Improving Maternal and Newborn Care in Northern Uganda · 2019-12-30 · 5 Improving maternal & Newborn care in Northern Uganda Acronyms AMSTL Active management of the third stage

Improving Maternal and Newborn Care in

Northern Uganda

A synthesis of the most robust, high-impact and evidence-based changes that resulted in facility and

community-level improvements in the processes and systems of providing maternal and newborn care

services

February 2017

This report on improving maternal and newborn care in Northern Uganda was prepared by University Research

Co., LLC (URC) with the Ministry of Health Reproductive Health division for United States Agency for

International Development (USAID) and was authored by Dr Paul Isabirye, Mabel Namwabira, Dr Dinah

Amongin, Dr Hellen Kyokutamba, Dr Damasco Wamboya, Ronald Tibita, Dr John Byabagambi, Dr Esther

Karamagi and Dr Mirwais Rahimzai of URC together with Dr Dinah Nakiganda & Dr Placid Mihayo of the

Ministry of Health and Dr. Christine Mugasha and Jackie Calnan of USAID Mission Uganda, through the

USAID Applying Science to Strengthen and Improve Systems (ASSIST) project.

DISCLAIMER: The contents of this report are the sole responsibility of University Research Co., LLC and do

not necessarily reflect the views of the United States Agency for International Development or the United States

Government.

2 Improving maternal & Newborn care in Northern Uganda

About USAID ASSIST

The USAID ASSIST project is made possible by the generous support of the American people through

USAID’s Bureau for Global Health, Office of Health Systems. Support for Improving Maternal and

Newborn care in Northern Uganda under the Saving Mothers Giving Life initiative was provided by the

U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

The USAID ASSIST project is managed by University Research Co., LLC (URC) under the terms of

Cooperative Agreement number AID-0AA-A-12-00101. URC’s global partners for the ASSIST project

include: Encompass LLC; FHI 360; Harvard University School of Public Health; HEALTHQUAL

International; Institute for Healthcare Improvement; Initiatives Inc.; Johns Hopkins University Center for

Communications Programs; and Women Influencing Health Education and Rule of Law (WI-HER), LLC.

For more information on the work of the USAID ASSIST project, please visit www.usaidassist.org or

send an e-mail to [email protected]

Recommended citation:

Isabirye P, Mabel Namwabira, Amongin D, Oleo C, Muwonge A, Wamboya D, Tibita R, Karamagi E,

Rahimzai M. Nakiganda D, Mihayo P. 2017. Improving maternal and newborn care in northern Uganda.

Published by USAID Applying Science to Strengthen and Improve Systems (ASSIST) project. Bethesda,

MD: University Research Co., LLC (URC)

http://www.usaidassist.org/

mailto:[email protected]


Table of Contents

Acknowledgements ....................................................................................................................................... 2

Acronyms ...................................................................................................................................................... 5

Glossary of terms ......................................................................................................................................... 6

1. Background and context: ...................................................................................................................... 7

3. Intended Use: .................................................................................................................................... 4

4. How to use the Change Package: ..................................................................................................... 4

Section One: Community Component ......................................................................................................... 5

Aims, Indicators, Results & Key change ideas........................................................................................... 5

Aim: Increase by 20% the proportion of pregnant women who attend first trimester ANC visits .... 5

Delay 1 indicator: percentage of pregnant women registered the community ............................................. 6

Aim: Increase by 30% the proportion of pregnant women receiving a skilled delivery ....................... 7

Delay 2 indicator: percentage of pregnant women saving money for birth and emergency funds .......... 7

Aim: All Pregnant Women with Complications Are Treated At A Health Facility ............................. 9

Aim: 95% of mothers and newborns receive postnatal visits in the community within 7 days after

delivery .................................................................................................................................................. 9

Section Two: Facility Component .............................................................................................................. 10 Aims, Indicators, Results & Key change ideas......................................................................................... 10

1. Improving the quality of antenatal care services ............................................................................ 10

Aim I: Improve routine screening for pregnancy induced hypertensive disorders, anemia and

syphilis. ................................................................................................................................................ 10

Aim: To increase to 80% the number of first ANC mothers screened and managed for syphilis and

anemia in pregnancy in 118 health facilities of the 6 SMGL supported districts of northern Uganda.

............................................................................................................................................................ 11

Improve the quality of labour and delivery care: .................................................................................... 12 Aim: Improving the use of a partograph during labor. ....................................................................... 12

Aim: Improving the quality of delivery care through active management of third stage of labor to

prevent post-partum hemorrhage. ..................................................................................................... 13

1. Improve the quality of newborn care services ................................................................................... 14

Aim: Improving routine provision of essential newborn care to every newborn before discharge. ..... 14

Aim: Improving provision of the essential newborn care package to every newborn before

discharge in 118 facilities of the 6 SMGL districts of northern Uganda. ............................................ 15

Aim: Improving the quality of Newborn resuscitation through promoting the use of HBB practices.

............................................................................................................................................................ 15

ii) Aim: Improving the quality of pre-term care through promoting the use of Kangaroo mother care

and antenatal cortico-steroids in pre-term births. ..................................................................................... 16

Emergency preparedness .................................................................................................................... 17

iii) Maternal and perinatal death review (MPDR)............................................................................... 18

Recommendations ...................................................................................................................................... 19

Appendix: Change Package – Community Component ............................................................................. 20

Changes to address the delay to decide to seek ANC and skilled delivery .......................................... 20

Step I: Identify and register pregnant women in the community ....................................................... 20

Step II: Follow up pregnant women for ANC .................................................................................... 21

Step III: Raise awareness on benefits of ANC and facility delivery and danger signs ......................... 21


Changes tested to address the delay to reach ANC and skilled delivery .............................................. 22

Step I: Prioritise pregnant women in high risk communities .............................................................. 22

Step II: Prepare women for facility delivery ........................................................................................ 23

Step III: Follow up pregnant women for skilled deliveries .................................................................. 24

Step IV: Mobilise social support for pregnant women ....................................................................... 25

Changes tested to improve postnatal visits within 7 days after delivery ............................................... 25

Appendix: Change Package – Facility Component .................................................................................... 26 Changes introduced to improve Screening for pregnancy induced hypertension among ANC mothers.

................................................................................................................................................................ 26 Changes introduced to improve Syphilis testing among 1st ANC mothers ......................... 27

Changes introduced to improve HB screening among 1st ANC mothers ............................ 28

Changes introduced to improve monitoring of mothers in labor with a partograph. ........................... 29

Changes introduced to improve application of active management of third stage of labor (AMTSL) at

birth to prevent post-partum hemorrhage. ............................................................................................ 31

Changes introduced to improve resuscitation of newborns with birth asphyxia. ................................. 32

Changes introduced to improve provision of a complete essential newborn care package before

discharge. ................................................................................................................................................ 34

Changes introduced to improve provision of kangaroo mother care (KMC) and antenatal cortico-

steroid use (ACS). ................................................................................................................................... 35

Changes introduced to improve emergency preparedness in the labor suit through increasing the

number of days when the emergency trays were fully constituted. ...................................................... 37

Changes tested to improve maternal and perinatal death reviews ........................................................ 38


Acronyms

AMSTL Active management of the third stage of labor

ASSIST USAID Applying Science to Strengthen and Improve Systems project

CCT Controlled Cord Traction

DHO District Health Officer

ENC Essential newborn care

FY Financial year

HC Health Centre

MNH Maternal and Newborn Health

MNCH Maternal, Newborn and Child Health

MoH Ministry of Health

MPDR Maternal and Perinatal Death Review

NGO Non-Governmental Organization

PEPFAR President’s Emergency Plan for AIDS Relief

QI Quality improvement

SMGL- Saving Mothers Giving Life Initiative

TEO Tetracycline Eye Ointment

URC University Research Co., LLC

USAID United States Agency for International Development

VHT Voluntary Health team member


Glossary of terms

Change concept – is a category of change ideas or interventions that are similar and have a common

underlying thought pattern.

Change idea – is a specific intervention that a health facility quality improvement team has tested

Change package - an organized summary of strategies and interventions that have been tested and

proven to improve care in a given context. In this case, the interventions being outlined have been

proven to result in improvements in maternal and neonatal care thereby reducing respective morbidity

and mortality rates.

