Making Pregnancy Safer Initiative in Soroti District, Uganda A Mid-term Review December 2002 World Health Organization Regional Office for Africa Brazzaville
Making Pregnancy Safer Initiative in Soroti District, Uganda A Mid-term Review December 2002 World Health Organization Regional Office for Africa Brazzaville? 2003 AFR/MPS/03.02
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This report was prepared by Professor Osato Frank Giwa-Osagie Department of Obstetrics and Gynaecology College of Medicine Idi Araba Suru Lere Lagos, Nigeria and Dr Stephen P. Munjanja Specialist Obstetrician and Gynaecologist 152 Baines Avenue Harare, Zimbabwe iii
CONTENTS iv Pages ABBREVIATIONS...v 1. INTRODUCTION... 1-3 1.1 Background...1 1.2 Midterm Review Methodology...2 2. ANALYSIS OF NEEDS ASSESSMENT SURVEY IN SOROTI DISTRICT, 2001...4 3. BASIC AND COMPREHENSIVE EMERGENCY OBSTETRIC CARE IN SOROTI DISTRICT... 5-22 3.1 Akoboi Health Centre II...5 3.2 Kyere Health Centre III...7 3.3 Apapai Health Centre II...9 3.4 Serere Health Centre IV...11 3.5 Tubur Health Centre III...14 3.6 Tirir Health Centre IV...16 3.7 Soroti Hospital as a District Referral Hospital...18 3.8 Coverage of Soroti District...21 4. COMMUNITY INVOVEMENT AND PARTICIPATION...22 5. ADVOCACY...23 6. OBSTACLES, CONSTRAINTS AND RECOMMENDED SOLUTIONS...24 7. INTERVENTIONS TO BE IMPLEMENTED... 25-27 7.1 Consolidation in Soroti Distict...25 7.2 Replication of MPS in Other Districts...26 7.3 WHO/AFRO Role in Consolidation of MPSI in Uganda...27 8. AREAS AND OPPORTUNITIES FOR COLLABORATION BETWEEN WHO AND OTHER STAKEHOLDERS...27 9. WHAT HAS BEEN DONE DIFFERENTLY...28 10. PARTICIPANTS...29 REFERENCES...30
ABBREVIATIONS ADB AIDS ANC ADH AFRO BEOC CEOC CPR DDHS DFID FP HC HIV HMIS IEC IMCI IPAS IPT IV LSS MO MOH MPS MPSI MTR MVA OPD PAC PNC PNM RH STI TBA TOR TT UNFPA UNICEF UPMM WHO African Development Bank Acquired Immunodeficiency Syndrome Antenatal Care Adolescent Reproductive Health Regional Office for Africa (WHO) Basic Emergency Obstetric Care Comprehensive Emergency Obstetric Care Contraceptive Prevalence Rate District Director of Health Services Department for International Development (United Kingdom) Family Planning Health Centre Human Immunodeficiency Virus Health Management Information System Information, Education and Communication Integrated Management of Childhood Illnesses International Pregnancy Advisory Services Intermittent Presumptive Treatment (of malaria with SP) Intravenous Life Saving Skills Medical Officer Ministry of Health Making Pregnancy Safer Making Pregnancy Safer Initiative Midterm review Manual Vacuum Aspiration Outpatient Department Post Abortion Care Postnatal Care Postnatal Mortality Reproductive Health Sexually Transmitted Infection Traditional Birth Attendant Terms of Reference Tetanus Toxoid United Nations Population Fund United Nations Children s Fund Uganda Prevention of Maternal Mortality Network World Health Organization v
Page 1 1. INTRODUCTION 1.1 Background In 1999, following a review of the slow progress in achieving safe motherhood in developing countries, the World Health Organization (WHO), together with other partners, issued a statement entitled Reduction of Maternal Mortality. The health sector strategy for reducing maternal mortality was subsequently outlined by WHO in the Making Pregnancy Safer (MPS) Initiative in 2000. The interventions recommended by the initiative to reduce maternal and perinatal mortality and morbidity were introduced in a few countries in Africa, Uganda being one of them. Uganda started the MPS Initiative in June 2001. This report is a midterm review (MTR) of the progress made so far. The consultants were asked to prepare a report using the terms of reference detailed below: 1.1.1 Review needs assessment survey in Soroti and determine the appropriateness of the indicators. 1.1.2 Evaluate the progress made in the implementation of MPS with particular attention to improve: Coverage of Basic Emergency Obstetric Care (BEOC) and Comprehensive Emergency Obstetric Care (CEOC) (b Quality of care. Utilization of services. 1.1.3 Assess community involvement and participation. 1.1.4 Review the role of advocacy in the implementation of MPS in Uganda. 1.1.5 Identify the obstacles and constraints and recommend solutions. 1.1.6 Propose interventions to be implemented with the support of the WHO Country Office and WHO/AFRO for the next biennium in view of consolidating the achievements in line with the country s priorities. 1.1.7 Identify areas/opportunities for collaboration/partnerships between the WHO and other stakeholders.
