Quality improvement collaboratives as part of a quality improvement intervention package for preterm births at sub-national level in East Africa: a multi-method analysis.

BACKGROUND: Quality improvement collaboratives (QIC) are an approach to accelerate the spread and impact of evidence-based interventions across health facilities, which are found to be particularly successful when combined with other interventions such as clinical skills training. We implemented a QIC as part of a quality improvement intervention package designed to improve newborn survival in Kenya and Uganda. We use a multi-method approach to describe how a QIC was used as part of an overall improvement effort and describe specific changes measured and participant perceptions of the QIC. METHODS: We examined QIC-aggregated run charts on three shared indicators related to uptake of evidence-based practices over time and conducted key informant interviews to understand participants' perceptions of quality improvement practice. Run charts were evaluated for change from baseline medians. Interviews were analysed using framework analysis. RESULTS: Run charts for all indicators reflected an increase in evidence-based practices across both countries. In Uganda, pre-QIC median gestational age (GA) recording of 44% improved to 86%, while Kangaroo Mother Care (KMC) initiation went from 51% to 96% and appropriate antenatal corticosteroid (ACS) use increased from 17% to 74%. In Kenya, these indicators went from 82% to 96%, 4% to 74% and 4% to 57%, respectively. Qualitative results indicate that participants appreciated the experience of working with data, and the friendly competition of the QIC was motivating. The participants reported integration of the QIC with other interventions of the package as a benefit. CONCLUSIONS: In a QIC that demonstrated increased evidence-based practices, QIC participants point to data use, friendly competition and package integration as the drivers of success, despite challenges common to these settings such as health worker and resource shortages. TRIAL REGISTRATION NUMBER: NCT03112018.

Provision and utilization of maternal health services during the COVID-19 pandemic in 16 hospitals in sub-Saharan Africa.

Objective: Maintaining provision and utilization of maternal healthcare services is susceptible to external influences. This study describes how maternity care was provided during the COVID-19 pandemic and assesses patterns of service utilization and perinatal health outcomes in 16 referral hospitals (four each) in Benin, Malawi, Tanzania and Uganda. Methods: We used an embedded case-study design and two data sources. Responses to open-ended questions in a health-facility assessment survey were analyzed with content analysis. We described categories of adaptations and care provision modalities during the pandemic at the hospital and maternity ward levels. Aggregate monthly service statistics on antenatal care, delivery, caesarean section, maternal deaths, and stillbirths covering 24 months (2019 and 2020; pre-COVID-19 and COVID-19) were examined. Results: Declines in the number of antenatal care consultations were documented in Tanzania, Malawi, and Uganda in 2020 compared to 2019. Deliveries declined in 2020 compared to 2019 in Tanzania and Uganda. Caesarean section rates decreased in Benin and increased in Tanzania in 2020 compared to 2019. Increases in maternal mortality ratio and stillbirth rate were noted in some months of 2020 in Benin and Uganda, with variability noted between hospitals. At the hospital level, teams were assigned to respond to the COVID-19 pandemic, routine meetings were cancelled, and maternal death reviews and quality improvement initiatives were interrupted. In maternity wards, staff shortages were reported during lockdowns in Uganda. Clinical guidelines and protocols were not updated formally; the number of allowed companions and visitors was reduced. Conclusion: Varying approaches within and between countries demonstrate the importance of a contextualized response to the COVID-19 pandemic. Maternal care utilization and the ability to provide quality care fluctuated with lockdowns and travel bans. Women's and maternal health workers' needs should be prioritized to avoid interruptions in the continuum of care and prevent the deterioration of perinatal health outcomes.

Transition from hospital to home care for preterm babies: A qualitative study of the experiences of caregivers in Uganda.

