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Emerging trends show declines in maternal and perinatal mortality and morbidity in urban populations might be slower than in rural areas in a variety of contexts. This is happening at a critical juncture in time when urban populations are rapidly increasing and might be partly driven by specifics of vulnerability of the urban poor in Low-income countries and High-income countries alike. Poor maternal and perinatal health outcomes are largely preventable but focusing solely on healthcare interventions misses critical opportunities to reduce ill-health. Social and environmental determinants such as poverty and the impact of climate change must be integrated into policy decisions, especially to benefit poor urban dwellers. Integrating data on the social determinants of health into policy decisions can help multisectoral stakeholders embrace a more Health-in-all-policy approach creating opportunities for better outcomes for these urban poor women and their offspring. We provide examples of two cities – Rotterdam and Kampala – to show that successful multi-sectoral approaches that can address urban maternal and perinatal inequalities should focus on interventions in which healthcare and non-healthcare determinants are integrated.

Background: Uganda like other low-income countries, preconception health has received no attention. Communications in this article are derived from preliminary findings of an ongoing preconception baseline pilot in Luuka-a rural eastern district of Uganda. This is a phased study, including a desk review of literature and a short baseline pilot. Methods: The review followed the methodology of systematic reviews. Key electronic databases were searched including PUBMED/MEDLINE and google scholar. Also, reports from ministries/academic institution libraries and views from experts were done. English articles published post 2000, covering preconception care, barriers, facilitators and policies were included in the review. Out of 110 shortlisted abstracts, 28 were included. Studies were extracted onto structured formats and analysed using the narrative synthesis approach. Results: There exist unstructured preconception health and service guidelines in Uganda. Barriers to preconception service integration into the district’s health system include; lack of a clear policy, careworn health system and care seeker related factors. Opportunities for preconception service integration include; poor maternal and neonatal health indicators, positive change in health seeking behaviour, existence of a gap in the care continuum, functional VHT system to link the community to services, anticipated roll out of key family care practises by Ministry of Health Uganda, and improved access to radio & mobile phones. Conclusion: Formulation of clear preconception guidelines, testing health system integration approaches, stakeholders’ engagement, awareness creation and strengthening the supply side is recommended as a way forward

Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.

Improving care for preterm babies could significantly increase child survival in low-and middle income countries. However, attention has mainly focused on facility-based care with little emphasis on transition from hospital to home after discharge. Our aim was to understand the experiences of the transition process among caregivers of preterm infants in Uganda in order to improve support systems. A qualitative study among caregivers of preterm infants in Iganga and Jinja districts in eastern Uganda was conducted in June 2019 through February 2020, involving seven focus group discussions and five in-depth interviews. We used thematic-content analysis to identify emergent themes related to the transition process. We included 56 caregivers, mainly mothers and fathers, from a range of socio-demographic backgrounds. Four themes emerged: caregivers’ experiences through the transition process from preparation in the hospital to providing care at home; appropriate communication; unmet information needs; and managing community expectations and perceptions. In addition, caregivers’ views on ‘peer-support’ was explored. Caregivers’ experiences, and their confidence and ability to provide care were related to preparation in the hospital after birth and until discharge, the information they received and the manner in which healthcare providers communicated. Healthcare workers were a trusted source of information while in the hospital, but there was no continuity of care after discharge which increased their fears and worries about the survival of their infant. They often felt confused, anxious and discouraged by the negative perceptions and expectations from the community. Fathers felt left-out as there was very little communication between them and the healthcare providers. Peer-support could enable a smooth transition from hospital to home care. Interventions to advance preterm care beyond the health facility through a well-supported transition from facility to home care are urgently required to improve health and survival of preterm infants in Uganda and other similar settings.

Background Consistent use of insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp) have been recommended as cost-effective interventions for malaria prevention during pregnancy in endemic areas. However, the coverage and utilization of these interventions during pregnancy in sub-Saharan Africa is still suboptimal. This study aimed to determine the uptake of IPTp and ITNs and associated factors among women during their recent pregnancy in Eastern Uganda. Methods This was a cross-sectional study conducted among 2062 women who had delivered within the last 12 months prior to the start of the study in three districts of Eastern Uganda. The primary outcomes were consistent ITN use and optimal uptake (at least 3 doses) of IPTp. A modified Poisson regression was used to examine the association between consistent ITN use and the uptake of optimal doses of IPTp with independent variables. Data were analysed using Stata 14 software. Results The level of uptake of IPTp3 (at least three doses) was 14.7%, while IPTp2 (at least two doses) was 60.0%. The majority (86.4%) of mothers reported regularly sleeping under mosquito nets for the full duration of pregnancy. Uptake of IPTp3 was associated with engaging in farming (adjusted PR = 1.71, 95% CI [1.28–2.28]) or business (adjusted PR = 1.60, 95% CI [1.05–2.44]), and attending at least 4 antenatal care (ANC) visits (adjusted PR = 1.72, 95% CI [1.34–2.22]). On the other hand, consistent ITN use was associated with belonging to the fourth wealth quintile (adjusted PR = 1.08, 95% CI [1.02–1.14]) or fifth wealth quintile (adjusted PR = 1.08, 95% CI [1.02–1.15]), and attending at least 4 ANC visits (adjusted PR = 1.07, 95% CI [1.03–1.11]). Conclusion Uptake of IPTp3 and consistent ITN use during pregnancy were lower and higher than the current Ugandan national targets, respectively. Study findings highlight the need for more efforts to enhance utilization of ANC services, which is likely to increase the uptake of these two key malaria preventive measures during pregnancy.

Introduction: Globally, out of 15 million babies born preterm each year, one million die. In Uganda, preterm deaths contribute 30% of the neonatal mortality rate. There is a paucity of information on the most critical time to conduct high impact interventions among neonate born preterm especially post-discharge from hospital. We determined the survival time to mortality and its predictors among preterm infants in the neonatal period post-discharge from hospital. Methods: We conducted a prospective cohort study in which 128 preterm infants were recruited from six hospitals including Jinja Regional Referral, St. Francis Buluba, Kamuli mission, Iganga, Kamuli and Bugiri district hospitals were prematurity was confirmed using gestation age and birth weight. Initially, background characteristics of the participants were assessed and then followed prospectively until 28 days. Kaplan-Meier survival analysis was used to estimate survival probabilities while time to preterm mortality was described using the 5thpercentile. Cox proportional hazards regression was used to determine predictors of survival. Results: Overall, 8% (10/128) of the preterm infants died; the 5th percentile survival time was 17 days. There was a 6-fold increase in hazard to mortality among preterm infants who had Kangaroo Mother Care (KMC) compared to those who did not (adjusted HR: 6.4, 95%CI: 1.7 – 24.5), a 5-fold increase in the hazard to preterm mortality among preterm infants born to HIV positive mothers compared to their counterparts who had HIV negative mothers (adjusted HR: 4.9, 95%CI: 1.1 – 22.2); and a 4-fold increase in the hazard to preterm mortality among preterm infants who were not exclusively breastfed compared to those who were exclusively breastfed (adjusted HR: 4.4, 95%CI: 1.1 – 18.3). Conclusion: Among babies who died, death occurred in the first 17 days while factors negatively associated with preterm survival included; not practicing Kangaroo Mother Care, not being breastfed exclusively and being born to an HIV positive mother. We recommend follow-up care for preterm infants following hospital discharge, implementation of prevention of mother to child transmission of HIV and exclusive breastfeeding of preterm babies.

ObjectiveTo investigate the interaction of risks for adverse maternal and perinatal outcomes (stillbirth, predischarge neonatal and maternal mortality) among caesarean section (CS) compared with vaginal deliveries (VD).DesignProspective cohort study.Setting10 CS-capable facilities in Busoga Region, East-Central Uganda and Migori County, Kenya.ParticipantsIndividual birth data were extracted from maternity registers between October 2016 and April 2019. There were a total of 77 242 livebirths and 3734 stillbirths. Overall, 24% of deliveries were by CS with a range of 9%–49% across facilities.Primary outcome measuresStillbirth, predischarge neonatal mortality and maternal mortality.ResultsThe adjusted ORs for stillbirth, predischarge neonatal mortality and maternal mortality after a CS were 1.3 (95% CI 1.1 to 1.6), 1.9 (95% CI 1.6 to 2.2) and 3.3 (95% CI 2.2 to 4.9), respectively, compared with a VD. The association between maternal mortality and CS was 3.9 (95% CI 2.8 to 5.5) when the delivery was a live birth and 1.7 (95% CI 1.0 to 3.0) when it was a stillbirth. Post hoc analyses showed that mothers who received a CS had a lower risk of stillbirth if they were documented as a referral.ConclusionIn this context, CS births were at higher risk for worse outcomes compared with VD. Better understanding of CS use and associated adverse outcomes within the mother–baby dyad is necessary to identify opportunities to improve quality of intrapartum care.Trial registration numberNCT03112018.

