Implementing the skilled birth attendance strategy in Uganda: a policy analysis

Abstract

Background Uganda, a low resource country, implemented the skilled attendance at birth strategy, to meet a key target of the 5th Millenium Development Goal (MDG), 75% reduction in maternal mortality ratio. Maternal mortality rates remained high, despite the improvement in facility delivery rates. In this paper, we analyse the strategies implemented and bottlenecks experienced as Uganda’s skilled birth attendance policy was rolled out. These experiences provide important lessons for decision makers as they implement policies to further improve maternity care. Methods This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, Professional Organisations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organisations, and District Health Officers. The Walt and Gilson health policy triangle guided data collection and analysis. Results The skilled birth attendance policy was an important priority on Uganda’s maternal health agenda and received strong political commitment, and support from development partners and national stakeholders. Considerable effort was devoted to implementation of this policy through strategies to increase the availability of skilled health workers for instance through expanded midwifery training, and creation of the comprehensive nurse midwife cadre. In addition, access to emergency obstetric care improved to some extent as the physical infrastructure expanded, and distribution of medicines and supplies improved. However, health worker recruitment was slow in part due to the restrictive staff norms that were remnants of previous policies. Despite considerable resources allocated to creating the comprehensive nurse midwife cadre, this resulted in nurses that lacked midwifery skills, while the training of specialised midwives reduced. The rate of expansion of the physical infrastructure outpaced the available human resources, equipment, blood infrastructure, and several health facilities were not fully functional. Conclusion Uganda’s skilled birth attendance policy aimed to increase access to obstetric care, but recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation. Further evaluation of this policy is needed as decision-makers develop strategies to improve access to skilled care at birth.

Implementation science in maternity care: a scoping review

“…Collectively, these findings demonstrate the challenges of implementation science in maternity care within nations that are less than affluent. To manage sociocultural barriers, it can be helpful to adapt an intervention to a given context [113,140,159,161]-this might Mixed-methods 27 Case study 12 [139][140][141][142][143][144][145][146][147][148][149][150] Pre-post study 8 [151][152][153][154][155][156][157][158] Ethnography 6 [159][160][161][162][163][164] Cohort study 4 [165][166][167][168] Pilot-test 8 [169][170][171][172][173][174][175][176] Longitudinal survey 2 [177,178] Quasi-experimental 1 [179] Randomised controlled trial 2 [180,…”

A critical interpretive synthesis of the roles of midwives in health systems

“…evacuation of pregnant women out of the community and the residential school system) (Canada and Australia) [ 34 , 54 – 58 ] • Caste system devalued midwifery because the profession is traditionally led by women caring for women (India) [ 59 ] • Midwives faced structural barriers to integration as a result of previous restrictive policies (e.g. midwives did not have a budget code in Mexico until 2011) [ 38 , 60 ] • Lack of gender-sensitive and rights-based policies reinforced structural gender inequalities (i.e. created barriers to respectful maternity care and participation in policy-making) [ 42 – 44 ] • Policy legacies that valued midwives and home births influenced the way the health system was organised (Netherlands) [ 49 ] • Midwifery as a tool to empower women and advance gender equality [ 61 ] • Professionalisation of midwifery began in the eighteenth century (Sweden) [ 62 ] • Universal Rights of Childbearing Women in the Respectful Maternity Care Charter, recognised that issues related to gender equity and gender violence were at the centre of maternity care – ‘safe motherhood’ extends to basic human rights for pregnant women [ 42 , 63 , 64 ] • The State of the World’s Midwifery 2014 was a global policy initiative that increased the status of midwifery at country levels and international policy dialogue [ 65 , 66 ] [ 11 , 13 , 34 , 40 – 66 ] Interests • Interests include societal interest groups (e.g.…”

“…• Midwives faced structural barriers to integration as a result of previous restrictive policies (e.g. midwives did not have a budget code in Mexico until 2011) [ 38 , 60 ]…”

<p>To What Extent Do Ecological Factors of Behavior Contribute to the Compliance of the Antenatal Care Program in Dumai City, Indonesia?</p>

“…Recruitment of health workers and infrastructural capacity to provide good quality care remains a challenge. 35 The placement and training of midwives in some areas are inadequate. The establishment of databased programs still needs to be improved.…”