Predictors of immediate neonatal outcome after cesarean section in Uganda.

OBJECTIVE: To identify predictors of low Apgar score, immediate neonatal death, and stillbirth after cesarean section in Uganda. METHODS: Records of cesarean sections performed at all 14 regional referral hospitals and also 14 first-level (district) hospitals in Uganda were reviewed. Both elective and emergency cases were included. Data comprised mother's age, indication, type of anesthesia, and immediate outcome of the newborn. To evaluate the relation of the predictor variables to outcome, regression analysis was performed. RESULTS: A total of 37 585 cesarean sections were recorded. The indications for cesarean section that led to the highest neonatal mortality and stillbirth rates and lowest mean Apgar scores were uterine rupture and hemorrhage. Emergency surgery and general anesthesia had worse neonatal outcomes than elective surgery and spinal anesthesia. Compared with general anesthesia, spinal anesthesia was favorable for neonatal outcomes. CONCLUSION: Elective surgical planning and scale-up of the use of spinal anesthesia may potentially reduce stillbirths and immediate neonatal deaths.

Ultrasound at labour triage in eastern Uganda: A mixed methods study of patient perceptions of care and providers' implementation experience.

In settings where antenatal ultrasound is not offered routinely, ultrasound use when a woman first presents to the maternity ward for labour (i.e., triage) may be beneficial. This study investigated patients' perceptions of care and providers' experience with ultrasound implementation during labour triage at a district referral hospital (DH) and three primary health centers (HC) in eastern Uganda. This was a mixed methods study comprising questionnaires administered to women and key informant interviews among midwives pre- and post-ultrasound introduction. Bivariate analyses were conducted using chi-square tests. Qualitative themes were categorized as (1) workflow integration; (2) impact on clinical processes; (3) patient response to ultrasound; and (4) implementation barriers. A total of 731 and 815 women completed questionnaires from the HCs and DH, respectively. At the HC-level, triage quality of care, satisfaction and recommendation ratings increased with implementation of ultrasound. In contrast, satisfaction and recommendation ratings did not differ upon ultrasound introduction at the DH, whereas perceived triage quality of care increased. Most participants noted a perceived improvement in midwives' experience and knowledge upon introduction of ultrasound. Women who underwent a scan also reported diverse feelings, such as fear or worry about their delivery, fear of harm due to the ultrasound, or relief after knowing the baby's condition. For the midwives' perspective (n = 14), respondents noted that ultrasound led to more accurate diagnoses (e.g., fetal position, heart rate, multiple gestation) and improved decision-making. However, they noted health system barriers to ultrasound implementation, such as increased workload, not enough ultrasound-trained providers, and irregular electricity. While triage ultrasound in this context was seen as beneficial to mothers and useful in providers' clinical assessments, further investigation around provider-patient communication, system-level challenges, and fears or misconceptions among women are needed.

Institutionalizing a Regional Model for Improving Quality of Newborn Care at Birth Across Hospitals in Eastern Uganda: A 4-Year Story.

INTRODUCTION: Despite the rapid increase in facility deliveries in Uganda, the number of adverse birth outcomes (e.g., neonatal and maternal deaths) has remained high. We aimed to codesign and co-implement a locally designed package of interventions to improve the quality of care in hospitals in the Busoga region. DESIGN AND IMPLEMENTATION: This project was designed and implemented in 3 phases in the 6 main hospitals in east-central Uganda from 2013 to 2016. First, the inception phase engaged health system managers to codesign the intervention. Second, the implementation phase involved training health providers, strengthening the data information system, and providing catalytic equipment and medicines to establish newborn care units (NCUs) within the existing infrastructure. Third, the hospital collaborative phase focused on clinical mentorship, maternal and perinatal death reviews (MPDRs), and collaborative learning sessions. ACHIEVEMENTS: In all 6 participating hospitals, we achieved institutionalization of NCUs in maternity units by establishing kangaroo mother care areas, resuscitation corners, and routine MPDRs. These improvements were associated with reduced maternal and neonatal deaths. Facilitators of success included a simple, low-cost, and integrated package designed with local health managers; the emergence of local neonatal care champions; implementation and support over a reasonably long period; decentralization of newborn care services; and use of mainly existing local resources (e.g., physical space, human resources, and commodities). Barriers to success related to limited hospital resources, unstable electricity, and limited participation from doctors. More advanced NCUs have been established in 3 of the 6 hospitals, and 7 high-volume comprehensive health centers have been established with functional NCUs. CONCLUSION: The involvement of local health workers and leaders was the foundation for designing, sustaining, and scaling up feasible interventions by harnessing available resources. These findings are relevant for the quality of care improvement efforts in Uganda and other resource-restrained settings.

Midwife-performed checklist and ultrasound to identify obstetric conditions at labour triage in Uganda: A quasi-experimental study.

