IMPROVING THE QUALITY OF MATERNAL DELIVERY AND
NEWBORN CARE SERVICES THROUGH STAFF REDEPLOYMENT
AND CAPACITY BUILDING AT MITYANA HOSPITAL
BY
BIZIMANA ABEL
MakSPH-CDC FELLOW
2012
.
i
IMPROVING THE QUALITY OF MATERNAL DELIVERY AND
NEWBORN CARE SERVICES THROUGH STAFF REDEPLOYMENT
AND CAPACITY BUILDING AT MITYANA HOSPITAL
BY
BIZIMANA ABEL
(MSC. HSM, UMU)
MakSPH-CDC FELLOW
NOVEMBER, 2012
ii
TABLE OF CONTENTS
DECLARATION ......................................................................................................... vi
DEDICATION............................................................................................................ vii
LIST OF ACRONYMS ............................................................................................. viii
OPERATIONAL DEFINITIONS ................................................................................ x
EXECUTIVE SUMMARY......................................................................................... xii
SECTION 1.
INTRODUCTION AND BACKGROUND ............................ 1
1.1.
Introduction ................................................................................................... 1
1.2.
Trends in maternal and neonatal morbidity and mortality ............................... 2
SECTION 2.
THE QUALITY IMPROVEMENT PROCESS ..................... 5
2.1.
Reasons for improvement .............................................................................. 5
2.2.
Examining the current situation ...................................................................... 5
2.3.
Problem analysis ............................................................................................ 7
SECTION 3.
PLANNING COUNTERMEASURES.................................. 10
3.1.
Intervention objective .................................................................................. 10
3.2.
Intervention strategies .................................................................................. 10
3.3.
Expected results ........................................................................................... 10
3.4.
Implementation framework .......................................................................... 11
3.5.
Reviewing staff redeployment ...................................................................... 13
3.6.
Training Midwives at Mityana hospital ........................................................ 13
SECTION 4.
THE QUALITY IMPROVEMENT OUTCOMES .............. 15
4.1.
Redeployment of midwives .......................................................................... 15
4.2.
Training process .......................................................................................... 16
4.3.
Other changes .............................................................................................. 17
4.4.
Intervention outcomes .................................................................................. 18
4.5.
Qualitative evaluation .................................................................................. 21
iii
4.6.
Institutionalization of CQI ........................................................................... 22
SECTION 5.
FUTURE PLANS .................................................................. 25
SECTION 6.
CHALLENGES ..................................................................... 26
SECTION 7.
DISCUSSIONS ...................................................................... 30
SECTION 8.
CONCLUSION AND RECOMMENDATION .................... 33
REFERENCES ........................................................................................................... 36
Appendix I. ................................................................................................................. 43
Appendix II ................................................................................................................. 48
Appendix III ............................................................................................................... 48
iv
LIST OF FIGURES
Figure 1-1: Risk factors found among mothers attending maternity ward in Mityana
hospital, 2011 (Mildmay Uganda, 2012) ......................................................................... 4
Figure 2-1: Fishbone analysis showing factors associated with deployment of few and
less skilled midwives in maternity ward .......................................................................... 8
Figure 4-1: At the stakeholders‟ meeting; the fellow makes a point as the RDC listens . 16
Figure 4-2: Participants of the stakeholders‟ Meeting ................................................... 16
Figure 4-3: Pre and post test results for 24 midwives trained at Mityana hospital. ........ 17
Figure 4-7: A midwife assisting a mother .................................................................... 18
Figure 4-4: Midwives and trainers ready for a practical session after 4-days theory ...... 18
Figure 4-5: One of the groups of trainees doing 5 pre-test ............................................ 18
Figure 4-6: A midwife gives a health talk mothers at discharge after delivery by C/S . 18
Figure 4-8: Trends of completely plotted partographs (January to November 2012) ..... 19
Figure 4-9: Trends of maternal and neonatal sepsis, postpartum hemorrhage and Fresh
Stillbirth (FSBs) ........................................................................................................... 20
Figure 4-10: Trends in delivery methods and FSBs in relation to completely filled
partgraphs. ................................................................................................................... 21
Table 2-1: Ranking of selected problems associated with poor quality of maternal
delivery and newborn care in Mityana hospital. .............................................................. 6
Table 2-2: Distribution of midwives in wards and departments of Mityana hospital........ 7
Table 3-1: Implementation framework ......................................................................... 12
v
DECLARATION
I Abel Bizimana do hereby declare that this programmatic report entitled
„Improving the Quality of Maternal Delivery and Newborn Care Services
Through Staff Redeployment and Capacity Building at Mityana Hospital’
has been prepared and submitted in fulfillment of the requirements of the
MakSPH-CDC Fellowship Program and has not been submitted for any academic
qualifications.
Signed……………………………………….
Date……………………….
Abel Bizimana,
Fellow
Signed……………………………………….
Date……………………….
Dr. Yvonne Karamagi
Primary Host Mentor, Mildmay Uganda
Signed……………………………………….
Date……………………….
MS. Mary Odiit,
Secondary Host Mentor, Mildmay Uganda
Signed……………………………………….
Dr. Geoffrey Kabagambe
Academic Mentor
vi
Date……………………….
DEDICATION
This report is dedicated to David Wilber Rwalinda and I.K. Murekezi who
unblocked „my academic road‟. I would not be at this professional level if they
did not intervene at strategic points in my career path. Late Pastor Jonathan
Nkiriyehe who provided a parental and moral background that enabled me to
socially fit in society.
Martha Nkiriyehe, Penninah N; Jane B, My children: Munyantwali, Muhoza,
Mbanjingabo, Mushakamba and Mberey‟ingoma and my family members whom
motivate me to work hard since I have to account for my absence while pursuing
my academic and professional goals.
Kisoro District Local Government that has provided me with capacity and
opportunity to become a public health professional; through supervision, training,
allocating challenging assignments hence allowing me to advance in my studies.
vii
LIST OF ACRONYMS
AIDS
Acquired Immune Deficiency Syndrome
AMTSL
Active Management of Third Stage of Labour
ANC
Antenatal Care
CAO
Chief Administrative Officer
CME
Continuous Medical Education
C/S
Caesarian Section
CQI
Continuous Quality Improvement
ECN
Essential Newborn Care
EmONC
Emergency Obstetric and Newborn Care
FHI
Family Health International
FIGO
Federation of International Gynaecology and Obstetrics
FSB
Fresh Stillbirth
HIV
Human Immunodeficiency Virus
ICM
International Confederation of Midwives
IMR
Infant Mortality Rate
IRB
Instructional Review Board
MCHIP
Maternal and Child Health integrated Program
MDGs
Millennium Development Goals
MMR
Maternal Mortality Rate
MDNBC
Maternal Delivery and Newborn Care
viii
MNPI
Maternal and Neonatal Program Index
MoH
Ministry of Health, Uganda
MTCT
Mother-To-Child transmission of HIV
MUg
Mildmay Uganda
PATH
Program for Appropriate Technology in Health
PNO
Principal Nursing Officer
PMTCT
Prevention of Mother-To-Child transmission of HIV
POPPHI
Prevention of Postpartum Hemorrhage Initiative
PPH
Postpartum Hemorrhage
QoC
Quality of Care
SAA
Sub-Saharan Africa
SBA
Skilled Birth Attendant
TQM
Total Quality Management
UBOS
Uganda Bureau of Statistics
UDHS
Uganda Demographic and Health Survey
UNFPA
United Nations Population Fund
USAID
United States Agency for International Development
WHO
World Health Organization
ix
OPERATIONAL DEFINITIONS
1.
Active Management of Third stage of e of Labour (AMTSL): Use of
oxytocics, controlled cord traction and massaging uterus (after delivery of
placenta) to prevent postpartum hemorrhage.
2.
Clients: A mother, her relative and a baby in the health facilities
3.