Improvement collaborative – refers to a collection of quality improvement teams that work

independently to address a common challenge, but are periodically brought together to share and learn

from one another, so that emerging best practices are easily and rapidly spread at scale

Plan-Do-Study-Act (PDSA) Cycle – refers to a structure for an efficient trial-and-learning

methodology used in trying out different change ideas and learning from them. It begins with a plan and

ends with action according to the learning gained from the Plan, Do and Study phases of the cycle. In

most cases, multiple PDSAs are needed to make successful changes.


1. Background and context:

Uganda’s maternal and newborn mortality remains unacceptably high (438 maternal deaths per 100,000

live births and 27 per 1,000 live births respectively)1 Most of these deaths occur around the time of

labour, delivery and immediate postpartum.

The Saving Mothers, Giving Life (SMGL) initiative launched in 2012 focused on implementing existing high

impact and evidence based interventions to accelerate the reduction of maternal and newborn deaths in

sub-Saharan African countries, starting with Uganda and Zambia (Phase I). Uganda’s Phase I was

implemented in 4 districts of Western Uganda (Kyenjojo, Kamwenge, Kabarole and Kibale). It was

designed to address the three major delays in health service delivery that are often associated with

maternal and newborn deaths: - a) delays in seeking appropriate care, b) inability to access the most

appropriate care in a timely manner, and c) inconsistencies in the quality of care provided at health

facilities.

Phase II of the initiative was scaling up to six districts (Nwoya, Gulu, Pader, Lira, Dokolo and Apac) of

northern Uganda. This was supported by USAID Applying Science to Strengthen and Improve Systems

(ASSIST) project through funding from USAID. Part of this phase was the community component which

addressed the factors affecting pregnant women and their facilities to make decisions and reach facilities

in a timely manner. A facility assessment conducted in the region revealed i) prolonged and often

obstructed labor, ii) postpartum hemorrhage, iii) pregnancy induced hypertension, iv) Neonatal sepsis,

and v) birth asphyxia as the top 5 causes of mortality. Community based barriers leading to these

complications include; inadequate knowledge and skills of village health teams to promote maternal and

newborn health at community level, inadequate preparation of mothers for facility deliveries, negative

perceptions and attitudes towards health seeking, influence from experienced mothers. The

interventions to prevent and address these gaps became the focus of USAID ASSIST’s quality

improvement efforts.

2. Implementation Approach

I. Staging the Scale-up

USAID ASSIST used a staged scale-up approach, initially focusing on improving quality of care at high

volume facilities and scaling up to additional facilities in two stages.

Stage 1: FY 14/15 targeted 20 high volume facilities (2 Regional referral hospitals, 3 General hospitals, 8

HCIVs and 7 HCIIIs) that contributed 64.4% of deliveries in FY 13/142. This mainly required developing a

team of regional mentors and coaches. Relatedly, community interventions targeted 144 communities in

16 out of 20 high volume facilities.

1 Uganda Bureau of Statistics and ICF International 2012. Uganda Demographic & Health Survey, 2011. 2 Ministry of Health, Annual Health Sector Performance report 2013/14


Stage 2: In FY 15/16, through the regional mentors and other learning platforms, effective changes were

spread from 20 to 98 spread facilities in two waves. First focusing on health center IIIs and later IIs. In a

similar way, community interventions also spread to 370 communities attached to 32 out of 98 spread

facilities.

II. The Improvement Approach

Improvement concentrated on improving the quality of MNCH content, processes of MNCH service

provision, strengthening local health networks and engaging communities to increase access to services.

a) Quality of MNCH content:

Technical training on MNCH: Using the ministry of health training

protocols including (HBB) Helping Babies Breathe, national and

regional trainers built the capacity of health workers on the essential

components of maternal, newborn care and family planning. The

regional trainers supported take the trainings to lower health facilities

through onsite mentorship.

Ensuring availability of essential supplies and commodities: ASSIST

supported health facilities to correctly quantify, forecast and submit

timely orders of essential MNCH commodities to National Medical

Stores (NMS) and Joint Medical Stores (JMS). Stock outs were

addressed by redistribution from stocked to understocked facilities.

USAID ASSIST also supported the distribution of equipment donated

by CURE project.

b) Processes of MNCH service provision:

Continuous quality improvement: In line with the national QI frame work

and strategic plan, USAID ASSIST supported the establishment of QI

structures in districts and health facilities. The teams applied the CQI

approach to identify and address gaps in maternal and newborn care

service provision. The project also supported the formation and

functionalizing Maternal and perinatal death reviews (MPDRs).

Learning and experiences were shared in structured learning sessions.

c) Strengthening local health networks: We identified and trained

mentors/coaches at regional and district level who led the spread and

building capacity facility level teams. These were supported by national level maternal and

newborn care specialists as per the national policy.

d) The community engagement approach:

Focused on addressing the delays in seeking appropriate care and inability to access care in a timely

manner. This involved;

i. Developing capacity of VHTs to promote maternal and newborn health at community level.

VHTs were mentored to identify, follow up and refer pregnant women and newborns for

antenatal care, delivery and postnatal care. Reporting and reference materials such as job aides

were provided.

The model for improvement


ii. Strengthening a network of community structures to support the demand creation functions.

USAID ASSIST engaged the national, districts, and community level VHT structures to support

improvement. At the lowest community level, existing social groups, opinion leaders,

influencers, organizations, religious leaders were brought together to support the health

promotion and community empowerment role.

iii. Behavior change communication and demand creation: awareness raising on the benefits of

seeking timely antenatal care, treatment for danger signs, skilled deliveries and postnatal care

was conducted through focused community dialogue sessions, social and religious gatherings.

iv. Continuous quality improvement: In low uptake communities, improvement teams were

established to apply basic improvement steps to address barriers to accessing services. They

comprised VHTs, social groups, health workers, VHT supervisors, opinion leaders etc. Learning

from these communities was shared during monthly support supervision visits and structured

learning sessions. Periodically coaching teams from MoH, district and USAID ASSIST visited the

teams.

This change package presents a synthesis of the most robust and effective changes in improving maternal

and newborn care at health facilities and communities in 6 districts of northern Uganda.

3. Intended Use:

Frontline facility and community health workers taking care of mothers and their newborn babies are

the primary intended users of this change package. Implementing partners involved in maternal and

newborn care, district health officers supervising health facilities and Ministry of Health officials working

on strategies for improving maternal and newborn health will find the evidence-based high impact

changes described in the following pages very useful and can adapt them for their work.

4. How to use the Change Package:

This package has two sections. Section I presents the community and Section II the facility level aims,

indicators, results and key change ideas. Each result area describes a key change idea and detailed

description of how the change was implemented and the result. The ideas are focused around the

improvement objectives and results achieved.

Facilities and communities are to use these change ideas which they believe may work in their context.

As they adopt these ideas they are to monitor performance using data to see whether it works in their

setting or modify the ideas. Teams can use the change concepts to generate other change ideas.


Section One: Community Component

Aims, Indicators, Results & Key change ideas

In order to increase access to quality ANC and skilled delivery services, the community initiative

focused on the following steps to address delays 1 and 2:

1. Aim: Increase by 20% the proportion of pregnant women who attend first trimester

ANC visits

Rationale: Early and regular prenatal care improves the chances of a healthy pregnancy. It helps

prevent the risk of pregnancy and newborn complications. In Uganda only 21% of pregnant women

attend ANC in the first trimester,this exposes most pregnant women to complications and limits the

opportunity to receive lifesaving interventions at health facilities. Lack of knowledge about the benefits

of early ANC, inadequate follow up for pregnant women, negative beliefs and perceptions affect health

seeking behaviours.


Delay 1 indicator: percentage of pregnant women registered in the community

Most effective change idea: Ask women about

possible pregnancies in the community.

During community gatherings or one-on-one

interactions with women, a VHT explains to women

about the importance of accessing health services when

they suspect pregnancy or when it is confirmed.

The VHT informs the women about his/her role in the

community. He/she explains that registering pregnant

women is important to help follow up pregnant women

to ensure that they all receive a safe and clean delivery.

This also helps the VHT to follow up women with

complications and conduct early referrals to the health

facility.

The VHT is given the names and contacts of the

pregnant women and conducts a home visit. Upon

confirmation of pregnancy, the women are registered in

the Village Register. This was implemented in all 89

villages.


