Improving the Quality of Family Planning Services in Uganda: Tested changes implemented in four districts in Western Uganda NOVEMBER 2016 This change package for improving the quality of family planning services was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) and authored by Rosette Birungi, John Byabagambi, and Mirwais Rahimzai of URC. It was developed as part of the Saving Mothers Giving Life work in Uganda funded by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR) and carried out under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is made possible by the generous support of the American people through USAID.
Improving the quality of family planning services in Uganda: Tested changes implemented in four districts in Western Uganda NOVEMBER 2016 Rosette Birungi, University Research Co., LLC John Byabagambi, University Research Co., LLC Mirwais Rahimzai, University Research Co., LLC DISCLAIMER The contents of this change package are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government.
Acknowledgements This compilation of changes tested that led to facility level improvements in the processes of providing family planning services in Uganda was developed for the United States Agency for International Development (USAID) by the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. The authors would like to thank Tamara Nsubuga-Nyombi, Bryan Tumusiime, Paul Isabirye, and Martin Muhire of University Research Co., LLC (URC) for the support provided in facilitating the different processes through which the changes presented in this package were harvested. We also acknowledge the 18 USAID ASSIST-supported health facilities in the four districts of Kyenjojo, Kamwenge, Kabarole, and Kibaale for their energy and commitment to improving family planning services and for providing us an opportunity to learn and improve maternal and new born health together through the Saving Mothers Giving Life (SMGL) initiative. The Ministry of Health and the SMGL implementing partners STRIDES for Family Health, Baylor Uganda, Infectious Diseases Institute, Securing Ugandans Rights to Essential Medicines (SURE) Project, and PACE contributed greatly to the family planning and reproductive health improvements observed in these health facilities. We acknowledge their contribution. The USAID ASSIST Project is made possible by the generous support of the American people through USAID s Bureau for Global Health, Office of Health Systems. Support for the SMGL initiative was provided by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR). The USAID ASSIST Project is managed by University Research Co., LLC (URC) under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC s global partners for the USAID ASSIST Project include: Encompass LLC; FHI 360; Harvard T. H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communications Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or send an e-mail to assist-info@urc-chs.com. Recommended citation Birungi R, Byabagambi J, Rahimzai M. 2016. Improving the quality of family planning services in Uganda: Tested changes implemented in four districts of western Uganda. Published by USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. Bethesda, MD: University Research Co., LLC (URC).
Table of Contents Glossary of Terms...iii INTRODUCTION... 5 Background of family planning in Uganda... 5 Intended use of this change package document... 5 CHANGE PACKAGE... 6 Using a continuous quality improvement approach to improve family planning services... 6 Change packages for the four aims... 8 APPENDICES... 12 Appendix 1: Changes introduced to build staff skills in providing family planning contraceptives including evidence... 12 Appendix 2: Changes introduced to improve family planning counseling and education including evidence... 13 Appendix 3: Changes introduced to improve availability of family planning services and privacy... 15 Appendix 4: Changes introduced to improve the use of tools to capture and monitor famly planning data... 17 List of Figures Figure 1: Barriers to uptake of family planning services in the supported districts... 6 Figure 2: Family planning QI team composition and roles... 6 Figure 3: Four aims of family planning improvement work in four SMGL districts... 7 Tested changes to improve family planning services in Uganda i
Acronyms ANC ASSIST CDC CEmNOC CME DHO FP HC HCIII HCIV IP IUD MOH MSU NGO OPD PDSA PEPFAR PNC QI RHU SMGL STI URC USAID Antenatal care USAID Applying Science to Strengthen and Improve Systems Project U.S. Centers for Disease Control and Prevention Comprehensive emergency obstetric and newborn care Continuing medical education District Health Officer Family planning Health center Health Center III Health Center IV Implementing partner Intrauterine device Ministry of Health Marie Stopes Uganda Non-governmental organization Outpatient department Plan-do-study-act U.S. President s Emergency Plan for AIDS Relief Postnatal care Quality improvement Reproductive Health Uganda Saving Mothers Giving Lives Initiative Sexually transmitted infection University Research Co., LLC United States Agency for International Development Tested changes to improve family planning services in Uganda ii
