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Kibiito Health Centre IV

Kibiito, Fort Portal, Karbole Region, Uganda

Initial visit by Dr Andrew Mullett, Dr Lesley Milne on

19th November 2014

Follow-up visit by Dr Mullett, Dr Milne and Dr Jon Nelson on 23rd December 2014

The new maternity building at Kibiito.

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Kibiito HCIV A Health Centre IV serving the region west of Fort Portal that

feeds into Fort Portal Regional Referral Hospital Introduction

We first heard of Kibiito HCIV in discussions with the Assistant District Health Officer (ADHO), Elizabeth, in October 2014. At that this Elizabeth seemed keen that we visit. Kibiito is about 34km outside of Fort Portal just off the road to Kassesee in a south south westerly direction. A few weeks later Andy met with a Dr Victor who is a paediatrician working with Baylor (a Non Governmental Organisation (NGO)) in the Rwenzori region. Victor mentioned that he was planning a trip to Kibiito to try and functionaries their neonatal unit. Andy mentioned that we would be very keen to come along with him and work together on this aim when Victor was next going. A week or two later Andy, Lesley and Victor went to Kibiito. These are our findings.

Baylor’s Involvement Kibiito has recently had a major refurbishment. It still has some older building (general ward and out patient department for example) but also a very new two story maternity building which was constructed by Baylor. We believe the previous building was in a very poor state of repair and may even have fallen down. Baylor are trying to work with the local doctors and team to functionalise the HCIV and reach is structural potential, but they are working on a three year programme of decreasing funding and support with the aim to finally withdraw completely. They are currently in the second year of this programme.

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The Facilities The building is on two levels. The lower level (ground floor) contains two large wards currently labelled as antenatal and postnatal. It also contains a labour suite and small room labelled the “neonatal unit”. There are several store rooms, examination rooms, sluice and other unlabelled locked rooms. The upper level (first floor) is currently completely empty and unused. It contains the following labelled rooms although we were not able to see in any of them: • Private rooms x5 • Doctors duty room • In charge room • Board room • Doctors changing room • Nurses changing room • Male and female toilets • Tea room • Side laboratory

The plaque commemorating the new maternity building at Kibiito.

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Please note that Kibiito HCIV are currently seeking permission to have private patients but currently do not have this permission.

The old buildings at Kibiito.

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Antenatal Ward This ward was completely unused. Discussions over the phone between Victor and the doctor in charge (who was not present on the day we visited) revealed that the reason given for the large number of unused areas was that they had insufficient staff to clean them so they preferred not to use them. It contained the following: • Beds x15 (we think a sixteenth was currently being used as a night nurses bed

in the disused neonatal unit)

The upstairs corridor of the new maternity building at Kibiito. Non of these rooms are currently in use.

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• Bedside cabinets x16 • Drip stands x4 • Double sockets x12 • Ceiling lights x10

Of note there were no sinks in the ward and it was not immediately obvious how one would be installed as we could not find piped water anywhere nearby. The closest sink we located from the ward was through at least 3 sets of doors and about 10m away.

Labour Suite Labour suite was in use, and in fact delivered 2 babies in the 2 hours that we were visiting. As per the Ugandan governments standard provision they have a total of 4 midwives employed. they normally staff one night midwife and one or two day midwives. On the day we visited there was only one midwife working the shift. It contains the following equipment: • Birthing beds x4 (removable bottom half of bed and lithotomy poles)

The antenatal ward in the new maternity building at Kibiito.

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• Curtains dividing each bed into separate cubicles • Neonatal ‘resuscitation station’ • Neonatal scales • Oxygen concentrator • Sink with running water and soap x1 (no alcohol gel or hand drying

apparatus) • Storage cupboard

The labour suite in the new maternity building at Kibiito. Please note the curtains separate the cubicles.

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The labour suites cubicles are all fitted with this kind of delivery bed.

The equipment and resuscitation area of labour suite.

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Postnatal Ward The postnatal ward was used jointly as antenatal and postnatal wards. it had two halves divided with a wall into a U shape. Only one arm of the U was in use. The ward contained the following: • Beds x22 • Bedside cabinets x22 • Drip stands x6 • Screen x1 • ‘Jerry-can with tap’ and soap (Nb. no water) • Landline (not working) Note there are no sinks, the nearest is in labour ward about a 15m walk away from the closes end of the ward. On postnatal ward the drugs and equipment immediately to hand were: • Fluids • Cannula’s • Ampicillin • Gentamicin • Dextrose.

The used half of the postnatal ward (also used for antenatal patients) in the new maternity building at Kibiito.

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Neonatal Unit The ‘neonatal unit’ is a small room that currently contains two resuscitaires. It has not, as yet, been used for any neonates. On this visit we were able to set up both resuscitaires and teach both the night and day midwife how to use them. Up to now it has also been being used as a night room for the midwife with a bed in it. Victor removed this bed at this visit and requested it not be used for this again. He pointed out to the staff that they would not receive any further funding regarding neonates if they could not show that they were starting to use the equipment they had already been given.

Summary In summary the infrastructure at Kibiito (more specifically the maternal and newborn services) is extremely extensive, although it has in places been poorly planned (e.g. the absence of sinks in clinical areas). We wondered how much planning has gone into requirements of the area prior to construction as at the time we visited there seemed more than enough room despite the fact they were

The postnatal ward (usused half) in the new maternity building at Kibiito.

