IMPROVING THE QUALITY OF MATERNAL … the quality of maternal...NEWBORN CARE SERVICES THROUGH STAFF...

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IMPROVING THE QUALITY OF MATERNAL DELIVERY AND

NEWBORN CARE SERVICES THROUGH STAFF REDEPLOYMENT

AND CAPACITY BUILDING AT MITYANA HOSPITAL

BY

BIZIMANA ABEL

MakSPH-CDC FELLOW

2012

.

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IMPROVING THE QUALITY OF MATERNAL DELIVERY AND

NEWBORN CARE SERVICES THROUGH STAFF REDEPLOYMENT

AND CAPACITY BUILDING AT MITYANA HOSPITAL

BY

BIZIMANA ABEL

(MSC. HSM, UMU)

MakSPH-CDC FELLOW

NOVEMBER, 2012

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TABLE OF CONTENTS

DECLARATION ......................................................................................................... vi

DEDICATION ............................................................................................................ vii

LIST OF ACRONYMS ............................................................................................. viii

OPERATIONAL DEFINITIONS ................................................................................ x

EXECUTIVE SUMMARY......................................................................................... xii

SECTION 1. INTRODUCTION AND BACKGROUND ............................ 1

1.1. Introduction ................................................................................................... 1

1.2. Trends in maternal and neonatal morbidity and mortality ............................... 2

SECTION 2. THE QUALITY IMPROVEMENT PROCESS ..................... 5

2.1. Reasons for improvement .............................................................................. 5

2.2. Examining the current situation ...................................................................... 5

2.3. Problem analysis ............................................................................................ 7

SECTION 3. PLANNING COUNTERMEASURES.................................. 10

3.1. Intervention objective .................................................................................. 10

3.2. Intervention strategies .................................................................................. 10

3.3. Expected results ........................................................................................... 10

3.4. Implementation framework .......................................................................... 11

3.5. Reviewing staff redeployment ...................................................................... 13

3.6. Training Midwives at Mityana hospital ........................................................ 13

SECTION 4. THE QUALITY IMPROVEMENT OUTCOMES .............. 15

4.1. Redeployment of midwives .......................................................................... 15

4.2. Training process .......................................................................................... 16

4.3. Other changes .............................................................................................. 17

4.4. Intervention outcomes .................................................................................. 18

4.5. Qualitative evaluation .................................................................................. 21

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4.6. Institutionalization of CQI ........................................................................... 22

SECTION 5. FUTURE PLANS .................................................................. 25

SECTION 6. CHALLENGES ..................................................................... 26

SECTION 7. DISCUSSIONS ...................................................................... 30

SECTION 8. CONCLUSION AND RECOMMENDATION .................... 33

REFERENCES ........................................................................................................... 36

Appendix I. ................................................................................................................. 43

Appendix II ................................................................................................................. 48

Appendix III ............................................................................................................... 48

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LIST OF FIGURES

Figure 1-1: Risk factors found among mothers attending maternity ward in Mityana

hospital, 2011 (Mildmay Uganda, 2012) ......................................................................... 4

Figure 2-1: Fishbone analysis showing factors associated with deployment of few and

less skilled midwives in maternity ward .......................................................................... 8

Figure 4-1: At the stakeholders‟ meeting; the fellow makes a point as the RDC listens . 16

Figure 4-2: Participants of the stakeholders‟ Meeting ................................................... 16

Figure 4-3: Pre and post test results for 24 midwives trained at Mityana hospital. ........ 17

Figure 4-7: A midwife assisting a mother .................................................................... 18

Figure 4-4: Midwives and trainers ready for a practical session after 4-days theory ...... 18

Figure 4-5: One of the groups of trainees doing 5 pre-test ............................................ 18

Figure 4-6: A midwife gives a health talk mothers at discharge after delivery by C/S . 18

Figure 4-8: Trends of completely plotted partographs (January to November 2012) ..... 19

Figure 4-9: Trends of maternal and neonatal sepsis, postpartum hemorrhage and Fresh

Stillbirth (FSBs) ........................................................................................................... 20

Figure 4-10: Trends in delivery methods and FSBs in relation to completely filled

partgraphs. ................................................................................................................... 21

Table 2-1: Ranking of selected problems associated with poor quality of maternal

delivery and newborn care in Mityana hospital. .............................................................. 6

Table 2-2: Distribution of midwives in wards and departments of Mityana hospital........ 7

Table 3-1: Implementation framework ......................................................................... 12

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DECLARATION

I Abel Bizimana do hereby declare that this programmatic report entitled

„Improving the Quality of Maternal Delivery and Newborn Care Services

Through Staff Redeployment and Capacity Building at Mityana Hospital’

has been prepared and submitted in fulfillment of the requirements of the

MakSPH-CDC Fellowship Program and has not been submitted for any academic

qualifications.

Signed………………………………………. Date……………………….

Abel Bizimana,

Fellow

Signed………………………………………. Date……………………….

Dr. Yvonne Karamagi

Primary Host Mentor, Mildmay Uganda

Signed………………………………………. Date……………………….

MS. Mary Odiit,

Secondary Host Mentor, Mildmay Uganda

Signed………………………………………. Date……………………….

Dr. Geoffrey Kabagambe

Academic Mentor

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DEDICATION

This report is dedicated to David Wilber Rwalinda and I.K. Murekezi who

unblocked „my academic road‟. I would not be at this professional level if they

did not intervene at strategic points in my career path. Late Pastor Jonathan

Nkiriyehe who provided a parental and moral background that enabled me to

socially fit in society.

Martha Nkiriyehe, Penninah N; Jane B, My children: Munyantwali, Muhoza,

Mbanjingabo, Mushakamba and Mberey‟ingoma and my family members whom

motivate me to work hard since I have to account for my absence while pursuing

my academic and professional goals.

Kisoro District Local Government that has provided me with capacity and

opportunity to become a public health professional; through supervision, training,

allocating challenging assignments hence allowing me to advance in my studies.

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LIST OF ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

AMTSL Active Management of Third Stage of Labour

ANC Antenatal Care

CAO Chief Administrative Officer

CME Continuous Medical Education

C/S Caesarian Section

CQI Continuous Quality Improvement

ECN Essential Newborn Care

EmONC Emergency Obstetric and Newborn Care

FHI Family Health International

FIGO Federation of International Gynaecology and Obstetrics

FSB Fresh Stillbirth

HIV Human Immunodeficiency Virus

ICM International Confederation of Midwives

IMR Infant Mortality Rate

IRB Instructional Review Board

MCHIP Maternal and Child Health integrated Program

MDGs Millennium Development Goals

MMR Maternal Mortality Rate

MDNBC Maternal Delivery and Newborn Care

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MNPI Maternal and Neonatal Program Index

MoH Ministry of Health, Uganda

MTCT Mother-To-Child transmission of HIV

MUg Mildmay Uganda

PATH Program for Appropriate Technology in Health

PNO Principal Nursing Officer

PMTCT Prevention of Mother-To-Child transmission of HIV

POPPHI Prevention of Postpartum Hemorrhage Initiative

PPH Postpartum Hemorrhage

QoC Quality of Care

SAA Sub-Saharan Africa

SBA Skilled Birth Attendant

TQM Total Quality Management

UBOS Uganda Bureau of Statistics

UDHS Uganda Demographic and Health Survey

UNFPA United Nations Population Fund

USAID United States Agency for International Development

WHO World Health Organization

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OPERATIONAL DEFINITIONS

1. Active Management of Third stage of e of Labour (AMTSL): Use of

oxytocics, controlled cord traction and massaging uterus (after delivery of

placenta) to prevent postpartum hemorrhage.

2. Clients: A mother, her relative and a baby in the health facilities

3. Client Participation: The process of getting clients‟ opinion on quality of

maternal and newborn care services which they consume with the purpose of

using the opinion to improve the services and client satisfaction.

4. Competence: Ability to do well tasks related to ensuring health of the

mother and the baby.

5. Continuous Quality improvement: Deliberate and defined processes of

continuously adding on on-going efforts to achieve measurable positive change on

performance, efficiency and effective „delivery and immediate postnatal newborn

services‟.

6. Delivery: A process of the childbirth that begins with labour pains and ends

when the baby and the placenta have been expelled from the uterus. It involves

procedures of clean birth and additional assistance to the mother, if labour does

not progress well.

7. Delivery and Immediate Postnatal Newborn Care Services: These are

services offered to a mother and newborn during delivery and within the first hour

after delivery to prevent and control of neonatal asphyxia, MTCT, postpartum

hemorrhage and sepsis.

8. Health worker: A midwife or any other competent person that

participates in conduct delivery and newborn care.

9. Improvements: Changing from low quality to higher quality of maternal

and newborn services

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10. Immediate Postpartum Care: The care of mother and baby aiming at

ensuring that the neonate breathes and is kept warm and promptly initiated to

breastfeeding, while the mother is assisted to prevent blood loss due to child birth.

