Assessing the Impact of Medical Interns on Healthcare Delivery at Kawempe National Referral Hospital. A cross-sectional study

Assessing the Impact of Medical Interns on Healthcare Delivery at Kawempe National Referral Hospital. A cross-sectional study | 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 Assessing the Impact of Medical Interns on Healthcare Delivery at Kawempe National Referral Hospital. A cross-sectional study Joel Lwasa Calls Njagala, Mabel Nekesa Mirembe, Henry Ssenyondo, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7922459/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background. According to the World Health Organization (WHO), quality of care is how health services in a given population yield desirable outcomes and align with evidence-based professional knowledge. This study aimed to assess the impact of medical interns on healthcare delivery at Kawempe National Referral Hospital. Methods: This was a cross-sectional study with three time points at Kawempe National Referral Hospital (KNRH), a national referral hospital for obstetrics and gynaecology. All patient records for the two time periods were reviewed, and the data were exported for statistical analysis. Results. Admissions in the hospital registered a slight decline of 0.35%, whereas the hospital register registered a decline in emergency procedures performed by 7.31%. There was an increase in the performance of elective procedures such as TAH (23.8 to 51.5%), vasectomy (1 to 99%), and elective c-section (24.1 to 35.8%). There was a decrease in maternal deaths during the period with no interns, and the number increased after return (27.4% to 24.1% to 48.5%). There was an increase in referrals (35 to 37.7%). Delivery outcomes included a significant decrease in FSB (42.2% to 29.5%), MSB (45.3% to 33.7%), and LNND (38.6% to 25.9%). Delivery outcomes included a significant decrease in FSB (42.2% to 29.5%), MSB (45.3% to 33.7%), and LNND (38.6% to 25.9%), and a decrease in vacuum deliveries (52.1 to 14.5%). Conclusion. The presence or absence of medical interns affected the hospital metrics during the study periods at Kawempe National Referral Hospital. The presence or absence of medical interns affected patient outcomes at Kawempe National Referral Hospital. Recommendation The Ministry of Health, the National Internship Committee, and the Ministry of Finance should develop policies that ensure the uninterrupted deployment of medical interns in public facilities. Medical interns Healthcare delivery Internship program Kawempe National Referral Hospital Figures Figure 1 Figure 2 Background According to the World Health Organization (WHO), quality of care is how health services in a given population yield desirable outcomes and align with evidence-based professional knowledge. Quality health services should be effective, safe, timely, equitable, efficient, integrated, and people-centred (Busse, Panteli, & Quentin, 2019). High-quality systems are estimated to reduce maternal deaths by half and newborn deaths by one million per year. (WHO, 2020)Service delivery is a portion of health systems where patients receive the care and materials to which they are legally entitled. Five processes have been identified to be involved in health care: primary prevention, health seeking, diagnosis, treatment, and end-of-life care. Primary prevention involves all processes to avoid the occurrence of morbidity. This starts in communities and extends to hospital settings and may involve, but is not limited to, immunization, physical activity, the use of malaria prevention bed nets, a healthy diet, access to clean water, and reduced tobacco use.(Kisling & Das, 2022 ) Detecting health problems involves promoting health-seeking, so the healthcare system must be proactive in its outreach. This is because assisting people in the healthcare system can be challenging if they choose not to speak up. This process is necessary to start the next stage of health care. Erroneous diagnosis is among the least economical options. Early diagnosis is crucial for many disease courses. The information and techniques for this process provided by the healthcare system include investigations, examinations, and history taking. Medical interns play a major role in this process in Ugandan hospitals. Treatment and good end-of-life care are the final processes involved in healthcare. (Bergman, Neuhauser, & Provost, 2011). Medical interns are bachelor's degree graduates of medicine and surgery, nursing, midwifery, dentistry, and pharmacy. They are expected to obtain clinical practice, communication, management, and health system management skills by working under supervision for one year before processing registration and licensure in their professional bodies. Medical interns in Uganda were not deployed for four months from the 1st of April 2023 to the 3rd of August 2023 for the first time in decades, and the MOH disrupted the medical internship cycle for four months due to a lack of funds to facilitate their allowances (Daily Monitor, 11th April, UMA, 2023). Whereas undergraduate students under MESAU have been proven to improve primary health care programs in the community (Atuyambe et al., 2016 ), the impact of medical interns on direct patient care has not been studied. Kawempe National Referral Hospital (KNRH) records a daily admission of approximately 123 and a high delivery rate averaging 60 births daily. Therefore, it relies strongly on the labour provided by medical interns, residents, medical officers of special grade (specialist obstetricians and gynaecologists, paediatricians, anaesthesiologists, radiologists, pathologists), medical officers, and nurses. Providing respectful maternity and neonatal care depends on teamwork among these professionals. The MOH does not spell out the actual roles of medical interns; however, they are expected to execute all duties as directed by their immediate supervisors. A study in