Uganda Struggles to Cope as 1 Mln South Sudanese Refugees Pour In,” Reuters 2017. 7. Peace Insight. 8. Human Rights Watch, “Uganda,” https://www.hrw.org/africa/uganda. 9. World Health Organization, “Who Country Cooperation Strategy, 2016-2020, Uganda,” (2016). 10. The Repub- lic of Uganda, “Roadmap for Accelerating the Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda, 2007-2015,” (2007). 11. S. Rudrum, “Traditional Birth Attendants in Rural Northern Uganda: Policy, Practice, and Ethics,” Health Care Women Int 37, no. 2 (2016).12. World Health Organization, “Who Country Cooperation Strategy, 2016-2020, Uganda.” UGANDA’S REGIONS THE KATAWI DISTRICT

PROJECT LOCATION

Katakwi District is one of the more remote districts The district has long been suffering the impacts in Uganda, situation in the north-east of the country. of conflict. Since the late 1940’s there has been It has a total population of 166,231 of which almost a significant history of cattle rustling by the all is rural. The areas targeted for engagement in Karimojong, who in 1979 acquired abandoned the first year of the project are the sub-counties of military weaponry, heightening the intensity and Kapujan, Ngariam and Ongongoja with the view to devastation of the frequent raids. An unsuccessful expand to Omodoi, Magoro and Usuk as resources attempt was made to disarm the Karimojong warriors allow. The total population of Kapujan, Ngariam and in 2001, and since 2002 there has been an increased Ongongoja is approximately 55,000. number of internally displaced person (IDP) camps along the Teso-Karamoja border.

08 SITUATION IN THE TESO REGION

MATERNAL NEWBORN HEALTH

Conflict has deeply impacted the lives of women and girls, and whole communities. The maternal mortality ratio in the district has improved with ongoing post-conflict recovery but is still 256 per 100,000 live births and the infant mortality rate is 42 per 1,000 live births. Just 42% of births are attended by skilled personnel. In Katakwi, over a quarter of the population is between 10-19 years, reflecting Uganda’s status as the world’s most youthful country with 78% of its total population under the age of 30. The Teso sub-region has the highest proportion of adolescents aged 15-19 who have begun childbearing (31%) - significantly greater than the national average of 25%. Adolescent pregnancy is known to be high risk, particularly in the earlier years. A girl who becomes pregnant under the age of 15 is at increased risk of suffering poor childbirth outcomes than any other age group. While physically undeveloped, adolescent girls who become pregnant are also more likely than their peers to be poor; with poorer nutrition and general health. These combined factors increase the likelihood of childbirth-related death and disability for adolescent mothers and their babies by as much as 50%. Access to basic antenatal care services has declined throughout Uganda in recent years. On average, 40% of adolescents did not attend the minimum of 4 visits with a health provider during their last pregnancy - with higher rates in underserved and rural areas.

13. CIA. 14. The Republic of Uganda.15. P. Che Chi, Urdal, H., “The Evolving Role of Traditional Birth Attendants in Maternal Health in Post-Conflict Africa: A Qualitative Study of Burundi and Northern Uganda,” SAGE Open Medicine 6 (2018).16. Rudrum. 17.Grace Bantebya 09 Kyomuhendo, “Low Use of Rural Maternity Services in Uganda: Impact of Women’s Status, Traditional Beliefs and Limited Resources,” Reproductive Health Matters 11, no. 21 (2003). 18.Ibid. 19.Ibid. 20.The Republic of Uganda. GENDER

In Uganda, men dominate the majority of decisions leaving them vulnerable to unwanted pregnancies related to women’s reproductive health, which has among other physical and psycho-social impacts. significant implications for family health outcomes and Education outcomes for girls in terms of school program planning. Additionally, women and girls have enrolment, attendance and completion are poorer fewer economic opportunities and access to assets for girls across all ages. Poor education attainment is meaning they have reduced financial independence and linked to earlier marriage, earlier first sex, and earlier access to services. Harmful practices such as early and commencement of childbearing - the burden of which is forced marriage, and gender-based violence are common primarily carried by girls and women. - further exploiting and harming girls and women and

