Lowering Risk Through Kindness

Lowering Risk Through Kindness

Uganda
Organization type: 
nonprofit/ngo/citizen sector
Project Stage:
Growth
Budget: 
$100,000 - $250,000
Project Summary
Elevator Pitch

Concise Summary: Help us pitch this solution! Provide an explanation within 3-4 short sentences.

The change I want to bring to the world is a fundamental shift in how maternity care is delivered to women in crisis. In too many places, maternity care provided through international aid or development channels evokes US maternity care in the 1950s: women are talked over, touched without their permission, cut with no warning, forced onto their backs for delivery. There is no doctrine of compassionate, woman-centered care. I believe this is a large and significant reason women don’t choose to give birth at institutions, even if available and affordable, even though it is the presence of a skilled care provider at the birth that saves lives. The essential change necessary to save women’s lives in childbirth is to provide care that treats women in crisis as autonomous individuals.

About Project

Problem: What problem is this project trying to address?

The change I want to bring to the world is a fundamental shift in how maternity care is delivered to women in crisis. In too many places, maternity care provided through international aid or development channels evokes US maternity care in the 1950s: women are talked over, touched without their permission, cut with no warning, forced onto their backs for delivery. There is no doctrine of compassionate, woman-centered care. I believe this is a large and significant reason women don’t choose to give birth at institutions, even if available and affordable, even though it is the presence of a skilled care provider at the birth that saves lives. The essential change necessary to save women’s lives in childbirth is to provide care that treats women in crisis as autonomous individuals.

Solution: What is the proposed solution? Please be specific!

Maternity care provided through aid and development channels has a strong emphasis on basic medical principles, but no emphasis on holistic principles of patient care. Steps taken in many countries to ensure women are active participants in their own care haven’t permeated aid work. Often we ask why women who claim to desire access to care won’t come to the health center to give birth. The truth is many avoid the hospital because of how they will be treated. At my clinic, women receive patient-centered, compassionate care from fellow Ugandans, many of them victims of the war themselves who are finding purpose and a livelihood working at the clinic. The midwifery model places enormous emphasis on the rights, desires and feelings of the pregnant woman. Keeping the midwifery model at the heart of the mission is the key to women seeking skilled care in labor. We know from other countries that this model is easy to replicate, and inexpensive. However, at the risk of offending powers that be, providing this kind of care in a development situation is innovative. There are more obstacles to overcome, and we are determined to try and defeat each and every one. We employ entrepreneurial community members to provide transport to the clinic for laboring women. We’ve been granted exemption from government regulations that disallow certain women from delivering at our out-of-hospital facility, removing another obstacle to care. Our continued and increasing success is due to the buzz in the community: patients at TSMP are treated with kindness and respect.
Impact: How does it Work

Example: Walk us through a specific example(s) of how this solution makes a difference; include its primary activities.

My project provides women-centered, compassionate care in some of the most desperate places in the world, to lower maternal, infant and child mortality. Currently, we work with victims of civil war in Uganda. The clinic provides prenatal care, a birth center, postpartum care, a childhood vaccine and medical clinic, mobile clinics to remote areas and comprehensive family planning services for destitute people in northern Uganda. Over 37,000 people were cared for in 2010. In a way, the primary activity of the clinic is to provide a vision of what’s possible in an area that is destabilized by war, poverty, and most significantly, corruption. People have no faith in public institutions; the destitute have learned not to ask for help. Most women in Uganda don’t seek the care of a trained professional during birth, and this leads to very high rates of morbidity and mortality. To counteract this loss of faith, the clinic does everything at the highest possible standard, emphasizing patient-centered care and treating patients with respect. This must become a cornerstone of overcoming the obstacle of women not seeking care in childbirth. Volunteers from the US and Canada ensure that the all-Ugandan staff at the clinic are accessing current information about best medical practices. Staff who came to the clinic under-educated are sent back to school for more education. Administration is mentored in efficient, fiscally transparent practices. The staff takes enormous pride in the excellence of the place, and steadily more and more control is in the hands of the local staff.
Sustainability

Marketplace: Who else is addressing the problem outlined here? How does the proposed project differ from these approaches?