Client Participation: The process of getting clients‟ opinion on quality of
maternal and newborn care services which they consume with the purpose of
using the opinion to improve the services and client satisfaction.
4.
Competence: Ability to do well tasks related to ensuring health of the
mother and the baby.
5.
Continuous Quality improvement: Deliberate and defined processes of
continuously adding on on-going efforts to achieve measurable positive change on
performance, efficiency and effective „delivery and immediate postnatal newborn
services‟.
6.
Delivery: A process of the childbirth that begins with labour pains and ends
when the baby and the placenta have been expelled from the uterus. It involves
procedures of clean birth and additional assistance to the mother, if labour does
not progress well.
7.
Delivery and Immediate Postnatal Newborn Care Services: These are
services offered to a mother and newborn during delivery and within the first hour
after delivery to prevent and control of neonatal asphyxia, MTCT, postpartum
hemorrhage and sepsis.
8.
Health worker: A midwife or any other competent person that
participates in conduct delivery and newborn care.
9.
Improvements: Changing from low quality to higher quality of maternal
and newborn services
x
10.
Immediate Postpartum Care: The care of mother and baby aiming at
ensuring that the neonate breathes and is kept warm and promptly initiated to
breastfeeding, while the mother is assisted to prevent blood loss due to child birth.
11.
Participatory Continuous Quality Improvement: It is a quality
improvement process that deliberately and systematically engages all stakeholders
involved in demand and utilization of maternal and newborn services.
12.
Performance: Higher productivity and better quality of maternal and
newborn services through adherence to standards of delivery and newborn care.
13.
Productivity improvement: Increase in outputs in delivery of maternal
and newborn care in a given time based on commitment and competence of
service provider aided by existing technology.
14.
Quality: The process of not only meeting clients‟ needs (expert opinion)
and expectations (clients wants) but also exceed them to attain unprecedented
levels of quality and safety of maternal and newborn health services
15.
Service Provider: A health worker qualified, employed and assigned
tasks that provide a service to clients.
16.
Skilled Birth Attendant: A doctor, midwife or nurse who has been
trained to proficiency in the skills needed to manage normal labor and be able to
identify, manage and refer mothers and newborns with complications with a goal
of having a live baby and a healthy mother.
17.
Standards:
A set of behaviors or performance below which it is not
acceptable ethically, professionally and technically. Standards are facts or
consensus-based minimum requirements according to what is considered to be
the norm.
xi
EXECUTIVE SUMMARY
This project report is about a quality improvement (QI) project which aimed at
improving the quality of maternal delivery and newborn care services in Mityana
hospital through increased availability and training of midwives.
We designed the project using the Continuous Quality Improvement (CQI)
approach which takes the CQI team through 7 seven steps of improving quality:
(1) reasons for improvement, (2) current situation, (3) analysis, (4)
countermeasures, (5) results, (6) standardization and (7) future plans. We focused
our intervention on making structural review and system improvements in (staff
availability, functional life-saving equipments, essential medicines and blood and
support supervision).
The Quality Improvement process
1. Establishing reasons for improvement: The project was initiated with a
rapid assessment to establish the status of quality of maternal delivery and
newborn care. The purpose of the assessment was to identify structural and
process-related barriers to quality improvement. The assessment was carried out
in January and February 2012. We interviewed 17 midwives, held 2 Focus
Group Discussions, made some observations and reviewed data from maternity
register. We used knowledge of health worker on Active Management of Third
Stage of Labour (AMTSL) and use of partograph as key indicators for reducing
maternal life- threatening risks such as severe anaemia (due to Post Partum
Hemorrhage) and obstructed labour. We observed facility readiness to quality
improvement by assessing availability of lifesaving drugs and other key medical
supplies. We also held two Focus Group Discussion (FGDs) meetings with 20
clients (10 clients per group) who had received delivery services in the hospital.
We reviewed data from maternity register for 2011 to obtain conditions related to
maternal and neonatal morbidity and mortality including pregnancy outcomes.
From interview of 17 midwives, 3 (17.5%) had ever heard about the term
AMTSL: We asked midwives to describe the process of managing labour so that
xii
we can determine inclusion of AMSTL and its components). Only 4 (23.5%) were
able to mention all the 3 components of AMTSL. Response counts of specific
AMTSL components were: (a) use of uterotonic (11 responses), controlled cord
traction (8 responses), massaging uterus after delivery of placenta (9 responses)
The hospital had adequate supply of oxytocics, and antibiotics and magnesium
sulphate. Blood was frequently out of stock risking lives of mothers that needed
it. Many partographs were incompletely plotted. Occasionally, waste disposal was
delayed causing a stinking smell on the ward. The disposal was so crude that
sharps, placentas and used cotton and gauze were dumped in uncovered pit; which
is why vultures were common birds in the hospital. There was an infection
prevention committee but it was non-functional. There was no running water at
service points and resuscitation equipment was faulty.
Clients were concerned about fewer midwives on the ward the extent that some
delivered in absence of a midwife. No quality improvement team that had been
formed. Clients were also concerned about waste management as they said that
sometimes the smell from decomposing wastes in waste bins were more
discomforting than labour pains. Clients complained of unfriendly response from
some midwives especially at night. In case of referral, clients fended for
themselves using expensive private means as there was no ambulance.
The commonest risks associated with maternal morbidity were pre and
postpartum hemorrhage, ruptured uterus, sepsis, obstructed labour and positive
HIV status
2. Defining the current situation: In response to the rapid assessment results, a
meeting was held at Mityana hospital drawing 28 top hospital and departmental
leaders to intervene using CQI approach. A hospital CQI committee was
established with a task to developing a one year roadmap for improving service
delivery in maternity ward. Lessons that would be leant in the medium term
would inform initiation of CQI projects in other departments. The CQI committee
members reexamined the current system and process-related issues by listing,
xiii
sorting, mult-voting and prioritizing problems that need intervention in order to
improve quality of care in maternity.
Fewer and less skilled midwives in maternity were the most voted problems that
needed immediate attention. However; some of the gaps identified by the rapid
assessment exercise were immediately addressed such as repairing resuscitation
equipment and procurement of lanterns as an alternative source of light.
3. Analysis: We listed and mapped out where midwives were located in the
hospital departments, in order to explore possibility of redeploying some of them
to maternity. The established midwifery posts at the hospital were 25 but there
were 38 midwives on the hospital staff list. Comparatively, of the 47 established s
for nurses, only 29 were filled. This showed overstaffing of midwives.
In spite of the “excess” midwives, the clients complained of inadequate number
of midwives. A fishbone analysis was developed to find why there was low
staffing of midwives yet the hospital had more midwives than they required. It
was found out that several midwives were assigned duties on general wards in
attempt to address the shortage of nurses leading to inadequate staffing in
maternity ward
The main reason why available midwives had inadequate knowledge and skills
was that there were limited opportunities for refresher courses and even the few
opportunities were not equitably distributed among all the midwives
4. Countermeasures: To address the poor quality of maternal and newborn
services, Mityana hospital and Mildmay Uganda (an integrated HIV/AIDS
implementing partner) jointly developed an intervention to address the quality
gaps identified by the assessment exercise in maternity ward where over 5000
mothers are delivered per year. The fellow was tasked to guide the development
of the implementation plan for the proposed intervention. The plan became the
fellow‟s programmatic activity.
xiv
The planned interventions were (1) review staff deployment and reallocate 6
midwives from other departments to maternity ward (2) conduct refresher training
for all the midwives serving in maternity and (3) organize midwives to form CQI
teams to progressively review and improve program performance.
Expected results from interventions were improved labour monitoring through
effective use of partograph. This would further reduce Fresh Stillbirth (FSB)
because obstructed labour and fetal stress would be detected and addressed in
time. Postpartum Hemorrhage (PPH) would reduce due to effective management
of third stage of labour. Trends of maternal and newborn sepsis would decline due
to improved infection prevention. These expected results would be augmented by
improved equipment especially resuscitation machines, improved lighting and
better waste management.