the United Kingdom revealed that junior doctors (similar to intern doctors) are expected to play multiple roles, including supporting roles such as admission, discharging patients, and practising independently by providing direct patient care through diagnosis, investigations, and treatment of conditions under the supervision of senior staff and learning new skills. They recommended that organisations support graduate health workers transitioning from student to real-world work. (Vance, Jandial, Scott, & Burford, 2019 ). A study also revealed that junior residents under direct supervision did not affect surgical outcomes, hospital costs, or patient satisfaction. The operation time increased; however, patient hospital stays were shortened. (Sibia, Turcotte, Klune, & Feather, 2020). Junior doctors were also more likely to introduce or embrace new ideas and appreciate technology integration into health systems, improving the quality of health services offered. (Ibrahim, Jeffcott, Davis, & Chadwick, 2013 ). Medical interns play major roles, such as triaging patients, index clerkships, resuscitation, ordering for and obtaining investigation results, timely consultation of residents and specialists of critical patients, participation in surgery, daily review and discharge of patients, administration of drugs, and other roles, as requested by supervisors. While they are first-line in patient management and are learning through apprenticeship, they are an invaluable cadre in patient care in Uganda’s health sector. They are thought to improve service delivery significantly. While stakeholders have negotiated to ensure the continuity of internships, the relevance of medical interns in Uganda’s health sector has been questioned. This study aimed to assess the impact of medical interns on healthcare delivery at Kawempe National Referral Hospital. Methodology Study Design This was a cross-sectional study that compared data from 3 time periods via a quantitative approach with no influence on the variables under study. Study Site KNRH is located in Kawempe Division, approximately 8 kilometres north of the central business district, and serves as a teaching hospital and national referral centre. It provides specialist care in obstetrics, gynecology, and pediatrics. It has a daily bed capacity of approximately 200 individuals, with a bed occupancy of 112% and actively manages an average of 80 women in the labour ward with 65 deliveries. On average, 80 infants/children are managed at the acute care unit, while 90 infants are admitted to the special care unit daily. The hospital's multidisciplinary healthcare team includes 30 obstetricians and gynecologists, 10 pediatricians, 2 anaesthesia and critical care specialists, 6 anaesthetic officers, 80 residents, 100 nurses/midwives, 5 pharmacists, and 120 medical interns, all of whom contribute to the care and treatment of patients. The hospital has outpatient, inpatient and intensive care points for paediatrics, obstetrics and gynecology. Records to be reviewed. The study included monthly medical records for health care sought at Kawempe National Referral Hospital during three distinct periods. The study months were conveniently determined as the initial 4-month span preceding the absence of medical interns (December 2022–March 2023) and the subsequent 4-month interval coinciding with the absence of medical interns (April 2023–July 2023) in comparison with the presence of interns in the period of April 2022–July 2022. Sample size and sampling procedure. Secondary data from hospital records were used. No sampling methods were employed during the study, as all hospital records from the four months preceding the medical interns' absence, the four months during their absence, and the four comparable months of their placement in 2022 (April to July) were used in the study. Study variables Independent variables: The presence or absence of medical interns Dependent Variables The dependent variables included numerical counts of the following Outpatient visits Acute care unit Gynecology emergency Gynaecology Oncology Clinic Laboursuite Antenatal clinic Reproductive gynecology clinic Urogynecology Clinic Family planning clinic Admissions NICU ACU Labor suit Gynaecological emergencies HDU ICU Emergency procedures. Emergency caesarean sections. Exploratory Laparotomy Manual vacuum aspiration Suction curettage Vaginal delivery Instrumental delivery Repair of 3 rd− and 4th -degree perineal tears Repair of cervical tears Elective procedures. Elective cesarean section Cervical cerclage Myomectomy Ovarian cystectomy Total abdominal hysterectomy Perineorrhaphy Patient outcomes Patient discharge Maternal deaths Refers Runaway Delivery outcomes Fresh stillborns (FSB) Macerated stillbirths (MSBs) Live births Early neonatal death (ENND) Late neonatal death (LNND). Study procedures and data collection A data collection tool was designed to capture all the study-dependent variables and was piloted to ensure its appropriateness to the variables. Quantitative data for assessing patient care metrics, such as hospital admissions, number of outpatients, emergency and elective procedures, and patient and delivery outcomes, were extracted from hospital databases and monthly summaries via the developed tool. The monthly summaries were double-checked with the source tools at the corresponding departments to ensure correctness. Standardized data extraction forms ensure uniformity in data collection across the entire sample. Data management. The medical records were entered into Microsoft Excel, reviewed to ensure accuracy, completeness, and correctness, and then exported into Stata 14, a statistical data package for data analysis. Data collected via the standardized extraction form were reviewed daily by an RA on a password-protected computer to ensure accuracy, completeness, and correctness. Data Analysis. Stata 14 was used to analyse the data; descriptive data are presented