APPENDICES FOR THE REGIONAL LEARNING NETWORK: A MODEL FOR IMPROVING MATERNAL AND NEWBORN HEALTH CARE OUTCOMES IN UGANDA Appendix I: Details of assessment methods Appendix II: Hoima Regional Learning Network (RLN) Conceptual framework Appendix III: How-to guides • Mentorship • Establishing and functionalizing skills labs • Learning Sessions • RMNCAH scorecards • Media engagement Appendix IV: URC Endline report From 2016 to 2017, Uganda’s Ministry of Health (MOH) with support from Save the Children and the University Research Company (URC) piloted the Regional Learning Network initiative (RLN), a quality improvement collaborative, in the Hoima Region. Save the Children prepared a brief detailing the work and lessons learned from the RLN. This supplementary file provides appendices for additional information related to the Save the Children brief including methods, conceptual framework and How To Guides for establishing a RLN. Access the brief at www.healthynewbornnetwork.org/resource/Uganda-RLN 1 Appendix I: Details on Hoima RLN assessment methods Mix-method baseline and endline assessments included interviews with health facility staff and district stakeholders, focus group discussions, data collection through questionnaires, maternity register reviews, and direct observation of clinical processes and outcomes. Methods URC assessments Purpose: To assess critical components needed to achieve high-quality newborn care including knowledge of healthcare providers about newborn care, infrastructure and personnel, availability of drugs and supplies, existing QI activities, coverage and quality of care during labour and delivery and newborn care, including complications. Timeframe conducted: baseline in May 2016 and endline from May to June 2017 (details in Table 1) Sampling: o Purposefully selected the 14 facilities in RLN o Questionnaire: purposefully selected 58 and then 50 health workers questionnaire o Observation and interviews: purposefully selected health workers at facilities o Maternity registers and case notes: randomly selected 25 mothers in maternity register per facility who delivered in prior week for some indicators otherwise all cases reviewed o Direct observations of normal deliveries: All deliveries on the day of assessment Data collection and analysis: o Trained data collectors spent ~2 days at each health facility to collect data o Seven pre-tested data collection forms used e.g. questionnaire and checklists o Quantitative—descriptive 2 Table 1: Methods of URC assessments according to components assessed Component Method and data Sampling Baseline sample Endline sample assessed source Health worker Self-administered Purposeful: 58 health 50 health workers knowledge and confidential workers <5 health confidence questionnaire with workers in each 20 multiple choice facility questions (form 1) representing given to health different health workers cadres* Infrastructure and Data collectors Purposeful 14/14 facilities 13/14 facilities personnel in recorded maternity and observations and newborn wards interviewed with facility-in charge (form 2) Drugs and Data collectors Purposeful 14/14 facilities 13/14 facilities supplies for interviewed chief newborn care pharmacists/drug store manager and conducted direct observations (form 3) Existing Data collectors Purposeful 14/14 facilities 13/14 facilities quality interviewed improvement maternity unit-in activities charge and/or facility- Health system readiness in charge (form 4) Monitoring of Data collectors Baseline 14/14 facilities 14/14 facilities labor and action in reviewed Randomly case of prolonged maternity register, selected 25 Maternity Maternity registers labor mothers’ mothers registers reviewed notes/files, and from reviewed 350 cases for partographs (form register 287 cases use of 5) who had for use of partograph delivered in partograph 160 cases of the 77 cases prolonged previous of labor, of these week (or all prolonged 147 had deliveries if labor clinical the number identified, records was less of these available for than 25) per 39 cases review facility had clinical records Endline available Purposeful: for review identified Coverage and quality of care cases in 3 maternity register of prolonged labor in previous quarter per facility Care during Data collectors GA: 14/14 facilities 11/14 facilities had labour and reviewed the Randomly had records records reviewed delivery maternity register selected 25 reviewed and clinical records mothers 275 deliveries for gestational age from 315 deliveries sampled (GA) assessment register sampled who had Records reviewed: Data collectors delivered in Records 275 cases for reviewed clinical the prior reviewed: gestational age records for all cases month (or 315 cases for assessment of other