Assessment of the quality of basic resuscitation services in Uganda
To guide future efforts to reduce preventable newborn mortality and stillbirth in Uganda, the USAID ASSIST Project carried out an assessment of the quality of newborn resuscitation services as part of integrated newborn care in 26 health facilities sampled from eight districts of Northern, Eastern, Central and Western regions. A total of 26 Integrated Maternity Registries, with more than 28,000 annual deliveries were reviewed; 96 providers completed survey questionnaires; 98 providers were assessed for skills and practice test using simulated clinical scenario on the “NeoNatalie” anatomic model. 26 checklist inventories, and structured surveys of facility and service delivery organization were completed by trained data collectors.
The assessment demonstrated significant “knowledge – do” gap between the knowledge and actual practice. Though 84% knew when to start ventilation with bag and mask, only 40% of care providers started the ventilation within the golden minute. Similarly, the assessment found a lack of effective teamwork (only 16% of care providers called a helper and prepared an emergency plan) during the clinical scenario even though 83% correctly noted these steps during the knowledge assessment. Overall, observation results on NR skills and practices were poor. Only 6% of care providers met the minimum skills requirement for resuscitation with a bag and mask.
These results clearly demonstrate the importance of developing and sustaining provider newborn resuscitation competence and skills. Noteworthy to mention that stratification of provider knowledge based on the training in newborn care during the last two years, did not reveal any major difference between knowledge of trained and not-trained health workers, except knowledge related to timing of clamping and cutting umbilical cord during the routine care where difference in correct response was 27%. While 89% of facilities reported newborn resuscitation training during last 3 months, the study confirmed a lack of anatomic models to practice skills in the facility (38%), as well as a lack of supportive supervision involving observation of resuscitation skills of care providers (10%).
The assessment also examined provider knowledge and practices for eye and cord care and Vitamin K administration, compliance with antenatal corticosteroid (ACS) administration among women from 24 weeks to 34 weeks of gestation who are at risk of preterm birth, and kangaroo mother care practices. The assessment identified many gaps in supporting system functions at the service delivery level, including provider competencies, availability of essential inputs, including resuscitation commodities, organization of care processes or capacity for continuous improvement within the health system.
The assessment results clearly demonstrate that in addition to building the clinical capacity of care providers and addressing the availability of essential key inputs at different levels of the health service delivery system, continuous improvement and shared learning, addressing gaps in structures, care processes and outcomes, are needed to scale up high-impact maternal and newborn care best practices (including newborn resuscitation) nationwide. The strong political commitment and leadership by the Government of Uganda to overcome many challenges identified in this assessment together with actions taken to strengthen health systems and improve coverage and utilization of high impact newborn care services have a great potential to achieve significant progress in ending preventable newborn mortality and stillbirths countrywide.