Facility readiness and knowledge of health care workers to manage postpartum hemorrhage in public health facilities within Kampala metropolitan areas, Uganda

Facility readiness and knowledge of health care workers to manage postpartum hemorrhage in public health facilities within Kampala metropolitan areas, Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Facility readiness and knowledge of health care workers to manage postpartum hemorrhage in public health facilities within Kampala metropolitan areas, Uganda Abdullahi Teituk, Sam Ononge, Annette Keesiga, Felix Bongomin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7053223/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Postpartum hemorrhage (PPH) accounts for about one-third of all institutional maternal deaths in Uganda. Evidence has shown improved maternal outcomes with better readiness and preparedness for PPH management. We determined the level of readiness of health facilities and knowledge of health care workers (HCWs) to manage PPH among public facilities in Kampala metropolitan areas, Uganda. Methods We conducted a cross-sectional study among comprehensive emergency obstetric and newborn care (CEmONC) public health facilities within the Kampala metropolitan areas (Kampala, Wakiso, Mukono, and Mpigi districts). Data was collected using a structured questionnaire and a facility observational checklist to assess the availability of indicators of readiness for PPH management. Adequate knowledge was defined as a score of ≥ 75%, and a facility was considered ready to manage PPH if it had a composite score of ≥ 90%. Results We included 191 HCWs from 14 CEmONC centres and Diploma Midwives constituted most study participants 42% (n = 81). Less than a third of health workers had received any recent in-service PPH training. Overall, 50 (26.3%, 95% CI; 20.2 — 33.2) HCWs had adequate knowledge of PPH management. The mean knowledge score was 65.4%, significantly different among cadres of HCWs (p < 0.001) and those with recent training (p < 0.001). Overall, 2 health facilities (14.3%) were ready to manage PPH. Conclusions The study showed that most public health facilities surveyed lacked the desired capacity to manage a PPH case with 14.3% (n = 2) found ready, coupled with low PPH knowledge among health workers. In-service training was found to improve the level of knowledge among health care workers. We recommend that stakeholders address the gaps in human resources, medicines and supplies, equipment, and health care worker competence in PPH management to promote a reduction in maternal mortality and morbidity from PPH. Facility readiness knowledge of health workers Postpartum hemorrhage Kampala metropolitan areas Background Globally, postpartum hemorrhage (PPH) is the leading cause of maternal deaths, and about 90% of the deaths occur in low-middle-income countries (1). PPH complicates about 10% of all deliveries in sub-Saharan Africa, however, it accounts for nearly half of PPH-related deaths globally (2). In Uganda, PPH accounts for about 34% of all institutional maternal deaths (3)(4). Furthermore, in about 17% of PPH survivors, morbidities such as significant organ impairment for some women which have long-lasting negative consequences for children, families, and communities have been described (1). The risk factors for PPH include; previous history of PPH, multiple pregnancies, fetal macrosomia, primigravidity, grand multi-parity, older age, pre-term births, genital tract injuries, non-use of oxytocics for PPH prophylaxis, labour induction, cesarean birth, being HIV positive, and intrauterine fetal deaths (3). PPH is an emergency where appropriate and timely management is crucial to prevent severe complications or death. With the increasing health facility deliveries in many low-resource settings, health facility readiness to enable appropriate management of PPH is crucial (2). The hemorrhage transition from the compensated to the decompensated stage is rapid and easily overlooked hence, prediction, early recognition, and intervention are critical to reduce the likelihood of or improve the clinical outcomes of severe PPH (5). The World Health Organization (WHO) defines health facility readiness as the availability of trained health workers, guidelines, equipment, essential medicines and supplies (2). A health facility survey reported poor readiness to provide PPH care according to WHO standards and health workers perceived poor health facility readiness as contributing to poor quality of care when managing life-threatening complications, including PPH (2). According to the district Health Information System 2 (DHIS2) 2020/21, Kampala metropolitan areas contributed the highest number of maternal deaths to the national figure, 17% (n = 187), 44.7% (n = 149) of which were caused by PPH (4). There was, however, little information on facility readiness and knowledge of health care workers to manage PPH in Uganda. This study sought to determine the level of facility readiness and knowledge of health care workers to manage PPH among public CEmONC facilities within Kampala metropolitan areas, Uganda. Methods Study Design: This was a facility-based cross-sectional study that was conducted among public comprehensive emergency obstetrics and newborn care (CEmONC) health facilities within Kampala Metropolitan areas, Uganda. Study setting: The study was conducted in public CEmONC health facilities within the Kampala metropolitan area which has a day-time population of about 3.5 million and is comprised of four districts of Kampala's capital city, Wakiso, Mukono, and Mpigi districts. According to the national health facility master of 2021, the Kampala metropolitan area comprised a total of fourteen public health facilities that were classified as CEmONC. Five facilities in Kampala Capital City, six facilities in Wakiso, Two facilities in Mukono, and one facility in Mpigi district (6). Study Population: We included all the 14 public health facilities that were classified as CEmONC and recruited a total of 191 health care workers across 3 cadres of Obstetricians, Medical Officers, and Midwives. All participants were 18 years of age or older and provided written informed consent. Data Collection: We used an observational facility checklist adopted from the World Health Organization (WHO) service availability and readiness assessment (SARA) tool for PPH (7). Details captured using the checklist included the availability of critical human resources, a functional operating theatre, essential medicines and supplies (availability, storage, and stock management), equipment, updated guidelines/protocols related to screening and management of PPH, availability of PPH kit in the maternity units, sustainable blood transfusion services, functional refrigerator for cold chain, and functional ambulance services. Study cases were used to capture the level of knowledge of health workers to manage PPH, which was adopted from the national PPH management guidelines using the care bundle approach in the essential maternal and newborn care guidelines for Uganda 2022 edition. (8). Study Outcome Measures: The proportion of health facilities that were ready to manage PPH was computed as the number of health facilities that had a readiness score ≥ 90%. The frequency tables and chart were presented. The proportion of health workers with adequate knowledge of PPH management was computed as the number of participants that scored ≥ 75%. Data analysis: The data were analyzed in STATA version 17.0. Categorical variables were summarized as frequencies and percentages. Continuous variables were summarized using mean and standard deviation. The Fisher’s exact confidence interval for the proportion was computed. The mean knowledge scores were compared by health facility level, cadre of health care workers, service years, and recent in-service PPH-related training preceding data collection. For independent variables with 2 levels, an independent samples t-test was used to assess the mean differences after fulfilling the normality (assessed using Sharpilo-Wilk’s test) and equal variance (assessed using Levin’s test) assumption. For variables with more than two levels, Kruskal-Walli’s test was used to assess the differences in the knowledge scores since the variances of knowledge scores were different among the levels of the variables. The P < 0.05 was considered statistically significant. Ethical considerations: Approval was obtained from the Makerere University School of Medicine research and ethics committee (SOMREC): Mak-SOMREC-2022-429. Written informed consent was obtained from each participant before their recruitment and participation in the study. Results Characteristics of health workers: Overall, we enrolled 191 HCWs. Most participants were diploma midwives 42.4% (n = 81), 26.2% (n = 50) health care workers had recent in-service training related to PPH, 36.1% (n = 69) worked at a level of a Health Center IV, and 91.6% (n = 175) had been in service for more than two years, Table 1 . Table 1 Characteristics of the 191 healthcare workers in the public CEmONC facilities that participated in the study within greater Kampala Variable Categories Frequency (N = 191) Percentage (%) Cadre of HCWs Enrolled Midwife 54 28.3 Diploma Midwife 81 42.4 Degree Midwife 14 7.3 Medical Officer 18 9.4 Obstetrician 24 12.6 Duration of employment < 2 Years 16 8.4 ≥ 2Years 175 91.6 Received recent in-service PPH training/CME Yes 50 26.2 No 141 73.8 Level of CEmONC facility of practice Health Center IV 69 36.1 General Hospital 31 16.2 Regional Referral 11 5.8 National Referral 80 41.9 Characteristics of Health Facilities: Of the 14 Public CEmONC health facilities surveyed, 42.9% (n = 6) were in Wakiso district, 64.3% (n = 9) were Health Center IVs, and 14.3% (n = 2) were National Referral Hospitals, Table 2 . Table 2 Characteristics of CEmONC health facilities that were assessed for readiness to manage PPH within greater Kampala Variable Categories Frequencies (N = 14) Percentage (%) District Kampala 5 35.7 Mpigi 1 7.1 Mukono 2 14.3 Wakiso 6 42.9 Level of CEmONC facility Health Center IV 9 64.3 General Hospital 2 14.3 Regional Referral 1 7.1 National referral 2 14.3 Availability of indicators of readiness for PPH management. Overall, 14.3% (n = 2) facilities were found ready to manage a case of PPH. Human Resource: 7.1% (n = 1) of the surveyed CEmONC facilities had 100% staffing positions for the critical health workers filled as per the staffing structure available at the time of the study. The average staffing level for critical health workers was at 50%, and the most understaffed cadres were anesthesia providers across all the facilities surveyed. Physical Infrastructure: All 14 CEmONC facilities surveyed had enabling physical infrastructure required for the management of PPH available with functional operating theatre (with evidence of at least an operation done within the last 3 months), delivery rooms, laboratory, and pharmacy. 