Background Globally, approximately 6,700 newborn deaths and 5,400 stillbirths occur daily. The true figure is likely higher, with under reporting of adverse pregnancy outcomes (APOs) noted. Decision-making in health is influenced by various factors, including one’s social networks. We sought to understand APOs disclosure within social networks in Uganda, Ghana, Guinea-Bissau and Bangladesh and how this could improve formal reporting of APOs in surveys. Methods A qualitative, exploratory multi-country study was conducted within four health and demographic surveillance system sites. 16 focus group discussions were held with 147 women aged 15–49 years, who had participated in a recent household survey. Thematic analysis, with both deductive and inductive elements, using three pre-defined themes of Sender, Message and Receiver was done using NVivo software. Results Disclosure of APOs was a community concern, with news often shared with people around the bereaved for different reasons, including making sense of what happened and decision-making roles of receivers. Social networks responded with comfort, providing emotional, in-kind and financial support. Key decision makers included men, spiritual and traditional leaders. Non-disclosure was usually to avoid rumors in cases of induced abortions, or after a previous bad experience with health workers, who were frequently excluded from disclosure, except for instances where a woman sought advice on APOs. Conclusions Communities must understand why they should report APOs and to whom. Efforts to improve APOs reporting could be guided by diffusion of innovation theory, for instance for community entry and sensitization before the survey, since it highlights how information can be disseminated through community role models. In this case, these gatekeepers we identified could promote reporting of APOs. The stage at which a person is in decision-making, what kind of adopter they are and their take on the benefits and other attributes of reporting are important. In moving beyond survey reporting to getting better routine data, the theory would be applicable too. Health workers should demonstrate a more comforting and supportive response to APOs as the social networks do, which could encourage more bereaved women to inform them and seek care.

Objective To test whether introduction of a midwife‐performed triage checklist and focused ultrasound improves diagnosis and referral for obstetric conditions, including multiple gestation, placenta previa, oligohydramnios, preterm birth, malpresentation, and abnormal fetal heart rate. Methods We implemented an intake log (Phase 1), a checklist (Phase 2), and a checklist plus ultrasound scan (Phase 3) at three primary health centers in Eastern Uganda for women presenting in labor. Intake diagnoses, referral status, and delivery outcomes were assessed, as well as sensitivity and positive predictive value (PPV). Results Between February 2018 and July 2019, 1155, 961, and 603 women were enrolled across the three phases (n=2719); 2339 had outcome data. Incidence of any outcome‐confirmed condition was 8.8%, 7.9%, and 7.1% (P=0.526) for each phase, respectively. The proportion of referred women with a condition did not change between Phases 1 and 2 (7.8% versus 8.6%, P=0.855), but increased in Phase 3 (48.4%, P, Triage ultrasound increased referrals for both correct and incorrect diagnosis of six obstetric conditions, whereas a triage checklist improved correct identification but not referral.

Background/aims Uninterrupted skin-to-skin contact in the first hour after birth increases the chance of exclusive breastfeeding, a practice which improves health outcomes for both mothers and neonates. This study aimed to compare mother–infant pairs who had or did not have skin-to-skin contact 1 hour after birth and investigate infant behaviour and maternal adaptation as a result. Methods This study investigated the impact of skin-to-skin contact on a number of health indicators after birth of both mother and child. Two groups were included: 51 mother–infant pairs with skin-to-skin contact and 152 with no skin-to-skin contact, who were observed for 1 hour after birth. Mothers were interviewed at discharge and at 14 weeks postpartum about their sociodemographic background, ability to interpret their infant's signals and interaction with the infant, their own health and their infant's health and feeding. The Student's t-test and Chi squared test were used to assess the associations between the groups and sociodemographic characteristics. The Cramer's V test was used to assess the effect size for variable latch on. Factor analysis was conducted on statements from interviews on mothers' feelings regarding motherhood. Results More infants latched on in the skin-to-skin contact group and the first breastfeeding was more often directed by the infants, compared to the no skin-to-skin contact group. Mothers in the skin-to-skin contact group were less likely to need help to breastfeed and tended to be more confident that they could provide sufficient milk for their child. They were also more likely to breastfeed longer and took no initiative to supplement the infant during the hospital stay, while mothers in the non-skin-to-skin contact group did so. More mothers in the skin-to-skin contact group believed that their infant could comfort itself. Conclusions The results suggest benefits to uninterrupted skin-to-skin contact between mothers and newborns 1 hour after birth in regard to initiation of breastfeeding, intended time to breastfeed, maternal self-confidence and infant self-regulation. Interventions to promote skin-to-skin contact should be implemented in this setting.

ObjectiveTo assess the level of knowledge and use of the lactational amenorrhoea method (LAM) among adolescents in Uganda between 2006 and 2016 using nationally representative data from Demographic and Health Surveys (DHS).DesignCross-sectional design involving analysis of three DHS (2006, 2011, and 2016) in Uganda.SettingThe data collection took place in Uganda. The DHS are nationally representative surveys on a wide range of indicators including contraception knowledge and use.ParticipantsA total of 1948 (2006), 2026 (2011) and 4276 (2016) adolescents (15–19 years) and 1662 (2006), 1666 (2011) and 3782 (2016) young women (20–24 years) were included.Primary outcome measureUse of LAM among adolescents and young women with a live birth within 6 months before each survey.ResultsIn 2016, less than 1.0% (95% CI: 0.2% to 3.5%) of eligible adolescents correctly used LAM, and 56.3% (95% CI: 48.8% to 63.6%) were passively benefitting from LAM. The median duration of postpartum amenorrhoea (PPA) among adolescents in 2016 was 6.9 months, declining from 8.3 months in 2006. Compared with adolescents (56.7%), eligible young women had higher knowledge of LAM (64.1%) and higher median PPA duration (8.0 months) in 2016. The percentage of eligible adolescents who met the LAM criteria irrespective of whether they reported LAM use (were protected by LAM) decreased from 76.4% (95% CI: 66.5% to 84.0%) in 2006 to 57.2% (95% CI: 49.5% to 64.6%) in 2016. More than 50.0% (95% CI: 49.2% to 63.8%) of eligible adolescents were aware of LAM in 2016, increasing from 6.0% (95% CI: 2.5% to 13.8) in 2006.ConclusionDespite increasing awareness of LAM, reported and correct use of LAM was low among adolescents who could benefit from this method in Uganda, and declining over time. Support for adolescents to harness the benefits of correct LAM use should be increased. Additional research is needed to better understand the dynamics of LAM use in adolescents, including the transition to use of other modern contraceptive methods.

Background Effective Antenatal Care (ANC) is dependent on timely initiation of the first visit and quality care to mitigate risk factors in pregnancy. However, most adolescent mothers attend their first visit later than the recommended time while others do not receive all the required components of care. This study sought to examine the predictors associated with timing of the first ANC visit and receipt of the recommended components of care among adolescent mothers in Luuka district. Methods The study was carried out between March and May 2021 among 248 adolescent mothers aged 10-19 years from Luuka district, who were either pregnant or postpartum with infants aged 0-3 months. Data analyses were done using descriptive techniques, Pearson chi-square and Fisher’s exact tests of independence were done at bivariate level and thereafter binary logistic regression. Results Findings showed that majority of the adolescent mothers (82%) attended ANC for their most recent pregnancy or birth. Still, only 47% had timely ANC visit while 36% had all the recommended components of care. Having knowledge on dangers signs in pregnancy was a determinant of both receipt of all components of ANC (AOR = 6.57, 95%CI = 1.75 - 24.65) and early timing of the first visit (AOR = 0.35, 95%CI = 0.12 – 0.97). Further, the odds of making the first visit after the first trimester were highest among adolescent mothers who had ever given birth (AOR = 3.67, 95%CI:1.68 - 8.02) and those without independent decisions on health care (AOR = 3.45, 95%CI:1.04 - 11.42). Conclusion Knowledge of obstetric pregnancy danger signs, having ever given birth and decision making on health care seeking are pivotal determinants of adolescent mothers’ timing of the first ANC visit and uptake of the recommended components of care. We therefore recommend the need to sensitize adolescent mothers through different channels of media on the benefits of ANC. Also, ensuring accessibility and affordability of these services among health facilities will significantly increase the uptake and early timing of the antenatal care services among adolescent mothers in rural communities.

