Shedding light on quality of care: a study protocol for a randomized trial evaluating the impact of the Solar Suitcase in rural health facilities on maternal and newborn care quality in Uganda

Slawa Rokicki, Brian Mwesigwa, Laura Schmucker, Jessica L Cohen, Slawa Rokicki, Brian Mwesigwa, Laura Schmucker, Jessica L Cohen

Abstract

Background: Continued progress in reducing maternal and newborn morbidity and mortality in low-income countries requires a renewed focus on quality of delivery care. Reliable electricity and lighting is a cornerstone of a well-equipped health system, but most primary maternity care facilities in sub-Saharan Africa are either not connected to the electrical grid or suffer frequent blackouts. Lack of reliable electricity and light in maternity facilities may contribute to poor quality of both routine and emergency obstetric and newborn care, by hindering infection control, increasing delays in providing care, and reducing health worker morale. The "Solar Suitcase" is a solar electric system designed specifically for maternity care facilities in low-resource environments. The purpose of this trial is to evaluate the impact of the Solar Suitcase on reliability of light, quality of obstetric and newborn care, and health worker satisfaction.

Methods: We are conducting a study with 30 maternity care facilities in rural Uganda that lack access to a reliable, bright light source. The study is a stepped wedge cluster randomized controlled trial. Study facilities are identified according to predefined eligibility criteria, and randomized by blocking on baseline covariates. The intervention is a "Solar Suitcase", a complete solar electric system that provides essential lighting and power for charging phones and small medical devices. The primary outcomes are the reliability and quality of light during intrapartum care, the process quality of obstetric and newborn care, and health worker satisfaction. Outcomes will be assessed via direct clinical observation by trained enumerators (estimated n = 1980 birth observations), as well as interviews with health workers and facility managers. Lighting and blackouts will be captured through direct observation and via light sensors installed in facilities.

Discussion: A key feature of a high quality health system is appropriate infrastructure, including reliable, bright lighting and electricity. Rigorous evidence on the role of a reliable light source in maternal and newborn care is needed to accelerate the "electrification" of maternity facilities across sub-Saharan Africa. This study will be the first to rigorously assess the extent to which reliable light is an important driver of the quality of care experienced by women and newborns.

Trial registration: ClinicalTrials.gov : NCT03589625 (July 18, 2018); socialscienceregistry.org : AEARCTR-0003078 (dated June 16, 2018).

Keywords: Electricity; Infrastructure; Maternal health; Newborn health; Quality of care; Solar energy; Stepped wedge cluster randomized trial; Uganda.

Conflict of interest statement

The authors declare that they have no competing interests. The study sponsor is the Harvard T.H. Chan School of Public Health. This trial is funded by a grant from the UBS Optimus Foundation to the NGO We Care Solar (WCS), and contracted to Innovations for Poverty Action, the Harvard School of Public Health, and University College Dublin to conduct the independent impact evaluation. The UBS Optimus Foundation reviewed the trial study design, while WCS reviewed and provided feedback on the trial study design, data collection tools and protocol manuscript. The independent impact evaluation team will share manuscripts for publication from the study with WCS prior to submission, but neither UBS nor WCS will have any input on data analysis, interpretation or writing of the manuscripts from this trial, including the final trial report. Neither UBS nor WCS will have authority over the decision to submit manuscripts for publication.

Figures

Fig. 1
Fig. 1
Image of The We Care Solar Suitcase® and component parts. Notes: Copyright by We Care Solar. Written permission was given by We Care Solar to reproduce this image
Fig. 2
Fig. 2
Flowchart of enrolment, randomization, and assessments during study period

