Perinatal care and its association with perinatal death among women attending care in three district hospitals of western Uganda.

BACKGROUND: Provision of effective care to all women and newborns during the perinatal period is a viable strategy for achieving the Sustainable Development Goal 3 targets on reducing maternal and neonatal mortality. This study examined perinatal care (antenatal, intrapartum, postpartum) and its association with perinatal deaths at three district hospitals in Bunyoro region, Uganda. METHODS: A cross-sectional study was conducted in which a questionnaire was administered consecutively to 872 postpartum women before discharge who had attended antenatal care and given birth in the study hospitals. Data on care received during antenatal, labour, delivery, and postpartum period, and perinatal outcome were extracted from medical records of the enrolled postnatal women using a pre-tested structured tool. The care received from antenatal to 24 h postpartum period was assessed against the standard protocol of care established by World Health Organization (WHO). Poisson regression was used to assess the association between care received and perinatal death. RESULTS: The mean age of the women was 25 years (standard deviation [SD] 5.95). Few women had their blood tested for hemoglobin levels, HIV, and Syphilis (n = 53, 6.1%); had their urine tested for glucose and proteins (n = 27, 3.1%); undertook an ultrasound scan (n = 262, 30%); and had their maternal status assessed (n = 122, 14%) during antenatal care as well as had their uterus assessed for contraction and bleeding during postpartum care (n = 63, 7.2%). There were 19 perinatal deaths, giving a perinatal mortality rate of 22/1,000 births (95% Confidence interval [CI] 8.1-35.5). Of these 9 (47.4%) were stillbirths while the remaining 10 (52.6%) were early neonatal deaths. In the antenatal phase, only fetal examination was significantly associated with perinatal death (adjusted prevalence ratio [aPR] = 0.22, 95% CI 0.1-0.6). No significant association was found between perinatal deaths and care during labour, delivery, and the early postpartum period. CONCLUSION: Women did not receive all the required perinatal care during the perinatal period. Perinatal mortality rate in Bunyoro region remains high, although it's lower than the national average. The study shows a reduction in the proportion of perinatal deaths for pregnancies where the mother received fetal monitoring. Strategies focused on strengthened fetal status monitoring such as fetal movement counting methods and fetal heart rate monitoring devices during pregnancy need to be devised to reduce the incidence of perinatal deaths. Findings from the study provide valuable information that would support the strengthening of perinatal care services for improved perinatal outcomes.

Midwives' perspectives about using individualized care plans in the provision of immediate postpartum care in Uganda; an exploratory qualitative study.

INTRODUCTION: Individualized care planning has been slowly integrated into practice in Uganda with minimal documentation of how the concept is applied in providing care. This study explored the perceptions of midwives about the use of individualized care plans (ICPs) in the provision of immediate postpartum care. METHODS: An exploratory descriptive qualitative approach was used in this study. We interviewed fifty midwives from 37 health facilities in Uganda's greater Mpigi region. The midwives, who were certificate and diploma holders, were purposively enrolled in the selected facilities. Deductive content analysis was done based on the COM-B model. RESULTS: Four themes emerged from the data namely; compatibility, motivation, opportunities, and the midwives' suggested strategies and targets for improved individualized care planning. The midwives were aware of individualized care planning and they utilized it in their provision of immediate postpartum care especially when assessing clients for risks, preparing clients for referral, caring for Human Immunodeficiency virus (HIV) exposed babies and their mothers, and educating/ supporting first-time mothers (automatic motivation). Having a good nurse-patient relationship, privacy, and ample time to care for the clients were noted as motivators for individualized care plan use, while poor documentation of care, high patient load, and perceived patients' lack of understanding of the complexities of illness in the immediate postpartum period were the barriers (social opportunity) identified by midwives to the use of individualized care planning. CONCLUSION: There are still capability, motivation, and opportunity hindrances to the use of individualized care planning. Staff recruitment, training, and harmonization of the documentation forms may improve the use of care plans in the postpartum period.

Experiences of referral with an obstetric emergency: voices of women admitted at Mbarara Regional Referral Hospital, South Western Uganda.

