Addressing the Third Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Ensuring Adequate and Appropriate Facility-Based Maternal and Perinatal Health Care

Diane Morof; Florina Serbanescu; Mary M. Goodwin; Davidson H. Hamer; Alice R. Asiimwe; Leoda Hamomba; Masuka Musumali; Susanna Binzen; Adeodata Kekitiinwa; Brenda Picho; Frank Kaharuza; Phoebe Monalisa Namukanja; Dan Murokora; Vincent Kamara; Michelle Dynes; Curtis Blanton; Agnes Nalutaaya; Fredrick Luwaga; Michelle M. Schmitz; Jonathan LaBrecque; Claudia Morrissey Conlon; Brian McCarthy; Charlan Kroelinger; Thomas Clark

doi:10.9745/GHSP-D-18-00272

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Context of Quality of Health Services for the Third Delay
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TABLE 1.

SMGL Interventions to Reduce the Third Delay, 2011–2016

Strategies and Approaches	Country-Specific Interventions^a
Strategies and Approaches	Uganda	Zambia
Strategy 1. Ensure facilities have adequate infrastructure to provide EmONC
Approach 1.1: Support expansion and renovation of operating theaters and facility enhancements to accommodate additional deliveries	Renovated and upgraded operating theaters Increased the size of labor rooms Provided additional delivery beds to allow more women to deliver in facilities and stay longer postpartum	Supported renovation of birthing centers, delivery rooms, and maternity annexes Provided additional delivery beds to allow more women to deliver in facilities and stay longer postpartum
Approach 1.2: Support facility enhancements to improve neonatal survival	Procured incubators, infant warmers, and phototherapy lamps Renovated infrastructure to have designated space for KMC and to create NICUs	Refurbished dedicated KMC rooms at hospitals
Approach 1.3: Support improved access to electricity and water	Provided safe water systems at health facilities Provided solar panels at facilities to improve continuity of access to electricity and light	Improved lighting systems for delivery rooms Improved piped water to maternity annexes
Strategy 2. Ensure sufficient medical supplies, equipment, and medications
Approach 2.1: Strengthen supply chains for essential supplies and medicines	Procured essential medication and backup supply of commodities for all sites on the SMGL project Redistributed supplies between health facilities to reduce stock-outs Implemented SMS reminder system to ensure timely drug ordering Equipped health centers with BEmONC equipment and supplies	Procured essential emergency medications and supplies with backup Trained staff in eLMIS Equipped health centers with BEmONC equipment and supplies Assembled and distributed uterine balloon tamponade kits, and CPAP machines
Approach 2.2: Strengthen availability of blood supplies and surgical equipment	Strengthened and maintained the blood supply system in CEmONC sites and supported new regional blood bank Provided new blood refrigerators Procured and distributed new surgical equipment to facilities	Procured and distributed centrifuges, refrigerators, and freezers to support blood bank Procured and distributed new surgical equipment to facilities
Strategy 3. Ensure sufficient trained health care providers at facilities
Approach 3.1: Recruited staff	Recruited new medical doctors and nurse/midwives through a joint hiring process with the districts	Recruited new nurse/midwives
Approach 3.2: Trained health professionals in emergency obstetric care, including obstetric surgeries	Trained medical officers, anesthetic officers, and midwives/nurses in CEmONC Conducted surgical skills course for medical officers, including decision making and caesarean section Trained providers on neonatal resuscitation/HBB and used drills to reinforce lessons	Trained doctors, nurses, midwives, and anesthetists in EmONC, clinical decision making, obstetric complications, hemorrhage management with uterine balloon tamponade, early HBB, and CPAP Limited rotation of trained providers to different wards Supported capacity building of laboratory staff for blood services
Approach 3.3: Provided mentoring and supportive supervision to newly hired and existing personnel	Conducted individual clinical mentorship sessions Provided selected nurses with intensive hands-on clinical skills placement to expand NICU skills	Trained district mentorship teams who then held monthly on site health facility staff training and mentorship visits on normal delivery and partograph use, EmONC, and HBB
Strategy 4. Improve quality of care and ensure care is evidence-based
Approach 4.1: Implemented quality, effective interventions to prevent and treat obstetric and newborn complications	Provided quality improvement practice to increase partograph use Implemented KMC	Introduced emergency kits and logs/registers to facilitate quick access to emergency supplies Implemented partograph use by facility staff Enhanced infection prevention practices
Approach 4.2: Introduced sound managerial practices using ‘short-loop' data feedback and response to ensure reliable delivery of quality essential and emergency maternal and newborn care	Incorporated concepts related to respectful maternity care into customer care training of midwives Used facility-generated data to review quality of care and implement practice changes	Incorporated respectful maternity care into EmONC and early newborn care and supported it through mentorship
Approach 4.3: Developed guidelines and policies, and ensured protocol adherence	Developed national standards for MDSR that were informed by SMGL processes Implemented BABIES matrix to prevent perinatal deaths by using data to guide actions	Developed clinical guidelines and protocols for diagnosing and managing most common obstetric emergencies Contributed to the development of the newborn health framework and guidelines Created standardized clinical forms to guide providers in recognizing danger signs and diagnosing the most common obstetric emergencies Introduced laminated checklists for quick reference in delivery rooms
Strategy 5. Ensure referral capacity exists to support transfers to higher-level care
Approach 5.1: Improved referral communication systems	Introduced ambulance referral forms to better track referrals Set up and supported district ambulance committees to work on referral-related issues Procured and maintained landline phones for facilities and mobile phones for village health workers	Used referral forms to improve communication between health centers and hospitals Set up and supported district ambulance committees to work on referral-related issues. Repaired and maintained 2-way radios at health facilities. Improved communications through the SMS and Remind-mi mHealth program (local communication programs)
Approach 5.2: Support increased transportation between facilities with motor vehicles or ambulances	Procured ambulances (vehicle and tricycle)	Procured ambulances (vehicle and motorcycle)
Strategy 6. Support effective maternal and perinatal health surveillance
Approach 6.1: Strengthen maternal and perinatal mortality surveillance in facilities and communities	Trained providers on MPDSR Set up MPDSR system, including committees to identify and understand maternal and newborn mortality at facilities and in communities Strengthened prospective health facility surveillance through the MOH DHIS2 Set up POMS and RAPID to understand facility maternal and perinatal mortality Developed national standards for MDSR that were informed by SMGL processes	Established MDSR including verbal autopsies at facilities with a community component Conducted MDR trainings for the district medical officer and health facility staff Supported MDR at facilities
Approach 6.2: Promote a government-owned HMIS data-gathering system to accurately record every birth outcome, obstetric and newborn complication, and treatment at facilities	Trained providers and implemented BABIES matrix Strengthened prospective health facility surveillance through the MOH DHIS2 Set up POMS	Supported national MDSR processes and expansion of MDSR to SMGL districts

