Antenatal care trends in Uganda:

A literature review of indicators and evidence

for mHealth programming in rural areas
Maddy Kluesner
April 25, 2018

Final Paper

PA 5301: Population Methods and Issues for the

United States and the Global South

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Table of Contents
Tables and Figures 1
Abstract 1
Introduction 1
Background 1
Uganda’s Antenatal Care 1
SMS Maama and mHealth 2
Literature Review 3
Regions of Uganda 3
Methodology 4
Common Themes 4
Indicators 5
Delay in Decision to Seek Care 6
Delay in Reaching Care 7
Delay in Receiving Adequate Health Care 8
DHS Analysis 10
Results 10
Discussion 12
Recommendations 13
Conclusion 15

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Tables and Figures

Figure 1: Map of Uganda Regions............................................................................................. 18

Figure 2: Map of Districts of Uganda by Percent of Urban Residents (With Map IDs) .............. 19
Figure 3: Urban-Rural Proportions of Number of ANC Visits in Uganda, 1995-2016................ 20
Figure 4: Total Proportions of Number of ANC Visits in Uganda, 1995-2016 ........................... 20
Figure 5: Urban-Rural Disparities in Number of ANC Visits Uganda, 1995-2016 ..................... 21
Figure 6: Map of Districts of Uganda by Women's Ability to Read a Whole Sentence............... 22
Figure 7: Map of Districts of Uganda by Women’s Use of Mobile Phones ................................ 23
Figure 8: Map of Districts of Uganda by Women’s Use of Mobile Phones for Finance ............. 24

Table 1: Color Coding Key for All Tables ................................................................................. 25

Table 2: Central Region of Uganda, Districts and Sub-Regions by Residency Status ................. 25
Table 3: Northern Region of Uganda, Districts and Sub-Regions by Residency Status .............. 26
Table 4: Western Region of Uganda, Districts and Sub-Regions by Residency Status ............... 27
Table 5: Eastern Region of Uganda, Districts and Sub-Regions by Residency Status................. 28
Table 6: Proportion of Live Births and Assistance by Skilled Provider by Sub-Region .............. 29
Table 7: Literacy and Mobile Phone Use by Districts of Uganda ............................................... 30

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Abstract

SMS Maama is a maternal health education mobile health (mHealth) project that aims to

improve maternal and newborn health (MNH) outcomes and seeks to expand from urban

Kampala to rural areas of Uganda. This report’s goal is provide recommendations for conducting

SMS Maama’s programming in rural regions. Methods include a narrative review of the

literature specific to Uganda on the delays to seeking antenatal care, and tabulations of data from

the 2016 Demographic Health Survey (DHS) for women, looking at the variables of antenatal

care from a skilled provider, delivery at a health facility, and delivery assisted by a skilled

provider, literacy levels, mobile phone use. The results indicate that places most amenable to

SMS Maama’s programming include central, western, and possibly eastern sub-regions, which

are ranked. The program requires participants to be literate and have consistent access to a

mobile phone, making the sub-regions of Ankole or Teso optimal rural areas for expansion

outside of central Uganda. However, SMS Maama also needs to take into account their capacity

to take on partnerships in this region and further analyze how women use health services in this

area. These findings have implications for other programs also conducting mHealth or MNH

programming in rural areas for understanding literacy and access to mobile phone technology for

medical use.

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Introduction

Uganda currently experiences geographic disparities in Maternal and Newborn Health

(MNH) outcomes. This is of particular importance to the program, SMS Maama, which is a

maternal health education and mobile health (mHealth) project that aims to improve MNH

outcomes by delivering educational text messages directly to women. This program is currently

conducting its pilot research study in Kampala, Uganda, with the eventual aim expanding to rural

areas of Uganda. Through the lens of Uganda’s geographic regions, this report contains

descriptive tabulations from the 2016 Demographic Health Survey (DHS) for women and

narratively summarizes the current literature on antenatal care (ANC) in Uganda and any

relevant applications of SMS-based mHealth. Indicators of interest include antenatal care from a

skilled provider, delivery at a health facility, and delivery assisted by a skilled provider; these

will illustrate the local need for antenatal care. Variables selected for tabulation include literacy

levels, and mobile phone use, which define the minimum requirements to participate in the

program. Thus, to better understand the needs of rural populations in Uganda, this paper will

serve as justification for any further expansion of the program and provide localized

recommendations for conducting SMS Maama’s programming.

Background

Uganda’s Antenatal Care

Uganda’s state of ANC is among the poorest in the world with 2.4 million pregnancies a

year, but the current workforce availability can only meet an estimated 27% of these clinical

needs (UNFPA, 2018). The need to fulfill these gaps in ANC is all the more important

considering that the maternal mortality ratio is 343 deaths per 100,000 live births and the neo-

natal infant mortality rate is 21 deaths per 100,000 live births, ranked the 36th and 51st highest in

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the world, respectively. However, MNH policies tends to rely on aggregated statistics that exist

at the national level, which can mask the sub-national and regional trends that reveal distinct

differences in quality of ANC (Ruktanonchai et al. 2016). Uganda’s most recent Demographic

Health Survey (DHS) shows that in rural areas of Uganda, 44% of women were not able to

access a skilled birth attendant, compared to 8.6% in urban areas, even though rural births make

up 89% of all births in Uganda (UBOS, 2016).

