By Dr. Bob Marley Achura (PhD)
In 2014, while conducting operational research on maternal and child health in Oyam District, Northern Uganda, I encountered a disturbing pattern, one so ordinary it risked being invisible. Health facilities required every expectant mother to carry an exercise book to record her antenatal and delivery information. A 48-page booklet, sold for less than 1,000 shillings, stood between life-saving care and denial.
It seemed like a harmless, even practical, requirement. But what I found was far more troubling: the “exercise book dilemma,” as it came to be known locally, was quietly sabotaging efforts to improve skilled deliveries and maternal outcomes. This simple paper booklet had become a gatekeeper, one that too often shut out the most vulnerable women.
A Walk of Pain and Shame.
Take Acen, a 28-year-old mother from Abela parish in Otwal sub-county. She walked three hours, under the punishing sun, to reach the nearest health centre, carrying her toddler on her back and her hopes in her heart. But when she arrived, the midwife frowned. “Where is your exercise book?” Acen had forgotten it. She was turned away. “Come back with your book,” they told her. The walk home was longer. Her body ached. Her spirit, too. That was her last antenatal visit during that pregnancy.
This is not an isolated story. From Alebtong to Amuru, women are carrying more than pregnancies; they’re carrying the burden of poverty, distance, stigma, and now, bureaucracy. Many mothers in Otwal confess they cannot afford even a single exercise book. Some tear out pages from their children’s schoolbooks. Others scribble health information on scraps of paper. A few have used old funeral programs, just to show something when they reach the clinic. In one heartbreaking case, a mother said her school-going child had taken her ANC book after being sent away for not having one. Another woman said her husband had used the pages to roll cigarettes.
What may sound absurd is, in reality, a quiet emergency. A paper book barely worth a coin has become the gatekeeper of life.
A Paper Barrier to Safe Motherhood
We often talk about Uganda’s maternal mortality challenge, about long distances to health centres, the lack of ambulances, and understaffed facilities. But rarely do we stop to examine these invisible, small barriers that tip the scales toward tragedy.
Let’s name them:
- Accessibility and Storage: Most rural families lack safe, dry spaces to store documents. Exercise books are destroyed by rain, eaten by rats, or misplaced entirely.
- Data Loss and Isolation: The information trapped inside these books is siloed. Health officers can’t analyze trends, track high-risk pregnancies, or make timely interventions.
- Out-of-Pocket Burden: Each year, thousands of shillings are spent by households on these books, money that could buy soap, food, or school fees.
- Stigma and Discrimination: Illiterate mothers are often humiliated or turned away when they present a “messy” book. Some stop returning out of shame.
These paper barriers are costing lives. They are reinforcing inequality. And yet, they persist, unchallenged and unfixed.
A Digital Ray of Hope: Then Bureaucracy Killed It!
In 2016, with support from Duke University postgraduate students and in partnership with the Oyam District Health Office, we piloted a simple but powerful solution: the Mothers Health Information Management System (MHIMS). It was a user-friendly mobile app tailored for frontline health workers. It worked offline, synced with the cloud when internet was available, and provided secure digital storage of maternal health records.
We deployed it at Agulurude Health Centre III. The impact was immediate and transformative:
- Midwives could retrieve a mother’s ANC history in seconds.
- Mothers no longer needed to carry paper books.
- Communication between providers and patients improved.
- Antenatal attendance increased.
- Skilled deliveries rose by 29.3% within just one year.
Financially, the case was even stronger. We found that maintaining MHIMS was 47% cheaper than the paper-based exercise book system. The difference? Digital costs are absorbed institutionally. The paper cost is carried by the mother.
But despite the glowing data, the pilot was never scaled. No further funding. No rollout. Just silence. Bureaucracy. Budget inertia. Leadership turnover.
I call it a betrayal.
Lessons from Across Africa.
Uganda is not alone in facing these barriers, but other countries are responding more boldly. In Rwanda, the RapidSMS system has transformed maternal care across rural districts. By using simple mobile phones, community health workers send real-time updates about pregnant women to district hospitals, allowing timely referrals and interventions. Maternal deaths have dropped significantly in pilot districts, and the model is now expanding nationwide.
In Kenya, the Linda Mama program (meaning “Protect the Mother”) enables digital registration of pregnant women and links them with free maternity services across public and some private facilities. Through NHIF’s digital platform, women no longer need to carry paper records, just their ID numbers.
These are not expensive, high-tech dreams. They are African realities, our continent proving that bold ideas can work.
A Call to Action: Now, Not Later
The exercise book dilemma is not about stationery. It is about values. It is about the invisible wall we place between mothers and the care they deserve. It is about the indignity of asking a woman in labour to produce a receipt before being helped.
This is not a call for tablets in every village. It is a call for:
- Immediate policy revisions to end the punitive rejection of mothers without exercise books.
- Investment in scalable, digital maternal health record systems.
- Training health workers to uphold compassion over compliance.
- Empowering community health workers to serve as record-keepers for vulnerable households.
A mother’s womb should never be treated with less dignity than a book.
Who Bewitched This Country?
Who decides that a child should be born or die because their mother didn’t bring a 1,000-shilling book? Who lets proven digital innovations rot on shelves while our maternal mortality rates remain unacceptably high?
We have solutions. We have champions. We have evidence. What we lack is the courage to act.
Let us unshackle our health system from outdated paper chains. Let us centre dignity in maternal care. Let us dare to build a system where no woman is turned away for lack of a booklet. Let the exercise book dilemma not be Uganda’s legacy. Let it be the turning point.