Improving care for preterm babies could significantly increase child survival in low-and middle income countries. However, attention has mainly focused on facility-based care with little emphasis on transition from hospital to home after discharge. Our aim was to understand the experiences of the transition process among caregivers of preterm infants in Uganda in order to improve support systems. A qualitative study among caregivers of preterm infants in Iganga and Jinja districts in eastern Uganda was conducted in June 2019 through February 2020, involving seven focus group discussions and five in-depth interviews. We used thematic-content analysis to identify emergent themes related to the transition process. We included 56 caregivers, mainly mothers and fathers, from a range of socio-demographic backgrounds. Four themes emerged: caregivers' experiences through the transition process from preparation in the hospital to providing care at home; appropriate communication; unmet information needs; and managing community expectations and perceptions. In addition, caregivers' views on 'peer-support' was explored. Caregivers' experiences, and their confidence and ability to provide care were related to preparation in the hospital after birth and until discharge, the information they received and the manner in which healthcare providers communicated. Healthcare workers were a trusted source of information while in the hospital, but there was no continuity of care after discharge which increased their fears and worries about the survival of their infant. They often felt confused, anxious and discouraged by the negative perceptions and expectations from the community. Fathers felt left-out as there was very little communication between them and the healthcare providers. Peer-support could enable a smooth transition from hospital to home care. Interventions to advance preterm care beyond the health facility through a well-supported transition from facility to home care are urgently required to improve health and survival of preterm infants in Uganda and other similar settings.

Effect of community-level intervention on antenatal care attendance: a quasi-experimental study among postpartum women in Eastern Uganda.

BACKGROUND: Early Initiation of antenatal care (ANC) and at least four visits during pregnancy allow screening and support for a healthy lifestyle and self-care during pregnancy however, community-directed interventions to improve access to these services are rarely explored. OBJECTIVE: To assess the effect of community health worker (CHW) involvement on utilisation of antenatal services during pregnancy in resource-constrained rural settings in Uganda. METHODS: We conducted a quasi-experimental evaluation study among mothers from Eastern Uganda. We used Difference in Differences (DiD) analysis to assess the effect of CHW intervention on ANC attendance. Components of the intervention included community dialogues and empowering CHWs to educate pregnant women about using maternal health services. The primary endpoints were early initiation of ANC and completion of at least 4 ANC visits. RESULTS: Overall, the intervention significantly improved attendance of ≥ 4 ANC visits (DiD = 5.5%). The increase was significant in both intervention and comparison areas (46.2-64.4% vs. 54.1-66.8%, respectively), with slightly greater gains in the intervention area. Other elements that predicted ≥4 ANC attendance besides the intervention were post-primary education (PR1.14, 95%CI 1.02-1.30), higher wealth quintile (PR1.17, 95%CI 1.06-1.30), and early initiation of ANC (PR1.58, 95%CI 1.49-1.68). The intervention did not significantly improve early initiation of ANC (DiD =-1.3%). Instead, early initiation of ANC was associated with higher husband education (PR1.19,95%CI 1.02-1.39), larger household size (PR = 0.81, 95%CI 0.70-0.95), and higher wealth index (PR1.19,95%CI 1.03-1.37). CONCLUSIONS: The CHW intervention improved attendance of at least 4 ANC visits but not early initiation of ANC. There is need to promote CHW-led health education to increase attendance at 4+ ANC visits, but other approaches to promote early initiation are urgently required.

Methodological reflections on health system-oriented assessment of maternity care in 16 hospitals in sub-Saharan Africa: an embedded case study.

Health facility assessments (HFAs) assessing facilities' readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate-crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study exploring the experiences of HFA data collectors in implementing a novel HFA tool developed using systems thinking approach. We assessed 16 hospitals in four countries (Benin, Malawi, Tanzania and Uganda) as part of a quality improvement implementation research. Our tool was organized in 17 sections and included dimensions of hospital governance, leadership and financing; maternity care standards and procedures; ongoing quality improvement practices; interactions with communities and mapping of the areas related to maternal care. Data for this study were collected using in-depth interviews with senior experts who conducted the HFA in the countries 1-3 months after completion of the HFAs. Data were analysed using the inductive thematic analysis approach. Our HFA faced challenges in logistics (accessing key hospital-based respondents, high turnover of managerial staff and difficulty accessing information considered sensitive in the context) and methodology (response bias, lack of data quality and data entry into an electronic platform). Data elements of governance, leadership and financing were the most affected. Opportunities and strategies adopted aimed at enhancing data collection (building on prior partnerships and understanding local and institutional bureaucracies) and enhancing data richness (identifying respondents with institutional memory, learning from experience and conducting observations at various times). Moreover, HFA data collectors conducted abstraction of records and interviews in a flexible and adaptive way to enhance data quality. Lessons and new skills learned from our HFA could be used as inputs to respond to the growing need of integrating the systems thinking approach in HFA to improve the contextual understanding of operations and structure.