Background Maintaining a motivated health workforce is critical to health system effectiveness and quality of care. Scant evidence exists on whether interventions aimed to strengthen health infrastructure in low-resource settings affect health workers. This study evaluated the impact of an intervention providing solar light and electricity to rural maternity facilities in Uganda on health workers’ job satisfaction. Methods We used a mixed-methods design embedded in a cluster randomized trial to evaluate whether and how the We Care Solar Suitcase intervention, a solar electric system providing lighting and power, affected health workers in rural Ugandan maternity facilities with unreliable light. Facilities were randomly assigned to receive the intervention or not without blinding in a cluster-randomized controlled trial. Outcomes were assessed through two rounds of surveys with health workers. We used regression analyses to examine the intervention’s impact on job satisfaction. We used an inductive approach to analyze qualitative data to understand the study context and interpret quantitative findings. Results We interviewed 85 health workers across 30 facilities, the majority of whom were midwives or nurses. Qualitative reports indicated that unreliable light made it difficult to provide care, worsened facility conditions, and harmed health workers and patients. Before the intervention, only 4% of health workers were satisfied with their access to light and electricity. After the installation, satisfaction with light increased by 76 percentage points [95% confidence interval (CI): 61–92 percentage points], although satisfaction with electricity did not change. Experience of negative impacts of lack of overhead light also significantly decreased and the intervention modestly increased job satisfaction. Qualitative evidence illustrated how the intervention may have strengthened health workers’ sense of job security and confidence in providing high-quality care while pointing towards implementation challenges and other barriers health workers faced. Conclusions Reliable access to light and electricity directly affects health workers’ ability to provide maternal and neonatal care and modestly improves job satisfaction. Policy makers should invest in health infrastructure as part of multifaceted policy strategies to strengthen human resources for health and to improve maternal and newborn health services. Trial registration socialscienceregistry.org: AEARCTR-0003078. Registered June 12, 2018, https://www.socialscienceregistry.org/trials/3078 Additionally registered on: ClinicalTrials.gov: NCT03589625, Registered July 18, 2018, https://clinicaltrials.gov/ct2/show/NCT03589625)

ObjectivesPolicy measures to slow the spread of coronavirus disease 2019 (COVID-19), such as curfews and business closures, may have negative effects on mental health. Populations in low- and middle-income countries (LMICs) may be particularly affected due to high rates of poverty and less comprehensive welfare systems, but the evidence is scarce. We evaluated predictors of depression, anxiety, and psychological distress in Uganda, which implemented one of the world's most stringent lockdowns.MethodsWe conducted a mobile phone-based cross-sectional survey from December 2020 through April 2021 among individuals aged 18 years or over in Uganda. We measured depression, anxiety, and psychological distress using the Patient Health Questionnaire (PHQ)-2, the Generalized Anxiety Disorder (GAD)-2, and the PHQ-4. We applied linear regression to assess associations between experiences of COVID-19 (including fear of infection, social isolation, income loss, difficulty accessing medical care, school closings, and interactions with police) and PHQ-4 score, adjusted for sociodemographic characteristics.Results29.2% of 4066 total participants reported scores indicating moderate psychological distress, and 12.1% reported scores indicating severe distress. Distress was most common among individuals who were female, had lower levels of education, and lived in households with children. Related to COVID-19, PHQ-4 score was significantly associated with difficulty accessing medical care, worries about COVID-19, worries about interactions with police over lockdown measures, and days spent at home.ConclusionsThere is an urgent need to address the significant burden of psychological distress associated with COVID-19 and policy responses in LMICs. Pandemic mitigation strategies must consider mental health consequences.

Background: AIDS is the leading cause of death among young people in sub-Saharan Africa. Adherence to antiretroviral therapy is the principal determinant for achieving and sustaining viral suppression, which decreases progression to AIDS and reduces risk of mortality. Few studies have evaluated mHealth adherence tools among youths in resource-limited settings.We aim to evaluate whethermHealth tool improves ART adherence outcomes among youth receiving ART at a rural district in Western Uganda. The Corona virus disease outbreak was announced a Public Health Emergency of International concern on Jan 2020; and declared a global pandemic by World Health Organization on Mar, 2020.In rural areas, there is little data on knowledge and myths on COVID among youths.General objective:To assessacceptability, effect and cost of themHealth tool on ART adherence, knowledge and myths on COVID-19among youth initiating and on ART at KiryandongoDistrict.Methods: This is a mixed methodsequential exploratory study, with the qualitative study conducted first followed by a randomized control trial and healthcare cost evaluation.The qualitative study will assess barriers, enablers of adherence and acceptability of mHealth among youths receiving care at three health facilities inKiryandongo District.The randomized control trial of 206 youth initiatingARTto either Standard of Care or mHealth tool plus Standard of care to assesseffect of mHealth tool on ART adherence and retention in care. Through a basic cell phone, participants in the intervention arm will receive pill reminders, clinic appointment reminders, health voice messages and self-reported symptoms in addition to standard of care. Collection of data on knowledge and myths on COVID-19, HIV and sexual behavior. The health care evaluationnested within randomized trial, will assess the cost of interventionin comparison to Standard of care.Discussion: This project will determine acceptability, effectiveness of mHealth, knowledge & myths on COVID-19and cost of delivering pill and clinic appointment reminders, and voice messages to a population with suboptimal ART adherence in a resource-limited setting.Trial registration: Fully registered under clinicaltrials.gov by 20th Jan 2021. The study is ongoing. Recruitment started Aug 2020.Clinical Trial registration: NCT 04718974

IntroductionThere are concerns about the impact of the COVID-19 pandemic on the continuation of essential health services in sub-Saharan Africa. Through the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health country collaborations, analysts from country and global public health institutions and ministries of health assessed the trends in selected services for maternal, newborn and child health, general service utilisation.MethodsMonthly routine health facility data by district for the period 2017–2020 were compiled by 12 country teams and adjusted after extensive quality assessments. Mixed effects linear regressions were used to estimate the size of any change in service utilisation for each month from March to December 2020 and for the whole COVID-19 period in 2020.ResultsThe completeness of reporting of health facilities was high in 2020 (median of 12 countries, 96% national and 91% of districts ≥90%), higher than in the preceding years and extreme outliers were few. The country median reduction in utilisation of nine health services for the whole period March–December 2020 was 3.9% (range: −8.2 to 2.4). The greatest reductions were observed for inpatient admissions (median=−17.0%) and outpatient admissions (median=−7.1%), while antenatal, delivery care and immunisation services generally had smaller reductions (median from −2% to −6%). Eastern African countries had greater reductions than those in West Africa, and rural districts were slightly more affected than urban districts. The greatest drop in services was observed for March–June 2020 for general services, when the response was strongest as measured by a stringency index.ConclusionThe district health facility reports provide a solid basis for trend assessment after extensive data quality assessment and adjustment. Even the modest negative impact on service utilisation observed in most countries will require major efforts, supported by the international partners, to maintain progress towards the SDG health targets by 2030.

IntroductionGlobally, the majority of births happen in urban areas. Ensuring that women and their newborns benefit from a complete package of high-quality care during pregnancy, childbirth and the postnatal period present specific challenges in large cities. We examine health service utilisation and content of care along the maternal continuum of care (CoC) in 22 large African cities.MethodsWe analysed data from the most recent Demographic and Health Survey (DHS) since 2013 in any African country with at least one city of≥1 million inhabitants in 2015. Women with live births from survey clusters in the most populous city per country were identified. We analysed 17 indicators capturing utilisation, sector and level of health facilities and content of three maternal care services: antenatal care (ANC), childbirth care and postnatal care (PNC), and a composite indicator capturing completion of the maternal CoC. We developed a categorisation of cities according to performance on utilisation and content within maternal CoC.ResultsThe study sample included 25 326 live births reported by 19 217 women. Heterogeneity in the performance in the three services was observed across cities and across the three services within cities. ANC utilisation was high (>85%); facility-based childbirth and PNC ranged widely, 77%–99% and 29%–94%, respectively. Most cities showed inconsistent levels of utilisation and content across the maternal CoC, Cotonou and Accra showed relatively best and Nairobi and Ndjamena worst performance.ConclusionThis exploratory analysis showed that many DHS can be analysed on the level of large African cities to provide actionable information about the utilisation and content of the three maternal health services. Our comparative analysis of 22 cities and proposed typology of best and worst-performing cities can provide a starting point for extracting lessons learnt and addressing critical gaps in maternal health in rapidly urbanising contexts.

Background Routine health facility data are a critical source of local monitoring of progress and performance at the subnational level. Uganda has been using district health statistics from facility data for many years. We aimed to systematically assess data quality and examine different methods to obtain plausible subnational estimates of coverage for maternal, newborn and child health interventions. Methods Annual data from the Uganda routine health facility information system 2015–2019 for all 135 districts were used, as well as national surveys for external comparison and the identification of near-universal coverage interventions. The quality of reported data on antenatal and delivery care and child immunization was assessed through completeness of facility reporting, presence of extreme outliers and internal data consistencies. Adjustments were made when necessary. The denominators for the coverage indicators were derived from population projections and health facility data on near-universal coverage interventions. The coverage results with different denominators were compared with the results from household surveys. Results Uganda’s completeness of reporting by facilities was near 100% and extreme outliers were rare. Inconsistencies in reported events, measured by annual fluctuations and between intervention consistency, were common and more among the 135 districts than the 15 subregions. The reported numbers of vaccinations were improbably high compared to the projected population of births or first antenatal visits – and especially so in 2015–2016. There were also inconsistencies between the population projections and the expected target population based on reported numbers of antenatal visits or immunizations. An alternative approach with denominators derived from facility data gave results that were more plausible and more consistent with survey results than based on population projections, although inconsistent results remained for substantive number of subregions and districts. Conclusion Our systematic assessment of the quality of routine reports of key events and denominators shows that computation of district health statistics is possible with transparent adjustments and methods, providing a general idea of levels and trends for most districts and subregions, but that improvements in data quality are essential to obtain more accurate monitoring.

