ACT for Birth: Improving the Quality of Care in Uganda

 ´I like it that we do audits now, because  it helps us to not relax but to be careful  and work diligent because otherwise  your patient dies and you need to  answer for that.´  

In the rural west-central district of  Nakaseke, Uganda, Senior midwife  Teopista enthusiastically comments on  her favorite component of the ACT for  Birth Uganda Project. ACT for Birth is an integrated innovation and is being implemented by Save the Children’s Saving Newborn Lives Program and partners in Uganda, with funding from the Saving Lives at Birth Grand ChallengeThe project comprises a package of interventions aimed at improving the quality of care for mothers and babies in Uganda. We must take action – ACT – where the greatest opportunities for saving lives are, at the most critical time of a life – during and just after birth.

The program consists of 3 different components;

A = Audit: Uganda’s national paper-based mortality audit forms have been adapted to a mobile phone platform, to capture and input information on maternal and neonatal deaths and stillbirths in real time into a central database. This data is analysed and used to inform decision-making for improved quality of care in the health facility of origin and beyond, and captures information on the causes of deaths and missed opportunities for care. 

= Connect Communities: Communities are directly connected to district hospital- or facility-based health workers through Village Health Teams (VHTs) with mobile phones and toll free calls. VHTs assist with referrals of mothers and newborns with danger signs (e.g. requesting emergency transport),  report births and deaths at community level to the hospital,  and conduct pre- and postnatal visits to promote best maternal and newborn care practices, including care seeking, facility based deliveries and the identification of danger signs.

T = technology and training: An innovative wind-up fetal heart rate monitor, powered by human energy (designed by PET and winner of the global INDEX design award) is paired with training on intrapartum care, empowering health workers  to provide better care.

Why change was needed to improve quality of care…

The project is being implemented in Nakaseke Hospital, a typical rural district hospital in Uganda, with 3,000 births per year and very challenging conditions for health workers, mothers and their newborns. There are 3 beds in the labor ward, which is already so small that it leaves very limited working space for the midwives. These beds are often in use, and direct sunshine, at times rain, and all the other possible incidents outside the hospital make themselves known through the broken windows. As if these are not problems enough for the congested rural hospital, power failures are the order of the day, and many babies are born by the light of a mobile phone.

 With 8 months into implementation of the ACT for Birth    Project, we asked the midwives what they thought  about the  changes the project has facilitated to date.  The responses  are overwhelmingly encouraging and  positive.

 “Audit helps us correct our mistakes and improve our  service-  the midwives are much more aware of their  responsibilities, because in the audit we talk all the time  about avoidable factors. I must make sure that I am not  the  one that did something that was avoidable”, one  midwife  says. Another midwife adds: “First audit was  just for the  midwives but now everybody is getting  involved. Even the  administrators  participate, they  actually even initiate the  meetings. It feels as if they  take us more serious now, they  listen to our problems and many things are changing.  Sometimes pregnant mothers were sent to the general ward, for example mothers who were not in active labour or mothers with malaria, because we did not have enough space. These mothers were not monitored at the general ward, which sometimes resulted in stillbirths . Now the administrators gave  midwives  a special 1st stage room and a space were we can take care of pregnant mothers with problems. I hope there will be less stillbirths now because of better monitoring. I feel proud of this, I made the suggestion during the meeting and it feels good when people listen to you. Audit helps us communicate what we feel should change.”

Eva, another senior midwife is very happy about the fact that the communities are better linked with the hospital through VHTs:

”The help of the VHTs is great-the mothers now come earlier, they used to only come when they had problems, but now they come before the problems are  there, and we can manage labor and birth  better. Some of the VHTs are very committed, they even accompany the mothers to the hospital to make sure that she arrives safely.” 

The midwives told us that getting VHTs involved in maternal and neonatal care in the communities linked to the hospital has been great for behaviour change and community mobilisation, and there has been an increase in the  demand for services.

”Some people were working as TBAs, they were delivering babies at their homes. Now they refer people to the hospital, and now more mothers deliver at the hospital.”

The last component of the program is implementing training and technology. The midwives were trained in intrapartum care and Doppler fetal heart rate monitors were provided.  For many midwives and most mothers, it was the first time that they were exposed to a fetal heart rate monitor.

”We love the Doppler, It shows you the fetal heart rate with much more precision, and we can act when something goes wrong. The mothers like it too. When the mother hears the sound, and you tell her that it is the baby’s heart, she smiles and feels happy.”

The training has also proven to be very helpful.

”I feel more empowered, the monitoring is more uniform, everybody does the same thing. We have improved our skills, you feel good about yourself because you know you can give better care. The best thing is that you have a better relationship with the mother when you monitor her correctly, because every 30 minutes you talk with the mother when you do your observation.”

Like in many developing countries and rural health facilities, the problems faced by mothers and health workers are composite. The ACT project has shown the power of an integrated approach to improving quality of care!  Sensitization and motivation at community level linked to the health facility will create a stronger and sustained demand for quality services and care. That way, improved facility care will benefit the mothers and newborns who need it most. 

Photos: Ian P. Hurley/Save the Children

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