Prospective study to explore changes in quality of care and perinatal outcomes after implementation of perinatal death audit in Uganda

Objective To assess the effects of perinatal death (PND) audit on perinatal outcomes in a tertiary hospital in Kampala. Design Interrupted time series (ITS) analysis. Setting Nsambya Hospital, Uganda. Participants Live births and stillbirths. Interventions PND audit. Primary and secondary outcome measures Primary outcomes: perinatal mortality rate, stillbirth rate, early neonatal mortality rate. Secondary outcomes: case fatality rates (CFR) for asphyxia, complications of prematurity and neonatal sepsis. Results 526 PNDs were audited: 142 (27.0%) fresh stillbirths, 125 (23.8%) macerated stillbirths and 259 (49.2%) early neonatal deaths. The ITS analysis showed a decrease in perinatal death (PND) rates without the introduction of PND audits (incidence risk ratio (IRR) (95% CI) for time=0.94, p<0.001), but an increase in PND (IRR (95% CI)=1.17 (1.0 to –1.34), p=0.0021) following the intervention. However, when overdispersion was included in the model, there were no statistically significant differences in PND with or without the intervention (p=0.06 and p=0.44, respectively). Stillbirth rates exhibited a similar pattern. By contrast, early neonatal death rates showed an overall upward trend without the intervention (IRR (95% CI)=1.09 (1.01 to 1.17), p=0.01), but a decrease following the introduction of the PND audits (IRR (95% CI)=0.35 (0.22 to 0.56), p<0.001), when overdispersion was included. The CFR for prematurity showed a downward trend over time (IRR (95% CI)=0.94 (0.88 to 0.99), p=0.04) but not for the intervention. With regards CFRs for intrapartum-related hypoxia or infection, no statistically significant effect was detected for either time or the intervention. Conclusion The introduction of PND audit showed no statistically significant effect on perinatal mortality or stillbirth rate, but a significant decrease in early neonatal mortality rate. No effect was detected on CFRs for prematurity, intrapartum-related hypoxia or infections. These findings should encourage more research to assess the effectiveness of PND reviews on perinatal deaths in general, but also on stillbirths and neonatal deaths in particular, in low-resource settings

Assessment of quality of care among in-patients with postpartum haemorrhage and severe pre-eclampsia at st. Francis hospital nsambya: a criteria-based audit.

BACKGROUND: The maternal mortality ratio of Uganda is still high and the leading causes of maternal mortality are postpartum haemorrhage (PPH), severe pre-eclampsia and eclampsia. Criteria-based audit (CBA) is a way of improving quality of care that has not been commonly used in low income countries. This study aimed at finding out the quality of care provided to patients with these conditions and to find out if the implementation of recommendations from the audit cycle resulted in improvement in quality of care. METHODS: This study was a CBA following a time series study design. It was done in St. Francis Hospital Nsambya and it involved assessment of adherence to standards of care for PPH, severe pre-eclampsia and eclampsia. An initial audit was done for 3 consecutive months, then findings were presented to health workers and recommendations made; we implemented the recommendations in a subsequent month and this comprised three interventions namely continuing medical education (CME), drills and displaying guidelines; a re-audit was done in the proceeding 3 consecutive months and analysis compared adherence rates of the initial audit with those of the re-audit. RESULTS: Pearson Chi-Square test revealed that the adherence rates of 7 out of 10 standards of care for severe pre-eclampsia/eclampsia were statistically significantly higher in the re-audit than in the initial audit; also, the adherence rates of 3 out of 4 standards of care for PPH were statistically significantly higher in the re-audit than in the initial audit. CONCLUSION: The giving of feedback on quality of care and the implementation of recommendations made during the CBA including CME, drills and displaying guidelines was associated with improvements in the quality of care for patients with PPH, severe pre-eclampsia and eclampsia

Low avidity of human papillomavirus (HPV) type 16 antibodies is associated with increased risk of low-risk but not high-risk HPV type prevalence

Peer reviewe

Care of The Newborn in Uganda : Studies of the use of simple affordable effective interventions