Background The neonatal mortality rate in Uganda has barely changed over the past decades, estimated at 28/1000 and 27/1000 live births in 2006 and 2016 respectively. The survivors have a higher risk of developing neurodevelopmental disabilities (NDD) due to brain insults from perinatal complications related to poor quality of health services during pregnancy, around the time of birth, and during the postnatal period. This study aimed to assess health facility readiness to care for high risk newborn babies in order to inform programming that fosters early childhood development in eastern Uganda. Methods A cross sectional study of 6 hospitals and 10 higher level health centers that offer comprehensive maternal and newborn care was carried out in February 2020 in eastern Uganda. A World Health Organization Service Availability and Readiness Assessment tool (SARA) was adapted and used to assess the health facility readiness to manage maternal and neonatal conditions that are related to NDD. In addition, 201 mothers of high risk newborn babies were interviewed on their satisfaction with health services received. Readiness scores were derived from percentage average facilities with available infrastructure and essential medical commodities to manage neonatal complications. Descriptive statistics were computed for client satisfaction with service provision, and p values used to compare private not for profit to public health facilities. Results There was limited availability in numbers and skilled human resource especially the neonatal nurses. Hospitals and health centers scored least in preterm and hypothermia care, with averages of 38% and 18% respectively. The highest scores were in essential newborn care, with readiness of 78% and 85% for hospitals and health centers, followed by resuscitation at 78% and 77%, respectively. There were no guidelines on positive interaction with newborn babies to foster neurodevelopment. The main cause of admission to neonatal care units was birth asphyxia followed by prematurity, indicative of intrapartum care challenges. The overall client satisfaction with health services was higher in private not for profit facilities at 91% compared to public hospitals at 73%, p = 0.017. Conclusion Health facility readiness was inadequate in management of preterm complications. Efforts should, therefore, be geared to improving availability of inputs and quality of emergency obstetric and newborn care in order to manage high risk newborns and reduce the burden of NDD in this setting.

Background: Serious infections and other complications from very low birth weight and prematurity are the leading causes of death for neonates worldwide. Infections partly result from the compromised skin barrier function in preterm neonates. Optimal skin care practices for neonates, especially in settings with limited access to adequate hygienic conditions, hold potential to reduce infection and avoid these preventable preterm neonatal deaths. The purpose of this protocol is to support a scoping review of neonatal skin care, emollient therapy and massage practices throughout sub-Saharan Africa. Protocol: The proposed review will follow a methodological framework consisting of the following five steps: (i) identifying the research question, (ii) identifying relevant studies, (iii) selection of eligible studies, (iv) charting the data, and (v) collating and summarizing the results. In addition, we will reflect on the implications of the findings for the feasibility and design of randomized controlled trials to examine the impact of emollient therapy on survival, growth, infection and neurodevelopment of very low birth weight infants in sub-Saharan Africa. We will search domestic and international databases for literature published in English between January 1, 2000, and July 12, 2021. Articles will be chosen based on standardized inclusion criteria. The primary criteria for inclusion will be a report on skin care practices administered to neonates in Africa. Conclusions: Documentation of common neonatal skin care practices throughout Africa has the potential to highlight opportunities for skin care intervention and future research on neonatal skin care practices in sub-Saharan Africa, and support the development of future emollient intervention trials for preterm and low birthweight neonates in low- and middle-income countries.

Uganda has achieved a considerable reduction in childhood stunting over the past 2 decades, although accelerated action will be needed to achieve 2030 targets.This study assessed the national, community, household, and individual-level drivers of stunting decline since 2000, along with direct and indirect nutrition policies and programs that have contributed to nutrition change in Uganda.This mixed-methods study used 4 different approaches to determine the drivers of stunting change over time: 1) a scoping literature review; 2) quantitative data analyses, including Oaxaca-Blinder decomposition and difference-in-difference multivariable hierarchical modeling; 3) national- and community-level qualitative data collection and analysis; and 4) analysis of key direct and indirect nutrition policies, programs, and initiatives.Stunting prevalence declined by 14% points from 2000 to 2016, although geographical, wealth, urban/rural, and education-based inequalities persist. Child growth curves demonstrated substantial improvements in child height-for-age z-scores (HAZs) at birth, reflecting improved maternal nutrition and intrauterine growth. The decomposition analysis explained 82% of HAZ change, with increased coverage of insecticide-treated mosquito nets (ITNs; 35%), better maternal nutrition (19%), improved maternal education (14%), and improved maternal and newborn healthcare (11%) being the most critical factors. The qualitative analysis supported these findings, and also pointed to wealth, women's empowerment, cultural norms, water and sanitation, dietary intake/diversity, and reduced childhood illness as important. The 2011 Uganda Nutrition Action Plan was an essential multisectoral strategy that shifted nutrition out of health and mainstreamed it across related sectors.Uganda's success in stunting reduction was multifactorial, but driven largely through indirect nutrition strategies delivered outside of health. To further improve stunting, it will be critical to prioritize malaria-control strategies, including ITN distribution campaigns and prevention/treatment approaches for mothers and children, and deliberately target the poor, least educated, and rural populations along with high-burden districts.

Background: Initiating antenatal care within the first trimester and making at least four visits during pregnancy are recommended to enable screening and support for healthy lifestyles, well-being, and self-care in pregnancy. Due to glaring evidence on inequalities in access to antenatal care, this study assessed the effect of engaging community health structures on utilization of antenatal care services during pregnancy in resource-constrained rural settings in Uganda. Methods: A quasi-experimental evaluation study was conducted among mothers in Eastern Uganda. The intervention components included community dialogues and empowering community health workers to sensitize expectant mothers on the use of maternal health services, and health facility strengthening. The primary outcomes were early initiation of antenatal care and completion of at least 4 ANC visits. We used Difference in Differences (DiD) analysis and multivariate regression to assess the effect of the intervention on ANC attendance.Results: Early initiation of antenatal care increased from 35.7% to 48.1% in the intervention area and 26.9% to 40.7% in the control area but with a non-significant net change of -1.3% (DID, p = 0.733) in the intervention area with respect to changes in the control area. The DiD results revealed the intervention resulted in a 5.5% net significant improvement in attendance of at least 4 ANC visits (p= 0.037). Higher education level of husband (PR1.19,95%CI 1.02–1.39), higher household size (PR=0.81, 95%CI 0.70–0.95), and higher wealth index (PR1.19,95%CI 1.03–1.37) predicted early initiation. Making at least 4 visits for antenatal care was influenced by post-primary education (PR1.14, 95%CI 1.02–1.30), higher wealth quintile (PR1.17, 95%CI 1.06 – 1.30), early initiation (PR1.58, 95%CI 1.49–1.68), and the community intervention (PR1.16, 95%CI 1.01–1.33). Conclusion: Although the community intervention improved the attendance of at least four antenatal care visits, effect estimates are low hence raising scepticisms on the feasibility of at least 8 visits as per the new WHO recommendations. Women with less education should be prioritized in maternal and child health (MCH) interventions as their families need economic empowerment to reduce financial barriers when access MCH services.

ObjectiveTo assess the level of knowledge and use of lactational amenorrhea method (LAM) among adolescents in Uganda between 2006 and 2016 using nationally representative data from Demographic and Health Surveys (DHS).DesignCross-sectional design involving analysis of three DHS (2006, 2011, and 2016) in Uganda.SettingThe data was collected in Uganda. The DHS are nationally representative surveys on a wide range of indicators including contraception knowledge and use.ParticipantsA total of 8,250 adolescents (15-19 years) and 7,110 young women (20-24 years) were included.Primary outcome measureUse of LAM among adolescents and young women with a livebirth within six months before each survey.ResultsIn 2016, less than 1% of eligible adolescents correctly used LAM and 56% were passively benefitting from LAM. The median duration of postpartum amenorrhea (PPA) among adolescents in 2016 was 6.9 months, declining from 8.3 months in 2006. Compared to adolescents, eligible young women had higher knowledge of LAM and higher medianPPA duration in 2016. The percentage of eligible adolescents who met the LAM criteria irrespective of whether they reported LAM use (protected by LAM) decreased from 76% in 2006 to 57% in 2016. More than 50% of eligible adolescents were aware of LAM in 2016, increasing from 6% in 2006, potentially in part due to change in survey question.ConclusionDespite increasing awareness of LAM, reported and correct use of LAM was low among adolescents who could benefit from this method in Uganda, and declining over time. Support for adolescents to harness the benefits of correct LAM use should be increased. Additional research is needed to better understand the dynamics of LAM use in adolescents, including the transition to use of other modern contraceptive methods.Strengths and limitations of this study➢Lactational amenorrhea method has the potential to promote healthy timing and spacing of pregnancies and to reduce repeat adolescent births, yet, its use among Ugandan adolescents has not been examined.➢This study provides useful insights into the behavior of adolescents mothers which can be targeted to improve their reproductive knowledge and wellbeing.➢The study used data from three standardised nationally representative surveys, thus findings are generalizable and comparable over time and across age groups.➢Assessment of knowledge of LAM was affected by a change in the phrasing of the question in 2016, thus providing limited comparability with previous surveys.➢The measurement of LAM use was based on self-report.