SMS Maama and mHealth

SMS Maama is a University of Minnesota student-run business venture aimed at increasing

access to maternal health information through a mobile health application. The organization is

currently conducting an IRB-approved pilot research study to test efficacy, feasibility, and

acceptance of its mHealth delivery system. The mHealth application works by sending women

text message (SMS) reminders through their mobile phones. It automatically sends three types of

simple-language text messages to women looking for more information about their pregnancies.

First, it sends informational texts related to pregnancy, birth, and the post-partum period. Second,

it sends antenatal appointment reminders, which encourage women to attend the appointments

and bring their partners with them to the clinic. Third, it sends yes/no screening questions to

identify serious health conditions, link women to care if needed, and also educate them on signs

and symptoms for the future. Women are also incentivized to participate with the provision of a

safe birthing kits, also known as a “maama kit”, which she can use during her delivery at a

hospital. These kits are often necessary because hospitals frequently lack adequate supplies and

often must turn women away (SMS Maama, 2018).

The justification for this program is modeled on previous mHealth program designs, and

specifically SMS mHealth projects that showed high response rates and activity in Uganda (de

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Lepper et al., 2013; Roberts et al, ). A randomized controlled trial intervention on 1311 women

in Zanzibar, Tanzania, demonstrated that their mobile phone interventions of a similar design to

SMS Maama’s led to a statistically significantly increased in skilled delivery attendance in urban

residence but was not able to impact rural areas. The authors claimed that the primary barriers

were likely the lack of access to mobile phones, compounded by high levels of illiteracy required

to send and read text messages (Lund et al., 2012). This highlights the need to analyze districts

by literacy level and access to mobile phones to determine appropriate places for implementing

an intervention similar to SMS Maama.

Literature Review

Regions of Uganda

For the purposes of most governmental administration, and for the DHS, Uganda is divided

into regions, sub-regions, districts. Figure 1 provides an overview of the central, north, east, and

west regions, while Figure 2 provides an overview of the districts’ and sub-regions’ urban-rural

proportional composition. Notably, the only sub-region that is a majority urban is Kampala. This

is because while a majority of the population lives in rural areas, the central region contains the

capital of Kampala, which gives it the largest proportion of urban residents. Lastly, there are only

five out of 112 districts that are majority urban1, with two in the central region (Table 2), one in

the northern region (Table 3), and one in the western region (Table 4), and none in the eastern

region (Table 5). Because of the overwhelming number of districts that are rural, it is all the

more important to pay attention to the specificities of rural areas.

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All tables are color coded according to Table 1 to represent the magnitude of proportionality.

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 Methodology

A review of the current literature used a variety of search terms, including Uganda, antenatal

care, rural, maternal health, pregnancy, mHealth, and mobile phone(s). Searches were conducted

in databases such as POPLINE, PubMed; articles that were determined relevant were included

anything written in the last 10 to 15 years, or 20 years if it was particularly relevant in other

areas. Relevant articles had to specifically focus on Uganda or compare Uganda to other

countries in the areas of antenatal care and maternal health. The designs of the studies could be

wide in their nature, and included both quantitative and qualitative methods, such as

demographic analyses, program evaluations of interventions, and ethnographic research. For

articles related to mHealth, inclusion criteria included being in East Africa and relevant to the

other search terms.

Common Themes

While the literature was not robust enough to identify trends distinguished by Uganda’s

geographic diversity, there were common themes that arose from the literature that met the

aforementioned search criteria. The review is structured around common indicators and how they

affect the ANC Attendance, delivery at institution, and skilled birth attendant at delivery. Also

contributing to the review structure are themes that arose from the Three Delays Model, which

identifies three key areas that block access to maternal health, including the delay in deciding to

seek care, the delay in reaching care, and the delay in receiving adequate health care (Maine,

1994).

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 Indicators

Antenatal Care Visits

The WHO recommends four antenatal care visits for an uncomplicated pregnancy, and

more in the case of complications (UNFPA 2018). Uganda currently faces disparities, with 66%

and 59% of women in urban and rural residences who make four or more ANC visits,

respectively (Figure 3). However, this disparity has been decreasing since its spike at a 27.7

percentage point difference in 2000, to a 7.9 percentage point difference in 2016 (Figure 5).

Moreover, this indicator has been increasing over time for the country as a whole, from 47% of

women making four or more visits in 1995 to 60% in 2016 (Figure 4). This is substantial

considering that a vast majority of the population lives in rural populations (UBOS, 2016).

An example of the attitudes behind this increase in ANC visits comes from a survey completed

in some northern districts of Uganda, where almost all women (94.5%) believed that starting

antenatal care visits early was beneficial to their pregnancy (Turyasiima et al. 2014). These

districts (Adjumani, Amuru, Kitgum, Lamwo, and Pader) are overwhelmingly rural, ranging

from 63-100% (Table 3). While variables age and number of children did not show to have an

effect on increasing the likelihood of obtaining four or more antenatal care visits, the variables

for increased education and wealth were shown to be positively correlated (Ruktanonchai et al.,

2016).

Delivery in a Formal Institution

Delivery at a formal institution in Uganda has shown to be related to parity and health

worker counseling. According to Paina et al., Uganda fares far better (71%) in the percentage of

women who deliver in a formal institution compared to Bangladesh (13%) and India (47%).

Overall, they found that women who had more than one child were also more likely to deliver in

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an institution (2016). Additionally, a mixed methods study in the Gulu district of Northern

Uganda supports the claim that a woman receiving advice from their health care worker to

deliver at the health facility was statistically significantly more likely to report giving birth at a

formal health facility (Anastasi et al., 2015).