Glossary of Terms Abstinence: Refraining from sexual intercourse of any type. Abstinence is highly effective in preventing pregnancy and the transmission of sexually transmitted infections (STIs), including HIV. Barriers to family planning methods: Availability, Accessibility and affordability are key factors that affect the provision and uptake of family planning services globally. Barrier method: A birth control method that provides a physical barrier between the sperm and the egg. Examples of barrier contraceptive methods include condoms, diaphragms, foam, sponges and cervical caps. The effectiveness rate for barrier methods ranges from 77% to 98% in preventing pregnancy. Birth control method: An effective, safe, comfortable method to prevent pregnancy. Birth control can be temporary; meaning you can stop using the method and possibly become pregnant. Temporary methods include birth control pills, Depo-Provera, Norplant, IUD, diaphragms, cervical caps, condoms, contraceptive sponges, spermicidal foams, films and creams. Permanent methods, which are not reversible, are tubal ligation for women and vasectomy for men. Change concept: A category of change ideas or interventions that are similar and have a common underlying thought pattern. Change idea: A specific intervention that a health facility quality improvement team has tested. Change package: An organized summary of strategies and interventions that have been tested and proven to improve care in a given context. In this case, the interventions being outlined have been proven to result in improvements in the quality of family planning services thereby reducing respective morbidity and mortality rates. Continuum of care: An approach to maternal, newborn, and child health that includes integrated service delivery for women and children from before pregnancy to delivery, the immediate postnatal period, and childhood. Continuous quality improvement (CQI): CQI is an approach to quality management that builds upon traditional quality assurance methods by emphasizing the organization and systems: it focuses on "process" rather than the individual; it recognizes both internal and external "customers"; it promotes the need for objective data to analyze and improve processes. Contraception: The intentional prevention of conception and pregnancy through hormones, technologies, sexual practices, or surgical procedures. Contraceptive prevalence rate: The percentage of women of reproductive age (15-49) who are practicing, or whose sexual partners are practicing, any form of contraception. Demographic dividend: The long-term economic benefits that result from lower fertility rates, the accompanying decrease in dependent populations, and the right investments in human capital. Family planning: The conscious effort of couples or individuals to plan the number of children they have and to regulate the spacing and timing of their births through contraception and the treatment of involuntary infertility. Health facility (HF): Under the Ministry of Health and the national health system, three district health facility levels exist where family planning services can be offered: General Hospital (GH), Health Center IV (HCIV), and Health Center III (HCIII), all of which provide comprehensive and basic emergency obstetric and neonatal care coupled with family planning services. The Regional Heferral Hospital (RRH) provides a broader range of FP services. Hormonal method: Hormonal birth control methods, including pills, rings, implants and patches, use hormones to prevent ovulation, and thus prevent pregnancy. Improvement collaborative: A strategy for linking the efforts of many quality improvement teams that work independently to address a common challenge, but are periodically brought together to Tested changes to improve family planning services in Uganda iii
share and learn from one another, so that emerging best practices are easily and rapidly spread at scale. Long term contraceptive (long acting reversible contraception): are methods of birth control that provide effective contraception for an extended period without requiring user action. They include injections, intrauterine devices (IUDs) and sub dermal contraceptive implants. They are the most effective reversible methods of contraception because they do not depend on patient compliance. So their 'typical use' failure rates, at less than 1% per year, are about the same as 'perfect use' failure rates. Maternal death: The death of a woman while pregnant or within 42 days of the termination of pregnancy, due to complications during pregnancy or childbirth. Maternal health: The health of women during pregnancy, childbirth, and the postpartum period. Maternal morbidity: Non-fatal injuries, conditions, or symptoms that result from or are worsened by pregnancy and childbirth, and often have long-term negative repercussions for mothers. Examples include obstetric fistula, anemia, infertility and chronic infection. Maternal mortality rate: The number of maternal deaths during a given time period per 100,000 women of reproductive age (15 to 49) during that same time period. Medical abortion: A safe option for terminating a pregnancy using medications (e.g., mifepristone and misoprostol or misoprostol alone). Plan-do-study-act (PDSA) cycle: An iterative and efficient trial-and-learning methodology used to test specific change ideas and learn from them. It begins with a plan and ends with action according to the learning gained from the Plan, Do and Study phases of the cycle. In most cases, multiple PDSAs are needed to make successful changes. Reproductive health: The state of complete physical, mental and social well-being in all matters relating to the reproductive system, its functions and its processes. Sexual and reproductive rights: A set of rights related to sexual and reproductive health, including the rights to freely and responsibly decide on the number, spacing, and timing of children; to receive the highest standard of sexual and reproductive health care; to make decisions about reproduction free from discrimination, coercion, and violence; and to pursue a safe, satisfying, and consensual sex life. Skilled attendants: Individuals with midwifery skills, such as doctors, nurses, and midwives, who have been trained to provide competent care during pregnancy and childbirth including family planning. Stock-outs: Extreme shortage of contraceptive supplies due to dwindling aid budgets, lack of government allocation, or inaccessibility of commodities for any other reason. Unmet need for family planning: The gap between women s stated desire to avoid having children and their actual use of contraception. Unsafe abortion: The termination of an unintended pregnancy, either by a person lacking the necessary skills, in an environment lacking minimal sanitary and medical standards, or both. Unwanted/unintended pregnancy: A pregnancy that a woman or girl decides, of her own free will, is undesired. Tested changes to improve family planning services in Uganda iv