as proportions. Poisson regression was used to infer associations, and p-values less than 0.05 were considered statistically significant. Quality Assurance and Control. The data collection tool was piloted to determine its Cronbach's alpha score for standardization. A set of standardized operating procedures (SOPs) was established. These SOPs guided the framework for systematically executing data collection, entry, and analysis. Research staff were provided training sessions and calibration exercises to mitigate potential variations in data collection practices. Data cleaning and validation procedures were implemented, involving a cross-referencing process against source documents to rectify discrepancies. Regular monitoring and internal audits were conducted. Results Description of the results from the three different periods: the period preceding the interns’ absence, the absence of interns, and the return of interns. Outpatient attendance at the different departments in the hospital during the different periods varied, with Uroclinic having the biggest decline from 58.3% to 9.4% while ACU had an increase in the numbers by 3.5%. The oncology clinic remained with almost the same number of patients throughout the periods. (Table 1 ). Table 1 Outpatient visits during the three different periods at the different departments. Department Period preceding interns’ absence Absence of interns Return of interns ACU GYN E ONCOLOGY ANC GYN CLINIC URO CLINIC FP CLINIC 5107(34.5%) 1531(47.7%) 1447(33.9%) 9606(35.5%) 578(32.1%) 105(58.3%) 2175(31.1%) 4762(32.2%) 936(29.1%) 1283(30.1%) 8558(31.6%) 660(36.6%) 58(32.2%) 1970(28.1%) 4922(38.4%) 744(23.2%) 1526(34.5%) 8893(32.9%) 564(31.3%) 17(9.4%) 2854(40.8%) % percentage Admissions of patients at different points in the hospital The hospital has four general admission points and one private admission point. During the study, it was found that NICU had 32.8%, 34% and 33.2% admissions, ACU had 27.9% admissions to 32.2% to 37.5% and labor suite had 34.1% to 33.2% to 32.7%. This is shown in Table 2 below. Table 2 Admissions at the different wards in the three periods of time Department Period preceding interns’ absence Absence of interns Return of interns NICU ACU Labour suite Gyn E HDU ICU 2541(32.8%) 1137(27.9%) 10556(34.1%) 1513(33.3%) 881(35.6%) 124(31.5%) 2634(34.0%) 1314(32.25%) 10279(33.2%) 1516(33.4%) 782(31.6%) 127(32.2%) 2567(33.2%) 1526(37.5%) 10108(32.7%) 1513(33.3%) 811(32.8%) 143(36.3%) % percentage Emergency procedures The hospital performs several emergency procedures, especially in obstetrics and gynecology, and paediatrics. In the three time periods, EM C/S were 31.3%, 33.8% and 34.8% while EXLAP were 30.9%, 34.5% and 34.8% and Cervical tears were 27.1%, 40.5% and 32.4% in the different time periods. This is shown in the table below (Table 3 ). Table 3 Emergency procedures performed in the three different periods Procedure Period preceding interns’ absence Absence of interns Return of interns EM C/S EXLAP MVA SVD Vacuum Perineal tear Cervical tear 2835(31.3%) 352(30.9%) 580(33.1%) 4579(39.9%) 61(52.1%) 34(28.8%) 30(27.1%) 3064(33.8%) 393(34.5%) 533(30.5%) 3551(30.2%) 17(14.5%) 47(39.8%) 45(40.5%) 3160(34.8%) 395(34.6%) 637(36.4%) 3643(30.9%) 39(33.3%) 37(31.4%) 36(32.4%) Elective procedures. The elective procedures performed in the three different periods included ELC/S at 24.1%, 35.8% to 40.1%; Myomectomy was 47.3% to 23.7% to 29.0% and Cystectomy was 34.2%,31.6% and 11.1%. These are presented in Table 4 below. Table 4 Elective procedures performed in the three different periods Procedure Period preceding interns’ absence Absence of interns Return of interns ELC/S Myomectomy Cystectomy TAH Perineorrhaphy Vasectomy 138(24.1%) 44(47.3%) 13(34.2%) 24(23.8%) 7(50.0%) 0(0.0%) 205(35.8%) 22(23.7%) 12(31.6%) 52(51.5%) 3(21.4%) 1(100.0%) 572(40.1%) 27(29.0%) 13(11.1%) 25(24.8%) 4(28.6%) 0(0.0%) Patient outcomes There are several outcomes when patients are admitted to the hospital across the three different periods. In this study, it was found that pediatric discharges were 35.7%, 28.5% and 35.8% in the 3 time periods, OBGYN discharges were 37.0%, 30.4% and 32.6% in the same periods. These are shown in the table below. (Table 5 ). Table 5 Outcomes recorded in the three periods. Outcome Period preceding interns’ absence Absence of interns Return of interns Pead discharges Obgyn discharges Referrals out Runaways 3743(35.7%) 10427(37.0%) 409(35.0%) 28(37.3%) 2987(28.5%) 8581(30.4%) 440(37.7%) 16(21.3%) 3759(35.8%) 9192(32.6%) 319(27.3%) 31(41.4%) Delivery outcomes Mothers admitted for obstetric management have several outcomes, and these included FSB went from 42.2% to 29.5% to 28.3%, ENND went from 30.8% to 31.8% to37.4% and Maternal deaths went from 27.4% to 24.1% to 48.5%. The table below (Table 6 ) illustrates the results. Table 6 Delivery outcomes in the three time periods Outcome Period preceding interns’ absence Absence of interns Return of interns FSB MSB ENND LNND Maternal deaths Live births 296(42.2%) 366(45.3%) 555(30.8%) 64(38.6%) 109(27.4%) 6271(34.2%) 207(29.5%) 272(33.7%) 572(31.8%) 43(25.9%) 96(24.1%) 5726(31.2%) 199(28.3%) 170(21.0%) 674(37.4%) 59(35.5%) 193(48.5%) 6336(34.6%) Graphical representations of the trends across the periods. Across the time periods, there was a change in the trends in OPD, Inpatients, electives and emergencies, is shown in the figure below (Fig. 1 ). The changes in the outcomes of obstetric and paediatric admissions over the three time periods were also displayed in a figure below (Fig. 2 ) to show the changes. Analysis of the results collected in the three periods. The period before the interns left was considered the baseline, and the two time periods were compared. It was found that there was a 11.3% ( p-value 0.01) negative change in outpatient attendance, 0.6% in admissions, and 9.7% in emergency procedures. This is shown in Table 7 below. Table 7 Showing the observed impact versus