Skilled Birth Attendant

A little over half of all women in rural areas who had delivered within the past 5 years at

the time of the 2011 DHS (55%) had a skilled birth attendant at their birth (Kwagala, 2013). The

statistically significant predictors of this factor were household wealth status, partner’s

education, ANC attendance, and level of parity. Similarly, Ruktanonchai et al. found that age and

parity were highly associated with outcomes, with older women more likely to have a skilled

birth attendant with each child they had (2016). Anastasi et al. also demonstrated that primary

barriers for women in having a skilled birth attendant were fear of maltreatment and neglect by

health care workers, lack of support for husband or partner, material factors, poverty,

transportation access, and preference for traditional methods and birthing positions (2015).

Delay in Decision to Seek Care

Traditional Beliefs

Traditional beliefs are often a substantial barrier in delaying the decision to seek care in

Uganda. For example, women may adhere to traditional birthing practices due to common beliefs

that pregnancy is a test of endurance, and the normalization or fatalistic attitudes towards

maternal death. Moreover, health units are considered as only a last resort when there are

complications (Kyomuhendo 2003). In a study by Amooti-Kaguna & Nuwaha, they found that

about 17% of women delivered with traditional birth attendants (2000). However, some women

prefer births at health facilities as a last option to assist with hemorrhaging and other obstetric

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issues, but often report fear of physical and emotional abuse of health care workers who scold

women about their health behaviors, often due to cultural differences and negative stereotypes

(Kwagala 2013). These research results are consistent with reasons behind why other women in

low and middle-income countries, according to a meta-analysis by Finlayson & Downe that

found most antenatal care to be odds with local beliefs (2013).

Support of Husband or Spouse

There is also a demonstrable link between spousal support and antenatal health outcomes,

wherein women can face issues in convincing their husbands to bring them to the hospital, as

Kwagala’s mixed methods study reported. While one woman preferred a hospital birth, her

traditional birthing attendant and husband did not approve and she felt compelled into an

unwanted home birth (2013). In a separate study, Kwagala also found that partner’s education

was statistically significant in whether or not she had a skilled birth attendant (2016). This is

valid considering that social influence from the spouse and relatives was a factor found to have a

statistically significant correlation with determining whether a woman would deliver in a formal

institution (Amooti-Kaguna & Nuwaha 2000), and the lack of support for husband or partner was

demonstrated to be a primary barrier for women in having a skilled birth attendant (Anastasi et

al. 2015).

Delay in Reaching Care

In addition to living in rural areas, Uganda’s natural topography introduces delays in

reaching care. Specifically, living in a rural area was associated with decreased odds in obtaining

MNH health care for the three key indicators (Ruktanonchai et al. 2016). “Southern” Uganda

(the central and western regions), despite its urban capital, actually had the lowest accessibility to

health facilities within the 5-country area of Uganda, Kenya, Tanzania, Rwanda, and Burundi,

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primarily due to the presence of Lake Victoria. Transportation access has also been reported as a

primary barrier to women accessing a skilled birth attendant (Anastasi et al. 2015). Rural delays

to care are underpinned by Finlayson & Downe’s findings for low and middle-income countries

that most antenatal care is hampered by the physical danger in paying for services and traveling

(2013).

Delay in Receiving Adequate Health Care

Supply Shortages

Many areas of Uganda, particularly in the eastern region, have been severely impacted by

a “brain drain” and thus a lack of adequate staffing available, particularly among nurses, who

provide key maternal health services. This leads to an insufficient provision of the full package

of antenatal care including tests, counseling women on risk factors, and preparing them for birth.

Hospital or health center visits are also characterized by long waiting times and frequent

shortages in essential drugs (Tetui et al. 2012, Finlayson and Downe 2013). Another key

example stems from a study in the Inganga and Mayuge districts in Eastern Uganda, where some

midwives admitted that they skipped routine examinations due to being overburdened by high

client loads, or due to not having enough equipment or drugs. This overburdening was evidenced

by the fact that women were often not checked for anemia, which requires no equipment, nor

were they checked for blood pressure or weight, even when the equipment was available (Conrad

et al. 2012).

Maama Kits

While Uganda is legally required to provide all mothers with a maama kit, health centers

often lack in supplies and women must purchase one for themselves, so they are not turned away

if they seek delivery assistance at a formal institution. Providing women with maama kits is an

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obvious way to give women with the supplies they need for a safe delivery2. However, some

evidence points to the idea that providing them can improve other birthing outcomes. While the

reasons for poor quality care are complex, one study in Northern Uganda reported an increase in

the number of pregnant women who deliver at their facility with the increased provision of

maama kits (Ediau et al. 2013). Amooti-Kaguna & Nuwaha also concluded from their study’s set

of semi-structured interviews that it was important to train and reach out to trained birth

attendants to equip them with maama kits, citing that this could help to reduce maternal mortality

even if women aren’t able to deliver at a formal institution (2000).

Abuse by Health Care Workers

As previously mentioned, health units are often considered as only a last resort when

there are complications (Kyomuhendo 2003). This is not only due to lack of skilled staff and

supplies, but complaints of poor treatment by hospital staff. Women report being abused or

neglected, not understanding the reasons for their procedures, and complain that health workers

tend to view them as ignorant or stupid (Kyomuhendo 2003; Anastasi et al. 2015). Women also

overwhelmingly report fear of physical or emotional abuse by health care workers, including

scolding them for traditional practices or physically assaulting them, and that this is often due to

cultural differences and negative stereotypes (Kwagala 2013; Finlayson and Downe 2013).