Strengthening capacity in hospitals to reduce perinatal morbidity and mortality through a codesigned intervention package: protocol for a realist evaluation as part of a stepped-wedge trial of the Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project.

INTRODUCTION: Despite a strong evidence base for developing interventions to reduce child mortality and morbidity related to pregnancy and delivery, major knowledge-implementation gaps remain. The Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project aims to overcome these gaps through strengthening the capacity of multidisciplinary teams that provide maternity care. The intervention includes competency-based midwife training, community engagement for study design, mentoring and quality improvement cycles. The realist process evaluation of ALERT aims at identifying and testing the causal pathway through which the intervention achieves its impact. METHODS AND ANALYSIS: This realist process evaluation complements the effectiveness evaluation and the economic evaluation of the ALERT intervention. Following the realist evaluation cycle, we will first elicit the initial programme theory on the basis of the ALERT theory of change, a review of the evidence on adoption and diffusion of innovations and the perspectives of the stakeholders. Second, we will use a multiple embedded case study design to empirically test the initial programme theory in two hospitals in each of the four intervention countries. Qualitative and quantitative data will be collected, using in-depth interviews with hospital staff and mothers, observations, patient exit interviews and (hospital) document reviews. Analysis will be guided by the Intervention-Actors-Context-Mechanism-Outcome configuration heuristic. We will use thematic coding to analyse the qualitative data. The quantitative data will be analysed descriptively and integrated in the analysis using a retroductive approach. Each case study will end with a refined programme theory (in-case analysis). Third, we will carry out a cross-case comparison within and between the four countries. Comparison between study countries should enable identifying relevant context factors that influence effectiveness and implementation, leading to a mid-range theory that may inform the scaling up the intervention. ETHICS AND DISSEMINATION: In developing this protocol, we paid specific attention to cultural sensitivity, the do no harm principle, confidentiality and non-attribution. We received ethical approval from the local and national institutional review boards in Tanzania, Uganda, Malawi, Benin, Sweden and Belgium. Written or verbal consent of respondents will be secured after explaining the purpose, potential benefits and potential harms of the study using an information sheet. The results will be disseminated through workshops with the hospital staff and national policymakers, and scientific publications and conferences. TRIAL REGISTRATION NUMBER: PACTR202006793783148.

Implementing the WHO Safe Childbirth Checklist modified for preterm birth: lessons learned and experiences from Kenya and Uganda.

BACKGROUND: The WHO Safe Childbirth Checklist (SCC) contains 29 evidence-based practices (EBPs) across four pause points spanning admission to discharge. It has been shown to increase EBP uptake and has been tailored to specific contexts. However, little research has been conducted in East Africa on use of the SCC to improve intrapartum care, particularly for preterm birth despite its burden. We describe checklist adaptation, user acceptability, implementation and lessons learned. METHODS: The East Africa Preterm Birth Initiative (PTBi EA) modified the SCC for use in 23 facilities in Western Kenya and Eastern Uganda as part of a cluster randomized controlled trial evaluating a package of facility-based interventions to improve preterm birth outcomes. The modified SCC (mSCC) for prematurity included: addition of a triage pause point before admission; focus on gestational age assessment, identification and management of preterm labour; and alignment with national guidelines. Following introduction, implementation lasted 24 and 34 months in Uganda and Kenya respectively and was supported through complementary mentoring and data strengthening at all sites. PRONTO® simulation training and quality improvement (QI) activities further supported mSCC use at intervention facilities only. A mixed methods approach, including checklist monitoring, provider surveys and in-depth interviews, was used in this analysis. RESULTS: A total of 19,443 and 2229 checklists were assessed in Kenya and Uganda, respectively. In both countries, triage and admission pause points had the highest rates of completion. Kenya's completion was greater than 70% for all pause points; Uganda ranged from 39 to 75%. Intervention facilities exposed to PRONTO and QI had higher completion rates than control sites. Provider perceptions cited clinical utility of the checklist, particularly when integrated into patient charts. However, some felt it repeated information in other documentation tools. Completion was hindered by workload and staffing issues. CONCLUSION: This study highlights the feasibility and importance of adaptation, iterative modification and complementary activities to reinforce SCC use. There are important opportunities to improve its clinical utility by the addition of prompts specific to the needs of different contexts. The trial assessing the PTBi EA intervention package was registered at ClinicalTrials.gov NCT03112018 Registered December 2016, retrospectively registered.