BACKGROUND: Life-threatening obstetric complications usually lead to the need for referral and constitute the commonest direct causes of maternal deaths. Urgent management of referrals can potentially lower the maternal mortality rate. We explored the experiences of women referred with obstetric emergencies to Mbarara Regional Referral Hospital (MRRH) in Uganda, in order to identify barriers and facilitating factors. METHODS: This was an exploratory qualitative study. In-depth interviews (IDIs) were conducted with 10 postnatal women and 2 attendants as key informants. We explored health system and client related factors to understand how these could have facilitated or hindered the referral process. Data was analyzed deductively employing the constructs of the Andersen Healthcare Utilization model. RESULTS: Women experienced transport, care delays and inhumane treatment from health care providers (HCPs). The obstetric indications for referral were severe obstructed labor, ruptured uterus, and transverse lie in advanced labor, eclampsia and retained second twin with intrapartum hemorrhage. The secondary reasons for referral included; non-functional operating theatres due to power outages, unsterilized caesarian section instruments, no blood transfusion services, stock outs of emergency drugs, and absenteeism of HCPs to perform surgery. Four (4) themes emerged; enablers, barriers to referral, poor quality of care and poor health facility organization. Most referring health facilities were within a 30-50 km radius from MRRH. Delays to receive emergency obstetric care (EMOC) led to acquisition of in-hospital complications and eventual prolonged hospitalization. Enablers to referral were social support, financial preparation for birth and birth companion's knowledge of danger signs. CONCLUSION: The experience of obstetric referral for women was largely unpleasant due to delays and poor quality of care which contributed to perinatal mortality and maternal morbidities. Training HCPs in respectful maternity care (RMC) may improve quality of care and foster positive postnatal client experiences. Refresher sessions on obstetric referral procedures for HCPs are suggested. Interventions to improve the functionality of the obstetric referral pathway for rural south-western Uganda should be explored.

Midwives' perceptions towards the ministry of health guidelines for the provision of immediate postpartum care in rural health facilities in Uganda.

BACKGROUND: Guidelines for clinical practice have been part of the Ministry of health's efforts to improve the quality of care for over two decades. Their benefits have been documented in Uganda. However, having practice guidelines may not always result in their use in care provision. We explored the midwives' perceptions towards the ministry of health guidelines for providing immediate postpartum care. METHODS: An exploratory descriptive qualitative study was conducted in three districts in Uganda from September 2020 to January 2021. In-depth interviews with 50 midwives from 35 health centers and 2 hospitals in Mpigi, Butambala, and Gomba districts were done. Thematic analysis of data was done. RESULTS: Three themes emerged; awareness and use of the guidelines, perceived drivers, and perceived barriers to the provision of immediate postpartum care. The subthemes for theme I included; awareness of the guidelines, variations in the postpartum care practices, variations in preparedness to manage women with complications, and varied access to continuing midwifery education. Fear of complications and litigation were the perceived drivers of guideline use. On the other hand, lack of knowledge, busy maternity units, organization of the care, and the midwives' perceptions about their clients were the barriers to guideline use. Midwives felt that new guidelines and policies regarding immediate postpartum care should be disseminated widely. CONCLUSION: The midwives felt that the guidelines were good for the prevention of postpartum complications but their knowledge of the guidelines for the provision of immediate postpartum care was suboptimal. They desired on-job training and mentorship to help them bridge the knowledge gaps. Variations in patient assessment, monitoring, and pre-discharge care were acknowledged and said to be due to a poor reading culture and health facility factors like patient-midwife ratios, unit setup, and prioritization of labor.

Readiness of rural health facilities to provide immediate postpartum care in Uganda.

BACKGROUND: Nearly 60% of maternal and 45% of newborn deaths occur within 24 h after delivery. Immediate postpartum monitoring could avert death from preventable causes including postpartum hemorrhage, and eclampsia among mothers, and birth asphyxia, hypothermia, and sepsis for babies. We aimed at assessing facility readiness for the provision of postpartum care within the immediate postpartum period. METHODS: A cross-sectional study involving 40 health facilities within the greater Mpigi region, Uganda, was done. An adapted health facility assessment tool was employed in data collection. Data were double-entered into Epi Data version 4.2 and analyzed using STATA version 13 and presented using descriptive statistics. RESULTS: Facility readiness for the provision of postpartum care was low (median score 24% (IQR: 18.7, 26.7). Availability, and use of up-to-date, policies, guidelines and written clinical protocols for identifying, monitoring, and managing postpartum care were inconsistent across all levels of care. Lack of or non-functional equipment poses challenges for screening, diagnosing, and treating postnatal emergencies. Frequent stock-outs of essential drugs and supplies, particularly, hydralazine, antibiotics, oxygen, and blood products for transfusions were more common at health centers compared to hospitals. Inadequate human resources and sub-optimal supplies inhibit the proper functioning of health facilities and impact the quality of postpartum care. Overall, private not-for-profit health facilities had higher facility readiness scores. CONCLUSIONS: Our findings suggest sub-optimal rural health facility readiness to assess, monitor, and manage postpartum emergencies to reduce the risk of preventable maternal/newborn morbidity and mortality. Strengthening health system inputs and supply side factors could improve facility capacity to provide quality postpartum care.