↵a This list is not exhaustive and activities noted may apply to more than one approach.
Abbreviations: BABIES, birth weight and age-at-death boxes for an intervention and evaluation system; BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; CPAP, continuous positive airway pressure; DHIS2, District Health Information System 2; eLMIS, Electronic Logistic Management Information System; EmONC, emergency obstetric and newborn care; HBB, Helping Babies Breathe; HMIS, Health Management Information System; KMC, kangaroo mother care; MDR, maternal death review; MDSR, maternal death surveillance and response; MOH, ministry of health; MPDSR, maternal and perinatal death surveillance and response; NICU, neonatal intensive care unit; NSCU, neonatal special care units; POMS, pregnancy outcome monitoring surveillance; RAPID, Rapid Ascertainment Process for Institutional Deaths; SMGL, Saving Mothers, Giving Life; SMS, short message service.

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BOX 1.

Definitions and Descriptions of Indicators of Interest for SMGL Monitoring and Evaluation

Indicator	Description
Performance of EmONC signal functions	Basic Services: Administer parenteral antibiotics Administer uterotonic drugs (e.g., parenteral oxytocin) Administer parenteral anticonvulsants for pre-eclampsia and eclampsia (e.g., magnesium sulfate) Manual removal of placenta Remove retained products (e.g., manual vacuum aspiration, dilation and curettage) Perform assisted vaginal delivery (e.g., vacuum extraction, forceps delivery) Perform basic neonatal resuscitation (e.g., bag and mask) Comprehensive Services: Perform surgery (e.g., caesarean section) Perform blood transfusion
Basic facility infrastructure	Electricity Regular water supply Functional communications systems Motorized vehicles available Services available 24 hours a day
Promotion of protocols and guidelines	Facilities with protocols available and displayed on the following topics: Obstetric and newborn complications Postpartum hemorrhage Active management of the third stage of labor Helping Babies Breathe or kangaroo mother care Early newborn care
Availability of essential drugs	Oxytocin, magnesium sulfate, gentamycin

Abbreviation: EmONC, emergency obstetric and newborn care.

