Strengthening Kampala's Urban Referral System for Maternal and Newborn Care Through Establishment of an Emergency Call and Dispatch Center.

INTRODUCTION: Most pregnant women living in urban slum communities in Uganda deliver at public health centers that are not equipped to provide emergency obstetric and newborn care. When obstetric emergencies occur, pregnant women are referred to a higher-level facility and are responsible for arranging and paying for their own transport. The Kampala Slum Maternal Newborn (MaNe) project developed and tested an emergency call and ambulance dispatch center and a mobile application to request, deploy, and track ambulances. We describe the development of these 2 interventions and findings on the feasibility, acceptability, and sustainability of the interventions. METHODS: MaNe conducted a mixed-method feasibility study that included an assessment of the acceptability and demand of the interventions. In-depth interviews (N=26) were conducted with facility proprietors, health providers, ambulance drivers, Kampala Capital City Authority officers, and community members to understand the successes and challenges of establishing the call center and developing the mobile application. Thematic content analysis was done. Quantitative data from the call center dispatch logs were analyzed descriptively to complement the qualitative findings. FINDINGS: Between April 2020 and June 2021, 10,183 calls were made to the emergency call and dispatch center. Of these, 25% were related to maternal and newborn health emergencies and 14% were COVID-19 related. An ambulance was dispatched to transfer or evacuate a patient in 35% of the calls. Participants acknowledged that the call center and mobile application allowed for efficient communication, coordination, and information flow between health facilities. Supportive district leadership facilitated the establishment of the call center and has taken over the operating costs of the center. CONCLUSION: The call center and referral application improved the coordination of drivers and ambulances and allowed facilities to prepare for and treat cases more efficiently.

Maternal and newborn healthcare utilization in Kampala urban slums: perspectives of women, their spouses, and healthcare providers.

BACKGROUND: It is assumed that the health conditions of urban women are superior to their rural counterparts. However, evidence from Asia and Africa, show that poor urban women and their families have worse access to antenatal care and facility childbirth compared to the rural women. The maternal, newborn, and child mortality rates as high as or higher than those in rural areas. In Uganda, maternal and newborn health data reflect similar trend. The aim of the study was to understand factors that influence use of maternal and newborn healthcare in two urban slums of Kampala, Uganda. METHODS: A qualitative study was conducted in urban slums of Kampala, Uganda and conducted 60 in-depth interviews with women who had given birth in the 12 months prior to data collection and traditional birth attendants, 23 key informant interviews with healthcare providers, coordinator of emergency ambulances/emergency medical technicians and the Kampala Capital City Authority health team, and 15 focus group discussions with partners of women who gave birth 12 months prior to data collection and community leaders. Data were thematically coded and analyzed using NVivo version 10 software. RESULTS: The main determinants that influenced access to and use of maternal and newborn health care in the slum communities included knowledge about when to seek care, decision-making power, financial ability, prior experience with the healthcare system, and the quality of care provided. Private facilities were perceived to be of higher quality, however women primarily sought care at public health facilities due to financial constraints. Reports of disrespectful treatment, neglect, and financial bribes by providers were common and linked to negative childbirth experiences. The lack of adequate infrastructure and basic medical equipment and medicine impacted patient experiences and provider ability to deliver quality care. CONCLUSIONS: Despite availability of healthcare, urban women and their families are burdened by the financial costs of health care. Disrespectful and abusive treatment at hands of healthcare providers is common translating to negative healthcare experiences for women. There is a need to invest in quality of care through financial assistance programs, infrastructure improvements, and higher standards of provider accountability are needed.

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.

BACKGROUND: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. METHODS: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. RESULTS: From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). INTERPRETATION: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. FUNDING: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.