Maternal and Neonatal Mortality

Global maternal mortality ratio (MMR) has remained unacceptably high at 216 per 100,000 live births. It is estimated that 830 women die from pregnancy-related complications around the world every day [1]. In low-income countries, one in 16 women dies of complications from pregnancy. In developed countries, the ratio is markedly lower, at one in 2,800 [2].

Uganda, situated in East Africa, shoulders a high MMR of 336 per 100,000 live births, largely attributable to hemorrhage (34%), hypertension (19%), abortions (9%), sepsis (8%), and indirect causes such as malaria, HIV, and other infections (18%) [3]. Uganda also has a high neonatal mortality rate (27 per 1,000 live births), mostly caused by birth asphyxia and trauma (28.6%), prematurity (27.9%), and sepsis (18.2%) [4].

Proven lifesaving interventions to prevent or treat the causes of maternal and newborn deaths are well known. They include neonatal resuscitation [5], kangaroo mother/father care [6], cord care with chlorhexidine 7.1% [7], antibiotic therapy, helping mother survive bleeding after birth, helping mother survive preeclampsia and eclampsia, and low-dose, high-frequency training in basic emergency obstetrics and newborn care (EMONC) [8], and emergency caesarian section [9].

Uganda Health System Challenges

In Uganda, as it is in many other low-income settings, the critical challenges affecting the scale up and implementation of the aforementioned lifesaving interventions are shortage of skilled birth attendants; [10] gaps in essential equipment and commodities; [10, 11, 12] limited hands-on in-service training, mentorship, coaching, and supervision of health workers; [10, 11, 12] inappropriate training approaches that are theoretical with inadequate simulation and practical sessions; [10] and ineffective engagement of community health workers and leaders to support last-mile distribution of interventions and services [11, 12].

The shortage of nurses and midwives is of primary concern. The nurse-midwife to patient ratio of 6:100,000 exemplifies the general shortage of health workers in Uganda, which is low compared to World Health Organization (WHO) recommendation of 2.5:1000 [13]. Figure 1 shows how the health workforce density inversely correlates with maternal and neonatal mortality in Uganda from World Health Organization (WHO) Global Health Observatory, WHO Global Atlas, World Bank, UN World Health Statistics, and African Development Bank Group 2005–2016.

Midwifery Education and Scope of Practice

The high number of births not attended to by skilled birth attendants is partly attributable to the inadequate numbers of nurse-midwives with advanced education in midwifery and maternal neonatal health to address obstetrical and perinatal emergencies.

Notably, the majority of midwives in Uganda are certificate- and diploma-level midwives who are trained to manage normal pregnancy, labor, postpartum care, and newborn care but not the complications of pregnancy, labor, and newborn [10], which are the aforementioned causes of maternal and newborn deaths. Therefore, the problem is a lack of midwives with higher education such as those with Bachelor’s and Master’s degrees to manage complications of pregnancy, labor, postpartum, and newborn health in addition to managing normal pregnancy, labor, and newborn care across the healthcare spectrum. The first-line solution to the above problem is a Bachelor’s-level program in midwifery that imparts the basic nursing skills plus the midwifery specialization required to improve the high maternal and newborn problems in Uganda and the region. The second-line solution is a Master’s level program in midwifery, with specialization in maternal and newborn healthcare.

To justify the need to increase the scope of practice of nurses and midwives with higher education, Dawson et al. [14] demonstrated that obstetric surgical competence and tasks shifting from physicians to non-physicians including nurses and midwives are cost effective, increases access to and availability of maternal and reproductive health services without compromising maternal and newborn health outcomes in Tanzania. Several other studies were conducted in the US and England to establish the effectiveness of nurse-midwives with higher education in the different clinical nursing disciplines (also called advanced practice nurse-midwives). Advanced practice nurse-midwives are shown by various studies in other countries to be very effective in reducing the cost of healthcare and improving general health outcomes of individuals and populations [15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25]. These studies highlighted many positive contributions from the advanced practice nurse-midwives, including improved quality healthcare services and bringing healthcare nearer to the population among others. Overall, the results show that nurse practitioners and advanced practice nurses are most likely to practice in rural settings, low economic areas, and other primary care settings where physicians are scarce. The healthcare services provided by the advanced practice nurses or nurse practitioners are of high quality, low cost, and address the prevalent diseases, health problems, and needs in underserved populations. Related studies conducted on quality of practice and clinical outcomes of nurse practitioners and advanced practice nurses of different specialties found that the nurse practitioners are very relevant and beneficial in primary care, pediatric, maternal, and child health, mental health, geriatrics care, and also in the management of chronic diseases.