MARGINALISED POPULATIONS Within the project area, particularly marginalised groups are: Communities near water bodies including riverside settlements and ferry ports; internally displaced persons camps; remote or significantly distant from health and education facilities; and those bordering the Karamojong cattle-rustlers; Families that are headed by single parents; are poor or unemployed; have members living with disabilities; Youth and young mothers that have discontinued their schooling at a young age; that are living with disabilities; are orphans and/or heads of families; those that have experienced early/forced marriage; those who are unmarried and pregnant; and those who are raised by a single parent. The voices of marginalised groups and people living with disabilities are heard through their representation at community meetings; and by building capacity and empowering health personnel to best care for their specific needs. Empowering marginalised groups on their rights is a thread that runs throughout every aspect of this project.

PRIORITY ISSUES The key focus issues to be addressed by this intervention are: • Weak service provision for adolescents • Limited access to maternity services by adolescents • Limited knowledge on reproductive health and rights amongst adolescents and families • An environment that does not facilitate policy implementation • Gender-based inequality in reproductive decision-making processes.

8King R, Jackson R, Dietsch E & Hailemariam A 2015 ‘Barriers and facilitators to accessing skilled birth attendants in Afar Region, Ethiopia’ Midwifery, 31:540-546 10 PROJECT OVERVIEW

GOAL The goal is to improve adolescent maternal and newborn outcomes in 3 sub-counties of Katakwi District, Uganda

OBJECTIVES Improved outcomes for mothers and babies will be achieved by addressing the identified issues of: limited access to and weak maternity service provision for adolescents; limited knowledge on reproductive health and rights amongst adolescents and families; an environment that does not facilitate policy implementation, and; gender-based inequality in reproductive decision-making processes. The key objectives are to: 1. Improve adolescent girls’ pregnancy, childbirth and postnatal experience 2. Improve adolescent reproductive outcomes 3. Increase boys’ and males’ contribution to adolescent reproductive and maternal wellbeing 4. Increase community support for adolescents’ reproductive health and rights

11 KEY OUTCOMES

IMPROVED PREGNANCY, IMPROVED ADOLESCENT CHILDBIRTH AND REPRODUCTIVE OUTCOMES POSTNATAL EXPERIENCE

Throughout this project, a key focus will be on This project will ensure adolescent mothers reducing risk - ensuring fewer adolescent girls experience adequate and targeted care throughout suffer death and disability as a result of childbearing the continuum of childbearing - through pregnancy, by promoting delayed marriage and delayed childbirth and the postnatal period. A positive commencement of childbearing. Most pregnancies experience means a good outcome for mothers, occur in marriage and, the earlier the marriage and families and newborns, but also increases demand earlier the commencement of childbearing, the greater for services through returning patients and personal the risk. referral. Through school and community programs for With health services better addressing the needs adolescents and caregivers, girls will have a better of adolescents and support from their families understanding of reproductive health and rights issues. and communities, more girls will attend antenatal Supported by their families and communities, more care (ANC) and more will give birth with a skilled girls will reach the age of 18 before becoming married attendant. Linked into the health system, girls will and the age of 20 before commencing childbearing. also have more access to clean supplies for personal hygiene, childbirth, and caring for their newborn.