Page 2 1.2 Midterm Review Methodology The MTR team reviewed documents from several sources, held discussions with project staff and other stakeholders, and conducted on-site direct observations during the field trip to Soroti District. The documents reviewed were made available to the team by WHO/AFRO, WHO Uganda Country Office, Ministry of Health (MOH) of Uganda, the MPS project and the office of the District Director of Health Services in Soroti. The most important of these documents are listed in the references (Section 11). Discussions, both formal and informal, were held with officials of the institutions listed above and also those from the United Nations Children s Fund (UNICEF) and the Japanese Ministry of Foreign Affairs. The officials are listed in Section 10. The team visited several health centres in Soroti District for direct observations and held focus group discussions with clients and members of the community. Since the dates of visits changed, contacts with clients and the community were unplanned and spontaneous. At the health centres, interviews were held with the staff. 1.2.1 Assessment Criteria To determine progress in the implementation of MPS, the following criteria were used: 1.2.1.1 Coverage of basic emergency obstetric care and comprehensive emergency obstetric care The details of the population in the catchment area, the existence of physical infrastructure, geographical location and the staff complement were used to determine coverage of BEOC and CEOC. 1.2.1.2 Quality of care The criteria of the WHO (1999) which define basic or comprehensive emergency obstetric care were used to determine improvement in quality of care. For BEOC, the signal functions were: administration of parenteral antibiotics administration of parenteral oxytocics
Page 3 (d) (e) (f) administration of parenteral anticonvulsants performance of manual vacuum aspirations (MVA) performance of manual removal of the placenta performance of assisted vaginal delivery. For CEOC, the signal functions, in addition to all of the above, were: performance of caesarean section performance of blood transfusion. Additional criteria used in the assessment of quality of care were the following: (d) (e) (f) (g) (h) caesarean sections as a proportion of all births proportion of women with complications treated at an emergency care facility case fatality rate staff skill levels, and whether upgrading had occurred or not availability of equipment for laboratory, clinical and surgical use availability of drugs for the signal functions above, but also for malaria and tetanus toxoid immunization availability of transport to collect referrals from the community and to transfer to a higher level health centre (HC); possible modes of transport were bicycle, motorbike or motorcar ambulance availability of radio or telephone communication. 1.2.1.3 Utilization of services The utilization of services was determined by examining health facility records, and the reproductive health (RH) database for Soroti District (see Reference list). The use of facilities for antenatal care (ANC), deliveries, tetanus toxoid immunization (TT), intermittent presumptive treatment (IPT) of malaria with Fansidar and family planning (FP) were documented in the database in all but two of the health centres participating in the MPS Initiative.
Page 4 1.2.1.4 Changes introduced by MPS Initiative The MTR team assessed for each health facility and for the whole district the changes brought about by the MPS Initiative. This was done by using the records supplied by the WHO Country Office and Soroti District health service, the equipment and supply inventory at the health facilities, and interviews with staff. For the impact in the community, there were discussions with community members and leaders, district health management committee members, traditional birth attendants (TBAs) and clients. These discussions, together with a review of information, education and communication (IEC) documents and Ministry of Health RH guidelines were also used to assess community participation and involvement, and the role of advocacy in the implementation of the MPS Initiative. 2. ANALYSIS OF NEEDS ASSESSMENT SURVEY IN SOROTI DISTRICT, 2001 The needs assessment survey entitled Making Pregnancy Safer Baseline Report Soroti was performed in July-August 2001. This comprehensive and detailed survey, supported by the WHO, studied the availability, accessibility, quality and utilization of essential obstetric care in Soroti District. The assessment was based on the Making Pregnancy Safer Guidelines of WHO using structured model survey forms initially designed for the Mother Baby Package Strategy. The major findings are summarized in the executive summary of the report. The survey assessed service delivery, logistics and supplies, infrastructure and equipment, quality of care, training and staffing, drugs and consumables, referral of patients, IEC, and monitoring and evaluation. The report also assessed the existence of national policies, guidelines and protocols in RH, and coordination and collaboration among the stakeholders. The report is very informative and detailed; it showed that there were major gaps in the infrastructure, staffing, equipment and supplies at the health centres. The survey reported on the facilities, categorising them into health post, health centre or hospital, but not by name of the facility. The report also included Kaberamaido County, which has now been moved to another administrative district. It was therefore difficult to perform, facility by facility, a comparison of past and present using the needs assessment survey. Not enough time has elapsed to expect much change in the physical infrastructure, for example. However, the indicators chosen for the survey were appropriate for the MPS Initiative. They include all the indicators chosen in the tools of assessment of this review.
Page 5 This MTR report is based on observations at the health centres where MPS interventions have started, and their catchment populations. With time, the initiative will include all the health centres and cover the whole Soroti district. When this has occurred, a repeat survey using exactly the same methodology as the MPS Baseline Report can be meaningfully compared to the first report. 3. BASIC AND COMPREHENSIVE EMERGENCY OBSTETRIC CARE IN SOROTI DISTRICT 3.1 Akoboi Health Centre II (visited 5/12/2002) 3.1.1 Coverage of basic and comprehensive emergency obstetric care This HC is a non-beoc unit offering outpatient services only. An outreach team consisting of a nurse and an educator come weekly from Serere HC IV. There is no resident staff to collect statistics to determine the coverage of services offered such as antenatal care, contraceptive prevalence rate etc. The local council chairman and TBAs collect birth and death statistics in the community and showed us sample registers they had filled. These indicated that when the HC is open for maternity patients, it would be doing 10 15 deliveries per month. There had not been a recorded maternal death in the period of the project. 3.1.2 Quality of care A three-roomed thatched hut constructed by the community is used for health care and IEC activities. A new clinic has been constructed by the government but has not yet been opened. The new building does not include maternity wards or a labour ward, so deliveries will not be offered with its opening. The outreach team brings family planning tablets and injectables (Depoprovera), simple analgesics, antibiotics, IEC materials, IPT and immunization drugs. TBA registers made available showed that they are doing 10 15 deliveries per month The main MPS activities offered are antenatal visits, IEC on nutrition, immunization, infant care, danger signs in pregnancy, mechanisms for referral, and husbands support for their wives in pregnancy and delivery. TBAs are taught and supervised on infection prevention, danger signs and indications for referral. Patients and family are encouraged to set aside money for transport and to purchase materials for delivery.
