COSAS Maternity Training (CMT).

Problem: Lack of in-service refresher training (ISRT) for frontline healthcare providers in rural Uganda has resulted into decline of skills and knowledge. Ultimately, this has affected the quality of the care offered to communities and it has greatly affected the quality of maternal and newborn care resulting in high maternal and newborn mortality.

CMT empowers front-line health-worker entrepreneurs to provide maternal and newborn care by combining training, quality improvement, and peer-to-peer learning. Five health workers attend a curated, accelerated instruction over twelve months covering topics: management skills; identifying gaps in service delivery; prioritizing areas for improvement; and techniques for developing, testing, and implementing changes to improve services that offer quality, accessible, subsidized care for clients.  Over the subsequent year, every team is united on a quarterly basis to share experiences and insights, spreading best practices.

In Uganda, most In-service refresher Training's (IST’s) are done in public and NGO facilities, benefiting urban based public health workers, leaving health workers working in rural and private for profit facilities with little or no access to such training despite clear evidence that in-service refresher training helps in maintaining, improving and adding new skills to better service provision. This has resulted in the decline of knowledge to provide quality care including maternity and newborn care.

 According to Konde – Lule et al (2006), in Uganda, the quality of healthcare provided is perceived as poor, and inadequate continuous professional development of which IST is part was cited as one of the responsible factors.  Most health professionals in Uganda’s rural and remote health units lack institutional libraries and access to medical journals due to geographical, economic and technological isolation. They do not have the personal resources to acquire up-to- date information.

While the need for quality maternal and newborn care continues to grow, the shortage of in-service maternal and newborn care refresher training is not improving. As a result, the gap between the need for good maternal and newborn care and accessibility continues to widen.

The goal of COSAS Maternity Training is to empower entrepreneurial primary healthcare providers across rural Uganda to provide quality, affordable maternal and newborn care to meet the needs of their community, by combining training, quality improvement, and peer-to-peer learning. It will be based on the growing success of COSAS Hospital’s operating model. COSAS Hospital has established a strong technological infrastructure and developed strategies that have dramatically increased maternal and newborn health in Kisoga and area.

COSAS Hospital will annually offer curated, accelerated instruction to five qualified healthcare professionals working in or willing to relocate to a rural setting in Uganda. Instruction will take place over twelve months at COSAS Hospital and will include training in: management skills; identifying gaps in service delivery; prioritizing areas for improvement; and techniques for developing, testing, and implementing changes to improve / expand services that offer quality, accessible, subsidized care for clients.

During each year of instruction, all participants will build an advisory board composed of role model clients, community members, and other healthcare providers. Over the subsequent year, every team will be united on a quarterly basis to share experiences and insights, spreading best practices.

COSAS Maternity Training focuses on three interdependent population categories: 

1. Delivering mothers and newborns: The primary delegate and COSAS hospital have synthesized the results of research about the preventable leading causes of maternal and newborn mortality and morbidity and have established a proven, evidence-based, cost effective model that delivers the best interventions and care.

2. Primary health workers: Entrepreneurial primary healthcare workers will be provided with the opportunity to improve and lead their own maternal care facilities. They will be supported on a career track that encourages professional growth while earning a sustainable wage without leaving rural communities. 

3. Communities: Maternity centers facilitated by COSAS training will be built, owned and operated by rural communities under the leadership of local healthcare worker-entrepreneurs or owned by local healthcare worker-entrepreneurs.

According to MIT Solve, every 11 seconds a woman or newborn under one-month old dies of complications related to pregnancy or childbirth, mostly from preventable or treatable causes, and mostly in low-income countries. COSAS Maternity Training is headquartered in rural Uganda where low (or no) income challenges the wellbeing of most people, especially women. COSAS Maternity Training will directly address this Challenge by expanding access to high-quality, affordable maternal and newborn care for new mothers and newborns, including by expanding the health workforce, improving service delivery and diagnostics, and lowering barriers to seeking care, including stigma, in rural Uganda.