the expected impact of the absence of interns Parameter Observed Expected %change p value Outpatients Admissions Electives Emergencies Maternal deaths Delivery outcomes 18227 16652 295 7650 96 1051 20549 16752 227 8471 109 1217 -11.3% -0.6% 16.7% -9.7% -11.9% -13.6% 0.001 0.001 0.001 0.001 0.001 0.002 In the period after the return of interns, there was a decline in outpatients, 43.9% (0.001), inpatients, 0.5% (0.001), and an increase in maternal death at 77.1% (0.15). The parameters showed that maternal death (p value 0.15) and delivery outcomes (0.16) did not significantly change between the baseline period and when the interns returned. Table 8 below shows the findings. Table 8 Changes when the interns returned Parameters Observed Expected %change P value Outpatients Inpatients Electives Emergencies Maternal Death Delivery outcomes 11510 16668 641 7947 193 1043 20549 16752 227 8471 109 1217 -43.9% -0.5% 182.4% -6.2% 77.1% -14.3% 0.001 0.001 0.001 0.001 0.150 0.159 In the analysis of the mean number of interns' presence and absence, it was found that there was a significant negative change in all the parameters when interns were present: OPD 19.51% (0.001), IPD 0.35% (0.001), Emergencies 7.31% (0.001), and Maternal death 57.29% (0.001). This is shown in Table 9 below. Table 9 Table showing the impact of interns on the relationship between the mean number of interns present and their absence. Parameters Observed Expected %change P value OPD IPD Electives Emergencies MD OB outcomes 18227 16652 295 7650 96 1051 21784 16710 754 8209 151 1130 -19.51% -0.35% -155.59% -7.31% -57.29% -7.52% 0.001 0.001 0.001 0.001 0.001 0.001 Discussion Outpatient services While studying outpatient attendance, a general decline in total outpatient attendance was noted compared with the mean of the two periods with interns present. This could have been due to the redistribution of the workforce (specialists, residents, medical officers) to attend inpatients and emergencies, cancellation of elective outpatient visits, and all mitigation strategies to reduce the adverse effects of strikes(Stoye & Warner, 2023 ). Ruiz reported a similar finding in the UK(Ruiz, Bottle, & Aylin, 2013 ). The intern strike was nationally publicized, which could have deterred clients from attending elective clinics.(Scanlon et al., 2021 )However, we noted only a slight decline in patient attendance at the different clinics: the ACU, the oncology clinic, ANC, and the Gyn Clinic. This could be attributed to the fact that these clinics were primarily run by midwives, residents, and medical officers, so the absence of intern doctors did not affect their operations. Admissions in the hospital registered a slight decline of 0.35%. The slight decline could have been due to the cancellation of elective admissions and prompt review and definitive management of those who attended the emergency unit by the specialist residents and medical officers, reducing unnecessary and inappropriate admissions(San Jose-Saras et al., 2023 ). A study in Kenya also revealed that pregnant patients during strikes were more likely to deliver in private centres and at home, another possible explanation for the slight decline(Coughtrey-Davenport, 2017 ). Notably, the special care unit, labor suite, and gynecological emergency did not significantly change across the periods; however, there was a gradual increase in admissions in the acute care ward from 27.9 to 32.3 to 37.5 and a decrease in admissions in the HDU from 35.6 to 31.6. This could be attributed to the fact that patients still access obstetric and neonatal services entirely, as this is independent of staff availability. The increase in the ACU is attributed to the sensitization of the service to the public, as it was not fully utilized earlier. At the same time, the decrease in the HDU was due to prompt and appropriate management of patients at different care points, mitigating adverse conditions that could warrant HDU admission. Elective procedures had a significant decline of over 155%. This could have been due to the suspension of outpatient booking clinics and the cancellation of elective admissions. Additionally, the workforce was redistributed to cater to emergencies. This finding was similar to that of a study performed after a one-day strike in NHS hospitals in 2012(Ruiz et al., 2013 ). The hospital registered a decline in emergency procedures performed by 7.31%. The strike of the country-wide interns could have prompted medical officers and specialists to increase their presence, reducing referral admissions at Kawempe National Referral Hospital. The decline in elective procedures did not translate into increased emergency procedures, probably because clients decided to seek care in private institutions. This was highlighted in a study by Coughtrey-Davenport, which reported an increase in delivery services during strike periods in private facilities, while the increase was realized in public facilities upon the end of the strike and full operationalization (Coughtrey-Davenport, 2017 ). The number of emergency procedures performed increased with the number of perineal and cervical tears (28.8–39.8 and 27.1–40.5, respectively). This could have been directly related to the absence of interns, which led to gaps in obstetric monitoring of the mothers in labour. This was also the finding of Atuyambe et al. ( 2016 ) that intern students were compassionate and caring as they participated in patient care, leading to better patient care (Atuyambe et al., 2016 ). There was an increase in the number of emergency caesarian sections (31.3–34.8), which could be explained by the fact that specialists were quick at making delivery decisions for mothers. There was a decrease in vacuum deliveries (52.1–14.5), which could be because of the improvement in quick decision-making for delivering mothers and avoiding the need for vacuum extraction. This finding is comparable to that of a study by