Assessment of the quality of perinatal care and development of an improved model to reduce perinatal deaths in Bunyoro Sub-Region, Uganda.

Abstract

Background: Perinatal mortality, a key indicator of healthcare quality, remains high worldwide. To address this, effective antenatal, intrapartum, and postnatal care in facilities is essential. The World Health Organization has established standards and recommendations to enhance care quality. However, sub–Saharan Africa continues to struggle with providing effective care to women. Efforts to close this quality gap are complicated by contextual factors, necessitating the adaptation of individual evidence-based interventions to local context. This study assessed the perinatal care quality, and developed an improved, context specific model to reduce perinatal deaths in public general (district) hospitals. Methods: A convergent parallel mixed-methods study was conducted in Masindi, Kagadi, and Kiryandongo districts, involving early postpartum women at discharge, maternal healthcare providers, facility managers, and district health officers. The study had two phases: the formative phase assessed health facility structures and processes, prevalence and associated factors of inappropriate perinatal care, the relationship between perinatal care and perinatal deaths, and the experiences of women and providers. Findings from this phase informed the development of a context-specific quality of perinatal care model using a modified Delphi technique. Quantitative data were collected using pre-tested questionnaires, observation checklists, and data extraction tool, and analysed using descriptive statistics and Poisson regression, compared against WHO standards. Qualitative data were gathered through in-depth individual interviews and focus group discussions, analysed using inductive thematic analysis. Results: The health care provider to women ratio in antenatal and maternity units was low (1:72 and 1:60 for doctors; 1:29 and 1:7 for midwives). The mean availability of basic equipment in the perinatal units was 76.2%, with the postnatal unit having the least (22.2%). Medicines and supplies were available at 66.7% while amenities were at 81.3%. Bed density was 6.6 beds per 1,000 pregnant women, with no designated waiting space for labouring women or leadership in the obstetrics and gynaecology department. Most staff (98.2%) were supervised during care but refresher trainings occurred only once in a year for 69.2%. Receiving units were not notified about referrals (64.8%), and patient care records were predominantly paper based (98.2%), with 40.7% recorded in exercise books/papers. Documentation of medications and physical assessment findings was also low (46.3% and 55.6% respectively). The majority of women received inappropriate care during the antenatal (99%, CI 0.00-0.00), intrapartum (79.1%, CI 0.00-0.01), and postpartum (91.2%, CI 0.00-0.01). Older women were more likely to receive inappropriate care (adjusted prevalence ratio [aPR] = 11.9, 95% Cl 2.8-51.4, p=0.001), while those with more than three children were less likely to receive it (aPR=0.3, 95% CI 0.1–0.8, p=0.018). There were 19 perinatal deaths, resulting in a perinatal mortality rate of 22/1,000 births (95% CI 8.1–35.5). Perinatal death was significantly lower in women whose fetal status were examined during antenatal (aPR=0.22, 95% CI 0.1–0.6, p=0.01). Three themes emerged from the client provider experiences: good care provision, receiving information about care, and provider and client satisfaction. There were feelings of inadequacy regarding facility structures and differing perspectives on facility processes. To develop a context specific quality of perinatal care model, five structural interventions were identified including financing, staffing, physical infrastructure, leadership, and equipment, supplies, and diagnostic tests. Additionally, four process interventions were identified: continuing professional development system, care transition, coordination, and continuity. Conclusions: The region faces inadequate resources and support for women’s care transitions and continuity which hinders adequate perinatal care provision, resulting in care below the WHO standards during antenatal, intrapartum, and postpartum. Although the perinatal mortality rate was high, it was lower than the national average and reduced among women whose fetal status was examined during antenatal care. Despite receiving inappropriate care, women reported positive experience, contrary to that of health care providers. This study highlights the need to implement targeted structural and process interventions focusing on financing, staffing, leadership, and enhancing continuing professional development and care transitions. We recommend that policy makers allocate the required resources based on the population served, adapt WHO recommendations for perinatal care, and enable hospitals to adopt sustainable strategies for quality improvement. Hospitals should establish clear referral and care documentation systems while empowering women and staff regarding the recommended perinatal care. Health care professionals must enhance their training on the recommended perinatal care and establish strong communication channels for effective referrals and continuity of care. Additionally, further research is needed to assess the effectiveness of these proposed interventions.