Counseling

In addition to hostile health care workers, counseling and education on maternal health is

often lacking in health care settings. Ayiasi et al. speculate that this is largely due to the fact that

staff are more inclined to offer clinical services in lieu of health education (2015). Other

2
Maama kits include plastic sheeting, razor blades, cotton wool, gauze pad, soap, surgical gloves, exam gloves, cord
ties, and a child health card.

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qualitative research by Ayiasi et al. that shows health education is provided in terms of a top-

down information transfer, as healthcare workers are not trained to counsel or educate (2013).

This is consistent with Conrad et al.’s research showing that health education services at

antenatal care visits are often of poor quality and poorly retained by the attendees (2012).

Midwives did not have a systemic way of making sure each client received all relevant

information, as education settings were often conducted in groups, and topics varied day to day.

As a result, women could not describe components of good pregnancy nutrition, or recognize

danger signs of a pregnancy. The counseling around antenatal health is also poor, as women

often had poor levels of knowledge on pregnancy-related topics, except for information related to

HIV (2012).

DHS Analysis

Descriptive statistics available in the 2016 UDHS final report do not disaggregate variables

at the district level (UBOS, 2016). However, UDHS datasets allow for disaggregation at the

district level for tabulating weighted frequencies, but at this level the sample sizes are too small

to conduct reliable statistical analyses. However, frequency tables are useful for estimating

proportions of these small populations that may be the target of service provision for SMS

Maama.

Results

Disaggregating national level statistics to the regional, sub-regional, and district level trends

allows for a more nuanced understanding of how antenatal care varies, where are the largest

disparities, and how have important indicators changed over time. Overall, there were six

primary variables examined. The first three are common indicators, measured as 1) the

percentage of live births in the three years preceding the survey who received antenatal care from

10
a skilled provider, 2) delivered at a health facility, and 3) assisted by a skilled provider. The data

for variables 1-3 were collected from STATcompiler which is online software that “allows users

to make custom tables based on thousands of demographic and health indicators through the

DHS website” (STATcompiler). However, this only allows for disaggregation at the sub-

regional level. The last three variables are 4) the proportion of women who are able to read a

whole sentence, 5) who own a mobile telephone, and 6) who use a mobile phone for financial

transactions. Variables 4-6 were analyzed and disaggregated at the district level by using the

UDHS datasets in STATA.

Per Table 6, the western sub-region of Bunyoro was ranked the lowest in antenatal care from

a skilled provider (0.92) and the eastern sub-region of Bugishu was ranked lowest in the

indicators of delivery at health facility (0.56) and delivery assisted by skilled provider (0.58).

The western sub-region of Kigezi was ranked the highest in antenatal care from a skilled

provider (~1.00), whereas the central sub-region of Kampala (home to the capital, Kampala),

ranked the highest in the indicators of delivery at health facility (0.94) and delivery assisted by

skilled provider (0.96).Literacy levels are summarized in Table 7, and literacy levels are mapped

in Figure 6. Mobile phone use is also mapped in Figure 7 showing the percent of women who

own a mobile telephone, and mapped in Figure 8 showing the percent of women who use a

mobile phone for financial transactions.

The areas with the highest level of literacy and phone ownership by women are in various

districts in the Central 1 sub-region and in the district of Bushenyi (Map ID = 12). The central

district of Wakiso (Map ID = 76) in the Central 1 sub-region has the highest proportion of

literacy (0.84) and mobile phone ownership (0.82), and the district of Kotido (Map ID = 44) in

the northern subregion of Karamoja has the lowest levels in both categories as well (0.02 and

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0.03, respectively). Overall, the central and western regions have higher literacy and mobile

phone use compared to the northern and eastern regions.

When looking at mobile phone use for financial transactions, the trend follows a similar

pattern to mobile phone ownership but is almost always a larger proportion. The only district that

is obvious outlier in this pattern is Bundibugyo (Map ID = 11), in the western sub-region of

Tooro, which has a negative 24 percentage point difference in mobile phone ownership

subtracted from mobile phone use for financial transactions.

Discussion

The combination of the themes from the literature review and the demographic analysis

show that there is substantial potential for program implementation for SMS Maama in rural

areas, as it addresses at all three of the delays in deciding to seek care and provides significant

incentives for women to deliver at a hospital and/or with a skilled birth attendant. SMS Maama’s

program design is suited to overcome both the first and third delay in deciding to seek care,

specifically regarding the fear of abuse by health workers, and the ineffective counseling that

exists in hospitals. The literature suggests that at least a majority of women, as high as 95% of

them in northern and possibly other regions, have a desire to seek out antenatal care but often

face hurdles related to either community or personal traditional beliefs. Using a mobile phone

could allow for privacy and consistency in providing education to women.

SMS Maama’s program is also especially well-suited for addressing the second delay to

care, particularly because rural areas in Uganda tend to have substantial barriers to care,

particularly in the “southern” areas where there is a lack of transportation access. The evidence

surrounding maama kits is helpful considering that even in the northern region, which is

substantially more impoverished, this is a strong enough incentive for women to make the

12
journey to deliver at a hospital. This suggests that an intervention with supplying maama kits

could be successful other regions that are less impoverished.