Health facility readiness to care for high risk newborn babies for early childhood development in eastern Uganda.

BACKGROUND: The neonatal mortality rate in Uganda has barely changed over the past decades, estimated at 28/1000 and 27/1000 live births in 2006 and 2016 respectively. The survivors have a higher risk of developing neurodevelopmental disabilities (NDD) due to brain insults from perinatal complications related to poor quality of health services during pregnancy, around the time of birth, and during the postnatal period. This study aimed to assess health facility readiness to care for high risk newborn babies in order to inform programming that fosters early childhood development in eastern Uganda. METHODS: A cross sectional study of 6 hospitals and 10 higher level health centers that offer comprehensive maternal and newborn care was carried out in February 2020 in eastern Uganda. A World Health Organization Service Availability and Readiness Assessment tool (SARA) was adapted and used to assess the health facility readiness to manage maternal and neonatal conditions that are related to NDD. In addition, 201 mothers of high risk newborn babies were interviewed on their satisfaction with health services received. Readiness scores were derived from percentage average facilities with available infrastructure and essential medical commodities to manage neonatal complications. Descriptive statistics were computed for client satisfaction with service provision, and p values used to compare private not for profit to public health facilities. RESULTS: There was limited availability in numbers and skilled human resource especially the neonatal nurses. Hospitals and health centers scored least in preterm and hypothermia care, with averages of 38% and 18% respectively. The highest scores were in essential newborn care, with readiness of 78% and 85% for hospitals and health centers, followed by resuscitation at 78% and 77%, respectively. There were no guidelines on positive interaction with newborn babies to foster neurodevelopment. The main cause of admission to neonatal care units was birth asphyxia followed by prematurity, indicative of intrapartum care challenges. The overall client satisfaction with health services was higher in private not for profit facilities at 91% compared to public hospitals at 73%, p = 0.017. CONCLUSION: Health facility readiness was inadequate in management of preterm complications. Efforts should, therefore, be geared to improving availability of inputs and quality of emergency obstetric and newborn care in order to manage high risk newborns and reduce the burden of NDD in this setting.

Implementing an intrapartum package of interventions to improve quality of care to reduce the burden of preterm birth in Kenya and Uganda.

BACKGROUND: Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication. METHODS: Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative. RESULTS: In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake. CONCLUSION: Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up. The trial is registered at ClinicalTrials.gov NCT03112018 , registered December 2016, posted April 2017.

Birthweight and gestational age-specific neonatal mortality rate in tertiary care facilities in Eastern Central Uganda.

BACKGROUND: An estimated 2.8 million neonatal deaths occur each year globally, which accounts for at least 45% of deaths in children aged less than 5 years. Birthweight and gestational age-specific mortality estimates are limited in low-resource countries like Uganda. A deeper analysis of mortality by birthweight and gestational age is critical in identifying the cause and potential solutions to decrease neonatal mortality. OBJECTIVES: We studied mortality before discharge in relation to birthweight and gestational age using a large sample size from selected tertiary care facilities in Uganda. METHODS: We used secondary data from the East Africa Preterm Birth Initiative study conducted in six tertiary care facilities. Birth records of infants born between October 2016 and March 2019 with a gestational age greater than or equal to 24 weeks and/or birthweight greater than or equal to 500 g were reviewed for inclusion in the analysis. Newborn death before discharge was the outcome variable of interest. Multivariable Poisson regression modeling was used to explore birthweight and gestational age-specific mortality rate. RESULTS: We analysed 50 278 birth records. Among these 95.3% (47 913) were live births and 4.8% (2365) were stillbirths. Of the 47 913 live births, 50% (24 147) were males. Overall, pre-discharge mortality was 13.0 per 1000 live births. For each 1 kg increase in birthweight, mortality before discharge decreased by -0.016. As birthweight increases, the mortality before discharge decreased from 336 per 1000 live births among infants born between 500 and 999 g, to 4.7 per 1000 live births among infants born weighing 3500 to 3999 g, and increased again to 11.2 per 1000 live births among infants weighing more than 4500 g. CONCLUSIONS: Our study highlights the need for further research to understand newborn survival across different birthweight and gestational categories.

