Figure 1
Inverse correlation between health workforce density and maternal and newborn mortality in Uganda (2005–2016).
Table 1
Recommended maternal and newborn health (MNH) services and staffing norms in Uganda by the level of health facility.
| Health facility level | Recommended MNH services | Recommended MNH cadres of health workers |
|---|---|---|
| National referral hospitals | Provide all maternal and newborn health services that are more comprehensive and advanced than regional referral and general hospitals. | Professors in obstetrics and gynecology, senior consultant obstetricians and gynecologists, consultant obstetrician and gynecologists, Master’s-level midwives and Bachelor’s-level midwives |
| Regional referral hospitals | Provide elective and emergency cesarean section (C/S) deliveries, laparatomies for ectopic pregnancies, assisted deliveries (vacuum extraction), management of referral of high-risk mothers, management of referral of mothers with severe complications of pregnancy, labor, postpartum, and the newborn, normal deliveries, antenatal care, postnatal care, newborn care, and maternal and child immunizations. Also, provide care to premature babies and asphyxiated newborns in NICU with incubation and CPAP facilities. | Senior consultant obstetrician and gynecologists, consultant obstetrician and gynecologists, Bachelor’s-level doctors, Master’s-level midwives; Bachelor’s-level midwives; diploma midwives; and certificate midwives |
| District general hospitals | Provide elective and emergency cesarean section (C/S) deliveries, laparatomies for ectopic pregnancies, assisted deliveries (vacuum extraction), management of high-risk mothers, management of complications of pregnancy, labor, postpartum, and the newborn, normal deliveries, antenatal care, postnatal care, newborn care, and maternal and child immunizations | Obstetricians and gynecologists; Bachelor’s-level doctors, Master’s-level midwives; Bachelor’s-level midwives; diploma midwives; and certificate midwives |
| Health centre IV level primary care facilities | Provide emergency cesarean section (C/S) deliveries, laparatomies for ectopic pregnancies, assisted deliveries, management of complications of pregnancy, labor, postpartum and the newborn, normal deliveries, antenatal care, postnatal care, newborn care, and maternal and child immunizations | Bachelor’s-level doctors; Master’s-level midwives; Bachelor’s-level midwives; diploma midwives; and certificate midwives |
| Health center III level primary care facilities | Provide health education, antenatal care, both presumptive and laboratory diagnosis and treatment of minor disorders of pregnancy, labor, postpartum and newborn, postnatal care, and maternal and child immunizations | Diploma midwives and certificate midwives |
| Health centre II level primary health care facilities | Provide health education, antenatal care, presumptive diagnosis, and treatment of minor disorders of pregnancy, postnatal care, and maternal and child immunizations | Certificate midwives |
| Health Centre I level, also known as village health teams (VHTs) | Provide community-based preventive and promotive services by community health workers such as distribution of information, educational and communication (IEC) materials, door-to-door child immunization, etc. | Volunteer village health teams |
Table 2
Midwifery education system in Uganda.
| Training programme | Duration | Award | Entry schemes |
|---|---|---|---|
| MSc Midwifery | 2 years | Master’s | Bachelor |
| BSc Midwifery | 4 years | Bachelor’s | UACE/Diploma or Mature age |
| BSc Nursing | 4 years | Bachelor’s | UACE/Diploma or Mature age |
| BSc Nursing completion | 2.5 years | Bachelor’s | Nursing or midwifery diploma |
| BSc Midwifery completion | 2.5 years | Bachelor’s | Midwifery or nursing diploma |
| RCN | 4 years | Diploma | UACE or nursing certificate |
| Registered Midwifery | 3 years | Diploma | UACE or midwifery certificate |
| RME | 1.5 years | Diploma | Certificate in Midwifery |
| ECN | 2.5 years | Certificate | UCE |
| Enrolled Midwifery | 1.5 years | Certificate | UCE |
[i] MSc is Master of Science; BSc is Bachelor of Science; UACE is Uganda Advanced Certificate of Education; RCN is Registered Comprehensive Nursing; RME is Registered Midwifery Extension; ECN is Enrolled Comprehensive Nursing; UCE is Uganda Certificate of Education.
Figure 2
Showing Lira University Teaching Hospital where the Midwifery students conduct clinical practice and patient care.
Figure 3
Trend in students’ enrollment into Bachelor of Science in Midwifery programme at Lira University Uganda (2013–2018).