28.6% (n = 4) of the facilities could not functionalize their operating theatres 24/7. Equipment: None of the health facilities had all the equipment required to adequately manage a case of PPH readily available and accessible 24/7. 28.6% (n = 4) of the facilities had ≥ 80% of the required equipment. 7.1% (n = 1) of health facilities had an anti-shock garment readily available in the labor ward. None of the health facilities had a complete and functional PPH emergency kit/box. 78.6% (n = 11) of the facilities had an available but incomplete PPH emergency kit/box. 78.6% (n = 11) of the facilities had a functional refrigerator for storage of oxytocin in the labor ward, Table 3 . Table 3 Availability of some essential equipment required for the management of PPH in the public CEmONC health facilities within greater Kampala Equipment Availability Number of Facilities N = 14 Percentage (%) Anti-Shock garment Available and functional 1 7.1 Available and dysfunctional 0 0.0 Not Available 13 82.9 PPH emergency kit/box Available and complete 0 0.0 Available but incomplete 11 78.6 Not Available 3 21.4 Perineal/cervical tear examination/suture pack. Available 10 71,4 Not available 4 28.6 Cold chain refrigerator Available and functional 11 78.6 Available and dysfunctional 3 21.4 Not Available 0 0.0 Medicines and supplies: Of the 14 facilities, 21.4% (n = 3) had all the essential drugs for managing PPH. Almost all health facilities 92.9% (n = 13) reported stock-outs of essential drugs and supplies required for PPH management for more than 15 days in the two months preceding data collection. Tranexamic acid was available in 21.4% (n = 3) facilities, with 33.3% (n = 1/3) facilities reporting no recent stock-outs of tranexamic acid. Oxytocin was out of stock in 3 (21.4%) facilities while Misoprostol in 1 (14.3%) facility, Table 4 . Table 4 Stockouts of some essential drugs in the management of PPH for more than 15 days in the past 2 months among the public CEmONC health facilities within greater Kampala. Drug Stock out more than 15 days in the last 2 months Number of Health Facilities N = 14 Percentage (%) Oxytocin Yes 3 21.4 No 11 78.6 Misoprostol Yes 2 14..3 No 12 85.7 Tranexamic acid Yes 13 92.9 No 1 7.1 Crystalloids Yes 6 42.9 No 8 57.1 Catheters Yes 9 64.3 No 5 35.7 Cannulas Yes 7 50 No 7 50 Gloves Yes 10 71.4 No 4 28.6 Updated guidelines and protocols for PPH management: Of the 14 facilities, 35.7% (n = 5) had updated PPH management guidelines/protocols available and visible on the labor ward walls, 35.7% (n = 5) had non-updated guidelines/protocols, 35.7% (n = 4) facilities had no guidelines/protocols. Auxiliary services: All health facilities surveyed had a functional backup generator/inverter and had access to clean piped water. 35.7% (n = 5) had no functional ambulance. 7.1% (n = 1) of the facilities lacked a functional blood storage refrigerator. 50% (n = 7) of the facilities had no access to blood products 24/7 in case of an emergency, while all facilities reported recent stockouts of blood products. The level of knowledge of PPH management among health care workers. The proportion of health care workers with adequate knowledge of PPH management in the surveyed CEmONC facilities was found to be low at 26.3% (95% CI; 20.2–33.2). The overall mean (SD) knowledge score was 65.4% (13.0) (95% CI; 63.5–67.2). The mean knowledge score was significantly different among the health care worker cadres (P value < 0.001). The mean knowledge score of obstetricians was significantly higher at 81.2% (95% CI; 78.2–84.3) than all other cadres of health care workers. The mean knowledge score for medical officers was significantly higher at 70.8% (95% CI; 66.8–74.8) than that of certificate and diploma midwives. The mean knowledge scores for Medical Officers was at 70.8% (95% CI; 66.8, 74.8) and that of degree midwives at 61.1% (95% CI; 61.1–71.1) were not statistically significant, Table 5 . Table 5 Comparison of mean knowledge scores of PPH management among 191 health workers working in public CEmONC health facilities within greater Kampala. Variable Categories Mean knowledge score (SD) P value Health facility level one Practiced Health Center IV 64.6 (11.7) 0.373 District hospital 67.6 (9.6) Regional referral 70.4 (8.2) National referral 64.5 (15.4) Cadre Obstetrician 81.2 (7.6) < 0.001 Medical officer 70.8 (8.4) Degree midwife 66.1 (9.5) Enrolled Midwife 60.1 (10.6) Registered Midwife 62.9 (13.2) Duration of employment Less than 2 years 63.5 (12.3) 0.554 2 years and above 65.5 (13.1) Recent in-service PPH training. Yes 73.4 (11.8) < 0.001 No 62.6 (12.3) All obstetricians were able to correctly define/identify PPH, while 77.8% (n = 42) of the certificate midwives were able to correctly define/identify PPH. About three-quarters of obstetricians were able to administer tranexamic acid as an initial intervention in the management of PPH compared to only 21.0% (n = 17) of diploma midwives. Close to three-quarters of obstetricians were able to consider carboprost administration as an intervention in the management of PPH as opposed to 5.6% (n = 3) of the certificate midwives. Obstetricians were generally able to perform more lifesaving interventions, especially for uterine atony before transferring a patient to the operating theatre or whenever the operating theatre was not ready compared to all other cadres, Table 6 . Table 6 Performance on knowledge areas about PPH recognition and management by health workers of public CEmONC health facilities within greater Kampala Knowledge area Obstetrician n (%) Medical officer n (%) Degree Midwife n (%) Diploma midwife n (%) Certificate midwife n (%) Yes No Yes No Yes No Yes No Yes No A correct definition of PPH (identify PPH) 24 (100.0) 0 (0.0) 17 (94.4) 1 (5.6) 12 (85.7) 2 (14.3) 65 (80.3) 16 (19.7) 42 (77.8) 12 (22.2) Administer Tranexamic acid 17 (70.8) 7 (29.2) 5 (27.8) 13 (72.2) 5 (35.7) 9 (64.3) 17 (21.0) 64 (79.0) 14 (25.9) 40 (74.1) Administer carboprost 15 (62.5) 9 (37.5) 2 (11.1) 16 (88.9) 6 (42.9) 8 (57.1) 19 (23.5) 62 (76.5) 3 (5.6) 51 (94.4) Interventions for refractory PPH Before Theatre Continue oxytocin infusion 19 (79.2) 5 (20.8) 14 (82.3) 3 (17.7) 10 (71.4) 4 (28.6) 63 (77.8) 18 (22.2) 47 (87.0) 7 (13.0) Bi-manual compression of uterus 22 (91.7) 2 (8.3) 10 (58.8) 7 (41.2) 10 (58.8) 4 (28.6) 53 (65.4) 28 (34.6) 23 (42.6) 31 (57.4) Uterine balloon tamponade 24 (100.0) 0 (0.0) 9 (52.9) 8 (47.1) 6 (42.9) 8 (57.1) 25 (30.9) 56 (69.1) 15 (27.8) 39 (72.2) Anti-shock garment 14 (58.3) 10 (41.7) 5 (29.4) 12 (70.6) 2 (14.3) 12 (85.7) 11 (13.6) 70 (86.4) 7 (13.0) 47 (87.0) Blood transfusion 16 (66.7) 8 (33.3) 14 (82.3) 3 (17.7) 10 (71.4) 4 (28.6) 54 (66.7) 27 (33.3) 27 (50.0) 27 (50.0) Discussion In this study, we surveyed all the public health facilities categorized as CEmONC centers within the Kampala metropolitan, Uganda to determine the level of facility readiness and knowledge of health care workers to manage postpartum hemorrhage which is the number one cause of maternal mortality in Uganda. Kampala metropolitan area contains some of the highest volume maternity centers in the country contributing a significant percentage to the national maternal and newborn indicators. This was the first ever survey conducted among public health facilities for postpartum hemorrhage. The facility observational checklist revealed gaps in the staffing levels, key equipment, medicines and supplies, guidelines and protocols, blood transfusion services and ambulance services. The study findings revealed 14.3% (n = 2) of the surveyed facilities had the desired capacity to readily manage a case of PPH. A similar study conducted in New Jersey and Georgia showed that 50.5% of the Hospitals had adequate readiness to manage PPH (9). The differences in readiness are possibly due to disparities in the levels of socio-economic development of the two study settings and the fact that our study used an observational checklist could have been more objective compared to the use of key informant interview. There was no local and regional published data for comparison. The study findings revealed a significant degree of understaffing for the most critical health workers required in PPH management with 7.1% (n = 1) facilities had 100% staffing levels as per the available staffing structure. These findings are consistent with most studies that have revealed poor health staffing levels among Hospitals in sub-Saharan Countries. A study in Uganda to assess health staffing levels showed shortages of health workers across all level health facilities, with only 42–70% of required nurses and 53–67% of needed midwives, while higher level facilities (Health centre IV and General hospital) had significantly fewer doctors (39–42%) than needed (10). This has got a great impact on the 3rd delay in accessing emergency obstetric care for mothers with PPH. It should be noted that anesthesia providers play a pivotal role in operationalizing theatre in management of refractory PPH, yet they were found to be the most understaffed cadres across the public CEmONC facilities that were studied. All the surveyed facilities had an enabling infrastructure, 28.6% (n = 4) facilities had operating theatres that could not function 24/7 and these were majorly health centre IVs. This was attributed to the understaffing of anesthesia providers and medical officers, and the frequent stock outs of essential drugs and supplies. The likely implication of this finding is an increase in the number of referrals of PPH cases that would need to be transferred to the operating theatre from lower CEmONC facilities to higher CEmONC facilities yet a referred PPH case is more likely to die than that managed at the incident facility due to referral challenges. In this study, 35.7% (n = 5) of facilities had updated PPH management guidelines/protocols available and visible on the labor ward walls. These findings provide an opportunity to improve the availability and visibility of the updated PPH guidelines to enhance care in the form of quick reference since studies done in Kenya and Tanzania revealed a knowledge gap among health workers in PPH management (11)(12). The