Neurodevelopmental outcomes of preterm babies during infancy in Eastern Uganda: a prospective cohort study.

BACKGROUND: Complications due to prematurity are a threat to child survival and full developmental potential particularly in low-income settings. OBJECTIVE: The aim of the study was to determine the neurodevelopmental outcomes among preterm infants and identify any modifiable factors associated with neurodevelopmental disability (NDD). METHODS: We recruited 454 babies (242 preterms with birth weight <2.5 kg, and 212 term babies) in a cohort study at birth from Iganga hospital between May and July 2018. We followed up the babies at an average age of 7 months (adjusted for prematurity) and assessed 211 preterm and 187 term infants for neurodevelopmental outcomes using the Malawi Developmental Assessment tool. Mothers were interviewed on care practices for the infants. Data were analyzed using STATA version 14. RESULTS: The study revealed a high incidence of NDD of 20.4% (43/211) among preterm infants compared to 7.5% (14/187) among the term babies, p < 0.001, of the same age. The most affected domain was fine motor (11.8%), followed by language (9.0%). At multivariate analysis, malnutrition and Kangaroo Mother Care (KMC) at home after discharge were the key factors that were significantly associated with NDD among preterm babies. The prevalence of malnutrition among preterm infants was 20% and this significantly increased the odds of developing NDD, OR = 2.92 (95% CI: 1.27-6.71). KMC practice at home reduced the odds of developing NDD, OR = 0.46, (95% CI: 0.21-1.00). Re-admission of preterm infants after discharge (a sign of severe illness) increased the odds of developing NDD but this was not statistically significant, OR = 2.33 (95% CI: 0.91-5.94). CONCLUSION: Our study has shown that preterm infants are at a high risk of developing NDD, especially those with malnutrition. Health system readiness should be improved to provide follow-up care with emphasis on improving nutrition and continuity of KMC at home.

Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-randomised facility-based trial.

BACKGROUND: Although gains in newborn survival have been achieved in many low-income and middle-income countries, reductions in stillbirth and neonatal mortality have been slow. Prematurity complications are a major driver of stillbirth and neonatal mortality. We aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised. METHODS: This unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. The study assessed outcomes of low-birthweight and preterm babies. Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention group or the control group. All facilities received maternity register data strengthening and a modified WHO Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. Liveborn or fresh stillborn babies who weighed between 1000 g and 2500 g, or less than 3000 g with a recorded gestational age of less than 37 weeks, were included in the analysis. We abstracted data from maternity registers for maternal and birth outcomes. Follow-up was done by phone or in person to identify the status of the infant at 28 days. The primary outcome was fresh stillbirth and 28-day neonatal mortality. This trial is registered with ClinicalTrials.gov, NCT03112018. FINDINGS: Between Oct 1, 2016, and April 30, 2019, 20 facilities were randomly assigned to either the intervention group (n=10) or the control group (n=10). Among 5343 eligible babies in these facilities, we assessed outcomes of 2938 newborn and fresh stillborn babies (1447 in the intervention and 1491 in the control group). 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group at 28 days (odds ratio 0·66, 95% CI 0·54-0·81). No harm or adverse effects were found. INTERPRETATION: Fresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening. FUNDING: Bill & Melinda Gates Foundation.

Caring for children with neurodevelopmental disability: Experiences from caretakers and health workers in rural eastern Uganda.