Salazar, which revealed a shorter length of stay in the emergency department when serious residents were replaced by physicians(Salazar et al., 2001 ). There was an increase in the performance of elective procedures such as TAH (23.8–51.5), vasectomy (1–99), and elective c-section (24.1–35.8). The specialists fully managed the wards; hence, they were able to identify in a timely manner the mothers and patients who needed the elective procedure and prescribed it. For patient outcomes such as discharge, the difference was minimal in line with admissions; however, there was a decrease in maternal deaths during the period with no interns, and the number increased after return (27.4 to 24.1 to 48.5). This could be because specialists provided timely interventions. However, they did not mentor the interns well enough to manage the mitigation of the outcome, which sided with the findings of Capinpuyan et al., who reported that internship programs sometimes leave interns unsupervised by the seniors, leading to medical errors and gaps in quality health care delivered(Capinpuyan & Miguel, 2019 ) because they are seen as supplements to low staff solutions, forgetting that they are still learning. Other studies have highlighted clinical teachers' challenges, such as Wilkerson (1998), who reported that specialists who are expected to engage in clinical teaching may not have received prior formal teaching training(Olasoji, Mu'azu, & Garba, 2019 ) and that the heavy workload associated with emergency departments(Quinn et al., 2019 ) hinders their capacity to teach their interns, affecting patient care adequately. There was an increase in referrals (35–37.7), which could have been a way of managing the overwhelming number of patients who attended Kawempe National Referral Hospital at the time; hence, more mothers were sent to Mulago Specialized Women’s and Neonatal Hospital and other specialized centers. Delivery outcomes significantly decreased in FSB (42.2–29.5), MSB (45.3–33.7), and LNND (38.6–25.9), and no significant changes in ENND were detected. This was attributed to better obstetric management of the mothers during labour, which improved outcomes. This was in line with a study by Nakibuuka et al. (2012) that showed that the level of knowledge and expertise of human resources contributed to the number of perinatal deaths in hospitals; thus, interns may have had limited knowledge, which could have caused the increase in the number of perinatal deaths. The specialists have more expertise, hence decreasing their presence. Conclusion The presence or absence of medical interns affected the hospital metrics during the study periods at Kawempe National Referral Hospital. The presence or absence of medical interns affected patient outcomes at Kawempe National Referral Hospital. Recommendations. The Ministry of Health, the National Internship Committee, and the Ministry of Finance should develop policies that ensure the uninterrupted deployment of medical interns in public facilities. The Ministry of Health and the National Internship Committee should collaborate with medical training institutions and the Federation of Uganda Medical Interns to develop sustainable strategies for ensuring the continued deployment of medical interns at public facilities. Follow-up studies to determine whether the presence or absence of medical interns affects the quality of care of patients and those that explain the observed changes in this study should be carried out. Abbreviations ACU: Acute Care Clinic ANC: Antenatal Clinic ENND: Early neonatal death FSB: fresh still birth KNRH Kawempe National Reference Hospital LNND: late neonatal death L/S: Labour suite MD: Maternal death MOH Ministry of Health MSB: Macerated Still Birth SCU: Special Care Unit WHO World Health Organization NICU: Neonatal intensive care unit Declarations Source of funding The study was funded by Kawempe National Referral Hospital Kampala. Conflict of interest. There are no conflicts of interest. Availability of data. The data used in this study are available upon request from the corresponding author. author's contribution. JLN and MNM designed the study, conducted the data collection, cleaned and analysed the data, and drafted the manuscript. MGN and HS supervised all stages of the study, from conceptualization of the topic to manuscript writing and submission. Ethical approval. Ethical approval and a waiver of consent were obtained from the Mildmay Uganda Research and Ethics Committee (MUREC). Approval was sought from the Uganda National Council of Science and Technology (UNCST). Administrative clearance was obtained from Kawempe National Referral Hospital. Informed consent A consent form was filled out by the respondents after they explained the purpose of the study to them. Anonymity and confidentiality were strictly observed during data collection, description, and reporting of findings. Written informed consent forms were provided, and the confidentiality of all the information about the respondents was communicated and maintained. Author biography Dr. Joel Lwasa Njagala is a medical doctor at Kawempe National Referral Hospital Kampala. Dr. Mabel Nekesa Mirembe, a medical doctor at Kawempe National Referral Hospital Kampala. Dr. Henry Ssenyondo is a medical doctor at Kawempe National Referral Hospital Kampala. Ms. Mary GraceNaggita is a nurse at Kawempe National Referral Hospital Kampala. Dr Emmanuel K Byaruhanga. is the Executive Director at Kawempe National Referral Hospital Kampala. References Atuyambe, L. M., Baingana, R. K., Kibira, S. P., Katahoire, A., Okello, E., Mafigiri, D. K., . . . Muggaga, K. (2016). Undergraduate students’ contributions to health service delivery through community-based education: A qualitative study by the MESAU Consortium in Uganda. BMC medical education, 16 , 1-11. Capinpuyan, A. L. C., & Miguel, R. T. D. (2019). Ethical Challenges in Medical Community Internships: Perspectives from Medical