Refresher training was organized with purpose to increase knowledge and skills
among midwives to effective management of labour and minimize risk
intrapartum factors. We used The Training Manual for Midwives in Provision of
Integrated Reproductive Health of Ministry of Health (MoH). The topics selected
included overview of reproductive health, effective management of labour,
provider-client communication, quality improvement principles and practices,
infection prevention and PMTCT. Two trainers were identified from the hospital
i.e. the incharge maternity ward and the Principal Nursing Officer (PNO). Both
were national trainers in integrated reproductive health care service. The fellow
together with the trainers developed the training content based on training needs
identified from the assessment exercise. Twenty four midwives were selected and
trained. The training was divided into two 4-days training session and each
session having 12 participants. Two more days per session were dedicated two
hands-on practices on ward with support of a coach
5. Results: The redeployment review resulted in obtaining six more midwives
who were deployed to maternity. It was not possible to get all 6 midwives from
the hospital departments because there were few nurses in such departments.
xv
Two were reallocated from the Antenatal Clinic and 4 were mobilized from
other health facilities through the District Health Officer (DHO) with support
from the Chief Administrative Officer (CAO). Two of external nurses and two
others were midwives: The nurses were allocated to female ward and OPD which
in turn released one midwife each. The two external midwives were absorbed in
ANC clinic. Consequently, ANC released 2 midwives that became part of
maternity ward staff.
We trained 24 midwives: The training report revealed that midwives had an
average score of 48.96% a (range of 31% to 67%) in a pretest; and average of
80.46% (range of 57% to 98%) in post test.
After two months of redeployment and training of midwives, we did review of
results: There was improvement in quality of maternal and newborn care based on
these indicators: the level of completion of partographs per month was raised,
there was a downward trend of maternal and neonatal sepsis, and FSB and
postpartum hemorrhage reduced.
Structural changes that are related to the intervention included high level of
participation of staff, health managers and district leaders. The waste management
has improved. The waste dumping ground has been relocated to a more secure
place. Two resuscitation machines were repaired. The hospital procured lanterns
to offer alternative light when there is electricity load shedding.
6. Standardization and future plans: Four CQI teams were formed in
maternity ward and were being supported by hospital-level CQI committee to
implement quality improvement projects. The projects are:
(i)
Reducing waiting time between maternity ward and theatre for mothers
needing emergency obstetric care
(ii)
Improved inter-clinic referral of exposed babies to maternal HIV
infection (maternity and Early Infant Diagnosis clinics)
(iii) Infection prevention
xvi
(iv) Adherence to standards of delivery and newborn care
The hospital CQI committee is examining the possibility of scaling up CQI to
other departments. However, it has been noted that some lessons from maternity
are informing management of processes on other wards.
There were challenges in getting the required number of midwives in maternity:
some could not be removed from other stations because it could cause severe
shortage; others had social and physical constraints that couldn‟t allow them serve
in maternity. Several midwives and nurses asked for maternity leave at the same
time as most them were in their early reproductive age and in need to have
children.
One lesson is that CQI process helps in identifying many quality gaps and with
support of the health facility managers and local leaders, some quality gaps can be
immediately addressed (such as staffing) and with support of partners, resources
can be mobilized.
We conclude that we succeeded in attaining short-term results such as
redeployment and increasing knowledge of service providers. We identified that
although the hospital was staffed with midwives beyond the staffing norms,
shortage of nurses caused virtual low staffing of midwives. At process level, we
see some changes after two months of reorganization of staff and training:
pregnancy monitoring has improved as reflected by increasing trends of
completely filled partographs. There is lowering trend of FSBs suggesting better
pregnancy monitoring of labour that leads to early detection of fetal distress and
action. In 11 months of 2012 the caesarian section rate was 22.4% compared to 24
% in 2012. However in 2012, there are lowering monthly trends in mothers who
had normal vaginal deliveries compared with those delivered by caesarian section.
This suggests that emergency obstetric care is prompt due to early detection of the
need.
We recommend regular staff deployment review to address internal staffing
challenges that would not be seen at organizational level. Maternity staff needs
xvii
regular refresher courses to maintain a high level of standard of care. Regular staff
support supervision, regular check of functionality of delivery equipment and
dissemination of service guidelines may improve quality consequently lowering
maternal and neonatal morbidity and mortality.
xviii
SECTION 1. INTRODUCTION AND BACKGROUND
1.1. Introduction
Most life-threatening conditions of newborns and mothers occur during and after
childbirth process are preventable. They include: sepsis, Postpartum Hemorrhage
(PPH), eclampsia, Mother To Child Transmission (MTCT) of HIV and
hypothermia (Mulumet et al, 2011; Kerber et al, 2007). To prevent and mitigate
maternal and neonatal life threatening conditions, health systems are designed to
increase Skilled Birth Attendance (MoH, 2007). Community mobilization
programs encourage health facility-based deliveries with assumption that it is
safer to deliver in health facilities than at home. However, the institutional quality
of maternal delivery and newborn care services by skilled attendants remains
poorly rated especially in developing countries and thus leading to persistently
high maternal and neonatal morbidity and mortality (Mulumet et al, 2011; Van de
Broek et al 2009;ICM, FIGO, WHO, 2006).
A combination of a SBA, appropriate medicines, equipment and infrastructure
provide a safe and clean delivery environment in which mothers and newborns
can survive the life threatening conditions (Bhutta et al 2010).
Quality of maternal and neonatal care must continuously improve to reduce the
vulnerability of pregnant mothers and newborns to life-threatening conditions.
Quality improvement is systematic, data-guided activities that are specifically
designed to cause prompt and substantial improvements in performance of health
process (USAID, 2012). According to Hulton et al (2000), QI in maternal health
care
is „ the degree to which maternal health services for individuals and
populations increase the likelihood of timely and appropriate treatment for the
purpose of achieving desired outcomes that are both consistent with current
professional knowledge and uphold basic reproductive rights.‟ It is never an
accident but a result of high intention, intelligent direction and skillful execution
of appropriate interventions; and systematic implementation to reduce health risks
in health facilities (Deboult & Mallen 2012; Massaoud et al, 2002).
1
Quality improvement approach ensures that standard guidelines which midwives
and other skilled birth attendants will use are available and utilized.
Inadequate, ill-equipped and unskilled SBA contribute to poor quality of maternal
and neonatal care services; for example, Prabhath et al (2002) found out that 73%
of maternal deaths that occurred in tertiary health facilities in the developing
world were due to substandard care offered by SBAs.
1.2. Trends in maternal and neonatal morbidity and mortality
The global burden of maternal and newborn morbidity and mortality is high: out
of global 536,000 maternal deaths each year, 99% are from developing countries;
80% of the deaths are preventable with timely interventions that are proven to be
effective (Van de Broek et al, 2009). Annually, over 4 million neonates die
worldwide (Mash et al, 2002; Lawn et al, 2009).
The African region has the highest rates of neonatal mortality in the world but two
thirds of these deaths can be averted with known strategies; however, this region
has shown the slowest progress so far in reducing neonatal deaths (WHO, 2012).
In Sub-Saharan Africa (SSA) alone, 279,000 neonates and 4.5 million infants die
every year (Mwaikambo, 2010). The total loss of mothers, newborns and children
in SSA every year is 4.7 million lives. Similarly over 880,000 babies are stillborn
in SSA every year (Kinney et al 2010).
In Uganda, maternal mortality ratio stands at 438 deaths per 100, 000 live births,
and neonatal mortality rate at 27 deaths per 1000 live births and infant mortality at
54 per 1000 live births. The under five deaths has reduced from 143 to 90 deaths
per 1000 live births between 2006 and 2011 (MOH, 2007; UBOS & ICF Int.
2011). Other studies show that in Uganda, 6,500-13,000 women and girls die
every year leaving over 405,000 with chronic and debilitating effects (Futures
Group, 2012).