BACKGROUND: Long term outcomes of children with neurodevelopmental disability are influenced by the condition itself, available health services and caretakers' coping ability to nurture the children which may be related to their beliefs and experiences. Most children with neurodevelopmental disabilities live in resource constrained settings. To inform design of contextually appropriate interventions, this study explored health workers' and caretakers' experiences in caring for infants with neurodevelopmental disability in rural eastern Uganda. METHODS: A qualitative case study was carried out in December 2017 and involved in-depth interviews with 14 caretakers of infants with severe neurodevelopmental disability, and five health workers in Iganga/Mayuge Demographic Surveillance Site in eastern Uganda. The interviews with caretakers were conducted in Lusoga, the local language, and in English for the health workers, using a pre-determined open-ended interview guide. Data were analyzed using latent content analysis. RESULTS: Caretakers described the experience of caring for children with neurodevelopmental disability as impoverishing and 'imprisoning' due to high care costs, inability to return to income generating activities and nursing challenges. The latter resulted from failure in body control and several aspects of nutrition and maintaining vital functions, coupled with limited support from the community and the health system. Many caretakers expressed beliefs in supernatural causes of neurodevelopmental disability though they reported about complications during and shortly after the birth of the affected child. Care-seeking was often challenging and impeded by costs and the feeling of lack of improvement. The health care system was also found to be incapable of adequately addressing the needs of such children due to lack of commodities, and human resource limitations. CONCLUSION: The caretakers expressed a feeling of emotional stress due to being left alone with a high nursing burden. Improvement in the health services including a holistic approach to care, improved community awareness and parental support could contribute to nursing of children with NDD.

Prevalence and associated factors of neurodevelopmental disability among infants in eastern Uganda: a population based study.

BACKGROUND: Neurodevelopmental disability (NDD) is increasingly acknowledged as one of the important causes of disease burden in low income countries. None the less, there is a dearth of data on the burden of NDD and its determinants in these settings. We aimed to establish the prevalence and factors associated with NDD among infants in Eastern Uganda. METHODS: We assessed 487 infants aged 9-12 months within Iganga-Mayuge Health Demographic Surveillance Site in Eastern Uganda using the Malawi Developmental Assessment Tool. The tool has four domains: gross motor, fine motor, language and social domains. An infant failed a domain if she/he failed more than two parameters of the expected at his/her age. We interviewed mothers on factors that could influence the infants' neurodevelopmental outcomes. Data were analysed using STATA version 14. We used odds ratios and 95% confidence intervals to assess statistical significance of associations. RESULTS: Of the 487 infants, 62(12.7%) had an NDD in at least one of the domains. The most affected was social behaviour where 52(10.7%) infants had an NDD. Severe impairment was seen among 9(1.8%) infants with NDD in either three or four domains. Factors associated with NDD at multivariate logistic regression included: parity of more than three children (aOR = 1.8, 95% CI: 1.02-3.18); failure to cry at birth (aOR = 3.6, 95% CI: 1.46-9.17) and post-neonatal complications (aOR = 4.15, 95% CI: 1.22-14.10). Low birth weight, immediate and exclusive breast feeding were not significantly associated with NDD. CONCLUSION: We found a high NDD burden among infants particularly in the social behaviour domain. To optimise the socio-neural development of infants, programs are needed to educate and work with families on how to engage and stimulate infants. Existing immunisation clinics and community health worker strategies provide an excellent opportunity for stemming this burden.

Applying the model of diffusion of innovations to understand facilitators for the implementation of maternal and neonatal health programmes in rural Uganda.

In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care - through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh's Model of Diffusion to reflect on these projects' approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.

Clinical cascades as a novel way to assess physical readiness of facilities for the care of small and sick neonates in Kenya and Uganda.