Notably, in Uganda as it is in many low-income countries, there is considerable variation in the cadre and the competence of midwives [26]. Unfortunately, not all supposed midwives at a given health facility have the necessary skills to conduct deliveries.

Although midwives with higher education in Uganda, such as those with Master’s degrees, are neither legally termed nor licensed as advanced practice midwives or nurse practitioners as it is in the United States of America (USA) and United Kingdom (UK), their scope of practice is comparable, for example, they can both do independent practice in midwifery. It is therefore plausible to hypothesize that they will address the health needs of Ugandans in comparable quality and a cost-effective way as is being done by advanced practice midwives or nurse practitioners in the US and UK. Currently, there is no data available from Uganda, nor from other settings comparable to Uganda, about the quality and benefits of advancing midwifery education to Bachelor’s or Master’s levels. Nevertheless, we expect the midwives with advanced education to practice at a higher scope than their colleagues with lower education, wherever they will be employed to practice, because the Uganda Nurses and Midwives Council first of all registers and license all midwives with diploma to doctorate levels of education as “registered midwives” without any distinction in their scope of practice. Secondly, Uganda Ministry of Health national health policy [27] defined staffing norms and minimum healthcare package by level of health facility (health centre I–IV, general hospital, regional referral hospital, and national referral hospital), and the definition doesn’t restrict the employment and placement of any midwife with advanced education to work at any level of health facility as long as they qualify to perform the minimum healthcare package recommended to be provided at that level of health facility. Table 1 shows an overview of the Uganda health system, staffing norms, and role of midwives.

Therefore, if the midwives with advanced education are employed in health centre II level, which is an outpatient health post, they will provide health education, antenatal care, maternal care, and childhood care, which is the scope of practice for midwives working in health centre level II. If they are employed and placed at health centre level III, which by design has an additional general ward and maternity ward but lacks a medical doctor, they will be conducting deliveries and management of complications of pregnancy, labor, postpartum, and newborn, plus all the aforementioned maternal and child health services of health centre level II. If they are employed and placed to work in an health centre IV and hospital, which by design has an additional obstetric theatre, anesthesia facilities, and a medical doctor, they will be assisting or actually conducting anesthesia or the cesarian section in addition to the aforementioned maternal and child health services for health centre level II and III. This is expected because medical doctors are in short supply and the few available are busy attending to healthcare needs of other patients, such as those with emergency medicine, internal medicine, pediatrics, surgery, gynecology, orthopedics, ophthalmology, or ear, nose, and throat conditions in addition to general administration and management of the health facility [28]. Arguably, the decentralization plus liberalization of the healthcare service delivery in Uganda to include privately owned health facilities [29] will see that the midwives with higher education will be employed by private sector health facilities because they are less expensive than physicians, and government facilities will continue to hire the less expensive diploma midwives.

Internship Placement

The findings from record review indicated that 356 students (40.2% male, 59.8% female) enrolled in the BSc Midwifery programme over the six years of the program (2013–2018) and the enrollment is on an increasing trend as shown in Figure 3.

The duration of midwifery practice of the graduate midwives ranged from 6–30 months. The graduate midwives with six months of practice experience were those from the 2015 cohort, who started midwifery practice in 2019, while those with 30 months of practice were from among the 2013 cohort, who started practice in 2017. The practice setting spans all the categories and levels of hospitals, a geographical mix, a rural-urban balance, and a public-private balance (Table 3).

