Improving maternal and newborn quality of care in Uganda

Maternal death can have catastrophic consequences for the whole family. Deaths continue to be concentrated in the selected Maternal Newborn Health Quality of Care (MNH QoC) learning districts of Hoima, Kamuli, Kasese, Kiryandongo, Nwoya, and Sheema, where the lifetime risk of a woman dying from pregnancy-related causes is about 100 times higher than that of a woman in a high-income country.

In 2018, Uganda was selected to be among the 11 participating countries in the Global Maternal Newborn Health Quality of Care (MNH QoC) Network, a 5-year initiative. The other countries include Malawi, Tanzania, Ethiopia, Cote d'Ivoire, India, Nigeria, Bangladesh, Ghana, Sierra Leona, Uganda, and most recently Kenya.

The goals of the MNH QoC Network include reducing both facility-based maternal and newborn deaths by 50% and improving client satisfaction. Four strategic objectives were coined, and they include leadership, action, learning, and accountability. The network activities began in early 2017 but Uganda intensified its activities in January 2018 due to some leadership challenges, piloting in different regions of the country.

As a country’s response, in 2019 six learning districts including Hoima, Kamuli, Kasese, Kiryandongo, Nwoya, and Sheema were selected. The selection was based on a number of criteria including willingness to participate, good leadership, registration of high numbers of maternal deaths, and partner support.

Mindful of the critical role of leadership was critical, a Monitoring and Evaluation focal person at the Ministry of Health (MoH) from the Standards, Compliance, Accreditation, and Patient Protection (SCAPP) was appointed by top MoH leadership to support the adaptation of the Common Core Indicators for monitoring the MNH QoC Network activities. In addition, a National Roadmap was drawn and shared among the stakeholders. Both the Makerere University School of Public Health and the Private Midwives Association team conducted the baseline at an interval of 2 years after polishing the MNH QoC data collecting tools. The latter team also conducted the community dialogues within the respective participating 18 learning health facilities.

The Ministry, using Global Facility Financing (World Bank Funding Mechanism to support RMNCAH), through its Uganda Reproductive Maternal and Child Improvement Project (URMCHIP), facilitated training of 65 Trainers of Trainees (TOT) and over 400 frontline providers in the Point of Care Quality Improvement methodology, which was adapted from the World Health Organization SEARO Region and customized for use in Uganda.

Also, using additional funding from the same source, mentorships of health workers were conducted at the participating 18 health facilities, three in each of the selected districts.

Health facility-based frontline providers enhanced their skills to identify MNH QoC performance gaps, used Quality Improvement (QI) tools to analyze and prioritized those gaps, and developed aim statements, and started quality improvement projects, which the health facility teams documented in paper-based MoH documentation journal. There is also ongoing efforts to improve the experience of care through exit interviews with beneficiaries and their care-takers.

Among the best practices, providers emphasize the use of partograph to monitor mothers in active labor and are making efforts to reduce the decision to incision time for the Ceaserian Section to less than 60 minutes.

As a result, slight reductions in maternal deaths, fresh and macerated stillbirths have been registered. However, across the six districts, registered an increase in neonatal deaths with the main attribute being late arrivals associated with birth asphyxia.

The country MNH QoC Network developed recommendations to improve implementation in the selected districts and beyond.  Among these, is the need for feedback to program implementers in a timely way so that the maximum possible use of data is made for course correction. Results must also be shared widely, particularly with decision and policymakers who can make policy and program changes to improve health services for women and children.

Community participation in analyzing information and in identifying possible solutions will promote ownership, address social determinants, meet community needs and incorporate a range of actors in the response.

Collaboration among community members and service providers to jointly define and improve quality can be an effective approach when a supportive dialogue process is facilitated well and involves and considers the perspectives of all diverse participants.

It will be important to Institute Quality-improvement structures to support ongoing collaboration among communities and service providers. It will be excellent when all members understand and are committed to the purpose of the group. But this will require continuous clarity on the roles and responsibilities and acceptability to all members and group governance practices support participation.

Joint assessment of health services and care is helpful to support informed decision-making. Ongoing monitoring of data helps to inform adaptation of strategies as necessary for continual improvement and accountability.