2
Institutional delay in maternal delivery is one of the three delays that increase the
risk to life loss among newborns and mothers (MoH, 2007). Other delays are:
delay to decide to go for skilled birth attendance and delay to reach a health
facility that has the capacity to meet emergency obstetric and newborn care needs
of mothers and babies. Most of Maternal-To Child Transmission (MTCT) (6070%) occur at the time of childbirth (Esiru, 2008). This was also documented by
Wabwire-Mangen et al, 2008.
This report focuses on Mityana hospital in Mityana district in Uganda where
quality maternal and newborn care improvement project was implemented.
Mityana Hospital is a public hospital with 100 bed-capacity.
Every year, about 5,000 mothers are delivered in maternity ward of Mityana
hospital. The ward also handles pregnant mothers with medical conditions such as
malaria, those who have just delivered either by caesarian section or normal
vaginal delivery and waiting mothers who have risk factors that need to be closely
monitored towards labour.
Mildmay Uganda and Makerere University School of Public Health-CDC
(MakSPH-CDC) Fellowship program supported Mityana hospital to review and
improve the quality of maternal delivery and newborn care services offered to
clients that come to this hospital. An assessment to establish status of quality of
delivery and newborn care in Mityana hospital was conducted in January 2012.
Midwives were interviewed, Focus Group Discussions were held with clients and
hospital data reviewed. Some key informant interviews were held and
observations made and recorded by the assessing team. Results showed that there
were several quality gaps: less than a quarter of midwives had comprehensive
knowledge about Active Management of Third Stage of Labour (AMTSL).
Although 38 midwives are employed in the hospital (13 in excess of established
of 25 midwives), only 18 conducted deliveries and the rest were multi tasking on
wards and clinics in the hospital. Midwives deployed in maternity are few
compared to the daily workloads on the ward. Maternity waste and placenta were
3
mixed up and dumped in an open pit and some staff members were demotivated
due to low pay. Power load-shedding was rampant; phone torches were usually
used in delivery as alternative light since the cost of fuel for generator
unaffordable by the hospital. Main transport for obstetric emergency was by
private motorcycles. There were few functional resuscitation gargets: the manual
sanction machine was faulty, the electric one lacked some parts. Clients
complained of smelly wastes on ward and staff negligence.
The common risk factors found from maternity register (2011) are shown in the
figure below: -
Frequency of risk conditions among mothers and their babies
in Mityana hospital in 2011 (%) n=116
25
20
15
10
5
0
20.7
19
17.2
8.6
7.8
7.8
7.8
6
5.2
Figure 1-1: Risk factors found among mothers attending maternity ward in
Mityana hospital, 2011 (Mildmay Uganda, 2012)
It is against this background that we purposed and pursued improvements in
delivery improved quality maternal delivery and newborn care services using CQI
approach as described in the following sections
4
SECTION 2. THE QUALITY IMPROVEMENT PROCESS
2.1. Reasons for improvement
We drew form the assessment results to design a quality improvement project.
The objective of improvement was to increase client access to effective skilled
birth attendance in order to reduce occurrence of maternal life-threatening factors
such as PPH, sepsis, obstructed labour; and neonatal health risks such as asphyxia
intrapartum HIV transmission, sepsis and deaths within 24 hours. This would be
achieved by identifying and reducing barriers to skilled care
2.2. Examining the current situation
We held quality improvement consultative meeting that attracted 28 participants
from various hospital departments to brainstorm on key causes of poor quality of
maternal delivery and newborn care. A brainstorming session identified 17
problem areas. Discussants set criteria for sorting one priority problem to solve.
The criteria were that the problem must be process-related, with locally available
solution, with greater impact on reduction of maternal and newborn morbidity and
mortality. Sorting left 7 key problem areas. Members held a 2-level multi voting:
the first round used nominal scale approach where each member was allowed to
vote only 3 problems and ranking them using a scale of 3:2:1. The most serious
problem was given 3 scores, the next serious problem given 2 scores and the least
important one 1 score. In round 2 problems that scored above 10 scores were
selected. Members were requested to rank the remaining problem with the most
important problem first and less important. Low staffing in maternity ward and
limited skills among health workers were priority problems to solve because
improvements in staff skills and staff numbers would form a firm foundation from
which other CQI project will develop.
5
Table 2.1 shows how we arrived at the priority problem: Table 2-1: Ranking of selected problems associated with poor quality of maternal
delivery and newborn care in Mityana hospital.
Problem
Round 1 of voting (using Round 2 of voting
(rearranging the first 4
nominal scale 3:2:1)
problems in descending
order of their strengths)
have 34
2
Lack of supplies e.g. 32
blood
3
Mothers delay to come to 24
deliver
4
Low staffing in maternity 24
ward
1
Most midwives
inadequate skills
No resuscitation corner
9
Low staff morale
8
Poor waste disposal
7
A mapping exercise for midwives was done to locate where they are located. The
table below shows their distribution:-
6
Table 2-2: Distribution of midwives in wards and departments of Mityana
hospital
Shift
Duty
No.
Total
On duty
Day
3
8
Evening
2
Night
3
After day-duty
3
After evening-duty
2
After Night-duty
3
Other
ANC clinic
7
assignments
Male ward
2
Paediatric Ward
2
Female ward
3
Out-Patient Department(OPD)
2
Chronic care clinic
2
Night superintendants
2
Off-duty
2
On leave
Total
8
20
2
38
Over 50% of midwives had no opportunity to conduct deliveries as they stayed in
other departments rather than maternity for a long time.
2.3. Problem analysis
To identify the root causes of low staffing and inadequate skills among midwives
in maternity, a fishbone approach was used. Key roots were: inadequate
opportunities for staff to acquire and improve on knowledge and skills in
conducting standard delivery and newborn care.
The figure below shows cause-causes of low staffing and less skilled midwives: -
7
Limited opportunities for staff to
improve knowledge and skills in
delivery and newborn care
Lack of refresher
training
Available training opportunity
dominated by a few midwives
Inadequate/irregular/lack of
effective support supervision
Some disallowed to practice
delivery as a disciplinary action.
Few and less
skilled midwives
in maternity ward
Exemption to deliver on
medical grounds
Long time without staff reshuffle
(over 6 months)
Some midwives lost interest to
deliver mothers due to heavy
workload.
Few midwives
available for maternity
services
Some midwives attracted to other clinics
and wards due to shortage of nurses or
dislike of difficult night duty associated
with maternity
Figure 2-1: Fishbone analysis showing factors associated with deployment of fewer and less skilled
midwives in maternity ward
8
The main cause of limited skills among midwives was inadequate opportunities
for training: few training opportunities are dominated by selected staff loyal to
decision makers. Some staff do not gain experience from practice because they
are not regularly supervised or transferred to other areas that promote professional
skill enhancement.
The reason why midwives may be few in a ward could be caused by low staffing
level of other health cadres leaving health managers with no option but to
redeploy midwives to perform non-midwifery duties. Some midwives may dislike
or fail to work in maternity due to various reasons such as health status of the
midwife or availability of less stressful alternative duties. Some midwives
overstay in midwifery-related stations but which are not involving delivery. This
may lead to skill decline and poor performance
9
SECTION 3.
PLANNING COUNTERMEASURES
In response to the assessment finds and in pursuit of implementation of the
roadmap for accelerating the reduction of maternal and neonatal mortality and
morbidity in Uganda (MoH, 2007) we set out to improve maternal and newborn
care services.
3.1. Intervention objective
The proposed intervention was to improve the quality of maternal delivery and
newborn care services through redeployment and capacity building of existing
health workers in Mityana hospital.
3.2. Intervention strategies
We set out to redeploy and train midwives as capacity improvement strategy to
improve the quality of maternal and neonatal care services. Below were the
intervention objectives: a) Review midwives deployment strategy to raise number of midwives
deployed to maternity ward of Mityana hospital from 18 to 24.
b) Conduct a refresher course for midwives focusing on knowledge and skill
gaps identified by the assessment report.
c) Facilitate establishment of CQI teams in maternity ward to continuously
review and improve maternal and newborn care
3.3. Expected results
Key process results expected were that 6 midwives would be redeployed form
other departments to maternity, 24 from maternity ward would be trained and
consequently, trends in maternal and neonatal sepsis and PPH would reduce.