11. Participatory Continuous Quality Improvement: It is a quality

improvement process that deliberately and systematically engages all stakeholders

involved in demand and utilization of maternal and newborn services.

12. Performance: Higher productivity and better quality of maternal and

newborn services through adherence to standards of delivery and newborn care.

13. Productivity improvement: Increase in outputs in delivery of maternal

and newborn care in a given time based on commitment and competence of

service provider aided by existing technology.

14. Quality: The process of not only meeting clients‟ needs (expert opinion)

and expectations (clients wants) but also exceed them to attain unprecedented

levels of quality and safety of maternal and newborn health services

15. Service Provider: A health worker qualified, employed and assigned

tasks that provide a service to clients.

16. Skilled Birth Attendant: A doctor, midwife or nurse who has been

trained to proficiency in the skills needed to manage normal labor and be able to

identify, manage and refer mothers and newborns with complications with a goal

of having a live baby and a healthy mother.

17. Standards: A set of behaviors or performance below which it is not

acceptable ethically, professionally and technically. Standards are facts or

consensus-based minimum requirements according to what is considered to be

the norm.

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EXECUTIVE SUMMARY

This project report is about a quality improvement (QI) project which aimed at

improving the quality of maternal delivery and newborn care services in Mityana

hospital through increased availability and training of midwives.

We designed the project using the Continuous Quality Improvement (CQI)

approach which takes the CQI team through 7 seven steps of improving quality:

(1) reasons for improvement, (2) current situation, (3) analysis, (4)

countermeasures, (5) results, (6) standardization and (7) future plans. We focused

our intervention on making structural review and system improvements in (staff

availability, functional life-saving equipments, essential medicines and blood and

support supervision).

The Quality Improvement process

1. Establishing reasons for improvement: The project was initiated with a

rapid assessment to establish the status of quality of maternal delivery and

newborn care. The purpose of the assessment was to identify structural and

process-related barriers to quality improvement. The assessment was carried out

in January and February 2012. We interviewed 17 midwives, held 2 Focus

Group Discussions, made some observations and reviewed data from maternity

register. We used knowledge of health worker on Active Management of Third

Stage of Labour (AMTSL) and use of partograph as key indicators for reducing

maternal life- threatening risks such as severe anaemia (due to Post Partum

Hemorrhage) and obstructed labour. We observed facility readiness to quality

improvement by assessing availability of lifesaving drugs and other key medical

supplies. We also held two Focus Group Discussion (FGDs) meetings with 20

clients (10 clients per group) who had received delivery services in the hospital.

We reviewed data from maternity register for 2011 to obtain conditions related to

maternal and neonatal morbidity and mortality including pregnancy outcomes.

From interview of 17 midwives, 3 (17.5%) had ever heard about the term

AMTSL: We asked midwives to describe the process of managing labour so that

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we can determine inclusion of AMSTL and its components). Only 4 (23.5%) were

able to mention all the 3 components of AMTSL. Response counts of specific

AMTSL components were: (a) use of uterotonic (11 responses), controlled cord

traction (8 responses), massaging uterus after delivery of placenta (9 responses)

The hospital had adequate supply of oxytocics, and antibiotics and magnesium

sulphate. Blood was frequently out of stock risking lives of mothers that needed

it. Many partographs were incompletely plotted. Occasionally, waste disposal was

delayed causing a stinking smell on the ward. The disposal was so crude that

sharps, placentas and used cotton and gauze were dumped in uncovered pit; which

is why vultures were common birds in the hospital. There was an infection

prevention committee but it was non-functional. There was no running water at

service points and resuscitation equipment was faulty.

Clients were concerned about fewer midwives on the ward the extent that some

delivered in absence of a midwife. No quality improvement team that had been

formed. Clients were also concerned about waste management as they said that

sometimes the smell from decomposing wastes in waste bins were more

discomforting than labour pains. Clients complained of unfriendly response from

some midwives especially at night. In case of referral, clients fended for

themselves using expensive private means as there was no ambulance.

The commonest risks associated with maternal morbidity were pre and

postpartum hemorrhage, ruptured uterus, sepsis, obstructed labour and positive

HIV status

2. Defining the current situation: In response to the rapid assessment results, a

meeting was held at Mityana hospital drawing 28 top hospital and departmental

leaders to intervene using CQI approach. A hospital CQI committee was

established with a task to developing a one year roadmap for improving service

delivery in maternity ward. Lessons that would be leant in the medium term

would inform initiation of CQI projects in other departments. The CQI committee

members reexamined the current system and process-related issues by listing,

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sorting, mult-voting and prioritizing problems that need intervention in order to

improve quality of care in maternity.

Fewer and less skilled midwives in maternity were the most voted problems that

needed immediate attention. However; some of the gaps identified by the rapid

assessment exercise were immediately addressed such as repairing resuscitation

equipment and procurement of lanterns as an alternative source of light.

3. Analysis: We listed and mapped out where midwives were located in the

hospital departments, in order to explore possibility of redeploying some of them

to maternity. The established midwifery posts at the hospital were 25 but there

were 38 midwives on the hospital staff list. Comparatively, of the 47 established s

for nurses, only 29 were filled. This showed overstaffing of midwives.

In spite of the “excess” midwives, the clients complained of inadequate number

of midwives. A fishbone analysis was developed to find why there was low

staffing of midwives yet the hospital had more midwives than they required. It

was found out that several midwives were assigned duties on general wards in

attempt to address the shortage of nurses leading to inadequate staffing in

maternity ward

The main reason why available midwives had inadequate knowledge and skills

was that there were limited opportunities for refresher courses and even the few

opportunities were not equitably distributed among all the midwives

4. Countermeasures: To address the poor quality of maternal and newborn

services, Mityana hospital and Mildmay Uganda (an integrated HIV/AIDS

implementing partner) jointly developed an intervention to address the quality

gaps identified by the assessment exercise in maternity ward where over 5000

mothers are delivered per year. The fellow was tasked to guide the development

of the implementation plan for the proposed intervention. The plan became the

fellow‟s programmatic activity.

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The planned interventions were (1) review staff deployment and reallocate 6

midwives from other departments to maternity ward (2) conduct refresher training

for all the midwives serving in maternity and (3) organize midwives to form CQI

teams to progressively review and improve program performance.

Expected results from interventions were improved labour monitoring through

effective use of partograph. This would further reduce Fresh Stillbirth (FSB)

because obstructed labour and fetal stress would be detected and addressed in

time. Postpartum Hemorrhage (PPH) would reduce due to effective management

of third stage of labour. Trends of maternal and newborn sepsis would decline due

to improved infection prevention. These expected results would be augmented by

improved equipment especially resuscitation machines, improved lighting and

better waste management.

Refresher training was organized with purpose to increase knowledge and skills

among midwives to effective management of labour and minimize risk

intrapartum factors. We used The Training Manual for Midwives in Provision of

Integrated Reproductive Health of Ministry of Health (MoH). The topics selected

included overview of reproductive health, effective management of labour,

provider-client communication, quality improvement principles and practices,

infection prevention and PMTCT. Two trainers were identified from the hospital

i.e. the incharge maternity ward and the Principal Nursing Officer (PNO). Both

were national trainers in integrated reproductive health care service. The fellow

together with the trainers developed the training content based on training needs

identified from the assessment exercise. Twenty four midwives were selected and

trained. The training was divided into two 4-days training session and each

session having 12 participants. Two more days per session were dedicated two

hands-on practices on ward with support of a coach

5. Results: The redeployment review resulted in obtaining six more midwives

who were deployed to maternity. It was not possible to get all 6 midwives from

the hospital departments because there were few nurses in such departments.

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Two were reallocated from the Antenatal Clinic and 4 were mobilized from

other health facilities through the District Health Officer (DHO) with support

from the Chief Administrative Officer (CAO). Two of external nurses and two

others were midwives: The nurses were allocated to female ward and OPD which

in turn released one midwife each. The two external midwives were absorbed in

ANC clinic. Consequently, ANC released 2 midwives that became part of

maternity ward staff.

We trained 24 midwives: The training report revealed that midwives had an

average score of 48.96% a (range of 31% to 67%) in a pretest; and average of

80.46% (range of 57% to 98%) in post test.

After two months of redeployment and training of midwives, we did review of

results: There was improvement in quality of maternal and newborn care based on

these indicators: the level of completion of partographs per month was raised,

there was a downward trend of maternal and neonatal sepsis, and FSB and

postpartum hemorrhage reduced.

Structural changes that are related to the intervention included high level of

participation of staff, health managers and district leaders. The waste management

has improved. The waste dumping ground has been relocated to a more secure

place. Two resuscitation machines were repaired. The hospital procured lanterns

to offer alternative light when there is electricity load shedding.

6. Standardization and future plans: Four CQI teams were formed in

maternity ward and were being supported by hospital-level CQI committee to

implement quality improvement projects. The projects are:

(i) Reducing waiting time between maternity ward and theatre for mothers

needing emergency obstetric care

(ii) Improved inter-clinic referral of exposed babies to maternal HIV

infection (maternity and Early Infant Diagnosis clinics)

(iii) Infection prevention

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(iv) Adherence to standards of delivery and newborn care

The hospital CQI committee is examining the possibility of scaling up CQI to

other departments. However, it has been noted that some lessons from maternity

are informing management of processes on other wards.