BACKGROUND: Globally, there were 2.7 million neonatal deaths in 2015. Significant mortality reduction could be achieved by improving care in low- and middle-income countries (LMIC), where the majority of deaths occur. Determining the physical readiness of facilities to identify and manage complications is an essential component of strategies to reduce neonatal mortality. METHODS: We developed clinical cascades for 6 common neonatal conditions then utilized these to assess 23 health facilities in Kenya and Uganda at 2 time-points in 2016 and 2017. We calculated changes in resource availability over time by facility using McNemar's test. We estimated mean readiness and loss of readiness for the 6 conditions and 3 stages of care (identification, treatment, monitoring-modifying treatment). We estimated overall mean readiness and readiness loss across all conditions and stages. Finally, we compared readiness of facilities with a newborn special care unit (NSCU) to those without using the two-sample test of proportions. RESULTS: The cascade model estimated mean readiness of 26.3-26.6% across the 3 stages for all conditions. Mean readiness ranged from 11.6% (respiratory distress-apnea) to 47.8% (essential newborn care) across both time-points. The model estimated overall mean readiness loss of 30.4-31.9%. There was mild to moderate variability in the timing of readiness loss, with the majority occurring in the identification stage. Overall mean readiness was higher among facilities with a NSCU (36.8%) compared to those without (20.0%). CONCLUSION: The cascade model provides a novel approach to quantitatively assess physical readiness for neonatal care. Among 23 facilities in Kenya and Uganda, we identified a consistent pattern of 30-32% readiness loss across cascades and stages. This aggregate measure could be used to monitor and compare readiness at the facility-, health system-, or national-level. Estimates of readiness and loss of readiness may help guide strategies to improve care, prioritize resources, and promote neonatal survival in LMICs.

Strengthening intrapartum and immediate newborn care to reduce morbidity and mortality of preterm infants born in health facilities in Migori County, Kenya and Busoga Region, Uganda: a study protocol for a randomized controlled trial.

BACKGROUND: Preterm birth (birth before 37 weeks of gestation) and its complications are the leading contributors to neonatal and under-5 mortality. The majority of neonatal deaths in Kenya and Uganda occur during the intrapartum and immediate postnatal period. This paper describes our study protocol for implementing and evaluating a package of facility-based interventions to improve care during this critical window. METHODS/DESIGN: This is a pair-matched, cluster randomized controlled trial across 20 facilities in Eastern Uganda and Western Kenya. The intervention facilities receive four components: (1) strengthening of routine data collection and data use activities; (2) implementation of the WHO Safe Childbirth Checklist modified for preterm birth; (3) PRONTO simulation training and mentoring to strengthen intrapartum and immediate newborn care; and (4) support of quality improvement teams. The control facilities receive both data strengthening and introduction of the modified checklist. The primary outcome for this study is 28-day mortality rate among preterm infants. The denominator will include all live births and fresh stillbirths weighing greater than 1000 g and less than 2500 g; all live births and fresh stillbirths weighing between 2501 and 3000 g with a documented gestational age less than 37 weeks. DISCUSSION: The results of this study will inform interventions to improve personnel and facility capacity to respond to preterm labor and delivery, as well as care for the preterm infant. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03112018 . Registered on 13 April 2017.

Uganda Newborn Study (UNEST) trial: Community-based maternal and newborn care economic analysis.

The Uganda Newborn Study (UNEST) was a two-arm cluster Randomized Control Trial to study the effect of pregnancy and postnatal home visits by local community health workers called 'Village Health Teams' (VHT) coupled with health systems strengthening. To inform programme planning and decision making, additional economic and financial costs of community and facility components were estimated from the perspective of the provider using the Excel-based Cost of Integrating Newborn Care Tool. Additional costs excluded costs already paid by the government for the routine health system and covered design, set-up, and 1-year implementation phases. Improved efficiency was modelled by reducing the number of VHT per village from two to one and varying the number of home visits/mother, the programme's financial cost at scale was projected (population of 100 000). 92% of expectant mothers (n = 1584) in the intervention area were attended by VHTs who performed an average of three home visits per mother. The annualized additional financial cost of the programme was $83 360 of which 4% ($3266) was for design, 24% ($20 026) for set-up and 72% ($60 068) for implementation. 56% ($47 030) went towards health facility strengthening, whereas 44% ($36 330) was spent at the community level. The average cost/mother for the community programme, excluding one-off design costs, amounted to $22.70 and the average cost per home visit was $7.50. The additional cost of the preventive home visit programme staffed by volunteer VHTs represents $1.04 per capita, 1.8% of Uganda's public health expenditure per capita ($59.00). If VHTs were to spend an average of 6 h a week on the programme, costs per mother would drop to $13.00 and cost per home visit to $3.20, in a population of 100 000 at 95% coverage. Additional resources are needed to rollout the government's VHT strategy nationally, maintaining high quality and linkages to quality facility-based care.