INCREASED CONTRIBUTION INCREASED COMMUNITY OF BOYS AND MEN TO SUPPORT FOR ADOLESCENTS’ ADOLESCENT REPRODUCTIVE REPRODUCTIVE HEALTH AND AND MATERNAL WELLBEING RIGHTS

A focus on gender and the role of boys and men in Recognising the importance of enabling promoting adolescent reproductive wellbeing will environments, this project will facilitate the bring the focus onto male youth, partners, fathers-to- involvement and empowerment of adolescents’ be and decision-makers to increase health-promoting parents and community structures to provide and health-seeking behaviours in target communities. greater support - to at-risk, pregnant and parenting The benefits of engaging men and boys in adolescents. Leaders at local, sub-country and district reproductive health are well known and improvements levels will be provided tools to promote policy and in maternal and newborn health rely on their effective structural change. involvement. Through ongoing advocacy and education, families Through school and community programs, adolescent will prohibit the early and forced marriages of their boys and men will gain a greater understanding of daughters and alongside their communities will reproductive health and rights issues. Fathers of better support adolescents in the event of pregnancy. adolescent girls will be engaged and a culture of male Community and district leadership will understand responsibility for health and informed decision-making and provide support for adolescent health initiatives. will be nurtured, such that boys and men participate in seeking care and preparing for birth

12 PROJECT COMPONENTS

ADOLESCENT-FRIENDLY HEALTH CARE PROVISION Health personnel (nurses, doctors, midwives) and village health teams receive training to help them better understand adolescence and the care that adolescents need these personnel provide clinical care and support groups hosted by the health facility. Selected midwives are supported to run adolescent pregnancy groups (group antenatal care) and outreach services.

BIRTHING KITS AND CLEAN, HYGIENIC SUPPLIES Clean birthing kits are provided by BKFA and distributed to maternity-level facilities, and for use by midwives running group antenatal care and outreach services. 2,500 kits are distributed in project areas each year. Adolescents learn sewing skills and are involved in the production of hygiene packs and clean packs for new mothers and babies, that are distributed to at-risk adolescents.

REACHING AT-RISK ADOLESCENT IN GROUPS AND SCHOOLS Groups of adolescents are hosted by selected schools and facilities to learn life and livelihood skills, with a focus on improving their reproductive health. The groups are facilitated by mentors and health workers who provide social, health and behavioural guidance, as well as the opportunity to learn practical skills such as sewing and basic financial literacy. A girl peer educator engages in each of these groups and provides support and referral to at-risk adolescents.

COMMUNITY ENGAGEMENT AND ADVOCACY Workshops on adolescent reproductive health issues, behaviours and support are conducted for community stakeholders including adolescents, parents of adolescents, clan leaders, Local Council and religious leaders. Educational and promotional materials - including printed resources and radio broadcasts - are utilised across all project sites. Open theatres and markets provide an opportunity for adolescent group members to connect, share learning and display/ sell their hygiene and birth packs.

13 OVERVIEW OF ACTIVITIES

YEAR 1 • Monitoring and evaluation framework development • Project launch • Baseline survey in 3 sub-counties • Establishment of school and community adolescent health groups (500 adolescents in 18 groups) • Skill-development with school and community adolescent groups to produce hygiene, clean birth and newborn packs. • Identification and training of 12 girl peer educators • Training for 36 health providers in adolescent health and care provision • Development of group antenatal care model • Workshops for 48 stakeholders on adolescent health issues and support • Distribution of Birthing Kits in project sites • Field monitoring and reporting • Project review and learning

$50,000 (+15% ICR*)

*Internal Cost Recovery accounts for BKFA’s project management expenses related to the project. Project agreement is made in Ugandan Shillings (UGX). All AUD figures are estimated on an exchange rate of UGX 2880.00 and actual project cost will be determined by the rate at time of transfer. 14 YEAR 2

• Facilitating 500 adolescents in 18 school and community groups • Strengthening production of hygiene, clean birth and newborn baby packs in all adolescent groups • Refresher training for 12 girl peer educators • Refresher training for 36 health providers in adolescent health and care provision • Strengthening group antenatal care model and provision of service • Workshops for 48 stakeholders on adolescent health issues and support • Educational open theatres by adolescents and market • Field monitoring and reporting

$40,000^ (+15% ICR)

^Estimated budget

YEAR 3

$40,000^ (+15% ICR)

^Estimated budget

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