There were challenges in getting the required number of midwives in maternity:

some could not be removed from other stations because it could cause severe

shortage; others had social and physical constraints that couldn‟t allow them serve

in maternity. Several midwives and nurses asked for maternity leave at the same

time as most them were in their early reproductive age and in need to have

children.

One lesson is that CQI process helps in identifying many quality gaps and with

support of the health facility managers and local leaders, some quality gaps can be

immediately addressed (such as staffing) and with support of partners, resources

can be mobilized.

We conclude that we succeeded in attaining short-term results such as

redeployment and increasing knowledge of service providers. We identified that

although the hospital was staffed with midwives beyond the staffing norms,

shortage of nurses caused virtual low staffing of midwives. At process level, we

see some changes after two months of reorganization of staff and training:

pregnancy monitoring has improved as reflected by increasing trends of

completely filled partographs. There is lowering trend of FSBs suggesting better

pregnancy monitoring of labour that leads to early detection of fetal distress and

action. In 11 months of 2012 the caesarian section rate was 22.4% compared to 24

% in 2012. However in 2012, there are lowering monthly trends in mothers who

had normal vaginal deliveries compared with those delivered by caesarian section.

This suggests that emergency obstetric care is prompt due to early detection of the

need.

We recommend regular staff deployment review to address internal staffing

challenges that would not be seen at organizational level. Maternity staff needs

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regular refresher courses to maintain a high level of standard of care. Regular staff

support supervision, regular check of functionality of delivery equipment and

dissemination of service guidelines may improve quality consequently lowering

maternal and neonatal morbidity and mortality.

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SECTION 1. INTRODUCTION AND BACKGROUND

1.1. Introduction

Most life-threatening conditions of newborns and mothers occur during and after

childbirth process are preventable. They include: sepsis, Postpartum Hemorrhage

(PPH), eclampsia, Mother To Child Transmission (MTCT) of HIV and

hypothermia (Mulumet et al, 2011; Kerber et al, 2007). To prevent and mitigate

maternal and neonatal life threatening conditions, health systems are designed to

increase Skilled Birth Attendance (MoH, 2007). Community mobilization

programs encourage health facility-based deliveries with assumption that it is

safer to deliver in health facilities than at home. However, the institutional quality

of maternal delivery and newborn care services by skilled attendants remains

poorly rated especially in developing countries and thus leading to persistently

high maternal and neonatal morbidity and mortality (Mulumet et al, 2011; Van de

Broek et al 2009;ICM, FIGO, WHO, 2006).

A combination of a SBA, appropriate medicines, equipment and infrastructure

provide a safe and clean delivery environment in which mothers and newborns

can survive the life threatening conditions (Bhutta et al 2010).

Quality of maternal and neonatal care must continuously improve to reduce the

vulnerability of pregnant mothers and newborns to life-threatening conditions.

Quality improvement is systematic, data-guided activities that are specifically

designed to cause prompt and substantial improvements in performance of health

process (USAID, 2012). According to Hulton et al (2000), QI in maternal health

care is „ the degree to which maternal health services for individuals and

populations increase the likelihood of timely and appropriate treatment for the

purpose of achieving desired outcomes that are both consistent with current

professional knowledge and uphold basic reproductive rights.‟ It is never an

accident but a result of high intention, intelligent direction and skillful execution

of appropriate interventions; and systematic implementation to reduce health risks

in health facilities (Deboult & Mallen 2012; Massaoud et al, 2002).

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Quality improvement approach ensures that standard guidelines which midwives

and other skilled birth attendants will use are available and utilized.

Inadequate, ill-equipped and unskilled SBA contribute to poor quality of maternal

and neonatal care services; for example, Prabhath et al (2002) found out that 73%

of maternal deaths that occurred in tertiary health facilities in the developing

world were due to substandard care offered by SBAs.

1.2. Trends in maternal and neonatal morbidity and mortality

The global burden of maternal and newborn morbidity and mortality is high: out

of global 536,000 maternal deaths each year, 99% are from developing countries;

80% of the deaths are preventable with timely interventions that are proven to be

effective (Van de Broek et al, 2009). Annually, over 4 million neonates die

worldwide (Mash et al, 2002; Lawn et al, 2009).

The African region has the highest rates of neonatal mortality in the world but two

thirds of these deaths can be averted with known strategies; however, this region

has shown the slowest progress so far in reducing neonatal deaths (WHO, 2012).

In Sub-Saharan Africa (SSA) alone, 279,000 neonates and 4.5 million infants die

every year (Mwaikambo, 2010). The total loss of mothers, newborns and children

in SSA every year is 4.7 million lives. Similarly over 880,000 babies are stillborn

in SSA every year (Kinney et al 2010).

In Uganda, maternal mortality ratio stands at 438 deaths per 100, 000 live births,

and neonatal mortality rate at 27 deaths per 1000 live births and infant mortality at

54 per 1000 live births. The under five deaths has reduced from 143 to 90 deaths

per 1000 live births between 2006 and 2011 (MOH, 2007; UBOS & ICF Int.

2011). Other studies show that in Uganda, 6,500-13,000 women and girls die

every year leaving over 405,000 with chronic and debilitating effects (Futures

Group, 2012).

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Institutional delay in maternal delivery is one of the three delays that increase the

risk to life loss among newborns and mothers (MoH, 2007). Other delays are:

delay to decide to go for skilled birth attendance and delay to reach a health

facility that has the capacity to meet emergency obstetric and newborn care needs

of mothers and babies. Most of Maternal-To Child Transmission (MTCT) (60-

70%) occur at the time of childbirth (Esiru, 2008). This was also documented by

Wabwire-Mangen et al, 2008.

This report focuses on Mityana hospital in Mityana district in Uganda where

quality maternal and newborn care improvement project was implemented.

Mityana Hospital is a public hospital with 100 bed-capacity.

Every year, about 5,000 mothers are delivered in maternity ward of Mityana

hospital. The ward also handles pregnant mothers with medical conditions such as

malaria, those who have just delivered either by caesarian section or normal

vaginal delivery and waiting mothers who have risk factors that need to be closely

monitored towards labour.

Mildmay Uganda and Makerere University School of Public Health-CDC

(MakSPH-CDC) Fellowship program supported Mityana hospital to review and

improve the quality of maternal delivery and newborn care services offered to

clients that come to this hospital. An assessment to establish status of quality of

delivery and newborn care in Mityana hospital was conducted in January 2012.

Midwives were interviewed, Focus Group Discussions were held with clients and

hospital data reviewed. Some key informant interviews were held and

observations made and recorded by the assessing team. Results showed that there

were several quality gaps: less than a quarter of midwives had comprehensive

knowledge about Active Management of Third Stage of Labour (AMTSL).

Although 38 midwives are employed in the hospital (13 in excess of established

of 25 midwives), only 18 conducted deliveries and the rest were multi tasking on

wards and clinics in the hospital. Midwives deployed in maternity are few

compared to the daily workloads on the ward. Maternity waste and placenta were

4

mixed up and dumped in an open pit and some staff members were demotivated

due to low pay. Power load-shedding was rampant; phone torches were usually

used in delivery as alternative light since the cost of fuel for generator

unaffordable by the hospital. Main transport for obstetric emergency was by

private motorcycles. There were few functional resuscitation gargets: the manual

sanction machine was faulty, the electric one lacked some parts. Clients

complained of smelly wastes on ward and staff negligence.

The common risk factors found from maternity register (2011) are shown in the

figure below: -

20.7 19 17.2

8.6 7.8 7.8 7.8 6 5.2

05

10152025

Frequency of risk conditions among mothers and their babies in Mityana hospital in 2011 (%) n=116

Figure 1-1: Risk factors found among mothers attending maternity ward in

Mityana hospital, 2011 (Mildmay Uganda, 2012)

It is against this background that we purposed and pursued improvements in

delivery improved quality maternal delivery and newborn care services using CQI

approach as described in the following sections

5

SECTION 2. THE QUALITY IMPROVEMENT PROCESS

2.1. Reasons for improvement

We drew form the assessment results to design a quality improvement project.

The objective of improvement was to increase client access to effective skilled

birth attendance in order to reduce occurrence of maternal life-threatening factors

such as PPH, sepsis, obstructed labour; and neonatal health risks such as asphyxia

intrapartum HIV transmission, sepsis and deaths within 24 hours. This would be

achieved by identifying and reducing barriers to skilled care

2.2. Examining the current situation

We held quality improvement consultative meeting that attracted 28 participants

from various hospital departments to brainstorm on key causes of poor quality of

maternal delivery and newborn care. A brainstorming session identified 17

problem areas. Discussants set criteria for sorting one priority problem to solve.