INTRODUCTION The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, in partnership with 17 United States Government implementing partners and the Ministry of Health (MOH), is implementing the Saving Mothers Giving Life (SMGL) initiative in the four districts of Kamwenge, Kyenjojo, Kabarole and Kibaale in mid-western Uganda, which registered the highest maternal mortality countrywide. One of the objectives of the initiative is to increase access to family planning information and modern contraceptive methods among women of reproductive age (15-49 years) who do not want to become pregnant, and to ensure a safe and healthy pregnancy and birth for those who wish to have children. This would subsequently contribute to maternal and infant mortality reduction in the country. Background of family planning in Uganda Globally, family planning (FP) is recognized as a key life-saving intervention for mothers and their children (WHO, 2012). 1 It contributes to a reduction in unintended and high risk pregnancies hence curbing maternal and infant mortalities. At an average annual growth rate of 3%, Uganda's population is projected to increase to 47.4 million by 2025 (UNFPA, 2015). 2 This is attributed to the country s high fertility rates of 5.9% children per woman (CIA.GOV, 2015). 3 Yet, only 26% (UDHS, 2011) of married women in their reproductive age (15-49 years) are using a modern family planning contraceptive method bringing about an unmet need of 34% (UDHS, 2011). 4 Similarly, Uganda faces a high maternal mortality rate of 438/100,000 live births, resulting from postpartum hemorrhage, prolonged and obstructed labor, pre-term delivery, hypertensive disorders, and unsafe abortions, among other key factors. Intended use of this change package document The purpose of this change package is to provide guidelines and knowledge on family planning counselling and provision to frontline health workers working at various entry points that serve women of reproductive age (15-49 years) including antenatal, postnatal, young child and adolescent clinics as well as maternity wards. Health workers should adapt the tested changes to the specific contexts in their health facilities and the resources available. In addition, non-governmental organizations (NGOs) and projects involved in reproductive health, family planning and maternal and newborn care, district health officers supervising health facilities and Ministry of Health officials working on strategies for improving family planning and maternal and newborn health will find the changes described in this report useful and can adapt them for their work as well. The change package aims to convey a synthesis of learning from ASSIST s experience in implementing quality improvement approaches to improve family planning and post-partum family planning services as a means of reducing maternal and newborn mortality in Uganda through provision of timely and appropriate modern contraceptive methods under the Saving Mothers Giving Life initiative. The change package provides a detailed description of what changes led to improvement for each of the four improvement aims. Each section outlines the problem being addressed, the change ideas tested, steps followed in introducing each change idea, and the evidence that it led to improvement. 1 World Health Organization. 2012 Family Planning Summit Overview July 2012. Available at: http://www.who.int/pmnch/about/steering_committee/b12-12-item5_fp_summit.pdf 2 http://countryoffice.unfpa.org/uganda/2014/12/23/11171/census_provisional_results_released 3 https://www.cia.gov/library/publications/the-world-factbook/rankorder/2127rank.html 4 http://www.ubos.org/onlinefiles/uploads/ubos/udhs/udhs2011.pdf Tested changes to improve family planning services in Uganda 5
CHANGE PACKAGE This change package focuses on the objective of increasing access to FP information and modern contraceptive methods among women of reproductive age. The interventions to prevent and address the barriers to uptake of family planning illustrated in Figure 1 were the focus of ASSIST s quality improvement efforts in Uganda. Figure 1: Barriers to uptake of family planning services in the supported districts Using a continuous quality improvement approach to improve family planning services USAID ASSIST s quality improvement work is based on the Plan-Do-Study-Act (PDSA) cycle which, starting in May 2013, was followed in implementing family planning improvement work in 18 highvolume health facilities in the four Western Uganda districts of Kyenjojo, Kamwenge, Kabarole and Kibaale. Health facility family planning quality improvement(qi) teams were initially trained by ASSIST on quality improvement methods; then ASSIST QI coaches supported teams on a monthly basis to identify gaps in family planning provision and counselling, prioritize areas of improvement, and develop, test, and successfully implement change ideas that would potentially lead to improvement. Figure 2 shows the composition of a typical QI team addressing family planning, Figure 2: Family planning QI team composition and roles Staff member Role Enrolled midwife - Team leader QI projects Enrolled midwife - FP counselling provision Nursing officer midwife- Dispensing contraceptives Nursing officer midwife -Managing side effects of FP methods Nursing officer nursing - Counselling and HIV testing The 18 health QI facility teams were then brought together in peer-to-peer learning