Gaps in available published data on abortion in Uganda and the missed opportunity to inform policy and practice.

Globally, 25% of pregnancies end up in induced abortion, the majority of which are unsafe. Abortion is safe when conducted according to WHO recommendations. The objective of the present study was to identify gaps in the data published on abortion and make recommendations to the Ministry of Health, Uganda. The search strategy included PubMed, Google Scholar articles (from October 2020 to May 2021) on unsafe abortion in Uganda, reviewed data from the Association of Obstetricians and Gynecologists of Uganda (AOGU) members' baseline survey (2019), Health Management Information System (HMIS) summary data (2015-2016 to 2019-2020), and the Uganda Demographic and Heath Survey (DHS) report (2011, 2016). From the 200 articles and national health surveys identified, 37 articles and two national representative surveys met our criteria: prevalence, factors, estimating cost of induced abortion, and complications associated with safe and unsafe abortion in both low- and high-income countries. There are many unsafe abortions in restrictive environments. Abortion is one of the leading causes of maternal and morbidity. Physicians favor dilatation and curettage over manual vacuum aspiration and medical methods for the evacuation of retained products. Several gaps still exist in the published articles, HMIS data, and DHS data, leading to missed opportunities for data to inform policy and practice.

Why mothers die at a busy tertiary urban hospital in Kampala, Uganda: a comprehensive review of maternal deaths 2016-2018 and implications for quality improvement to reduce deaths.

Background: Reviewing maternal deaths and drawing out lessons for clinical practice is part of an effective cohesive intervention strategy to reduce future deaths. Objective: To review maternal deaths at the National Referral hospital in Kampala over a 3-year period (2016-2018) to determine causes of death, extent of preventability, proportion of deaths notified and audited as per national guidelines. Methods: Trained-multidisciplinary panels (obstetricians and senior midwives) conducted retrospective reviews of maternal deaths that occurred. Results: Major causes of deaths: obstetric haemorrhage (158/350; 45%), hypertensive disorders of pregnancy (87/350; 25%) and infection (95/350; 27%). Overall, 294/350 (84%) of maternal deaths were considered preventable. In 95% (332/350) of cases, delays within healthcare facilities were identified (64%; 226/350). We note that only 115/350 (33%) cases had been audited. This proportion did not change during the studied period. In 48% (167/350) of cases, notification to the Ministry of Health occurred, but only 11% of deaths (39/350) were notified within the recommended 24-hours. Conclusions: A high proportion (84%) of deaths were preventable. Significant delays to care occurred within health-care facilities. Results suggest that a well-supported, and timely maternal death review process with targeted and pragmatic interventions might be effective in reducing maternal deaths in this setting.

Perinatal care in Western Uganda: Prevalence and factors associated with appropriate care among women attending three district hospitals.

BACKGROUND: Perinatal mortality remains high globally and remains an important indicator of the quality of a health care system. To reduce this mortality, it is important to provide the recommended care during the perinatal period. We assessed the prevalence and factors associated with appropriate perinatal care (antenatal, intrapartum, and postpartum) in Bunyoro region, Uganda. Results from this study provide valuable information on the perinatal care services and highlight areas of improvement for better perinatal outcomes. METHODS: A cross sectional survey was conducted among postpartum mothers attending care at three district hospitals in Bunyoro. Following consent, a questionnaire was administered to capture the participants' demographics and data on care received was extracted from their antenatal, labour, delivery, and postpartum records using a pre-tested structured tool. The care received by women was assessed against the standard protocol established by World Health Organization (WHO). Poisson regression with robust standard errors was used to assess factors associated with appropriate postpartum care. RESULTS: A total of 872 mothers receiving care at the participating hospitals between March and June 2020 were enrolled in the study. The mean age of the mothers was 25 years (SD = 5.95). None of the mothers received appropriate antenatal or intrapartum care, and only 3.8% of the participants received appropriate postpartum care. Factors significantly associated with appropriate postpartum care included mothers being >35 years of age (adjusted prevalence ratio [aPR] = 11.9, 95% confidence interval [CI] 2.8-51.4) and parity, with low parity (2-3) and multiparous (>3) mothers less likely to receive appropriate care than prime gravidas (aPR = 0.3, 95% CI 0.1-0.9 and aPR = 0.3, 95% CI 0.1-0.8 respectively). CONCLUSIONS: Antenatal, intrapartum, and postpartum care received by mothers in this region remains below the standard recommended by WHO, and innovative strategies across the continuum of perinatal care need to be devised to prevent mortality among the mothers. The quality of care also needs to be balanced for all mothers irrespective of the age and parity.

