Quality of Obstetric and newborn services: A case study of Kasese and Bundibugyo districts, Midwestern Uganda

Maternal and newborn care has long been a global health priority and forms part of the Sustainable Development Goals specifically target 3. Various health programs and systems have laid out strategies to achieve this target (Samuel et al., 2021). The United Nations Maternal Mortality Estimation Inter-Agency Group (UN MMEIG) estimated a 38% reduction in maternal mortality ratios (MMR) from 342 deaths to 211 deaths per 100,000 live births between 2000 and 2017. This, however, falls far below the target of 70 deaths per 100,000 live births by 2030(Organization, 2019). Despite the efforts, it is estimated that of the 139 million births every year, 2.6 million end up as stillbirths, while 2.9 million live babies die within their first month of life(Renfrew et al., 2014). It is also estimated that 287,000 pregnant women will die before, during, or soon after birth. The estimates indicate that 95% of all maternal deaths occur in low and lower-middle-income countries, with Sub-Saharan Africa alone accounting for over 70% of the deaths (202,000). This maternal mortality ratio (MMR) is unacceptably high (WHO fact sheet, 2024). The MMR in Uganda is 189 deaths per 100,000 live births, much higher than the global average(UDHS, 2022).

Existing evidence in similar contexts has shown that the Quality of Maternal and Newborn Care(QMNC) is a major determinant in the continued high maternal deaths globally. Further evidence indicates that 75% of maternal and newborn deaths could be averted by improving access to timely and appropriate care alone. The QMNC services affect maternal mortality and have significant short- and long-term effects on the maternal and infant physical and psychosocial well-being. These, in turn, eventually have an economic effect on the communities and country, which underscores national progress(Darroch and Singh, 2009). Since all pregnant women are at risk of complications, there is a need for universal access to quality emergency obstetrics and Newborn care (EmONC). Whereas the availability of the EmONC services to all pregnant women is very crucial, it is not enough. It neither guarantees usage nor ensures the use of the maternal services to achieve optimal maternal outcomes(Hulton et al., 2000). It is the broader quality of care provided and experienced by the mothers that has a huge impact on maternal and neonatal outcomes(Thaddeus and Maine, 1994).

In Uganda, health care is delivered through a decentralized (devolved) health care system with the bulk of care through Primary Health Care (PHC) at the lower public health facilities at the district, supplemented by the private for-profit (PFP) and private not-for-profit (PNFP)facilities(Mijumbi-Deve R et al., 2017). Under this PHC model, through its National Minimum Health Care Package, Uganda has made significant strides and has put a lot of effort on improving Health facility deliveries away from traditional birth attendants. The recent Uganda Demographic Health Survey(UDHS) report shows a great improvement in skilled birth attendance, with only 4% of deliveries now being attended to by traditional birth attendants(UDHS, 2022). Whereas there is now an increasing number of women seeking obstetric care at the health facilities, there is a need to evaluate the quality of care being provided there, especially since this has not translated into a proportionate reduction in maternal and newborn deaths. While health facility readiness may not be directly used as an indicator of quality of care, it is a proxy measure of the Quality of obstetric and newborn care and examines how prepared health facilities are to deliver this care. It is very pertinent that these health facilities in the emerging increase of health facility deliveries have the necessary resources and equipment to deliver this care(Namutebi et al., 2023).

That being mentioned, therefore, assessment of the quality of Maternal and Newborn Care (MNC) is an essential component of any program and health system that upholds reproductive and child health and is likely to have better outcomes. It is very crucial in creating evidencebased initiatives for programs and policies that improve maternal and child health outcomes(Hulton et al., 2000). It is, however, clear from a review of the current literature that there is a paucity of data on the quality of MNC in Uganda and especially for rural health facilities.

Kasese and Bundibugyo districts are among the districts that report very high maternal and perinatal deaths annually and have poor indicators on coverage of maternal and newborn services. Kasese district, for example, reported the 8th highest number of perinatal deaths (563) among the 132 districts in Uganda in 2019/20(“MOH report 2020.). They have also been greatly affected by insurgencies and wars, especially since they neighbor the Democratic Republic of Congo.

Quality of care is not easy to define or measure; several frameworks have been developed to guide this process, with a number of these piloted in non-Sub-Saharan African countries (Hulton et al., 2000) . The World Health Organization(WHO) framework on quality maternal and newborn care (QMNC) and the WHO Service Availability and Readiness Assessment (SARA) tool have been widely used to measure the quality of care and the health facility’s readiness to deliver care. Service provision measurement in both the WHO framework SARA tool has been dominantly done through signal functions of the Basic EmONC (BEmONC) and Comprehensive EmONC services(CEmONC)(Cranmer et al., 2018). The signal functions outline and help trace health facility availability and usage of key clinical interventions required to avert maternal and newborn deaths, but do not comprehensively look beyond the clinical care aspect of the WHO framework (Moxon et al., 2024) . The WHO framework defines Quality of care as: “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable, and people-centered. It embeds the quality of care into a health systems framework based on the structure, process, and output(WHO, 2016; WHO SARA, 2015).

This evaluation cannot be complete without considering the systemic drivers that influence the provision of maternal and newborn care in Uganda. There is growing recognition of the need to analyze health system drivers in quality of care assessments. This is hinged on the belief that the quality of care is immensely influenced by factors operating at different levels within and outside the health system, and controlling for these drivers is crucial for a more comprehensive assessment(Samuels et al., 2017). These are driven by the needs, values, and behaviors of a wide range of actors, ranging from the community to service providers, national policy makers, and the global agenda(Khatri et al., 2023). Whereas some earlier studies examined values, views, interests, and power of actors using views of national policy makers and global stakeholders, no studies have been done in Uganda to assess the” street level bureaucrats” /health providers’ perspectives on the drivers of MNC. For us to assess the current quality provision of MNC, we must map key stakeholder views on MNC(Mukuru et al., 2020). Ignoring these perspectives only delays the country in achieving the SDGs and reducing maternal and newborn deaths. This therefore provides an opportunity for re-engineering the health care system and opening up space for meaningful percolation of ideas from the frontline providers, hence building greater consensus to improve maternal and newborn outcomes in Uganda. The purpose of this study is to therefore assess the quality of care provided in the public health facilities in Midwestern Uganda and thereby propose relevant strategies for obstetric and newborn services.