Effect of a participatory multisectoral maternal and newborn intervention on maternal health service utilization and newborn care practices: a quasi-experimental study in three rural Ugandan districts.

BACKGROUND: The MANIFEST study in eastern Uganda employed a participatory multisectoral approach to reduce barriers to access to maternal and newborn care services. OBJECTIVES: This study analyses the effect of the intervention on the utilization of maternal and newborn services and care practices. METHODS: The quasi-experimental pre- and post-comparison design had two main components: community mobilization and empowerment, and health provider capacity building. The primary outcomes were utilization of antenatal care (ANC), delivery and postnatal care, and newborn care practices. Baseline (n = 2237) and endline (n = 1946) data were collected from women of reproductive age. The  data was analysed using difference in differences (DiD) analysis and  logistic regression. RESULTS: The DiD results revealed an 8% difference in early ANC attendance (p < 0.01) and facility delivery (p < 0.01). Facility delivery increased from 66% to 73% in the intervention area, but remained unchanged in the comparison area (64% vs 63%, p < 0.01). The DiD results also demonstrated a 20% difference in clean cord care (p < 0.001) and an 8% difference in delayed bathing (p < 0.001). The intervention elements that predicted facility delivery were attending ANC four times [adjusted odds ratio (aOR) 1.42, 95% confidence interval (CI) 1.17-1.74] and saving for maternal health (aOR 2.11, 95% CI 1.39-3.21). Facility delivery and village health team (VHT) home visits were key predictors for clean cord care and skin-to-skin care. CONCLUSIONS: The multisectoral approach had positive effects on early ANC attendance, facility deliveries and newborn care practices. Community resources such as VHTs and savings are crucial to maternal and newborn outcomes and should be supported. VHT-led health education should incorporate practical measures that enable families to save and access transport services to enhance adequate preparation for birth.

Working with community health workers to improve maternal and newborn health outcomes: implementation and scale-up lessons from eastern Uganda.

BACKGROUND: Preventable maternal and newborn deaths can be averted through simple evidence-based interventions, such as the use of community health workers (CHWs), also known in Uganda as village health teams. However, the CHW strategy faces implementation challenges regarding training packages, supervision, and motivation. OBJECTIVES: This paper explores knowledge levels of CHWs, describes the coverage of home visits, and shares lessons learnt from setting up and implementing the CHW strategy. METHODS: The CHWs were trained to conduct four home visits: two during pregnancy and two after delivery. The aim of the visits was to promote birth preparedness and utilization of maternal and newborn health (MNH) services. Mixed methods of data collection were employed. Quantitative data were analyzed using Stata version 13.0 to determine the level and predictors of CHW knowledge of MNH. Qualitative data from 10 key informants and 15 CHW interviews were thematically analyzed to assess the implementation experiences. RESULTS: CHWs' knowledge of MNH improved from 41.3% to 77.4% after training, and to 79.9% 1 year post-training. However, knowledge of newborn danger signs declined from 85.5% after training to 58.9% 1 year later. The main predictors of CHW knowledge were age (≥ 35 years) and post-primary level of education. The level of coverage of at least one CHW visit to pregnant and newly delivered mothers was 57.3%. Notably, CHW reports complemented the facility-based health information. CHWs formed associations, which improved teamwork, reporting, and general performance, and thus maintained low dropout rates at 3.6%. Challenges included dissatisfaction with the quarterly transport refund of 6 USD and lack of means of transportation such as bicycles. CONCLUSIONS: CHWs are an important resource in community-based health information and improving demand for MNH services. However, the CHW training and supervision models require strengthening for improved performance. Local solutions regarding CHW motivation are necessary for sustainability.