Factors associated with low childbirth self-efficacy for normal birth amongst women attending an urban prenatal clinic in Eastern Uganda.

OBJECTIVE: While childbirth self-efficacy is a very important feature for normal birth, this concept has received limited scholarly attention, particularly in developing countries. This study explored childbirth self-efficacy and the associated factors amongst pregnant women. DESIGN: A descriptive cross-sectional study. We used the Childbirth Self-Efficacy Inventory to assess childbirth self-efficacy for normal birth. and determined the associated factors. SETTING: Jinja regional referral hospital, Uganda. PARTICIPANTS: 425 pregnant women at ≥ 28 weeks of gestation were included. MEASUREMENTS: Participants with summated self-efficacy scores ≥ median were considered to have high childbirth self-efficacy, and those with less than the median summated score were considered to have low childbirth self-efficacy. Bivariate and multivariate binary logistic regressions were used to determine the factors associated with low childbirth self-efficacy. FINDINGS: The Childbirth Self-Efficacy Inventory items consistently measured childbirth self-efficacy with a Cronbach's α 0.934. Childbirth self-efficacy scores ranged from 84 to 303 with a median score of 233 and a mean score of 228.7 (SD: 40.9). Dissatisfaction with prenatal care (aOR = 2.687; 95% CI: 1.124-6.427; P = 0.026), perception of community social support for women during childbirth as lacking (aOR = 2.274; 95% CI: 1.159-4.458; P = 0.017) and use and/or intention to use herbal medicines in the current pregnancy (aOR = 2.850; 95% CI: 1.553-5.232; P = 0.001) were associated with low childbirth self-efficacy for normal birth. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Low childbirth self-efficacy for normal birth was associated with dissatisfaction with prenatal care, lack of community social support for women during childbirth and use or intention to use herbal medicines in the current pregnancy. Identifying the associated characteristics and developing interventions for low childbirth self-efficacy is of clinical importance to promote normal birth.

Using Andersen's Behavioral Model of Health Care Utilization to Assess Contraceptive Use among Sexually Active Perinatally HIV-Infected Adolescents in Uganda.

BACKGROUND: Contraceptive practices of perinatally HIV-infected adolescents (PHIAs) have implications related to pregnancy prevention, risks of HIV heterosexual transmission, reinfection, and vertical transmission. The study assessed contraceptive use among sexually active PHIAs in Uganda. METHODS: Mixed methods consisting of a survey and in-depth interviews were employed among 213 sexually active PHIAs who were attending antiretroviral therapy (ART) clinics. The study was guided by Andersen's Behavioral Model of Health Service Use as a theoretical framework to identify factors that influence contraceptive use. These factors include health care factors, personal characteristics, enabling factors, and needs. The outcome was contraceptive use. Multivariable logistic regression was used to establish determinants of contraceptive use. Qualitative data were analyzed by thematic analysis. RESULTS: Most PHIAs were female (67.6%); the mean (SD) and median (IQR) age was 17.5 (±1.4) and 18 (17-19) years. The mean age of sexual debut and at marriage were 15 (±1.7) and 17 (±1.1), respectively. Condoms were the most known method of family planning (indicated by 55.4%). Only 16.9% of the participants knew about dual protection (condom use for FP as well as HIV/STI prevention). Of the PHIAs, 43.6% had ever used modern contraception and 56.9% of the females had ever been pregnant. The odds of contraceptive ever-use were significantly higher among adolescents aged 17-19 years (OR 5.1, 95% CI: 2.1-13.3) compared to those aged 10-16 years, those in school (OR 1.8, 95% CI: 1.07-3.2) compared to those out of school, and those with perceived need to use FP (OR 2.0, 95% CI: 1.1-3.9) compared to their counterparts. The odds of contraceptive used were lower among females (OR 0.13, 95% CI: 0.06-0.28) compared to males. From the in-depth interviews, the attitude of health workers, availability of health workers, having a friend using family planning, and waiting time were viewed to affect contraceptive use. CONCLUSION: Contraceptive use among sexually active perinatally HIV-infected adolescents was (43.6%). However, out of those who used family planning majority were using short-term methods. The unmet need for family planning was high (47%) with high reports of pregnancy (56.9%). The factors associated with contraceptive use included education, age, sex (predisposing factors), and perceived need of family planning (need factors). Other factors that could affect contraceptive use from qualitative analysis included attitude of health workers, availability of health workers, having a friend using family planning (predisposing factors), and waiting time (health system factors). HIV care for adolescents should be promoted using SRH approach. There is a need to provide training for all providers to cater for SRH services. We should continue to provide youth-responsive adolescent sexual and reproductive health services across all ART facilities and build a supportive environment and continue to integrate SRH services into HIV care.