The criteria were that the problem must be process-related, with locally available

solution, with greater impact on reduction of maternal and newborn morbidity and

mortality. Sorting left 7 key problem areas. Members held a 2-level multi voting:

the first round used nominal scale approach where each member was allowed to

vote only 3 problems and ranking them using a scale of 3:2:1. The most serious

problem was given 3 scores, the next serious problem given 2 scores and the least

important one 1 score. In round 2 problems that scored above 10 scores were

selected. Members were requested to rank the remaining problem with the most

important problem first and less important. Low staffing in maternity ward and

limited skills among health workers were priority problems to solve because

improvements in staff skills and staff numbers would form a firm foundation from

which other CQI project will develop.

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Table 2.1 shows how we arrived at the priority problem: -

Table 2-1: Ranking of selected problems associated with poor quality of maternal

delivery and newborn care in Mityana hospital.

Problem Round 1 of voting (using

nominal scale 3:2:1)

Round 2 of voting

(rearranging the first 4

problems in descending

order of their strengths)

Most midwives have

inadequate skills

34 2

Lack of supplies e.g.

blood

32 3

Mothers delay to come to

deliver

24 4

Low staffing in maternity

ward

24 1

No resuscitation corner 9

Low staff morale 8

Poor waste disposal 7

A mapping exercise for midwives was done to locate where they are located. The

table below shows their distribution:-

7

Table 2-2: Distribution of midwives in wards and departments of Mityana

hospital

Shift Duty No. Total

On duty Day 3 8

Evening 2

Night 3

Off-duty After day-duty 3 8

After evening-duty 2

After Night-duty 3

Other

assignments

ANC clinic 7 20

Male ward 2

Paediatric Ward 2

Female ward 3

Out-Patient Department(OPD) 2

Chronic care clinic 2

Night superintendants 2

On leave 2 2

Total 38

Over 50% of midwives had no opportunity to conduct deliveries as they stayed in

other departments rather than maternity for a long time.

2.3. Problem analysis

To identify the root causes of low staffing and inadequate skills among midwives

in maternity, a fishbone approach was used. Key roots were: inadequate

opportunities for staff to acquire and improve on knowledge and skills in

conducting standard delivery and newborn care.

The figure below shows cause-causes of low staffing and less skilled midwives: -

8

Limited opportunities for staff to

improve knowledge and skills in

delivery and newborn care

Available training opportunity

dominated by a few midwives

Lack of refresher

training

Long time without staff reshuffle

(over 6 months)

Some midwives attracted to other clinics

and wards due to shortage of nurses or

dislike of difficult night duty associated

with maternity

Some midwives lost interest to

deliver mothers due to heavy

workload.

Exemption to deliver on

medical grounds

Some disallowed to practice

delivery as a disciplinary action.

Few midwives

available for maternity

services

Few and less

skilled midwives

in maternity ward

Figure 2-1: Fishbone analysis showing factors associated with deployment of fewer and less skilled

midwives in maternity ward

Inadequate/irregular/lack of

effective support supervision

9

The main cause of limited skills among midwives was inadequate opportunities

for training: few training opportunities are dominated by selected staff loyal to

decision makers. Some staff do not gain experience from practice because they

are not regularly supervised or transferred to other areas that promote professional

skill enhancement.

The reason why midwives may be few in a ward could be caused by low staffing

level of other health cadres leaving health managers with no option but to

redeploy midwives to perform non-midwifery duties. Some midwives may dislike

or fail to work in maternity due to various reasons such as health status of the

midwife or availability of less stressful alternative duties. Some midwives

overstay in midwifery-related stations but which are not involving delivery. This

may lead to skill decline and poor performance

10

SECTION 3. PLANNING COUNTERMEASURES

In response to the assessment finds and in pursuit of implementation of the

roadmap for accelerating the reduction of maternal and neonatal mortality and

morbidity in Uganda (MoH, 2007) we set out to improve maternal and newborn

care services.

3.1. Intervention objective

The proposed intervention was to improve the quality of maternal delivery and

newborn care services through redeployment and capacity building of existing

health workers in Mityana hospital.

3.2. Intervention strategies

We set out to redeploy and train midwives as capacity improvement strategy to

improve the quality of maternal and neonatal care services. Below were the

intervention objectives: -

a) Review midwives deployment strategy to raise number of midwives

deployed to maternity ward of Mityana hospital from 18 to 24.

b) Conduct a refresher course for midwives focusing on knowledge and skill

gaps identified by the assessment report.

c) Facilitate establishment of CQI teams in maternity ward to continuously

review and improve maternal and newborn care

3.3. Expected results

Key process results expected were that 6 midwives would be redeployed form

other departments to maternity, 24 from maternity ward would be trained and

consequently, trends in maternal and neonatal sepsis and PPH would reduce.

11

The indicators of success included improved labour monitoring. It was expected

that as skills improve and workload reduce due to increased staffing in maternity,

there would be more effective pregnancy monitoring with complete partographs.

Improved monitoring of labour would result into early detection of fetal and

maternal distress with timely management leading reduction in fresh stillbirths

and other complications. Reduction of trends in maternal and neonatal sepsis

would show improved infection prevention on the ward (improved practice).

Another expectation of quality improvement would be compliancy to conducting

AMTSL according to standards. Since the registers do not capture data on

effectiveness of AMTSL, we targeted seeing reductions in PPH as an indicator of

effective AMTSL the condition of PPH is the commonest cause of maternal

mortality.

3.4. Implementation framework

The implementation of the countermeasures is described in the table below: -

12

Table 3-1: Implementation framework

Quality gap Countermeasure Indicator of

improvement

Baseline Target MOV Assumptions

Few midwives in

maternity ward

Redeploy more midwives

from other departments to

maternity

No. of midwives

redeployed

18 24 Minutes

and duty

roster

Redeployment won‟t cause

severe staff shortage at

departmental level

Inadequate knowledge &

skills about delivery and

newborn care among

midwives working in

maternity

Train all midwives

deployed in maternity to

deliver mothers and care

for babies according to

standards

No. of midwives

trained

Knowledge gain

by participants

0

unknown

24

post test

with at

least 65%

Training

report

Pre and

post test

results

All midwives planned to be

deployed to maternity will be

available for training

No competing priority programs

at the hospital

Midwives unable to offer

standard care

Trained midwives able to

deliver and care for

mother and baby

according to standards

No. of

partographs

completely

filled

unknown 80% Data from

maternity

Midwives are continuously

supervised and supplied with

partographs, medicines and

other supplies

Persistently raising trends

of key risk factors

Maintain a standard of

care using knowledge &

skills from training

Reducing trends

of PPH, sepsis,

fresh still births,

Data

from

maternity

register

Not

known

Lowering

trends

after

training

Midwives posted in maternity

are not immediately transferred

13

3.5. Reviewing staff redeployment

The fellow engaged the in-charge of maternity ward, the Principal Nursing

Officer and the Medical Superintendent in dialogue to discuss the deployment

strategy of midwives so that more will be added on those currently allocated to

maternity without compromising the functions of other departments which are

supported by midwives. The hospital senior managers undertook the task of

reviewing the staff deployment strategy to identify 6 more midwives to redeploy

in maternity. It was found out that the staffing norm for midwives in the hospital

was 25 but the staff list had 38. Comparatively the staffing norm for nurses was

47 but there were only 29 nurses. When adjustments were made to find which

midwives to post to maternity, only two from ANC clinic were identified. A

series of dialogue meetings with district leaders and hospital stakeholders lead to

securing 4 nurses and 2 midwives from other facilities that made it possible to

have 6 midwives redeployed in maternity.

3.6. Training Midwives at Mityana hospital

Twenty four midwives were identified for training with the view that they will

take turns to attend to mothers and babies in maternity. Training was preceded by

preparatory training meetings at Mityana hospital. We developed the training

content based on Integrated Reproductive Health Training Manuals of MoH. We

focused the training on the overview of reproductive health services, Focused

ANC, principles of CQI, managing labour with emphasis to 3rd

stage and use of

partograph. Other topics covered were communication skills, emergency

situations for mothers and neonates, infection prevention and introduction to

PMTCT.

The refresher course was divided into two 4-days session; each session had 12

trainees. Each group of trainees had two more days for practicing with a coach

14

on ward. We evaluated trainees with a pre and post test followed by observations

as they did practical session under supervision of a trainer as a coach.

15

SECTION 4. THE QUALITY IMPROVEMENT OUTCOMES

4.1. Redeployment of midwives

We had planned to adjust staff redeployment and redeploy 6 midwives from

other departments to maternity so that staffing in maternity ward can increase

from 18 to 24 midwives. We mapped location of all 38 midwives considered

work schedule (morning, evening and night duties) and workloads in various

departments.

To get six more midwives to deploy to maternity, we attempted to get all

midwives from other departments but we succeeded to get only 2 from ANC

clinic. We could not redeploy all the required number of midwives from the

hospital departments because it would cause severe staff shortage at department

level. Engaging both hospital and district stakeholders (as individuals and

groups) through a series of meetings led to deploying 4 more staff (2 midwives

and 2 nurses) from other health facilities in the district to the hospital.