sessions every three months to share their experiences in implementing family planning counselling and service provision QI work. These sessions also provided a basis for spreading best practices among the quality improvement teams. Community volunteer - Sensitizing the Community Nursing assistant - Registering clients The ASSIST quality improvement collaborative approach is in line with the MOH quality improvement framework and strategic plan. In an improvement collaborative, teams involved in addressing similar challenges receive regular coaching and are brought together to learn from each other in interactive meetings known as learning sessions. The 18 health facility QI teams identified and prioritized four areas of FP counselling and service provision that they focused on to improve upon gaps that they identified during their coaching and learning sessions. The gaps included: inadequate staff skills to provide FP; lack of patient privacy; stock-out of FP commodities; limited FP counselling and education; and poor ability to document FP services in the MOH tools. Figure 3 summarizes the prioritized improvement aims by the teams to close these gaps. Tested changes to improve family planning services in Uganda 6
Figure 3: Four aims of family planning improvement work in four SMGL districts Build health care worker skills to provide FP services Improve FP counselling and education Improve availability of FP services and privacy Improve the use of tools to capture and monitor FP data For each of these four aims, this change package describes what actions QI teams in the four districts took (that is, what changes did they try out) to address specific gaps in order to reach the aim and gives details on how to implement each change. The Appendices to this change package provide more details on changes tested to achieve each aim: Appendix 1 describes changes introduced to build staff skills in family planning (Aim 1), the rationale for each change, suggestions on how to implement the change, and evidence that the change led to improvement. Appendix 2 describes changes introduced to improve family planning counselling and education (Aim 2), the rationale for each change, suggestions on how to implement the change, and evidence that the change led to improvement. Appendix 3 describes changes introduced to improve the availability of family planning services and privacy (Aim 3), the rationale for each change, suggestions on how to implement the change, and evidence that the change led to improvement. Appendix 4 describes changes introduced to improve the use of tools to capture and monitoring family planning data (Aim 4), the rationale for each change, suggestions on how to implement the change, and evidence that the change led to improvement. Tested changes to improve family planning services in Uganda 7
Change packages for the four aims AIM 1 Build health care worker skills to provide family planning services Change idea Logic for change How the change was carried out Identify a focal person responsible for coordinating all FP activities including trainings and mentorships Conduct on job training and mentorships on FP Lobbied USAID implementing partners for additional FP training (mainly focused on long-term methods) Lack of a mechanism to coordinate skills building activities New staff allocated to the maternal newborn and child health departments had no skills to provide the long term family planning methods Despite trainings in school, workshops, and Continuous Medical Education (CME) sessions, some midwives lacked hands on skills to provide long-term contraceptives Many women wanted long-term contraceptive methods but health care workers lacked the skills to provide them leading to missed opportunities to provide FP. During the counseling sessions, midwives were afraid to talk to their clients about long-term methods because they were afraid they would not be able to dispense or administer them--in particular the intrauterine device (IUD). Identified a member of the team who had the skills to provide all FP contraceptives, including long-term contraceptives, to be responsible for coordinating all FP activities (e.g., orientation of new staff on dispensing FP contraceptives and allocation of skilled staff to provide FP services at various service points, including outreach). The focal persons included experienced midwives who had undertaken refresher training in provision of long-term contraceptives (5 health facilities tested and implemented this change) Identified skilled midwives, doctors and a few nurses trained in provision of longterm FP contraceptive methods to mentor less-skilled midwives and nurses. Duty schedules were adjusted to ensure that the mentors and mentees shared the same duty shifts to enable these mentorships (6 health facilities tested and implemented this change) Facility QI teams wrote to MSU, ACCORD under UNFPA, PACE & RHU program coordinators requesting for training of all technical staff in family planning. The team justified the training need by providing data of clients who were not provided long-term FP methods due to lack of provider skills to do so. The QI teams selected a week when most staff are available to take part in the training on provision of long term contraceptive methods. The onsite FP training included theory and discussions in the morning and mentorships and on the job training in the afternoon (2 health facilities implemented) Tested changes to improve family planning services in Uganda 8
