Recording and materials from the 4th webinar on point of care quality improvement - Step 3: Developing and testing changes


The Network for Improving Quality of Care for Maternal, Newborn and Child Health (Quality of Care Network) held a webinar on ‘Point of care quality improvement for maternal and newborn health – Step 3: Developing and testing changes’ on 15 June.

Listen to the recording of the session

Dr Esther Karamagi, from University Research Co., LLC presented the work of a quality improvement team in a facility in Western Uganda to improve the use of partograph as a monitoring tool during labour. Sr Mary Atim, Nursing Officer in charge of the maternity ward in Anaka Hospital in Northern Uganda, described her experience using quality improvement methods to make partpgraphs more and better used in the hospital.

See their presentation here

This is the 4th webinar in a series on point of care quality improvement. Read more about the series and access the materials from previous webinars here.

(Photo: In April 2013 in Nigeria, a woman holds her infant at Father Matthias Health Care Centre in the town of Naka, in Gwer West, a Local Government Area of Benue State. She is awaiting vaccination and growth monitoring for her child. ©UNICEF/Esiebo)


Is it not better to do improvement on partograph completeness than utilization?


Improvement focuses on testing changes to solve the root cause of the performance gaps. The first step in improvement is to identify the gap. Either or both completeness and utilization may be the performance gap. If both are gaps, the improvement team will need to prioritize one and test changes to improve. We find that teams usually prioritize utilization of the partogram. After all staff are using the partogram, the teams shift focus to correct and complete use of every partogram.


With the multiple challenges at health facilty level, how many change processes is it possible for the teams to work on at any one time?


Teams are supported to test one change at a time so that they can relate the improvement to the changes tested.

I must congratulate you and your team in achieving these results. Use of the partogram and completeness of recording of data are important. How was the accuracy of the assessment of the patient in labor by the health care provider for documentation on the partogram ensured in this quality of care program?


1.     During a particular shift, the senior midwife supported the rest of the team on how to correctly use a partogram and conducted spot checks on how well they were filled and provided just on time feedback.

2.     During the quality improvement team meetings that were conducted weekly, a sample of patient charts was obtained and used to review utilisation, correctness and completeness. Feedback and appropriate changes were implemented as was necessary.


A partograph is only a tool in management of labour. It should be used with a plan of care if any abnormalities are detected on partograph. Was there a standard protocol used for the management? Besides FSB reduction, was there an increase in oxytocin use, caesarean section, etc? Any information on client satisfaction?


The Uganda Ministry of Health has standard protocols and guidelines for management of labor and its complications and these are available in all the health units that do conduct deliveries.

The improvement team looked at improving maternal and newborn care  starting from ANC, labor, delivery and post-partum period. Partograph utilization was used as an example in this case.

In these facilities, active management of third stage of labor improved to 100% oxytocin administration within one minute of birth.

Through the WHO Quality of Care initiative, maternity teams have identified a resourceful person within their facilities who conducts exit interviews about the care received by the mother at discharge. Anaka hospital has received positive feedback on client satisfaction as a result of partograph utilization. Mothers percieve it as increased attention to them during labor when a midwife closely monitors labor with a partograph.

Why was there low attitude towards partogram use?


Low attitude to partograph use always arises due to a wrong perception among health workers that a partogram is a time consuming detailed tool and difficult to fill. With continuous support from the improvement coaches, the attitude of midwives changed. The team started appreciating the results of using partogram to monitor labor which motivated them.

What was the reason for the decrease in use in June 2012. what was the newborn outcome then? How did you assess that they were using it for decision making? Also that they were not filling it retrospectively.


The team undergoes several ups and downs before stabilization. Some common factors affecting performance are; festive season, epidemics of other diseases, political elections, or any other events happening at the facility or in the district. The team is not able to recall what exactly happened in June 2012.

Is the PDSA a linear process, following one step at a time; what point in time is for review?


PDSAs are cyclic, iterative processes. One PDSA leads to another.