Ethical tensions in the informed consent process for randomized clinical trials in emergency obstetric and newborn care in low and middle-income countries.

BACKGROUND: There is unanimous agreement regarding the need to ethically conduct research for improving therapy for patients admitted to hospital with acute conditions, including in emergency obstetric care. We present a conceptual analysis of ethical tensions inherent in the informed consent process for randomized clinical trials for emergency obstetric care and suggest ways in which these could be mitigated. DISCUSSION: A valid consenting process, leading to an informed consent, is a cornerstone of this aspect necessary for preservation and maintenance of respect for autonomy and dignity. In emergency obstetric care research, obtaining informed consent can be problematic, leading to ethical tension between different moral considerations. Potential participants may be vulnerable due to severity of disease, powerlessness or impaired decisional capacity. Time for the consent process is limited, and some interventions have a narrow therapeutic window. These factors create ethical tension in allowing potentially beneficial research while avoiding potential harms and maintaining respect for dignity, human rights, justice and autonomy of the participants. CONCLUSION: Informed consent in emergency obstetric care in low- and middle-income countries poses numerous ethical challenges. Allowing research on vulnerable populations while maintaining respect for participant dignity and autonomy, protecting participants from potential harms and promoting justice underlie the ethical tensions in the research in emergency obstetric and newborn care. Those involved in research conduct or oversight have a duty of fair inclusion, to avoid denying participants the right to participate and to any potential research benefits.

A need to accelerate health research productivity in an African University: the case of Makerere University College of Health Sciences.

BACKGROUND: In the last decade, Makerere University College of Health Sciences (MakCHS) has taken strides in research and training to improve healthcare through collaborative training and research programs. However, there is limited data on the trends of MakCHS faculty contributions to research and on faculty growth to take leading roles in health research. This paper reviews MakCHS faculty research publications over 15.5 years and outlines possible strategies to enhance faculty research outputs. METHODS: We used a mixed methods approach. A systematic review of research publications by faculty at MakCHS (PubMed and Google Scholar from January 1, 2000, to June 30, 2015) to quantify the number of research articles, areas researched, authorship contribution by MakCHS faculty, source of funding, as well as affiliated local and international collaborations. Graphs were used to shown trends in publications and leadership of authorship by faculty. Annual individual faculty research productivity was presented as publication per capita. Qualitative data on high priority needs to improve research outputs was collected through focus group discussions (FGDs) with faculty members, and analysed manually into emerging themes. RESULTS: Of 298 faculty at MakCHS at 2015, 89 (30%) were female and 229 (77%) were junior and mid-level faculty (senior lecturer and below). The PubMed and Google Scholar searches yielded 6927 published articles, of which 3399 (49%) full-text articles were downloaded for analysis, 426/3825 (11%) available as titles/abstracts only, and 598/4423 (14%) were excluded. Only 614 articles were published in 2014, giving a publication per capita of 2.1 for any authorship, and 0.3 for first and last authorship positions. MakCHS faculty increasingly contributed as first, second, third, and last authors. Up to 57% of research was in infectious diseases, followed by non-communicable diseases (20%) and non-communicable maternal child health (11%). Priority needs to improve research outputs, as expressed by faculty, were (1) an institutionally led faculty career development program, (2) skills building in research methods and scientific writing, (3) protected time for research related activities, (4) opportunities for collaborative research, and (5) use of individual development plans. CONCLUSION: Faculty research productivity was low and dominated by infectious diseases and non-communicable disease research. There is a need for structured institutional support to optimise faculty research outputs. Only with increased research productivity will MakCHS and other academic institutions be able to make a significant contribution in addressing national health challenges.