The two external nurses went to female ward and OPD which in turn released

one midwife each. The two external midwives were absorbed in ANC so that 2

more midwives (from existing staff) were redeployed to maternity ward.

The final adjustments led to staffing in maternity raise from 18 to 24 midwives

achieving 100% of targeted staffing in maternity ward.

16

4.2. Training process

In September 2012, we trained of 24 midwives. The training was organized in

two phases and each phase taking 12 trainees. We used 4 days to provide theory

and two days for practice. While the first group was starting their practice on 5th

day, the second group had their first day of theory study. This led to running

concurrently the practical session for the first group of trainees with theory of the

second one. This provided trainees with 6 days of training both in class and on

the ward.

Generally, the trainees performed well as reflected in the knowledge acquisition.

The combined results of the pre and post test below show how trainees acquired

knowledge (1st group is no.1 to 12 and 2

nd group is no. 13 to 24): -

Figure 4-2: Participants of the

stakeholders‟ Meeting

Figure 4-1: At the stakeholders‟

meeting; the fellow makes a point as the

RDC listens

17

Figure 4-3: Pre and post test results for 24 midwives trained at Mityana

hospital.

The trainees had an average score of 48.96% a (range of 31% to 67%) in a

pretest; and average of 80.46% (range of 57% to 98%) in post test.

4.3. Other changes

The hospital management first addressed some gaps that were identified during

quality assessment: these include, repairing recitation machines, getting

alternative light to address lighting challenges when electricity load shedding

takes place. These were fixed: 4 lanterns were bought, 2 sanctions machines

were repaired and the hospital did not renew the contract of the supplier of

sanitation services because he had not managed to support staff to improve waste

management.

Trainee identification No

%

18

The following are some of the photos taken during the training sessions: -

Figure 4-7: A midwife assisting a mother

To breastfeed as the fellow observes

4.4. Intervention outcomes

We expected change behavior of health workers conducting delivery such as

plotting and completing partograph we targeted improvements in effective

Figure 4-5: One of the groups of

trainees doing 5 pre-test

Figure 4-4: Midwives and trainers

ready for a practical session after 4-

days theory

Figure 4-6: A midwife gives a health

talk mothers at discharge after

delivery by C/S

19

AMSTL. We did not collect data on effectiveness of AMTSL since it was not

captured by data from maternity register. We expected that reductions in PPH

would show how midwives were effective in conducting AMTSL The figure

below shows trends in completion of partographs: -

Figure 4-8: Trends of completely plotted partographs (January to November

2012)

In July, midwives were encouraged to complete partographs as a measuere to

demonstrate that labour was completely monitored. The trends of completely

partographs increased from July and peaked in October, one mothe after training

midwives.

We observed rising trends in some of the indicators of quality improvement

outcomes: Below is a figure showing trends of key risk factors associated with

Partograph completion initiated (July 2012)

Training takes

place (Sept. 2012)

Months

No.

20

poor quality of maternal delivery and newborn care:

Figure 4-9: Trends of maternal and neonatal sepsis, postpartum hemorrhage and

Fresh Stillbirth (FSBs)

Months

NO.

21

The trends in the risk factors were higher in September (when training was done

and sharply lowered in October. There is lowering trend of FSB after September

training. It is not clear why most of the trends increased during the month of

training (September) but the reductions in the following month suggest quality

could have improved.

Figure 4-10: Trends in delivery methods and FSBs in relation to completely

filled partgraphs.

The raising trend of complete partographs followed by flatening trends of FSB,

the raising of monthly cases of mothers who delivered by caeseian section and

the lowering of number of mothers had biths suggest improvements of pregnancy

outcomes through completion of partographs

4.5. Qualitative evaluation

Before the pretest, trainees could not believe that they had such knowledge gap.

One trainee stated: “We did not know how uninformed we were until you showed

us the pretest results!”

Several trainees said they had been giving oxytocin to mothers during labour to

minimize hemorrhage after birth but could not mind about injecting it in

Months

No.

22

stipulated time. One midwife stated: “I knew that giving oxytocin injection was

to prevent severe postpartum hemorrhage but I did not recognize the importance

of giving it as soon as the baby is delivered‟.

Some midwives had negative attitude about filling a partograg. One of the senior

midwives noted: “Before this training, I disliked filling the partograph because it

looked so complicated and I felt that I could still detect danger without it; I now

feel that filling a partograph is important and not so hard”. Another midwife felt

that she had negative attitude about clients‟ conduct: “I thought clients were to

blame for most problems during labour and handling of babies; now I feel we

health workers fail to do some things or do them haphazardly because of lack of

knowledge or what to use. This causes poor quality of services.

Some midwives did not know that their supervisors were professional trainers as

noted by one midwife: “We are lucky that our supervisors are also trainers; they

can help us do better if they planned to coach us on ward on regular basis”

4.6. Institutionalization of CQI

After the training, the hospital management used experience from maternity to

design scale-up strategy to enable other departments also improve the quality of

service they offer to clients. At the hospital level, an interdepartmental CQI

team was formed to oversee improvement initiatives in all departments. The

maternity staff continued CQI by identifying more QI areas. All 24 trained

midwives grouped themselves in 4 teams each targeting a specific thematic area.

The themes of focus were: reduction of number of babies lost to follow-up

between maternity ward and EID clinic, infection prevention, adherence to

delivery standards, improving client flow to reduce waiting time and improving

provider-client relations.

23

During the process of discussing CQI, staff members were pleased to participate

in program planning as stated by one junior midwife: “We used to wait for

decisions from our seniors, but with quality improvement process everyone

participated”. It was noted that for quality to improve, interdepartmental

linkages must be strengthened. One senior midwife commented that: “We need to

improve coordination with theater staff because some deaths occur due to

delayed response from there. We should educate mothers not to delay, and health

workers in lower units should be told to refer mothers in time”. Another midwife

commented: “I appreciate the part of using data to show how well or poor we

are performing”

The fellow observed that like any other skill-based task holders, midwives need

routine refresher courses at the facility emphasizing hands on sessions. More that

60% of midwives had difficulties in plotting a partograph; actually most of the

mothers were delivered without it. The understanding of common concepts

among midwives was still low; for example 15 out of 24 midwives did not know

the meaning of nosocomial infections and some who attempted called them

„infections of the nose‟ instead of „infections acquired by patients/clients from

the hospital‟. The universal precautions concept (that outlines infection

prevention key practices) was not known by all the groups. For example when

the groups were made to discuss this package, only 3 out of eight precaution

measures for infection prevention came out. During practice on the ward, most of

the procedures were correctly done except resuscitation of the baby using

ambubag and cardiac massage. The concept of CQI was new to almost 90% of

participants.

In conclusion the programmatic activity was successfully completed. We

planned to deploy 24 midwives and now they are on duty roster of maternity

ward. We had planned to train 24 midwives and all were trained. What remains

24

is trainee follow-up and mentoring CQI teams to effectively manage their

projects and document final quality status. We did not conduct client

consultation to measure change in satisfaction. The project that was planned to

start in May actually started in August. This was due to delayed process of

redeployment and postponement of training midwives by district leaders due to

competing priorities such as national HPV vaccination campaign.

25

SECTION 5. FUTURE PLANS

The implementation of the programmatic activity attracted health workers who

appreciated the CQI approach to program performance improvement. The

hospital management planned to continue more CQI projects in maternity as

other departments learn so that lessons learnt can be scaled up to other hospital

departments. One CQI team was formed to plan quality improvements at

organization level. In maternity ward, 4 sub-teams were established to create

CQI projects on 4 thematic areas: one for improving inter-clinic referral of

exposed babies to maternal HIV for Early Infant Diagnosis (EID), improving

infection prevention, reduction of waiting time, improving customer

communication and improving standard of delivery and newborn care.

Each team would brainstorm on quality-related problems in each thematic area

prioritize key problems, develop intervention plans, monitor and communicate

results during departmental meetings and Continuing Medical Education

sessions. Immediate results would be charts of standard operating procedures,

review meetings held and copies of work plan in place. Medium term results

would be performance review charts, improvement in client satisfaction, reduced

incidence of severe hemorrhage and sepsis. Long range results would be reduced

morbidity and mortality of mothers and babies, reduced maternal transmission of

HIV to exposed babies and reduced complaints work overload among staff

members. By the time of developing this report, teams had reached

brainstorming stage of CQI process.

26

SECTION 6. CHALLENGES

1) Some midwives had spent longtime without delivering. Training

them would not put them to a level that can provide effective and

efficient maternal delivery and newborn care.

2) Some wards were too understaffed with nurses that the midwife in that

ward was the most reliable source of service delivery and removing

her would leave the ward so deficient.

3) Some midwives were advanced in age, other had chronic illness; their

health would not allow them serve effectively in maternity especially

on night duties. Other midwives with chronic illness needed frequent

sick leave and were in reliable for redeployment.