Potential areas where this could be successful would have to have a literate population of

women and a high proportion of mobile phone ownership. Areas with high literacy and high

mobile phone use for women tend to overlap, which is likely correlated with other unexamined

variables such as socioeconomic status or education. Many of the areas with low literacy and

high mobile phone use for women tend to be 100% rural, which makes it difficult to find an

optimal area that would most benefit from program implementation but would also have a

population that is both literate and owns a mobile phone.

The larger use of mobile phones for financial transactions compared to mobile phone

ownership among women is also indicative that even a lack of phone ownership might not be a

substantial barrier. This could likely be to people borrowing other people’s cells phones to make

quick financial transactions through phone calls, or it could be that financial transactions using a

mobile phone do not require literacy skills, depending on whether they are calling or doing SMS-

based transactions. This is important to point out to demonstrate how mobile phone sharing is

possible through networks, opening the doors for other forms of telemedicine related to antenatal

health programming for SMS Maama.

Recommendations

When selecting rural areas for program implementation, not only is it important to select

areas with high rates of literacy and high use of mobile phones, but to consider how existing

health trends in rural areas might interact with a program implementation of SMS Maama.

When ranking the variables of by proportion of rural residents, literacy, and cell phone use, there

are three districts that stand out in the top within the Central region. They are in the sub-regions

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Central 1, districts Kalungu, Bukomansimbi, or Butambala (Map IDs = 90, 84, and 86,

respectively). One option would be to expand programming to these areas; Butambala has a rural

population of at least 85,000, whereas Kalungu and Bukomansimbi are around 150,000 each,

according to the latest 2014 census. Even though these districts are a little under average in

population size compared to other rural districts in Uganda, because they are geographically

contiguous, it would also be possible to hypothetically serve across all of them if the program

were to expand beyond the population of a single district.

However, if SMS Maama were to expand beyond the central region, the same ranking of

districts excluding all central ones shows that either the eastern sub-regions of Teso (contiguous

districts Serere and Ngora, Map IDs =110, 105, respectively) or the western sub-region of

Ankole (home to the non-contiguous districts Mitooma or Buhweju, Map IDs = 102, 81,

respectively).

Additionally, Serere and Ngora have rural populations of at least 270,000 and 130,000,

respectively, whereas Mitooma and Buhweju have 174,000 and 121,000, respectively. It would

be possible to expand to these populations and thus serve a greater number of women within the

area who may need antenatal care and counseling but are unable to make the trips to the hospital

because of their rural location.

Comparing Ankole and Teso’s antenatal health indicators shows that Ankole has only a

slightly higher need than Teso across all three key indicators. However, evidence from the

literature points to a potentially higher need in regions closer to Lake Victoria, which showed

access to health care decreased with increased proximity to the lake, making Ankole the

preferred choice. However, choosing between the districts in Teso and Ankole would come

down to deciding how rural of a population SMS Maama is capable of serving, as well as further

14
investigation into capacity and willingness of local partners to participate in implementing SMS

Maama’s programming.

Conclusion

SMS Maama’s expansion into rural areas of Uganda is feasible for the current design of

the program. The literature on antenatal care in rural areas of Uganda suggests that interventions

of a similar nature have improved antenatal care outcomes, such as the provision of maama kits

to women. Moreover, the primary delays to seeking care are areas where the implementation of

mHealth would be especially well suited to address transportation issues, community stigma, and

lack of spousal support for transportation. It would also supply the education and counseling that

is often lacking in physical hospitals by nurses, and circumvent discrimination by health care

workers against rural patients with traditional beliefs. Because the program requires participants

to be literate and own a mobile phone, a prime rural area that meets these requirements is the

sub-region of Ankole. However, successful program implementation is dependent on effective

partnership with local hospitals. For future analysis, other variables not taken into consideration

in this report would include the type and capacity of health facilities by district level, as well as

women’s preference for facility type, e.g. public or private. With thoughtful programming, and

particular consideration to population demographics, SMS Maama’s program expansion can

serve as a model for improving MNH outcomes in rural settings.

15
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Kwagala, B., Nankinga, O., Wandera, S. O., Ndugga, P., & Kabagenyi, A. (2016).
Empowerment, intimate partner violence and skilled birth attendance among women in
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Figure 1: Map of Uganda Regions

Regions
Northern
Eastern
Western
Central West Nile Acholi

Karamoja

Lango

Teso
Bunyoro
Bugisu

Central 2 Bugosa

Tooro Bukedi

Central 1
Kampala
Ankole

Kigezi

0 40 80 160 Miles

18
Figure 2: Map of Districts of Uganda by Percent of Urban Residents (With Map IDs)

% of Residences Urban
0% - 20%
20.1% - 40%
40.1% - 60% 22
58
43 77 97
60.1% - 80% 42

80.1% - 100% 50 2
39
44
6 68
78
17
1
57
112 107
65 108
104
67
93
47 79
4
92
10 16
5 35
62
25 74
52 80
3
105
110 85 94
18 45
64 83 33
88 9
69
73
95 63
28 91 7 49
106 54
37 30 14 101
38 48 15
36
11 98 75
46 20
24 60 21 8
96 56
13
29 82 53
31
89 86 61 103
34 76
72 59
19 87
84 90
40 100
109 27
81
99
12 51
111 55
102
71 70
32 26
66