Delay 1 indicator: Number of pregnant women receiving messages on benefits of ANC and skilled

delivery

The total number of the pregnant women receiving information on ANC and skilled deliveries was 2,896. The

messages were mainly disseminated to women through saving group meeting or religious gatherings. The key change

idea to raise awareness was the involvement of opinion leader’s e.g. religious leaders, cultural heads, mothers in-law

and traditional birth attendants to influence change and to address negative perceptions. To standardize information,

VHTs shared key messages with the leaders and follow up done for feedback.

Result: Almost two fold increase in first trimester ANC attendance at health facilities from the baseline in February

2015 (17%) to December 2017 (30%).

2. Aim: Increase by 30% the proportion of pregnant women receiving a skilled delivery

Rationale: delivery under skilled care and proper hygiene conditions reduces the risk of complications and

infections that may cause death or severe illness to either the mother or the baby. Only 57% of births take place in a

health facility. In the north, 4 in 10 pregnant women deliver at home. This has life threatening consequences to both

the mother and newborn. Factors affecting accessing skilled deliveries include inadequate preparation, influence from

Traditional Birth Attendants and older women, inaccessible facilities at night.

Delay 2 indicator: percentage of pregnant women saving money for birth and emergency

funds

In the graph below, the proportion of women saving for birth and emergency expenses in 80 SMGL villages

improved from 44% at the start to 66% in December 2016. In 23 villages in Apac saving increased from 48% to 73%

in the same period.

Community

intervention


Result: The number of pregnant women receiving a skilled delivery increased by 57.8% across 30 SMGL health

facilities

Most effective change: Promote

saving for pregnancy in Village

Savings & Loans Associations

The VHTs ask all pregnant women

registered if they belong to a saving

group. The VHT visits the saving group

and talks about the benefits of saving for

birth including the ability to get and pay

for transport when labor starts.

Pregnant women either top up on the

village saving for birth funds or are

prioritized for loans. Pregnant women

request for funds at least two weeks

before the date of delivery.

This was implemented in all 89 villages.

Community

intervention

Community

intervention


Most effective change idea: registration for all births that occur within 7 days Trained VHTs reach out to all pregnant women who delivered and use a “danger sign counselling card” to identify women and newborns with danger signs. VHT conducts referral when a danger sign is identified for treatment at a health facility. This change idea was implemented across all SMGL villages.

3. Aim: All Pregnant Women with Complications Are Treated At a Health Facility

At SMGL facilities, the number of women with danger signs increased from 210 in February 2015 to 310 in

December 2016. The most effective change was the use of a pictorial “pregnancy danger signs” card to identify

women in danger.

4. Aim: 95% of mothers and newborns receive postnatal visits in the community within 7 days

after delivery

Rationale: most of the mothers and newborns die in the first week after delivery. Women spend at least two days

in health facilities to receive the first postnatal visit within 48 hours. To prevent death and complications after

childbirth, both mother and newborn need visits up to 7 days. From day 2 to 7, visits are conducted in the

community to identify and refer mothers and newborns with danger signs to health facilities.

Indicator: Number of women visited 2-3 and 4-7 days after child birth

Result: on average 94% of all mothers receive postnatal visits within 7 days after delivery. Those that occur

between 2-3 days increased from 0% in August 2015 to 51% December 2016. Day 4-7 visits improved from 0% to

49%.

A danger signs counselling card for VHTs


Section Two: Facility Component

Aims, Indicators, Results & Key change ideas

Improving the quality of antenatal care services

1. Aim I: Improve routine screening for pregnancy induced hypertensive disorders, anemia and

syphilis.

Rationale: Hypertensive disorders, anemia and syphilis are some of the leading maternal conditions associated with

still births in developing countries (WHO 2016). Screening for these conditions during antenatal care therefore

facilitated early identification and hence treatment of these complications in a bid to reduce the high macerated still

birth rate of 8.9 / 1000 live births (Jan – Dec 2014, baseline data) in the SMGL supported facilities in the region..

Hypertensive disorders were the third leading cause of maternal death in 2015/16 in Uganda. Although preeclampsia

may not be absolutely preventable, deaths due to this condition can be prevented by routine screening, which

involves blood pressure measurements and urine testing. These must be done for all pregnant mothers in pregnancy

and during labor as guided by the ministry of health.

Improvement Objective: To increase to 80% the number of ANC mothers screened and managed for pregnancy

induced hypertension at every visit in 118 health facilities of the 6 SMGL supported districts of northern Uganda.

Indicator: Percentage of ANC mothers where a blood pressure reading is taken at every visit.

Results: Improving screening for pregnancy induced hypertension among ANC mothers through blood pressure

measurement.


2. Aim: To increase to 80% the number of first ANC mothers screened and managed for syphilis

and anemia in pregnancy in 118 health facilities of the 6 SMGL supported districts of northern

Uganda.

Indicator: Percentage of 1st ANC mothers screened and managed for syphilis.

Indicator: Percentage of 1st ANC mothers screened and managed for anemia.

Results: Improving screening of syphilis among 1st ANC mothers in 118 facilities in 6 SMGL supported districts of

northern Uganda (Jan-Sept 2016).


Results: Improving screening for anemia among 1st ANC mothers in 118 facilities of 6 SMGL supported districts of

northern Uganda (Jan-Sept 2016).

Improve the quality of labour and delivery care 3. Aim: Improving the use of a partograph during labor.


Rationale: Obstructed labor was the 2nd leading cause of maternal mortality in the SMGL supported districts, and it

was responsible for approximately 60% of the causes of birth asphyxia in two of the ASSIST supported hospitals in

Northern Uganda (USAID/ASSIST project data). Use of a partograph for all mothers in active labor with no

contraindication for vaginal delivery is a recommendation by the Ministry of Health Uganda as well as the World

Health Organization. A partograph is an in-expensive, relatively simple tool which provides continuous pictorial

overview on the progress of labor (Ashish et.al 2016). It is a vital tool for health providers to facilitate early

identification of complications during labor and timely intervention. Focus on this aim was prompted by a low

partograph use of 29% in the 20 SMGL facilities at baseline (March 2015); and similar to what was demonstrated in a

study by Ashish KC et.al (Ashish et.al 2016), it could have been responsible for the high fresh still birth rate at the

time (15.8/1000 live births; Jan – Dec 2015).

Improvement Objective: To increase to 80% the percentage of deliveries monitored with a partograph to detect

and manage prolonged and obstructed labor in 118 health facilities of the 6 SMGL districts of northern Uganda.

Indicator: Percentage of deliveries monitored using a partograph during labor at 118 health facilities in the 6 SMGL

districts of northern Uganda.

4. Aim:

Improving the quality of delivery care through active management of third stage of labor to

prevent post-partum hemorrhage.


Rationale: Active management of the third stage of labor is a cornerstone in helping a mother survive bleeding at

birth. It is an intervention that has been proven to reduce postpartum hemorrhage by 60% (WHO, 2015).

Implementation of this recommendation as guided by the ministry of health was widely disseminated in the SMGL

districts based on data that showed postpartum hemorrhage as the leading cause of maternal mortality.

Improvement Objective: To increase to 100% the percentage of deliveries where active management of third

stage of labor is applied to prevent postpartum hemorrhage in the 6 SMGL supported districts of northern Uganda.

Indicator: Percentage of deliveries where a utero-tonic drug is administered within one minute of birth to prevent

PPH.

Improve the quality of newborn care services

1. Aim: Improving routine provision of essential newborn care to every newborn before

discharge.

Rationale: The essential newborn care package is a simple, multi-faceted intervention aimed at improving newborn

survival through ensuring a baby is breathing at birth, preventing infections, reduced risk of hypoglycemia,


hypothermia and hemorrhage, improved nutrition and a more nurturing environment (Valera 2014). The

components of the essential newborn care as recommended by the ministry of health include helping a baby breathe

at birth, warmth, early initiation of breast feeding, cord care, vaccination, tetracycline eye ointment and assessment

for signs of infection. These simple interventions have been shown to contribute to a reduction in neonatal

mortality (Akter et.al 2016).

Improvement Objective: To increase to 90% the percentage of newborns discharged having received a complete

essential newborn care package to prevent early neonatal complications.

Indicator: Percentage of newborn babies given a complete package of essential newborn care (ENBC) package

before discharge.