Background Uninterrupted skin-to-skin contact between mothers and newborns during the first hour after birth has been reported to be 2% in Uganda. Aims To investigate if a low-cost intervention targeting the behaviors of hospital staff would increase skin-to-skin contact and to investigate whether skin-to-skin contact stabilised temperature in the newborn. Methods The study had a quasi-experimental, before and after design. The sample included 110 in the pre-intervention group, and 93 in the post-intervention group. Data collection included observations of skin-to-skin contact and temperature measurements. Data were also collected from medical records and interviews. Findings No infants had skin-to-skin contact before the intervention, whereas the proportion was 54.8% after the intervention. Infants who received skin-to-skin contact (n=51) and infants who did not receive skin-to-skin contact (n=146) increased in temperature; however, infants who received skin-to-skin contact were significantly warmer after 5 minutes and remained so at 60 minutes. Conclusions The intervention increased the practice of skin-to-skin contact, which was found to be safe in regard to temperature stabilisation.

In Uganda, more than 336 out of every 100,000 women die annually during childbirth. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care – through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this short report, we used an adaptation of Greenhalgh’s Model of Diffusion to reflect on these projects’ approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs. Electronic supplementary material The online version of this article (10.1186/s12992-019-0483-9) contains supplementary material, which is available to authorized users.

Background One of the greatest challenges that countries face regarding the achievement of the Sustainable Development Goal (SDG) targets for child health regard the actions required to improve neonatal health; these interventions have to be informed by evidence. In view of the persisting high numbers of newborn deaths in Uganda, we aimed to define a locally contextualised national research agenda for newborn health to guide national investments towards SDG targets. Methods We adopted a systematic approach for priority-setting adapted from the Child Health and Nutrition Research Initiative. We identified and listed local newborn researchers and experts in Uganda by reviewing the PubMed database, through a snowballing technique, and engaged the Ministry of Health. Participants were requested to generate at least three research questions. The collated questions were sent to the same expert group to be rated using five criteria, including answerability, scalability, impact, generalisability and speed. Findings Of the 300 researchers and stakeholders contacted, 104 responded (36%) and generated 304 questions. These questions were collated and duplicates removed giving a condensed list of 41 research questions. These questions were then rated by 82 experts. Of the top 15 research questions, 86.7% (13/15) were in the service delivery and 6.7% (1/15) in the development domain, while only 6.7% (1/15) was in the group ‘other’. None of the leading 15 questions was in the discovery domain. Strategies to improve quality of intrapartum care featured high in the responses, while research around care for premature babies was not a perceived focus of research. Conclusions The focus of improved evidence to guide and innovate service delivery, foremost intrapartum care, reflects the importance of this area as accelerated improvement is likely to yield fast and sustained survival gains in the neonatal period and beyond in Uganda. We recommend that other countries adapt a similar approach in defining priority reproductive, maternal, newborn and child health areas for investment in order to accelerate progress towards achieving the SDGs. Electronic supplementary material The online version of this article (10.1186/s12961-019-0459-5) contains supplementary material, which is available to authorized users.

Limited evidence exists regarding the drivers of vaccination coverage and equity in Kampala city, despite frequent measles outbreaks, inequities in vaccination coverage, and the decline in vaccination coverage rates. This study was designed to determine vaccine coverage among children aged 12-36 months and to understand its demand-side drivers.We utilized a mixed-methods parallel convergent study design. A household survey was conducted to quantify the drivers of vaccine coverage among households with children aged 12-36 months. We employed a multistage sampling approach to select households, using a primary sampling unit of an enumeration area. We conducted 30 key informant interviews, 7 focus group discussions, and 6 in-depth interviews with representatives from the immunization program, health workers, and parents residing in areas with low vaccine coverage.Of the 590 enrolled children, 340 (57.6%) were partially vaccinated, 244 (41.4%) were fully vaccinated and had received all the recommended vaccinations, and 6 (1.0%) had never received any vaccine. Of the 244 with all recommended vaccinations, only 65 (26.6%) received their vaccines on time. Access to vaccination services was high (first dose of diphtheria, pertussis, and tetanus [DPT1] coverage of 96%), but utilization decreased over time, as shown by a dropout rate of 17.3% from the first to third dose of DPT. The main driver of complete vaccination was the parents' appreciation of the benefits of vaccination. Among partially vaccinated children, the barriers to vaccination were inadequate information about vaccination (its benefits and schedule), vaccine stock-outs, long waiting times to receive vaccination services, and hidden vaccination costs.Vaccination needs to be targeted to all children irrespective of whether they reside in slum areas or nonslum areas, as most are under-vaccinated. Social mobilization and communication efforts should be tailored to the complexities of urban settings characterized by transient and diverse populations with different cultures.

All around the world, health systems fail to provide good quality of care (QoC). By developing learning systems, health systems are able to better identify good practices and to explain how to sustain and scale these good practices. To facilitate the operationalisation of national learning systems, the Network for Improving Quality of Care for Maternal Newborn and Child Health (the Network) developed a conceptual framework for national learning systems to support QoC at scale. The Network facilitated an iterative process to reach consensus on a conceptual framework for national learning systems to sustain and scale up delivery of quality healthcare. Following a landscape analysis, the Network Secretariat and WHO convened two consultative meetings with country partners, technical experts and stakeholders. Based on these inputs, we developed a conceptual framework for national learning systems to support QoC at scale. National learning systems use a variety of approaches to identify practices that have improved QoC at the patient and provider levels. They also facilitate scale up and sustain strategies used successfully to support quality improvement. Despite growing consensus on the importance of learning for QoC, no one has yet detailed how this learning should be operationalised nationally. Our conceptual framework is the first to facilitate the operationalisation of national learning systems so that health systems can begin to develop, adapt and implement mechanisms to learn about what works or fails and to scale up and sustain this learning for QoC.

IntroductionA follow-up programme designed for high-risk newborns discharged from inpatient newborn units in low-resource settings is imperative to ensure these newborns receive the healthiest possible start to life. We aim to assess the feasibility, acceptability and early outcomes of a discharge and follow-up programme, called Hospital to Home (H2H), in a neonatal unit in central Uganda.Methods and analysisWe will use a mixed-methods study design comparing a historical cohort and an intervention cohort of newborns and their caregivers admitted to a neonatal unit in Uganda. The study design includes two main components. The first component includes qualitative interviews (n=60 or until reaching saturation) with caregivers, community health workers called Village Health Team (VHT) members and neonatal unit staff. The second component assesses and compares outcomes between a prospective intervention cohort (n=100, born between July 2019 and September 2019) and a historical cohort (n=100, born between July 2018 and September 2018) of infants. The historical cohort will receive standard care while the intervention cohort will receive standard care plus the H2H intervention. The H2H intervention comprises training for healthcare workers on lactation, breast feeding and neurodevelopmentally supportive care, including cue-based feeding, and training to caregivers on recognition of danger signs and care of their high-risk infants. Infants and their families receive home visits until 6 months of age, or longer if necessary, by specially trained VHTs. Quantitative data will be analysed using descriptive statistics and regression analysis. All results will be stratified by cohort group. Qualitative data will be analysed guided by Braun and Clarke’s thematic analysis technique.Ethics and disseminationThis study protocol was approved by the relevant Ugandan ethics committees. All participants will provide written informed consent. We will disseminate through peer-reviewed publications and key stakeholders and public engagement.Trial registration numberISRCTN51636372; Pre-result.