Performance of the advance midwifery skills during internship practice

The findings from the interviews with the graduate midwives shown in Table 4 revealed that all the graduate midwives were able to perform 92% (59 out of the 64) of the advanced obstetrics, gynecology, and abnormal newborn care (neonatology) skills from their training. One of them explained the practice as follows:

During my practice, I was able to carry out the so called “difficult deliveries”, providing care as required even in a resource-limited setting. I was able to conduct so many breech deliveries, twin deliveries, managed emergencies like shoulder dystocia, the mighty postpartum hemorrhage that has claimed lives of many mothers and almost attained 99.9% survival of my mothers and their babies (Female graduate midwife from the 2014 cohort).

As shown in Table 4, there were 16 top advanced obstetrics and newborn care skills performed by most of the graduate midwives at their clinical workplaces. These include postpartum hemorrhage (PPH) management, pre-eclampsia management, breech delivery, neonatal resuscitation, eclampsia management, twin delivery, antepartum hemorrhage (APH) management, premature rupture of membranes (PROM) management, shoulder dystocia management, manual vacuum aspiration (MVA) of retained products of conception, manual removal of retained placenta (MRRP), assisting in cesarean section (C/S), dilatation and curettage (D&C), urinary tract infections (UTI) in pregnancy management, and premature baby care.

Many of the graduate midwives placed in rural district general hospitals where there are no obstetricians and gynecologists performed most of the added obstetrical skills solo. One of them explained his solo management of a case of premature rupture of membrane as follows:

I received a prime gravida with complaint of draining liquor, I observed her and she was not pushing or grunting. The abdomen had no previous cesarian section scar, no horizontal ridges across lower abdomen. I felt the abdomen for contractions frequency; duration was mild, each lasting less than 20 seconds; fundal height was 38/40; fetal lie was longitudinal; presentation was cephalic and fetal movement not felt. I listened to the fetal heartbeat, was 140 beats/minute. I checked for maternal blood pressure (BP), temperature, pallor, sunken eyes, all were normal. On vaginal examination, there was no bulging perineum, no vaginal bleeding, but there was visible leaking amniotic fluid, which was not meconium stained. I performed digital vaginal examination and found cervical dilatation was 2 cm and < 2 contraction in 10 minutes. I administered prophylaxis antibiotics Ampicillin 2g start. Did and obtained Bishop Score of 8. I chose to perform induction of labor with hormonal method using Oxytocin. I administered Oxytocin IV 2.5 IU in 500 mL of normal saline at start infusion rate of 10 drops/minute. I increased infusion rate by 10 drops every 30 minutes (max 60 minutes) until good contraction pattern was established (3–5 contractions in 10 minutes, each lasting >40 seconds). I maintained this rate until delivery was complete. The mother had normal spontaneous vaginal delivery to baby girl, 2.5 kg. Both mother and baby were discharged in good conditions (Male graduate midwife of 2014 cohort).

Additionally, there are other added skills performed by at least two of the midwives in their respective clinical practices with positive outcomes for both the mothers and babies. These include assisting in laparotomies for ectopic pregnancies, cord prolapse delivery, cutting and repairing of episiotomies, repairing of second-degree tears, abortion management, cervical cancer screening, prolonged labor management, uterine rupture management where one mother died, post-abortion care, obstructed labor management, induction of labor, vacuum extraction, preoperative care, postoperative care, prolonged labor management and neonatal sepsis management. One of the graduate midwives explained how he successfully managed postpartum hemorrhage and how the success brought him joy as a midwife:

PPH (postpartum hemorrhage) claims many lives of mothers in Uganda, and at times it poses a nightmare for midwives and doctors. During my three-month rotation in labor suite, I faced eight different PPH cases. Terrifying at the first encounter but with more composure, I resolved and determined my mindset and well prepared with equipment and necessary materials, I managed PPH cases after personally conducting the deliveries or after the student midwives (certificate and diploma midwife) with help of mainly senior midwives and intern doctors. This was through various interventions, which included uterine massage, Oxytocin infusion, expelling clots, emptying the bladder by urinary catheter, repairing mainly second-degree tears, and using balloon tamponade. It brought much joy and satisfaction to me when homeostasis was achieved and the mother was in stable condition with healthy baby (Male graduate midwife of 2014 cohort).