2. Aim: Improving provision of the essential newborn care package to every newborn before

discharge in 118 facilities of the 6 SMGL districts of northern Uganda.

3. Aim: Improving the quality of Newborn resuscitation through promoting the use of HBB

practices.

Rationale: In a country burdened with birth asphyxia as one of the leading causes of newborn deaths, the newborn

resuscitation skills of the health workers were noted to be inadequate. This was demonstrated in an assessment of

the quality of basic resuscitation services in Uganda, which found that only 6% of health care providers met the


minimum skills requirement for resuscitation with bag and mask (Tamar et.al 2016). Helping babies’ breathe (HBB) is

a strategy to improve the quality of care of a new born with asphyxia.

Improvement Objective: To increase the percentage of newborns delivered with birth asphyxia who are

successfully resuscitated in 118 facilities of 6 SMGL districts of northern Uganda.

Indicator: Percentage of asphyxiated newborn babies successfully resuscitated.

Results: Improving newborn resuscitation in 118 facilities of the 6 SMGL supported districts of northern Uganda

4. Aim: Improving the quality of pre-term care through promoting the use of Kangaroo mother

care and antenatal cortico-steroids in pre-term births.

Rationale: Preterm birth is estimated to be the cause of 28% of neonatal deaths in the world, and the 3rd leading

cause of newborn deaths in Uganda. The ministry of health guidelines emphasize the use of antenatal corticosteroids

and kangaroo method of care to improve survival and the quality of life of all preterm babies. These simple

interventions improve the quality of life by enhancing lung maturity (antenatal corticosteroids) and regulating the

babies breathing, preventing hypothermia, and promoting successful breastfeeding and weight gain (kangaroo method

of care).

Improvement Objective: To increase to 80% the percentage of pre-term births receiving antenatal cortico-

steroids and preterm babies receiving the kangaroo method of care in 118 health facilities of the 6 SMGL districts of

northern Uganda.

Indicator: Percentage of preterm births receiving antenatal cortico-steroids.


Percentage of pre-term babies receiving kangaroo method of care.

Results: Improving pre-term birth care in 20 high volume facilities of the 6 SMGL districts of northern Uganda.

Emergency preparedness

Rationale: All health facilities that provide basic and comprehensive emergency obstetric care services are required

to have systems, processes and strategies in place that ensure readiness to act on any life threatening situation or

condition at all times. This is to ensure a team and an environment that is prepared to manage obstetric and

gynecological emergencies which are to some extent inevitable. The ministry of health and the American College of

Obstetricians and Gynecologists recommends this as a requirement for facilities providing obstetrics and gynecology

services.


Maternal and perinatal death review (MPDR).

Rationale: Despite a high institutional maternal mortality ratio and neonatal mortality rate of 320/100,000 live

births and 22 / 1000 live births respectively in Uganda, only 37% of these deaths are audited (AHSPR 2015/16), a

picture that is not different in the SMGL supported districts in Northern Uganda. The maternal and perinatal death

review process is a quality assurance mechanism that was put in place to consolidate accountability of each maternal

and perinatal death by the facility and district level.


Recommendations

To get the best benefit from the change ideas shared in this document, health facilities should establish and cultivate

an environment that embraces change in order to nurture improvements. The following ideas can help the team in

getting started:

Additional change ideas that contributed to general improvements in maternal and newborn care focused

on the following thematic areas:


Appendix: Change Package – Community Component

Changes to address the delay to decide to seek ANC and skilled delivery

Step I: Identify and register pregnant women in the community

Specific

Problem

being

addressed

Change

concept

Change

ideas tested

Steps in introducing the change

ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

No

information

on existing

pregnancies

in the

community

Develop

a system

of

identifyin

g

pregnant

women

in the

communi

ty

Register

women of

child bearing

age and

evaluate for

signs and

symptoms of

pregnancy

VHTs records all household

members in the village register. For

every woman of child bearing age

registered, the VHT asks women if

they experienced the signs of

pregnancy on his list. Women who

missed the past two menstrual

periods are sent to health facilities

for a test using a referral.

Evaluated with

medium rank

80 villages

Ask women

about possible

pregnancies in

the

community.

During community meetings or

interactions with community

members, a VHT asks non-pregnant

women about pregnant women in

their neighborhood. The VHT is

informed about the locations of the

pregnant women and are visited.

Evaluated with

high rank

80 villages

Identify

unregistered

pregnant

women during

ANC visits.

All pregnant women attending ANC

at health facilities are asked if they

are registered by their VHT. VHTs

are informed by the health worker

about the women who are not

registered in their villages. The

household number from the village

register is written on the mothers

ANC record by the VHT as proof of

registration. A mother missing this

number implies no registration.

Evaluated with

medium rank

23 villages

Use pregnant

women to link

their peers to

VHTs

Pregnant women registered by the

VHT are asked about their peers. A

VHT conducts a home visit to the

home and registers the pregnant

woman.

Evaluated with

high rank

80 villages

False

information

from older

women and

in-laws

Involve

key

influence

rs to

mobilise

women

Involve key

influencers e.g.

mothers in

law, elder

women,

Traditional

Birth

Attendants to

First, a VHT talks to influencers

during a home visit. VHT explains

the benefit of early ANC to

influencers. Using the list of

pregnancy signs, he asks elder

persons or mothers in-law he also

asks if there are suspected

pregnancies in the household.

Evaluated with

high rank

80 villages


identify

suspected

pregnancies

Step II: Follow up pregnant women for ANC

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

Unknown

locations

of

pregnant

women

Locate

pregnancie

s in the

communit

y

Update and

identify homes

of pregnant

women on the

village map

VHT draws a village map showing all

households. Homes of pregnant

women are identified by drawing a

square around it.

Evaluated with

medium rank

80 villages

Evaluate

pregnant

women for

ANC status

VHT asks pregnant women about

ANC status for present pregnancy.

Women not attending are referred

to a health facility. A follow up visit

is conducted by the VHT to confirm

attendance.

Evaluated with

high rank

80 villages

Step III: Raise awareness on benefits of ANC and facility delivery and danger signs

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

Negative

perception

s e.g.

disclosure

of

pregnancy

early

brings bad

luck to

both

mother

and baby,

long

Dispel

myths and

misconcep

tions

Involve

opinion

leaders in low

uptake

communities

to raise

awareness

about

importance of

ANC and

facility

deliveries

Using facility records, identify

communities with low uptake of

skilled deliveries. VHT reaches out

to opinion leaders and share key

messages on ANC and institutional

delivery. The messages are

disseminated during religious and

social gatherings. A list of health

facilities and available services is also

shared with the leaders.

Evaluated with

high rank

80 villages


waiting

times at

facilities,

Invite religious

to attend

meetings at

facilities to

discuss

maternal

health gaps.

VHTs inform health facilities about

the most influential leaders in their

communities. Health facilities invite

the leaders to facility meetings

where facts on maternal and

newborn care are given including the

risks. A fact sheet is given to the

leaders for dissemination during

their gatherings.

Evaluated with

high rank

2 health

facilities

Conduct

focused

dialogue

meetings with

pregnant

women and

community

members to

find reasons

for low uptake

for services

and address

concerns.

In low uptake communities, VHTs

and health workers raise awareness

and conduct focused discussions

with community members to find

barriers. The barriers are prioritized,

implemented and feedback on

service uptake is shared in

consecutive meetings.

Evaluated with

medium rank

44 villages

Home to

home

visits are

expensive

and in

some

instances

women

and

partners

are absent

for visits

Utilise

existing

social

gatherings

to

disseminat

e messages

Integrate

messages on

ANC and

facility

deliveries in

saving group

meetings.

VHT maps all existing saving groups

in the village. During saving group

meetings, the VHT is given time

before the group meeting to share

information. The VHT asks the

group members to share with their

neighbors and receives feedback in

subsequent meetings.

Evaluated with

high rank

80 villages

Communi

ties don’t

know

about all

danger

signs.

Build

capacity of

communiti

es to

identify

danger

signs

Use danger

signs

counselling

card showing

pictures of

danger signs

During a home visit or community

meeting, the VHT shows a placard

with pictures of danger signs.