10
The indicators of success included improved labour monitoring. It was expected
that as skills improve and workload reduce due to increased staffing in maternity,
there would be more effective pregnancy monitoring with complete partographs.
Improved monitoring of labour would result into early detection of fetal and
maternal distress with timely management leading reduction in fresh stillbirths
and other complications. Reduction of trends in maternal and neonatal sepsis
would show improved infection prevention on the ward (improved practice).
Another expectation of quality improvement would be compliancy to conducting
AMTSL according to standards. Since the registers do not capture data on
effectiveness of AMTSL, we targeted seeing reductions in PPH as an indicator of
effective AMTSL the condition of PPH is the commonest cause of maternal
mortality.
3.4. Implementation framework
The implementation of the countermeasures is described in the table below: -
11
Table 3-1: Implementation framework
Quality gap
Countermeasure
Indicator
of Baseline
Target
MOV
Assumptions
24
Minutes
Redeployment
improvement
Few
midwives
in Redeploy more midwives No. of midwives
maternity ward
Inadequate knowledge &
midwives
care
maternity
roster
departmental level
Training
All midwives planned to be
report
deployed to maternity will be
Train
all
midwives No. of midwives
in for babies according to
maternity
cause
and
among deliver mothers and care
working
won‟t
from other departments to redeployed
skills about delivery and deployed in maternity to trained
newborn
18
standards
24
0
unknown
duty severe
post test
with
at Pre
and
by participants
least 65% post
test
results
Trained midwives able to No.
standard care
deliver
mother
and
care
and
for
of unknown
80%
baby completely
according to standards
at
No competing priority programs
at the hospital
Data from Midwives
maternity
partographs
shortage
available for training
Knowledge gain
Midwives unable to offer
staff
are
supervised and supplied with
partographs,
filled
continuously
medicines
and
other supplies
Persistently raising trends
Maintain a standard of Reducing trends
Data
Not
Lowering
Midwives posted in maternity
of key risk factors
care using knowledge & of PPH, sepsis,
from
known
trends
are not immediately transferred
skills from training
maternity
after
register
training
fresh still births,
12
3.5.
Reviewing staff redeployment
The fellow engaged the in-charge of maternity ward, the Principal Nursing
Officer and the Medical Superintendent in dialogue to discuss the deployment
strategy of midwives so that more will be added on those currently allocated to
maternity without compromising the functions of other departments which are
supported by midwives. The hospital senior managers undertook the task of
reviewing the staff deployment strategy to identify 6 more midwives to redeploy
in maternity. It was found out that the staffing norm for midwives in the hospital
was 25 but the staff list had 38. Comparatively the staffing norm for nurses was
47 but there were only 29 nurses. When adjustments were made to find which
midwives to post to maternity, only two from ANC clinic were identified. A
series of dialogue meetings with district leaders and hospital stakeholders lead to
securing 4 nurses and 2 midwives from other facilities that made it possible to
have 6 midwives redeployed in maternity.
3.6. Training Midwives at Mityana hospital
Twenty four midwives were identified for training with the view that they will
take turns to attend to mothers and babies in maternity. Training was preceded by
preparatory training meetings at Mityana hospital. We developed the training
content based on Integrated Reproductive Health Training Manuals of MoH. We
focused the training on the overview of reproductive health services, Focused
ANC, principles of CQI, managing labour with emphasis to 3 rd stage and use of
partograph. Other topics covered were communication skills, emergency
situations for mothers and neonates, infection prevention and introduction to
PMTCT.
The refresher course was divided into two 4-days session; each session had 12
trainees. Each group of trainees had two more days for practicing with a coach
13
on ward. We evaluated trainees with a pre and post test followed by observations
as they did practical session under supervision of a trainer as a coach.
14
SECTION 4.
THE QUALITY IMPROVEMENT OUTCOMES
4.1. Redeployment of midwives
We had planned to adjust staff redeployment and redeploy 6 midwives from
other departments to maternity so that staffing in maternity ward can increase
from 18 to 24 midwives. We mapped location of all 38 midwives considered
work schedule (morning, evening and night duties) and workloads in various
departments.
To get six more midwives to deploy to maternity, we attempted to get all
midwives from other departments but we succeeded to get only 2 from ANC
clinic. We could not redeploy all the required number of midwives from the
hospital departments because it would cause severe staff shortage at department
level. Engaging both hospital and district stakeholders (as individuals and
groups) through a series of meetings led to deploying 4 more staff (2 midwives
and 2 nurses) from other health facilities in the district to the hospital.
The two external nurses went to female ward and OPD which in turn released
one midwife each. The two external midwives were absorbed in ANC so that 2
more midwives (from existing staff) were redeployed to maternity ward.
The final adjustments led to staffing in maternity raise from 18 to 24 midwives
achieving 100% of targeted staffing in maternity ward.
15
Figure 4-2:
Participants
stakeholders‟ Meeting
of
Figure 4-1: At the stakeholders‟
the meeting; the fellow makes a point as the
RDC listens
4.2. Training process
In September 2012, we trained of 24 midwives. The training was organized in
two phases and each phase taking 12 trainees. We used 4 days to provide theory
and two days for practice. While the first group was starting their practice on 5 th
day, the second group had their first day of theory study. This led to running
concurrently the practical session for the first group of trainees with theory of the
second one. This provided trainees with 6 days of training both in class and on
the ward.
Generally, the trainees performed well as reflected in the knowledge acquisition.
The combined results of the pre and post test below show how trainees acquired
knowledge (1st group is no.1 to 12 and 2nd group is no. 13 to 24): -
16
%
Trainee identification No
Figure 4-3: Pre and post test results for 24 midwives trained at Mityana
hospital.
The trainees had an average score of 48.96% a (range of 31% to 67%) in a
pretest; and average of 80.46% (range of 57% to 98%) in post test.
4.3. Other changes
The hospital management first addressed some gaps that were identified during
quality assessment: these include, repairing recitation machines, getting
alternative light to address lighting challenges when electricity load shedding
takes place. These were fixed: 4 lanterns were bought, 2 sanctions machines
were repaired and the hospital did not renew the contract of the supplier of
sanitation services because he had not managed to support staff to improve waste
management.
17
The following are some of the photos taken during the training sessions: -
Figure 4-5: One of the groups of
trainees doing 5 pre-test
Figure 4-4: Midwives and trainers
ready for a practical session after 4days theory
Figure 4-7: A midwife assisting a mother Figure 4-6: A midwife gives a health
talk mothers at discharge after
To breastfeed as the fellow observes
delivery by C/S
4.4. Intervention outcomes
We expected change behavior of health workers conducting delivery such as
plotting and completing partograph we targeted improvements in effective
18
AMSTL. We did not collect data on effectiveness of AMTSL since it was not
captured by data from maternity register. We expected that reductions in PPH
would show how midwives were effective in conducting AMTSL The figure
below shows trends in completion of partographs: -
Partograph completion
initiated (July 2012)
No.
Training takes
place (Sept. 2012)
Months
Figure 4-8: Trends of completely plotted partographs (January to November
2012)
In July, midwives were encouraged to complete partographs as a measuere to
demonstrate that labour was completely monitored. The trends of completely
partographs increased from July and peaked in October, one mothe after training
midwives.
We observed rising trends in some of the indicators of quality improvement
outcomes: Below is a figure showing trends of key risk factors associated with
19
poor
quality
of
maternal
delivery
and
newborn
care:
NO.
