Readiness of rural health facilities to provide immediate postpartum care in Uganda

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Study Justification:
– Maternal and newborn deaths within 24 hours after delivery are a significant concern in Uganda.
– Immediate postpartum monitoring can prevent deaths from preventable causes.
– This study aimed to assess the readiness of rural health facilities in Uganda to provide postpartum care.
Study Highlights:
– The study involved 40 health facilities in the greater Mpigi region of Uganda.
– Facility readiness for postpartum care was low, with a median score of 24%.
– Inconsistent availability and use of policies, guidelines, and protocols for postpartum care were observed.
– Lack of functional equipment and frequent stock-outs of essential drugs and supplies were common challenges.
– Inadequate human resources and sub-optimal supplies impacted the quality of postpartum care.
– Private not-for-profit health facilities had higher readiness scores.
Recommendations for Lay Readers:
– Strengthen health system inputs and supply side factors to improve facility capacity for postpartum care.
– Increase availability and use of up-to-date policies, guidelines, and clinical protocols.
– Address equipment challenges and ensure consistent availability of essential drugs and supplies.
– Address human resource shortages and improve supply management to enhance postpartum care quality.
Recommendations for Policy Makers:
– Allocate resources to strengthen health system inputs and supply side factors for postpartum care.
– Develop and implement up-to-date policies, guidelines, and clinical protocols for postpartum care.
– Improve equipment availability and maintenance to enable proper screening, diagnosis, and treatment.
– Address stock-outs of essential drugs and supplies, particularly in health centers.
– Increase human resources and optimize supply management to enhance postpartum care quality.
Key Role Players:
– Ministry of Health
– District Health Officers
– Facility Administrators
– Midwives and other healthcare providers
– Maternity Ward In-charges
– Research Assistants
Cost Items for Planning Recommendations:
– Resources for strengthening health system inputs and supply side factors
– Development and dissemination of policies, guidelines, and clinical protocols
– Equipment procurement, maintenance, and repairs
– Drug and supply procurement and management
– Human resource recruitment, training, and retention efforts

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study involving 40 health facilities in Uganda. The study design and methodology are clearly described, and the data were analyzed using appropriate statistical methods. The findings indicate low facility readiness for postpartum care, with inconsistent availability of policies, guidelines, and equipment across all levels of care. The study provides valuable insights into the challenges faced by rural health facilities in providing immediate postpartum care. However, to improve the strength of the evidence, future studies could consider increasing the sample size and including a wider range of health facilities. Additionally, incorporating qualitative methods to gather more in-depth information and perspectives from healthcare providers and patients would further enhance the findings.

Background: Nearly 60% of maternal and 45% of newborn deaths occur within 24 h after delivery. Immediate postpartum monitoring could avert death from preventable causes including postpartum hemorrhage, and eclampsia among mothers, and birth asphyxia, hypothermia, and sepsis for babies. We aimed at assessing facility readiness for the provision of postpartum care within the immediate postpartum period. Methods: A cross-sectional study involving 40 health facilities within the greater Mpigi region, Uganda, was done. An adapted health facility assessment tool was employed in data collection. Data were double-entered into Epi Data version 4.2 and analyzed using STATA version 13 and presented using descriptive statistics. Results: Facility readiness for the provision of postpartum care was low (median score 24% (IQR: 18.7, 26.7). Availability, and use of up-to-date, policies, guidelines and written clinical protocols for identifying, monitoring, and managing postpartum care were inconsistent across all levels of care. Lack of or non-functional equipment poses challenges for screening, diagnosing, and treating postnatal emergencies. Frequent stock-outs of essential drugs and supplies, particularly, hydralazine, antibiotics, oxygen, and blood products for transfusions were more common at health centers compared to hospitals. Inadequate human resources and sub-optimal supplies inhibit the proper functioning of health facilities and impact the quality of postpartum care. Overall, private not-for-profit health facilities had higher facility readiness scores. Conclusions: Our findings suggest sub-optimal rural health facility readiness to assess, monitor, and manage postpartum emergencies to reduce the risk of preventable maternal/newborn morbidity and mortality. Strengthening health system inputs and supply side factors could improve facility capacity to provide quality postpartum care.