Page 6 3.1.3 Utilization of services The services have only recently been established so no proper documentation of utilization rates within the catchment area of this HC is possible at this time. 3.1.4 Changes introduced by MPSI (d) (e) Increased community awareness of health education, pregnancy complications and the need for referral to hospital of women in labour Community commitment to contribute to ambulance service Collection of RH and vital statistics by TBAs and local councillors Training of 14 community educators and supply of bicycles to them Development of health guide book in local language. 3.1.5 Constraints (d) (e) (f) Poor roads impair access to this community and delay patient referral HC III or HC IV No radio communication No ambulance or bicycle ambulance No delivery facilities No resident midwife Current services only available once a week. 3.1.6 Recommendations (d) (e) (f) The clinic building should be opened and two midwives or a midwife and a nurse posted so that normal deliveries can take place and complications reduced; this will strengthen the strong community mobilization for MPS which has already taken place Provide essential drugs for obstetric care and delivery Provide bicycle ambulance Train midwife and nurse when available in life saving skills (LSS), manual vacuum aspiration (MVA) and family planning (FP) provision Provide IEC posters on prevention and management of the common obstetric problems and use of the partogram Strengthen collection of vital statistics.
Page 7 3.1.7 Comment This health centre, which was scheduled for upgrading to BEOC status, needs to have improvements completed in order to take advantage of the increased community participation which has been generated by the MPSI. 3.2 Kyere Health Centre III (visited 5/12/2002) 3.2.1 Coverage of basic and comprehensive emergency care This HC, which is staffed by one clinical officer, two midwives, three nurses and an educator, serves a catchment population of 30,486. No doctor is stationed here. Geographically, it is situated centrally in the sub-district. The size of unit and staff establishment gives adequate MPS Coverage for the population. 3.2.2 Quality of care The HC has an outpatient block for antenatal visits, IEC and immunizations and a building for antenatal, labouring and postnatal patients. No surgical theatre or laboratory is available. Essential drugs and supplies for BEOC such as parenteral antibiotics, anticonvulsants and intravenous (IV) infusions were available but there were no oxytocics (stock was depleted two weeks before). No blood transfusions are done. This is a busy HC that performs normal deliveries and does all the functions of BEOC except assisted vaginal delivery. Training for vacuum extraction has been given and the equipment is present but has not been used because there is no radio or ambulance in case of a failed procedure. Only a bicycle ambulance is available. Staff have been trained in clinical and community LSS, post abortion care (PAC) and MVA. We saw correct use of the partogram firsthand when a delivery occurred during our visit. 3.2.3 Utilization of services The contraceptive prevalence rate (CPR), and coverage of antenatal visits, deliveries, IPT and TT have increased, indicating greater utilization. There were no maternal deaths during the period of review. The table shows the HC statistics for certain process indicators (see Kyere HC III RH Database).
Page 8 Percentage utilization of HC services Service 2000 01 2001 02 CPR 2 3 Antenatal coverage 31 37 IPT 0 7 TT 36 60 Deliveries 9 35 The most significant change occurred in the number of deliveries conducted. The unit was performing less than the minimum 15% of the expected deliveries in 2000 2001 but is now well above this percentage. The CPR is low but family planning attendance has increased. The HC does not have a trained FP provider. 3.2.4 Changes introduced by MPSI Training: clinical and community LSS, sexually transmitted infections/human immunodeficiency virus (STI/HIV), screening for cancer of cervix, adolescent reproductive health (ADH) Supplies: essential obstetric drugs (seed stock), ANC/postnatal care (PNC) cards, IEC materials, partogram charts, sphygomanometer Health Management Information System (HMIS) training and setting up RH database. 3.2.5 Constraints (d) No trained FP provider No proper ambulance Inadequate funding of drama group Inadequate monitoring of drug supply. 3.2.6 Recommendations (d) Ensure essential drugs for BEOC are always available A proper ambulance is required since some health units refer to Kyere HC On site training for assisted vaginal delivery A laboratory and laboratory assistant should be provided
Page 9 (e) (f) More staff should be trained in RH service provision, especially FP and MVA More funding for drama group to cover uniforms, public address system and a small allowance for their fortnightly activities. 3.2.7 Comment Apart from assisted vaginal delivery, this HC performs all the signal functions of BEOC. Once an ambulance is available and staff have refresher training in vacuum extraction, it will be a fully functional BEOC unit. 3.3 Apapai Health Centre II (visited 6/12/2002) 3.3.1 Coverage of basic and comprehensive emergency obstetric care Apapai HC is a facility serving a total population of 9,537; the estimated number of women of reproductive age is 2,194. The expected number of pregnancies is 477 annually. It has a staff of one clinical officer and two midwives. The nurse: population ratio and its geographical position would offer an acceptable coverage for the expected number of pregnancies, but facilities do not exist for BEOC. 3.3.2 Quality of care There is an outpatient facility for antenatal care, family planning, immunizations and IEC messages on MPS and infant welfare. There is no maternity ward, but some deliveries are done on the couches in the examination room if the woman presents in the second stage. Upgrading activities have included the construction of a theatre, doctor s house and nurse staff quarters but only the latter has been opened. A radio was recently installed and the HC has both a bicycle and car ambulance. The unit refers about 20 maternity patients monthly. The HC has adequate parenteral antibiotics, anticonvulsants and oxytocics; IV infusions are done. Despite its limited facilities, staff have performed manual removal of placenta, and starting this year, they should be able to perform MVA. They have also received training in LSS, ADH, Integrated Management Childhood Illnesses (IMCI) and FP. 3.3.3 Utilization of services The table below shows that CPR and coverage of antenatal care, IPT and TT have increased since the beginning of the project (see Apapai HC II RH Database).