Months
Figure 4-9: Trends of maternal and neonatal sepsis, postpartum hemorrhage and
Fresh Stillbirth (FSBs)
20
The trends in the risk factors were higher in September (when training was done
and sharply lowered in October. There is lowering trend of FSB after September
training. It is not clear why most of the trends increased during the month of
training (September) but the reductions in the following month suggest quality
could have improved.
No.
Months
Figure 4-10: Trends in delivery methods and FSBs in relation to completely
filled partgraphs.
The raising trend of complete partographs followed by flatening trends of FSB,
the raising of monthly cases of mothers who delivered by caeseian section and
the lowering of number of mothers had biths suggest improvements of pregnancy
outcomes through completion of partographs
4.5. Qualitative evaluation
Before the pretest, trainees could not believe that they had such knowledge gap.
One trainee stated: “We did not know how uninformed we were until you showed
us the pretest results!”
Several trainees said they had been giving oxytocin to mothers during labour to
minimize hemorrhage after birth but could not mind about injecting it in
21
stipulated time. One midwife stated: “I knew that giving oxytocin injection was
to prevent severe postpartum hemorrhage but I did not recognize the importance
of giving it as soon as the baby is delivered‟.
Some midwives had negative attitude about filling a partograg. One of the senior
midwives noted: “Before this training, I disliked filling the partograph because it
looked so complicated and I felt that I could still detect danger without it; I now
feel that filling a partograph is important and not so hard”. Another midwife felt
that she had negative attitude about clients‟ conduct: “I thought clients were to
blame for most problems during labour and handling of babies; now I feel we
health workers fail to do some things or do them haphazardly because of lack of
knowledge or what to use. This causes poor quality of services.
Some midwives did not know that their supervisors were professional trainers as
noted by one midwife: “We are lucky that our supervisors are also trainers; they
can help us do better if they planned to coach us on ward on regular basis”
4.6. Institutionalization of CQI
After the training, the hospital management used experience from maternity to
design scale-up strategy to enable other departments also improve the quality of
service they offer to clients. At the hospital level, an interdepartmental CQI
team was formed to oversee improvement initiatives in all departments. The
maternity staff continued CQI by identifying more QI areas. All 24 trained
midwives grouped themselves in 4 teams each targeting a specific thematic area.
The themes of focus were: reduction of number of babies lost to follow-up
between maternity ward and EID clinic, infection prevention, adherence to
delivery standards, improving client flow to reduce waiting time and improving
provider-client relations.
22
During the process of discussing CQI, staff members were pleased to participate
in program planning as stated by one junior midwife: “We used to wait for
decisions from our seniors, but with quality improvement process everyone
participated”. It was noted that for quality to improve, interdepartmental
linkages must be strengthened. One senior midwife commented that: “We need to
improve coordination with theater staff because some deaths occur due to
delayed response from there. We should educate mothers not to delay, and health
workers in lower units should be told to refer mothers in time”. Another midwife
commented: “I appreciate the part of using data to show how well or poor we
are performing”
The fellow observed that like any other skill-based task holders, midwives need
routine refresher courses at the facility emphasizing hands on sessions. More that
60% of midwives had difficulties in plotting a partograph; actually most of the
mothers were delivered without it. The understanding of common concepts
among midwives was still low; for example 15 out of 24 midwives did not know
the meaning of nosocomial infections and some who attempted called them
„infections of the nose‟ instead of „infections acquired by patients/clients from
the hospital‟. The universal precautions concept (that outlines infection
prevention key practices) was not known by all the groups. For example when
the groups were made to discuss this package, only 3 out of eight precaution
measures for infection prevention came out. During practice on the ward, most of
the procedures were correctly done except resuscitation of the baby using
ambubag and cardiac massage. The concept of CQI was new to almost 90% of
participants.
In conclusion the programmatic activity was successfully completed. We
planned to deploy 24 midwives and now they are on duty roster of maternity
ward. We had planned to train 24 midwives and all were trained. What remains
23
is trainee follow-up and mentoring CQI teams to effectively manage their
projects and document final quality status. We did not conduct client
consultation to measure change in satisfaction. The project that was planned to
start in May actually started in August. This was due to delayed process of
redeployment and postponement of training midwives by district leaders due to
competing priorities such as national HPV vaccination campaign.
24
SECTION 5. FUTURE PLANS
The implementation of the programmatic activity attracted health workers who
appreciated the CQI approach to program performance improvement. The
hospital management planned to continue more CQI projects in maternity as
other departments learn so that lessons learnt can be scaled up to other hospital
departments. One CQI team was formed to plan quality improvements at
organization level. In maternity ward, 4 sub-teams were established to create
CQI projects on 4 thematic areas: one for improving inter-clinic referral of
exposed babies to maternal HIV for Early Infant Diagnosis (EID), improving
infection prevention,
reduction of waiting
time,
improving
customer
communication and improving standard of delivery and newborn care.
Each team would brainstorm on quality-related problems in each thematic area
prioritize key problems, develop intervention plans, monitor and communicate
results during departmental meetings and Continuing Medical Education
sessions. Immediate results would be charts of standard operating procedures,
review meetings held and copies of work plan in place. Medium term results
would be performance review charts, improvement in client satisfaction, reduced
incidence of severe hemorrhage and sepsis. Long range results would be reduced
morbidity and mortality of mothers and babies, reduced maternal transmission of
HIV to exposed babies and reduced complaints work overload among staff
members. By the time of developing this report, teams had reached
brainstorming stage of CQI process.
25
SECTION 6. CHALLENGES
1) Some midwives
had spent longtime without delivering. Training
them would not put them to a level that can provide effective and
efficient maternal delivery and newborn care.
2) Some wards were too understaffed with nurses that the midwife in that
ward was the most reliable source of service delivery and removing
her would leave the ward so deficient.
3) Some midwives were advanced in age, other had chronic illness; their
health would not allow them serve effectively in maternity especially
on night duties. Other midwives with chronic illness needed frequent
sick leave and were in reliable for redeployment.
4) Other midwives were multi-skilled experts at the clinics they were
serving and irreplaceable. The magnitude of the tasks was enormous
that they are not available for other duties. The specialties include
ART, family planning, EID and community health program.
5) Other midwives were on leave or preparing to go for leave (mostly
maternity leave)
6) The right to specific number of days of being off duty made over 40%
of
midwives
not
available
for
mothers
mimicking
virtual
understaffing.
7) Some midwives revealed that, some of their colleagues regarded
delivery as hectic and had created „possible‟ reasons not to be
deployed to maternity. This means some midwives had abandoned
26
midwifery „in their hearts‟ and taking them back to maternity was like
a punishment.
8) It was observed that some midwives had been
previously cautioned
for indiscipline while serving in maternity. The hospital management
had removed them from there as a disciplinary action or protecting the
clients and integrity of the hospitals.
9) Others viewed understaffing in maternity as result of inefficient
management of midwifery staff.
With above background, increasing midwives from 18 to 24 would be difficult.
After readjusting the staffing, only 2 midwives would be available to raise
needed number to twenty. Four more midwives would be needed. Discussions
were made to that effect and the hospital management sought to lobby for more
staff from the CAO. However, it was widely known that the district had severe
shortage of staff in lower level facilities and there was a ban on recruitment of
more health workers. The hospital management decided to use the assessment
report on quality of delivery and newborn as a tool for lobbing
more staff.
Managers chose to demonstrate high hospital utilization and associated
compromises of quality. The hospital technical team requested the fellow to
organize and disseminate the report on status of quality of delivery and
newborn care to key stakeholders that influence discussion on staff and other
resource mobilization. They planned to use the government 5-year strategy:
„accelerating the reduction of maternal and neonatal mortality and morbidity in
Uganda‟ as a tool for advocacy.
At the same time of implementing the project, MoH released a report about
staffing in hospitals in Uganda. The study that used Workload Indicators for
27
Staffing Needs (WISN) methodology reported overstaffing of midwives in the
hospital and recommended that some midwives be allocated elsewhere in the
health system.