Interns in the Philippines. Health Hum Rights, 21 (1), 141-147. Coughtrey-Davenport, T. (2017). When the Health System Fails You: Maternal Care Under Kenya’s 2017 Nurses' Strike. Ibrahim, J. E., Jeffcott, S., Davis, M. C., & Chadwick, L. (2013). Recognizing junior doctors' potential contribution to patient safety and health care quality improvement. Journal of health organization and management, 27 (2), 273-286. Kisling, L. A., & Das, J. M. (2022). Prevention strategies. In StatPearls [internet] : StatPearls Publishing. Olasoji, H. O., Mu'azu, A. B., & Garba, M. H. (2019). A study of clinical teachers' attitude to teaching and perceived learning needs in a medical college in Nigeria. Adv Med Educ Pract, 10 , 605-617. doi:10.2147/amep.S171550 Quinn, A., Gottlieb, M., Chan, T. M., Nickson, C. P., Mitzman, J., Natesan, S., . . . Messman, A. (2019). Curated Collections for Educators: Five Key Papers on Clinical Teaching. Cureus, 11 (11), e6084. doi:10.7759/cureus.6084 Ruiz, M., Bottle, A., & Aylin, P. (2013). A retrospective study of the impact of the doctors' strike in England on 21 June 2012. J R Soc Med, 106 (9), 362-369. doi:10.1177/0141076813490685 Salazar, A., Corbella, X., Onaga, H., Ramon, R., Pallares, R., & Escarrabill, J. (2001). Impact of a resident strike on emergency department quality indicators at an urban teaching hospital. Acad Emerg Med, 8 (8), 804-808. doi:10.1111/j.1553-2712.2001.tb00210.x San Jose-Saras, D., Vicente-Guijarro, J., Sousa, P., Moreno-Nunez, P., Espejo-Mambié, M., & Aranaz-Andres, J. M. (2023). Inappropriate Hospital Admission According to Patient Intrinsic Risk Factors: an Epidemiological Approach. J Gen Intern Med, 38 (7), 1655-1663. doi:10.1007/s11606-022-07998-0 Scanlon, M. L., Maldonado, L. Y., Ikemeri, J. E., Jumah, A., Anusu, G., Bone, J. N., . . . Christoffersen-Deb, A. (2021). A retrospective study of the impact of health worker strikes on maternal and child health care utilization in western Kenya. BMC Health Serv Res, 21 (1), 898. doi:10.1186/s12913-021-06939-7 Stoye, G., & Warner, M. (2023). The effects of doctor strikes on patient outcomes: Evidence from the English NHS. Journal of Economic Behavior & Organization, 212 , 689-707. doi:https://doi.org/10.1016/j.jebo.2023.06.011 Vance, G., Jandial, S., Scott, J., & Burford, B. (2019). What are junior doctors for? The work of Foundation doctors in the UK: a mixed methods study. BMJ Open, 9 (4), e027522. doi:10.1136/bmjopen-2018-027522 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 01 May, 2026 Reviews received at journal 21 Dec, 2025 Reviews received at journal 12 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers invited by journal 01 Dec, 2025 Editor invited by journal 01 Nov, 2025 Editor assigned by journal 29 Oct, 2025 Submission checks completed at journal 29 Oct, 2025 First submitted to journal 22 Oct, 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-7922459","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":553860352,"identity":"51f25dbf-b06e-4dff-a8a1-367f45e08a7e","order_by":0,"name":"Joel Lwasa Calls Njagala","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYBACxnbmBhAtByIOPCBKSzMjWIsxWEsCUdYwQ7QkgkmitDA3M7ZJ/Phjlz4/7PBDoC12croNhB3WJtnblpy78XaaAVBLsrHZASK03OBtYM7dODsBpOVA4jZitNz886c+3XB2+gfitdzmYTucIC+dQ7wt7b9l244bbpDOKTiQYECEXwzbmw8bvvlTLS8/O33zhw8VdnKEtTRAGQZglQYElIOAPJzRgEfVKBgFo2AUjGwAAD31RtYq2R/wAAAAAElFTkSuQmCC","orcid":"","institution":"KAWEMPE NATIONAL REFERRAL HOSPITAL","correspondingAuthor":true,"prefix":"","firstName":"Joel","middleName":"Lwasa Calls","lastName":"Njagala","suffix":""},{"id":553860356,"identity":"8864196f-2107-4c60-a2ff-1db8985c5ca3","order_by":1,"name":"Mabel Nekesa Mirembe","email":"","orcid":"","institution":"KAWEMPE NATIONAL REFERRAL HOSPITAL","correspondingAuthor":false,"prefix":"","firstName":"Mabel","middleName":"Nekesa","lastName":"Mirembe","suffix":""},{"id":553860357,"identity":"2fb598a8-ab87-451e-89f9-6e2d1644836c","order_by":2,"name":"Henry Ssenyondo","email":"","orcid":"","institution":"KAWEMPE NATIONAL REFERRAL HOSPITAL","correspondingAuthor":false,"prefix":"","firstName":"Henry","middleName":"","lastName":"Ssenyondo","suffix":""},{"id":553860358,"identity":"7633779c-443d-4644-a9be-ca26afeca782","order_by":3,"name":"Mary Grace Naggita","email":"","orcid":"","institution":"KAWEMPE NATIONAL REFERRAL HOSPITAL","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"Grace","lastName":"Naggita","suffix":""},{"id":553860359,"identity":"b9351d2b-97ac-436b-928f-ec269def8d09","order_by":4,"name":"Emmanuel KAYOGOZA Byaruhanga","email":"","orcid":"","institution":"KAWEMPE NATIONAL REFERRAL HOSPITAL","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"KAYOGOZA","lastName":"Byaruhanga","suffix":""}],"badges":[],"createdAt":"2025-10-22 10:23:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7922459/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7922459/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97342810,"identity":"d5d909a1-8aff-442e-b96c-7a6895938f46","added_by":"auto","created_at":"2025-12-03 11:32:56","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":304128,"visible":true,"origin":"","legend":"","description":"","filename":"assesingtheimpactofInternsmanuscriptedit.doc","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/82ed9421330698714b51c920.doc"},{"id":97370005,"identity":"48d21035-a080-4f53-885e-182baacc217c","added_by":"auto","created_at":"2025-12-03 16:26:22","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7580,"visible":true,"origin":"","legend":"","description":"","filename":"d588903e583a4f2db9efc7cb0dcad888.json","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/381b243e41d221272f8e80e2.json"},{"id":97371292,"identity":"6c8a1ec0-d6be-46ab-b21a-ef632e8a2135","added_by":"auto","created_at":"2025-12-03 