Page 10 Percentage utilization of HC services Service 2000 01 2001 02 CPR 2 8 ANC coverage 36 62 IPT 0 15 TT 17 39 Deliveries 0 0 The statistics indicate greater utilization of services which also will be enhanced by the opening of a maternity ward. 3.3.4 Changes introduced by MPSI (d) (e) Ambulance service Two-way radio communication Supplies: gloves, boots, ANC and PNC cards, partograph charts Training: Clinical and community LSS, STI/HIV, cancer of the cervix screening, ADH and supervisory skills HMIS training and setting up of the RH database. 3.3.5 Constraints (d) Inadequate buildings: outpatient department (OPD) too small, no maternity ward and insufficient staff quarters No laboratory or technical staff Theatre not open Inadequate staff.
Page 11 3.3.6 Recommendations (d) Expansion of OPD, building of admission and labour wards and installation of the accompanying infrastructure, i.e. water, toilets Recruitment of extra staff (nurses, midwives and laboratory technician) Recruitment of a doctor Expansion of staff quarters. 3.3.7 Comment This HC has the potential to contribute significantly to MPS objectives. Although it currently has non-beoc status, when the planned improvements are completed it will attain CEOC status. 3.4 Serere Health Centre IV (visited 7/12/2002) 3.4.1 Coverage of basic and comprehensive emergency obstetric care Serere HC is a level IV facility offering services to a catchment population of 24, 811 from whom 1,241 pregnancies are expected annually. It is situated strategically for the lower level centres that refer to it, and there is a good road to Soroti District Hospital. There are 26 staff, including two clinical officers, three midwives, five nurses, a laboratory technician and a records assistant. The HC conducts eight integrated outreach visits per month, during which the clients are offered FP, ANC, IPT, TT and immunizations for children. 3.4.2 Quality of care The clinical officers, nurses and midwives have been trained in LSS, MVA, PAC and manual removal of placenta. One midwife has been trained in vacuum extraction but has not yet performed the procedure since returning from Soroti Hospital although the equipment is available. All staff are familiar with the use of the partogram. Essential drugs including parenteral oxytocics, anticonvulsants, antibiotics and intravenous fluids are available. Protocols/guidelines on the use of these drugs and the management of obstetric complications were displayed on posters.
Page 12 All the signal functions for BEOC except vacuum extraction are carried out. No caesarean sections are performed. Since the start of the MPS project, the services have been upgraded by the addition of the following facilities: (d) (e) Buildings: theatre, doctor s and staff quarters, additional kitchens, toilets and bathrooms Two-way radio communication an ambulance extra water tanks training of staff in LSS, MVA, PAC, FP provision, IEC methods and the dissemination of MPS messages. The RH database for Serere included two indicators to assess amount of care. The number of stillbirths and early neonatal deaths rose from 20 in 2000 01, to 26 in 2001 02. This is likely to be due to improved transport and communication which facilitated the referral of high risk pregnancies from lower level health centres to Serere HC. The other indicator, the number of unsuccessful abortions treated, shows a rapidly rising trend. This is all the more impressive since none were being attended to in 2000. 3.4.3 Utilization of services Utilization of MPS services has increased impressively since the inception of the MPS project as reflected below. Percentage utilization of HC services Service 2000 01 2001 02 CPR 13 20 ANC coverage 64 72 IPT 0 48 TT 105 102 Deliveries 70 83 CPR is the highest in the district as is the utilization of the facility for deliveries. The data for tetanus toxoid utilization may be a reflection of the outreach work or use of facilities by women from outside the catchment area.
Page 13 3.4.4 Changes introduced by MPSI (d) (e) (f) (g) (h) (i) Supplies: gloves, boots, aprons, sphygmomanometer, three MVA kits, ANC and PNC cards, partogram charts and essential drugs (seed stock only) Renovations of ward toilets and bathrooms in maternity wing Ambulance Two-way radio Support for IEC: materials and funds for drama group Support for community outreach HMIS training and setting up the RH database Training: LSS, ADH, STI/HIV, cancer of the cervix screening Electric autoclave. 3.4.5 Constraints Theatre built but not yet functional No doctor, no nurse anaesthetist No storage of blood for transfusion. 3.4.6 Recommendations (d) (e) Theatre should be made functional as soon as possible A storage refrigerator for blood should be acquired A doctor and a nurse anaesthetist should be stationed here A second ambulance is required because the current one is unavailable for emergencies or outreach visits; Serere HC refers 30 50 patients to Soroti monthly Midwives and clinical officers should receive more training in assisted vaginal delivery once the doctor is stationed here.