AIM 2 Improve family planning counselling and education Change Idea Logic for change How the change happened Set up a family planning comprehensive counselling tray to allow mothers to see and touch the contraceptives during all health education and counselling session Work with satisfied users to share testimonies and experiences using modern family planning contraceptives Assign a midwife to provide family planning education and counselling every morning to postnatal mothers at the maternity ward prior to discharge Orientation of village health teams (VHTs) on key messages to talk about during FP counselling sessions Women did not know what some contraceptive methods looked like. For example, some mothers thought that the IUD was a big metal piece to be inserted into their body. Women had wrong information regarding different family planning methods. Some thought the IUD can cause cancer of the cervix and that the implant rods were comprised of hard metal that could dislocate from the site of insertion causing bleeding and eventually death. Myths, misinformation and fear of modern FP contraceptives among women of reproductive age was a key barrier toward use. Mothers thought that if one doesn t bleed while on contraception, blood collects somewhere in the body, will one day burst will bleed and die. The IUD can dislodge pierce the heart causing death, it can cause cancer of the cervix. Mothers immediate postobstetric event were being discharged with no family planning education and counseling Priority for one-onone counselling was given to the high-risk mothers (e.g., grand multiparas and those who presented with complications). There were few staff working in the maternal newborn and child health departments. They were not able to provide family planning education and counselling on a daily basis due to their busy schedules. Facility QI teams organized a tray containing all contraceptive methods, in addition to anatomical models and flip charts that showed how family planning methods are used.the tray was used during family planning education and counselling sessions for both group and individual sessions. It displayed all the methods, helps to reduce women s anxieties, as well as clear up the myths and misconceptions regarding various contraceptive methods. This change was successfully tested at 7 health facilities. The anatomical models were used to demonstrate how some methods are used (e.g., demonstrating condom use on the penile model). The flip charts had pictures showing where a particular contraceptive is placed in the body; this made it clearer to the client. Identified women in the Elimination of Mother To Child Transmission (EMTCT) program with HIV negative babies, who used FP contraceptives (commonly referred to as peer mothers). The peer mothers came from nearby facilities, supported by existing USAID Implementing Partners. They shared their experiences during the FP education sessions at various entry points; including antiretroviral therapy (ART), postnatal care (PNC), maternity care, and immunization and young child clinics (YCC). (Four health facilities tested this change). A midwife skilled in counseling and dispensing a range of FP contraceptives was assigned the role for counselling and providing family planning services at the maternity wards. The role was rotated on a monthly basis among the midwives working in the various MNCH departments (Four health facilities tested this change) Village health team members who were trained in family planning counselling and education were provided job aids and a guide on key messages to talk about at every FP counseling session that was held at the health facility on a daily basis. The VHT conducted a family planning group education session as the midwife listened, complimented and answered the technical questions. The midwife gave feedback to the VHT on how best to improve. (Six health facilities tested this change) Tested changes to improve family planning services in Uganda 9
AIM 3 Improve availability of family planning services and privacy Change Idea Logic for change How the change happened Include the medical stores manager in the family planning improvement work to monitor and give regular feedback on stock levels Identify a room and reorganize it for family planning services and use available curtains to create privacy for family planning services Redistribution of FP supplies from health facilities that had enough supply to health facilities that had stock-outs Lobby the existing IPs to provide buffer stock.. The team was not aware of the contraceptive methods available in the medical stores, and they had no idea as to why some methods were not supplied. Inadequate privacy for family planning services. Mothers could not openly talk to providers about personal matters, including their experiences, fears, and concerns in public regarding the use of FP contraceptives. Often, sites had stock-outs of commonly used family planning contraceptives. In some sites, it happened as a result of increased utilization of the services. Recurrent stock-out of contraceptives. The team realized that the stock-outs were due to poor projections by the medical stores personnel. Forecasts were made without consultation with the midwives. Made the store managers or keepers part of the MNCH QI teams. The team included stock updates on the weekly MNCH QI meeting s agenda. Developed a tool to show stock levels and hung it in different departments for staff reference. (One health center tested this change). Site teams worked with the head of the health facility to identify a room that could be reorganized and used for family planning services. Other teams used Primary Health Care (PHC) delegated funds to procure curtain material to create privacy screens. (Four health facilities successfully tested this change). Through the QI team leader, the stock levels were communicated to the facility in charge. Before the stock ran out, the facility in charge contacted the district medicine supervisor to find out where there were more stocks in order to redistribute them to sites where the stock was lower. (Six health facilities tested this change). The facility in-charge authorized the MNCH incharge to participate in the projections for the MNCH team. Periodically, based on the National Medical Stores schedule, the MNCH in-charge filled out and submitted a separate form for reproductive health and FP commodities Requested implementing partners to provide buffer stock of the various contraceptive methods at the end of the outreach activities. Reproductive Health Uganda, Marie Stopes Uganda, and PACE provided buffer stocks. In other sites, the problem was shared with the facility in-charge by the MNCH QI team leader. (Four health facilities tested this change). Tested changes to improve family planning services in Uganda 10