Women are asked to point to a

picture that

Evaluated with

high rank

80 villages

Changes tested to address the delay to reach ANC and skilled delivery

Step I: Prioritise pregnant women in high risk communities

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation


Inadequat

e

resources

to cover

all

communit

ies

Target

high risk

communiti

es

Target

communities

with low

uptake of

maternal and

new-born

services

Establish the population of each

village in the catchment of every

health facility

Calculate the number of expected

pregnant women from each parish =

population of the village x 5%

Identify villages with fewer deliveries

compared to the expected

pregnancies

Target villages having the least

number of deliveries compared to

expected pregnancies.

Evaluated with

high rank

30 health

facilities

Step II: Prepare women for facility delivery

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

Women

lacked

birth

items list

Build VHT

capacity to

support

birth

preparatio

n

Teach VHTs

about birth

planning

emergency

preparation

list items

needed for

birth and

follow up

acquisition of

items.

During routine VHT meetings at a

health facility, health workers teach

VHTs the birth items and are

informed about the minimum

amount of money (Ugx. 50,000/=) a

mother needs for emergency

transportation to a health facility at

the time of delivery. The VHTs are

shown how the birth items look like.

Evaluated with

high rank

80 villages

Lack of

means for

saving

money for

birth

expenses

Support

birth and

emergency

preparedn

ess

Link pregnant

women to

saving groups.

The VHT communicates to pregnant

women the estimated amount of

money required for emergency

transport to pregnant women. Since

most of the women save through

groups, a VHT together with a

community development staff lists

current VSLAs (Village Savings &

Loans Associations). Women who

are not belonging to any saving

group are linked or supported to

start one. Ask women who opt for

personal savings to save money on a

daily basis.

Evaluated with

high rank

80 villages

Difficulty

to access

transport

to health

facilities

when an

Develop

networks

with

private

transporte

rs

Involve Boda

boda

(motorcycle)

riders to

support

VHT maps existing boda-boda riders

and transport costs. Pregnant

women are given at least 3 contacts

of close by riders and associated

costs. The riders are also informed

about the pregnant women.

Evaluated with

high rank

18 villages


emergenc

y arises.

emergency

transportation

Health

facility

services,

times and

midwives

are

unknown

Inform

communities

and pregnant

women about

ANC and

delivery

services

available and

access times.

VHTs compile a list of health

facilities, service times and contacts

of health workers. The information

is pinned as posters in the

community or shared with pregnant

women during one-to-one visits.

Evaluated with

high rank

6 villages

Inadequat

e

implemen

tation of

birth plans

Assess

readiness

for

institution

al delivery

Conduct birth

planning and

readiness

meetings with

pregnant

women

Women with birth plans listed, are

invited by a VHT to a meeting in the

community to share progress on

their plans. Every woman invited to a

meeting has to carry her plan.

Challenges are shared and women

supported to address them.

Evaluated with

medium rank

15 villages

Set short

and

achievable

saving

targets.

Break down

estimated

delivery costs

into short and

achievable

saving targets.

Together with the pregnant woman,

a VHT estimates the cost for a

facility delivery. The cost of divided

into weekly and monthly targets and

followed by the VHT at an agreed

time.

Evaluated with

medium rank

80 villages

Step III: Follow up pregnant women for skilled deliveries

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

Lack of

informatio

n on when

women

are due to

deliver

Follow up

deliveries

by

gestation

Follow up

pregnant

women by

delivery date.

VHT registers pregnant women by

expected date of delivery. Pregnant

women of 36+ weeks of gestation

are followed up routinely. All

deliveries due in a month are

communicated to the health worker

for preparation.

Evaluated with

medium rank

18 villages

Health

workers give a

list of pregnant

woman at 36+

gestation to

VHTs for

follow up

Midwives generate a list of pregnant

women of 36+ weeks of gestation

per village and share with VHTs.

Evaluated with

low rank

3 health

facilities


Step IV: Mobilise social support for pregnant women

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

Partner

consent

sought

before

attending

ANC

visits.

Recognise

couples

for early

attendance

.

Issue ANC

certificate and

invite male

partner to

ANC

A health worker issues an ANC

certificate to women who attend

first trimester visits. The certificate

also appreciates the partner and

invites him for subsequent visits.

Names and contacts of health

workers are listed and signed by the

in-charge of health unit.

Evaluated with

medium rank

2 health

facilities

Women

prevented

from ANC

without

partner

Address

women’s

needs.

Accept

pregnant

women to

attend ANC

without

partner

During a general health talk, the

health worker tells women about

the importance of involving partners

in ANC e.g. monitor baby together,

test and treat existing conditions.

Health workers give ANC service to

women without partners but

strengthen couple visits during

subsequent visits.

Evaluated with

high rank

All 30 SMGL

facilities

Facility

deliveries

perceived

to be

expensive

and rude

health

Involve

promoters

of

communit

y

deliveries

Involve TBAs

(Traditional

Birth

Attendants) to

promote

facility

deliveries

VHTs with support from leaders,

conduct mapping of active TBAs in

their villages. A meeting with the

TBAs is conducted to share risks of

conducting home deliveries. TBAs

are asked to identify a role they can

play other delivering women. The

new roles are acknowledged by the

TBAs and disseminated in the

community.

Evaluated with

high rank

48 villages

Changes tested to improve postnatal visits within 7 days after delivery

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

No

informatio

n on

lactating

women in

the

communit

y

Identify

lactating

mothers

and

newborns

Register

lactating

women in the

village.

VHT conducts door to door visits to

lactating women. The VHT uses a

danger signs job aide to help women

identify dangers for mothers and

newborns. VHT issues a referral for

treatment of a danger sign at the

health facility.

Evaluated with

high rank

80 villages


Appendix: Change Package – Facility Component

Changes introduced to improve Screening for pregnancy induced hypertension among ANC

mothers.

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

Lack of

functional

BP

machine

Improving

availability

of

functional

BP

machines

Reallocation/st

ationing of BP

machine to

ANC

QI meeting decided that the in-

charge ANC requisitions for a BP

machine from the store Or the in-

charge facility reallocates from other

departments to ANC.

BP machine is stationed at the

observations table in ANC

6 facilities

improved by

100

percentage

points

The change

was

implemented

by 6 facilities


Lack of

batteries

for digital

BP

machines

Allocation of

resources to

purchase

batteries.

Adequate

monthly

orders for

Batteries.

In-charge facility agreed to allocate

funds from PHC to purchase

adequate quantities of batteries.

In-charge ANC requisitioned for

monthly quantities of batteries.

8 facilities

improved by

40 percentage

points

The change

was

implemented

in 8 facilities

Faulty BP

machines

Engage the

equipment

maintenance

unit at the

regional

referral

hospital to get

the BP

machines

repaired

In-charge of ANC liaised with the in-

charge facility to take faulty BP

machines to the equipment

workshop at regional referral

hospital.

An assigned staff member would

follow up with the workshop and

return the machine after repair.

4 facilities

improved by

50 percentage

points

This change

was

implemented

by 4 facilities.

BP

measurem

ents not

taken for

all

mothers

during

ANC

Improving

continuity

of services

Assigned a

staff to

oversee BP

taking in ANC

A staff was assigned by the in-charge

ANC to oversee BP taking.

She reviewed the ANC register for

mothers who had missed BP and

provided feedback to staff who were

on duty.

She was also responsible for

ensuring the BP machine was in good

condition and was accessible during

ANC

3 facilities

improved by

50 percentage

points

This change

was tested

by 3 facilities.

Changes introduced to improve Syphilis testing among 1st ANC mothers

Specific

Problem

being

addresse

d

Change

concept

Change ideas

tested


ideas

Evidence that

the changes

led to

Improvement

Scale of

Impleme

ntation

Syphilis

test kits

not

available

in ANC

Avail

adequate

stocks of

RPR test

kits in

ANC

Include RPR

test kits in the

ANC orders

from

stores/laborato

ry

MNCH QI members agreed through a

meeting to incorporate requisition of

RPR test strips in ANC orders.

Requisition was done by ANC in-

charge or any assigned staff on duty

Monthly stock taking by ANC in-charge

or her Assignee.

4 sites improved

by 80

percentage

points.

Change

was tested

in 4

facilities

Stock

out of

RPR test

kits

Requisitioning

of additional

RPR Kits from

stocked

facilities to

cater for ANC

mothers

Requisitions were generated by the

ANC in-charge, authorized by the

facility in-charge and DHO. These were

then submitted to the identified facility

to supply the RPR kits.