4) Other midwives were multi-skilled experts at the clinics they were

serving and irreplaceable. The magnitude of the tasks was enormous

that they are not available for other duties. The specialties include

ART, family planning, EID and community health program.

5) Other midwives were on leave or preparing to go for leave (mostly

maternity leave)

6) The right to specific number of days of being off duty made over 40%

of midwives not available for mothers mimicking virtual

understaffing.

7) Some midwives revealed that, some of their colleagues regarded

delivery as hectic and had created „possible‟ reasons not to be

deployed to maternity. This means some midwives had abandoned

27

midwifery „in their hearts‟ and taking them back to maternity was like

a punishment.

8) It was observed that some midwives had been previously cautioned

for indiscipline while serving in maternity. The hospital management

had removed them from there as a disciplinary action or protecting the

clients and integrity of the hospitals.

9) Others viewed understaffing in maternity as result of inefficient

management of midwifery staff.

With above background, increasing midwives from 18 to 24 would be difficult.

After readjusting the staffing, only 2 midwives would be available to raise

needed number to twenty. Four more midwives would be needed. Discussions

were made to that effect and the hospital management sought to lobby for more

staff from the CAO. However, it was widely known that the district had severe

shortage of staff in lower level facilities and there was a ban on recruitment of

more health workers. The hospital management decided to use the assessment

report on quality of delivery and newborn as a tool for lobbing more staff.

Managers chose to demonstrate high hospital utilization and associated

compromises of quality. The hospital technical team requested the fellow to

organize and disseminate the report on status of quality of delivery and

newborn care to key stakeholders that influence discussion on staff and other

resource mobilization. They planned to use the government 5-year strategy:

„accelerating the reduction of maternal and neonatal mortality and morbidity in

Uganda‟ as a tool for advocacy.

At the same time of implementing the project, MoH released a report about

staffing in hospitals in Uganda. The study that used Workload Indicators for

28

Staffing Needs (WISN) methodology reported overstaffing of midwives in the

hospital and recommended that some midwives be allocated elsewhere in the

health system.

The stakeholders‟ meeting that involved District Executive Committee,

members of the hospital management board, from district health team and the

office of the RDC resolved that more staff be deployed to the hospital to allow

effective deployment of more idwives to maternity; meanwhile the CAO posted

2 midwives and 2 nurses to the hospital. With this additional staff, the PNO was

now able to increase number of midwives from 18 to 24 as proposed in the

intervention plan. She however noted that this arrangement is fragile until the

district considers more staffing of the hospital. For example she said that more

staff will require leave, others may fall sick and the established number of 24

midwives may not be stable for longtime.

The Medical Superintendant recommended that the quality of maternal

delivery and neonatal care be strengthened at lower units so that mothers can

increase demand of these services a lower level. Quality improvement also

would mean training and equipping providers at lower level to timely detect

and appropriately refer mothers in need of emergency care.

The stakeholders, having received both reports (WISN and status of quality of

maternal delivery and newborn care in Mityana hospital) decided that practical

problems needed practical solutions. The CAO, DHO and Medical

Superintendant were requested to ensure that adequate number of skilled

midwives is provided. The fellow informed the stakeholders that Mildmay

Uganda was willing to train the midwives that will be stationed in maternity.

One councilor who had served two terms of political leadership at the

district level and was a member of the health committee challenged the

29

previous staff recruitment process that brought in more midwives than

nurses. The RDC agreed that the hospital needed more staff and equipment and

instilled hope in stakeholders that with government plan to upgrade the

infrastructure of hospital. He promised to mobilize other politicians to compel

Ministry of Finance, Planning and Economic Development to lift the ban on

recruitment of health workers. “Although additional staff would be immediate

response, it could be possible that the hospital management is not well

utilizing available midwives” the RDC noted.

The PNO appreciated stakeholders‟‟ response but warned that the issue of

staffing was so complex that routine review was necessary. For example 3

midwives were about to go for their maternity leave. “Most of our midwives are

in their prime reproductive age and will need frequent maternity leave that takes

60 days. This creates a shortage but when you look at the staff list, you think staff

is big” she noted.

30

SECTION 7. DISCUSSIONS

Our intervention of increasing the number of midwives followed by training

them in basic package of managing labour and newborn care resulted in

knowledge increase in availability of skilled birth attendants. Two months after

increased staffing of maternity and training midwives serving in maternity ward,

the number of partographs completely filled increased and there was a decline in

trends of life-threatening conditions among mothers and newborns such as PPH

among mothers and maternal and neonatal sepsis. Fresh still births reduced.

Although we can attribute the changes to our intervention, factors such as

training from MoH and STRIDES could have contributed to the changes

registered.

Taking from approaches suggested by Scott (2003) in determining staffing

needs, we used consultative approach to conclude that staffing in maternity was

low compared to workload.

We trained midwives based on training needs from the assessment report which

had reflected low level of basic knowledge in standard management of labour

and newborn. Trained midwives had an average score of 48.96% a (range of

31% to 67%) in a pretest; and average of 80.46% ( range of 57% to 98%) in post

test. This raise in knowledge following a short training of health workers in

quality improvement of management of labour and newborn care, is also noted

by Harvey et al, (2007) where trainees scored an average of 62% after training

The impact of provider‟s competence (through training and supervision) and

client‟s health improvement has been documented: Parsley and Corrigan (2000)

argue that client‟s improvement and shorter length of stay in a health facility

depends largely on competence of the provider. Kaye (2000) also observed that

31

inadequate number of, and skills among service providers are significant drivers

of poor quality of care. Studies show that when staffing and skilling improved in

Malaysia and Thailand, maternal and infant mortality reduced. From our project,

the impact of training was evident: in short time midwives were able to improve

their knowledge and skills in a period less than one week. We conclude therefore

that the investment made in training midwives will greatly contribute to quality

maternal and newborn care services

We learn that balanced staff needs should be considered. The former staff

recruitment had considered midwives as a way of improving availability of SBA.

By not considering a balance of midwives and nurses during recruitment,

midwives were made to cover nurses‟ roles defeating the planned purpose.

We also learn that ensuring staff availability is a complicated intervention due to

dynamics in among individual staff members and institutional demands. During

staff deployment process, we discovered that it may be misguiding to consider

adequate staff norms as an indicator of staff availability: one of the reasons why

some midwives were not deployed was their poor health. Another challenge was

that the young energetic midwives were more likely to seek maternity leave. This

reduces man-hours and causes virtual shortage of staff. There are inevitable

situations that reduce staff availability such as sickness and study leave.

We learn that reflecting on departmental performance can lead to numerous

positive changes including resource mobilization for improvement. This does not

only benefit the clients but also service providers; for example, after

disseminating the assessment findings, instant changes occurred: midwives were

32

trained, some equipments repaired, alternative light in form of lanterns procured

and the service provider offering hospital cleaning services changed. The

undertaking to improve quality of maternal and newborn services in Mityana

provided an opportunity for stakeholders to meet and share the need to safeguard

mothers who seek care in the hospital. The issue of mothers and babies was

brought on the agenda of key stakeholders leading to 4 more health workers

deployed in the hospital. Mildmay provided additional staff and some equipment

(such as tyres for ambulance) and MakSPH-CDC fellowship availed the

resources in from of funds and a fellow who provided technical capacity to the

hospital to improve quality of delivery. These resources could have been

available for other cause but reflecting and communicating on safe motherhood

issues made these resources available

It was beneficial to train health workers within the walls of the hospital. Cases

that were of importance would be visited which wouldn‟t be possible if the

trainees were in a distant training venue.

This intervention also has shown that one needs to be a little more patient while

dealing with Public Health institutions. The implementation of this programmatic

activity was delayed due to failure on the part of the Hospital management to

timely identify staff to train. Even when the trainees were finally identified,

competing priorities pushed training further; there was a national campaign to

vaccinate girls against Human Papilloma Virus and selected trainees were

involved.

33

SECTION 8. CONCLUSION AND RECOMMENDATION

We conclude that we succeeded in attaining short-term results such as

redeployment and increasing knowledge of service providers. We identified that

although the hospital was staffed with midwives beyond the staffing norms,

shortage of nurses caused virtual low staffing of midwives. At process level, we

see some changes after two months of reorganization of staff and training:

pregnancy monitoring has improved as reflected by increasing trends of

completely filled partographs. There is lowering trend of FSBs suggesting better

pregnancy monitoring of labour that leads to early detection of fetal distress and

action. There are lowering trends in mothers who had normal vaginal deliveries

while those delivered by caesarian section increased. This suggests that

emergency obstetric care is prompt due to early detection of the need.

Identifying staffing and training needs of midwives serving in maternity wards

can improve pregnancy monitoring and better pregnancy outcomes. Increasing

knowledge and skills among midwives improved pregnancy monitoring such as

completion of plotting partographs: A complete partograph serves as an indicator

that labour was well monitored and any complication timely detected and

managed.