They are a group of destitute people who fled a brutal civil war. By 2006, more than 30,000 Ugandans had flocked to squalid, overcrowded internally displaced persons (IDP) camps in and around Soroti, where the clinic is located. They overwhelmed an already fragile infrastructure, and most failed to find any employment. There is widespread hunger and poverty. Displaced people from very different tribes and areas have been thrown together in very close and stressful living situations, and they are deeply traumatized. The traditional ways of living are extremely disrupted. They’ve been ordered to “return home” now, but so much has been destroyed that even if it were clear where home once was, roads are overgrown. There are no schools or health centers, and no basic services. The history of the country since independence has been mostly north vs. south tribal conflict, with the south currently in power. The central government understates and denies the conflict, and women and children suffer. Very few aid organizations are present. The maternal mortality rate in Uganda is 440 deaths per 100,000 births, about 16 women each day. Another 130,000 to 405,000 women suffer from disabilities caused by complications of pregnancy and childbirth each year. Women are insufficiently attended in childbirth, and they end up suffering long-term disabilities, such as fistula. The country has one of the highest child mortality rates in the world at 128 out of 1,000 children younger than five, while also having the largest proportion of people younger than 15 of any country in the world.
About You
Organization:
International Midwife Assistance
About You
First Name

Jennifer

Last Name

Braun

Twitter
About Your Organization
Organization Name

International Midwife Assistance

Organization Phone

303-588-1663

Organization Address

P.O. Box 916, Boulder, CO 80306

Organization Country
Country where this project is creating social impact

, SOR

How long has your organization been operating?

More than 5 years

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Innovation
What stage is your project in?

Operating for 1‐5 years

Tell us about the community that you engage? eg. economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts.

They are a group of destitute people who fled a brutal civil war. By 2006, more than 30,000 Ugandans had flocked to squalid, overcrowded internally displaced persons (IDP) camps in and around Soroti, where the clinic is located. They overwhelmed an already fragile infrastructure, and most failed to find any employment. There is widespread hunger and poverty. Displaced people from very different tribes and areas have been thrown together in very close and stressful living situations, and they are deeply traumatized. The traditional ways of living are extremely disrupted. They’ve been ordered to “return home” now, but so much has been destroyed that even if it were clear where home once was, roads are overgrown. There are no schools or health centers, and no basic services.

The history of the country since independence has been mostly north vs. south tribal conflict, with the south currently in power. The central government understates and denies the conflict, and women and children suffer. Very few aid organizations are present.

The maternal mortality rate in Uganda is 440 deaths per 100,000 births, about 16 women each day. Another 130,000 to 405,000 women suffer from disabilities caused by complications of pregnancy and childbirth each year. Women are insufficiently attended in childbirth, and they end up suffering long-term disabilities, such as fistula. The country has one of the highest child mortality rates in the world at 128 out of 1,000 children younger than five, while also having the largest proportion of people younger than 15 of any country in the world.

Share the story of the founder and what inspired the founder to start this project

I founded International Midwife Assistance after being invited to join a group of women in Boulder, Colorado who aspired to reach out to the women of Afghanistan. In 2004, I traveled around Afghanistan to bring assistance and to determine how we might best help in a sustainable way. After returning to the US, I redoubled my Farsi studies and incorporated the organization. IMA began a more than two-year-long project training rural Afghan women to be midwives. The patient-centered, compassionate model was transformative not only to the delivery of maternal/child health in Bamiyan Hospital, it was transformative in the lives of the Afghan students. All 22 students graduated, and all 22 continue to provide care to their rural villages.

Unfortunately, the situation in Afghanistan became too dangerous for us to hold another class. One of our volunteer nurses connected us to a dire situation in Soroti, Uganda, after her friend conducted a needs assessment there. It was a perfect fit. Founding the Teso Safe Motherhood Project has been a huge joy. I myself am the child of refugees. My desire is to bring aid to those feeling forgotten.

I really feel I was born a midwife. I began attending home births as an apprentice in 1982. I went on to university after the birth of my first child in 1984, but I have remained a midwife and continued to attend births in a variety of settings from 1982 up until now. I’ve had the privilege of working with some amazing mentors, and that, plus some natural talent, has helped me to become an accomplished midwife.

Social Impact
Please describe how your project has been successful and how that success is measured

We measure success in terms of numbers of mothers’ and children’s lives saved. For mothers, we know two things save lives in childbirth: the presence of a skilled attendant, and the opportunity to choose not to be pregnant in the first place. So we decided to focus on increasing family planning utilization, to make sure that child spacing is emphasized in our safe motherhood message. At that time we saw about 150 family planning patients a month. That number is now an average of 300, with 384 served last month. Birth control saves lives. We know that it is the presence of an attendant at the birth that saves lives, so every woman who chooses to deliver at the birth center is a success. Providing motorbike transport for women in labor doubled the number of babies born monthly from 8 to 17. Permission from officials now allows us to care for first-time mothers and “grand multips,” mothers who have delivered five or more babies, previously considered too high risk to deliver out of hospital. The first week after the rule change, five babies were born at the clinic in one night, three of them to mothers who previously wouldn’t have been allowed there. Every birth attended by a midwife is a success. A very reliable way to save children’s lives is to vaccinate them for the killer diseases. When we began mobile outreach, the highest rate of vaccination coverage among the children of the displaced people was 60%. Now, district officials credit our vaccine program with eradicating Pertussis in the area with 100% vaccine coverage. That is one of my favorite successes.