Table 3
Midwifery practice sites of the graduate midwives.
| Practice site | Facility category | Number of midwives |
|---|---|---|
| Maracha hospital | Northwestern rural public district general hospital | 1 |
| Nebbi hospital | Northwestern rural public district general hospital | 1 |
| Lacor hospital | Northern private general hospital | 1 |
| Kitgum hospital | Northern rural private general hospital | 1 |
| Lira hospital | Northern urban public regional referral hospital | 1 |
| Mbale hospital | Eastern urban public regional referral hospital | 2 |
| Jinja hospital | Eastern urban public regional referral hospital | 2 |
| Mulago hospital | Central urban public national referral hospital | 1 |
| Mengo hospital | Central urban private hospital | 1 |
| Case hospital | Central urban private general hospital | 1 |
| Naguru hospital | Central urban public general hospital | 1 |
| Mubende hospital | Central rural public regional referral hospital | 1 |
| Bombo hospital | Central rural military general hospital | 1 |
| Masaka hospital | Southwestern rural public regional referral hospital | 1 |
| Kalisizo hospital | Southwestern public district general hospital | 1 |
| Mbarara hospital | Southwestern rural public regional referral hospital | 1 |
| Ishaka hospital | Southwestern rural private general hospital | 2 |
| Fort portal hospital | Western rural public regional referral hospital | 2 |
Table 4
The top 16 advance obstetric and newborn care skills perform by the graduate midwives during clinical practice, their specific roles and the maternal and newborn outcomes.
| Sn | Advance obstetric and newborn care skills performed | Tallies total | Tallies by midwives’ specific roles during the performance | Maternal outcome (+ vs. –) | Newborn outcome (+ vs. –) | ||
|---|---|---|---|---|---|---|---|
| Solo actor | Team member | Assisting Physician | |||||
| 1 | PPH management | 12 | 1 | 10 | 1 | 12 vs. 0 | NA |
| 2 | Pre-eclampsia management | 11 | 11 | 0 | 0 | 11 vs. 0 | 11 vs 0 |
| 3 | Breech delivery | 10 | 7 | 3 | 0 | 10 vs. 0 | 10 vs. 0 |
| 4 | Neonatal resuscitation | 9 | 8 | 1 | 0 | NA | 7 vs. 2c |
| 5 | Eclampsia management | 8 | 3 | 5 | 0 | 8 vs. 0 | 6 vs. 2a |
| 6 | Twin delivery | 8 | 6 | 2 | 0 | 8 vs. 0 | 8 vs. 0 |
| 7 | APH management | 7 | 7 | 0 | 0 | 7 vs. 0 | 7 vs. 0 |
| 8 | PROM management | 5 | 3 | 2 | 0 | 5 vs. 0 | 5 vs. 0 |
| 9 | Shoulder dystocia management | 5 | 2 | 3 | 0 | 4 vs. 1b | 5 vs. 0 |
| 10 | MVA | 5 | 5 | 0 | 0 | 5 vs. 0 | NA |
| 11 | MRRP | 4 | 4 | 0 | 0 | 4 vs. 0 | NA |
| 12 | Assisting in C/S delivery | 4 | 0 | 0 | 4 | 4 vs. 0 | 4 vs. 0 |
| 13 | D&C | 4 | 4 | 0 | 0 | 4 vs. 0 | NA |
| 14 | Malaria in pregnancy management | 3 | 3 | 0 | 0 | 3 vs. 0 | 3 vs. 0 |
| 15 | UTI in pregnancy management | 3 | 3 | 0 | 0 | 3 vs. 0 | 3 vs. 0 |
| 16 | Premature baby care | 3 | 0 | 3 | 0 | NA | 2 vs. 1 |
[i] a One baby was a fresh still birth and the other died from the from neonatal intensive care unit (NICU).
b One mother got second-degree tear, which was repaired.
c One baby died on the resuscitation table and the second one died in the NICU.
Table 5
Challenges and barriers for the graduate midwives’ failure to perform some of the added skills.
| Sn | Added skills not or underperformed | The challenges or barriers responsible |
|---|---|---|
| 1 | Delivering babies with shoulder dystocia from both rural and urban regional referral hospitals | Cases are rare, high competition amongst health workers for the few available cases; some clinical supervisors prefer to refer the cases to theatre for operation by physicians instead of first giving the chance for the graduate midwives to manage. |
| 2 | Performing symphysiotomy from urban and rural regional referral hospitals and even rural district general hospital | Clinical supervisors block the graduate midwives from performing symphysiotomy, on the premise that they are not experienced enough to safely perform the procedure |
| 3 | Performing of C/S delivery from urban and rural regional referral hospitals and even rural district general hospitals | Clinical supervisors block the graduate midwives from performing C/S delivery, on the premise that they are not licensed for the role |
| 4 | Performing laparotomies for ectopic pregnancies from urban and rural regional referral hospitals and even rural district general hospitals | Clinical supervisors block the graduate midwives from performing C/S delivery, on the premise that they are not licensed for the role |
| 5 | Repairing of third- and fourth-degree perineal tears from national and regional referral hospitals | Clinical Supervisors block the graduate midwives from repairing of third and fourth degree perineal tears, on the premise that they are not licensed for the role |
Table 6
Employment Prospects for Graduate Midwives in Uganda.