Page 14 3.4.7 Comment This facility has the greatest potential to give better quality obstetric care with minimal expenditure on further upgrading. Currently, apart from assisted vaginal delivery, all the signal functions of BEOC are provided, and it can rapidly attain CEOC status if the planned improvements are completed. 3.5 Tubur Health Centre III (visited 9/12/2002) 3.5.1 Coverage of basic and comprehensive emergency obstetric care This HC serves a catchment population of 10,853, and the expected number of pregnancies annually is 543. The staff comprises of two midwives, one enrolled nurse, a record assistant and a nursing assistant. For the expected workload, the staff establishment is acceptable. The enrolled nurse has gone for training as a clinical officer. A midwife and an educator provide outreach services. The HC is geographically well situated for its catchment population. 3.5.2 Quality of care Two midwives have been trained in clinical and community LSS, MVA, PAC and manual removal of placenta. The physical infrastructure consists of an OPD room for ANC, immunizations, IEC and minor ailments. A maternity ward includes beds for antenatal and postnatal care and labour ward. There is no electricity or solar lighting, and water is fetched from a borehole 4 km away. A large water storage tank is available but has not been installed. The OPD has been renovated and a toilet and bathroom provided for maternity. There is no theatre or laboratory. A bicycle ambulance is available but is not used often because the roads are bad and the distance to the main road is considerable. All BEOC signal functions are carried out except vacuum extraction. Supplies of parenteral antibiotics, anticonvulsants and oxytocics were available. Stock control of drugs, however, is done by Tirir HC. The RH database shows that the number of procedures for abortions has risen from nothing in 2000 to about two per month in 2001 02. Postnatal mortality (PNM) has remained unchanged.
Page 15 There had been one maternal death in a village near the HC, which was reported by the TBA and the community. The midwife visited the family and established that it had been caused by postpartum haemorrhage due to a retained placenta. 3.5.3 Utilization of services The indicators for utilization revealed increases in 2001 02. CPR, ANC registration and visits, IPT, TT and number of deliveries in health units have all increased since the beginning of the project. This is shown in the table (see Tubur HC III RH Database). Percentage utilization of HC services Service 2000 01 2001 02 CPR 2 3 ANC coverage 23 38 IPT 0 11 TT 58 64 Deliveries 29 48 This HC III has increased its workload. Capacity to do more will be enhanced when the clinical officer returns from training. 3.5.4 Changes introduced by MPSI Training in clinical and community LSS, STI/HIV, cancer of the cervix screening, ADH Supplies: ANC and PNC cards, partogram charts, IEC materials, and sphygmomanometer HMIS training and setting up the RH database. 3.5.5 Constraints (d) (e) No piped water supply No electricity Inadequate OPD and staff quarters No radio communication Drug stock control done by another HC.
Page 16 3.5.6 Recommendations (d) (e) Expand physical infrastructure by installing a piped water supply, enlarging the OPD and building staff quarters Expand solar facility to include lighting Install radio communication Review and correct drug supply routine Provide motorbike or motorcar ambulance. 3.5.7 Comment This level three facility has non-beoc status. When the clinical officer returns and a radio and ambulance have been acquired, the facility can start performing vacuum extractions. 3.6 Tirir Health Centre IV (visited 9/12/2002) 3.6.1 Coverage of basic and comprehensive emergency obstetric care This is a level IV health facility from which catchment population data were unavailable. The staff establishment includes one clinical officer, a comprehensive nurse, a midwife and two nurses. It is the only level IV facility for a wide geographical area, and several lower level facilities refer to it. 3.6.2 Quality of care The staff have received training in clinical and community LSS/HIV, cancer of the cervix screening, MVA, PAC and manual removal of the placenta. The physical structures present are an OPD building, an unopened theatre, a new but uncompleted maternity ward and some staff quarters. No piped water is available, and there is no radio or ambulance. An uncompleted building has been roofed and plastered using Uganda Prevention of Maternal Mortality (UPMM) funds, and is being used as the antenatal clinic and for counselling. Drugs for the BEOC signal functions are available. Deliveries are being conducted in a converted OPD room. MVA and manual removal of placenta have been performed despite the limitations; however, any further improvements will only occur
Page 17 after considerable development of the infrastructure. There were no data to determine the quality of service provision as the RH database had not yet been set up for the area. 3.6.3 Utilization of services There is no data to document utilisation of services, but the staff said the workload had gone up since the MPS project started, and indeed evidence was observed. The OPD on the day of the visit was full of patients, many of them pregnant. There were two women in labour, one of whom had been brought in by a TBA. The TBA said she had brought the woman because she had noticed that her bladder was very full and this would lead to delay in delivering. 3.6.4 Changes introduced by MPSI Training: clinical and community LSS, STI/HIV, cancer of the cervix screening, ADH, MVA and PAC Supplies: essential drugs (seed stock), IEC materials, ANC and PNC cards, partogram charts, MVA kits. 3.6.5 Constraints Physical: no piped water, electricity, maternity or labour wards or functioning theatre; inadequate staff quarters Transport: no motorized ambulance Communication: no two-way radio. 3.6.6 Recommendations Improve physical infrastructure to bring piped water, build wards and staff quarters; install theatre equipment thereafter Provide an ambulance Provide two-way radio communication. 3.6.7 Comment Although all the signal functions for BOEC status are being performed (except vacuum extraction), there is no accommodation for pregnant women. Major improvements are required before this HC can deliver better quality MPS services or achieve CEOC status.