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BackgroundWorldwide, an estimated 5.1 million stillbirths and neonatal deaths occur annually, 98% in low- and middle-income countries. Limited coverage of civil and vital registration systems necessitates reliance on women’s retrospective reporting in household surveys for data on these deaths. The predominant platform, Demographic and Health Surveys (DHS), has evolved over the last 35 years and differs by country, yet no previous study has described these differences and the effects of these changes on stillbirth and neonatal death measurement.MethodsWe undertook a review of DHS model questionnaires, protocols and methodological reports from DHS-I to DHS-VII, focusing on the collection of information on stillbirth and neonatal deaths describing differences in approaches, questionnaires and geographic reach up to December 9, 2019. We analysed the resultant data, applied previously used data quality criteria including ratios of stillbirth rate (SBR) to neonatal mortality rate (NMR) and early NMR (ENMR) to NMR, comparing by country, over time and by DHS module.ResultsDHS has conducted >320 surveys in 90 countries since 1984. Two types of maternity history have been used: full birth history (FBH) and full pregnancy history (FPH). A FBH collecting information only on live births has been included in all model questionnaires to date, with data on stillbirths collected through a reproductive calendar (DHS II-VI) or using additional questions on non-live births (DHS-VII). FPH collecting information on all pregnancies including live births, miscarriages, abortions and stillbirths has been used in 17 countries. We found no evidence of variation in stillbirth data quality assessed by SBR:NMR over time for FBH surveys with reproductive calendar, some variation for surveys with FBH in DHS-VII and most variation among the surveys conducted with a FPH. ENMR:NMR ratio increased over time, which may reflect changes in data quality or real epidemiological change.ConclusionDHS remains the major data source for pregnancy outcomes worldwide. Although the DHS model questionnaire has evolved over the last three and half decades, more robust evidence is required concerning optimal methods to obtain accurate data on stillbirths and neonatal deaths through household surveys and also to develop and test standardised data quality criteria.

BackgroundTermination of pregnancy (TOP) is a common cause of maternal morbidity and mortality in low- and middle-income countries. Population-based surveys are the major data source for TOP data in LMICs but are known to have shortcomings that require improving. The EN-INDEPTH multi-country survey employed a full pregnancy history approach with roster and new questions on TOP and Menstrual Restoration. This mixed methods paper assesses the completeness of responses to questions eliciting TOP information from respondents and reports on practices, barriers, and facilitators to TOP reporting.MethodsThe EN-INDEPTH study was a population-based cross-sectional study. The Full Pregnancy History arm of the study surveyed 34,371 women of reproductive age between 2017 and 2018 in five Health and Demographic Surveillance System (HDSS) sites of the INDEPTH network: Bandim, Guinea-Bissau; Dabat, Ethiopia; IgangaMayuge, Uganda; Kintampo, Ghana; and Matlab, Bangladesh. Completeness and time spent in answering TOP questions were evaluated using simple tabulations and summary statistics. Exact binomial 95% confidence intervals were computed for TOP rates and ratios. Twenty-eight (28) focus group discussions were undertaken and analysed thematically.ResultsCompleteness of responses regarding TOP was between 90.3 and 100.0% for all question types. The new questions elicited between 2.0% (1.0–3.4), 15.5% (13.9–17.3), and 11.5% (8.8–14.7) lifetime TOP cases over the roster questions from Dabat, Ethiopia; Matlab, Bangladesh; and Kintampo, Ghana, respectively. The median response time on the roster TOP questions was below 1.3 minutes in all sites. Qualitative results revealed that TOP was frequently stigmatised and perceived as immoral, inhumane, and shameful. Hence, it was kept secret rendering it difficult and uncomfortable to report. Miscarriages were perceived to be natural, being easier to report than TOP. Interviewer techniques, which were perceived to facilitate TOP disclosure, included cultural competence, knowledge of contextually appropriate terms for TOP, adaptation to interviewee’s individual circumstances, being non-judgmental, speaking a common language, and providing detailed informed consent.ConclusionsSurvey roster questions may under-represent true TOP rates, since the new questions elicited responses from women who had not disclosed TOP in the roster questions. Further research is recommended particularly into standardised training and approaches to improving interview context and techniques to facilitate TOP reporting in surveys.

In settings where antenatal ultrasound is not offered routinely, ultrasound use when a woman first presents to the maternity ward for labour (i.e., triage) may be beneficial. This study investigated patients’ perceptions of care and providers’ experience with ultrasound implementation during labour triage at a district referral hospital (DH) and three primary health centers (HC) in eastern Uganda. This was a mixed methods study comprising questionnaires administered to women and key informant interviews among midwives pre- and post-ultrasound introduction. Bivariate analyses were conducted using chi-square tests. Qualitative themes were categorized as (1) workflow integration; (2) impact on clinical processes; (3) patient response to ultrasound; and (4) implementation barriers. A total of 731 and 815 women completed questionnaires from the HCs and DH, respectively. At the HC-level, triage quality of care, satisfaction and recommendation ratings increased with implementation of ultrasound. In contrast, satisfaction and recommendation ratings did not differ upon ultrasound introduction at the DH, whereas perceived triage quality of care increased. Most participants noted a perceived improvement in midwives’ experience and knowledge upon introduction of ultrasound. Women who underwent a scan also reported diverse feelings, such as fear or worry about their delivery, fear of harm due to the ultrasound, or relief after knowing the baby’s condition. For the midwives’ perspective (n = 14), respondents noted that ultrasound led to more accurate diagnoses (e.g., fetal position, heart rate, multiple gestation) and improved decision-making. However, they noted health system barriers to ultrasound implementation, such as increased workload, not enough ultrasound-trained providers, and irregular electricity. While triage ultrasound in this context was seen as beneficial to mothers and useful in providers’ clinical assessments, further investigation around provider-patient communication, system-level challenges, and fears or misconceptions among women are needed.

BackgroundRisks of neonatal death, stillbirth and miscarriage are highest in low- and middle-income countries (LMICs), where data has most gaps and estimates rely on household surveys, dependent on women reporting these events. Underreporting of pregnancy and adverse pregnancy outcomes (APOs) is common, but few studies have investigated barriers to reporting these in LMICs. The EN-INDEPTH multi-country study applied qualitative approaches to explore barriers and enablers to reporting pregnancy and APOs in surveys, including individual, community, cultural and interview level factors.MethodsThe study was conducted in five Health and Demographic Surveillance System sites in Guinea-Bissau, Ethiopia, Uganda, Bangladesh and Ghana. Using an interpretative paradigm and phenomenology methodology, 28 focus group discussions were conducted with 82 EN-INDEPTH survey interviewers and supervisors and 172 women between February and August 2018. Thematic analysis was guided by an a priori codebook.ResultsSurvey interview processes influenced reporting of pregnancy and APOs. Women found questions about APOs intrusive and of unclear relevance. Across all sites, sociocultural and spiritual beliefs were major barriers to women reporting pregnancy, due to fear that harm would come to their baby. We identified several factors affecting reporting of APOs including reluctance to speak about sad memories and variation in recognition of the baby’s value, especially for APOs at earlier gestation. Overlaps in local understanding and terminology for APOs may also contribute to misreporting, for example between miscarriages and stillbirths. Interviewers’ skills and training were the keys to enabling respondents to open up, as was privacy during interviews.ConclusionSociocultural beliefs and psycho-social impacts of APOs play a large part in underreporting these events. Interviewers’ skills, careful tool development and translation are the keys to obtaining accurate information. Reporting could be improved with clearer explanations of survey purpose and benefits to respondents and enhanced interviewer training on probing, building rapport and empathy.

A locally developed, low-cost package of interventions implemented in a regional network of hospitals resulted in significant reductions in mortality for mothers and newborns as well as the institutionalization of the quality improvement initiative. This work demonstrates that it is possible to achieve the World Health Organization/United Nations Children's Fund Quality of Care targets in hospitals., Key Findings The interventions implemented led to improvements in maternal and newborn outcomes and the institutionalization and scale-up of the quality improvement process at both hospitals and high-volume health centers.Critical factors for success included codesigning and implementing a package of services that fit the context. This package was locally led, integrated but simple, and built on and sustained by mainly local resources to develop local champions.Challenges included lack of participation from doctors due to high doctor-patient ratio, scarcity of human and other resources, inadequate infrastructure, unstable electricity, and multiplicity of other initiatives. Key Implications Successful quality improvement projects must be integrated but feasible, based on the context and building onto the available resources, and implemented over a fairly long time. Creating a network of regional hospitals via a quality improvement collaborative rapidly leads to improved referral care and increased access to high-quality services for mothers and newborns. Once these efforts are operationalized and functional in hospitals, high-volume primary health centers can be brought aboard, which leads to scale-up.Having a network of hospitals working to improve quality can be a platform for learning, research, and knowledge generation and for building advanced neonatal care units in places where they hitherto never existed. However, such efforts must be complemented by recruiting more specialized health workers, such as neonatal nurses, pediatricians, and neonatologists, into regional and district hospitals so that nurses and midwives are well supported., Introduction: Despite the rapid increase in facility deliveries in Uganda, the number of adverse birth outcomes (e.g., neonatal and maternal deaths) has remained high. We aimed to codesign and co-implement a locally designed package of interventions to improve the quality of care in hospitals in the Busoga region. Design and Implementation: This project was designed and implemented in 3 phases in the 6 main hospitals in east-central Uganda from 2013 to 2016. First, the inception phase engaged health system managers to codesign the intervention. Second, the implementation phase involved training health providers, strengthening the data information system, and providing catalytic equipment and medicines to establish newborn care units (NCUs) within the existing infrastructure. Third, the hospital collaborative phase focused on clinical mentorship, maternal and perinatal death reviews (MPDRs), and collaborative learning sessions. Achievements: In all 6 participating hospitals, we achieved institutionalization of NCUs in maternity units by establishing kangaroo mother care areas, resuscitation corners, and routine MPDRs. These improvements were associated with reduced maternal and neonatal deaths. Facilitators of success included a simple, low-cost, and integrated package designed with local health managers; the emergence of local neonatal care champions; implementation and support over a reasonably long period; decentralization of newborn care services; and use of mainly existing local resources (e.g., physical space, human resources, and commodities). Barriers to success related to limited hospital resources, unstable electricity, and limited participation from doctors. More advanced NCUs have been established in 3 of the 6 hospitals, and 7 high-volume comprehensive health centers have been established with functional NCUs. Conclusion: The involvement of local health workers and leaders was the foundation for designing, sustaining, and scaling up feasible interventions by harnessing available resources. These findings are relevant for the quality of care improvement efforts in Uganda and other resource-restrained settings.