| Primary healthcare providers in midwifery and maternal child health specialties |
| Midwifery clinical specialists |
| Clinical researcher, research coordinators, quality control and monitoring officers |
| Midwife educators or lecturers |
| Principal nursing officers – midwifery in governmental, non-governmental, and private healthcare sectors |
| Reproductive health, maternal child health program/project officers or managers |
| Clinical leaders in reproductive health and family planning service organizations |
| Private midwifery practice in homes or maternity homes |
| Primary healthcare providers in midwifery and maternal child health specialties |
| Entrepreneurs providing midwifery/maternity services, primary, and reproductive health services |
Table 7
Examples of value addition from graduate midwives to the Uganda health system.
| Ugandan health system | Value additions from the graduate midwives well and above those being provided by the existing certificate and diploma midwives |
|---|---|
| Health centre level I, which is a mobile voluntary village health team without physical infrastructure. | No value addition |
| Health centre level II primary care facility, which has an outpatient department without maternity ward or physician | Increased management of moderate to severe complications of pregnancy, postpartum, and the newborn. This is because the certificate and diploma midwives can only manage the minor disorders. Additionally, there will be reduction in referrals to higher-level facilities of mothers and newborns for management of moderate-severe complications and thus saving time and cost to families. Lastly, there will be an improved leadership and management in the maternal child health department. |
| Health centre level III primary care facility which has an outpatient department, maternity ward, laboratory testing but no theatre or physician | Increased management of moderate to severe complications of pregnancy, labor, postpartum, and the newborn. This is because the certificate and diploma midwives can only manage the minor disorders. More so, there will also be reduction in presumptive diagnosis of maternal and newborn conditions from increased ordering of laboratory testing from the graduate midwives, which will improve the accuracy of diagnosis, treatments, and reduce drug wastage. Additionally, there will be reduction in referrals to higher-level facilities of mothers and newborns for management of moderate to severe complications including complications of labor and thus saving time and cost to families. Lastly, there will be an improved leadership and management in the maternal child health department, labor, and postnatal wards. |
| Health centre level IV primary care facility which has an outpatient department, maternity ward, laboratory testing, theatre and physician. The physician often one position is also administrative and management duties of the health centre. In addition, to note that most of the level IV facilities have no physicians nor anesthetic officers for the operation of the theatre. | Increased management of moderate to severe complications of pregnancy, labor, postpartum and the newborn. This is because the certificate and diploma midwives can only manage the minor disorders. More so, there will also be reduction in presumptive diagnosis of maternal and newborn conditions from increased ordering of laboratory testing from the graduate midwives, which will improve the accuracy of diagnosis, treatments and reduce drug wastage. Additionally, there will be reduction in referrals to hospitals of mothers and newborns for management of moderate to severe complications including complications of labor and thus saving time and cost to families. Also, there will be an improved leadership and management in the maternal child health department, labor, and postnatal wards. There will be increased cesarean section rate and improved outcomes of mothers from theatre as the graduate midwives will improve preoperative care, increase assistance of the physician during cesarean section, improve anesthesia and theatre techniques, improve postoperative care, and improve newborn care from resuscitation. If the facility does not have a physician, the graduate midwives will perform emergency cesarean section if licensed to do so. |
| Hospitals | Increased management of moderate to severe complications of pregnancy, labor, postpartum, and the newborn. This is because the certificate and diploma midwives can only manage the minor disorders. More so, there will also be reduction in presumptive diagnosis of maternal and newborn conditions from increased ordering of laboratory testing from the graduate midwives, which will improve the accuracy of diagnosis and treatments and reduce drug waste. Additionally, there will be a reduction in referrals to hospitals of mothers and newborns for management of moderate to severe complications, including complications of labor and thus saving time and cost to families. Also, there will be an improved leadership and management in the maternal child health department, labor, and postnatal wards. There will be increased cesarean section rate and improved outcomes of mothers from theatre as the graduate midwives will improve preoperative care, increase assistance of the physician during cesarean section, improve anesthesia and theatre techniques, improve postoperative care, and improve newborn care from resuscitation. If the facility does not have a physician, the graduate midwives will perform emergency cesarean section if licensed to do so. |
| District health office as assistant district health officer – nursing and maternal child health | Improvement in the management, particularly midwifery, maternal, and child health services in the district from quality technical monitoring, supervision, mentorship of certificate and diploma midwives at health facilities. |
| Health development partners working on maternal child health programs as program officers, technical advisors, project managers, etc. | Improvements in quality of programs for midwifery, maternal, and child health in the district health office and health facilities. |