survey revealed gaps in ambulance and blood products with 35.7% (n = 5) without a functional ambulance and these were mainly lower CEmONC facilities (Health centre IVs) and half of the facilities (n = 7) had no access to blood products 24/7 while all surveyed facilities reported to have had recent blood stockouts. The absence of a functional ambulance at some lower CEmONC health facilities can greatly impact on the second delay in seeking further skilled care at the higher CEmONC health facilities since most lacked obstetricians in the staffing structure. Also, the fact that all study facilities had reported stockout of blood products within 3 months preceding the data collection, greatly affects PPH management since often mothers require blood transfusion during PPH management. The findings were consistent with those from a study done in northern Uganda that identified lack of blood and functionality and delays in the interfacility referral system as the biggest contributors to third delays to emergency obstetric and newborn care (EmONC) services in hospitals (13). This survey revealed chronic stockouts with one facility that had 100% of all the required medicines and supplies for PPH management available at the time of the study. This could be because the same facility despite being public, had user fees where patients paid slightly subsidized fees for the services offered unlike the other thirteen facilities surveyed which were totally on a public basis. These findings were consistent with those from a study done in northern Uganda that identified a shortage of medicines and supplies among others as the biggest contributor to 3rd delays to EmONC services in hospitals (13). Despite the WHO 2017 recommendations on the use of tranexamic acid in PPH management, it was found to be available in 21.4% (n = 3) of health facilities. Oxytocin and misoprostol were found to be the least stocked-out drugs at 21.4% (n = 3) for oxytocin and 14.3% (n = 1) for misoprostol. A study in India to assess readiness and preparedness for PPH management found oxytocin and misoprostol to be available in only 50% of the health facilities (14). One facility had an anti-shock garment available in the labor ward and operating theatre possibly because this facility had been part of a study for this gadget that remained behind after the study. The survey also revealed that none of the health facilities had a complete PPH emergency kit available in the labor wards. 78.6% (n = 11) had an incomplete PPH emergency kit. A plausible explanation for the incompleteness of the PPH emergency kits found in the eleven CEmONC facilities was that the items constantly got used up in the management of PPH and other obstetric emergencies due to chronic stockouts of drugs and supplies and the used items were often not replaced. These findings negatively impact readiness for timely interventions for PPH management. Evidence from a study in the United Kingdom using simulations showed a 79.8% reduction in the time required and an 88.7% reduction in the distance covered to pick items required during a PPH emergency if items are kept in emergency box/kit (15). The study findings revealed that the level of adequate knowledge of PPH management among health workers in the public CEmONC facilities was low at 26.3% (95% CI; 20.2, 33.2) with the overall mean (SD) knowledge score to be 65.4 (13.0) with a 95% CI (63.5, 67.2). This means that on average, healthcare workers who scored 75% and above on the knowledge assessment elements for PPH ranged between 20.2%-33.2% of the total number (191) interviewed and about 3 in every 4 health workers had inadequate knowledge to manage PHH. The average knowledge score ranged between 63.5%-67.2%. Two similar studies done in Kenya and Tanzania also revealed inadequate levels of knowledge of PPH management among health workers with providers scoring an average of 0.71 (95% CI: 0.69–0.72) across all questions (11) and 63.9% ± 21.1% (12) respectively. A plausible explanation for this is the relatedness of the study setting and similarity of study participants and the socioeconomic development of the Countries. Health workers who reported to have had recent in-service training on PPH management and those higher in cadre were more knowledgeable compared to those who had no recent in-service training on PPH management and the lower cadre staff with P value < 0.001. These findings conform to the already existing evidence of an increase in knowledge with higher levels of education and the justification to have regular training in PPH to keep the healthcare workers updated on PPH management. On the contrary, the study findings revealed that the level of knowledge of PPH management among health workers was not affected by the number of years in service or by the level of CEmONC facility one practiced with P values 0.554 and 0.373 respectively. These findings were consistent with a similar study in Kenya that found that experience in years was not associated with higher scores and had a coefficient of 0.00 (95% CI: 0.00-0.08) and specialists had higher knowledge scores compared to other health providers (11). Strengths and limitations of the study This study did not assess the skill and attitude of the health workers on PPH management due to limited time and resources. PPH simulation drills coupled with direct observations of practice and skills would have been a better competence assessment of health workers but our study was limited by resources and time. Conclusion The study findings showed that most of the public facilities 85.7% (n = 12) surveyed lacked the desired capacity to manage a PPH case, coupled with low PPH knowledge among health care workers. In-service training was found to improve the level of knowledge among health care workers. We believe that the survey findings could be worse in the more rural public health facilities yet they constitute the majority of health care providers. There is a clear need to address the gaps in human resources, medicines and supplies, equipment, blood, and blood products. Updated PPH management guidelines/protocols and items for the emergency box/kit need to be availed. Provider competence in PPH management needs to be improved through regular in-service mentorships and training to promote timely and appropriate interventions leading to a reduction in maternal mortality and morbidity from PPH. Abbreviations ACOG American College of Obstetricians and Gynecologists CEmONC Comprehensive Emergency Obstetric and Newborn Care CS Cesarean Section DHIS District Health Information System DHO District Health Officer GCP Good Clinical Practice HC Health Centre HCWs Healthcare Workers IRB Institutional Review Board KCCA Kampala Capital City Authority LMICs Low and Middle-Income Countries (LMICs) MMR Maternal Mortality Ratio MOH Ministry of Health NASG Nonpneumatic anti-shock garment NMS National Medical Stores PI Principal Investigator PPH Postpartum Hemorrhage SOMREC School of Medicine Research and Ethics Committee SPPH severe postpartum hemorrhage STROBE Strengthening the Reporting of Observational Studies in Epidemiology UBOS Uganda Bureau of Statistics WHO World Health Organization GDP Gross domestic product Declarations Ethics approval and consent to participate:Permission to conduct this study was sought from the department of obstetrics and gynecology, Makerere University and the management of the 14 health facilities studied. Ethical approval was obtained from School of Medicine research and ethics committee (SOMREC) of Makerere University ( Mak-SOMREC-2022-429) . All participants were informed of the intentions of the research and only those who accepted to sign informed consent forms were involved and given the liberty to withdraw from the study as and when they wished to. Health workers’ anonymity was guaranteed on the questionnaires to ensure confidentiality by using study numbers instead of names . The study tools were kept under lock and key only accessible to the research team to ensure that there was no breach of confidentiality. Consent for publication:Not applicable Availability of data and materials:The datasets used and/or analyzed during the study are available from the corresponding author on official request. Competing interests:The authors declare that they have no competing interests. Funding:The funding for the study was provided by the first author Authors' contributions: AT : Conceptualization, formal analysis, investigation, Methodology, Project administration, resources, validation, visualization, writing – original draft, writing – review & editing. SO : Conceptualization, validation, supervision, review and editing. AK : Conceptualization, supervision, validation, writing – review & editing FB : Manuscript writing, review and editing. OK : Conceptualization, validation, writing – review & editing Acknowledgments: We would like to acknowledge Prof. Joseph Ngonzi, Prof. Dan Kaye, Dr. Mike N Kagawa, and Dr. Nanzira S Racheal for reviewing the initial draft and for positive criticism. References Borovac-Pinheiro A, Priyadarshani P, Burke TF. A review of postpartum hemorrhage in low-income countries and implications for strengthening health systems. Vol. 154, International Journal of Gynecology and Obstetrics. 2021. 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Available from: http://library.health.go.ug/sites/default/files/resources/National Health Facility Master List 2018_0.pdf WHO. Service Availability and Readiness Assessment (SARA): An annual monitoring system for service delivery - Reference Manual, Version 2.2. Heal Stat Inf Syst [Internet]. 2015;175. Available from: https://apps.who.int/iris/bitstream/handle/10665/149025/WHO_HIS_HSI_2014.5_eng.pdf of Health U. Essential {Maternal} and {Newborn} {Clinical} {Care} {Guidelines} for {Uganda}, {May} 2022 {\textbar} {Ministry} of {Health} {Knowledge} {Management} {Portal}. 2022;(March). Available from: http://library.health.go.ug/publications/sexual-and-reproductive-health/essential-maternal-and-newborn-clinical-care-1 Bingham D, Scheich B, Byfield R, Wilson B, Bateman BT. Postpartum Hemorrhage Preparedness Elements Vary Among Hospitals in New Jersey and Georgia. JOGNN - J Obstet Gynecol Neonatal Nurs. 2016;45(2). Namaganda G, Oketcho V, Maniple E, Viadro C. Making the transition to workload-based staffing: Using the Workload Indicators of Staffing Need method in Uganda. Hum Resour Health [Internet]. 