Background: There are evidence based cost effective interventions available, which could decrease neonatal mortality, if scaled up and delivered under ideal conditions. Aim: To determine the causes of perinatal deaths, risk factors for neonatal hypothermia and explore the acceptability and feasibility of recommended perinatal practices in hospital and community settings in Uganda. Settings: St. Raphael of St. Francis Hospital, Nsambya in Kampala and rural villages in Ntungamo, Kayunga and Soroti district. Methods: The study period was from 1997-2008. A data form with a checklist and structured written questionnaires were used to collect data for studies I, II, III. 235 hospital records of women who had experienced a perinatal death in study I were reviewed. A perinatal audit and feedback was also conducted in study I. In studies II and III, 300 babies and 249 babies were recruited, and rectal and tympanic temperature measurements were performed on babies at specific time points post delivery in both studies. Babies of mothers in study III were randomized to receive early bathing after 1 hour or no bathing. Purposive sampling was done and Focus group discussionsconducted in studies IV and V. In addition six in depth interviews were performed for selected respondents in study V. Uni-, bi- and multi-variable analyses were carried out, using Epi info and Stata 10 for studies I, II and III, and content analysis for studies IV and V. Findings A high perinatal mortality was noted in the hospital at 68.3 per 1000 total births. The still birth rate was 40.9 per 1000 total births, and the early neonatal death rate was 29.3 per 1000 live births in study I. In study II the proportions of hypothermic newborns at 10, 30, 60 and 90 minutes were 29%, 82%, 83%, and 79 %, respectively. Babies who had not been bathed were associated with an odds reduction of experiencing hypothermia of 68% at 70 minutes (OR 0.32; 95% CI 0.17-0.60) and 63% at 90 minutes post delivery (OR 0.37; 95% CI 0.20-0.67) compared to bathed babies in study III. The odds of being exposed to hypothermia for a baby weighing less than 2500 grams was five times greater compared to a baby with a birth weight of more than 2500grams over the different time points. The odds of being exposed to hypothermia if a baby was female increased more than 1.5 times at the different time points. This gender difference was also observed at 90 minutes in study III. Some of the recommended newborn practices were deemed to conflict with traditional and cultural practices. It was noted that promotion of delayed bathing and dry cord were unlikely to be accepted without local adaptation. In studies IV and V, cultural and spiritual beliefs were attached to the use of local herbs for bathing or smearing of the baby´s skin. Traditional birth attendants reportedly did engage in a number of positive practices when caring for newborn babies, which were in agreement with biomedical recommendations, including thermo-protection of the newborn, early referrals to the health units and advising mothers to take the newborns for immunization in study V. Conclusion: There was a high perinatal mortality rate at the hospital. Thermoprotective guidelines were not being practiced well, and the prevalence of hypothermia was high. Bathing of babies within the first hour of life is associated with an increased risk of hypothermia. It may be necessary to modify some of the recommended evidence based practices, before they are accepted at community level

MOESM1 of Prevalence of hyperglycaemia first detected during pregnancy and subsequent obstetric outcomes at St. Francis Hospital Nsambya

Additional file 1: Appendix 1. Questionnaire

MOESM2 of Prevalence of hyperglycaemia first detected during pregnancy and subsequent obstetric outcomes at St. Francis Hospital Nsambya

Additional file 2: Appendix 2. Specifications for the glucometer used (GlucocardTM ∑ GT-1070)

Newborn survival in Uganda: a decade of change and future implications.

Each year in Uganda 141 000 children die before reaching their fifth birthday; 26% of these children die in their first month of life. In a setting of persistently high fertility rates, a crisis in human resources for health and a recent history of civil unrest, Uganda has prioritized Millennium Development Goals 4 and 5 for child and maternal survival. As part of a multi-country analysis we examined change for newborn survival over the past decade through mortality and health system coverage indicators as well as national and donor funding for health, and policy and programme change. Between 2000 and 2010 Uganda's neonatal mortality rate reduced by 2.2% per year, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period. While existing population-based data are insufficient to measure national changes in coverage and quality of services, national attention for maternal and child health has been clear and authorized from the highest levels. Attention and policy change for newborn health is comparatively recent. This recognized gap has led to a specific focus on newborn health through a national Newborn Steering Committee, which has been given a mandate from the Ministry of Health to advise on newborn survival issues since 2006. This multi-disciplinary and inter-agency network of stakeholders has been able to preside over a number of important policy changes at the level of facility care, education and training, community-based service delivery through Village Health Teams and changes to essential drugs and commodities. The committee's comprehensive reach has enabled rapid policy change and increased attention to newborn survival in a relatively short space of time. Translating this favourable policy environment into district-level implementation and high quality services is now the priority

The Uganda Newborn Study (UNEST) : an effectiveness study on improving newborn health and survival in rural Uganda through a community-based intervention linked to health facilities - study protocol for a cluster randomized controlled trial

