Postpartum care in Uganda: facility readiness, midwives perspectives, individualized care planning and patient outcomes

Abstract

Background: Globally, a woman dies every two minutes due to pregnancy or childbirth. Two-thirds of maternal deaths occur in the postpartum period and in Sub-Saharan Africa due to preventable causes such as sepsis, postpartum hemorrhage (PPH), and eclampsia. These deaths may reflect the care provided by the health workers. While individualized care has been slowly integrated into practice in Uganda, there is minimal documentation regarding provision of postpartum care and the implementation of individualized care plans (ICPs) for women after birth. Objectives: To assess the facilities’ readiness for the provision of Postpartum care (PPC), explore the midwives’ perspectives about the postpartum care guidelines and individualized care planning (ICP), and determine the factors associated with postpartum complications among women in the greater Mpigi region. Methods: The studies were conducted in three districts in central Uganda (Mpigi, Butambala, Gomba); in 2 hospitals, 3 health centre (HC) IVs, and 35 HC IIIs. Sub-study I utilized a descriptive cross-sectional design, involving 40 health facilities and employed an adapted facility assessment tool. Descriptive statistics were computed. Sub-studies II and III employed an exploratory descriptive qualitative design, involving 50 in-depth interviews with midwives in 37 HCs. Thematic analysis was done for Sub-study II. The Capability-Motivation-Opportunity for Behaviour change model (COM-B) guided the deductive content analysis for Sub-study III. Sub-study III was a cross-sectional study, involving 263 observations of postpartum women in three health facilities before discharge. Data collection employed an observation checklist and a data abstraction form. Multi-variable logistic regression analysis was done. Results: Facility readiness for the provision of PPC was low (median score 24% (IQR: 18.7, 26.7). Availability and use of up-to-date policies, guidelines and written clinical protocols for identifying, monitoring, and managing PPC were inconsistent across all levels of care. Frequent stock-outs of essential drugs and supplies, particularly hydralazine (52.5%), adult resuscitation equipment (60%), oxygen, and examination gloves (17,5%)/ gynecologic gloves (27.5%), were more common at HCs compared to hospitals. Overall, private not for profit HCs (26.7%, IQR 20.0-30.0) had higher facility readiness scores compared to public facilities (21.93, IQR 17.3-26.7). Three themes emerged regarding the midwives’ perspectives towards the MoH guidelines including; awareness and use of guidelines, drivers of guideline use, and perceived barriers to provision of immediate PPC. Midwives reported mixed perceptions about the PPC guidelines, variations in PPC practices, disparities in preparedness to manage postpartum complications, and no continuing midwifery education. Of the 263 women observed in Sub Study IV, only 3/263(1.14%) were assessed within the first 2 hours, 29/263 (11.02%) at three hours and 10/263 (3.8%) at the fourth hour after delivery as per the MoH guidelines. The prevalence of postpartum complications was at 14.1% of which 68% had PPH. Regarding ICP use, midwives were aware and used critical thinking and reasoning in drawing up ICPs (capability) which they used for high-risk women, HIV positive women, and first-time mothers (automatic motivation). A good midwife-patient relationship, privacy, and ample time to care for women were noted as reflective motivators for ICP use. Social opportunities and barriers for use of ICP were; poor documentation of care, high patient load, and perceived patients’ lack of understanding of the complexities of illness in the immediate postpartum period. Other challenges were lack of training, materials for documentation, high patient load and poor documentation culture (Capability). Conclusion: There are still gaps in the facility readiness, use of the MoH guidelines and ICPs in the provision of PPC. Increased financing, staff recruitment, training, and harmonization of the documentation forms may improve the use of care plans in the postpartum period. Furthermore, wide dissemination of the guidelines, mentorship, and support supervision could facilitate the use of ICPs and the MoH guidelines in the provision of PPC.