Raise in number of midwives in maternity alone is expected to improve quality

of care. This observation is also seen cross-national study which showed that for

each additional patient per nurse, the likelihood of a patient within that nurse‟s

care dying within 30 days of admission increased by 7%, and that low-quality

patient care was three times as likely in hospitals with insufficient staffing

(WHO, 2003)

34

We agree with Scot (2003) that good management practice involves undertaking

periodic reviews of staffing and skill mix. They suggest that staffing decisions

should be informed by detailed knowledge about a particular ward or department

and, once made, should be monitored for their impact on patient and staff

outcomes. By assessing nursing needs of patients/clients by nurses themselves

using CQI approach, optimum utilization of available midwives can be achieved.

We recommend regular program performance review through system and staff

appraisal in relation to service outcomes they produce. We also recommend CQI

tailored to individual department roles in relation to program and institutional

expectations. This will facilitate clearer identification of quality gaps from which

to base when designing effective service delivery.

In facilities with high utilization rate, health managers should go beyond

departmental staffing needs and consider general staffing dynamics because

basing staff adequacy on staffing norms may cause heavy workloads, client

dissatisfaction and poor delivery of services.

Our interventions are not without limitations. We evaluated the impact of staff

redeployment and training only after two months. It is also difficult to attribute

the change to our training intervention since the hospital had already been

exposed to the need to improve quality of maternal and newborn care by the

assessment exercise the gains from the intervention may not be sustainable if

supervision of providers is not sustained. Supervisors need motivation to

maintain sustained coaching. This can be realized though facilitating the

supervisors and CQI teams with aides that can enable them to review CQI

35

regularly. The aides include planned meetings, support from hospital

administration with refreshments and external technical support from Mildmay

Uganda.

36

REFERENCES

ACM, FIGO, WHO. Strengthening Midwifery Toolkit 4.Developing Standards

to Improve Midwifery Practice and Ensure safe Pregnancy and Childbirth.

Department of making Pregnancy safer, WHO, 2006.

Alparslan O and Dohaner G. 2009 Relationship behavior levels of burn out of

midwives who work in SIVAS, Turkey province centre and identified socio

economic characteristics. International foundation of Nursing and Midwifery

Vo/ 1 (2) PP 019-02 Nov.2009

Anderson JM Prevention and management of Postpartum Hemorrhage. AmFam

Physician 2007 75: 875-82

Bhutta ZA., Lassi ZS, Mansoor N. Systematic Review on Human Resources for

Health Interventions to Improve Maternal Health Outcomes: Evidence from

Developing Countries. HRH for Maternal Health, WHO, 2010

Cham M; Sundby J; Vargen S. Maternal Mortality in the Rural Gambia: A

qualitative Study on Access to emergency Obstetric Care. Reproductive Health

2005, 2:3.

Changole J, Bandawe C, Makanani B, Nkanaunenena K, Taulo F, Malunga E,

Kafulafula G. Patients satisfaction with reproductive health services at Gogo

37

Chatinkha maternity unit, Queen Elizabeth central hospital, Blantyre Malawi.

Malawi Medical Journal 22 (1): 5-9 2010

Christine P. Maternal Mortality in Sub-Saharan Africa.

http://www.ucl.ac.uk/global-health/cs/pegel. Accessed on line on 11/10/2012

DeBolt B & Mallen B. Quality improvements in Public Health: an Overview .

Accessed on line on 12th March 2012

Developing quality health care services delivery. Discussion paper no. 1

WHO

Esiru G. Annual report 2008. Protecting Families Against HIV/AIDS (PREFA).

FHI, 2011. Keys to reducing Maternal Mortality: Circumstances of Maternal

deaths investigated in Indonesia. Network, 2002 vol. 22 no.2. Center for health,

university of Indonesia.

Futuresgroup. Maternal and Neonatal program effort Index (MNPI). Maternal

health Study www futuresgroup.com. Access on line on 12/01/, 2006.

Hulton LA, Matthews Z, Stones RW. A framework for evaluation of quality of

care in maternity services. Southampton. University of Southampton 2000. SO 17

IBJ. ISBN 08532702 9.

Kerber KJ, Graft-Johnson JE, Bhuta ZA Okong P, Starrs A, Lawn JE.

Continuum of Care for maternal, neonatal and child health: From slogan to

service delivery, 2007

http://www.ucl.ac.uk/global-health/cs/pegel

38

Kinney MV, Kerber KJ, Black RE, Cohen B, Nkrumah F, Coovadias H,

Nampala PM Lawn JE. Sub-Saharan African Mothers, Newborns and Children:

where and how do they die? Science in Action: Saving the lives of Africa‟s

mothers, newborns, and children working group. PLoS Med 7(6): e1000294;

2010

Koegler E. National Health Care Quality Improvement Strategy Meeting:

Technical report. Kampala Uganda March 21-22 March 2011.

Lawn JE, Cousens S, Zupan J. Four Million neonatal deaths: when?, where?

Why? The Lancet Vol. 365 Issue 9462 pg. 891-900

Lochoro P. Measuring patient satisfaction in UCMB health institutions. Health

Policy and development Vol. 2 no. 3 pp 243-246, 2004

Marsh DR, Darmstadt GL, Moor J, Daly P, Oot D, Tinker A. Advancing

Newborn Health and Survival in Developing Countries. A conceptual

Framework. Journal of Perinatology Vol. 23 no.7 pg. 572-572

Massaoud T,Askov K, Reink J, Franco LM, Bornstein T, Knebel E. A modern

Paradigm of Improving Health Care Quality 2000.

Mildmay Uganda. The status of quality of maternal and newborn care services in

Mityana hospital: An assessment report April,2012 (unpublished).

Minca M. Midwifery in Uganda in-depth country analysis May 2011. Back

ground document prepared for the state of the world‟s Midwifery report 2011

(unpublished).

39

Ministry of health(MOH), Uganda 2007. Roadmap for Accelerating the

Reduction of Maternal and Neonatal Mortality and Morbidity in Uganda 2007-

2015.

Mulumet A, Abebe G Tefera B. Predictors of safe delivery service utilization in

Arsi zone, South-East Ethiopia. Ethiop J health Sci, vol 21 Special issue , August

2011

Mussi-Pinhat MM, Dornellas do Nascimento S. Neonatal nosocomial infections.

Journal de Pediatria vol. 77 supl. 1, 2001

Mwaikambo E. improving Maternal, Newborn and Child Healkth in Tanzania.

From science to action. Presented on 3rd

Professor Hubert Kairuki memorial

on 5th Feb. 2010 (Unpublished). Accessed on line on 12

th January 2012.

Omaswa F, Burnham G,Baingana G, Mwebesa h, Morrow R. introducing

Quality Improvement into Primary Health Care in Uganda. Bulletin of the World

Health Organization 75 (2) 155-161

Omaswa F.G, Baingana G, Mwebesa H.G, Burnham G. Quality Assurance for

Health Workers in Uganda. Quality Assurance Program, Ministry of Health

Uganda, 1996.

Parsley K &Corrigan P. Quality Improvement in Health Care: Putting evidence

into Practice. Nelson Thornes ltd. 2nd

Ed. 2002. ISBN 07487 33558

Prabhath T, Wagaarachchi, Fenando F. Trends in maternal mortality and

assessment of substandard care in a tertiary care hospital in a developing

40

country. European Journal of Obstetrics and Gynaecology and reproductive

Biology vol. 101, issue 1 pp 36-40, 2002.

Programe for Appropriate Technology in Healthy (PATH) & USAID. Maternal

and neonatal Health special Issue. Preventing PPH: Managing the third Stage of

labor. Outlook Vol. 19, no. 2001

Riley WJ, Moran JW Corso LC, Beltsch LM, Bialek R, Cofsky A. Defining

quality improvement in produce health. J Public Health Management Practice,

2010. 16(1) 5-7

Robie BD & Zaks L. Total Quality management. Management of International

Public Health/CDC. Accessesd on line on 12th March 2012.

Rodríguez C, Gómez I, Ayabaca P, Djibrinaf S & The Nicaraguan Maternal and

Neonatal Health Quality Improvement Group. Are skilled birth attendants really

skilled? A measurement method, Some disturbing results and a potential way

forward. Bulletin of the World Health Organization 2007;85:783–790.

Sandal J. HomerC, Sandler E, Rudisila, Bourgeant, Bewleys Nelson P, Cowle

Cooper, Curry N. Staffing in maternity units; getting people in the right place

at the right time. The kings fund 2011 www.kingfound.org.uk

Scott C. Setting safe nurse staffing levels Royal College of Nursing, 2003

Solberge LI. Continous Quality Improvement. www. healthpartners.com

Accesses on line on 12th March 2012

http://www.kingfound.org.uk/

41

The world health report 2006.

Thorsen VC, Tharp ALT, Meguid T. High rates of burn out among maternal

health staff at a referral hospital in Malawi. A cross sectional Study. BMC

nursing 2011, 10:9

Tuncalp O, Hindin MJ, Adu-Bonsaffoh, Adanu R. listening to Women‟s voices:

The quality of care of women experiencing severe maternal morbidity in Accra

Ghana. PLoS ONE 7(8): e44336, 2012.