This was a cross sectional study that employed quantitative methods of data collection using a facility assessment tool. This study design was adopted because we sought to collect data at a single point in time to assess how prepared the facilities were to provide care to women and babies within the immediate postpartum period. The study setting was in the greater Mpigi region found in central Uganda, which consists of three districts namely: Butambala, Gomba, and Mpigi. This region was chosen because it is centrally located and it has health facilities in both the peri-urban and rural settings, which serve a wide population. The health system in Uganda has several tiers including: health centers I, II, III, IV; general hospitals; regional referral hospitals; national referral hospitals; and national specialized hospitals. A health center I is located at the village level and provides basic home-based care and health promotion. The care at this level is provided by the village health teams comprised of volunteers in the community. Health center IIs are located at the parish level and provide outpatient curative services and outreach for health promotion. At the sub-county level, we have health center IIIs, which provide all the above and inpatient medical, antenatal and maternity care. Next is the health center IV at the health sub-district, where emergency surgical and maternity care, blood transfusion and laboratory services are available, together with the health promotion and outpatient curative care. Then we have the general hospital at the district level that provides all the care and services provided by the health center IVs, in addition to general surgical care, mental health care, dental care and some specialized services like physiotherapy. At the regional referral hospitals, clients can access specialized medical services. These also offer training for different cadres of health workers. There are 9 national-level hospitals, of which 5 are specialized. None of these national referral or specialized hospitals were included in this study. The target population for this study were all the health facilities in our study area that provide intrapartum care services and health facility based postpartum care which include: hospitals, health center IVs and health center IIIs according to the current Ministry of Health (MOH) policy guidelines for health care services [14, 21]. The facilities in the greater Mpigi region that were eligible to participate in this study were those that conducted deliveries and had been providing the service for at least 6 months at the time of the data collection. The three district health officers and all included facility administrators provided administrative clearance for the study to be conducted at their health facilities. Thereafter, permission was sought from the maternity ward in-charges to conduct the study on their units. Informed consent was sought from all the midwives and mothers who participated in the study. The sample size of 40 health facilities was calculated using the simplified formula by Yamane [22] at a confidence interval of 95%, error of 5%, and a total population of 44 health facilities in the greater Mpigi region that provided delivery services based on the national health facilities inventory [21]. There were two hospitals, three health center IVs and 39 health center IIIs in the official list of registered health facilities in the three districts [21]. Out of 44 health facilities, 40 health facilities were assessed in this study. All the hospitals and three health center IVs in the three districts plus all the health center IIIs in Butambala and Gomba were purposively included in the study because they were few. Health center IIIs within Mpigi district were recruited consecutively until all the required sample (for Mpigi district) of 17 health center IIIs was reached. The data were collected using a facility assessment tool that has been adapted from the Ministry of Health’s original result-based financing (RBF) assessment and the SARA facility assessment tools [23]. The MOH tool’s sections were retained but adjusted to focus on postpartum care provision. The tool has eight sections including; presence of a written policy on hospital stay after delivery (scored as 5 or 0), availability of a checklist for routine monitoring of women post-delivery (scored as (15 to 0), presence of a clean, private, dedicated area for postpartum care (scored as 5 or 0). presence of tracer medicines and commodities for basic obstetric care (oxytocin, misoprostol, magnesium sulphate, amoxicillin, metronidazole, vitamin K, tetracycline chlorhexidine gel, normal saline, ringers lactate, 50% dextrose, surgical gloves, examination gloves, sutures (vicryl), gauze, alcohol, hibitane solution and surgical blades) (scored as 5 or 0), availability of a checklist for counselling postpartum women (scored as 15 to 0), availability of tracer equipment for postpartum care provision (blood pressure machines, thermometer. tape measures, glucometer, pulse oximeters) (scored as 15 or 0). presence of a functional transport system (scored as 5 or 0), presence of a viable client information and educational program (scored as 10 or 0), Each section was scored separately and an overall score for the facility was computed with a maximum score of 70 and a minimum score of zero. The scores were then transformed into percentage scores. The median scores per district, facility