Sorry team I joined late due to technical glitches but caught up and I get the webinar very well. I am very interested in the program because 3 of my directors are part of the ASSIST quality improvement team.

In determining the change processes to focus on do you rely only on a health facilty specific problem or is it possible at times to look at the problem from a broader angle, say a district, and work on a particular problem from that level?


This will depend on where you want your improvement to take place and the magnitude of the problem. A clear initial baseline assessment and problem analysis should guide your improvement efforts. If the problem can be solved by changes at the district level, then the district needs to be included in the solutions.

What criteria were taken for completeness of partogarph  and who collated it?


A sample of partogram sheets was reviewed and checked for completeness of all parameters on a partograph as well as appropriate actions. This was done during a particular shift and during team meetings.

Since this tool only collects data during birth (??? I beg to be corrected), how does it prevent stillbirths? Because I assume a still birth is a result of so many factors before birth?


A partogram monitors maternal and fetal wellbeing during labor. It is a critical tool for detecting any deviations from normal and taking appropriate action including intrapartum resuscitation, C-sections or referral for lower health units. It helps in addressing fresh stillbirths because these happen during the period of labor. Still birth can also be caused by problems outside the delivery period – but these are not the majority.

How much external hand holding by USAID ASSIST was needed? Or was the local facility team able to do and sustain?


The team had all it needed to improve partograph utilization including ; a photocopier to obtain copies of partograms, staff skilled in partograph use who could train others etc. USAID ASSIST provided the team with a copy of the MOH partogram tool, trained the team in quality improvement methods and the team led the rest of the improvement process.

Typically, intensive handholding is needed for the first few months to support the team to understand how to apply improvement methods. After that, they use the same approach to solve any new problem.

Excellent work . How as immediate feedback on partogarph was provided?


During a particular shift and team meetings when partograph sheets were reviewed.


Thank you for the very clear process that has been shared with good results. In Zambia, we have noted an increase in partogram use as measured by the proportion of deliveries with a completed partogram. However, we have also noted in some cases that staff begin to complete the tool after the fact, thereby negating the very objective of using it. Have you experienced this during this quality improvement project? And if so, what intervention has been used to ensure that the tool is really used to monitor?


One fundamental question of improvement is ; What are you trying to accomplish? We support teams to improve processes while focusing on the outcome. A partograph filled afterwards will not improve outcomes. Through close supervision of a senior staff on every shift, these instances were eliminated

In the Ugandan context; how feasible is the ASSIST quality improvement approach to scale up? What do you consider would be the biggest challenges in taking this to scale?

(Similar question: What do you consider would be the biggest challenges in taking this to scale?)


From the start, we set up with the intention to take to scale. We engage health facilities representing a slice of the health system. These form model sites for similar health facilities in other districts or subcounties at scale up stage. What worked and what did not work is documented in a change package for reference to during scale up.

One of the main challenges of scale up is attaining commitment from leaders. The change packages usually provide information useful at the facility level. Engaging leaders in scale up districts is necessary for success. Another challenge is measurement of improvement. When indicators for improvement are not a part of the HMIS system, it is resource intensive to use the mat scale. You would need to find a proxy which is in the HMIS system, so as the mesaure progress in scale up through the electronic DHIS2 system

Great talk by Esther & Mary .Congratulations ! Keep Good work !!

Excellent.... just wanted to know who are your internal and external coaches for quality improvement?


We identify champions at facility level and Maternal/newborn supervisors/trainers at district and regional levels who we train in quality improvement methods. We initially conduct joint site visits to build their capacity untill they are confident to conduct independent coaching visits.

Thank you, Esther and Sr. Mary!  Such a clear and informative presentation!

Thank you Dr. Esther and Sr. Mary, I am hoping that MOH one day takes this as policy, I am sure this will reduce maternal and fetal deaths, I hope this reaches Eastern Uganda.


Partograph utilization is a policy in Uganda and there is a national guideline on how to use and fill a partograph. USAID ASSIST project, through its mandate of supporting USAID funded partners, is working with USAID RHITES-EC and E to scale this up to the East.

Thank you.

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