Timeliness of Delivery Care and Maternal and Neonatal Health Outcomes in Private Facilities in Masaka Area, Uganda: A Quasi-Experimental Study.

OBJECTIVES: While access to basic emergency obstetric and newborn care is necessary to reduce maternal and neonatal morbidity in low- and middle-income countries, data on the timeliness and quality of care at lower-level facilities is limited. This study examines timeliness of labor and delivery interventions and maternal and neonatal health status following deliveries in Uganda. METHODS: Women were recruited from 6 rural, private facilities in the greater Masaka area, Uganda on admission to the labor ward. Research assistants directly observed timeliness and quality of care from admission through discharge. Research assistants also abstracted medical chart information. All 6 facilities received training from LifeNet International on quality-of-care interventions for maternal and newborn health. RESULTS: 321 participants were directly observed during delivery, and 304 participants were followed at 28 days postpartum. Labor and delivery processes were overall timely and reflect international guidance on labor interventions. Maternal and neonatal health was good at discharge (90.6% and 88.8%) and 28 days postpartum (93.1% and 87.5%). However, there was no association between health at discharge and at 28 days for mothers or neonates (p = 0.67, p = 1.0, respectively). Demographic characteristics associated with maternal and neonatal health on discharge were different than those associated with maternal and neonatal health at 28 days. CONCLUSIONS FOR PRACTICE: Evidence on timeliness and quality of care can help inform strategies to further decrease maternal and neonatal morbidity. Additional focus is needed to retain patients in care to identify those developing poor health after delivery.

Impact evaluation of a maternal and neonatal health training intervention in private Ugandan facilities.

Global and country-specific targets for reductions in maternal and neonatal mortality in low-resource settings will not be achieved without improvements in the quality of care for optimal facility-based obstetric and newborn care. This global call includes the private sector, which is increasingly serving low-resource pregnant women. The primary aim of this study was to estimate the impact of a clinical and management-training programme delivered by a non-governmental organization [LifeNet International] that partners with clinics on adherence to global standards of clinical quality during labour and delivery in rural Uganda. The secondary aim included describing the effect of the LifeNet training on pre-discharge neonatal and maternal mortality. The LifeNet programme delivered maternal and neonatal clinical trainings over a 10-month period in 2017-18. Direct clinical observations of obstetric deliveries were conducted at baseline (n = 263 pre-intervention) and endline (n = 321 post-intervention) for six faith-based, not-for-profit primary healthcare facilities in the greater Masaka area of Uganda. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum haemorrhage and neonatal resuscitation). Data were supplemented by daily facility-based assessments of infrastructure during the study periods. Results showed positive and clinically meaningful increases in observed handwashing, observed delayed cord clamping, partograph use documentation and observed 1- and/or 5-minute APGAR assessments (rapid scoring system for assessing clinical status of newborn), in particular, between baseline and endline. High-quality intrapartum facility-based care is critical for reducing maternal and early neonatal mortality, and this evaluation of the LifeNet intervention indicates that their clinical training programme improved the practice of quality maternal and neonatal healthcare at all six primary care clinics in Uganda, at least over a relatively short-term period. However, for several of these quality indicators, the adherence rates, although improved, were still far from 100% and could benefit from further improvement via refresher trainings and/or a closer examination of the barriers to adherence.

Medical record bias in documentation of obstetric and neonatal clinical quality of care indicators in Uganda.

OBJECTIVE: To achieve a high quality of care (QoC), accurate measurements are needed. This study evaluated the validity of QoC data from the medical records for childbirth deliveries and assessed whether medical records can be used to evaluate the efficacy of interventions to improve QoC. STUDY DESIGN AND SETTING: This study was part of a larger study of QoC training program in Uganda. Study data were collected in two phases: (1) validation data from 321 direct observations of deliveries paired with the corresponding medical records; (2) surveillance data from 1,146 medical records of deliveries. Sensitivity, specificity, and predictive values were used to measure the validity of the medical record from the validation data. Quantitative bias analysis was conducted to evaluate QoC program efficacy in the surveillance data using prevalence ratio and odds ratio. RESULTS: On average, sensitivity (84%) of the medical record was higher than the specificity (34%) across 11 QoC indicators, showing a higher validity in identifying the performed procedure. For 5 out of 11 indicators, bias-corrected odds ratios and prevalence ratios deviated significantly from uncorrected estimates. CONCLUSION: The medical records demonstrated poor validity in measuring QoC compared with direct observation. Using the medical record to assess QoC program efficacy should be interpreted carefully.

Beneath the Surface: A Comparison of Methods for Assessment of Quality of Care for Maternal and Neonatal Health Care in Rural Uganda.

OBJECTIVES: Efforts to improve access to healthcare in low-income countries will not achieve the maternal and child health (MCH) Sustainable Development Goals unless a concomitant improvement in the quality of care (QoC) occurs. This study measures infrastructure and QoC indicators in rural Ugandan health facilities. Valid measure of the quality of current clinical practices in resource-limited settings are critical for effectively intervening to reduce adverse maternal and neonatal outcomes. METHODS: Facility-based assessments of infrastructure and clinical quality during labor and delivery were conducted in six primary care health facilities in the greater Masaka area, Uganda in 2017. Data were collected using direct observation of clinical encounters and facility checklists. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum hemorrhage, neonatal resuscitation). Health providers were assessed on their adherence to best practice standards of care. RESULTS: The quality of facility infrastructure was relatively high in facilities, with little variation in availability of equipment and supplies. However, heterogeneity in adherence to best clinical practices was noted across procedure type and facility. Adherence to crude measures of clinical quality were relatively high but more sensitive measures of the same clinical practice were found to be much lower. CONCLUSIONS FOR PRACTICE: Standard indicators of clinical practice may be insufficient to validly measure clinical quality for maternal and newborn care if we want to document evidence of impact.