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using less than a quarter of the beds downstairs and none of the space upstairs. Victor did mention that they had planned the new building with space for further expansion, although it seems the amount of extra space is rather more than is likely to be required by maternity services alone any time soon. There is certainly space to expand the current services and it would be good to start looking at better uses of the space they have available to them. However it may be necessary to facilitate the employment of further cleaning staff in order to persuade them to use their new facilities due to the current fear or messing up the new clean space.

Dr Lesley and Dr Victors standing outside the doors to the neonatal unit.

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Follow-up visit 23/12/14 Following a meeting earlier this week with the assistant DHO Elizabeth Makemato we conducted a follow-up visit to meet the doctor-in-charge Dr Bijja Robert. At this visit we discussed with him how we might work with the staff at the health centre in the future.

On this occasion we were able to obtain some more data about the current and historic use of the facilities. We were able to obtain this data with help from David the data analysis at the health centre.

Since the opening of the new maternity building in September 2014 there has been a surge in admissions and deliveries as shown by the graph below:

Unfortunately this has resulted in the deterioration of some quality indicators probably due to staff workload. For example partograph use was at 70-80% in the months leading up to September 2014, but in September was 53%, October 53% and November 49%. It is important to note that this was readily supplied by the staff and were open about these shortcomings and challenges. There was similar data about other quality indicators such as active management of 3rd stage, care of the newborn and family planning counselling. To address the increased workload Baylor have provided funding and recruited some new staff members:

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Axis

Tit

le

Delivery rate

Delivery rate

new maternity building opened

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-­‐ three newborn staff nurses (but actually working as midwives as the neonatal unit is still not functional)

-­‐ three new midwives taking the total to six

-­‐ one new anaesthetic officer taking the total to two

-­‐ two new cleaners taking the total to three (but one has not turned up to work yet)

Table to show maternity department statistics for September – November 2014 at Kibiito Health Centre IV Sep 2014 Oct 2014 Nov 2014

1st antenatal clinic attendance 213 160 127

4th antenatal clinic attendance 81 91 74

Total antenatal clinic attendance 525 468 398

ANC referred in 5 3 6

ANC referred out 0 0 2

IPT 1st dose 104 45 120

IPT 2nd dose 86 39 91

Iron/folate 1st dose 213 166 125

ITNs (mosquito nets given out) 0 0 0

Syphilis tested 147 91 138

Syphilis +ve 5 1 5

Known HIV +ve 10 10 11

On ARTs for own health 7 10 28

HIV tested 169 135 138

HIV +ve 3 6 8

Counselled for ARTs 5 5 8

ARTs started 3 5 1

Male partners tested (offered to all)

0 1 3

Admissions 209 215 175

Deliveries 155 147 116

Live births 150 143 111

Fresh stillbirths 3 4 0

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Macerated stillbirths 2 1 4

Early neonatal death (<7 days) 1 0 1

Birth asphyxia 6 6 3

Birth weight <2500g 3 14 3

Referrals in 18 16 19

Referrals out 15 14 5

HIV +ve deliveries 13 15 18

HIV +ve livebirths 12 15 17

Antiretroviral (ARTs) use 13 15 18

Babies given ARTs 12 15 17

Traditional birth attendance at delivery

0 0 0

Postnatal attendance rate 14 27 13

Total patient days 337 429 333

Av. Length of stay (days) 1.6 1.9 1.9

Av. Bed occupancy (based on 23) 11.2 (48.6%) 13.8 (60%) 11.1 (48.2%)

Caesarean sections 5 17 10

Evacuations 1 2 0

Oral contraceptive pill (OCP) new 1 4 1

OCP continued 2 5 1

Female condom new 0 0 0

Female condom continued 0 0 2

Condoms new 2 16 3

Condoms continued 3 1 1

Injectable new 18 21 8

Injectable continued 7 11 20

Others (inc. implants) new 0 13 10

Others continued 0 9 9

Theatre During this second visit we were able to get into the operating theatre. We were actually able to be of some clinical assistance resuscitating a patient and assisting

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with a caesarean hysterectomy following a ruptured uterus. The theatre had a changing room, scrub room, main theatre, sluice room and its own toilets. The operating table was height adjustable and functional. Anaesthetic equipment available included an oxygen concentrator, EMO machine, lifebox pulse oximeter, laryngoscopes and blades, a manual sphygmomanometer, drip stands and drugs (thiopentone, ketamine, pethidine, diclofenac, bupivacaine, heavy lidocaine, various antibiotics). There was also a GE9100C anaesthetic machine unused due to lack of pressurised gases (as in most health facilities with theatres in Uganda).

Future involvement with Kibiito We are planning a programme of visits in the coming months to provide some clinical training and support during the rapid expansion period. We discussed and Dr Bijja will invite staff from surrounding health facilities that feed into Kibiito. Dr Mullett will work on functionalising the neonatal unit including provision of guidelines. Dr Nelson will undertake antenatal, delivery suite and postnatal ward round alongside local staff in order to provide bedside teaching/advice, and provide some guidelines surrounding postnatal and care in labour. Dr Milne will liaise with the anaesthetic officers to ensure appropriate guidelines/protocols are available and used in theatre. We will all be instigating a programme of emergency obstetric and neonatal training for all cadres of staff. Although Jean Skeen (volunteer midwife working in Fort Portal) has not been able to visit Kibiito yet she hopes to also be involved in working and training there.