2015;13(1):1–11. Available from: http://dx.doi.org/10.1186/s12960-015-0066-7 Henry J, Clarke-Deelder E, Han D, Miller N, Opondo K, Oguttu M, et al. Health care providers’ knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study. BMC Pregnancy Childbirth [Internet]. 2022;22(1):1–12. Available from: https://doi.org/10.1186/s12884-022-05128-6 Carnahan LR, Geller SE, Leshabari S, Sangu W, Hanselman B, Patil CL. Healthcare providers’ knowledge and practices associated with postpartum hemorrhage during facility delivery in Dar es Salaam, Tanzania. Int J Gynecol Obstet. 2016;135(3). Alobo G, Ochola E, Bayo P, Muhereza A, Nahurira V, Byamugisha J. Why women die after reaching the hospital: A qualitative critical incident analysis of the € third delay’ in postconflict northern Uganda. BMJ Open. 2021;11(3):1–11. Jayanna K, Mony P, Ramesh BM, Thomas A, Gaikwad A, Mohan HL, et al. Assessment of facility readiness and provider preparedness for dealing with postpartum haemorrhage and pre-eclampsia/eclampsia in public and private health facilities of northern Karnataka, India: A cross-sectional study. BMC Pregnancy Childbirth. 2014;14(1). Kogutt BK, Kim JM, Will SE, Sheffield JS. Development of an Obstetric Hemorrhage Response Intervention: The Postpartum Hemorrhage Cart and Medication Kit. Jt Comm J Qual Patient Saf. 2022;48(2). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 Aug, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers agreed at journal 26 Jul, 2025 Reviewers invited by journal 22 Jul, 2025 Editor assigned by journal 06 Jul, 2025 Submission checks completed at journal 06 Jul, 2025 First submitted to journal 05 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7053223","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489457292,"identity":"0c66d5ac-3276-4ef9-b7ce-5d0558b0ca0b","order_by":0,"name":"Abdullahi Teituk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYDACCQYDhgcFDAkMDIwNDAwHbIBCjI0HCGpJACIeoMoGhgNpIC0NxGoBWXPgMFgQrxb+2c3bJBIM7PLs2ZvbH/OcOW+3tv0w0JYam2icltw5VgbUklzMw3OwsZnnxu3kbWcSgVqOpeU24NJzI8cMqIU5sUciEajlw+1kswNALYwNh3FqkYdoqU/skX8I0nIu2ez8Q/xaDCBaDgNtYQQ57ICd2Q0CthjeOVZskWBwPLHnTGLjzDlnkhPMbgBtScDjF7nbzRtvfKioTmxvP/7gw5tjdvZm59MfPvhQY4Pb++ggEawygVjlIGBPiuJRMApGwSgYGQAAgpNr0XRe4hwAAAAASUVORK5CYII=","orcid":"","institution":"Mubende Regional Referral Hospital","correspondingAuthor":true,"prefix":"","firstName":"Abdullahi","middleName":"","lastName":"Teituk","suffix":""},{"id":489457294,"identity":"162ee653-7936-41e6-bb96-d2717e094b47","order_by":1,"name":"Sam Ononge","email":"","orcid":"","institution":"Jinja Regional Referral Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sam","middleName":"","lastName":"Ononge","suffix":""},{"id":489457295,"identity":"98c2979a-e33c-45a6-8c7a-cae696794c7f","order_by":2,"name":"Annette Keesiga","email":"","orcid":"","institution":"Kawempe National Referral Hospital","correspondingAuthor":false,"prefix":"","firstName":"Annette","middleName":"","lastName":"Keesiga","suffix":""},{"id":489457297,"identity":"53180ec8-c9a9-4821-b7f6-09da0ce97d0a","order_by":3,"name":"Felix Bongomin","email":"","orcid":"","institution":"Gulu University","correspondingAuthor":false,"prefix":"","firstName":"Felix","middleName":"","lastName":"Bongomin","suffix":""},{"id":489457299,"identity":"3ee77e61-1afd-4b47-b83a-3e6dd84b78a4","order_by":4,"name":"Othman Kakaire","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Othman","middleName":"","lastName":"Kakaire","suffix":""}],"badges":[],"createdAt":"2025-07-05 13:08:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7053223/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7053223/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87605095,"identity":"ad552cfc-6603-4f8a-8774-bd9fd84e9ace","added_by":"auto","created_at":"2025-07-25 18:01:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1115269,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7053223/v1/c69e5ec5-70b6-440e-84af-555281bbbb00.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Facility readiness and knowledge of health care workers to manage postpartum hemorrhage in public health facilities within Kampala metropolitan areas, Uganda","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, postpartum hemorrhage (PPH) is the leading cause of maternal deaths, and about 90% of the deaths occur in low-middle-income countries (1). PPH complicates about 10% of all deliveries in sub-Saharan Africa, however, it accounts for nearly half of PPH-related deaths globally (2). In Uganda, PPH accounts for about 34% of all institutional maternal deaths (3)(4).\u003c/p\u003e\u003cp\u003eFurthermore, in about 17% of PPH survivors, morbidities such as significant organ impairment for some women which have long-lasting negative consequences for children, families, and communities have been described (1). The risk factors for PPH include; previous history of PPH, multiple pregnancies, fetal macrosomia, primigravidity, grand multi-parity, older age, pre-term births, genital tract injuries, non-use of oxytocics for PPH prophylaxis, labour induction, cesarean birth, being HIV positive, and intrauterine fetal deaths (3).\u003c/p\u003e\u003cp\u003ePPH is an emergency where appropriate and timely management is crucial to prevent severe complications or death. With the increasing health facility deliveries in many low-resource settings, health facility readiness to enable appropriate management of PPH is crucial (2). The hemorrhage transition from the compensated to the decompensated stage is rapid and easily overlooked hence, prediction, early recognition, and intervention are critical to reduce the likelihood of or improve the clinical outcomes of severe PPH (5).\u003c/p\u003e\u003cp\u003e The World Health Organization (WHO) defines health facility readiness as the availability of trained health workers, guidelines, equipment, essential medicines and supplies (2). A health facility survey reported poor readiness to provide PPH care according to WHO standards and health workers perceived poor health facility readiness as contributing to poor quality of care when managing life-threatening complications, including PPH (2).\u003c/p\u003e\u003cp\u003eAccording to the district Health Information System 2 (DHIS2) 2020/21, Kampala metropolitan areas contributed the highest number of maternal deaths to the national figure, 17% (n\u0026thinsp;=\u0026thinsp;187), 44.7% (n\u0026thinsp;=\u0026thinsp;149) of which were caused by PPH (4). There was, however, little information on facility readiness and knowledge of health care workers to manage PPH in Uganda. This study sought to determine the level of facility readiness and knowledge of health care workers to manage PPH among public CEmONC facilities within Kampala metropolitan areas, Uganda.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design: This was a facility-based cross-sectional study that was conducted among public comprehensive emergency obstetrics and newborn care (CEmONC) health facilities within Kampala Metropolitan areas, Uganda.\u003c/p\u003e\u003cp\u003eStudy setting: The study was conducted in public CEmONC health facilities within the Kampala metropolitan area which has a day-time population of about 3.5\u0026nbsp;million and is comprised of four districts of Kampala's capital city, Wakiso, Mukono, and Mpigi districts. According to the national health facility master of 2021, the Kampala metropolitan area comprised a total of fourteen public health facilities that were classified as CEmONC. Five facilities in Kampala Capital City, six facilities in Wakiso, Two facilities in Mukono, and one facility in Mpigi district (6).\u003c/p\u003e\u003cp\u003eStudy Population: We included all the 14 public health facilities that were classified as CEmONC and recruited a total of 191 health care workers across 3 cadres of Obstetricians, Medical Officers, and Midwives. All participants were 18 years of age or older and provided written informed consent.\u003c/p\u003e\u003cp\u003eData Collection: We used an observational facility checklist adopted from the World Health Organization (WHO) service availability and readiness assessment (SARA) tool for PPH (7). Details captured using the checklist included the availability of critical human resources, a functional operating theatre, essential medicines and supplies (availability, storage, and stock management), equipment, updated guidelines/protocols related to screening and management of PPH, availability of PPH kit in the maternity units, sustainable blood transfusion services, functional refrigerator for cold chain, and functional ambulance services. Study cases were used to capture the level of knowledge of health workers to manage PPH, which was adopted from the national PPH management guidelines using the care bundle approach in the essential maternal and newborn care guidelines for Uganda 2022 edition. (8).\u003c/p\u003e\u003cp\u003eStudy Outcome Measures: The proportion of health facilities that were ready to manage PPH was computed as the number of health facilities that had a readiness score\u0026thinsp;\u0026ge;\u0026thinsp;90%. The frequency tables and chart were presented. The proportion of health workers with adequate knowledge of PPH management was computed as the number of participants that scored\u0026thinsp;\u0026ge;\u0026thinsp;75%.\u003c/p\u003e\u003cp\u003eData analysis: The data were analyzed in STATA version 17.0. Categorical variables were summarized as frequencies and percentages. Continuous variables were summarized using mean and standard deviation. The Fisher\u0026rsquo;s exact confidence interval for the proportion was computed. The mean knowledge scores were compared by health facility level, cadre of health care workers, service years, and recent in-service PPH-related training preceding data collection. For independent variables with 2 levels, an independent samples t-test was used to assess the mean differences after fulfilling the normality (assessed using Sharpilo-Wilk\u0026rsquo;s test) and equal variance (assessed using Levin\u0026rsquo;s test) assumption. For variables with more than two levels, Kruskal-Walli\u0026rsquo;s test was used to assess the differences in the knowledge scores since the variances of knowledge scores were different among the levels of the variables. The P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003eEthical considerations: Approval was obtained from the Makerere University School of Medicine research and ethics committee (SOMREC): \u003cb\u003eMak-SOMREC-2022-429.