References

    1. Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN maternal mortality estimation inter-agency group. Lancet. 2016;387:462–474. doi: 10.1016/S0140-6736(15)00838-7.
    1. Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every newborn: progress, priorities, and potential beyond survival. Lancet. 2014;384:189–205. doi: 10.1016/S0140-6736(14)60496-7.
    1. Murray SF, Hunter BM, Bisht R, Ensor T, Bick D. Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth. 2014;14:30. doi: 10.1186/1471-2393-14-30.
    1. Chaturvedi S, Randive B, Diwan V, Costa AD. Quality of obstetric referral Services in India’s JSY cash transfer Programme for institutional births: a study from Madhya Pradesh Province. PLoS One. 2014;9:e96773. doi: 10.1371/journal.pone.0096773.
    1. Austin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the quality of maternal and newborn health care: an overview of the evidence. Reprod Health. 2014;11:S1. doi: 10.1186/1742-4755-11-S2-S1.
    1. Souza JP, Gülmezoglu AM, Vogel J, Carroli G, Lumbiganon P, Qureshi Z, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO multicountry survey on maternal and newborn health): a cross-sectional study. Lancet. 2013;381:1747–1755. doi: 10.1016/S0140-6736(13)60686-8.
    1. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016;388:2176–2192. doi: 10.1016/S0140-6736(16)31472-6.
    1. Kruk ME, Leslie HH, Verguet S, Mbaruku GM, Adanu RM, Langer A. Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys. Lancet Glob Health. 2016;4:e845–e855. doi: 10.1016/S2214-109X(16)30180-2.
    1. Adair-Rohani H, Zukor K, Bonjour S, Wilburn S, Kuesel AC, Hebert R, Fletcher ER. Limited electricity access in health facilities of sub-Saharan Africa: a systematic review of data on electricity access, sources, and reliability. Glob Health Sci Pract. 2013;1(2):249–61. doi: 10.9745/GHSP-D-13-00037.
    1. Essendi H, Johnson FA, Madise N, Matthews Z, Falkingham J, Bahaj AS, et al. Infrastructural challenges to better health in maternity facilities in rural Kenya: community and healthworker perceptions. Reprod Health. 2015;12:103. doi: 10.1186/s12978-015-0078-8.
    1. Humphreys G. Harnessing Africa’s untapped solar energy potential for health. World Health Organ Bull World Health Organ Geneva. 2014;92:82–83. doi: 10.2471/BLT.14.020214.
    1. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38:1091–1110. doi: 10.1016/0277-9536(94)90226-7.
    1. Pacagnella RC, Cecatti JG, Parpinelli MA, Sousa MH, Haddad SM, Costa ML, et al. Delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. BMC Pregnancy Childbirth. 2014;14:159. doi: 10.1186/1471-2393-14-159.
    1. Forshaw J, Raybould S, Lewis E, Muyingo M, Weeks A, Reed K, et al. Exploring the third delay: an audit evaluating obstetric triage at Mulago National Referral Hospital. BMC Pregnancy Childbirth. 2016;16:300. doi: 10.1186/s12884-016-1098-2.
    1. Goodman DM, Srofenyoh EK, Olufolabi AJ, Kim SM, Owen MD. The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana. BMC Pregnancy Childbirth. 2017;17:216. doi: 10.1186/s12884-017-1407-4.
    1. Knight HE, Self A, Kennedy SH. Why are women dying when they reach hospital on time? A systematic review of the “third delay.”. PLoS One. 2013;8:e63846. doi: 10.1371/journal.pone.0063846.
    1. Bernard T. Impact analysis of rural electrification projects in sub-Saharan Africa. World Bank Res Obs. 2012;27:33–51. doi: 10.1093/wbro/lkq008.
    1. Owili PO, Muga MA, Mendez BR, Chen B. Quality of maternity care and its determinants along the continuum in Kenya: a structural equation modeling analysis. PLoS One. 2017;12:e0177756. doi: 10.1371/journal.pone.0177756.
    1. Apenteng BA, Opoku ST, Ansong D, Akowuah EA, Afriyie-Gyawu E. The effect of power outages on in-facility mortality in healthcare facilities: evidence from Ghana. Glob Public Health. 2016:1–11.
    1. Mbonye AK, Asimwe JB. Factors associated with skilled attendance at delivery in Uganda: results from a national health facility survey. Int J Adolesc Med Health. 2010;22:249-56.
    1. UNDP . UNDP support to the implementation of the sustainable development goals. New York: United Nations development Programme; 2016.
    1. World Bank . Climate-smart healthcare. Low-carbon and resilience strategies for the health sector [internet] Washington D.C: World Bank; 2017.
    1. Uganda Bureau of Statistics . 2016 Statistical abstract [internet] Kampala: Uganda Bureau of Statistics; 2016.
    1. Uganda Bureau of Statistics and ICF International . Uganda demographic and health survey 2016 [internet] Kampala, Uganda and Rockville: UBOS and ICF; 2018.
    1. World Bank. World Bank Develoment Indicators. [Internet]. Washington D.C.: World Bank; Available from: .
    1. Uganda Bureau of Statistics (UBOS) and ICF Internatinoal Inc . Uganda demographic and health survey 2006 [internet] Kampala, Uganda and Calverton: Uganda Bureau of Statistics and ICF International; 2007.
    1. Waiswa P, Kallander K, Peterson S, Tomson G, Pariyo GW. Using the three delays model to understand why newborn babies die in eastern Uganda. Trop Med Int Health TM IH. 2010;15:964–972. doi: 10.1111/j.1365-3156.2010.02557.x.
    1. Ministry of Health, Health Systems 20/20, and Makerere University School of Public Health . Uganda Health System Assessment 2011 [Internet] Kampala, Uganda and Bethesda: Health Systems 20/20 project, Abt Associates Inc; 2012.
    1. Ministry of Health Uganda and Macro International Inc. Uganda service provision assessment survey 2007 [internet]. Kampala, Uganda and Calverton: Ministry of Health and Macro International Inc.; 2008. Available from: .
    1. United Nations. Health Facility Energy Needs Assessment Uganda Country Summary Report [Internet]. United Nations Foundation; 2015. Available from:
    1. Ministry of Health Uganda . Uganda Services Availability and Readiness Assessment 2013 Summary report: key findings in figures [internet] Kampala: Ministry of Health, Uganda; 2013.
    1. Institute for Health Metrics and Evaluation (IHME) Health service provision in Uganda: assessing facility capacity, costs of care, and patient perspectives [internet] Seattle: IHME; 2014.
    1. Clinton Health Access Initiative. Data from CHAI Uganda Health Facility Assessment. 2016.
    1. USAID . Maternal and child health integrated program (MCHIP) [internet] Washington D.C.: USAID/Jhpiego; 2013.
    1. Tripathi V, Stanton C, Strobino D, Bartlett L. Development and validation of an index to measure the quality of facility-based labor and delivery care processes in sub-Saharan Africa. PLoS One. 2015 [cited 2017 Jul 25];10. Available from:
    1. World Bank. Impact evaluation toolkit for results based financing in health [internet]. World Bank. Available from: .
    1. Kruk ME, Larson E, Twum-Danso NAY. Time for a quality revolution in global health. Lancet Glob Health. 2016;4:e594–e596. doi: 10.1016/S2214-109X(16)30131-0.
    1. Kruk ME, Kujawski S, Mbaruku G, Ramsey K, Moyo W, Freedman LP. Disrespectful and abusive treatment during facility delivery in Tanzania: a facility and community survey. Health Policy Plan. 2018;33:e26–e33. doi: 10.1093/heapol/czu079.
    1. Koroglu M, Irwin BR, Grépin KA. Effect of power outages on the use of maternal health services: evidence from Maharashtra. India. BMJ Global Health. 2019;4(3):e001372. doi: 10.1136/bmjgh-2018-001372.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren