Maternal and neonatal mortality in Uganda is quite high. The lifetime risk of maternal death for a Ugandan woman is 1 in 35; 28 neonates die for every 1,000 live births, a relatively high rate that has declined very little in recent years. At the same time, the contraceptive prevalence rate stands at just 24 percent of women for all methods. The limited use of services has been attributed to lack of access and poor quality of services. Many districts still do not implement high-impact maternal, newborn care and family planning practices.
Introducing an Improvement Collaborative
In Uganda, E2A worked with STRIDES for Family Health, a USAID-supported project that operated in 15 districts of Uganda, from March 2012 to June 2013, to introduce a demonstration Improvement Collaborative—a systematic approach for introducing and scaling up best practices. The Improvement Collaborative was introduced in two districts (Mityana and Nakasongola), with a goal of improved quality and scale-up of high-impact maternal, neonatal and family planning interventions at public-sector health facilities.
The initiative involved the introduction of a package of family planning, reproductive health, and maternal and neonatal health best practices in 10 selected demonstration sites of Mityana and Nakasongola using the Improvement Collaborative methodology. The methodology involves working with health service delivery teams in a structured approach over a 12- to 24-month period to achieve significant improvements in a set of practices that includes integration of family planning with postpartum and postabortion care services, and specific neonatal care, essential obstetric care and infection prevention practices.
In the collaborative, teams work independently to test changes in how they deliver care, implementing best practices and accepted standards for the best practices that they have identified. The teams use a common set of indicators to measure the changes in quality of care that the collaborative is trying to improve and, where possible, the desired health outcomes. The collaborative organizes the regular sharing of results among teams through learning sessions in which teams learn from each other about which changes were successful and which were not. This results in a dynamic improvement strategy in which many teams working on related problem areas can learn from each other in a way that facilitates rapid dissemination of successful practices.
E2A’s assistance to the larger initiative involved support to several components:
- Developing standards of quality for the selected best practices.
- Training facility- and central-level quality improvement teams in the clinical aspects of the improvement collaborative package and quality improvement.
- Developing supervision and documentation tools, job aids and checklists, while STRIDES works with the government to ensure the availability of medical supplies to the sites.
- Working with emerging leaders to support the implementation of improvement collaborative changes and supporting quarterly follow-on learning sessions.
- Co-facilitating baseline data collection at facility level, followed by monthly data collection related to the selected best practices.
With E2A/STRIDES support, the initiative has been scaled up by the government teams in 46 health facilities in 10 districts of Uganda. A brief describing this work can be accessed here.
Expanding to the Community
E2A and STRIDES, through the Improvement Collaborative in Mityana and Nakasongola, found that although quality of care improved at demonstration faciltiies, there was minimal increase in the uptake of postpartum family planning services, largely due to weak demand for the services.
Working with Makrere University, from September 2014 to January 2015, the E2A-STRIDES team then introduced a second community-based Improvement Collaborative in two new districts of Uganda—Kamwenge and Kyenjojo—to generate demand for postpartum family planning services, increase uptake of those services, and inform the future scale-up of postpartum family planning in Uganda. The community-based Improvement Collaborative specifically sought to address the following challenges to family planning service delivery:
- Lack of male involvement
- Obstacles to uptake of postpartum intrauterine device
- Lack of family planning outreach activities
In Uganda, community health workers, who work on Village Health Teams, deliver community-based services including family planning. They have contributed to increased uptake of family planning services by making them convenient and accessible. E2A and STRIDES, through these community health workers, introduced the community-based Improvement Collaborative. The community health workers were linked with nearby facilities through training and shared learning sessions to address aspects of quality and supervision.
Results from the community-based Improvement Collaborative, although the implementation period was short, show that there is a signficant unmet need for family planning counseling and services during the extended postpartum period and the importance of reaching women at this crucial time. Of the more than 2,500 women reached by the community health workers during the intervention period, more than half were eligible for postpartum family planning services. And of those who were eligible, 85 percent of women chose to use either Lactational Ammenorhea Method (45 percent) or injectable contraceptives (40 percent). Other methods were also accepted, but less often.