\u003c/b\u003e Written informed consent was obtained from each participant before their recruitment and participation in the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eCharacteristics of health workers: Overall, we enrolled 191 HCWs. Most participants were diploma midwives 42.4% (n\u0026thinsp;=\u0026thinsp;81), 26.2% (n\u0026thinsp;=\u0026thinsp;50) health care workers had recent in-service training related to PPH, 36.1% (n\u0026thinsp;=\u0026thinsp;69) worked at a level of a Health Center IV, and 91.6% (n\u0026thinsp;=\u0026thinsp;175) had been in service for more than two years, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the 191 healthcare workers in the public CEmONC facilities that participated in the study within greater Kampala\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;191)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCadre of HCWs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnrolled Midwife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiploma Midwife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e42.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDegree Midwife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical Officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eObstetrician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of employment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e91.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReceived recent in-service PPH training/CME\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e73.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel of CEmONC facility of practice\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Center IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeneral Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegional Referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNational Referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e41.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCharacteristics of Health Facilities: Of the 14 Public CEmONC health facilities surveyed, 42.9% (n\u0026thinsp;=\u0026thinsp;6) were in Wakiso district, 64.3% (n\u0026thinsp;=\u0026thinsp;9) were Health Center IVs, and 14.3% (n\u0026thinsp;=\u0026thinsp;2) were National Referral Hospitals, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of CEmONC health facilities that were assessed for readiness to manage PPH within greater Kampala\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequencies (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDistrict\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKampala\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMpigi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMukono\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWakiso\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel of CEmONC facility\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Center IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeneral Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegional Referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNational referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAvailability of indicators of readiness for PPH management.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOverall, 14.3% (n\u0026thinsp;=\u0026thinsp;2) facilities were found ready to manage a case of PPH.\u003c/p\u003e\u003cp\u003eHuman Resource: 7.1% (n\u0026thinsp;=\u0026thinsp;1) of the surveyed CEmONC facilities had 100% staffing positions for the critical health workers filled as per the staffing structure available at the time of the study. The average staffing level for critical health workers was at 50%, and the most understaffed cadres were anesthesia providers across all the facilities surveyed.\u003c/p\u003e\u003cp\u003ePhysical Infrastructure: All 14 CEmONC facilities surveyed had enabling physical infrastructure required for the management of PPH available with functional operating theatre (with evidence of at least an operation done within the last 3 months), delivery rooms, laboratory, and pharmacy. 28.6% (n\u0026thinsp;=\u0026thinsp;4) of the facilities could not functionalize their operating theatres 24/7.\u003c/p\u003e\u003cp\u003eEquipment: None of the health facilities had all the equipment required to adequately manage a case of PPH readily available and accessible 24/7. 28.6% (n\u0026thinsp;=\u0026thinsp;4) of the facilities had\u0026thinsp;\u0026ge;\u0026thinsp;80% of the required equipment. 7.1% (n\u0026thinsp;=\u0026thinsp;1) of health facilities had an anti-shock garment readily available in the labor ward. None of the health facilities had a complete and functional PPH emergency kit/box. 78.6% (n\u0026thinsp;=\u0026thinsp;11) of the facilities had an available but incomplete PPH emergency kit/box. 78.6% (n\u0026thinsp;=\u0026thinsp;11) of the facilities had a functional refrigerator for storage of oxytocin in the labor ward, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAvailability of some essential equipment required for the management of PPH in the public CEmONC health facilities within greater Kampala\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEquipment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailability\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of Facilities N\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnti-Shock garment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailable and functional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailable and dysfunctional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot Available\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e82.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePPH emergency kit/box\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailable and complete\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailable but incomplete\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot Available\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerineal/cervical tear examination/suture pack.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71,4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot available\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCold chain refrigerator\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailable and functional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailable and dysfunctional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot Available\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMedicines and supplies: Of the 14 facilities, 21.4% (n\u0026thinsp;=\u0026thinsp;3) had all the essential drugs for managing PPH. Almost all health facilities 92.9% (n\u0026thinsp;=\u0026thinsp;13) reported stock-outs of essential drugs and supplies required for PPH management for more than 15 days in the two months preceding data collection. Tranexamic acid was available in 21.4% (n\u0026thinsp;=\u0026thinsp;3) facilities, with 33.3% (n\u0026thinsp;=\u0026thinsp;1/3) facilities reporting no recent stock-outs of tranexamic acid. Oxytocin was out of stock in 3 (21.4%) facilities while Misoprostol in 1 (14.3%) facility, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStockouts of some essential drugs in the management of PPH for more than 15 days in the past 2 months among the public CEmONC health facilities within greater Kampala.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrug\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStock out more than 15 days in the last 2 months\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of Health Facilities N\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOxytocin\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMisoprostol\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14..3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTranexamic acid\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCrystalloids\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCatheters\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCannulas\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGloves\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Updated guidelines and protocols for PPH management: Of the 14 facilities, 35.7% (n\u0026thinsp;=\u0026thinsp;5) had updated PPH management guidelines/protocols available and visible on the labor ward walls, 35.7% (n\u0026thinsp;=\u0026thinsp;5) had non-updated guidelines/protocols, 35.7% (n\u0026thinsp;=\u0026thinsp;4) facilities had no guidelines/protocols.\u003c/p\u003e\u003cp\u003eAuxiliary services: All health facilities surveyed had a functional backup generator/inverter and had access to clean piped water. 35.7% (n\u0026thinsp;=\u0026thinsp;5) had no functional ambulance. 7.1% (n\u0026thinsp;=\u0026thinsp;1) of the facilities lacked a functional blood storage refrigerator. 50% (n\u0026thinsp;=\u0026thinsp;7) of the facilities had no access to blood products 24/7 in case of an emergency, while all facilities reported recent stockouts of blood products.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe level of knowledge of PPH management among health care workers.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe proportion of health care workers with adequate knowledge of PPH management in the surveyed CEmONC facilities was found to be low at 26.3% (95% CI; 20.2\u0026ndash;33.2). The overall mean (SD) knowledge score was 65.4% (13.0) (95% CI; 63.5\u0026ndash;67.2).\u003c/p\u003e\u003cp\u003eThe mean knowledge score was significantly different among the health care worker cadres (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean knowledge score of obstetricians was significantly higher at 81.2% (95% CI; 78.2\u0026ndash;84.3) than all other cadres of health care workers. The mean knowledge score for medical officers was significantly higher at 70.8% (95% CI; 66.8\u0026ndash;74.8) than that of certificate and diploma midwives. The mean knowledge scores for Medical Officers was at 70.8% (95% CI; 66.8, 74.8) and that of degree midwives at 61.1% (95% CI; 61.1\u0026ndash;71.1) were not statistically significant, Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of mean knowledge scores of PPH management among 191 health workers working in public CEmONC health facilities within greater Kampala.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean knowledge score (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealth facility level one Practiced\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Center IV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64.6 (11.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.373\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistrict hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67.6 (9.