Table 4 Factors contributing to maternal and newborn deaths and solutions proposed

Delay in deciding to seek care for ANC and delivery

Religious leaders, community health workers and local leaders to continue participating in sensitising their communities on the importance of accessing maternal health services from health facilities during home visits and community dialogues; this was proposed during sub-county second quarter meeting during the first year and it was done

Delay in deciding to refer the mother to hospital

“The first time she attended ANC, she was advised to go to the hospital. However, she never went because she thought using the local herbs would cure her. When the time for delivery reached, she went to [HC III] (immediately the labour started, 8:00 am). When the facility staff failed, they referred her to the hospital at 11:00 pm (at night). The hospital opted for a caesarean. After the operation, she bled too much, and this resulted in her death. Fortunately, the baby survived” Deceased’s sister

Strengthen monitoring of women in labour using partographs through mentorship and support supervision so that referrals are not delayed; this was proposed by the district health management team in second quarterly meeting during the first year of implementation, Makerere University then trained district mentors who conducted subsequent mentorship and support supervision to health workers

Poor health worker attitudes

Health workers advised to relax the policy of only working on women who attended ANC with their partners; this was suggested by the district local leader (Local Councillor V); the decision was welcomed since the main aim is to make sure women reach health facilities regardless of whom they go with

“I went to the facility when my pregnancy was 2 months but was denied access to services because I had not gone with my husband. I again went there when it was 6 months and the same happened. …. I tried to explain to the health worker, but she could not listen to me. When the time for delivery reached, I decided to deliver from home because I feared to go back to the facility. Two days after delivery, my child died” Mother 35 y, gravid 5 and above

Delay in deciding to refer the mother

Strengthen monitoring of women in labour using partographs through mentorship and support supervision so that referrals are not delayed; this was suggested by the district health management team in second quarterly meeting during the first year of implementation, Makerere University then trained district mentors who conducted subsequent mentorship and support supervision to health workers

Lack of immediate transport for referral

“I reached the [HC] at 2:00 pm but was referred to hospital at 3:00 am… the health workers found that they could not manage me and I was referred to the [regional referral hospital]. Unfortunately, the driver for the ambulance was not around, and the vehicle was got at 4:00 am…. When I reached [regional hospital], a decision was made to do a caesarean. Unfortunately, the baby died immediately after delivery” Mother, 29 y, gravid 5 and above

District health office to work with CAO to make sure the ambulance driver and fuel are always available to ease referral; this was suggested by CAO and a budget line to avail money for the driver and ambulance was allocated immediately during the meeting

Lack of health worker skills in managing obstructed labour

Obstetricians and gynaecologists to continue mentoring midwives on how to handle complications during delivery through mentorship; this was suggested by the district health officer and Makerere University School of Public Health agreed to take-up this role of training mentors who will be responsible for scaling up the skills in all health facilities within the district

“I attended ANC four times at [HC III]. During delivery, the baby's head came out, but other parts could not come out. I tried to push but it could not come out. Unfortunately, it died before even coming out. I think it was too big” Mother 24 y, gravid 3