AIM 4 Improve the use of tools to capture and monitor family planning data Change Idea Logic for change How the change happened Use tally sheets and note books to track crucial family planning data Create a column in the register to track clients receiving FP counseling Use of a notebook to track family planning follow up appointments and referred clients Use of a summarized indicator table to capture progress on FP indicators at different service points Mothers were receiving family planning services (especially FP counselling) with no records made. It was very difficult for teams to assess performance in FP service provision and develop strategies moving forward. Clients receiving FP counseling and contraceptives through various entry points were not identified in a register since some MOH tools (e.g., the maternity register) did not have a provision for these services. Mothers receiving FP education and counseling immediate postpartum were choosing methods they were not eligible for. These were, in particular, the hormonal methods which are contraindicated for breastfeeding mothers before six weeks postpartum. The teams were taking very long to track performance on the various FP indicators. This was due to the heavy work load as data accumulated at the end of the month. During the QI review meeting it was realized that data had not been captured to monitor FP performance. This was as a result of the absence of a FP monitoring tool, especially to monitor clients who received FP counselling. The team used a notebook to record clients receiving counseling and FP education. (Four health facilities tested this change). A column was created in the maternity and the FP register to track clients receiving FP services at various entry points. This aided teams to distinguish service points by performance and develop targeted interventions. (Six health facilities tested this change). A new appointment register (that did not previously exist) was opened to follow up new mothers who opted for a method they could not take at the time of discharge so they can receive it at six weeks followup. Every clinic day mothers who received counselling and chose a method were identified and provided with the FP method. (One health facility tested this change). Midwives on duty in the antenatal and postnatal clinics and maternity wards used a notebook to summarize the contraceptives dispensed, new contraceptive users during the year, the refills, and the referred cases in the appropriate registers on a daily basis and extracted this information for discussion and decision during the weekly QI team meetings. Tested changes to improve family planning services in Uganda 11
APPENDICES Appendix 1: Changes introduced to build staff skills in providing family planning contraceptives including evidence CHANGE IDEA RATIONALE FOR THE CHANGE IDEA HOW TO GUIDE Conducting CMEs on Family Planning Lobby for FP training from the existing implementing partners In the 18 participating sites, an average of five staff had been trained in provision of FP contraceptives, but only two were able to provide contraceptives including the long-term methods. Mothers opted for long term contraceptive methods but health care workers needed skills to provide them leading to missed opportunities. During the counselling sessions midwives did not emphasize long-term methods in fear of mothers opting for them, and they are unable to dispense them. The contraceptive method affected most was the longterm IUD, midwives were not emphasizing its benefits in of fear that women may opt for it and no staff could give it Through brainstorming sessions in QI team meetings, inadequate skills to provide long-term FP contraceptives scored highest as a factor hindering quality FP services in the facilities. Topics for discussion were agreed upon in the meeting. Feed back to the facility in-charge about the need to build staff skills in provision of FP contraceptives was given by the QI team leader. The CME focal person was requested to include FP topics selected for discussion on the facility CME schedule. A memo was circulated to all departments to ensure that all technical staff participate in the discussion. One of the skilled staff was chosen to take lead in ensuring that the topic is researched about and presented to all the facility staff focusing more on the midwives since by the nature of their job they handle mothers more than other staff in the facilities. (Kibito, Rukunyu and Kyarusozi HCIVs) Wrote to the program coordinator requesting for support. The request was backed up with evidence of the number of clients who missed the contraceptives due to lack of skills to provide the long term IUD. Identified a day when most staff are available to participate in the meeting. Invited all staff at the facility to attend the training. (Kyaru//sozi HCIV and Rwamwanja HCIII) Tested changes to improve family planning services in Uganda 12
