Improving Partograph Use in Uganda Through Coaching and Mentoring UGANDA
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UGANDA Improving Partograph Use in Uganda through Coaching and Mentoring WHAT IS FISTULA? Introduction and Background Obstetric fistula is a childbirth Uganda is making progress in improving maternal health: The maternal mortality ratio has declined by 47% over the past 20 years, from 600 maternal injury, usually occurring when deaths per 100,000 live births in 1990 to 438 per 100,000 in 2011 (UBOS a woman is in labor too long & ICF International, 2012; WHO et al., 2012). However, this rate is still or when delivery is obstructed, unacceptably high, and Uganda will need to make significant improvements to and she has no access to a achieve its Millennium Development Goal 5 target of 131 deaths per 100,000 cesarean section. She endures live births by 2015 (Uganda Ministry of Finance, Planning, and Economic Development, 2010). internal injuries that leave her Obstructed labor is a major cause of maternal and newborn morbidity and incontinent, trickling urine mortality in developing countries such as Uganda. It can lead to postpartum and sometimes feces through hemorrhage, infection, and fetal death, as well as obstetric fistula. The risk of her vagina. experiencing these birth-related injuries or death increases in low-resource settings with limited health services. The partograph—a preprinted form on which labor observations are Fistula Care works to prevent recorded—is a low-tech, inexpensive tool designed to monitor labor and fistula from occurring, treats and prevent obstructed labor. It provides a graphic overview of the progress of cares for women with fistula, labor and records information about the condition of the mother and the child. The partograph (also called the partogram) acts as an early warning system; it and assists in their rehabilitation can alert care providers to deviations from normal progress and indicate when and reintegration. For more a woman requires emergency intervention, such as referral to a higher-level information about fistula and facility, labor augmentation, or cesarean section. the Fistula Care project, visit The World Health Organization (WHO) recommends partograph use www.fistulacare.org. (1994). However, in many low-resource settings, including Uganda, the tool is underutilized, and many health care providers do not know how to use it properly (Levin & Kabagema, 2011). Fistula Care promotes correct and consistent use of the partograph as one of its key fistula prevention interventions. Since 2010, Fistula Care has collaborated with the Reproductive Health Department of the Ugandan Ministry of Health (MOH) to strengthen partograph use. This brief describes the challenges and achievements of developing and implementing a new approach to support partograph use at five facilities across three districts. Partograph Training: Coaching and Mentoring Initial Data Collection and Planning In 2008, the Uganda MOH, with support from Fistula Care, trained service providers in emergency obstetric care (EmOC), including the partograph, at www.fistulacare.org 12 health service sites, ranging from health centers to district hospitals. Follow-up visits to these sites revealed that staff were not using the partograph the entire site, promotes teamwork, and encourages facility leadership and supportive supervision. By bringing all site staff together in a communal effort to improve performance and quality of care, it enables those who are trained to share their knowledge and skills with others who may be new to the site. It also can engender a critical mass to lobby for more resources and provide a forum for discussion of common problems, which can catalyze a range of quality improvement initiatives. Thus far, only the partograph skills training and coaching component of the approach have Health workers practice plotting observations using the partograph board at been comprehensively implemented. Kitovu Hospital. Selected facilities will implement the mentoring component of the approach, using “fistula champions”— well and were not applying the skills • Minimal partograph training from individuals identified by district and knowledge acquired during nursing and midwifery preservice supervisors as the most enthusiastic training. A new training approach education and successful in implementing was needed. In response, the MOH, in partner- partograph use after training. To better understand barriers to ship with Fistula Care, decided to In addition to piloting a new training partograph use, the MOH and Fistula implement a coaching and mentoring approach, the MOH’s Reproductive Care conducted a baseline situation training approach to improve Health Division initiated a process to analysis at these 12 health care partograph use. Through coaching, review existing national guidelines facilities in 2011. Facility staff and an individual with knowledge, skills, on partograph use. Fistula Care the district health management team and competency in a particular area identified and shared a number of (DHMT) identified six main barriers to helps others to develop that skill gaps with the MOH, which made partograph use: set through on-site training and revisions (Uganda MOH Reproductive • Lack of essential supplies and ongoing supportive monitoring and Health Division, 2010) to ensure that equipment in maternity units, feedback. A mentoring approach they were in line with current WHO such as partograph forms, blood utilizes ongoing, long-term recommendations.1 pressure machines, or watches relationships between the “experts” and clocks with which to record and the “trainees,” building on shared Site Selection maternal and fetal heart rates experience. Coaching and mentoring In a series of planning meetings, the • Failure of health care managers, take place in the trainees’ workplace MOH and Fistula Care decided to including senior staff at maternity environment and are strengthened pilot the approach over a one-year units, to recognize thepartograph’s through trust and respect. period at five health care facilities in value or support its use The MOH and Fistula Care decided Masaka, Kasese, and Kalungu districts. • Lack of ongoing supervision and to use a whole-site training approach The coaching and mentoring approach clinical audits (Bradley et al., 1998; EngenderHealth, entails an intense level of resources; • High staff turnover at maternity 2001) because of its perceived thus, a small number of facilities were units, resulting in the loss of advantages over other methods, chosen for the pilot. The criteria for valuable skills and training based on experience and a literature site selection included the maternity investments review conducted by Fistula Care caseload, management’s commitment • Differences in the versions of staff. Whole-site training meets the to the process and outcomes, and the the partograph used at various learning needs of all staff at a health desire to have a balance of public- and facilities care delivery site, builds capacity at private-sector sites. 1 A revised draft has been completed and is being used nationwide. The World Bank and WHO are gathering resources with which to print and disseminate the revised guidelines. 2 Improving Partograph Use in Uganda The facilities chosen were Kitovu, Kagando, and Bwera hospitals and two Health Centre III facilities2: Kalungu and Karambi. Kitovu Hospital and Kagando Hospital are private not-for- profit hospitals led by the Catholic and Anglican churches, respectively. Bwera Hospital and Kalungu and Karambi health centers are public- sector facilities. Buy-In and Participation Uganda has a decentralized health system, so obtaining buy-in from district leaders was critical to the success of the intervention. Fistula Care held orientation meetings for district leaders of the three selected districts and for the DHMTs, to highlight the value of partograph use in improving clinical decision making Health workers review and score partographs using the partograph review tool during and the overall quality of EmOC. on-site coaching and mentoring training at Hoima Hospital. During these orientation meetings, district teams developed preliminary following training. A facility focal action plans to improve partograph improving over time and whether the person reviewed each partograph on use; they also decided how best to percentage of client files containing file and computed the scores. allocate sufficient resources and partographs increased over time. The initial scoring scheme for how to integrate plans into existing Unfortunately, this change in scoring the assessment tool required that safe motherhood strategies. District occurred prior to the three-month or every component of the partograph safe motherhood supervisors3 were six-month follow-up visits at most be correctly completed for the given the responsibility of ensuring intervention sites, which meant that record to be considered “correct.” partograph availability and of working scores collected before training and However, this grading system made it with facility supervisors to monitor during earlier follow-up visits were difficult to measure gradual changes partograph use at the selected sites. in a different format, impeding the in partograph performance. In ability to monitor overall trends for December 2011, the grading system the intervention. Data Collection was modified to provide a more The scores for each site were not As part of the baseline situation nuanced picture of how the sites intended to serve as evaluation analysis conducted at the 12 sites were performing. Each partograph