How many people have been impacted by your project?

More than 10,000

How many people could be impacted by your project in the next three years?

More than 10,000

Winning entries present a strong plan for how they will achieve growth. Identify your six-month milestone for growing your impact

I will grow the impact of the project by increasing the number of births at the birth center. A 50 percent increase to 150 in six months is the milestone for growing impact.

Task 1

During appointments, nurses and midwives will inform each prenatal patient that first-time mothers and “grand multips” may now give birth at TSMP clinic.

Task 2

The family planning outreach drama troupe takes a strong message to the community: what it’s like to give birth at the center, availability of free transport and the new rules are shared.

Task 3

All departments at TSMP will present a unified message to spread to all patients about the benefits of birthing in our health center and the free transportation service available to laboring mothers.

Identify your 12-month impact milestone

At 12 months, 300 or more babies will have been born at the health center, with first-time mothers and grand multips demonstrating no greater risk than the other mothers, due to excellent midwives.

Task 1

We will document the experiences of first-time mothers and grand-multip mothers who deliver at the birth center to articulate what they found inviting about the place.

Task 2

We will keep meticulous records of the formerly prohibited patients – the numbers who attend prenatal clinic, who give birth and of any special challenges associated with their births.

Task 3

We will involve the local government in our progress and seek opportunities to present our successes as replicable. We will lecture at the Soroti Regional Referral Hospital to share our findings.

How will your project evolve over the next three years?

In three years we should reach a “tipping-point” when compassionate midwifery care attracts enough mothers to tip the behavior of the community, and women choose to birth with a skilled attendant. Two other significant things will happen over the next three years of evolution. Plans are to grow from a Level III Health Center to a hospital, fully equipped to provide emergency, life-saving surgery to women in labor as well as things like fistula surgery. We are currently seeking funding for this growth. This evolution is concurrent with the ongoing transition of control of the project. More and more decision making is moving from the US group to the hands of the Ugandan staff and board of directors. Ultimately, the Ugandans will take complete control. This transition is already underway.

Sustainability
What barriers might hinder the success of your project and how do you plan to overcome them?

Estimates vary, but it is widely agreed that significantly less than 50% of Ugandan women seek care in a health facility for labor and delivery. While cost and access are factors, the behavior is also cultural and deeply ingrained. Women fear the labor ward. Recent press coverage has described the plight of women in the hospital left to die, usually bleeding to death. When we ask women directly why they avoid the hospital, the number one reason is quite consistent: they fear being treated harshly. In order to overcome the cultural resistance, we have to create an alternative experience, a place where women are treated with loving kindness. They have to trust their care providers, and we must not betray that trust.

Another significant potential barrier to success is political instability. Uganda is experiencing volatility, extreme inflation and devaluation of currency. President Museveni has been in office since 1986 and he has changed the Ugandan constitution to allow it. There is no freedom of speech or assembly. While once hailed as a strong democracy, the government is progressively more totalitarian. In order to prevent this situation from hindering our progress, we must at once cultivate a good relationship with the national government and with local powers that may be perceived as opposing government. We nurture our relationship with the central and local government through liaising with national licensing, medical reporting and drug authorities. This is a precarious situation, but a natural product of our policy only to work in very desperate places.

Tell us about your partnerships

We enjoy partnerships with both government and private groups, and both are vital. To work in an area that is experiencing such a serious crisis in maternal/child health is to be in a place that also presents security challenges. In this volatile environment, making a clear contribution to the community, and really being part of the community, keeps everyone at the project safer - both the local staff and volunteers from other countries. Partnerships can wage peace in violent places. When government sees us as a partner rather than a competitor, more patients benefit. Our relationship with government not only allows us to work here, but also it makes government facilities more receptive to messages about best practices.

Our partners provide significant material support to the project. Private partners provide subsidized drugs and supplies, share training and community mobilizers, particularly in the area of family planning. We have seen a lot of success reaching women with birth control methods through our partnerships with two Ugandan groups: PACE (Program for Accessible health Communication and Education) and Uganda Health Marketing Group. Our Ugandan partner BeadforLife provides funding for our family planning program. Our partner The AIDS Support Organization (TASO) provides training to our staff and anti-retroviral drugs to our HIV positive patients when availability is low. We collaborate with children’s groups to provide to care to the orphans and vulnerable children they identify, we also provide medical care to children less than 15 years.