Appendix 2: Changes introduced to improve family planning counseling and education including evidence CHANGE IDEA RATIONALE FOR THE CHANGE IDEA HOW TO GUIDE EVIDENCE OF SUCCESSFUL CHANGE Assign a midwife to provide family planning education and counselling every morning before postnatal mothers are discharged. Mothers immediate post-obstetric event were being discharged with no family planning education and counselling. Priority was given to the high-risk mothers like the grand multiparas and those that presented with complications. A midwife skilled in counselling and dispensing a range of contraceptives was identified as focal person for provision of family planning services. Every month the family planning focal person allocated a midwife to conduct group education and counselling sessions on family planning. This is done at the postnatal ward. Allocation was exchanged on a monthly basis to give chance to all midwives take part in the activity hence, building their counselling and health education skills. (Kyenjojo General Hospital, Fort Portal Regional Referral Hospital, Rukunyu and Bukuuku HCIVs). Proportion of mothers immediate post-obstetric event receiving family planning education improved from 0% in Jan 2014 to 75% by July 2014 Develop and display a reminder for midwives to provide counselling before mothers are discharged Family planning education was not prioritized at different MNCH departments. Midwives were forgetting to talk about family planning to women attending the various maternal new-born and child health clinics Focal persons responsible for designing reminders was identified, agreed on the reminder message. Remember to give family planning information to all women 15-49years at every opportunity This was hung at nurse s station at the postnatal, antenatal, maternity, and immunization clinics. (Kibito HCIV) Women receiving family planning counselling and education at the Young Child Clinic and Immunization clinic improved from 00% in Jan 2014 to 90% by the end of March 2014 Develop key family planning health messages and display in the waiting area Whenever midwives gave family planning education and counselling, some very important information not included on the counselling charts was often times forgotten. Village health team (VHT) members allocated to support family planning education were giving differing information on family planning. The skilled midwives provided a group education and counselling session, as the VHTs observed. VHTs gave a session in the presence of the midwives. The midwife identified the key messages that were missed. These messages were basically the benefits of FP to the mother, father, children and the community. Messages were developed and displayed in the waiting areas for VHTs to refer to during education sessions and for mothers to read while waiting to be served. (Kibito Bukuuku and Kyarusozi HCIVs, Kyenjojo General Hospital and Butiiti HCIII) Tested changes to improve family planning services in Uganda 13
CHANGE IDEA RATIONALE FOR THE CHANGE IDEA HOW TO GUIDE EVIDENCE OF SUCCESSFUL CHANGE Conducting counselling during the ward rounds Some mothers were not able to attend the group education and counselling sessions Clients who missed counselling during labor are identified during the ward rounds and are counseled. A midwife is always allocated to conduct the counselling sessions for clients who are high risk or missed counselling at the time of admission, during labor and delivery. (Rukunyu HCIV) Integrate family planning education and counselling into the existing routine health education sessions Family planning education was not routinely done at the various service points. During a family planning learning session, teams shared this as a best practice with evidence of increasing percentage of women reached with information on FP. Comprehensive FP group education and counselling sessions are included on the health education schedules at the postnatal, Young Child, and immunization clinics. The group education sessions are followed by the individual counselling session for those who opt for family planning. (Fort Portal RRH, Kyenjojo General Hospital, Bukuuku, Rukunyu and Kyarusozi HCIVs) Conducting individual counselling sessions every after the group counselling and education session In a group education session, some women don t open up. There was fears, myths, misinformation, and stigma related to family planning After a group education and counselling session, individuals are called upon to have a one-on-one counselling sessions and to ask any question for clarity. This allowed for clearing all the myths and misinformation regarding FP contraceptive use. (Fort Portal RRH, Kyenjojo General Hospital, Bukuuku, Rukunyu and Kyarusozi HCIVs, Nyabani and Butiiti HCIIIs ) Tested changes to improve family planning services in Uganda 14
Appendix 3: Changes introduced to improve availability of family planning services and privacy CHANGE IDEA RATIONALE OF THE CHANGE IDEA HOW TO GUIDE Provision of priority services to couples Setting minimum stock levels Lobby from the exiting IP to provide buffer stock Identification of a room and reorganize it for family planning services. Use of curtains to create privacy for family planning services Integration of FP services in other services Male partners were not involved in the family planning and reproductive health services. Recurrent stock-outs of family planning contraceptives was attributed to lack of knowledge regarding stock levels. The requisitions were made late leading to late delivery of the contraceptives. Recurrent stock-out of contraceptives Inadequate privacy for family planning services. Mothers were not able to open up and share their experiences regarding use of family planning contraceptives. Site teams lacked privacy for FP services. Women were not able to open up in the group education and counselling session this left them with a lot of unclear information regarding family planning contraceptives. FP contraceptives were kept in the same room to ensure constant access to contraceptives. Involve men by providing them with health care services they may need: may include taking their Blood pressure, deworming and let them receive mosquito nets as a couple. Recognize the couples present and thank the men