6 sites improved

by 40%

percentage

points.

Change

was tested

in 6

facilities

Knowled Improvin Practical Through a QI team meeting, the 7 sites improved Change


ge gap in

conducti

ng the

RPR test

g staff

compete

nce to

conduct

the RPR

test

demonstration

in ANC on

how to

conduct RPR

test.

knowledge gaps were identified.

The lab team was contacted to provide

practical demonstrations on how to

carry out the RPR test to midwives in

ANC.

The lab team collected samples from

ANC mothers and carried out the test-

in real time, explaining each step to

midwives.

Team members then took turns doing

the same, while the lab assistant

critiqued and corrected mistakes.

Session was attended by midwives,

Nurses and COs

by 30

percentage

points

was tested

in 7

facilities

Heavy

work

load in

the

laborator

y

Improvin

g

efficiency

of

syphilis

testing

Shift testing of

RPR from lab

to ANC.

Use of one

blood sample

for both

Syphilis and

HIV test

Testing kits for syphilis were shifted to

ANC after orientation of the ANC

staff.

Identify space in the ANC to carry out

HIV testing and RPR.

One blood sample was drawn from the

mother and used for both HIV and

syphilis testing.

7 sites improved

by 40

percentage

points

Change

was tested

in 7 sites

Changes introduced to improve HB screening among 1st ANC mothers

Specific

Problem

being

addressed

Change

concept

Change ideas

tested

Steps in introducing the

change ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Impleme

ntation

Non

Functional

HB machine

Improving

availability

of HB

testing

equipment

Repair HB

equipment

Requisition of

HB reagents

from stocked

facilities.

ANC in-charge contacted the

facility in-charge to allocate

resources to repair the HB

equipment

The lab in-charge requisitioned

for reagents of the calorimeter

from stocked facilities.

6 facilities

improved by

40 percentage

points.

This

change

was tested

in 6

facilities


Late

delivery of

samples to

the

laboratory

Improving

efficiency of

services

Flow of

mothers

changed to

start with Lab

tests

1st ANC mothers are registered

first and directed to the ANC

side lab for bleeding

One blood sample is obtained for

all the ANC screening blood tests

Blood for HB is taken to the

laboratory

Booking is done after blood

samples are taken to the lab.

In-charge ANC obtained

vacuutainers from the laboratory

to ANC

Each clinic day, a midwife is

assigned to bleed the mothers.

Lab in-charge assigned one staff

to process ANC samples each

ANC day, these are picked by

midwife on duty.

7 facilities

improved by

30 percentage

points.

This

change

was tested

by 7

facilities

HB results

not received

from the

laboratory

on the same

Antenatal

clinic day

Assigned a

midwife to

follow up HB

results in the

lab

Set a time limit when the last

sample should reach the lab.

Follow up of results is conducted

after one hour by the assigned

staff.

2 facilities

improved by

15 percentage

points

This

change

was tested

by 2

facilities

Lack of

awareness

of the

significance

of anemia

screening in

pregnancy

Orient staff

on HB

screening

during

pregnancy

Orientation

meeting on

importance of

screening for

anaemia in

pregnancy

Reminder note

on the ANC

work table to

collect HB

sample

ANC and maternity teams had a

QI meeting where it was noted

that staff had deficient knowledge

regarding HB screening.

An orientation meeting was

conducted by the ANC in-charge

and one lab personnel.

2 facilities

improved by

20 percentage

points.

This

change

was tested

by 2

facilities

Changes introduced to improve monitoring of mothers in labor with a partograph.

Specific

Problem

being

addressed

Change

concept

Change

ideas

tested


change ideas

Evidence that

the changes led

to Improvement

Scale of

Implemen

tation

Knowledg

e gap

Improving

staff

competenc

e

One on

one

mentorship

Staffs having gaps in filling

partographs were identified during

a QI team meeting

Skilled staff in partograph use were

attached to those that required

support.

Duties were arranged so that the

mentors and the mentees worked

on the same shift.

6 facilities tested

this change and

improved by 40

percentage points.

This change

was tested

by 6

facilities.


Practical

demonstrat

ions on

partograph

use

Gaps in filling partographs were

identified during QI team meetings.

A skilled staff in partograph use

was identified to train the rest of

the maternity staff, the session

involved exercises and case

scenarios to guide in filling

partographs. Gaps were identified

and corrected.

6 facilities tested

this change and

improved by 30

percentage points.

This change

was tested

by 6

facilities.

Stock out

of

partograp

hs

Improving

availability

Printing/ph

otocopying

of

partograph

s

Staff in the MCH unit quantified the

partographs needed and shared

these quantities with the unit in-

charge.

The facility in-charge allocated

funds meant for stationary under

PHC to ensure weekly

photocopying of partographs.

These were photocopied and

placed in the labor suit for easy

access by staff.

6 sites tested this

change and

improved by 30

percentage points

This change

was tested

by 6

facilities.

Assigning a

FP to

monitor

availability

of

partograph

s

During a QI meeting in maternity,

members agreed that a staff be

assigned to monitor stocks of

partographs. The assigned staff

worked with the records officer to

supply the needed partographs in

time.

3 facilities tested

this change and

improved by 50

percentage points

This change

was tested

by 3

facilities

Inaccessib

ility of

partograp

hs within

the Labor

suit

Improving

access

Re-allocate

partograph

s to the

admission

table in the

labor suit

Staff noted the unavailability of

partographs in the labor suit.

They identified a box file where the

unused copies of partographs were

kept and placed on the admission

table in the labor suit

2 facilities tested

this change and

improved by 50

percentage points

This change

was

implemente

d in 2

facilities

Attach

partograph

s to

admission

forms

Reviewing the daily duty work, it

was found out that not all midwives

monitor labor using partographs as

admission forms were kept

separately from partographs.

In a staff meeting, it was decided

that partographs were going to be

stapled together with admission

forms.

This was further communicated to

the administration so that

partographs are printed together

with admission forms.

8 facilities tested

this change and

improved by 50

percentage points.

This change

was tested

by 8

facilities

Incomplet

e

document

ation on

partograp

hs

Improve on

data quality

Daily/weekl

y checking

of

partograph

s for

completene

ss

At shift handovers, midwives

noted numerous parameters

unfilled in the partographs.

The assigned midwife for

partograph use reviewed

partographs either daily (during

shift handovers) or at the end of

every week, noting gaps in filling

and provided individual feedback.

7 sites tested this

change and

improved by 20

percentage points

This change

was

implemente

d in 7

facilities


Changes introduced to improve application of active management of third stage of labor

(AMTSL) at birth to prevent post-partum hemorrhage.

Specific

Problem

being

addressed

Change

concept

Change ideas

tested


change ideas

Evidence that

the changes led

to Improvement

Scale of

Implemen

tation

Incomplet

e

document

ation of

AMTSL

componen

ts

Improving

data

quality

Identified where

to document the

components of

AMTSL in the

maternity register

Staff agreed to document

the components of AMTSL

under the column of

management of third stage

of labor

8 facilities

implemented these

changes and

improved by 70

percentage points

These

changes was

implemente

d by 8

facilities

Assigned a focal

person to check

on proper

documentation of

AMTSL

The in charge maternity

notified staff on the

incomplete documentation

of AMTSL in the register.

A midwife was assigned to

review the entries on a daily

basis and ensure staff

correctly document in the

register.

Delay in

administra

tion of

Pitocin

Improving

access to

pitocin

Use of cold boxes

with ice packs

changed every 24

hours to store

oxytocin

Identification of a

utero-tonic corner

in the labor suit

Maternity staff identified the

issue of limited access to

Pitocin in the labor suit due

to lack of cold chain facilities.

The team resolved to obtain

Pitocin from the stores and

use a vaccine carrier from

the EPI room and position

the carrier containing Pitocin

in the labor suit with ice

packs changed every 24

hours

The team identified a Pitocin

corner where the cold box

was placed.

At shift change every

incoming staff was assigned

by the in- charge the duty of

changing icepacks in the

vaccine carrier and

replenishing stocks of Pitocin

used in the previous shift

15 sites

implemented this

change and

improved by 20

percentage points.