Explain your selections

My selections represent sources of funding and supplies. The organization grew out of concerned individuals looking to send direct support to desperate areas, and is funded mostly by individuals. There are some family and friends among the earliest donors because they believed in me. But now as our fundraising efforts have expanded, the donor base has diversified well beyond that. We seek foundation support, but funding by individuals gives us maximum flexibility and the potential to educate thousands of needy people through outreach efforts. Funding this project allows them to have direct knowledge of where the funds are going and what is being done. Some donors prefer to provide specific things rather than funds, and their relationship with the clinic allows them knowledge of what we need. Recently I was free to ask an individual to fund a new microscope for the lab, for example.

From regional government we receive condoms, HIV test kits and anti-retroviral drugs (when they are available) and vaccines. From the national government we received clearance to receive vaccines from the district level, plus the proper refrigerator and cold chain supplies. From other NGOs (PACE, Uganda Health Marketing Group) we receive family planning supplies and community health workers trained and funded to help us with community sensitization. We are pursuing funding now from the local government to increase sustainability as we put more and more responsibility in the hands of the local staff.

How do you plan to strengthen your project in the next three years?

My priority for strengthening the project is building capacity in the local staff to take more and more responsibility to run the clinic independently. I still provide an enormous amount of oversight, but the plan is gradually to put complete responsibility in the hands of the Ugandans over the next 36 months. Already there is much more taking of responsibility, planning ahead and fiscal transparency in a place where those things are rare. I send volunteers to mentor the staff on a variety of issues. Best medical practices, continuing medical education, computer skills and accounting (especially fiscal transparency) are the areas of focus. We are adding mentoring in grant writing and reporting to provide the necessary skills for continued funding. Also, we are pursuing funding by local government, as that is the best way for the project to have sustained support independent of my efforts.

As well, key individuals have been identified for future leadership and sent to school for training. One example is an excellent nurse whose intellect and character are extremely distinguishing. He is a natural leader and teacher. He accepted a lot of responsibility in the clinic and performed amazingly. We’ve sent him to medical school, his dream, and he will re-join the project as a medical officer. The finance officer is being sent to night school to increase his skills and complete a degree. One very gifted nursing assistant has just completed her nurse midwifery training through our support. She has returned to work at TSMP a future leader.

Challenges
Which barriers to health and well-being does your innovation address?
Please select up to three in order of relevancy to your project.

PRIMARY

Health behavior change

SECONDARY

Lack of affordable care

TERTIARY

Lack of physical access to care/lack of facilities

Please describe how your innovation specifically tackles the barriers listed above.

We tackle the barriers of access by being a no-cost clinic conveniently located near where the displaced are relocating. The behavior this innovation addresses is the reluctance of women to seek care at an appropriate facility during labor. This begins during the first pregnancy. They know it’s likely they’ll be denied admission to the hospital, and if admitted they will almost certainly be mistreated. By providing a good experience with a health center during her first birth, a woman is much more likely to seek care there for future deliveries. As well, when mothers who have many children choose to access services in labor, that sends a strong message to their community that the service is desirable. These two groups can provide a tipping point to catalyze the behavior change.

How are you growing the impact of your organization or initiative?
Please select up to three potential pathways in order of relevancy to you.

PRIMARY

SECONDARY

Influenced other organizations and institutions through the spread of best practices

TERTIARY

Other (please specify below)

Please describe which of your growth activities are current or planned for the immediate future.

Drama troupes are a very popular form of conveying information in Uganda. To raise awareness and increase utilization, our new drama troupe is performing about safe motherhood. They travel to rural areas and address both resistance to delivering in the health center and stigmas against birth control. They promote the use of our free transport in labor service (another growth activity) and publicize that all mothers can deliver at TSMP. They deploy role models from each community who have had good experiences delivering at the clinic and with using birth control methods. By using the local practice of new dramas and songs for passing along important messages, the community is more engaged in learning. Birth center and family planning utilization are increasing with each performance.

Do you collaborate with any of the following: (Check all that apply)

Government, NGOs/Nonprofits, Academia/universities.

If yes, how have these collaborations helped your innovation to succeed?

By collaborating with government, we have gained their trust to be a demonstration project that delivers “high-risk” mothers out of hospital. That has brought more women to be delivered by our skilled midwives. Hospitals and schools invite our staff members to lecture and teach. These presentations are uniformly well-received, methods taught by our people make their way to the government hospital, and quality of care is improved for still more women. Collaboration with other NGOs has brought both funding (our partner BeadforLife) and material support through supplies (Pilgrim provides us with vitamins). Many of the children we treat come to us through partner organizations (Pilgrim, Save the Children, World Vision) so our collaborations provide opportunities to reach more people.

Comments

James Waruiru's picture

Hi there, I just want to tell you that you are doing a good job, may you gather strength and resources to push forward. I may want to visit next time I am in Uganda. You can inbox me on details of your location.

Thumbs up...!

James

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