The stakeholders‟ meeting that involved
District Executive
Committee,
members of the hospital management board, from district health team and the
office of the RDC resolved that more staff be deployed to the hospital to allow
effective deployment of more idwives to maternity; meanwhile the CAO posted
2 midwives and 2 nurses to the hospital. With this additional staff, the PNO was
now able to increase number of midwives from 18 to 24 as proposed in the
intervention plan. She however noted that this arrangement is fragile until the
district considers more staffing of the hospital. For example she said that more
staff will require leave, others may fall sick and the established number of 24
midwives may not be stable for longtime.
The Medical Superintendant recommended
that
the quality of maternal
delivery and neonatal care be strengthened at lower units so that mothers can
increase demand of these services a lower level. Quality improvement also
would mean training and equipping providers at lower level to timely detect
and appropriately refer mothers in need of emergency care.
The stakeholders, having received both reports (WISN and status of quality of
maternal delivery and newborn care in Mityana hospital) decided that practical
problems needed practical solutions.
The CAO, DHO and Medical
Superintendant were requested to ensure that adequate number of skilled
midwives is provided. The fellow informed the stakeholders that Mildmay
Uganda was willing to train the midwives that will be stationed in maternity.
One councilor who had served two terms of political leadership at the
district level and was a member of the health committee challenged the
28
previous staff recruitment process that brought in more midwives than
nurses. The RDC agreed that the hospital needed more staff and equipment and
instilled hope in stakeholders that with government plan to upgrade the
infrastructure of hospital. He promised to mobilize other politicians to compel
Ministry of Finance, Planning and Economic Development to lift the ban on
recruitment of health workers. “Although additional staff would be immediate
response, it could be possible that the hospital management is not well
utilizing available midwives” the RDC noted.
The PNO appreciated stakeholders‟‟ response but warned that the issue of
staffing was so complex that routine review was necessary. For example 3
midwives were about to go for their maternity leave. “Most of our midwives are
in their prime reproductive age and will need frequent maternity leave that takes
60 days. This creates a shortage but when you look at the staff list, you think staff
is big” she noted.
29
SECTION 7. DISCUSSIONS
Our intervention of increasing the number of midwives followed by training
them in basic package of managing labour and newborn care resulted in
knowledge increase in availability of skilled birth attendants. Two months after
increased staffing of maternity and training midwives serving in maternity ward,
the number of partographs completely filled increased and there was a decline in
trends of life-threatening conditions among mothers and newborns such as PPH
among mothers and maternal and neonatal sepsis. Fresh still births reduced.
Although we can attribute the changes to our intervention, factors such as
training from MoH and STRIDES could have contributed to the changes
registered.
Taking from approaches suggested by Scott (2003) in determining staffing
needs, we used consultative approach to conclude that staffing in maternity was
low compared to workload.
We trained midwives based on training needs from the assessment report which
had reflected low level of basic knowledge in standard management of labour
and newborn. Trained midwives had an average score of 48.96% a (range of
31% to 67%) in a pretest; and average of 80.46% ( range of 57% to 98%) in post
test. This raise in knowledge following a short training of health workers in
quality improvement of management of labour and newborn care, is also noted
by Harvey et al, (2007) where trainees scored an average of 62% after training
The impact of provider‟s competence (through training and supervision) and
client‟s health improvement has been documented: Parsley and Corrigan (2000)
argue that client‟s improvement and shorter length of stay in a health facility
depends largely on competence of the provider. Kaye (2000) also observed that
30
inadequate number of, and skills among service providers are significant drivers
of poor quality of care. Studies show that when staffing and skilling improved in
Malaysia and Thailand, maternal and infant mortality reduced. From our project,
the impact of training was evident: in short time midwives were able to improve
their knowledge and skills in a period less than one week. We conclude therefore
that the investment made in training midwives will greatly contribute to quality
maternal and newborn care services
We learn that balanced staff needs should be considered. The former staff
recruitment had considered midwives as a way of improving availability of SBA.
By not considering a balance of midwives and nurses during recruitment,
midwives were made to cover nurses‟ roles defeating the planned purpose.
We also learn that ensuring staff availability is a complicated intervention due to
dynamics in among individual staff members and institutional demands. During
staff deployment process, we discovered that it may be misguiding to consider
adequate staff norms as an indicator of staff availability: one of the reasons why
some midwives were not deployed was their poor health. Another challenge was
that the young energetic midwives were more likely to seek maternity leave. This
reduces man-hours and causes virtual shortage of staff. There are inevitable
situations that reduce staff availability such as sickness and study leave.
We learn that reflecting on departmental performance can lead to numerous
positive changes including resource mobilization for improvement. This does not
only benefit the clients but also service providers; for example, after
disseminating the assessment findings, instant changes occurred: midwives were
31
trained, some equipments repaired, alternative light in form of lanterns procured
and the service provider
offering hospital cleaning services changed. The
undertaking to improve quality of maternal and newborn services in Mityana
provided an opportunity for stakeholders to meet and share the need to safeguard
mothers who seek care in the hospital. The issue of mothers and babies was
brought on the agenda of key stakeholders leading to 4 more health workers
deployed in the hospital. Mildmay provided additional staff and some equipment
(such as tyres for ambulance) and MakSPH-CDC fellowship availed the
resources in from of funds and a fellow who provided technical capacity to the
hospital to improve quality of delivery. These resources could have been
available for other cause but reflecting and communicating on safe motherhood
issues made these resources available
It was beneficial to train health workers within the walls of the hospital. Cases
that were of importance would be visited which wouldn‟t be possible if the
trainees were in a distant training venue.
This intervention also has shown that one needs to be a little more patient while
dealing with Public Health institutions. The implementation of this programmatic
activity was delayed due to failure on the part of the Hospital management to
timely identify staff to train. Even when the trainees were finally identified,
competing priorities pushed training further; there was a national campaign to
vaccinate girls against Human Papilloma Virus and selected trainees were
involved.
32
SECTION 8. CONCLUSION AND RECOMMENDATION
We conclude that we succeeded in attaining short-term results such as
redeployment and increasing knowledge of service providers. We identified that
although the hospital was staffed with midwives beyond the staffing norms,
shortage of nurses caused virtual low staffing of midwives. At process level, we
see some changes after two months of reorganization of staff and training:
pregnancy monitoring has improved as reflected by increasing trends of
completely filled partographs. There is lowering trend of FSBs suggesting better
pregnancy monitoring of labour that leads to early detection of fetal distress and
action. There are lowering trends in mothers who had normal vaginal deliveries
while those delivered by caesarian section increased. This suggests that
emergency obstetric care is prompt due to early detection of the need.
Identifying staffing and training needs of midwives serving in maternity wards
can improve pregnancy monitoring and better pregnancy outcomes. Increasing
knowledge and skills among midwives improved pregnancy monitoring such as
completion of plotting partographs: A complete partograph serves as an indicator
that labour was well monitored and any complication timely detected and
managed.
Raise in number of midwives in maternity alone is expected to improve quality
of care. This observation is also seen cross-national study which showed that for
each additional patient per nurse, the likelihood of a patient within that nurse‟s
care dying within 30 days of admission increased by 7%, and that low-quality
patient care was three times as likely in hospitals with insufficient staffing
(WHO, 2003)
33
We agree with Scot (2003) that good management practice involves undertaking
periodic reviews of staffing and skill mix. They suggest that staffing decisions
should be informed by detailed knowledge about a particular ward or department
and, once made, should be monitored for their impact on patient and staff
outcomes. By assessing nursing needs of patients/clients by nurses themselves
using CQI approach, optimum utilization of available midwives can be achieved.
We recommend regular program performance review through system and staff
appraisal in relation to service outcomes they produce. We also recommend CQI
tailored to individual department roles in relation to program and institutional
expectations. This will facilitate clearer identification of quality gaps from which
to base when designing effective service delivery.
In facilities with high utilization rate, health managers should go beyond
departmental staffing needs and consider general staffing dynamics because
basing staff adequacy on staffing norms may cause heavy workloads, client
dissatisfaction and poor delivery of services.