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegional referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70.4 (8.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNational referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64.5 (15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCadre\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eObstetrician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81.2 (7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedical officer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70.8 (8.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDegree midwife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66.1 (9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnrolled Midwife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60.1 (10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegistered Midwife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.9 (13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of employment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLess than 2 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.5 (12.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.554\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 years and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e65.5 (13.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRecent in-service PPH training.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73.4 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.6 (12.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAll obstetricians were able to correctly define/identify PPH, while 77.8% (n\u0026thinsp;=\u0026thinsp;42) of the certificate midwives were able to correctly define/identify PPH. About three-quarters of obstetricians were able to administer tranexamic acid as an initial intervention in the management of PPH compared to only 21.0% (n\u0026thinsp;=\u0026thinsp;17) of diploma midwives. Close to three-quarters of obstetricians were able to consider carboprost administration as an intervention in the management of PPH as opposed to 5.6% (n\u0026thinsp;=\u0026thinsp;3) of the certificate midwives. Obstetricians were generally able to perform more lifesaving interventions, especially for uterine atony before transferring a patient to the operating theatre or whenever the operating theatre was not ready compared to all other cadres, Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePerformance on knowledge areas about PPH recognition and management by health workers of public CEmONC health facilities within greater Kampala\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge area\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eObstetrician\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eMedical officer n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eDegree Midwife\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eDiploma midwife\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003eCertificate midwife\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eA correct definition of PPH (identify PPH)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (94.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12 (85.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e65 (80.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e16 (19.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e42 (77.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e12 (22.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdminister Tranexamic acid\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (70.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (27.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (72.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5 (35.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9 (64.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e17 (21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e64 (79.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e14 (25.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e40 (74.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAdminister carboprost\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (62.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (11.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16 (88.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6 (42.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8 (57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e19 (23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e62 (76.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e3 (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e51 (94.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInterventions for refractory PPH Before Theatre\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eContinue oxytocin infusion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (79.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (20.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (82.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10 (71.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4 (28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e63 (77.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e18 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e47 (87.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e7 (13.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBi-manual\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ecompression of uterus\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (91.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (58.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (41.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10 (58.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4 (28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e53 (65.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e28 (34.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e23 (42.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e31 (57.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUterine balloon tamponade\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (52.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (47.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6 (42.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8 (57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e25 (30.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e56 (69.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e15 (27.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e39 (72.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnti-shock garment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (70.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12 (85.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e11 (13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e70 (86.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e7 (13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e47 (87.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBlood transfusion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (82.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10 (71.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4 (28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e54 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e27 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e27 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e27 (50.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we surveyed all the public health facilities categorized as CEmONC centers within the Kampala metropolitan, Uganda to determine the level of facility readiness and knowledge of health care workers to manage postpartum hemorrhage which is the number one cause of maternal mortality in Uganda. Kampala metropolitan area contains some of the highest volume maternity centers in the country contributing a significant percentage to the national maternal and newborn indicators. This was the first ever survey conducted among public health facilities for postpartum hemorrhage. The facility observational checklist revealed gaps in the staffing levels, key equipment, medicines and supplies, guidelines and protocols, blood transfusion services and ambulance services.\u003c/p\u003e\u003cp\u003eThe study findings revealed 14.3% (n\u0026thinsp;=\u0026thinsp;2) of the surveyed facilities had the desired capacity to readily manage a case of PPH. A similar study conducted in New Jersey and Georgia showed that 50.5% of the Hospitals had adequate readiness to manage PPH (9). The differences in readiness are possibly due to disparities in the levels of socio-economic development of the two study settings and the fact that our study used an observational checklist could have been more objective compared to the use of key informant interview. There was no local and regional published data for comparison.\u003c/p\u003e\u003cp\u003eThe study findings revealed a significant degree of understaffing for the most critical health workers required in PPH management with 7.1% (n\u0026thinsp;=\u0026thinsp;1) facilities had 100% staffing levels as per the available staffing structure. These findings are consistent with most studies that have revealed poor health staffing levels among Hospitals in sub-Saharan Countries. A study in Uganda to assess health staffing levels showed shortages of health workers across all level health facilities, with only 42\u0026ndash;70% of required nurses and 53\u0026ndash;67% of needed midwives, while higher level facilities (Health centre IV and General hospital) had significantly fewer doctors (39\u0026ndash;42%) than needed (10). This has got a great impact on the 3rd delay in accessing emergency obstetric care for mothers with PPH. It should be noted that anesthesia providers play a pivotal role in operationalizing theatre in management of refractory PPH, yet they were found to be the most understaffed cadres across the public CEmONC facilities that were studied.\u003c/p\u003e\u003cp\u003eAll the surveyed facilities had an enabling infrastructure, 28.6% (n\u0026thinsp;=\u0026thinsp;4) facilities had operating theatres that could not function 24/7 and these were majorly health centre IVs. This was attributed to the understaffing of anesthesia providers and medical officers, and the frequent stock outs of essential drugs and supplies. The likely implication of this finding is an increase in the number of referrals of PPH cases that would need to be transferred to the operating theatre from lower CEmONC facilities to higher CEmONC facilities yet a referred PPH case is more likely to die than that managed at the incident facility due to referral challenges.