This change

was

implemente

d by 15

facilities

Lack of

skills in

providing

all the 3

componen

ts of

AMTSL

Building

staff

competen

ce

One on one on

job mentorship

During a unit QI meeting, it

was noted that a number of

staff lacked skills in provision

of all components of AMTSL.


held for the maternity staff

on AMTSL conducted by a

3 facilities

implemented this

change and

improved by 20

percentage points

This change

was

implemente

d by 3

facilities


trained staff. This was

supplemented by one on one

on job mentorship in the

labor suit while conducting

deliveries.

Pitocin

not

administer

ed within

1 minute

of birth

Improve

efficiency

Pre-loading Pitocin

in a syringe ready

to use within one

minute of birth

In a maternity QI meeting, it

was identified that not all

staff were administering

Pitocin within one minute of

birth.

During one of the onsite

coach visits, the staff were

oriented on pre-packing

oxytocin in a syringe for

mothers in second stage of

labor.

The team agreed to pre-pack

oxytocin in a syringe

together with delivery

instruments in preparation

for delivery.

20 facilities

implemented this

change and

improved by 50

percentage points

This change

was

implemente

d by 20

health

facilities

Inadequat

e stocks of

Pitocin

Improve

availability

Redistribution of

pitocin from

stocked facilities

Use of data from

the maternity

register to

quantify orders for

pitocin

A stores person was engaged

in the maternity ward

meetings where the issue of

Pitocin stocks outs was

highlighted. The stores

person supported the

maternity team to

redistribute pitocin from

stocked facilities in case of

stock outs. The stores

person engaged maternity

staff in reviewing their

registers and correctly

quantify the right quantities

of Pitocin.

15 facilities tested

this change and

improved by 40

percentage points

This change

was tested

in 15

facilities

Changes introduced to improve resuscitation of newborns with birth asphyxia.

Specific

Problem

being

addressed

Change

concept

Change ideas

tested


change ideas

Evidence that the

changes led to

Improvement

Scale of

Implemen

tation

Skills gap

in new

born

resuscitati

on

Improving

staff skills

One on one on

job mentorship

Midwife in-charge of

maternity identified staff

with skills gaps. Paired

knowledgeable staff to

work with less

knowledgeable staff during

work shifts.

11 facilities

implemented this

change and

improved by 40

percentage points

This change

was

implemente

d in 11

facilities

Establishment of

an HBB skills lab

Identified space/room

where to arrange the HBB

14 facilities

implemented this

This change

was


training materials. Staff

trained in HBB were

identified to guide the rest

of the team in HBB

practical sessions. The

team scheduled days to

meet and conduct the

simulation sessions.

change and

improved by 35

percentage points

implemente

d in 14

facilities

Resuscitat

ion

corner

not set

Improving

accessibility

Identify a

resuscitation

corner in the

labor suit.

The maternity team

identified a corner in the

labor suit and set up a tray

containing all the necessary

resuscitation equipment.

This was positioned and

labelled.

20 facilities

implemented this

change and achieved

40 percentage

points

This change

was

implemente

d in all the

20 facilities.

Lack of

/inadequa

te

resuscitati

on

equipmen

t

Improve

availability

of

resuscitatio

n

equipment

Reallocation of

resources to

acquire new born

resuscitation

equipment

The maternity in-charge

informed the facility in-

charge of the missing

equipment. The in-charge

facility allocated part of the

PHC funds to buy some

low cost new born

resuscitation equipment

(bulb syringes).

2 facilities

implemented this

change and

improved by 20

percentage points.

This change

was

implemente

d in 2

facilities.

Redistribution

from better

equipped facilities

The improvement team in

maternity identified missing

resuscitation equipment

and informed the facility in-

charge who requisitioned

for these from the higher

facilities

4 facilities

implemented this

change and

improved by 40

percentage points.

This change

was

implemente

d in 4

facilities

Physical handover

of complete tray

from one shift to

another

A QI meeting was held and

staff agreed that when

anyone is leaving duty, they

physically handover a

complete resuscitation tray

14 facilities

implemented this

change and

improved by 50

percentage points

This change

was

implemente

d at 14

facilities

Lobby for

resuscitation

equipment from

partners through

the DHO’s office

Staff identified the missing

resuscitation equipment.

The maternity ward in-

charge through the facility

in charges requested for

these equipment from the

district stores and MNH

Implementing partners in

the respective districts

which were supplied.

8 facilities

implemented this

change and

improved by 20

percentage points

This change

was

implemente

d in 8

facilities

Incomplet

e

emergenc

y

tray/resus

citation

corner

Improving

continuity

Inclusion of

resuscitation

items in the

handover report

Staff agreed that the

contents / missing items of

the resuscitation tray be

added to the handover

reports and so that they

get replenished.

1 facility

implemented this

change and

improved by 40

percentage points.

This change

was tested

at Lira RRH.

Assign a focal

person for new

born

One of the maternity staff

was assigned a role to

coordinate the

5 facilities

implemented this

change and

This change

was

implemente


resuscitation. completeness of the

resuscitation tray and the

performance of new born

resuscitation

improved by 30

percentage points.

d by 5

facilities.

Changes introduced to improve provision of a complete essential newborn care package before

discharge.

Specific

Problem

being

addressed

Change

concept

Change ideas

tested


change ideas

Evidence that the

changes led to

Improvement

Scale of

Implemen

tation

Babies

born on

weekends

and

Public

holidays

missing

out on

immunisa

tion

Improving

accessibility

of services

Re-allocation of

the key to EPI

room to maternity

to access vaccines

during weekends

and public

holidays

The key to the EPI fridge

was kept away over

weekends and public

holidays by the EPI focal

person. During a QI team

meeting, it was agreed that

this key is kept in a

designated and labelled

area known to all staff in

the maternity ward.

3 facilities tested

this change and

improved by 30

percentage points.

This change

was tested

at 3 facilities

One EPI staff

assigned each

weekend to

provide vaccines

to the midwife on

duty

A meeting was organised

for EPI & maternity staff.

The in- charge EPI was

requested to allocate an

EPI staff to provide

vaccines to the midwife on

duty over weekends and

public holidays for

vaccination

5 facilities tested

this change and

improved by 30

percentage points

This change

was

implemente

d in 5

facilities.

Inadequat

e supply

of vitamin

K ,TEO

and BCG

vaccine

Improve

availability

Re allocation of

Vitamin K and

TEO to labour

suite on the ENC

tray from mini

store of maternity

In addition to the

emergency tray in the labor

suit, each staff was tasked

to prepare vitamin K and

TEO to the ENC tray.

4 facilities tested

this change and

improved by 40

percentage points

This change

was

implemente

d at 4

facilities

Redistribution of

ENBC supplies

from better

stocked facilities

During stock outs, the in-

charge maternity submitted

a requisition through the

facility in-charge to

redistribute supplies from

other facilities that are

stocked.

6 facilities

implemented this

change and

improved by 20

percentage points

This change

was

implemente

d at 6

facilities

EPI and maternity

making joint

requisitions from

the district store.

Meetings were held

between the in charge

maternity and EPI on a

monthly basis to requisition

1 facility tested this

change and

improved by 30

percentage points

This change

was

implemente

d in one


for vaccines. facility

Knowledg

e gap on

administr

ation of

ENC

drugs

Improving

staff

competenc

es

On job training on

how to provide

each element of

ENC

A general orientation on

how to provide each ENC

component was conducted

by the maternity in-charge.

This was supplemented by

a one on one on job

training on how to

administer the various

elements of ENC.


change and

improved by 10

percentage points.

This change

was

implemente

d at one

facility.

Display of SOPs

and Job aids on

how to provide

component of

ENC

The ward in charge

together with the team

developed job aids on how

to provide each element of

ENC and displayed them in

labor suit.

20 facilities

implemented this

change and

improved by 20

percentage points.

This change

was

implemente

d in 20

facilities.

Incomplet

e

document

ation

Improving

data quality

Cross-checking

documentation

gaps at handover

of shifts

In coming staff checks on

documentation of ENC

components provided

before the out-going staff

leaves the ward. The staff

checks the maternity

register and the

partographs for that duty


change and

improved by 30

percentage points

This change

was

implemente

d at one

facility.