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TABLE 2.

Monitoring and Evaluation Outcomes Associated With Strategies to Reduce the Third Delay in Uganda, 2011–2016 (N=105 facilities)

Indicators	Baseline^a Value	Endline^a Value	% Relative Change^b	Sig. Level^c
Strategy 1: Ensure facilities have adequate infrastructure to provide EmONC
Total number of EMONC facilities	10	25	150.0	N/A
Number of CEmONC facilities	7	17	142.9	N/A
Number of BEmONC facilities	3	8	166.7	N/A
Deliveries in EmONC facilities	28.2%	41.0%	45.4	***
Hospitals/health center IVs that perform blood transfusions^d	56.3%	100.0%	77.6	N/A
Hospitals/health center IVs that have capacity to perform surgery (caesarean-section)^d	50.0%	100.0%	100.0	N/A
Facilities with electricity	57.1%	96.2%	68.5	***
Facilities with water	76.2%	100.0%	31.2	N/A
Strategy 2: Ensure sufficient medical supplies and medications
Facilities experiencing no stock-out of oxytocin in the past 12 months	56.2%	81.9%	45.7	***
Facilities experiencing no stock-out of magnesium sulfate in the past 12 months	47.6%	63.8%	34.0	***
Facilities reporting gentamycin antibiotic currently available	90.5%	88.6%	−2.1	NS
Strategy 3: Ensure sufficient trained health care providers at facilities
Facilities reporting at least 1 doctor, nurse, or midwife is on staff	100.0%	100.0%	0.0	NS
Health center IIIs that are open 24/7^e	74.6%	82.9%	11.1	NS
Facilities reporting EmONC lifesaving interventions performed in the past 3 months^f
Parenteral antibiotics	85.7%	92.4%	7.8	NS
Parenteral oxytocin	69.5%	98.1%	41.2	***
Parenteral anticonvulsants	48.6%	34.3%	−29.4	**
Manual removal of placenta	28.6%	54.3%	89.9	***
Remove retained products	19.0%	61.9%	225.8	***
Assisted vaginal delivery	4.8%	10.5%	118.8	NS
Newborn resuscitation	34.3%	87.6%	155.4	***
Strategy 4: Improve quality of care and ensure care is evidence-based
Facilities with protocols and guidelines available and displayed on EmONC lifesaving interventions
AMTSL	39.0%	58.1%	49.0	***
Postpartum hemorrhage	15.2%	85.7%	463.8	***
Eclampsia or magnesium sulfate use	8.6%	74.3%	764.0	***
Obstetric and newborn complications	26.7%	61.0%	128.5	***
Immediate newborn care	30.5%	79.0%	159.0	***
Facilities that report routine practice of partograph	33.3%	92.4%	177.5	***
Facilities that report routine practice of AMTSL	75.2%	96.2%	27.9	***
Facilities reporting that obstetric patients never share beds	35.2%	91.4%	159.7	***
Facilities reporting that women never deliver on the floor	85.7%	91.4%	6.7	NS
Strategy 5: Ensure referral capacity to support transfers to higher-level care
Facilities with at least 1 method of communication for referrals^g	93.3%	99.0%	6.1	**
Facilities that reported having available transportation (motor vehicle or motorcycle)^h	61.0%	59.0%	−3.3	NS
Strategy 6: Support effective maternal and perinatal health surveillance
Facilities with maternal death reviews performed	6.7%	32.4%	383.6	***
Hospital and health center IVs that performed maternal death reviews^d	31.3%	94.1%	200.6	***

↵a Baseline period was June 2011 to May 2012; endline period was January to December 2016.
↵b Percentage change calculations are based on unrounded numbers.
↵c Asterisks indicate significance levels calculated with a z-statistic using McNemar's as follows: *** = P<.01, ** = P<.05, NS = not significant. In cases where significance testing is not warranted, this is denoted as N/A.
↵d Hospital and health center IV was n=16 at baseline and n=17 at endline of HFA.
↵e Health center III was n=71 at baseline and n=70 at endline of HFA.
↵f Performance during the previous 3 months preceding the assessment.
↵g Includes facility owned landline, mobile phone, 2-way radio, or individual had a mobile phone.
↵h Includes available and functional motorized vehicle with fuel today and funds generally available.
Abbreviations: AMSTL, active management of the third stage of labor; BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; HFA, health facility assessments; N/A, not applicable; NS, not significant; Sig, significance.