41 23

0 40 80 160 Miles

19
Figure 3: Urban-Rural Proportions of Number of ANC Visits in Uganda, 1995-2016

Figure 4: Total Proportions of Number of ANC Visits in Uganda, 1995-2016

20
Figure 5: Urban-Rural Disparities in Number of ANC Visits Uganda, 1995-2016

21
Figure 6: Map of Districts of Uganda by Women's Ability to Read a Whole Sentence

% of Women Literate
0% - 20%
20.1% - 40%
40.1% - 60%
60.1% - 80%
80.1% - 100% West Nile Acholi

Karamoja

Lango

Teso
Bunyoro
Bugisu

Central 2 Bugosa

Tooro
Bukedi

Central 1
Kampala
Ankole

Kigezi

0 40 80 160 Miles

22
Figure 7: Map of Districts of Uganda by Women’s Use of Mobile Phones

% of Women Using
Mobile Phones
0% - 20%
20.1% - 40%
40.1% - 60%
60.1% - 80%
80.1% - 100% West Nile Acholi

Karamoja

Lango

Teso
Bunyoro
Bugisu

Central 2 Bugosa

Tooro
Bukedi

Central 1
Kampala
Ankole

Kigezi

0 40 80 160 Miles

23
Figure 8: Map of Districts of Uganda by Women’s Use of Mobile Phones for Finance

% of Women Using
Mobile Phones for Finance
0% - 20%
20.1% - 40%
40.1% - 60%
60.1% - 80%
80.1% - 100% West Nile Acholi

Karamoja

Lango

Teso
Bunyoro
Bugisu

Central 2 Bugosa

Tooro
Bukedi

Central 1
Kampala
Ankole

Kigezi

0 40 80 160 Miles

24
Table 1: Color Coding Key for All Tables
Key
Highest Value in Range of Variable
Lowest Value in Range of Variable

Table 2: Central Region of Uganda, Districts and Sub-Regions by Residency Status

Sub-Region Kampala Central 1 Central 2

Map ID Districts vs. Residency Urban Rural Urban Rural Urban Rural
29 Kampala 1.00 0.00
76 Wakiso 0.65 0.35
51 Masaka 0.44 0.56
59 Mpigi 0.43 0.57
99 Lwengo 0.26 0.74
72 Ssembabule 0.12 0.88
27 Kalangala 0.07 0.93
70 Rakai 0.00 1.00
84 Bukomansimbi 0.00 1.00
86 Butambala 0.00 1.00
89 Gomba 0.00 1.00
90 Kalungu 0.00 1.00
100 Lyantonde 0.00 1.00
82 Buikwe 0.86 0.14
95 Kyankwanzi 0.44 0.56
61 Mukono 0.36 0.64
64 Nakasongola 0.36 0.64
56 Mityana 0.35 0.65
48 Luwero 0.21 0.79
87 Buvuma 0.11 0.89
60 Mubende 0.09 0.91
36 Kayunga 0.00 1.00
38 Kiboga 0.00 1.00
63 Nakaseke 0.00 1.00
Total Proportion Urban/Rural 1.00 0.00 0.42 0.58 0.29 0.71

25
Table 3: Northern Region of Uganda, Districts and Sub-Regions by Residency Status

Sub-Region Acholi Karamoja West Nile Lango

Map ID Districts vs. Residency Urban Rural Urban Rural Urban Rural Urban Rural
17 Gulu 0.38 0.62
42 Kitgum 0.36 0.64
97 Lamwo 0.21 0.79
78 Agago 0.18 0.82
68 Pader 0.00 1.00
107 Nwoya 0.00 1.00
39 Amuru 0.00 1.00
44 Kotido 0.69 0.31
57 Moroto 0.16 0.84
62 Nakapiripirit 0.09 0.91
104 Napak 0.00 1.00
22 Kaabong 0.00 1.00
80 Amudat 0.00 1.00
1 Abim 0.00 1.00
2 Adjumani 0.49 0.51
50 Maracha 0.23 0.77
77 Yumbe 0.22 0.78
65 Nebbi 0.11 0.89
6 Arua 0.03 0.97
112 Zombo 0.00 1.00
58 Moyo 0.00 1.00
43 Koboko 0.00 1.00
16 Dokolo 0.26 0.74
47 Lira 0.20 0.80
108 Otuke 0.17 0.83
93 Kole 0.09 0.91
67 Oyam 0.00 1.00
5 Apac 0.00 1.00
3 Amolatar 0.00 1.00
79 Alebtong 0.00 1.00
Total Proportion Urban/Rural 0.23 0.77 0.20 0.80 0.13 0.87 0.08 0.92

26
Table 4: Western Region of Uganda, Districts and Sub-Regions by Residency Status

Sub-Region Ankole Bunyoro Kigezi Tooro

Map ID Districts vs. Residency Urban Rural Urban Rural Urban Rural Urban Rural
111 Sheema 0.61 0.39
19 Ibanda 0.48 0.52
55 Mbarara 0.47 0.53
12 Bushenyi 0.37 0.63
40 Kiruhura 0.19 0.81
66 Ntungamo 0.12 0.88
26 Isingiro 0.12 0.88
109 Rubirizi 0.00 1.00
102 Mitooma 0.00 1.00
81 Buhweju 0.00 1.00
92 Kiryandongo 0.32 0.68
52 Masindi 0.27 0.73
18 Hoima 0.20 0.80
37 Kibaale 0.06 0.94
10 Buliisa 0.00 1.00
32 Kanungu 0.27 0.73
71 Rukungiri 0.24 0.76
23 Kabale 0.17 0.83
41 Kisoro 0.00 1.00
106 Ntoroko 0.48 0.52
24 Kabarole 0.32 0.68
34 Kasese 0.27 0.73
96 Kyegegwa 0.15 0.85
46 Kyenjojo 0.10 0.90
31 Kamwenge 0.00 1.00
11 Bundibugyo 0.00 1.00
Total Proportion Urban/Rural 0.28 0.72 0.18 0.82 0.17 0.83 0.21 0.79