Pathfinder International has implemented Health of People and Environment in the Lake Victoria Basin (HoPE-LVB) Project since 2011. HoPE-LVB reduces threats to biodiversity conservation and ecosystem degradation in the LVB while simultaneously increasing access to family planning and sexual reproductive health to improve maternal and child health in project communities. The project works with fisheries and on land management, wetlands protection, alternative income generation, women's empowerment, health systems strengthening, and activities to promote maternal health and family planning.
E2A has provided support for HoPE-LVB in three key areas: 1) systematically expanding and institutionalizing innovations, 2) ensuring rigorous monitoring and evaluation of the HoPE-LVB model and scaling-up process, and 3) policy and communications activities. E2A’s core partner ExpandNet plays an integral role in the scale-up of HoPE-LVB, using its own approach, Beginning with the End in Mind. Inherent to this approach and integral to the scale-up process is the engagement of key stakeholders, specifically Population, Health, and Environment Champions. With ExpandNet’s approach to scale-up, HoPE-LVB has seen optimistic initial results especially related to sustainability, including garnering the support of government stakeholders and the Lake Victoria Basin Commission.
Uganda Protestant Medical Bureau (UPMB)
From September 2014 to June 2016, E2A provided a grant and technical assistance to UPMB. The grant was one of three E2A provided to faith-based member organizations of the African Christian Health Associations Platform. Under the grant, UPMB worked to improve family planning services in nine UPMB health facilities and among communities in the surrounding catchement areas. The grant supported UPMB to build the capacities of facilities and facility-based providers, enhance community-based provision of counseling and methods, and engage religious leaders to encourage acceptance of and demand for family planning methods.
Strengthening Pre-Service Education using the Training Resource Package for Family Planning
Pre-service education plays a critical role in developing the required professional competencies of nurses and midwives and prepares them for service provision in the long-term. Investing in strengthening pre-service education therefore constitutes an efficient use of resources toward improving maternal and newborn health through the delivery of quality family planning services. This is why E2A—with a mandate to strengthen family planning and reproductive health service delivery globally—promoted use of and supported adaptation of the Training Resource Package for Family Planning (TRP) to strengthen pre-service education on family planning in Tanzania and Uganda. E2A worked with several partners on this effort including the East, Central and Southern Africa Health Community (ECSA) and its college of nursing (ECSACON), Pathfinder International, the IBP Imitative as well professional associations, regulatory councils, national ministries of health and education, and nursing and midwifery schools in the two countries. A similar process was followed in the two countries, including:
- Discussions with ECSA, the local ECSACON chapter, nursing and midwifery councils, and nursing leadership to better understand the policy environment, challenges the countries needed to address through application of the TRP, and to clarify expectations.
- Review of curricula, training resources, and capacities.
- Three-day orientation and planning workshop with representatives of ECSACON, national nursing and midwifery service managers, nursing and midwifery council leadership, in-service training managers, and representatives from each nursing and midwifery training program. The main objectives of the three-day workshops were to: familiarize the participants with current family planning/reproductive health training in pre-service education to gain a better understanding of how the TRP could be applied to address current gaps in training; obtain an overview of family planning in-service training curricula and training materials that could provide local guidance service delivery guidelines and standards to be included in pre-service education curricula; review curricula and regional family planning training materials that could be used in alignment with the TRP; and clarify expectations and plan for a follow-on workshop.
- Five-day workshop on comptency-based training skills, contraceptive technology update, the new Medical Eligibility Criteria related to family planning, revision of family planning curricula content and learning outcomes, and demonstration of TRP using selected modules.
In Uganda, participants at the five-day workshop also developed developed the Uganda Family Planning Trainers Reference Guide for Pre-Service Education for Nurses and Midwives. The Uganda Nurses and Midwives Council, Commissioner Nursing Services, and ECSACON Uganda Chapter endorsed the guide.