for participating in the reproductive health and Family Planning activities (Bukuuku HCIV, and Rwamwanja HCIII) The team Agreed on the minimum stock levels beyond which an order was made. A member of the QI team was given the role of closely monitoring contraceptive stock levels and alert the in charge when need arises. (Butiiti HCIII) Request the visiting implementing partners to provide buffer stock of the various contraceptive methods at the end of the outreach activities. The request is made through the facility in charge to the outreach team leader ( Fort portal RRH, Kibito, Kakumiro and Kakindo HCIVs) Work with the in charge to identify if there is a room that can be reorganized specifically for FP services. Label the room to ensure easy location by mothers referred for FP services to avoid getting lost between departments. (Kibito, Ntara, Kakindo HCIVs and Bufunjo HCIII) Use the same room for HIV counselling and testing to provide FP services. Allocated an examination coach for provision of FP services to ensure that thorough physical examination is done, including cervical cancer screening before methods are dispensed. Made a rota for staff to work in the FP clinic (Bukuuku, Kibiito, Kakumiro, Ntara, and Kakindo HCIVs, Fort Portal RRH) Tested changes to improve family planning services in Uganda 15
CHANGE IDEA RATIONALE OF THE CHANGE IDEA HOW TO GUIDE Contacting the referral site before Mothers were being referred to site without prior knowledge of availability of the contraceptive methods in the referral site. Teams were not sure whether the referred clients would be attended to. Informed the in-charge about the need for contacting the referral site before referrals are made. The in-charge included air time for calling referral sites on the monthly PHC budgets. A list of contacts for the referral sites including the IPs was generated and hung at the nurse s station. Referral sites are called before the clients are referred to confirm the availability of their FP preferred contraceptive (Fort Portal RRH, Kibito HCIV, and Butiiti HCIII) Tested changes to improve family planning services in Uganda 16
Appendix 4: Changes introduced to improve the use of tools to capture and monitor famly planning data CHANGE IDEA RATIONALE FOR THE CHANGE IDEA HOW TO GUIDE Use tally sheets together with the counter books Create a column in the register to capture FP counselling Use a note book to capture family planning follow-up appointments Introduction of internal referral cards from different departments Introduction of a counter book for referred clients Orientation of staff on use of the referral forms Use a summary sheet for the process and outcome indicators from the different service points Mothers were receiving Family Planning services with no records taken. It was very difficult for teams to asses performance and lay strategies moving forward. Clients receiving counselling and FP contraceptives through various entry points were not captured since some MOH tools like the maternity register did not have a provision for these services. Mothers receiving FP education and counselling immediate postpartum were choosing methods they were not eligible for. The FP methods were particularly the hormonal which are contraindicated for breast feeding mothers before six weeks postpartum. Hence not dispensed on discharge. Mothers were being referred from the different service points, to the FP clinic. Some were getting for those who reached lacked detail of services they had received and where they had received it. This led to missed opportunities and long waiting times, since the midwife had to start the process afresh. While in a QI team meeting, members realized that clients who were referred or provided with the modern contraceptives methods were not captured anywhere. New staff had been allocated to the various departments with no detailed orientation of the various process of FP services, including referral. The newly allocated staff continued to refer clients with no notes. The teams take so long to track performance on the various indicators. In QI review meeting it was realized that data had not been captured to monitor performance. This was as a result of absence of a monitoring tool, especially to monitor clients who received counselling. The team committed to use tally sheets and a note book to record clients receiving counselling and family planning education. (Bufunjo HCIII, Kakumiro and Bukuuku HCIVs Fort Portal RRH) A column was created in the maternity and the FP register to capture clients receiving FP services at various entry points (Kigalare, Nyabani HCIIIs, Kakumiro HCIV and Kyenjojo General Hospital Bukuuku HCIV and Bufunjo HCIII) An appointment register was opened to follow up clients who opted for a method they could not take at the time of discharge so they can receive it at six weeks. (Bukuuku HCIV). Every clinic day mothers who received counselling and chose a method are identified and provided with the FP method. Used empty medicine boxes to design interdepartmental referral notes. The referral note should include all the details of the client, including the method they are opting for and referring service point. These are used when referring clients from different departments to the FP clinic (Kyenjojo General Hospital) The team through the team leader requested the facility in-charge to avail a counter book to enable the team to keep track of all the referred clients. (Bukuuku HCIV, FRRH, Kakumiro HCIV) In a QI meeting, all team members were taken through the locally developed monitoring tools to improve client referral for FP services. Every end of the clinic days, staff make a summary of the contraceptives dispensed, new users of the year, the refills, and the referred cases. Tested changes to improve family planning services in Uganda 17
Tested changes to improve family planning services in Uganda 18