Background: Little has been published on neonatal outcomes from low resource facilities during the COVID-19 pandemic. In the past 20 years Uganda has improved newborn mortality but the pandemic and resulting restrictions threaten to affect this vulnerable segment of the population. During the first two months of the pandemic in Uganda travel was tightly restricted for pregnant women and sick newborns and public transport was difficult to access for two months thereafter. Methods: We report outcomes from admissions captured in an existing electronic dataset of a well-established newborn unit in central Uganda before (September 2019 to March 2020) and during the early COVID-19 period (April – September 2020). We report excess mortality as the percent change in mortality over what was expected based on seasonal trends. Findings: There was an 8% decrease in admissions from outside the facility and an increase in overall admissions with birth asphyxia (22% vs. 15%) during the early pandemic. Patients born outside the facility were older on admission than previously (median 1 day of age vs. on the day of birth). Mortality significantly differed between the COVID-19 period and pre-COVID-19 periods [15·7% (89/567) vs. 11·1% (69/619), p=0·017]. Mortality was increased in all categories of birthweight and diagnosis. Most prominent was the increased mortality among patients born outside the facility (21·2% vs. 14·3%, p= 0·028), a relative increase of 55% above seasonal expected mortality in this group. Interpretation: This increased mortality is likely attributed to disruptions due to the pandemic affecting maternal and newborn demand for, access to and quality of peripartum healthcare. Impacts on these vulnerable newborns requires deliberate focus by health officials to prioritize their care despite pandemic conditions. Funding Information: Adara Development. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: Human Subjects Approval was obtained from Makerere University School of Public Health Institutional Review Board (protocol number 917) and approved by the Uganda National Council for Science and Technology (registration number SS813ES). The University of Washington institutional review board designated this as an exempt study.

Background: Uganda has achieved a considerable reduction in childhood stunting over the past two decades, though accelerated action will be needed to achieve 2030 targets. This study assessed the national, community, household, and individual-level drivers of stunting decline since 2000, along with direct and indirect nutrition policies and programs that have contributed to nutrition change in Uganda. Methods: This mixed-methods study used 4 different approaches to determine the drivers of stunting change over time: 1) a systematic literature review; 2) quantitative data analyses, including Oaxaca-Blinder decomposition and difference-in-difference multivariable hierarchical modeling; 3) national and community-level qualitative data collection and analysis; and 4) analysis of key direct and indirect nutrition policies, programs, and initiatives. Findings: Stunting prevalence declined by 14% points from 2000 to 2016, though geographical, wealth, urban/rural, and education-based inequalities persist. Child growth curves demonstrated substantial improvements in child height-for-age z-scores (HAZ) at birth, reflecting improved maternal nutrition and intrauterine growth. The decomposition analysis explained 82% of HAZ change, with increased coverage of insecticide-treated mosquito nets (ITNs; 35%), better maternal nutrition (19%), improved maternal education (14%), and improved maternal and newborn healthcare (11%) being the most critical factors. The qualitative analysis supported these findings, and also pointed to wealth, women’s empowerment, cultural norms, water and sanitation, dietary intake, and childhood illness as important. The 2011 Uganda Nutrition Action Plan was an essential multi-sectoral strategy that shifted nutrition out of health and mainstreamed it across related sectors. Interpretation: Uganda’s success in stunting reduction was multi-factorial, but driven largely through indirect nutrition strategies delivered outside of health. To further improve stunting, it will be critical to prioritize malaria-control strategies, including ITN distribution campaigns and prevention/treatment approaches for mothers and children, and deliberately target the poor, least educated and rural populations along with high-burden northern and western districts. Funding: This study was funded by the Bill & Melinda Gates Foundation and Gates Ventures. Declaration of Interest: None to declare. Ethical Approval: Ethics approval was obtained from the Makerere University School of Public Health Higher Degrees Research Ethical Committee (Uganda), the Uganda National Council of Science and Technology, and the Research Ethics Board at the Hospital for Sick Children (Canada).

Background: Policy measures to slow the spread of COVID-19, such as curfews and business closures, may have negative effects on mental health. Populations in low- and middle-income countries (LMICs) may be particularly affected due to high rates of poverty and less comprehensive welfare systems, but evidence is scarce. We evaluated predictors of psychological distress in Uganda, which implemented one of the world’s most stringent lockdowns. Methods: We conducted a mobile phone-based cross-sectional survey from December 2020 through April 2021 among individuals aged 18+ in Uganda. Psychological distress was measured using the Patient Health Questionnaire (PHQ)-4. We applied linear regression to assess associations between experiences of COVID-19 (including fear of infection, social isolation, income loss, difficulty accessing medical care, school closings, and interactions with police) and PHQ-4 score, adjusted for sociodemographic characteristics. Findings: 29.2% (95%CI 27.8% to 30.6%) of 4,066 total participants reported scores indicating moderate psychological distress, and 12.1% (11.1% to 13.1%) reported scores indicating severe distress. Distress was most common among individuals who were female, had lower levels of education, and lived in households with children. Related to COVID-19, PHQ-4 score was significantly associated with difficulty accessing medical care (p=0.01), worries about COVID-19 (p

Background In Uganda, there are persistent weaknesses in obtaining accurate, reliable and complete data on local and external investments in immunization to guide planning, financing, and resource mobilization. This study aimed to measure and describe the financial envelope for immunization from 2012 to 2016 and analyze expenditures at sub-national level. Methods The Systems of Health Accounts (SHA) 2011 methodology was used to quantify and map the resource envelope for immunization. Data was collected at national and sub-national levels from public and external sources of immunization. Data were coded, categorized and disaggregated by expenditure on immunization activities using the SHA 2011. Results Over the five-year period, funding for immunization increased fourfold from US$20.4 million in 2012 to US$ 85.6 million in 2016. The Ugandan government was the main contributor (55%) to immunization resources from 2012 to 2014 however, Gavi, the Vaccine Alliance contributed the majority (59%) of the resources to immunization in 2015 and 2016. Majority (66%) of the funds were managed by the National Medical Stores. Over the five-year period, 80% of the funds allocated to immunization activities were spent on facility based routine immunization (expenditure on human resources and outreaches). At sub-national level, districts allocated 15% of their total annual resources to immunization to support supervision of lower health facilities and distribution of vaccines. Health facilities spent 5.5% of their total annual resources on immunization to support outreaches. Conclusion Development partner support has aided the improvement of vaccine coverage and increased access to vaccines however, there is an increasing dependence on this support for a critical national program raising sustainability concerns alongside other challenges like being off-budget and unpredictable. To ensure financial sustainability, there is need to operationalize the immunization fund, advocate and mobilize additional resources for immunization from the Government of Uganda and the private sector, increase the reliability of resources for immunization as well as leverage on health financing reforms like the National Health Insurance.

Background Complications due to prematurity are a threat to child survival and full developmental potential particularly in low-income settings. Objective The aim of the study was to determine the neurodevelopmental outcomes among preterm infants and identify any modifiable factors associated with neurodevelopmental disability (NDD) Methods We recruited 454 babies (242 preterms with birth weight

ObjectivesGlobally, hundreds of women die daily from preventable pregnancy-related causes, with the greatest burden in sub-Saharan Africa. Five key emergencies—bleeding, infections, high blood pressure, delivery complications and unsafe abortions—account for nearly 75% of these obstetric deaths. Skilled clinicians with strategic supplies could prevent most deaths. In this study, we (1) measured facility readiness to manage common obstetric emergencies using the clinical cascades and signal function tracers; (2) compared these readiness estimates by facility characteristics; and (3) measured cascading drop-offs in resources.DesignA facility-based cross-sectional analysis of resources for common obstetric emergencies.SettingData were collected in 2016 from 23 hospitals (10 designated comprehensive emergency obstetric care (CEmOC) facilities) in Migori County, western Kenya, and Busoga Region, eastern Uganda, in the Preterm Birth Initiative study in East Africa. Baseline data were used to estimate a facility’s readiness to manage common obstetric emergencies using signal function tracers and the clinical cascade model. We compared emergency readiness using the proportion of facilities with tracers (signal functions) and the proportion with resources for identifying and treating the emergency (cascade stages 1 and 2).ResultsThe signal functions overestimated practical emergency readiness by 23 percentage points across five emergencies. Only 42% of CEmOC-designated facilities could perform basic emergency obstetric care. Across the three stages of care (identify, treat and monitor-modify) for five emergencies, there was a 28% pooled mean drop-off in readiness. Across emergencies, the largest drop-off occurred in the treatment stage. Patterns of drop-off remained largely consistent across facility characteristics.ConclusionsAccurate measurement of obstetric emergency readiness is a prerequisite for strengthening facilities’ capacity to manage common emergencies. The cascades offer stepwise, emergency-specific readiness estimates designed to guide targeted maternal survival policies and programmes.Trial registration numberNCT03112018.