OBJECTIVE: The aim of this study was to evaluate the effect of a midwife-performed checklist and limited obstetric ultrasound on sensitivity and positive predictive value for a composite outcome comprising multiple gestation, placenta praevia, oligohydramnios, preterm birth, malpresentation, abnormal foetal heart rate. DESIGN: Quasi-experimental pre-post intervention study. SETTING: Maternity unit at a district hospital in Eastern Uganda. INTERVENTIONS: Interventions were implemented in a phased approach: standardised labour triage documentation (Phase 1), a triage checklist (Phase 2), and checklist plus limited obstetric ultrasound (Phase 3). PARTICIPANTS: Consenting women presenting to labour triage for admission after 28 weeks of gestation between February 2018 and June 2019 were eligible. Women not in labour or those requiring immediate care were excluded. 3,865 women and 3,937 newborns with similar sample sizes per phase were included in the analysis. MEASUREMENT AND FINDINGS: Outcome data after birth were used to determine true presence of a complication, while intake and checklist data were used to inform diagnosis before birth. Compared to Phase 1, Phase 2 and 3 interventions improved sensitivity (Phase 1: 47%, Phase 2: 68.8%, Phase 3: 73.5%; p ≤ 0.001) and reduced positive predictive value (65.9%, 55%, 48.7%, p ≤ 0.001) for the composite outcome. No phase differences in adverse maternal or foetal outcomes were observed. CONCLUSION: Both a triage checklist and a checklist plus limited obstetric ultrasound improved accurate identification of cases with some increase in false positive diagnosis. These interventions may be beneficial in a resource-limited maternity triage setting to improve midwives' diagnoses and clinical decision-making.

Effect of a labor triage checklist and ultrasound on obstetric referral at three primary health centers in Eastern Uganda.

OBJECTIVE: To test whether introduction of a midwife-performed triage checklist and focused ultrasound improves diagnosis and referral for obstetric conditions, including multiple gestation, placenta previa, oligohydramnios, preterm birth, malpresentation, and abnormal fetal heart rate. METHODS: We implemented an intake log (Phase 1), a checklist (Phase 2), and a checklist plus ultrasound scan (Phase 3) at three primary health centers in Eastern Uganda for women presenting in labor. Intake diagnoses, referral status, and delivery outcomes were assessed, as well as sensitivity and positive predictive value (PPV). RESULTS: Between February 2018 and July 2019, 1155, 961, and 603 women were enrolled across the three phases (n=2719); 2339 had outcome data. Incidence of any outcome-confirmed condition was 8.8%, 7.9%, and 7.1% (P=0.526) for each phase, respectively. The proportion of referred women with a condition did not change between Phases 1 and 2 (7.8% versus 8.6%, P=0.855), but increased in Phase 3 (48.4%, P<0.001). Sensitivity improved with each intervention; PPV decreased with ultrasound. CONCLUSION: Use of ultrasound plus checklist increased referrals and sensitivity for high-risk conditions, with decreased PPV. The checklist alone improved correct diagnosis, but not referral. Further evaluation of these triage interventions to maximize diagnostic accuracy, referral decisions, and outcomes are warranted.

Efficacy of an ultrasound training program for nurse midwives to assess high-risk conditions at labor triage in rural Uganda.

Many high-risk conditions of pregnancy are undetected until the time of delivery in low-income countries. We developed a point-of-care ultrasound training protocol for providers in rural Uganda to detect fetal distress or demise, malpresentation, multiple gestation, placenta previa, oligohydramnios and preterm delivery. This was a mixed-methods study to evaluate the 2-week training curriculum and trainees' ability to perform a standard scanning protocol and interpret ultrasound images. Surveys to assess provider confidence were administered pre-training, immediately after, and at 3-month follow up. Following lecture and practical demonstrations, each trainee conducted 25 proctored scans and were required to pass an observed structured clinical exam (OSCE). All images produced 8 weeks post course underwent blinded review by two ultrasound experts to assess image quality and to identify common errors. Key informant interviews further assessed perceptions of the training program and utility of point-of-care ultrasound. All interviews were audio recorded, transcribed, and reviewed by multiple readers using a content analysis approach. Twenty-three nurse/nurse midwives and two physicians from one district hospital and three health centers participated in the training curriculum. Confidence levels increased from an average of 1 point pre-course to over 6 points post-course for all measures (maximum of 7 points). Of 25 participants, 22 passed the OSCE on the first attempt (average score 89.4%). Image quality improved over time; the final error rate at week 8 was less than 5%, with an overall kappa of 0.8-1 for all measures between the two reviewers. Among the 12 key informant interviews conducted, key themes included a desire for more hands-on training and longer duration of training and challenges in balancing clinical duties with ability to attend training sessions. This study demonstrates that providers without previous ultrasound experience can detect high-risk conditions during labor with a high rate of quality and accuracy after training.

Surgery in district hospitals in rural Uganda-indications, interventions, and outcomes.