16:28:41","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83195,"visible":true,"origin":"","legend":"","description":"","filename":"d588903e583a4f2db9efc7cb0dcad8881enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/0779376377635170057bee9d.xml"},{"id":97342806,"identity":"a249126f-4775-4bf9-a27e-a75868ae6213","added_by":"auto","created_at":"2025-12-03 11:32:56","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23848,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/b6df528cb02b08dbd988aafd.png"},{"id":97342809,"identity":"503a7df0-7de0-4d88-928d-07818649da8b","added_by":"auto","created_at":"2025-12-03 11:32:56","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66248,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/09632c992760f3a01c2f781d.png"},{"id":97342807,"identity":"b6adcb2a-a08f-488a-8920-c17f5373cab4","added_by":"auto","created_at":"2025-12-03 11:32:56","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9431,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/bcbdc5a1c3b3cd6addb269ae.png"},{"id":97370339,"identity":"472df4fa-500a-4628-9b52-e1f2e3d18343","added_by":"auto","created_at":"2025-12-03 16:27:11","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":26689,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/03d0425c8ad9d9a78e684f86.png"},{"id":97342813,"identity":"e2850392-147b-496b-9f82-e0857f3c26af","added_by":"auto","created_at":"2025-12-03 11:32:57","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78753,"visible":true,"origin":"","legend":"","description":"","filename":"d588903e583a4f2db9efc7cb0dcad8881structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/d467945edde16f8529df4054.xml"},{"id":97342814,"identity":"71ab1f02-4e40-4403-b82e-60321713a5cd","added_by":"auto","created_at":"2025-12-03 11:32:57","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":89964,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/fe1fe12bac71dac0a0af42dd.html"},{"id":97342804,"identity":"9eb25149-b68a-46db-a37d-feff2973bb63","added_by":"auto","created_at":"2025-12-03 11:32:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34955,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends in outpatients, admissions, elective surgeries, and emergency procedures across the periods.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/0a25a8c115da9ac900cf9ec9.png"},{"id":97342805,"identity":"f43352fc-192a-4f12-982a-465d89b19b6f","added_by":"auto","created_at":"2025-12-03 11:32:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":80733,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends in obstetric outcomes such as maternal death, FSB, MSB, and ENND\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/147ecba30004ec19cf43f3b1.png"},{"id":97892763,"identity":"b44f9d14-8fc4-4e2a-bcf4-16e934d0ce48","added_by":"auto","created_at":"2025-12-10 15:20:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1455886,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7922459/v1/16a984d2-c0d8-4807-beb1-ce120eabf65e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the Impact of Medical Interns on Healthcare Delivery at Kawempe National Referral Hospital. A cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eAccording to the World Health Organization (WHO), quality of care is how health services in a given population yield desirable outcomes and align with evidence-based professional knowledge. Quality health services should be effective, safe, timely, equitable, efficient, integrated, and people-centred (Busse, Panteli, \u0026amp; Quentin, 2019). High-quality systems are estimated to reduce maternal deaths by half and newborn deaths by one million per year. (WHO, 2020)Service delivery is a portion of health systems where patients receive the care and materials to which they are legally entitled. Five processes have been identified to be involved in health care: primary prevention, health seeking, diagnosis, treatment, and end-of-life care.\u003c/p\u003e\u003cp\u003ePrimary prevention involves all processes to avoid the occurrence of morbidity. This starts in communities and extends to hospital settings and may involve, but is not limited to, immunization, physical activity, the use of malaria prevention bed nets, a healthy diet, access to clean water, and reduced tobacco use.(Kisling \u0026amp; Das, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) Detecting health problems involves promoting health-seeking, so the healthcare system must be proactive in its outreach. This is because assisting people in the healthcare system can be challenging if they choose not to speak up.\u003c/p\u003e\u003cp\u003eThis process is necessary to start the next stage of health care. Erroneous diagnosis is among the least economical options. Early diagnosis is crucial for many disease courses. The information and techniques for this process provided by the healthcare system include investigations, examinations, and history taking. Medical interns play a major role in this process in Ugandan hospitals.\u003c/p\u003e\u003cp\u003eTreatment and good end-of-life care are the final processes involved in healthcare. (Bergman, Neuhauser, \u0026amp; Provost, 2011). Medical interns are bachelor's degree graduates of medicine and surgery, nursing, midwifery, dentistry, and pharmacy. They are expected to obtain clinical practice, communication, management, and health system management skills by working under supervision for one year before processing registration and licensure in their professional bodies. Medical interns in Uganda were not deployed for four months from the 1st of April 2023 to the 3rd of August 2023 for the first time in decades, and the MOH disrupted the medical internship cycle for four months due to a lack of funds to facilitate their allowances (Daily Monitor, 11th April, UMA, 2023). Whereas undergraduate students under MESAU have been proven to improve primary health care programs in the community (Atuyambe et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), the impact of medical interns on direct patient care has not been studied.