International audience; No abstract available

Author(s): Mubiri, Paul; Nambuya, Harriet; Kajjo, Darious; Butrick, Elizabeth; Namazzi, Gertrude; Santos, Nicole; Walker, Dilys; Waiswa, Peter | Abstract: BackgroundAn estimated 2.8 million neonatal deaths occur each year globally, which accounts for at least 45% of deaths in children aged less than 5 years. Birthweight and gestational age-specific mortality estimates are limited in low-resource countries like Uganda. A deeper analysis of mortality by birthweight and gestational age is critical in identifying the cause and potential solutions to decrease neonatal mortality.ObjectivesWe studied mortality before discharge in relation to birthweight and gestational age using a large sample size from selected tertiary care facilities in Uganda.MethodsWe used secondary data from the East Africa Preterm Birth Initiative study conducted in six tertiary care facilities. Birth records of infants born between October 2016 and March 2019 with a gestational age greater than or equal to 24 weeks and/or birthweight greater than or equal to 500 g were reviewed for inclusion in the analysis. Newborn death before discharge was the outcome variable of interest. Multivariable Poisson regression modeling was used to explore birthweight and gestational age-specific mortality rate.ResultsWe analysed 50 278 birth records. Among these 95.3% (47 913) were live births and 4.8% (2365) were stillbirths. Of the 47 913 live births, 50% (24 147) were males. Overall, pre-discharge mortality was 13.0 per 1000 live births. For each 1 kg increase in birthweight, mortality before discharge decreased by -0.016. As birthweight increases, the mortality before discharge decreased from 336 per 1000 live births among infants born between 500 and 999 g, to 4.7 per 1000 live births among infants born weighing 3500 to 3999 g, and increased again to 11.2 per 1000 live births among infants weighing more than 4500 g.ConclusionsOur study highlights the need for further research to understand newborn survival across different birthweight and gestational categories.

In this edition of BMJ Global Health , Roder-DeWan and colleagues suggest ways in which we might rethink care models to close the equity gap in maternal and newborn health.1 Their analysis article follows from the work of the Lancet Global Health Commission on High-Quality Health Systems , proposing design reforms with quality at the centre.2 The authors suggest that all childbirth care services should be moved to hospitals in all countries, combined with improvements in (1) the quality of care provided in these facilities; (2) transportation from home to hospital; and (3) continuity of care through hub-and-spoke arrangements. We agree in principle with the need to shift childbirth care services towards higher level facilities. The quality of care provided to women and their newborns in low and middle-income countries (LMICs) is inadequate.1 Economic development and advances in communication and transportation should redefine the paradigm of proximity to care.1 Also Kruk and colleagues estimated that more lives are lost today due to substandard care than due to limited geographical access.3 So it is important to rethink where and how childbirth care should be made available. However, such health system redesign needs to respond to local needs and bottlenecks—that is, redesign must centre human resources, particularly midwifery providers ; respond to the local context ; and be fit for purpose . To cite Lynn Freedman, ‘ The point is not that global strategies, evidence-based guidelines, or high-level monitoring and accountability initiatives are inherently wrong or unnecessary. But when they consume most of the oxygen in the room, drowning out voices and signals coming from the ground, they distort both understanding and action. ’ 4 Redesigning maternal and perinatal care needs to be done with a view to strengthening district health systems in a sustainable and crisis-resilient …

Summary Background Although gains in newborn survival have been achieved in many low-income and middle-income countries, reductions in stillbirth and neonatal mortality have been slow. Prematurity complications are a major driver of stillbirth and neonatal mortality. We aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised. Methods This unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. The study assessed outcomes of low-birthweight and preterm babies. Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention group or the control group. All facilities received maternity register data strengthening and a modified WHO Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. Liveborn or fresh stillborn babies who weighed between 1000 g and 2500 g, or less than 3000 g with a recorded gestational age of less than 37 weeks, were included in the analysis. We abstracted data from maternity registers for maternal and birth outcomes. Follow-up was done by phone or in person to identify the status of the infant at 28 days. The primary outcome was fresh stillbirth and 28-day neonatal mortality. This trial is registered with ClinicalTrials.gov , NCT03112018 . Findings Between Oct 1, 2016, and April 30, 2019, 20 facilities were randomly assigned to either the intervention group (n=10) or the control group (n=10). Among 5343 eligible babies in these facilities, we assessed outcomes of 2938 newborn and fresh stillborn babies (1447 in the intervention and 1491 in the control group). 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group at 28 days (odds ratio 0·66, 95% CI 0·54–0·81). No harm or adverse effects were found. Interpretation Fresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening. Funding Bill & Melinda Gates Foundation.

Background Although under-five (U5) mortality in Uganda has dropped over the past two decades, rates in urban slum neighborhoods remain high. As part of a broader verbal and social autopsy study of U5 deaths, this study explored the perspectives of volunteer community health workers, called Village Health Teams (VHTs), on why children under five in Kampala’s informal settlements are still dying despite living in close proximity to nearby health facilities. Methods This exploratory, qualitative study took place between January and March 2020 in the Rubaga division of Kampala, Uganda. VHTs from the slums of Kawaala and Nankulabye parishes, both located near a large government health center, were interviewed by a trained local interviewer to determine their perceptions of barriers to care-seeking and attribution for U5 childhood deaths. All interviews were audiotaped, transcribed into English, imported into NVivo V 12.0 and thematically analyzed using the Attride-Stirling framework. Results 20 VHTs were interviewed, yielding two global themes, the first focusing on VHTs perceptions of their role in the community to promote positive health outcomes, and the second focusing on VHTs’ perceptions of how prompt care-seeking is disincentivized. Within the latter theme, three inter-related sub-themes emerged: disincentives for care-seeking at the health system level, which can drive negative beliefs held by families about the health system, and in turn, drive incentives for alternative health behaviors, which manifest as “incentivized delays” to care-seeking. Discussion This study illustrates VHT perspectives on the complex interactions between health system disincentives and the attitudes and behaviors of families with a sick child, as well as the reinforcing nature of these factors. Findings suggest a need for multi-pronged approaches that sensitize community members, engage community and health system leadership, and hold providers accountable for providing high-quality care. VHTs have enormous potential to foster improvement if given adequate resources, training, and support.

BackgroundGlobally, the under-10 years of age mortality has not been comprehensively studied. We applied the life-course perspective in the analysis and interpretation of the event history demographic and verbal autopsy data to examine when and why children die before their 10th birthday.MethodsWe analysed a decade (2005-2015) of event histories data on 22385 and 1815 verbal autopsies data collected by Iganga-Mayuge HDSS in eastern Uganda. We used the lifetable for mortality estimates and patterns, and Royston-Parmar survival analysis approach for mortality risk factors' assessment.ResultsThe under-10 and 5-9 years of age mortality probabilities were 129 (95% Confidence Interval [CI] = 123-370) per 1000 live births and 11 (95% CI = 7-26) per 1000 children aged 5-9 years, respectively. The top four causes of new-born mortality and stillbirth were antepartum maternal complications (31%), intrapartum-related causes including birth injury, asphyxia and obstructed labour (25%), Low Birth Weight (LBW) and prematurity (20%), and other unidentified perinatal mortality causes (18%). Malaria, protein deficiency including anaemia, diarrhoea or gastrointestinal, and acute respiratory infections were the major causes of mortality among those aged 0-9 years-contributing 88%, 88% and 46% of all causes of mortality for the post-neonatal, child and 5-9 years of age respectively. 33% of all causes of mortality among those aged 5-9 years was a share of Injuries (22%) and gastrointestinal (11%). Regarding the deterministic pattern, nearly 30% of the new-borns and sick children died without access to formal care. Access to the treatment for the top five morbidities was after 4 days of symptoms' recognition. The childhood mortality risk factors were LBW, multiple births, having no partner, adolescence age, rural residence, low education level and belonging to a poor household, but their association was stronger among infants.ConclusionsWe have identified the vulnerable groups at risk of mortality as LBW children, multiple births, rural dwellers, those whose mother are of low socio-economic position, adolescents and unmarried. The differences in causes of mortalities between children aged 0-5 and 5-9 years were noted. These findings suggest for a strong life-course approach in the design and implementation of child health interventions that target pregnant women and children of all ages.