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GLOBVAC-Global helse- og vaksin.forskn

Evidence-based policies and health systems interventions for antenatal care

Alternative title: Kunnskapsbaserte retningslinjer og helsesystemintervensjoner i svangerskapsomsorgen

Awarded: NOK 12.0 mill.

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Project Period:

2021 - 2025


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In the district of Mukono, Uganda, 30,000 women give birth every year. Among them, 130 will die during pregnancy, childbirth, or within 42 days, and 1400 will experience that their baby dies after 28 weeks of pregnancy or during the first week of life. Mukono has 57 health facilities that provide antenatal care (ANC). Their health information system consists of paper register books and records that they manually count, aggregate, and report from. Most pregnant women will come at least once, but only slightly more than half will visit the health care center four times or more, and few receive the essential services they need during ANC. In the ePOSIT project, scientists and health professionals from Uganda and Norway will work to transform the Ugandan ANC health information system from paper to digital, through a co-design process with the users. This system will not only serve as digital health records with clinical decision support for care providers, but also send ANC appointment reminders to women by SMS, and automatically report performance to managers. We aim to strengthen both attendance and quality of ANC. We will study the factors that help make such systems feasible, acceptable, effective, and sustainable in a Ugandan setting. Finally, we will use the digital ANC registry to help study whether it is feasible and effective to double the number of ANC visits, from four to eight, as the WHO now recommends. In a setting like Uganda, who do not yet manage to provide four ANC visits of good quality to all, we do not know how such a change will affect attendance and quality of care, and whether it would actually improve health outcomes. We will study this in a cluster-randomized controlled trial. Our ambition is to assist Uganda with better evidence to improve essential health services for pregnant women and their babies. The project is a partnership between the Norwegian Institute of Public Health, and the universities of Bergen, Makerere, and Oslo.

Universal effective coverage of antenatal care (ANC) is a cornerstone for the SDGs for maternal and child health, and beyond. In low- and lower middle-income countries (LLMICs), access, use, equity, and quality of ANC - all leave much to be desired. Guided by two new WHO guidelines, Uganda strives to improve ANC. Firstly, the new WHO guideline on digital health interventions (DHIs) recommends established DHIs to support effective coverage of care in LLMICs. But, there are many implementation caveats and WHO identifies a priority research question: What are the enabling factors, supporting interventions, environment and facilitation that can ensure feasibility, acceptability, fidelity and effectiveness in implementations of combined DHIs at scale? Second, the WHO guideline for ANC suggests LLMIC should double the number of ANC visits from four to eight, while countries struggle to have quality content in four ANC visits. WHO therefore identifies a priority research question: Does the WHO ANC model with a minimum of eight contacts impact the quality of ANC in LLMICs and what is the effect on health, values, acceptability, resources, feasibility, and equity parameters? In this project, we aim to respond to both research questions from the WHO by studying the implementation of digital health innovations in ANC services in the district of Mukono, Uganda. These innovations, DHIS2 eRegistries, will support care providers with shared health records for continuity of care with integrated work and decision-support, automated reporting with results dashboards for supervisors, and it will support women with automated personalized SMS-messages and reminders to improve uptake of ANC services. In such a setting of strengthened ANC services, we will put the WHO guidance to test in a randomized trial of clinics offering either four ANC visits as today or the new model of eight visits, and measure what model is the best in a Ugandan setting, according to the WHO criterions.

Funding scheme:

GLOBVAC-Global helse- og vaksin.forskn