BACKGROUND: There is a vast unmet need for surgical interventions in resource scarce settings. The poorest 2 billion people share 3·5% of the world's operations. The highest burden of surgical disease is seen in Africa where surgery could avert many deaths. Prospective studies investigating interventions, indications, and outcomes including perioperative mortality rates (POMR) after surgery are scant. The aim of the study was to describe the situation of surgery in a low-income setting in sub-Saharan Africa. METHODS: In this descriptive, facility-based study, data were prospectively collected in questionnaires by 41 staff employed at two hospitals (Iganga General Hospital and Buluba Mission Hospital) in eastern Uganda during 4 months (major surgeries) and 3 months (minor surgeries) in 2011. Data included patient characteristics, interventions, indications for surgery, and in-hospital mortality after surgery. Descriptive statistical methods were used to analyse the data. FINDINGS: 2701 patients underwent 2790 surgical interventions. Of these, 1051 patients underwent major surgery, which corresponds to a major surgery rate of 224·8 per 100 000 population. Most patients undergoing major surgery were women (n=923, 88%). Pregnancy related complications (n=747, 66%) leading to caesarean section (n=496, 47%) and evacuation (n=244, 22%) or gynaecological conditions (n=114, 10%) were common indications for surgery. General surgery interventions registered were herniorrhaphy (n=103, 9%), explorative laparotomy (n=60, 5%), and appendicectomy (n=31, 3%). Overall, the POMR was 0·6% (16 deaths); for major surgery it was 1·3% (14 deaths) and for minor surgeries it was 0·1% (two of 1650 patients). High POMR were seen following explorative laparotomy (13·3%, eight deaths) and caesarean section (0·8%, four deaths). Of the 510 babies delivered through caesarean section, 59 (12%) were still born or died before discharge. INTERPRETATION: Rates of surgery are low in the study setting compared with in high-income settings where surgical rates exceed 11 000 per 100 000 population. POMR are high after exploratory laparotomy and caesarean section. Although very detailed, a larger study could be undertaken to investigate the situation in other settings. Underlying reasons leading to death and quality of surgical care should be investigated further so that POMR can be reduced in this setting. FUNDING: The Swedish Society of Medicine and the Golje Foundation.

Cost of surgery in a low-income setting in eastern Uganda.

BACKGROUND: Operative interventions have traditionally been seen as expensive; therefore, surgery has been given low priority in global health care planning in low-income countries. A growing body of evidence indicates that surgery can also be highly cost effective in low-income settings, but our current knowledge of the actual cost of surgery in such settings is limited. This study was carried out to obtain data on the costs of commonly performed operative procedures in a rural/semiurban setting in eastern Uganda. METHODS: A prospective, facility-based study carried out at a general district hospital (public) and a mission hospital (private, not-for-profit) in the Iganga and Mayuge districts in eastern Uganda. Items included in the cost calculations were staff time, materials and medicines, overhead costs, and capital costs. RESULTS: The cost of surgery was higher at the mission hospital, with higher expenditure and lower productivity than the public hospital. The most commonly performed major procedures were caesarean section, uterine evacuation, and herniorrhaphy for groin hernia. The costs for these interventions varied between $68.4 and $74.4, $25.0 and $32.6, and $58.6 and $66.0, respectively. The most commonly performed minor procedures were circumcision, suture of cuts and lacerations, and incision and drainage of abscess. The costs for these interventions varied between $16.2 and $24.6, $15.8 and $24.3, and $10.1 and $18.6, respectively. CONCLUSION: The cost of surgery in the study setting compares favorably with other prioritized health care interventions, such as treatment for tuberculosis, human immunodeficiency virus/AIDS, and childhood immunization. Surgery in low-income settings can be made more cost effective, leading to increased quantity and improved quality of surgical services.

District-level surgery in Uganda: Indications, interventions and perioperative mortality.

BACKGROUND: The world's poorest 2 billion people, benefit from no more than about 3.5% of the world's operative procedures. The burden of surgical disease is greatest in Africa, where operations could save many lives. Previous facility-based studies have described operative procedure caseloads, but prospective studies investigating interventions, indications and perioperative mortality rates (POMR), are rare. METHODS: A prospective, questionnaire-based collection of data on all major and minor operative procedures was undertaken at 2 hospitals in rural Uganda covering 4 and 3 months in 2011, respectively. Data included patient characteristics, indications for the interventions performed, and outcome after surgery. RESULTS: We recorded 2,790 operative procedures on 2,701 patients. The rate of major operative procedures per 100,000 population per year was 225. Patients undergoing major operative procedures (n = 1,051) were mostly women (n = 923; 88%) because most interventions were performed owing to pregnancy-related complications (n = 747; 67%) or gynecologic conditions (n = 114; 10%). General operative interventions registered included herniorrhaphy (n = 103; 9%), exploratory laparotomy (n = 60; 5%), and appendectomy (n = 31; 3%). The POMR for major operative procedures was 1% (n = 14) and was greatest after exploratory laparotomy (13%; n = 8) and caesarean delivery (1%; n = 4). Most deaths (n = 16) were a result of sepsis (n = 10-11) or hemorrhage (n = 3-5). CONCLUSION: The volume of surgery was low relative to the size of the catchment population. The POMR was high. Exploratory laparotomy and caesarean section were identified as high-risk procedures. Increased availability of blood, improved perioperative monitoring, and early intervention could be part of a solution to reduce the POMR.