level, and facility type were computed. The tool was checked for content validity by DKK and GKN, then pilot tested by assessing two senior midwives working at a referral hospital in Kampala. Changes were made to the tool as suggested by the midwives and the two coauthors. During the training of the research assistant, care was taken to minimize inter-rater variability to increase the reliability of the scores. Whenever possible, the two assessors both scored the facility visited and compared their scores before agreeing on the final facility score. The dependent variable for this study was the facility readiness for the provision of postpartum care, which was the median score for all the facilities based on the facility readiness assessment scores. The independent variables included: facility level, ownership, number of midwives, district, average number of deliveries per month, and number of postnatal beds. Data were collected over a period of 4 months between August and December 2020. After verifying the functionality of the facilities identified in the national health facility inventory [21] with each district health office, each facility in-charge or medical superintendent was contacted by telephone or email and briefed about the study before the facility was visited. Those that responded positively were scheduled for a visit and the in-charge was informed of the possible date for the visit. On arrival at the health facility, administrative clearance was sought from the in-charge who introduced the study team to the midwife on duty or the maternity in-charge. The team then explained what they needed to do and proceeded to complete the assessment with the help of either the midwife or the maternity in-charge. Those facilities where administrative clearance was not obtained were excluded from the study. Various items were assessed in the facility readiness assessment tool including: length of hospital stay following a normal delivery; routine monitoring of postpartum care; availability of space; tracer medicines; commodities; equipment; sundries; a functional transport system; and a health education program for the postpartum women and their care givers. Completion of the assessment tool included verification of the presence or absence of the various equipment, drugs, postnatal charts, MOH guidelines for postpartum care, standard operating procedures for the provision of postpartum care, visual reminders for midwives / checklists for care provision, discharge guidelines, health education guides (models, flip charts, posters, time table, and other teaching aids), brochures for information provision, examination room / couch, cleaning materials and cleaning schedule for the postnatal unit. For sections where there was observation of care being provided, the team requested to be present while care was being provided to a postpartum mother so as to observe the care provided to the client. No identifying information regarding the clients was collected, as the researchers were only interested in observing what the midwife did in providing care. The clients were informed about the study and requested for consent to be observed while receiving care. In facilities where there were no clients found at the time of the visit, the midwife was asked to describe what she does for each client from the time of delivery of the baby to the time of discharge, and this was assessed against the postpartum care guidelines for both the mother and newborn. The midwife was then asked to avail the team with policy guidelines and checklists that were being used for the provision of care and health education. She also took the team to the ward, store and laboratory where they checked for the availability of drugs, sundries (IV giving sets, blood giving sets, cotton, gauze, examination gloves, surgical gloves, and gynecological gloves), equipment, blood products, and laboratory equipment. Regarding the postpartum counseling done and documented by the midwife. We interviewed one midwife at each health center III and health center IV. At the hospitals, we interviewed and observed 3 midwives providing in-facility postpartum care but only one midwife who was the maternity in-charge assisted the researchers in ascertaining the presence of the required documents, drugs and equipment. The number of midwives assessed was based on the guidance from the tool and the availability of the midwives/ patients at the health facility at the time of the facility assessment. The team spent at least 1 day at each facility depending on the availability of the facility in-charge, midwife and the postpartum clients. Each filled assessment tool was reviewed for completeness before leaving the facility and any missed observations were completed before departure from the facility. Data were double entered into Epi data version 3.1, cleaned, and exported to Stata version 14.2 for analysis [24, 25]. Univariate analysis was performed for health facility characteristics and presented as frequencies and percentages. All facilities that scored 80% and above were considered to be prepared to provide postpartum care while those that scored below the 80% were considered not ready to provide postpartum care. The facility readiness score was also reported in a table reflecting minimum and maximum scores and the median per district because the scores were skewed to the left. Higher scores denoted that a facility was better prepared to provide postpartum care.