Effect of suppressive acyclovir administered to HSV-2 positive mothers from week 28 to 36 weeks of pregnancy on adverse obstetric outcomes: a double-blind randomised placebo-controlled trial.

BACKGROUND: Acyclovir (ACV) given to HSV-2 positive women after 36 weeks reduces adverse outcomes but its benefit at lower gestation was undocumented. We determined the effect of oral acyclovir administered from 28 to 36 weeks on premature rupture of membranes (PROM) primarily and preterm delivery risk. METHODS: This was a randomized, double-blind placebo-controlled trial among 200 HSV-2 positive pregnant women at 28 weeks of gestation at Mulago Hospital, Uganda. Participants were assigned randomly (1:1) to take either acyclovir 400 mg orally twice daily (intervention) or placebo (control) from 28 to 36 weeks. Both arms received acyclovir after 36 weeks until delivery. Development of Pre-PROM by 36 weeks and preterm delivery were outcomes. RESULTS: One hundred women were randomised to acyclovir and 100 to placebo arms between January 2014 and February 2015. There was tendency towards reduction of incidence of PROM at 36 weeks but this was not statistically significant (4.0% versus 10.0%; RR 0.35; 95% 0.11-1.10) in the acyclovir and placebo arms respectively. However, there was a significant reduction in the incidence of preterm delivery (11.1% versus 23.5%; RR 0.41; 95% 0.20-0.85) in the acyclovir and placebo arms respectively. CONCLUSIONS: Oral acyclovir given to HSV-2 positive pregnant women from 28 to 36 weeks reduced incidence of preterm delivery but did not significantly reduce incidence of pre-PROM. TRIAL REGISTRATION: www.pactr.org, PACTR201311000558197 .

Prevalence and predictors of unknown HIV status among women delivering in Mulago National Referral Hospital, Kampala, Uganda.

INTRODUCTION: Knowledge of a person's HIV status during pregnancy is critical for prevention of mother to child transmission of HIV. OBJECTIVES: To determine the prevalence and factors associated with unknown HIV status among women delivering in Mulago Hospital. METHODS: This was a cross-sectional study of women that had just delivered. The women's demographic characteristics, health seeking behaviour, health system-related factors and knowledge on PMTCT were collected. Fisher's exact test, Wilcoxon rank sum test and logistic regression were used to test associations. RESULTS: The prevalence of unknown HIV status was 2.6% (10/382). Attending ANC at higher level facilities (OR =0.1 95% CI 0.0 - 0.4) and having been counselled for HIV testing during ANC (OR=0.1, 95% CI 0.0 - 0.4) were associated with likelihood of having a known HIV status. Out of the ten women with unknown HIV status, 4/6 who attended ANC in public/government accredited health facilities "opted out" of HIV testing due to personal reasons. Among the four who attended ANC in private clinics, two were not offered HIV testing and one "opted out". CONCLUSION: Most participants had a known HIV status at labour (97%). Private clinics need to be supported to provide free quality HCT services in ANC.

Incidence and risk factors for herpes simplex virus type 2 seroconversion among pregnant women in Uganda: A prospective study.

INTRODUCTION: Herpes simplex virus type 2 (HSV-2) acquired during pregnancy is associated with adverse outcomes such as perinatal HSV-2 transmission. HSV-2 seroconversion occurs within four weeks of HSV-2 acquisition. There was neither documented incidence nor risk factors for HSV-2 seroconversion during pregnancy in Uganda. The objective of this study was to determine the incidence and risk factors for HSV-2 seroconversion among pregnant women in Mulago Hospital, Uganda. METHODOLOGY: A prospective study of 200 consenting HSV-2-negative women between 26 and 28 weeks of gestation was done between November 2013 and October 2014. HSV-2 serostatus was determined using HerpeSelect HSV-2 enzyme-linked immunosorbent assay (ELISA). Interviewer-administered questionnaires were used to collect socio-demographic characteristics and sexual history. Human immunodeficiency virus (HIV) serostatus was obtained from antenatal records. A total of 191 women completed follow-up and repeat HSV-2 serology by 38 weeks. Negative binomial regression analysis was used to estimate risk ratios for risk factors for HSV-2 seroconversion. RESULTS: Of 191 women, 15 (7.9%) seroconverted during pregnancy. Having multiple sexual partners, being in polygamous unions, and having HIV-positive serostatus were found to be risk factors for HSV-2 seroconversion. CONCLUSIONS: The incidence of HSV-2 seroconversion during pregnancy in Uganda was high. Multiple sexual partners, polygamy, and HIV-positive serostatus were risk factors for HSV-2 seroconversion during pregnancy. Strengthening health education on the avoidance of multiple sexual partners during pregnancy is paramount in prevention of HSV-2 seroconversion.

Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit.

BACKGROUND: Obstructed labour remains a major cause of maternal morbidity and mortality whose complications can be reduced with improved quality of obstetric care. The objective was to assess whether criteria-based audit improves quality of obstetric care provided to women with obstructed labour in Mulago hospital, Uganda. METHODS: Using criteria-based audit, management of obstructed labour was analyzed prospectively in two audits. Six standards of care were compared. An initial audit of 180 patients was conducted in September/October 2013. The Audit results were shared with key stakeholders. Gaps in patient management were identified and recommendations for improving obstetric care initiated. Six standards of care (intravenous fluids, intravenous antibiotics, monitoring of maternal vital signs, bladder catheterization, delivery within two hours, and blood grouping and cross matching) were implemented. A re-audit of 180 patients with obstructed labour was conducted four months later to evaluate the impact of these recommendations. The results of the two audits were compared. In-depth interviews and focus group discussions were conducted among healthcare providers to identify factors that could have influenced the audit results. RESULTS: There was improvement in two standards of care (intravenous fluids and intravenous antibiotic administration) 58.9 % vs. 86.1 %; p < 0.001 and 21.7 % vs. 50.5 %; P < 0.001 respectively after the second audit. There was no improvement in vital sign monitoring, delivery within two hours or blood grouping and cross matching. There was a decline in bladder catheterization (94 % vs. 68.9 %; p < 0.001. The overall mean care score in the first and second audits was 55.1 and 48.2 % respectively, p = 0.19. Healthcare factors (negative attitude, low numbers, poor team work, low motivation), facility factors (poor supervision, stock-outs of essential supplies, absence of protocols) and patient factors (high patient load, poor compliance to instructions) contributed to poor quality of care. CONCLUSION: Introduction of criteria based audit in the management of obstructed labour led to measurable improvements in only two out of six standards of care. The extent to which criteria based audit may improve quality of obstetric care depends on having basic effective healthcare systems in place.

Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants and prognostic factors.

BACKGROUND: Maternal near misses occur more often than maternal deaths and could enable more comprehensive analysis of risk factors, short-term outcomes and prognostic factors of complications during pregnancy and childbirth. The study determined the incidence, determinants and prognostic factors of severe maternal outcomes (near miss or maternal death) in two referral hospitals in Uganda. METHODS: A prospective cohort study was conducted between March 1, 2013 and February 28, 2014, where cases of severe pregnancy and childbirth complications were included. The clinical conditions included abortion-related complications, obstetric haemorrhage, hypertensive disorders, obstructed labour, infection and pregnancy-specific complications such as febrile illness, anemia and premature rupture of membranes. Near miss cases were defined according to the WHO criteria. Multivariate logistic regression analysis was conducted to identify prognostic factors for severe maternal outcomes. RESULTS: Of 3100 women with severe obstetric complications, 130 (4.2%) were maternal deaths and 695 (22.7%) were near miss cases. Severe pre-eclampsia was the commonest morbidity (incidence ratio (IR) 7.0%, case-fatality rate (CFR) 2.3%), followed by postpartum haemorrhage (IR 6.7%, CFR 7.2%). Uterine rupture (IR 5.5%) caused the highest CFR (17.9%), followed by eclampsia (IR 0.4%, CFR 17.8%). The three groups (maternal deaths, near misses and non-life-threatening obstetric complications) differed significantly regarding gravidity and education level. The commonest diagnostic criteria for maternal near miss were admission to the high dependency unit (HDU) or to the intensive care unit (ICU). Thrombocytopenia, circulatory collapse, referral to a more specialized unit, intubation unrelated to anaesthesia, and cardiopulmonary resuscitation were predictive of maternal death (p < 0.05). Gravidity (ARR 1.4, 95% C1 1.0-1.2); elevated serum lactate levels (ARR 4.5, 95% CI 2.3-8.7); intubation for conditions unrelated to general anaesthesia (ARR 2.6 (95% CI 1.2-5.7), cardiovascular collapse (ARR 4.9, 95% CI 2.5-9.5); transfusion of 4 or more units of blood (ARR 1.9, 95% CI 1.1-3.1); being an emergency referral (ARR 2.6, 95% CI 1.2-5.6); and need for cardiopulmonary resuscitation (ARR 6.1, 95% CI 3.2-11.7), were prognostic factors. CONCLUSIONS: The analysis of near misses is a useful tool in the investigation of severe maternal morbidity. The prognostic factors for maternal death, if instituted, might save many women with obstetric complications.