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TABLE 3.

Monitoring and Evaluation Outcomes Associated With Strategies to Reduce the Third Delay in Zambia, 2011–2016 (N=110 facilities)

Indicators	Baseline^a Value	Endline^a Value	%Relative Change^b	Sig. Level^c
Strategy 1: Ensure facilities have adequate infrastructure to provide EmONC
Total number of EMONC facilities	7	13	85.7	N/A
Number of CEmONC facilities	4	5	25.0	N/A
Number of BEmONC facilities	3	8	166.7	N/A
Deliveries in EmONC facilities	26.0%	29.1%	12.2	***
Hospitals that perform blood transfusions^d	100.0%	83.3%	−16.7	N/A
Hospitals that have capacity to perform surgery (caesarean section)^d	83.3%	83.3%	0.0	NS
Facilities with electricity	55.5%	92.7%	67.0	***
Facilities with water	90.0%	97.3%	8.1	**
Strategy 2: Ensure sufficient medical supplies and medications
Facilities experiencing no stock out of oxytocin in the past 12 months^e	75.3%	75.0%	−0.4	NS
Facilities experiencing no stock out of magnesium sulfate in the past 12 months^e	20.0%	43.0%	115.0	***
Facilities reporting gentamycin antibiotic currently available^e	67.3%	48.2%	−28.4	***
Strategy 3: Ensure sufficient trained health care providers at facilities
Facilities reporting that at least one doctor, nurse, or midwife is on staff	90.0%	98.8%	9.8	**
Health centers that are open 24/7^f	64.8%	95.5%	47.4	***
Facilities reporting EmONC lifesaving interventions performed in the past 3 months^g
Parenteral antibiotics	79.1%	73.6%	−7.0	NS
Parenteral oxytocin	90.9%	95.5%	5.1	NS
Parenteral anticonvulsants	44.6%	40.0%	−10.3	NS
Manual removal of placenta	39.1%	30.0%	−23.3	NS
Remove retained products	17.3%	49.1%	183.8	***
Assisted vaginal delivery	10.0%	15.5%	55.0	NS
Newborn resuscitation	27.3%	74.6%	173.3	***
Strategy 4: Improve quality of care and ensure care is evidence-based
Facilities that report routine practice of AMTSL	71.8%	95.5%	33.0	***
Facilities reporting that obstetric patients never share beds	62.7%	73.6%	17.4	NS
Facilities reporting that women never deliver on the floor	71.3%	83.8%	17.5	NS
Strategy 5: Ensure referral capacity to support transfers to higher-level care
Facilities with at least 1 method of communication for referrals^h	44.6%	100.0%	124.2	N/A
Facilities that reported having available transportation (motor vehicle or motorcycle)ⁱ	55.5%	72.7%	31.0	***
Strategy 6: Support effective maternal and perinatal health surveillance
Facilities with maternal death reviews performed	42.5%	75.0%	76.5	**
Hospitals that performed maternal death reviews^d	50.0%	100.0%	100.0	N/A

↵a Baseline period was June 2011 to May 2012; endline period was January to December 2016.
↵b Percentage change calculations are based on unrounded numbers.
↵c Asterisks indicate significance levels calculated with a z-statistic using McNemar's as follows: *** = P<.01, ** = P<.05, NS = not significant. In cases where significance testing is not warranted, this is denoted with N/A.
↵d Hospitals (n=6) included in the HFA.
↵e Data were not collected in Kalomo facilities so they were excluded from the analysis.
↵f Health centers (n=88) included in the HFA.
↵g Performance during the previous 3 months preceding the assessment.
↵h Includes two-way radio or mobile phone with service.
↵i Includes motor vehicle, motorcycle, or bicycle.
Abbreviations: AMSTL, active management of the third stage of labor; BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; EmONC, emergency obstetric and newborn care; HFA, health facility assessments; N/A, not applicable; NS, not significant; Sig, significance.