Inaccessib

le ENC

compone

nts

Improving

accessibility

of supplies

Set a complete

ENC tray within

the Labor suit

There was no set tray for

ENBC in the labor suit, one

midwife was then assigned

to assemble all the

components of the ENBC

tray to which a list was

provided and displayed in

the labor suit.

20 facilities tested

this change and

improved by 50

percentage points

This change

was

implemente

d in 20

facilities

Not all

elements

of ENC

were

being

provided

to babies

at birth

Display of ENC

checklist in the

Labor suit

A number of items were

missing from the ENC tray

and staff were not aware

which ones, the ward

matron assigned a staff to

come up with a list of items

according to the protocols

supplied by MOH and

displayed it in the labor

suit.

6 facilities tested

this change and

improved by 30

percentage points

This change

was

implemente

d in 6

facilities

Changes introduced to improve provision of kangaroo mother care (KMC) and antenatal cortico-

steroid use (ACS).

Specific

Problem being

addressed

Change

concept

Change ideas

tested

Steps in

introducing the

change ideas

Evidence that

the changes

led to

Improvement

Scale of

Implementation

Knowledge gap

on KMC and

ACS

Improving

staff

competence

Practical

demonstration

on KMC using

models

An orientation

meeting was

organized by the in-

charge maternity. The

11 facilities

tested this

change and

improved by 50

This change was

implemented by

11 facilities


Orientation of

staff on

administration

of ACS

team identified one

staff skilled in pre-

term care and

demonstrated to the

rest of the team on

KMC and

administration of

ACS.

percentage

points.

Display of SOPS

on

administration

of

Dexamethasone

in labour ward

SOPs on ACS were

obtained from the

supporting partner

and displayed in the

labor suit.

11 facilities

tested this

change and

improved by 40

percentage

points

This change was

tested by 11

facilities

NO KMC

corner

Improving

access to

KMC

services

Identified a

KMC corner /

bed on post

natal ward

Health facilities

realised that while

they were conducting

preterm management

practices, no

designated space was

provided for

providing KMC.

The maternity team

identified a bed in one

of the warm and well

aerated corners in

the postnatal ward

and labelled it KMC

corner

20 facilities

tested this

change and

improved by 20

percentage

points

This change was

implemented in 20

facilities

Myths and

misconceptions

to KMC

practices

Improve

continuity

of services

Sensitise and

support

mothers and

care takers to

practice KMC

The maternity QI

team developed

talking points about

KMC and every

midwife was assigned

to use during health

education in the post

natal and ante natal

wards to demystify

care for the

premature new-born

and tasked to

physically

demonstrate to

mothers and

caretakers how to

conduct KMC and its

benefits.

6 facilities

tested this

change and

improved by 50

percentage

points

This change was

implemented in 6

facilities

Stock out of inj.

Dexamethasone

Improving

availability

of supplies

Re-distribution

from stocked

facilities

The in-charge

maternity

requisitioned inj.

Dexamethasone

through the facility in

charge to obtain

stocks of

11 health

facilities tested

this change and

improved by 40

percentage

points

This change was

implemented in 11

health facilities


dexamethasone from

stocked health

facilities.

Incomplete

documentation

Improving

data quality

Focal person

assigned to

regularly check

the register for

proper

documentation

The facility in charge

identified one of the

QI team members

and was tasked to

check the

documentation of

ACS and KMC

related data in the

register on a daily

basis. This midwife

notifies other staff of

errors to address

them.

3 facilities

implemented

this change and

improved by 20

percentage

points.

This change was

implemented by 3

facilities.

Changes introduced to improve emergency preparedness in the labor suit through increasing the

number of days when the emergency trays were fully constituted.

Specific

Problem

being

addressed

Change

concept

Change

ideas

tested


change ideas

Evidence that

the changes

led to

Improvement

Scale of

Implementation

Lack of

awareness

on the

constitution

of

emergency

trays

Improving

staff

competence

Orientation

of staff on

composition

of the

emergency

tray


scheduled for maternity staff to

be trained on emergency

preparedness and its

importance.

The orientation was mainly on

the contents of the emergency

tray and how to use each

element using a standard

checklist.

6 facilities

implemented

this change and

improved by 30

percentage

points.

This change was

tested by 6

facilities

Preparation

and display of

the

emergency

checklist

Following the orientation

meeting, the maternity in-

charge assigned a staff to

prepare a checklist and display

it at the emergency corner.

8 facilities

tested this

change and

improved by 20

percentage

points

This change was

implemented by 8

health facilities

Incomplete

emergency

trays

Improving

availability

Utilize the

emergency

check list to

replenish the

emergency

tray on a

weekly basis

Using the emergency drug

check list, staff were tasked on

a weekly basis to compare the

drugs available and those in the

tray, replacing those missing

from the facility store.

3 facilities

tested this

change and

improved by 30

percentage

points

This change was

implemented by 3

health facilities


Changes tested to improve maternal and perinatal death reviews

Specific

Problem

being

addressed

Change

concept

Change

ideas tested


ideas

Evidence

that the

changes led

to

Improvemen

t

Scale of

Implement

ation

NO MPDR

committee

in place

Functional

MPDR

committee

in place

Re-constitute

a

multidisciplinar

y MPDR

committee

The first meeting was conducted by

the facility administration where

members were selected and roles

and responsibilities assigned.

Necessary tools including MPDR

books were provided to the

committee

Assigned a facility MPDR focal

person to coordinate all MPDR

activities

All the 20

facilities

formed MPDR

committees

and improved

auditing by

60%

All the 20

facilities

formed

MPDR

committees

Knowledge

gap on

MPDR

Improving

staff

competenc

e

Orientation of

the MPDR

committee

The medical officer in charge of

maternity mobilised staff and took

the entire facility team through the

MPDR process and team

functionality

13 facilities

tested this

change and

improved by

20 percentage

points

This change

was tested

in 13

facilities

Irregular

MPDR

committee

meetings

Improving

continuity

of services

Display

Reminders on

notice boards

Set up a

minimum

number of

members of

the committee

required for

the audits to

take place.

MPDR focal person scheduled

meetings before hand and put

reminder notices on all notice

boards. These were followed up by

phone calls on the day of the

meeting.

The committee agreed on a

minimum number of members

required for the audits to take place.

12 facilities

implemented

this change

and improved

by 20

percentage

points

This change

was

implemented

by 12

facilities

Schedule

meetings on a

weekly or

monthly basis

A day was identified in week that

was less busy and scheduled MPDR

meetings to take place either on a

weekly or monthly basis.

7 facilities

implemented

this change

and improved

This change

was tested

by 7 facilities

Assigning a

midwife to

check the

emergency

tray for

completeness

The midwife was assigned to

check the contents and expiry

dates of the emergency tray

drugs as well as coordinate the

replenishing of stocked out

drugs on the tray.

4 facilities

tested this

change and

improved by 20

percentage

points

This change was

implemented by 4

facilities

Physical

handover of

a complete

emergency

tray

During shift change, maternity

staff were tasked to handover

complete emergency trolleys

to the incoming shifts

One facility

tested this

change and

improved by 40

percentage

points

This change was

tested at one

facility.


by 50

percentage

points

No clear

follow up

mechanism

of MPDR

recommend

ations

Improving

efficiency of

services

Develop

action plans

from the

recommendati

ons made.

During the MPDR meetings,

recommendations are made and

action plans developed. Members are

assigned roles to follow up on each

action point developed in a

stipulated time period.

13 facilities

implemented

this change

and improved

by 50

percentage

points

This change

was tested

by 13

facilities

Stock out of

MPDR forms

Improving

availability

Improvised a

counter book

for reviews

Requisitioned a counter from the

records office. Using the format of

the filled MPDR forms, the counter

book was formatted accordingly.

After auditing, the pages used in the

counter book were scanned for

reporting to MOH.

4 facilities

implemented

this change

and improved

by 50

percentage

points

This change

was tested

by 4 facilities

Redistribution

of MPDR

forms from

other stocked

health facilities

The facility in charge/MPDR focal

person identified and requisitioned

for extra MPDR books from other

facilities that had extra copies.

2 facilities

implemented

this change

and improved

by 20

percentage

points

This change

was tested

by 2

facilities.

.

Documents

Improving Maternal and Newborn Care in Northern Uganda · 2019-12-30 · 5 Improving maternal & Newborn care in Northern Uganda Acronyms AMSTL Active management of the third stage