\u003c/p\u003e\u003cp\u003e In this study, 35.7% (n\u0026thinsp;=\u0026thinsp;5) of facilities had updated PPH management guidelines/protocols available and visible on the labor ward walls. These findings provide an opportunity to improve the availability and visibility of the updated PPH guidelines to enhance care in the form of quick reference since studies done in Kenya and Tanzania revealed a knowledge gap among health workers in PPH management (11)(12).\u003c/p\u003e\u003cp\u003eThe survey revealed gaps in ambulance and blood products with 35.7% (n\u0026thinsp;=\u0026thinsp;5) without a functional ambulance and these were mainly lower CEmONC facilities (Health centre IVs) and half of the facilities (n\u0026thinsp;=\u0026thinsp;7) had no access to blood products 24/7 while all surveyed facilities reported to have had recent blood stockouts. The absence of a functional ambulance at some lower CEmONC health facilities can greatly impact on the second delay in seeking further skilled care at the higher CEmONC health facilities since most lacked obstetricians in the staffing structure. Also, the fact that all study facilities had reported stockout of blood products within 3 months preceding the data collection, greatly affects PPH management since often mothers require blood transfusion during PPH management. The findings were consistent with those from a study done in northern Uganda that identified lack of blood and functionality and delays in the interfacility referral system as the biggest contributors to third delays to emergency obstetric and newborn care (EmONC) services in hospitals (13).\u003c/p\u003e\u003cp\u003eThis survey revealed chronic stockouts with one facility that had 100% of all the required medicines and supplies for PPH management available at the time of the study. This could be because the same facility despite being public, had user fees where patients paid slightly subsidized fees for the services offered unlike the other thirteen facilities surveyed which were totally on a public basis. These findings were consistent with those from a study done in northern Uganda that identified a shortage of medicines and supplies among others as the biggest contributor to 3rd delays to EmONC services in hospitals (13).\u003c/p\u003e\u003cp\u003eDespite the WHO 2017 recommendations on the use of tranexamic acid in PPH management, it was found to be available in 21.4% (n\u0026thinsp;=\u0026thinsp;3) of health facilities. Oxytocin and misoprostol were found to be the least stocked-out drugs at 21.4% (n\u0026thinsp;=\u0026thinsp;3) for oxytocin and 14.3% (n\u0026thinsp;=\u0026thinsp;1) for misoprostol. A study in India to assess readiness and preparedness for PPH management found oxytocin and misoprostol to be available in only 50% of the health facilities (14).\u003c/p\u003e\u003cp\u003eOne facility had an anti-shock garment available in the labor ward and operating theatre possibly because this facility had been part of a study for this gadget that remained behind after the study. The survey also revealed that none of the health facilities had a complete PPH emergency kit available in the labor wards. 78.6% (n\u0026thinsp;=\u0026thinsp;11) had an incomplete PPH emergency kit. A plausible explanation for the incompleteness of the PPH emergency kits found in the eleven CEmONC facilities was that the items constantly got used up in the management of PPH and other obstetric emergencies due to chronic stockouts of drugs and supplies and the used items were often not replaced. These findings negatively impact readiness for timely interventions for PPH management. Evidence from a study in the United Kingdom using simulations showed a 79.8% reduction in the time required and an 88.7% reduction in the distance covered to pick items required during a PPH emergency if items are kept in emergency box/kit (15).\u003c/p\u003e\u003cp\u003eThe study findings revealed that the level of adequate knowledge of PPH management among health workers in the public CEmONC facilities was low at 26.3% (95% CI; 20.2, 33.2) with the overall mean (SD) knowledge score to be 65.4 (13.0) with a 95% CI (63.5, 67.2). This means that on average, healthcare workers who scored 75% and above on the knowledge assessment elements for PPH ranged between 20.2%-33.2% of the total number (191) interviewed and about 3 in every 4 health workers had inadequate knowledge to manage PHH. The average knowledge score ranged between 63.5%-67.2%. Two similar studies done in Kenya and Tanzania also revealed inadequate levels of knowledge of PPH management among health workers with providers scoring an average of 0.71 (95% CI: 0.69\u0026ndash;0.72) across all questions (11) and 63.9% \u0026plusmn; 21.1% (12) respectively. A plausible explanation for this is the relatedness of the study setting and similarity of study participants and the socioeconomic development of the Countries.\u003c/p\u003e\u003cp\u003eHealth workers who reported to have had recent in-service training on PPH management and those higher in cadre were more knowledgeable compared to those who had no recent in-service training on PPH management and the lower cadre staff with P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001. These findings conform to the already existing evidence of an increase in knowledge with higher levels of education and the justification to have regular training in PPH to keep the healthcare workers updated on PPH management. On the contrary, the study findings revealed that the level of knowledge of PPH management among health workers was not affected by the number of years in service or by the level of CEmONC facility one practiced with P values 0.554 and 0.373 respectively. These findings were consistent with a similar study in Kenya that found that experience in years was not associated with higher scores and had a coefficient of 0.00 (95% CI: 0.00-0.08) and specialists had higher knowledge scores compared to other health providers (11).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStrengths and limitations of the study\u003c/strong\u003e\u003cp\u003eThis study did not assess the skill and attitude of the health workers on PPH management due to limited time and resources. PPH simulation drills coupled with direct observations of practice and skills would have been a better competence assessment of health workers but our study was limited by resources and time.\u003c/p\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study findings showed that most of the public facilities 85.7% (n\u0026thinsp;=\u0026thinsp;12) surveyed lacked the desired capacity to manage a PPH case, coupled with low PPH knowledge among health care workers. In-service training was found to improve the level of knowledge among health care workers. We believe that the survey findings could be worse in the more rural public health facilities yet they constitute the majority of health care providers. There is a clear need to address the gaps in human resources, medicines and supplies, equipment, blood, and blood products. Updated PPH management guidelines/protocols and items for the emergency box/kit need to be availed. Provider competence in PPH management needs to be improved through regular in-service mentorships and training to promote timely and appropriate interventions leading to a reduction in maternal mortality and morbidity from PPH.\u003c/p\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACOG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American College of Obstetricians and Gynecologists\u003c/p\u003e\n\u003cp\u003eCEmONC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Comprehensive Emergency Obstetric and Newborn Care\u003c/p\u003e\n\u003cp\u003eCS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cesarean Section\u003c/p\u003e\n\u003cp\u003eDHIS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;District Health Information System\u003c/p\u003e\n\u003cp\u003eDHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;District Health Officer\u003c/p\u003e\n\u003cp\u003eGCP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Good Clinical Practice\u003c/p\u003e\n\u003cp\u003eHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health Centre\u003c/p\u003e\n\u003cp\u003eHCWs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Healthcare Workers\u003c/p\u003e\n\u003cp\u003eIRB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Institutional Review Board\u003c/p\u003e\n\u003cp\u003eKCCA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Kampala Capital City Authority\u003c/p\u003e\n\u003cp\u003eLMICs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Low and Middle-Income Countries (LMICs)\u003c/p\u003e\n\u003cp\u003eMMR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Maternal Mortality Ratio\u003c/p\u003e\n\u003cp\u003eMOH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ministry of Health\u003c/p\u003e\n\u003cp\u003eNASG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Nonpneumatic anti-shock garment\u003c/p\u003e\n\u003cp\u003eNMS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;National Medical Stores\u003c/p\u003e\n\u003cp\u003ePI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Principal Investigator\u003c/p\u003e\n\u003cp\u003ePPH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Postpartum Hemorrhage\u003c/p\u003e\n\u003cp\u003eSOMREC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;School of Medicine Research and Ethics Committee\u003c/p\u003e\n\u003cp\u003eSPPH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;severe postpartum hemorrhage\u003c/p\u003e\n\u003cp\u003eSTROBE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Strengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e\n\u003cp\u003eUBOS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Uganda Bureau of Statistics\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e\n\u003cp\u003eGDP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Gross domestic product\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:Permission to conduct this study was sought from the department of obstetrics and gynecology, Makerere University and the management of the 14 health facilities studied. Ethical approval was obtained from School of Medicine research and ethics committee (SOMREC) of Makerere University (\u003cstrong\u003eMak-SOMREC-2022-429)\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eAll participants were informed of the intentions of the research and only those who accepted to sign informed consent forms were involved and given the liberty to withdraw from the study as and when they wished to. Health workers’ anonymity was guaranteed on the questionnaires to ensure confidentiality by using study numbers instead of names\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eThe study tools were kept under lock and key only accessible to the research team to ensure that there was no breach of confidentiality.