Factors associated with early resumption of sexual intercourse among postnatal women in Uganda.

BACKGROUND: Despite being a key component to be addressed during postnatal period, sexuality has long been a subject of secrecy and taboo in Africa. Resumption of sexual intercourse after giving birth has been shown to reduce extramarital affairs and consequently reduce risk of sexually transmitted infections like HIV/AIDS. Consequences of early resumption of sexual intercourse include unwanted pregnancy, genital trauma and puerperal infection. The objective of the study was to assess prevalence and factors associated with early resumption of sexual intercourse among postnatal mothers attending postnatal clinic at a National referral Hospital in Uganda. METHODOLOGY: A cross-sectional study that employed an interviewer-administered questionnaire was conducted among 374 women who delivered six months prior to conducting the study. The independent variables included socio-demographic characteristics of the participant, socio-demographic characteristics of the spouse, perceived cultural norms, medical history, mode of delivery, and postpartum complications. The dependent variable was timing of resumption of sexual intercourse after childbirth (before or after six weeks postpartum). Data were analysed using SPSS version 16.0. RESULTS: The study showed that 105 participants (21.6%) had resumed sexual intercourse before 6 weeks after childbirth. The participants' education level, occupation, and parity; education level of the spouse, age of baby and use of family planning were the factors associated with early resumption of sexual intercourse after child birth (before six weeks postpartum) (p < 0.05). CONCLUSION: Many women resumed sexual intercourse after six weeks. Women with high income, low parity, who ever-used contraception or had a spouse with high education level were more likely to have early resumption of sexual intercourse.

Incidence and determinants of neonatal morbidity after elective caesarean section at the national referral hospital in Kampala, Uganda.

BACKGROUND: Elective caesarean sections (ECS) have been implicated in increased risk of adverse neonatal outcomes. The primary objective was to assess the incidence and determinants of neonatal morbidity after elective caesarean section deliveries. The secondary objective was to describe the maternal morbidity associated with elective caesarean section. METHODS: This was a prospective cohort study of women admitted for ECS, as well as their newborns, conducted at Mulago hospital from March 1, 2013 to February 28, 2014. These were followed from the time of the operation until 6 weeks after hospitalization following the caesarean delivery. Data was collected using an interviewer-administered questionnaire and review of medical records for demographic characteristics, obstetric history, current pregnancy complications and pregnancy outcomes up to hospital discharge. Study outcomes were maternal and neonatal morbidity. The data was analyzed using Stata version 12. RESULTS: There were 25,846 deliveries during the study period, of which 20,083 (77.7%) were vaginal deliveries or assisted deliveries, and 5763 (22.3%) were caesarean sections. Of the caesarean sections, 920 (15.9%) were ECS. The commonest maternal morbidity was hemorrhage (17.2%). A birth weight less than 2500 g (aRR 11.0 [95% CI 8.1-17.2]) or more than 4000 g (aRR 12.2 [95% CI 10.6-23.2]), delivery at gestation age less than or equal to 38 weeks (aRR 1.62 [95% 1.20-2.10]), multigravidity (aRR 1.70 [95% CI 1.20-2.90]) and using general anaesthesia (aRR 2.43 [95% CI 1.20-5.90]) were associated with risk of neonatal morbidity. The commonest neonatal morbidity is respiratory distress especially if delivery occurs at a gestation age of 37 weeks or lower, if the birth weight is less than 2500 g or more than 4000 g, and if general anesthesia is used. CONCLUSION: Our study shows that at Mulago Hospital, ECS is associated with significant neonatal and maternal morbidity. We recommend that elective caesarean sections be performed after 39 weeks of gestation, and preferably avoid using general anaesthesia.