More so, there are other added skills performed by at least one graduate midwife during their clinical practices with positive outcomes for both the mothers and babies. These include severe hyperemesis gravidarum management, assisting in laparotomies for ectopic pregnancies, family planning method particularly intrauterine contraceptive device and implants counseling and insertion, birth asphyxia management, fetal distress management, intrauterine fetal death management, sickle cell crisis in pregnancy management, intrauterine fetal resuscitation, infertility management, cervical dystocia management, post-term pregnancy management, birth defect counseling and referral, compound presentation management, arm prolapse management, placenta pacrater management, triplet delivery, sexually transmitted infection (STI) treatment, molar pregnancy management, unconscious mother in labor management, ectopic pregnancy management, neonatal jaundice management, anemia in pregnancy management, puerperal sepsis management, neonatal necrotizing enterocolitis management, neonatal hypothermia management, and neonatal respiratory distress management.

Another most exciting bit was when I was managing third stage of labor after I delivered the baby. I followed all the steps of AMTSL (active management of third stage of labor), but to my surprise, the placenta could not be delivered for some good time despite of all the intervention. Mother was not bleeding and the placenta showed me that it was not about to be delivered. I thought of option B that was manual removal. I shared the option with my senior; she said its fine go on. I prepared to deliver the placenta manually, guess what, when held the cord with my left hand and as I followed the cord with the other hand trying to locate the edges of the placenta, I realized the cord was entering to the uterine wall. I was shocked. We called the gynecologist; he told me it was placenta pacrater. She was later taken in for hysterectomy (Female graduate midwife from 2014 cohort).

There were only five added skills that the graduate midwives were not able to perform during their clinical practice. These were performing cesarean section, laparotomies for ectopic pregnancy, symphysiotomy, and repair of third- and fourth-degree perineal tears. The challenges and barriers are listed in Table 5, which ranges from few or total lack of patients with the indications for the intervention. Also, some graduate midwives were denied the chance to perform the procedures by their supervisors due to the misperception that they are not qualified enough or the procedure or intervention should be performed by physicians who have the authentic license or permit to perform the procedures.

It is important to note that even for skills like manual vacuum aspiration, dilatation and curettage, vacuum extraction, forceps deliveries and assisting in cesarian section (C/S) deliveries, which were performed by a few of the graduate midwives from rural hospitals, it is not universal as such. Some clinical supervisors in some of the above hospitals blocked the graduate midwives from performing the procedures on the ground being that they are not qualified enough, or the government of Uganda has not yet licensed them to perform those skills. Other graduate midwives simply did not perform the added skills because of lack of cases with the indications for the intervention or just lack of equipment or facilities. Several graduate midwives commented on this:

I was not permitted to perform cesarean section, exploratory laparotomy for ectopic pregnancy, nor vacuum delivery. Most reasons pointed towards lack of clear guidelines and policies in relation to midwives’ license to perform such procedures (Male graduate midwife from 2013 cohort).

Some conditions like shoulder dystocia are very rare. I haven’t come across one in six months. Here, procedures like manual vacuum aspiration, dilatation, and curettage are purely for doctors (Female graduate midwife from 2014 cohort).

I did not do cases concerning shoulder dystocia, deliveries by vacuum extraction, manual removal of the retained placenta because there was high competition for skills among the intern midwives, intern doctors, and students (Female graduate midwife from 2014 cohort).

Post-internship Work and Application of the Added Skills

Of the 34 students in the first 2013 cohort, 94.1% graduated and completed internships in record time. Post-clinical midwifery internship employment status of the 32 midwives who completed internships show that by January 2019, 25% were retained at Lira University Hospital as Midwives and Teaching Assistants, 62.5% gained employment in various maternal and newborn healthcare programs across Uganda. The remaining 12.4% ventured into private midwifery practice. Overall, there is 88% retention of the graduates at in-country hospitals.