Page 18 3.7 Soroti Hospital as a District Referral Hospital (visited 6/12/2002) 3.7.1 Coverage of comprehensive emergency obstetric care The catchment population for Soroti District is 333,662. According to WHO guidelines, it should be served by at least one CEOC. Soroti Hospital qualifies as a CEOC unit because of its staff, physical infrastructure and services offered. The number of expected pregnancies in the district annually is 16,683, of which 15% (2,502) would be expected to have complications. The hospital has 12 doctors and 90 nurses; it serves as a regional referral centre for Katukwi, Kaberamaido and Kumi districts. Among its 12 doctors are six specialists (two surgeons, two community health physicians, one obstetrician and one paediatrician) and four general medical officers. The medical officers (MOs) rotate through the various specialities for 1 2 years at a time and provide the on-call with assistance for routine emergencies. An additional paediatrician is expected in January 2003. The 90 nurses include 29 midwives. One nurse anaesthetist is available, and more trainees have been sent to the one-year training programme. Facilities already existed for CEOC before MPS activities started and included a theatre that is shared with surgeons, a blood storage refrigerator and an ambulance. The specialist obstetrician who has been there for several years has been providing a full service, including hysterectomy for ruptured uterus. 3.7.2 Quality of care Since the inception of the project, doctors, midwives and nurses have had their skills upgraded in clinical LSS, MVA and PAC. Protocols and guidelines on aspects of emergency obstetric and neonatal care were displayed as posters. All drugs required for EOC, including parenteral antibiotics, anticonvulsants and oxytocics, are available. An IV infusion manufacture unit is available. Upgrading of facilities has included the installation of a two-way radio system linking the hospital with the ambulance and some HC III and IV units. An additional maternity ward renovated by the hospital is ready to be opened. The water system has been upgraded, and there is a standby electricity generator. Quality of care indicators showed that the numbers of complications and caesarean sections are increasing. The caesarean section rate at the hospital is 10%, while that for the whole district is 6%. These figures are above the minimum acceptable
Page 19 level of care. The met need for complicated cases has risen from 15% to 18%, but this is far below the recommended 100%. The number of admissions for complications has increased, and the case fatality rate and number of maternal deaths have dropped. The case fatality rate dropped in one year from 28% to 9.6%, and the number of maternal deaths decreased from 15 to 8. Since data collection only covered an 18-month period, it is too early to comment on the trend of maternal mortality. The perinatal mortality rate for the district is 46, while that of the hospital was 65 in 2000 01 and 53 in 2001 02. There has been an increase in neonatal deaths over the period, probably due to more effective transfer of women at-risk from premature delivery. The hospital is aware of the deficiencies in neonatal care and has ordered two new incubators. The improvement in quality of care at Soroti can be attributed to the interventions introduced by the MPS project, especially training of staff, raising community awareness and upgrading lower level health units. 3.7.3 Utilization of services The utilization of RH services in Soroti District has risen significantly in all functions except IPT. These changes are illustrated in the table below (see Soroti District RH Database and Soroti Hospital as a District Hospital RH Database). The figures refer to the whole district except where stated. Percentage utilization of services Service 2000 01 2001 02 CPR 1 1.4 ANC coverage 24 42 IPT 12 10 TT 14 21 Deliveries 13 16 Coverage of complications 15 18 Bed occupancy (hospital) 156 120 Caesarean section rate (hospital) 10 Caesarean section rate 6 Case fatality rate (hospital) 28 9.6 For the whole district, deliveries in health facilities rose from 13 to 16%; this is just above the minimum acceptable figure of 15%. The increasing number of admissions and complicated cases put a strain on the maternity wards, and increasing use was made of floor beds. However, in the last 12 months the mean hospital stay for
Page 20 complicated cases and caesarean sections has dropped from 6.5 to 4.5 days. This was attributed to more efficient management of complications, especially infections. The hospital also has access to its own fund for drugs and is now able to purchase appropriate antibiotics independently. 3.7.4 Changes introduced by MPSI (d) Training: clinical LSS, MVA, PAC, ADH, supervisory skills, STI/HIV, screening for cancer of the cervix Supplies: essential obstetric drugs (seed stock), IEC materials, ANC/PNC cards, partogram charts, treated mosquito bednets, sphygmomanometers and plastic curtains for the partitioning of labour ward HMIS training and setting up of the RH database Facilitating supervisory support for level III and IV units. 3.7.5 Constraints (d) (e) (f) (g) Increase in workload due to referrals and positive results but no increase in staffing due to government policy Shared theatre now inadequate for workload Only one nurse anaesthetist available IV infusion manufacture unit is now outdated Too few maternity beds Inadequate supervision of nurses and clinical officers in level III and IV units Blood supply from Mbale Regional Blood Bank sometimes unreliable. 3.7.6 Recommendations Commence use of the additional maternity ward to meet the increased demand for obstetric services Use trained midwives and medical officers from Soroti Hospital for the clinical supervision of staff in health centres III and IV to facilitate greater use of such procedures as MVA and vacuum extraction at these units; onsite training will reduce need to bring staff to Soroti for training; an appropriate budget line for this clinical supervision by trained staff from Soroti Hospital should be included in the year 2003 MPS budget
Page 21 (d) (e) (f) (g) (h) (i) (j) (k) (l) Arrange for medical officers in Soroti Hospital to rotate for short periods in the level IV health centres (one month) to facilitate training, and upgrading of these units; it will also improve the quality of care and reduce the morbidity of referrals to Soroti Hospital Arrange for all MOs employed by the district to spend four weeks of orientation at Soroti Hospital before being posted to HC IV units Allow Soroti Hospital to replace retired or dead doctors and nurses, or to employ two more medical officers to meet increased demand and to facilitate the rotation suggested above Upgrade IV infusion production unit; the upgrade grant was apparently promised by the WHO Provide training in care of the newborn for midwives and MOs to address the issue of morbidity and mortality in neonates; train staff in HC III and IV Link Soroti Hospital by two-way radio to all HC III and IV and ambulances Provide protective goggles (one per staff member) for all maternity and theatre staff to reduce morbidity/mortality from infection Provide a separate theatre for maternity patients Provide a second nurse anaesthetist for Soroti Hospital, and one each for the level IV units Provide appropriate kitchen and toilets for relatives cooking for patients; allow patients who prefer to pay for hospital food to do so; expedite the opening of the private ward as a way of generating funds for the hospital. 3.7.7 Comment This was an already functioning CEOC, and effectiveness has been improved by the project. Because of the increasing workload, care must be taken to sustain the achievements through continuous supervision and taking steps to maintain staff morale. 3.8 Coverage of Soroti District Although not all the health centres in the district were visited, the information gathered and that which was made available allowed the team to make observations on the coverage of emergency obstetric care in the whole district. This is summarized below.
Page 22 Population of Soroti District 350,000 At least one CEOC facility for the population yes At least four BEOC facilities Deliveries in health facilities at least 15% 100% of women with complications treated in facilities no Caesarean sections not less than 5% of all births yes Case fatality rate in EOC facilities less than 1% no yes not known Due to the MPSI, Soroti District is on the verge of being able to offer the minimum acceptable coverage for EOC according to WHO criteria. Three out of five HC III and IV facilities are providing all the signal functions of BEOC apart from assisted vaginal delivery, and they need minimal further inputs to achieve full BEOC status. Due to communication and transport problems, it was difficult to ensure that 100% of women with complications were treated in facilities during the period under review. Soroti District will find this the hardest requirement to fulfil. Furthermore, the RH database did not collect data on complications. This is the reason why the case fatality rate for the district could not be computed. 4. COMMUNITY INVOLVEMENT AND PARTICIPATION Throughout the district, there was evidence of increased awareness of the need to make pregnancies safer, and willingness to participate in the activities of the MPS project. Discussions were held with one community and also with patients, local council leaders, health management committee members and the district civic leaders who were all aware of the initiative and were giving it active support. Spot checks with patients and their relatives showed that they knew the danger signs of pregnancy. At Akoboi, a meeting was held with about 160 people of the area, more than half of whom were women. The community was well motivated on MPS and is prepared to contribute to the cost of running the ambulance and also to donate blood for transfusion. The TBAs support the community request for maternity services to be provided at this HC and that a bicycle ambulance should be made available. The group stated the following as the common reasons for a woman to deliver at home: TBAs are available in the community and are tried and tested. Some have been upgraded through training.
Page 23 (d) (e) (f) There may be no one to look after children if the husband follows the wife to hospital. Patients are sometimes re-assured by nurses at antenatal visits that all is well. Labour often occurs at night and unexpectedly. The community associates referral to hospital with caesarean section delivery. When women of the community mix with others in hospital who are better off, they feel self conscious about the clothes and food that they have brought. The improved awareness has been achieved by the distribution of IEC materials in the local language, outreach visits from the HC staff, and involvement of the local and district leaders in the project. A weekly programme on Soroti Community Radio presented by a midwife is widely followed. Three ambulance committees have decided to help with the fuel and running costs, through sub-county authorities. As a result of this community involvement, the local council chairmen are assisting with data collection. They compile the birth and death register in their area with help from TBAs, and this has provided more accurate information for the RH database. However, despite the high degree of awareness, CPR remains very low. This is a challenge to the project. 5. ADVOCACY Uganda is a good example of advocacy in reproductive health. Due to the AIDS crisis, which the country is recovering from, the political leadership is well ahead of those in other sub-saharan African countries in advocating for better reproductive health. There was ample evidence of commitment from politicians, civic leaders and members of the health professions in the mass media of Uganda. Radio programmes encourage free discussion of issues relating to RH, and many are geared towards the youth. The Government of Uganda has also published many policy documents on RH which include guidelines on adolescent health, sexual and reproductive health, AIDS and family planning. In the national context, advocacy for safe motherhood is only one of the many RH messages competing for public attention. In Soroti, the MPS project reveals what can be achieved in a short time. This can be duplicated on the national scale, since the basic commitment and some of the resources (e.g. radio stations) already exist. If the
Page 24 other districts in Uganda are similar to Soroti, then one important area for advocacy is to reduce the problems of early and too frequent pregnancies. A programme of community FP advocacy and distribution is a priority. 6. OBSTACLES, CONSTRAINTS AND RECOMMENDED SOLUTIONS For the sake of clarity, and in order to assist the district authorities, Ministry of Health and the WHO Country Office, constraints and recommended solutions were discussed by health facility in Section 3. They will not be repeated here. This section will only discuss generic constraints and recommendations affecting the whole project. The major constraint for the achievement of MPS objectives is the slow pace of the physical upgrading of the facilities. The software (community mobilization and staff training) is now in place but the hardware (buildings, ambulances, radios) is not ready in many places. Sections 7 and 8 will discuss recommendations for completing the improvements. Another major constraint is that the funds initially allocated by WHO were never going to be sufficient for the achievement of the MPS objectives unless other partners came up with their contributions on schedule. The project coordinators and partners should develop a costing exercise and timetable for the completion of the improvements. If the other stakeholders are too slow or no longer able to contribute, then WHO will have to fund the unfinished work. It is very important that the MPS concept be taken to its logical conclusion and the results analysed and the total cost of the exercise (not just the WHO contribution) be known. The RH database did not cover the whole district; this is understandable since it takes time to train staff in all the health centres and lay people in the community to collect data. The RH database should expand to include the whole district, and it should record all complications of pregnancy by type. The number of abortions presenting should be recorded separately from the number of MVAs performed. In order to increase the coverage of deliveries, all HC II units should be upgraded to provide maternity care. Lastly, it is recommended that the office of the District Director of Health Services should acquire a simple accounting software program to make it easy for them to give financial reports. It is also recommended that the MOH and DDHS should start providing a greater budgetary commitment to the MPS initiative.
Page 25 7. INTERVENTIONS TO BE IMPLEMENTED The MTR team visited the health centres targeted by the MPS initiative in Soroti. Certain trends and conclusions are evident. Community mobilization and IEC improves health-seeking behaviour regarding antenatal care, referrals, deliveries, immunizations, abortion complications and nutrition. Service provider training and the availability of essential drugs, even when the infrastructure is incomplete, has led to increased utilization, improvement of output indicators and more accurate recording of statistics. The provision of an ambulance and radio communication led to increased referrals but a decreased case fatality rate at the district hospital. These interventions have cost relatively little and would have achieved even more with closer coordination of implementation between the MOH, WHO, the district and other donor partners. These lessons have to lead the next steps for the biennium which should focus on consolidation in Soroti District and replication in two or three other selected districts in Uganda. 7.1 Consolidation in Soroti District The consolidation of the MPS activities can be grouped. 7.1.1 Completion of the upgrading of the physical infrastructure For Soroti District to offer full basic and emergency obstetric care, four facilities, which are currently HC levels III or IV, should be upgraded to BEOC status. In order of priority, these should be Serere, Kyere, Tirir and Apapai. The physical, transport and communication improvements required are detailed in Section 3. If enough coordination with the other partners is achieved (see section below), then all these improvements can be completed in the next biennium. 7.1.2 Service provider training The MPS project should offer more training in care of the newborn, vacuum extraction and prevention of mother-to-child transmission of HIV infection. Care of the newborn needs to be strengthened because of the increased number of at-risk pregnancies reaching the health centres. Although service providers in the HC III and IV units have been given training in assisted vaginal delivery (vacuum extraction), no procedures were being carried out due to lack of confidence and absence of radio communication or ambulance. The MTR team agreed with the decision of the midwives and clinical officers not to perform the procedure under such circumstances.
Page 26 However, when communication and transport are installed, refresher training will be needed to utilize the training. Continued outreach service provider training should be offered from the reservoir of trainers at Soroti Hospital. The doctors and experienced clinical officers should be rotated through the HC III and IV units, providing on-site training to ensure sustained use of procedures such as MVA, vacuum extraction and tubal ligation. A budget line should be provided to fund this, and it should be separate from the administrative vote for the DDHS. 7.1.3 Training in FP promotion and provision To reduce unwanted and early pregnancies, a special effort is needed to train service providers in FP promotion and community-based distribution. If the staff of the HCs is too busy, community-based distributors can be trained for this. 7.1.4 Community mobilization The positive work already done for community mobilization should be continued to reduce the first delay. However, this mobilization is not enough if the second delay, from a BEOC to a CEOC unit, is not reduced. It is very important that the improvements occur in tandem to sustain the interest of the community. 7.2 Replication of MPS in Other Districts When WHO and the other partners have completed the suggested physical upgrading in Soroti District, they should cost the exercise. This will assist plans for the replication of the initiative in other districts. Since the cost can only be known at the end of the biennium, this means that only preliminary plans for such replication can take place in the next two years. These would include selecting three districts which are strategically located and conducting a needs assessment survey. Financially, it will be easier to start with the districts where the HCs are already physically advanced and have radios, piped water etc. However, the capacity at the WHO Country Office to supervise the initiative means that MPS activities should not start in the selected district until the Soroti project is completed and all the lessons can be drawn from it.