\u003c/p\u003e\n\u003cp\u003eConsent for publication:Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:The datasets used and/or analyzed during the study are available from the corresponding author on official request.\u003c/p\u003e\n\u003cp\u003eCompeting interests:The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:The funding for the study was provided by the first author\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors' contributions:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAT\u003c/strong\u003e: Conceptualization, formal analysis, investigation, Methodology, Project administration, resources, validation, visualization, writing – original draft, writing – review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSO\u003c/strong\u003e: Conceptualization, validation, supervision, review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAK\u003c/strong\u003e: \u0026nbsp;Conceptualization, supervision, validation, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFB\u003c/strong\u003e: Manuscript writing, review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOK\u003c/strong\u003e: \u0026nbsp;Conceptualization, validation, writing – review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe would like to acknowledge Prof. Joseph Ngonzi, Prof. Dan Kaye, Dr. Mike N Kagawa, and Dr. Nanzira S Racheal for reviewing the initial draft and for positive criticism.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBorovac-Pinheiro A, Priyadarshani P, Burke TF. A review of postpartum hemorrhage in low-income countries and implications for strengthening health systems. Vol. 154, International Journal of Gynecology and Obstetrics. 2021.\u003c/li\u003e\n\u003cli\u003eAlwy Al-beity F, Pembe AB, Kwezi HA, Massawe SN, Hanson C, Baker U. “We do what we can do to save a woman” health workers’ perceptions of health facility readiness for management of postpartum haemorrhage. Glob Health Action [Internet]. 2020;13(1). Available from: https://doi.org/10.1080/16549716.2019.1707403\u003c/li\u003e\n\u003cli\u003eOnonge S, Mirembe F, Wandabwa J, Campbell OMR. Incidence and risk factors for postpartum hemorrhage in Uganda. Reprod Health. 2016;13(1).\u003c/li\u003e\n\u003cli\u003eMinistry of Health U. The National FY 2020 / 2021Annual Maternal and Perinatal Death Surveillance and Response ( MPDSR ) Report September 2021. 2021;(September).\u003c/li\u003e\n\u003cli\u003eLiu C ning, Yu F bing, Xu Y zhe, Li J sheng, Guan Z hong, Sun M na, et al. Prevalence and risk factors of severe postpartum hemorrhage: a retrospective cohort study. BMC Pregnancy Childbirth. 2021;21(1).\u003c/li\u003e\n\u003cli\u003eMinistryof Health Uganda. National Health Facility Master List 2018. Minist Heal Uganda [Internet]. 2018;(November):1–164. Available from: http://library.health.go.ug/sites/default/files/resources/National Health Facility Master List 2018_0.pdf\u003c/li\u003e\n\u003cli\u003eWHO. Service Availability and Readiness Assessment (SARA): An annual monitoring system for service delivery - Reference Manual, Version 2.2. Heal Stat Inf Syst [Internet]. 2015;175. Available from: https://apps.who.int/iris/bitstream/handle/10665/149025/WHO_HIS_HSI_2014.5_eng.pdf\u003c/li\u003e\n\u003cli\u003eof Health U. Essential {Maternal} and {Newborn} {Clinical} {Care} {Guidelines} for {Uganda}, {May} 2022 {\\textbar} {Ministry} of {Health} {Knowledge} {Management} {Portal}. 2022;(March). Available from: http://library.health.go.ug/publications/sexual-and-reproductive-health/essential-maternal-and-newborn-clinical-care-1\u003c/li\u003e\n\u003cli\u003eBingham D, Scheich B, Byfield R, Wilson B, Bateman BT. Postpartum Hemorrhage Preparedness Elements Vary Among Hospitals in New Jersey and Georgia. JOGNN - J Obstet Gynecol Neonatal Nurs. 2016;45(2).\u003c/li\u003e\n\u003cli\u003eNamaganda G, Oketcho V, Maniple E, Viadro C. Making the transition to workload-based staffing: Using the Workload Indicators of Staffing Need method in Uganda. Hum Resour Health [Internet]. 2015;13(1):1–11. Available from: http://dx.doi.org/10.1186/s12960-015-0066-7\u003c/li\u003e\n\u003cli\u003eHenry J, Clarke-Deelder E, Han D, Miller N, Opondo K, Oguttu M, et al. Health care providers’ knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study. BMC Pregnancy Childbirth [Internet]. 2022;22(1):1–12. Available from: https://doi.org/10.1186/s12884-022-05128-6\u003c/li\u003e\n\u003cli\u003eCarnahan LR, Geller SE, Leshabari S, Sangu W, Hanselman B, Patil CL. Healthcare providers’ knowledge and practices associated with postpartum hemorrhage during facility delivery in Dar es Salaam, Tanzania. Int J Gynecol Obstet. 2016;135(3).\u003c/li\u003e\n\u003cli\u003eAlobo G, Ochola E, Bayo P, Muhereza A, Nahurira V, Byamugisha J. Why women die after reaching the hospital: A qualitative critical incident analysis of the € third delay’ in postconflict northern Uganda. BMJ Open. 2021;11(3):1–11.\u003c/li\u003e\n\u003cli\u003eJayanna K, Mony P, Ramesh BM, Thomas A, Gaikwad A, Mohan HL, et al. Assessment of facility readiness and provider preparedness for dealing with postpartum haemorrhage and pre-eclampsia/eclampsia in public and private health facilities of northern Karnataka, India: A cross-sectional study. BMC Pregnancy Childbirth. 2014;14(1).\u003c/li\u003e\n\u003cli\u003eKogutt BK, Kim JM, Will SE, Sheffield JS. Development of an Obstetric Hemorrhage Response Intervention: The Postpartum Hemorrhage Cart and Medication Kit. Jt Comm J Qual Patient Saf. 2022;48(2).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"reproductive-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"reph","sideBox":"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)","snPcode":"12978","submissionUrl":"https://submission.nature.com/new-submission/12978/3","title":"Reproductive Health","twitterHandle":"@Reprod_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Facility readiness, knowledge of health workers, Postpartum hemorrhage, Kampala metropolitan areas","lastPublishedDoi":"10.21203/rs.3.rs-7053223/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7053223/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePostpartum hemorrhage (PPH) accounts for about one-third of all institutional maternal deaths in Uganda. Evidence has shown improved maternal outcomes with better readiness and preparedness for PPH management. We determined the level of readiness of health facilities and knowledge of health care workers (HCWs) to manage PPH among public facilities in Kampala metropolitan areas, Uganda.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a cross-sectional study among comprehensive emergency obstetric and newborn care (CEmONC) public health facilities within the Kampala metropolitan areas (Kampala, Wakiso, Mukono, and Mpigi districts). Data was collected using a structured questionnaire and a facility observational checklist to assess the availability of indicators of readiness for PPH management. Adequate knowledge was defined as a score of \u0026ge;\u0026thinsp;75%, and a facility was considered ready to manage PPH if it had a composite score of \u0026ge;\u0026thinsp;90%.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e We included 191 HCWs from 14 CEmONC centres and Diploma Midwives constituted most study participants 42% (n\u0026thinsp;=\u0026thinsp;81). Less than a third of health workers had received any recent in-service PPH training. Overall, 50 (26.3%, 95% CI; 20.2 \u0026mdash; 33.2) HCWs had adequate knowledge of PPH management. The mean knowledge score was 65.4%, significantly different among cadres of HCWs (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and those with recent training (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Overall, 2 health facilities (14.3%) were ready to manage PPH.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe study showed that most public health facilities surveyed lacked the desired capacity to manage a PPH case with 14.3% (n\u0026thinsp;=\u0026thinsp;2) found ready, coupled with low PPH knowledge among health workers. In-service training was found to improve the level of knowledge among health care workers. We recommend that stakeholders address the gaps in human resources, medicines and supplies, equipment, and health care worker competence in PPH management to promote a reduction in maternal mortality and morbidity from PPH.\u003c/p\u003e","manuscriptTitle":"Facility readiness and knowledge of health care workers to manage postpartum hemorrhage in public health facilities within Kampala metropolitan areas, Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-25 17:52:57","doi":"10.21203/rs.3.rs-7053223/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-08-07T07:16:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324428606791817803948104860190259911960","date":"2025-07-30T06:35:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133069707125490514238262400489116619898","date":"2025-07-26T05:51:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-23T02:30:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-06T23:43:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-06T23:43:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Reproductive Health","date":"2025-07-05T12:53:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"reproductive-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"reph","sideBox":"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)","snPcode":"12978","submissionUrl":"https://submission.nature.com/new-submission/12978/3","title":"Reproductive Health","twitterHandle":"@Reprod_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c97f447c-3286-4e1e-8bbc-4c33807d9c35","owner":[],"postedDate":"July 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-25T17:52:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-25 17:52:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7053223","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7053223","identity":"rs-7053223","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}