27
Table 5: Eastern Region of Uganda, Districts and Sub-Regions by Residency Status

Sub-Region Bugishu Bukedi Busoga Teso

Map ID Districts vs. Residency Urban Rural Urban Rural Urban Rural Urban Rural
33 Kapchorwa 0.45 0.55
54 Mbale 0.37 0.63
101 Manafwa 0.14 0.86
73 Sironko 0.13 0.87
9 Bukwo 0.00 1.00
49 Bududa 0.00 1.00
85 Bulambuli 0.00 1.00
94 Kween 0.00 1.00
13 Busia 0.24 0.76
15 Butaleja 0.18 0.82
75 Tororo 0.17 0.83
69 Pallisa 0.08 0.92
7 Budaka 0.00 1.00
91 Kibuku 0.00 1.00
21 Jinja 0.45 0.55
8 Bugiri 0.37 0.63
103 Namayingo 0.29 0.71
30 Kamuli 0.15 0.85
20 Iganga 0.13 0.87
14 Namutumba 0.00 1.00
28 Kaliro 0.00 1.00
53 Mayuge 0.00 1.00
88 Buyende 0.00 1.00
98 Luuka 0.00 1.00
74 Soroti 0.40 0.60
83 Bukedea 0.17 0.83
45 Kumi 0.16 0.84
4 Amuria 0.00 1.00
25 Kaberamaido 0.00 1.00
35 Katakwi 0.00 1.00
105 Ngora 0.00 1.00
110 Serere 0.00 1.00
Total Proportion Urban/Rural 0.22 0.78 0.13 0.87 0.16 0.84 0.13 0.87

28
Table 6: Proportion of Live Births and Assistance by Skilled Provider by Sub-Region

ANC from Skilled Delivered at Health Delivery Assisted by

Region Sub-Region
Provider* Facility** Skilled Provider***
Western Kigezi 1.00 0.70 0.71
Eastern Teso 0.99 0.74 0.75
Central Central 2 0.99 0.75 0.77
Northern West Nile 0.99 0.78 0.78
Western Tooro 0.98 0.74 0.76
Central Kampala 0.98 0.94 0.96
Eastern Busoga 0.98 0.77 0.75
Northern Acholi 0.97 0.84 0.81
Northern Karamoja 0.97 0.71 0.73
Northern Lango 0.97 0.66 0.68
Eastern Bugishu 0.97 0.56 0.58
Western Ankole 0.97 0.71 0.71
Eastern Bukedi 0.97 0.66 0.67
Central Central 1 0.96 0.81 0.82
Western Bunyoro 0.92 0.57 0.58

Full Indicator Definitions as Defined by the DHS

* Percentage of live births in the three years preceding the survey who received antenatal care from a skilled
provider
** Percentage of live births in the three years preceding the survey delivered at a health facility
*** Percentage of live births in the three years preceding the survey assisted by a skilled provider.

29
Table 7: Literacy and Mobile Phone Use by Districts of Uganda

Uses Mobile
Able to Read a Owns a mobile
Map ID District Sub-Region Region Phone for
Whole Sentence telephone
Finance*
1 Abim Karamoja North 0.41 0.22 0.69
2 Adjumani West Nile North 0.46 0.36 0.51
3 Amolatar Lango North 0.47 0.08 0.80
4 Amuria Teso East 0.46 0.21 0.56
5 Apac Lango North 0.41 0.11 0.51
6 Arua West Nile North 0.45 0.35 0.51
7 Budaka Bukedi East 0.43 0.26 0.80
8 Bugiri Busoga East 0.47 0.38 0.76
9 Bukwo Bugishu East 0.15 0.15 1.00
10 Buliisa Bunyoro West 0.13 0.16 0.29
11 Bundibugyo Tooro West 0.18 0.46 0.22
12 Bushenyi Ankole West 0.80 0.64 0.70
13 Busia Bukedi East 0.49 0.40 0.76
14 Namutumba Busoga East 0.46 0.24 0.50
15 Butaleja Bukedi East 0.35 0.16 0.82
16 Dokolo Lango North 0.44 0.29 0.52
17 Gulu Acholi North 0.46 0.35 0.63
18 Hoima Bunyoro West 0.47 0.53 0.60
19 Ibanda Ankole West 0.75 0.55 0.58
20 Iganga Busoga East 0.61 0.42 0.81
21 Jinja Busoga East 0.64 0.68 0.84
22 Kaabong Karamoja North 0.03 0.04 0.64
23 Kabale Kigezi West 0.69 0.48 0.61
24 Kabarole Tooro West 0.56 0.56 0.62
25 Kaberamaido Teso East 0.49 0.23 0.49
26 Isingiro Ankole West 0.59 0.43 0.55
27 Kalangala Central 1 Central 0.63 0.69 0.81
28 Kaliro Busoga East 0.38 0.10 0.55
29 Kampala Kampala Central 0.82 0.82 0.88
30 Kamuli Busoga East 0.62 0.41 0.89
31 Kamwenge Tooro West 0.40 0.42 0.52
32 Kanungu Kigezi West 0.72 0.58 0.75
33 Kapchorwa Bugishu East 0.57 0.51 0.62
34 Kasese Tooro West 0.45 0.46 0.69
35 Katakwi Teso East 0.44 0.11 0.75
36 Kayunga Central 2 Central 0.39 0.31 0.64
37 Kibaale Bunyoro West 0.41 0.33 0.59