Background: Reducing neonatal-related deaths is one of the major bottlenecks to achieving Millennium Development Goal 4. Studies in Asia and South America have shown that neonatal mortality can be reduced through community-based interventions, but these have not been adapted to scalable intervention packages for sub-Saharan Africa where the culture, health system and policy environment is different. In Uganda, health outcomes are poor for both mothers and newborn babies. Policy opportunities for neonatal health include the new national Health Sector Strategic Plan, which now prioritizes newborn health including use of a community model through Village Health Teams (VHT). The aim of the present study is to adapt, develop and cost an integrated maternal-newborn care package that links community and facility care, and to evaluate its effect on maternal and neonatal practices in order to inform policy and scale-up in Uganda. Methods/Design: Through formative research around evidence-based practices, and dialogue with policy and technical advisers, we constructed a home-based neonatal care package implemented by the responsible VHT member, effectively a Community Health Worker (CHW). This CHW was trained to identify pregnant women and make five home visits - two before and three just after birth - so that linkages will be made to facility care and targeted messages for home-care and care-seeking delivered. The project is improving care in health units to provide standardized care for the mother and the newborn in both intervention and comparison areas. The study is taking place in a new Demographic Surveillance Site in two rural districts, Iganga and Mayuge, in Uganda. It is a two-arm cluster randomized controlled design with 31 intervention and 32 control areas (villages). The comparison parishes receive the standard care already being provided by the district, but to the intervention villages are added a system for CHWs to visit the mother five times in her home during pregnancy and the neonatal period. Both areas benefit from a standardized strengthening of facility care for mothers and neonates. (Continued on next page) Discussion: UNEST is designed to directly feed into the operationalization of maternal and newborn care in the national VHT strategy, thereby helping to inform scale-up in rural Uganda. The study is registered as a randomized controlled trial, number ISRCTN50321130

Strengthening health facilities for maternal and newborn care : experiences from rural eastern Uganda

BACKGROUND: In Uganda maternal and neonatal mortality remains high due to a number of factors, including poor quality of care at health facilities. OBJECTIVE: This paper describes the experience of building capacity for maternal and newborn care at a district hospital and lower-level health facilities in eastern Uganda within the existing system parameters and a robust community outreach programme. DESIGN: This health system strengthening study, part of the Uganda Newborn Study (UNEST), aimed to increase frontline health worker capacity through district-led training, support supervision, and mentoring at one district hospital and 19 lower-level facilities. A once-off supply of essential medicines and equipment was provided to address immediate critical gaps. Health workers were empowered to requisition subsequent supplies through use of district resources. Minimal infrastructure adjustments were provided. Quantitative data collection was done within routine process monitoring and qualitative data were collected during support supervision visits. We use the World Health Organization Health System Building Blocks to describe the process of district-led health facility strengthening. RESULTS: Seventy two per cent of eligible health workers were trained. The mean post-training knowledge score was 68% compared to 32% in the pre-training test, and 80% 1 year later. Health worker skills and competencies in care of high-risk babies improved following support supervision and mentoring. Health facility deliveries increased from 3,151 to 4,115 (a 30% increase) in 2 years. Of 547 preterm babies admitted to the newly introduced kangaroo mother care (KMC) unit, 85% were discharged alive to continue KMC at home. There was a non-significant declining trend for in-hospital neonatal deaths across the 2-year study period. While equipment levels remained high after initial improvement efforts, maintaining supply of even the most basic medications was a challenge, with less than 40% of health facilities reporting no stock-outs. CONCLUSION: Health system strengthening for care at birth and the newborn period is possible even in low-resource settings and can be associated with improved utilisation and outcomes. Through a participatory process with wide engagement, training, and improvements to support supervision and logistics, health workers were able to change behaviours and practices for maternal and newborn care. Local solutions are needed to ensure sustainability of medical commodities

A randomised placebo-controlled safety and acceptability trial of PRO 2000 vaginal microbicide gel in sexually active women in Uganda.

OBJECTIVES: To determine the safety of 0.5% and 2% PRO 2000 gel in terms of local and systemic adverse events (AE) and the acceptability of gel use. DESIGN: A randomised placebo-controlled trial among healthy, sexually active African women aged 18-45 years. Between June 2003 and September 2004, 180 consenting women were randomly assigned to one of four groups: PRO 2000 gel (0.5% or 2%), placebo gel, or condom use only. Participants were screened for sexually transmitted infections, with HIV counselling and testing. Women randomly assigned to gel used this intravaginally twice a day for 28 days. Follow-up visits were fortnightly up to 6 weeks from enrolment, and comprised a physical examination including colposcopy, laboratory testing and questionnaire interviews. RESULTS: Ten women were lost to follow-up, none due to AE. Adherence with total gel doses was 69%. Observed rates of the primary toxicity endpoints, ulceration greater than 2 x 1 cm and clinically relevant coagulation abnormalities were, for PRO 2000 0.5%: 1.6% (95% CI 0.04% to 8.5%) and 0% (97.5% CI 0% to 5.7%), and for PRO 2000 2%: 0% and 0% (97.5% CI 0% to 5.9%). Women randomly assigned to active gels did not show an increased rate of AE. Gel use had no significant effect on haematology and biochemistry results. Women found gel use highly acceptable. CONCLUSIONS: Both concentrations of PRO 2000 gel were found to be safe and well tolerated. These data justified testing the gels in large-scale effectiveness trials