conditions: all deliveries gestational 547 newborn newborn asphyxia, if the age asphyxia cases PPROM, and number was assessment 37 PPROM cases premature (form 6) less than newborn 275 premature 25) per asphyxia birth cases facility cases – not reported Other 14 PPROM conditions: cases all cases in 96 the premature previous birth cases quarter Newborn Care Data collectors Register 14/14 facilities 11/14 reviewed the review for facilities maternity register the last 100 16 normal for documentation live births in deliveries 26 normal of ENC in the last the last observed deliveries 100 live births in quarter observed the last quarter (form 6) Observation of deliveries Data collectors on the day recorded direct of observation of 12 assessment components of ENC (form 7 – checklist) Early institutional Data collectors All births Live births: Live births: newborn extracted data from 1995 2062 mortality rate DHIS2 Total births: Total 2034 births: Fresh stillbirth 2098 Mortality outcome rate * The sample was not randomly chosen and included only the maternity staff present during the endline assessment period who routinely attended deliveries. 4 Table 2: Details of URC assessment by data collection form Data collection Purpose Method and data source Baseline sample Endline sample form Form 1: Health Assessed health worker’s level of Self-administered confidential questionnaire with 20 58 health 50 health workers worker knowledge knowledge on key competencies of multiple choice questions workers and confidence maternal and newborn care. <5 health workers in each facility representing different health cadres* Form 2: Assessed availability of infection Data collectors recorded observations and 14/14 facilities 13/14 facilities Infrastructure and control measures at maternal and interviewed with facility-in charge personnel in newborn units, essential lifesaving maternity and commodities and equipment, newborn wards necessary infrastructure, and staffing levels Form 3: Drugs and Assessed availability of essential Data collectors interviewed chief pharmacists/drug 14/14 facilities 13/14 facilities supplies for drugs and supplies present in store manager and conducted direct observations. newborn care facility pharmacy and stores. Form 4: Assessed quality improvement, Data collectors interviewed maternity unit-in charge 14/14 facilities 13/14 facilities Existing quality activities, projects and available and/or facility-in charge. improvement documentation. activities Form 5: Partograph Reviewed maternity register, Data collectors reviewed maternity register for 14/14 facilities 14/14 facilities review mothers’ notes/files, and week prior to the assessment, randomly selected partographs to assess 25 mothers who had delivered in the previous Maternity Maternity monitoring of labor and action week (or all deliveries if the number was less than registers registers in case of prolonged labor. 25), and assessed availability and completeness of reviewed reviewed partograph. 287 cases 350 cases for use of for use of For endline only: Data collectors reviewed partograph partograph maternity register to identify cases of prolonged 77 cases of 160 cases of labor in the previous quarter (February-March prolonged prolonged 2017) and reviewed clinical records to assess if labor labor, of proper protocol was followed. 5 identified, these 147 of these 39 had clinical cases had records clinical available for records review available for review Form 6: Collected data on assessment of Data collectors reviewed the maternity register for 14/14 facilities 11/14 facilities had Maternity gestational age, provision of the week prior to the endline assessment and had records records reviewed register and antenatal corticosteroids for randomly selected 25 mothers who had delivered in reviewed clinical record threatened preterm births, the prior month (or all if deliveries in prior week 275 deliveries review neonatal resuscitation and was less than 25). 315 deliveries sampled provision of KMC for low birth sampled weight babies. Clinical records were reviewed for gestational age, Records reviewed: for all cases of newborn asphyxia, PPROM, and Records 275 cases for premature birth reviewed: gestational age (275) in the previous quarter. 315 cases for assessment gestational 547 newborn Data collectors reviewed the maternity register for age asphyxia cases documentation of ENC in the last 100 live births in assessment 37 PPROM the last quarter newborn cases asphyxia 275 premature cases – not birth cases reported 14 PPROM cases 96 premature birth cases Form 7: Essential Assessed provision of a Data collectors recorded direct observation of 12 14/14 facilities 11/14 Newborn Care complete and immediate components of ENC: preparation for childbirth,