30
 Uses Mobile
Able to Read a Owns a mobile
Map ID District Sub-Region Region Phone for
Whole Sentence telephone
Finance*
38 Kiboga Central 2 Central 0.64 0.47 0.74
39 Amuru Acholi North 0.26 0.12 0.45
40 Kiruhura Ankole West 0.64 0.51 0.57
41 Kisoro Kigezi West 0.45 0.43 0.64
42 Kitgum Acholi North 0.47 0.22 0.59
43 Koboko West Nile North 0.18 0.17 0.30
44 Kotido Karamoja North 0.02 0.03 0.15
45 Kumi Teso East 0.64 0.23 0.72
46 Kyenjojo Tooro West 0.37 0.32 0.51
47 Lira Lango North 0.45 0.33 0.63
48 Luwero Central 2 Central 0.72 0.63 0.82
49 Bududa Bugishu East 0.41 0.22 0.63
50 Maracha West Nile North 0.26 0.31 0.39
51 Masaka Central 1 Central 0.76 0.82 0.82
52 Masindi Bunyoro West 0.51 0.49 0.60
53 Mayuge Busoga East 0.51 0.41 0.73
54 Mbale Bugishu East 0.61 0.55 0.85
55 Mbarara Ankole West 0.71 0.57 0.82
56 Mityana Central 2 Central 0.68 0.49 0.67
57 Moroto Karamoja North 0.23 0.28 0.63
58 Moyo West Nile North 0.39 0.41 0.32
59 Mpigi Central 1 Central 0.55 0.81 0.84
60 Mubende Central 2 Central 0.52 0.41 0.53
61 Mukono Central 2 Central 0.74 0.69 0.86
62 Nakapiripirit Karamoja North 0.20 0.19 0.67
63 Nakaseke Central 2 Central 0.59 0.62 0.69
64 Nakasongola Central 2 Central 0.70 0.54 0.68
65 Nebbi West Nile North 0.42 0.32 0.58
66 Ntungamo Ankole West 0.67 0.49 0.61
67 Oyam Lango North 0.46 0.23 0.56
68 Pader Acholi North 0.36 0.34 0.62
69 Pallisa Bukedi East 0.44 0.22 0.80
70 Rakai Central 1 Central 0.50 0.40 0.65
71 Rukungiri Kigezi West 0.72 0.55 0.74
72 Ssembabule Central 1 Central 0.56 0.48 0.85
73 Sironko Bugishu East 0.48 0.35 0.72
74 Soroti Teso East 0.64 0.46 0.78
75 Tororo Bukedi East 0.51 0.39 0.79
76 Wakiso Central 1 Central 0.84 0.82 0.86

31
 Uses Mobile
Able to Read a Owns a mobile
Map ID District Sub-Region Region Phone for
Whole Sentence telephone
Finance*
77 Yumbe West Nile North 0.20 0.32 0.39
78 Agago Acholi North 0.32 0.08 0.51
79 Alebtong Lango North 0.38 0.16 0.56
80 Amudat Karamoja North 0.03 0.18 0.13
81 Buhweju Ankole West 0.64 0.24 0.56
82 Buikwe Central 2 Central 0.70 0.70 0.96
83 Bukedea Teso East 0.57 0.35 0.74
84 Bukomansimbi Central 1 Central 0.78 0.53 0.82
85 Bulambuli Bugishu East 0.46 0.16 0.86
86 Butambala Central 1 Central 0.66 0.66 0.65
87 Buvuma Central 2 Central 0.44 0.52 0.76
88 Buyende Busoga East 0.37 0.24 0.85
89 Gomba Central 1 Central 0.51 0.37 0.70
90 Kalungu Central 1 Central 0.80 0.54 0.67
91 Kibuku Bukedi East 0.36 0.26 0.70
92 Kiryandongo Bunyoro West 0.38 0.25 0.73
93 Kole Lango North 0.31 0.11 0.42
94 Kween Bugishu East 0.34 0.12 0.86
95 Kyankwanzi Central 2 Central 0.76 0.64 0.71
96 Kyegegwa Tooro West 0.44 0.34 0.47
97 Lamwo Acholi North 0.55 0.22 0.52
98 Luuka Busoga East 0.69 0.38 0.81
99 Lwengo Central 1 Central 0.81 0.64 0.78
100 Lyantonde Central 1 Central 0.52 0.44 0.42
101 Manafwa Bugishu East 0.58 0.29 0.61
102 Mitooma Ankole West 0.72 0.59 0.86
103 Namayingo Busoga East 0.48 0.38 0.79
104 Napak Karamoja North 0.07 0.12 0.18
105 Ngora Teso East 0.60 0.23 0.63
106 Ntoroko Tooro West 0.41 0.43 0.53
107 Nwoya Acholi North 0.32 0.21 0.37
108 Otuke Lango North 0.34 0.11 0.31
109 Rubirizi Ankole West 0.51 0.49 0.66
110 Serere Teso East 0.64 0.17 0.53
111 Sheema Ankole West 0.73 0.60 0.73
112 Zombo West Nile North 0.23 0.15 0.38
*Proportion of women who use mobile phone for financial transactions

32