As noted above, quite a good number of the graduate midwives from the 2013 cohort were retained at Lira University and Lira University Teaching Hospital. In the teaching hospital, they are involved in teaching students, supervising and mentoring diploma midwives, and research in addition to participating in managing mothers with obstetrics and gynecological conditions. The work of the graduate midwives in teaching hospitals is explained as follows:

I am currently working at Lira University and Lira University Teaching Hospital as a Teaching Assistant in the Department of Nursing and Midwifery. I teach, set examination, and supervise students in the clinical areas, attend ward rounds, give treatment to patients, monitor mothers in labor, conduct deliveries, supervise other clinical staffs [diploma midwives] in my unit and participate in research. I am able to apply most of the obstetrics skills l learnt like managing a mother with pre-eclampsia and eclampsia, PPH (post-partum hemorrhage), shoulder dystocia, resuscitating newborns, manual removal of retained placenta, etc. (Female graduate midwife from 2013 cohort).

Notably, the graduate midwives from the 2014 cohort have also finished internship practice and entered into the job market. Of the nine of them in this study sample, seven are employed and working. Two of them were employed in Sanyu Africa Research Institute – one as a research midwife, where she is applying research skills – and one in the International Rescue Committee as a reproductive health officer, responsible for programming reproductive health services in a refugee settlement. Some of them were employed as nursing officers in midwifery at Mbarara Regional Referral Hospital, which has all the necessary equipment or instruments for managing obstetric complications and therefore are able to apply the added obstetrics skills. One of them described the following:

I am currently working with Global Health Collaboration that partners with Mbarara Regional Referral Hospital as a nursing officer–midwifery, and l do clinical work in the obstetrics and gynecology department. I am able to apply the following abnormal midwifery skill: management of PPH, breach delivery, episiotomy and repair of both episiotomy and perineal tears up to second degree, newborn resuscitation, twin deliveries, and cord prolapse deliveries (Male graduate midwife from 2014 cohort).

Some graduate midwives from the 2014 cohort are employed and working in remote lower-level public health centres (Warr health centre IV in Zombo district in northern Uganda and Namisindwa health centre III in Namisindwa district in Eastern Uganda). The one working in health centre IV with a theatre facility is able to assist in cesarian section delivery, conduct pre- and post-operative care and neonatal resuscitation. The one working in health centre III with a maternity ward but no theatre and equipment for managing obstetric cases is only able to conduct the routine antenatal care, delivery of mothers with normal labor, referral of high-risk mothers to higher-level health facilities and managing the maternity ward. The work of the graduate midwives in the lower level primary care health facilities with maternity ward but without theatre or equipment for managing obstetric cases is described as follows:

I work with Namisindwa local government, which is one of the newly created districts in Uganda, as nursing officer – midwifery in health center three. It is a very hard-to-reach area with a health center three being the highest level of care facility in the entire district.

The work I do are: organizing and participating in departmental meeting; ordering, balancing, and keeping drugs and supplies records updated; making of duty rosters and ensuring all duties are covered accordingly; writing weekly and monthly reports; coaching and mentoring the junior staff on new midwifery knowledge and skills to enable efficient and quality service or care delivery to all mothers and their unborn babies; working hand-in-hand with visiting medical personnel to improve on services given to clients; [and] performing activities like ensuring cleanliness of the department, managing deliveries, providing general nursing care to all clients entrusted in my care, preventing and treating minor ailments, early identification of complications and referring for appropriate care to Mbale regional referral hospital because the district has no capacity to handle any emergency cases (Female graduate midwife from 2013 cohort).

The practice is a bit different for those employed in urban private general hospitals. There are many high-risk mothers but their obstetricians and gynecologists are always available for them and do much caring to prevent the occurrence of the obstetric complications. Consequently, the graduate midwives conduct normal deliveries, normal newborn care and postnatal care where there are limited chances of applying their added obstetrics skills. One of them had this to explain:

Currently, I am working at Case Hospital as a midwife for experience as I am looking for a better job. I am majorly working in labor ward and NICU (Neonatal Intensive Care Unit). Being a private setting [hospital], it is a different protocol all together. Mostly, we work hand-in-hand with the gynecologists and pediatricians. They are there for each of their mothers and newborns. In most cases, they do a lot of preventive measures as a result there are few cases of abnormal midwifery. The few are pre-eclampsia, twin delivery, PROM (premature rupture of membranes), etc. But personally the only challenge I faced was during PPH (post-partum hemorrhage) caused by cervical tear (Female graduate midwife from 2014 cohort).