Continual monitoring and evaluation is critical in maternal and newborn health care
By Julia Le | My time in Uganda provided incredible opportunities to observe and learn about maternal and newborn health within the Busoga region. I spent time at two Preterm Birth Initiative (PTBi) Uganda sites—Iganga General Hospital and Jinja Regional Referral Hospitals—reviewing cases in the records room and shadowing in the wards to identify successes and challenges within the system. Over my six weeks, I noticed the need for continual monitoring and evaluation of maternal and newborn quality improvement efforts at these facilities.
While at Jinja Regional Referral Hospital, I was particularly impressed with the hospital’s weekly perinatal mortality case reviews and quality improvement meetings, some of which are supported by PTBi and other development partners. Composed of major stakeholders such as midwives, physicians, intern physicians, and the lab, the team comes together to discuss recent perinatal mortality cases and what can be done to remedy hiccups in the system.
I sat in on a particularly interesting maternal death review where the team had a very in-depth conversation. This case highlighted that the blood supply remained an issue. When mothers present with or develop a hemorrhage during labor and delivery, having blood available is critical to improving survival. However, due to the lack of blood supplies available, the care team was recently unable to provide a blood transfusion, which lead to a maternal death. The team discussed creative solutions, such as redistributing nearly expired blood to the facility, to improve the supply chain and delegated concrete tasks to begin making changes. They also discussed the progress of newly implemented quality improvement programs and adjusted based on the feedback of those in the room.
These meetings show promise by acknowledging areas that need improvement within the facility and including a broad range of perspectives on how best to approach solutions. It is great the staff is willing to quickly pivot and make modifications where necessary. During the meeting I observed, I did not see quantitative data being used for decision making or to evaluate previously implemented changes. For example, no statistics about how often blood was unavailable was shared. While it may be difficult for the hospital to calculate, having these numbers can provide a strong case to outside stakeholders on the need for improving the supply chain. After implementing the quality improvement program, evaluation can also provide support for the program and possible expansion. Furthermore, keeping track of what programs were implemented and when is important for partners working with facilities to conduct proper monitoring and evaluation of their programming.
I was also impressed with the quality of the clinical notes at Jinja Hospital. While in the records room, I noticed how consistently provider notes were time stamped and how clear patient care plans were. While observing the case review meetings, the team also emphasized the need for time stamped documentation for them to properly review patient care. By being able to retrospectively construct the patient timeline, indicators can be derived to measure the quality of care. For example, an indicator I was interested in was the decision to incision time for caesarean sections. Thanks to the quality of the clinical notes, I could derive these times and discovered a gap between provider estimations and the cases reviewed. While providers believed it took about an hour for a patient to receive an emergency caesarean section, my sample showed a median wait time of over 3 hours. This may suggest a gap within the system that may impact outcomes and a quality improvement program can be developed to remedy the problem. Continual efforts to encourage complete and accurate record keeping is a quality improvement project that is essential to the quality improvement process.
I would like to sincerely thank the Makerere University Centre of Excellence for Maternal Newborn and Child Health, Iganga General Hospital, and Jinja Regional Referral Hospital for hosting me this summer. I look forward to disseminating my findings to the team and facilities to continue improving maternal and newborn survival.
* The author is a Master of Science in Global Health candidate at the University of Notre Dame Eck Institute for Global Health. She recently completed a 6-week placement at the Makerere University Centre of Excellence for Maternal Newborn and Child Health.