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Based on the information provided, here are some potential innovations that could be recommended to improve access to maternal health:

1. Strengthening Health System Inputs: This could involve improving the availability and use of up-to-date policies, guidelines, and written clinical protocols for identifying, monitoring, and managing postpartum care. It could also include addressing the challenges posed by lack of or non-functional equipment for screening, diagnosing, and treating postnatal emergencies.

2. Addressing Stock-outs of Essential Drugs and Supplies: Efforts could be made to address frequent stock-outs of essential drugs and supplies, particularly hydralazine, antibiotics, oxygen, and blood products for transfusions. This could involve improving supply chain management and ensuring a consistent and reliable supply of these critical items.

3. Increasing Human Resources: Inadequate human resources were identified as a barrier to providing quality postpartum care. Therefore, efforts could be made to increase the number of skilled healthcare providers, such as midwives, in rural health facilities. This could involve recruitment and training programs, as well as incentives to attract and retain healthcare professionals in rural areas.

4. Improving Facility Readiness Scores: The study found that facility readiness for the provision of postpartum care was low. Therefore, interventions could be implemented to improve facility readiness scores, such as providing training and support to healthcare providers, ensuring the availability of necessary equipment and supplies, and implementing quality improvement initiatives.

5. Leveraging Technology: Technology could be utilized to improve access to maternal health services in rural areas. This could include telemedicine programs that allow healthcare providers to remotely monitor and provide guidance to postpartum women, as well as mobile health applications that provide information and support to pregnant women and new mothers.

6. Public-Private Partnerships: The study found that private not-for-profit health facilities had higher facility readiness scores. Therefore, exploring partnerships between public and private healthcare providers could be beneficial in improving access to maternal health services in rural areas.

These are just a few potential innovations that could be considered to improve access to maternal health based on the findings of the study. It is important to note that the specific context and needs of the community should be taken into account when implementing any innovation.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health would be to strengthen the readiness of rural health facilities in Uganda to provide immediate postpartum care. This can be achieved through the following actions:

1. Develop and implement up-to-date policies, guidelines, and written clinical protocols for identifying, monitoring, and managing postpartum care. Ensure consistent availability and use of these resources across all levels of care.

2. Address the lack of or non-functional equipment in health facilities. Provide necessary screening, diagnostic, and treatment equipment for postnatal emergencies.

3. Address frequent stock-outs of essential drugs and supplies, particularly hydralazine, antibiotics, oxygen, and blood products for transfusions. Improve supply chain management to ensure consistent availability of these items, especially in health centers.

4. Increase the number of human resources and improve their training to enhance the proper functioning of health facilities and the quality of postpartum care.

5. Focus on strengthening health system inputs and supply side factors to improve facility capacity to provide quality postpartum care.

6. Provide support and resources to private not-for-profit health facilities, which showed higher readiness scores, to further enhance their capacity to provide postpartum care.

By implementing these recommendations, rural health facilities in Uganda can improve their readiness to assess, monitor, and manage postpartum emergencies, ultimately reducing the risk of preventable maternal and newborn morbidity and mortality.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthening Policies and Guidelines: Develop and implement up-to-date policies, guidelines, and written clinical protocols for identifying, monitoring, and managing postpartum care. Ensure consistent availability and use of these resources across all levels of care.

2. Improving Equipment and Supplies: Address the challenges posed by lack of or non-functional equipment by ensuring the availability of necessary equipment for screening, diagnosing, and treating postnatal emergencies. Address frequent stock-outs of essential drugs and supplies, particularly hydralazine, antibiotics, oxygen, and blood products for transfusions.

3. Increasing Human Resources: Address the inadequate human resources by recruiting and training more midwives and healthcare professionals to meet the demand for postpartum care. This will help improve the functioning of health facilities and the quality of postpartum care.

4. Enhancing Health System Inputs: Strengthen health system inputs by ensuring a consistent supply of essential drugs, equipment, and supplies. Improve the functionality of health facilities to provide quality postpartum care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as the number of women receiving postpartum care, the availability of essential drugs and supplies, and the presence of trained healthcare professionals.

2. Collect baseline data: Gather data on the current state of access to maternal health, including the availability of resources, the number of healthcare professionals, and the utilization of postpartum care services.

3. Implement the recommendations: Introduce the recommended interventions, such as strengthening policies and guidelines, improving equipment and supplies, increasing human resources, and enhancing health system inputs.

4. Monitor and evaluate: Continuously monitor the implementation of the recommendations and collect data on the indicators identified in step 1. Evaluate the impact of the interventions on access to maternal health by comparing the post-intervention data with the baseline data.

5. Analyze the data: Use statistical analysis techniques to analyze the collected data and assess the impact of the recommendations on improving access to maternal health. This could include comparing pre- and post-intervention data, conducting regression analysis, or using other appropriate statistical methods.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the interventions in improving access to maternal health. Make recommendations for further improvements or adjustments to the interventions based on the findings.

7. Communicate the results: Share the findings of the impact assessment with relevant stakeholders, including policymakers, healthcare providers, and the community. Use the results to advocate for continued support and investment in improving access to maternal health.

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