UAC, 2011. National HIV prevention strategy 2010-2015. Expanding and doing

HIV prevention better. Uganda AIDS Commission,2011

Uganda Bureau of Statistics (UBOS) and ICF International Inc. 2012. Uganda

Demographic and Health Survey 2011. Kampala, Uganda: UBOS and Calverton,

Maryland: ICF International Inc.

UNFPA. Maternal and Neonatal Health in East & S. East Asia. Country

Technical Services for East-south of Asia Bangkok, Thailand, 2006.

USAID, 2012. Preventing Postpartum Hemorrhage; why quality improvement

matters.

USAID/HCI project. University Research Co., LLC. www.hciproject.org

Van den Broek NR, Graham WJ. Quality of care for maternal and newborn

health: the neglected agenda. BJOG 2009, 116 (suppl. 1): 18-21.

http://www.hciproject.org/

42

Wabwire-Mangen F, Odiit M, Kirungi W, Kisitu DK, Wanyama JO. Uganda

HIV Modes of Transmission and Prevention Response Analysis, 2009. Republic

of Uganda.

Weller B. Guidelines: Incentives for health professionals. International Council

of Nurses.

WHO 2003: Nursing and Midwifery Management workforce: Management

conceptual framework WHO 2003.

WHO Secretariat. Strengthening nursing and midwifery Fifty-sixth World Health

Assembly a56/19; April 2003

WHO, 2010 Monitoring the building blocks of health systems. A handbook of

indicators and other measurements strategies. WHO, 2010

WHO, 2010. PMTCT Strategic vision 2010-2015: moving towards elimination

of pediatric HIV, WHO,2010

WHO. Opportunities for Africa‟s Newborns: Practical data, policy and

programmatic support for newborn care in Africa, WHO 2012

AWood ward CA and WHO. Improving provider skills: Strategies for a

assisting health workers to modify and improve their skills. Issues in Health

Services Delivery. A discussion Paper no 1, WHO, 2000

43

Appendix I.

Time table for training midwives in quality maternal delivery and newborn care

quality in Mityana hospital

TIME TABLE FOR TRAINING MIDWIVES IN QUALITY

MATERNAL DELIVERY AND NEWBORN CARE QUALITY MITYANA HOSPITAL

TIME TOPIC FACILITATOR

DAY 1

8:30-10:00 Participants‟ registration.

Participant‟s expectations and fears

Pretest.

Training objectives

Administrative briefs

Official opening by hospital administration.

Betty Ezaru

Abel Bizimana

Najuma Kalule

9:00 - 10:45 Overview of reproductive health in Uganda.

Components of RH

Key policies & guidelines

Abel Bizimana

Najuma Kalule

10:45 - 11:00 HEALTH BREAK All

11:00 - 12:30 Causes and magnitude of maternal and newborn

morbidity and mortality.

Najuma Kalule

12:30 - 1:00 Group work: 4 groups formed to discuss common

causes of maternal and newborn morbidity and mortality

in Mityana Hospital

Abel Bizimana

Najuma Kalule

44

1:00 – 2:00 LUNCH BREAK All

2:00 – 2:45 Plenary: presenting group work Betty Ezaru, Abel

Bizimana, Najuma

Kalule

2:45 – 3:15 Introduction to management of delivery to ensure clean

and safe child birth

Betty Ezaru,

3:15 – 4:15 Normal and abnormal labour process abnormal obstetric

and newborn emergencies

Betty Ezaru,

4:15 -4:45 Group work

- Common obstetric and newborn care

emergencies in Mityana

- Challenges of managing

(1) Obstetric emergencies

(2) Newborn emergencies

Betty Ezaru, Najuma

Kalule

4;45 – 5:00 - Evaluation of the day

- Participants departure

Najuma Kalule

5:00 – 5:30 Trainers meeting All trainers

DAY 2

8:30-9:00 Recap of previous day Najuma Kalule

9:00 – 9:30 Plenary : group work presenting on challenges of

managing obstetric and newborn emergencies in

Mityana hospital

Abel Bizimana

45

9:30 – 10:45 PMTCT in labour

Active management of third stage of labour rationale

and procedure

Betty Ezaru

10:45 - 11:00 HEALTH BREAK ALL

11:00 - 12:00 Newborn care /basic and emergency Betty Ezaru

12:00 - 12:45 Introduction to communication &MCR model

Purpose of communication

Abel Bizimana

12:45 – 1:00 Group work (4 groups)

Communication needs for

(1) Clients and client caretakers

(2) Colleagues on ward

(3) Staff from other departments

(4) Team leaders and managers

Abel Bizimana, Najuma

Kalule

1:00 – 2:00 LUNCH BREAK ALL

2:00 – 2:45 7 Cs of effective communication Abel Bizimana

2:45-3:00 The place of emotional intelligence & conflict

management in effective communication

Abel Bizimana, Najuma

Kalule

3:00 – 3:15 Post a tour of group work on communication needs of

various target audiences c lose before lunch

Najuma Kalule, betty

Ezaru

3:15 – 4:15 Introduction to quality improvement

- CQI principals

- SOPs, guidelines + polices

- Benefits of CQl

Abel Bizimana

4:15 – 4:15 The CQl process Abel Bizimana

46

4:15 – 5:00 - Day evaluation

- Participants departure

Betty Ezaru

5:00 -5:15 Trainers meting All

DAY 3

8:30-9:00 Recap of the day Betty Ezaru

9:00 – 10:45 Introduction infection prevention

The universal precautions

Possible sources of nosocomial infection

Maternal and neonatal sepsis

PMTCT- handling placentas and wastes

Protecting self other staff clients and care

takers from infections

Proper waste disposing

Najuma Kalule

10:45 - 11:00 HEALTH BREAK ALL

11:00 - 12:00 Preparing trainers for practical session sharing tools

for practical‟s mentoring process

Betty Ezaru ,

Abel Bizimana

Najuma Kalule

12:00 - 12:45 Post test

1:00 – 2:00 LUNCH BREAK

2:00 - 4:45 Practical: mentoring and coaching trainees Betty Ezaru

Abel Bizimana

Najuma Kalule

DAY 4

8:30 – 9:00 Recap of previous day

47

NB. Practical: 1. Mentoring and coaching trainees continues with emphasis on

trainees whose skills are wanting.

9:00 – 10-45 Practical: mentoring and coaching trainees Betty Ezaru

Abel Bizimana,

Najuma Kalule

10:45 – 11:00 Health break

11:00 – 1:00 Practical: mentoring and coaching trainees Betty Ezaru

Abel Bizimana

Najuma Kalule

1:00 – 2:00 Lunch breezing

2:00 -4:45 Practical: mentoring and coaching trainees Betty Ezaru

Abel Bizimana

Najuma Kalule

4:15 – 5:00 Trainers meeting All trainers

48

Appendix II

Pre and Post test

1. State 4 principles of quality improvement

2. Mention components of reproductive health package.

3. Define communication

4. List five major activities carried out at Antenatal Clinic

5. Describe the stages of labour and how each stage is managed.

6. Give the reasons why we use a partograph in monitoring labour.

7. Mention 5 obstetric emergencies

8. Describe the purpose of infection prevention in maternity.

9. What are common causes of maternal deaths

10. Explain the importance of knowing a mother‟s HIV status during ANC.

Appendix III

The training content outline:

Overview of reproductive health

(a) Components of reproductive health services in Uganda

(i) Safe motherhood (ANC, safe delivery, EmONC , PNC,

cervical /breast cancer screening and treatment

(ii) Post-abotal care

(iii) Family planning

(iv) Adolescent sexual and reproductive health and rights

(v) Gender issues and discrimination

(vi) HIV/AIDS/STIs prevention and management

(vii) Infertility prevention and management

(viii) Management of menopause and adropose

49

(ix) Common causes and magnitude of maternal and newborn

morbidity and mortality.

1. Management of delivery

(i) PMTCT

(ii) Labour

(a) Normal labour

(b) Abnormal labor obstetric and newborn care emergencies

(c) Determining abnormal labor using a partograph

(iii) Active management of third stage of labour

(iv) Newborn care including resuscitation

2. Communication

- The (Sender, Message, Channel, Receiver ( SMCR) model of

communication

- The seven Cs of effective communication

- Communication needs to clients, care takers, colleagues on the ward,

staff from within and from other departments, team leaders and

managers.

- Purposes of communication

3. Quality Improvement

(1) Overview of quality assurance and Continuous Quality Improvement

(CQI)

(2) Principles of CQI

(3) Standard guidelines , SOPs and policy documents as tools for CQI

(4) Measuring results using CQI approach

4. Infection prevention

(i) The concept of nosocomial infections, where and how they occur

50

(ii) A clean delivery that protects a mother, baby, service provider,

client‟s care taker

1. MTCT

2. Waste disposal

3. The universal precautions

4. Managing sepsis

5. Practical focus

- Use of partograph

- Client communication

- Timely seeking assistance from colleague or and others

- AMTSL

- Newborn care

- New born resuscitation

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