COSAS Hospital was established as a primary care clinic in 2015 and has since gained a wealth of experience and information by serving and engaging delivering mothers and their newborns in Kisoga and area. The primary delegate for our solution (noted below) also has years of additional experience launching and operating a clinic that offered similar services. Meanwhile, the primary delegate and COSAS have synthesized the results of research about the preventable leading causes of maternal and newborn mortality and morbidity and have established a proven, evidence-based, cost effective model that delivers the best interventions and care. From this foundation we build out several innovations:

1) We train and share our experience with smaller growing clinics.

2) Our model scales by creating partnerships and strengthening our partners already existing and operating within the community.

3) Our technologies support clinic staff to be able to monitor mothers and their babies during pregnancy, labor and postpartum.

4) Uniting the team on a quarterly basis helps to share experiences and insights, spreading best practices.

Engaging private service provider increases the platform for maternal and newborn care.

Digital Partograph

A digital partograph is an electronic implementation of the standard paper-based partograph/partogram that can work on a mobile or tablet PC. Partograph is a paper-based tool developed by the WHO to monitor labour during pregnancy. The use of the partograph is recommended as an important indicator for monitoring intrapartum care. Partograph includes several labour vitals including cervix dilatation of the mother. Plotting the cervix dilatation against time can help in predicting deviation from the normal progress of labour. In order to overcome the limitations of paper-based partograph, various researchers have suggested the use of digital partograph. Lots of literature is available regarding the feasibility of a digital partograph.

Advantages

Mitigating human errors; Increased accountability & preventing false data entry; Allows easy data analysis; Availability: 

Note: Where digital partographs cannot be used, Paper partographs apply

The partograph is a very useful graphical record of the course of labor that yields optimum results when employed in labor management by obstetric caregivers (OCGs). As an obstetric tool, its usefulness and efficiency cut across resource-poor and developed nations. Evidence abounds that the acquisition of knowledge of its use and ensuring proper application of that knowledge would culminate in a remarkable reduction in the incidence and outcomes of prolonged and obstructed labor, which are reported to be associated with 8%–10% of maternal deaths. Aside from the contributions of traditional birth attendants (TBAs), who also give primary obstetric care, this service is rendered in Nigeria and most developing countries by general duty doctors, nurses, and midwives, and community health workers of diverse training, including the community health extension workers (CHEWs). Having knowledge and making use of this simple tool by these OCGs, will be an important step for designing appropriate intervention strategies that would encompass: training, retraining, and continuous professional educational programs to further empower them in safe motherhood practices.

References

World Health Organization Preventing Prolonged Labour: a practical guide. The partograph. Part I: Principles and Strategy. [Accessed September 9, 2014]. Available from: http://whqlibdoc.who.int/hq/1993/WHO_FHE_MSM_93.8.pdf.

World Health Organization Preventing Prolonged Labour: a practical guide. The partograph. Part II: User’s Manual. [Accessed September 9, 2014]. Available from: http://whqlibdoc.who.int/hq/1993/WHO_FHE_MSM_93.9.pdf.

Organization: Cosas Hospital

Activity: Cosas Maternity Training

Output: Improved access to and utilization of apartograph in monitoring labor + improved quality of service delivered.

Early outcome: Early identification of danger signs

Medium term outcome: good maternal and newborn outcomes

Longterm outcome: decreased maternal and newbon mortality.

Currently, Cosas is training 5 health workers from facilities which served about 800 mothers combined in 2019 hence: 

- Directly - 5 health workers trained; 

- Indirectly - 200 mothers and 200 babies reached

1 year

- Directly - 10

- Indirectly - 1200 mothers and 1200 babies

5 years

- Directly - 25 health-workers

- Indirectly - 5000 mothers and 5000 babies

- To increase the capacity of cosas hospital to be able to provide the required training.

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