Strengthening Health Facilities for Maternal Newborn Care:

experiences from rural eastern Uganda

Authors: G Namazzi, P. Waiswa, S. Peterson R. Byaruhanga, et al

The Uganda health care system

Village/Home(Village health team, CHWs)

Primary Health Centers(HC levels II to IV)

Hospitals(district, regional & national)

2

≈ 14,000 HC ≈ 100 Hospitals≈ 55,000 villages

33 million people Total fertility rate 6.7/woman 57% deliver in a health facility MMR=438/100,000 live birthsNMR= 27/1,000 live births (38,000 newborn

deaths annually) plus similar number of stillbirths

72% population in 5 Km of a health facility –but most do not provide newborn care

Objective of the study

• This study was part of the Uganda Newborn Study

(UNEST) a cluster-randomised control trial testing an

integrated community-facility package

• Facility intervention aimed to increase frontline

health worker capacity at one district hospital and 19

lower level facilities to improve health outcomes for

mothers and newborn babies in Iganga /Mayuge DSS

Methods • District-led training, support supervision and

mentoring addressing the main causes of maternal and newborn death

• Supported use of partographs (previously used poorly or not at all)

• Introduced care for small and sick babies • Introduced maternal and perinatal death review• Once-off provision of basic equipment,

medicines & supplies • 2 midwives received extra training at national

special care unit for hands-on experience in care of high risk babies

• Identified local champions/mentors for newborn care to support ongoing uptake

Results: Knowledge and skills building

• 72 % of targeted frontline health workers trained

• Mean pre-training score was 32% vs 68% post training

• After one year, mean score was 80%.

• Midwives were able to confidently resuscitate newborns, pass nasogastric tubes and IV cannulas

• Kangaroo Mother Care for preterm babies training and unit established

Utilization and care practices

• Health facility delivery increased by 27% (from 2700 to 3435, larger than the increase in births in the districts)

• 547 preterm babies were admitted to Kangaroo Care, 85% were discharged alive

• 249 sick newborn babies were admitted on the paediatric unit; with 75% survival rate

• Bathing within 6 hrs decreased from 56% to 20% although almost all bathed within 24 hours

• Immediate initiation of breastfeeding increased from 52% to 80%

Maternal and Perinatal mortality

In-hospital maternal deaths reduced during the study period and sustained decreases even beyond the study period

In-hospital perinatal mortality reduced from 65/1000 at baseline to 50/1000 live births in 2013

Challenges• Contextual issues e.g. lack of accommodation for

staff, constraining availability of 24/7 services for some lower level facilities

• Maintaining supply of even the most basic medications was a challenge with less than 40% of health facilities reporting no stock-outs

• Avoidable factors identified through mortality audit were difficult to address especially at administrative/ managerial and community level

• Incompleteness of HMIS records hampered accountability and process documentation

Conclusion

• Through a participatory process with wide engagement, improvements to training, support supervision and logistics, health workers were able to change behaviours and practices for maternal and newborn care.

• Addressing quality of care bottlenecks is a significant challenge and further innovative solutions are needed for resource constrained settings in order to save the lives of mothers and babies and help them thrive.