Our interventions are not without limitations. We evaluated the impact of staff
redeployment and training only after two months. It is also difficult to attribute
the change to our training intervention since the hospital had already been
exposed to the need to improve quality of maternal and newborn care by the
assessment exercise the gains from the intervention may not be sustainable if
supervision of providers is not sustained. Supervisors need motivation to
maintain sustained coaching. This can be realized though facilitating the
supervisors and CQI teams with aides that can enable them to review CQI
34
regularly. The aides include planned meetings, support from hospital
administration with refreshments and external technical support from Mildmay
Uganda.
35
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Appendix I.
Time table for training midwives in quality maternal delivery and newborn care
quality in Mityana hospital
TIME TABLE FOR TRAINING MIDWIVES IN QUALITY
MATERNAL DELIVERY AND NEWBORN CARE QUALITY MITYANA HOSPITAL
TIME
TOPIC
FACILITATOR
Participants‟ registration.
Betty Ezaru
Participant‟s expectations and fears
Abel Bizimana
Pretest.
Najuma Kalule
DAY 1
8:30-10:00
Training objectives
Administrative briefs
Official opening by hospital administration.
9:00 - 10:45
Overview of reproductive health in Uganda.
Abel Bizimana
Components of RH
Najuma Kalule
Key policies & guidelines
10:45 - 11:00
HEALTH BREAK
All
11:00 - 12:30
Causes and magnitude of maternal and newborn Najuma Kalule
morbidity and mortality.
12:30 - 1:00
Group work: 4 groups formed to discuss common Abel Bizimana
causes of maternal and newborn morbidity and mortality Najuma Kalule
in Mityana Hospital
43
1:00 – 2:00
LUNCH BREAK
All
2:00 – 2:45
Plenary: presenting group work
Betty
Ezaru,
Bizimana,
Abel
Najuma
Kalule
2:45 – 3:15
Introduction to management of delivery to ensure clean Betty Ezaru,
and safe child birth
3:15 – 4:15
Normal and abnormal labour process abnormal obstetric Betty Ezaru,
and newborn emergencies
4:15 -4:45
Group work
-
Common
Betty Ezaru, Najuma
obstetric
and
newborn
care Kalule
emergencies in Mityana
-
Challenges of managing
(1) Obstetric emergencies
(2) Newborn emergencies
4;45 – 5:00
5:00 – 5:30
-
Evaluation of the day
-
Participants departure
Trainers meeting
Najuma Kalule
All trainers
DAY 2
8:30-9:00
Recap of previous day
Najuma Kalule
9:00 – 9:30
Plenary : group work presenting on challenges of Abel Bizimana
managing obstetric and newborn emergencies in
Mityana hospital
44
9:30 – 10:45
PMTCT in labour
Betty Ezaru
Active management of third stage of labour rationale
and procedure
10:45 - 11:00
HEALTH BREAK
ALL
11:00 - 12:00
Newborn care /basic and emergency
Betty Ezaru
12:00 - 12:45
Introduction to communication &MCR model
Abel Bizimana
Purpose of communication
12:45 – 1:00
Group work (4 groups)
Abel Bizimana, Najuma
Communication needs for
Kalule
(1) Clients and client caretakers
(2) Colleagues on ward
(3) Staff from other departments
(4) Team leaders and managers
1:00 – 2:00
LUNCH BREAK
ALL
2:00 – 2:45
7 Cs of effective communication
Abel Bizimana
2:45-3:00
The place of emotional intelligence & conflict Abel Bizimana, Najuma
management in effective communication
3:00 – 3:15
3:15 – 4:15
4:15 – 4:15
Kalule
Post a tour of group work on communication needs of Najuma
Kalule,
various target audiences c lose before lunch
Ezaru
Introduction to quality improvement
Abel Bizimana
-
CQI principals
-
SOPs, guidelines + polices
-
Benefits of CQl
The CQl process
Abel Bizimana
45
betty
4:15 – 5:00
5:00 -5:15
-
Day evaluation
Betty Ezaru
-
Participants departure
Trainers meting
All
8:30-9:00
Recap of the day
Betty Ezaru
9:00 – 10:45
Introduction infection prevention
DAY 3
 The universal precautions
Najuma Kalule
 Possible sources of nosocomial infection
 Maternal and neonatal sepsis
 PMTCT- handling placentas and wastes
 Protecting
self other staff clients and care
takers from infections
 Proper waste disposing
10:45 - 11:00
HEALTH BREAK
ALL
11:00 - 12:00
Preparing trainers for practical session sharing tools Betty Ezaru ,
for practical‟s mentoring process
Abel Bizimana
Najuma Kalule
12:00 - 12:45
Post test
1:00 – 2:00
LUNCH BREAK
2:00 - 4:45
Practical: mentoring and coaching trainees
Betty Ezaru
Abel Bizimana
Najuma Kalule
DAY 4
8:30 – 9:00
Recap of previous day
46
9:00 – 10-45
Practical: mentoring and coaching trainees
Betty Ezaru
Abel
Bizimana,
Najuma Kalule
10:45 – 11:00
Health break
11:00 – 1:00
Practical: mentoring and coaching trainees
Betty Ezaru
Abel Bizimana
Najuma Kalule
1:00 – 2:00
Lunch breezing
2:00 -4:45
Practical: mentoring and coaching trainees
Betty Ezaru
Abel Bizimana
Najuma Kalule
4:15 – 5:00
Trainers meeting
All trainers
NB. Practical: 1. Mentoring and coaching trainees continues with emphasis on
trainees whose skills are wanting.
47
Appendix II
Pre and Post test
1. State 4 principles of quality improvement
2. Mention components of reproductive health package.
3. Define communication
4. List five major activities carried out at Antenatal Clinic
5. Describe the stages of labour and how each stage is managed.
6. Give the reasons why we use a partograph in monitoring labour.
7. Mention 5 obstetric emergencies
8. Describe the purpose of infection prevention in maternity.
9. What are common causes of maternal deaths
10. Explain the importance of knowing a mother‟s HIV status during ANC.
Appendix III
The training content outline:
Overview of reproductive health
(a) Components of reproductive health services in Uganda
(i)
Safe motherhood (ANC, safe delivery, EmONC , PNC,
cervical /breast cancer screening and treatment
(ii)
Post-abotal care
(iii)
Family planning
(iv)
Adolescent sexual and reproductive health and rights
(v)
Gender issues and discrimination
(vi)
HIV/AIDS/STIs prevention and management
(vii)
Infertility prevention and management
(viii)
Management of menopause and adropose
48
(ix)
Common causes and magnitude of maternal and newborn
morbidity and mortality.
1. Management of delivery
(i)
PMTCT
(ii)
Labour
(a) Normal labour
(b) Abnormal labor obstetric and newborn care emergencies
(c) Determining abnormal labor using a partograph
(iii)
Active management of third stage of labour
(iv)
Newborn care including resuscitation
2. Communication
-
The (Sender, Message, Channel, Receiver ( SMCR) model of
communication
-
The seven Cs of effective communication
-
Communication needs to clients, care takers, colleagues on the ward,
staff from within and from other departments, team leaders and
managers.
-
Purposes of communication
3. Quality Improvement
(1) Overview of quality assurance and Continuous Quality Improvement
(CQI)
(2) Principles of CQI
(3) Standard guidelines , SOPs and policy documents as tools for CQI
(4) Measuring results using CQI approach
4. Infection prevention
(i)
The concept of nosocomial infections, where and how they occur
49
(ii)
A clean delivery that protects a mother, baby, service provider,
client‟s care taker
1. MTCT
2. Waste disposal
3. The universal precautions
4. Managing sepsis
5. Practical focus
-
Use of partograph
-
Client communication
-
Timely seeking assistance from colleague or and others
-
AMTSL
-
Newborn care
-
New born resuscitation
50