\u003c/p\u003e\u003cp\u003eKawempe National Referral Hospital (KNRH) records a daily admission of approximately 123 and a high delivery rate averaging 60 births daily. Therefore, it relies strongly on the labour provided by medical interns, residents, medical officers of special grade (specialist obstetricians and gynaecologists, paediatricians, anaesthesiologists, radiologists, pathologists), medical officers, and nurses. Providing respectful maternity and neonatal care depends on teamwork among these professionals. The MOH does not spell out the actual roles of medical interns; however, they are expected to execute all duties as directed by their immediate supervisors. A study in the United Kingdom revealed that junior doctors (similar to intern doctors) are expected to play multiple roles, including supporting roles such as admission, discharging patients, and practising independently by providing direct patient care through diagnosis, investigations, and treatment of conditions under the supervision of senior staff and learning new skills. They recommended that organisations support graduate health workers transitioning from student to real-world work. (Vance, Jandial, Scott, \u0026amp; Burford, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA study also revealed that junior residents under direct supervision did not affect surgical outcomes, hospital costs, or patient satisfaction. The operation time increased; however, patient hospital stays were shortened. (Sibia, Turcotte, Klune, \u0026amp; Feather, 2020). Junior doctors were also more likely to introduce or embrace new ideas and appreciate technology integration into health systems, improving the quality of health services offered. (Ibrahim, Jeffcott, Davis, \u0026amp; Chadwick, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMedical interns play major roles, such as triaging patients, index clerkships, resuscitation, ordering for and obtaining investigation results, timely consultation of residents and specialists of critical patients, participation in surgery, daily review and discharge of patients, administration of drugs, and other roles, as requested by supervisors. While they are first-line in patient management and are learning through apprenticeship, they are an invaluable cadre in patient care in Uganda\u0026rsquo;s health sector. They are thought to improve service delivery significantly. While stakeholders have negotiated to ensure the continuity of internships, the relevance of medical interns in Uganda\u0026rsquo;s health sector has been questioned. This study aimed to assess the impact of medical interns on healthcare delivery at Kawempe National Referral Hospital.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis was a cross-sectional study that compared data from 3 time periods via a quantitative approach with no influence on the variables under study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Site\u003c/h3\u003e\n\u003cp\u003eKNRH is located in Kawempe Division, approximately 8 kilometres north of the central business district, and serves as a teaching hospital and national referral centre. It provides specialist care in obstetrics, gynecology, and pediatrics. It has a daily bed capacity of approximately 200 individuals, with a bed occupancy of 112% and actively manages an average of 80 women in the labour ward with 65 deliveries. On average, 80 infants/children are managed at the acute care unit, while 90 infants are admitted to the special care unit daily. The hospital's multidisciplinary healthcare team includes 30 obstetricians and gynecologists, 10 pediatricians, 2 anaesthesia and critical care specialists, 6 anaesthetic officers, 80 residents, 100 nurses/midwives, 5 pharmacists, and 120 medical interns, all of whom contribute to the care and treatment of patients. The hospital has outpatient, inpatient and intensive care points for paediatrics, obstetrics and gynecology.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecords to be reviewed.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study included monthly medical records for health care sought at Kawempe National Referral Hospital during three distinct periods. The study months were conveniently determined as the initial 4-month span preceding the absence of medical interns (December 2022\u0026ndash;March 2023) and the subsequent 4-month interval coinciding with the absence of medical interns (April 2023\u0026ndash;July 2023) in comparison with the presence of interns in the period of April 2022\u0026ndash;July 2022.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample size and sampling procedure.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSecondary data from hospital records were used. No sampling methods were employed during the study, as all hospital records from the four months preceding the medical interns' absence, the four months during their absence, and the four comparable months of their placement in 2022 (April to July) were used in the study.\u003c/p\u003e\n\u003ch3\u003eStudy variables\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eIndependent variables:\u003c/h2\u003e\u003cp\u003eThe presence or absence of medical interns\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDependent Variables\u003c/strong\u003e\u003cp\u003eThe dependent variables included numerical counts of the following\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutpatient visits\u003c/h3\u003e\n\u003cp\u003eAcute care unit\u003c/p\u003e\u003cp\u003eGynecology emergency\u003c/p\u003e\u003cp\u003eGynaecology\u003c/p\u003e\u003cp\u003eOncology Clinic\u003c/p\u003e\u003cp\u003eLaboursuite\u003c/p\u003e\u003cp\u003eAntenatal clinic\u003c/p\u003e\u003cp\u003eReproductive gynecology clinic\u003c/p\u003e\u003cp\u003eUrogynecology Clinic\u003c/p\u003e\u003cp\u003eFamily planning clinic\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eAdmissions\u003c/h2\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003eNICU\u003c/h2\u003e\u003cdiv id=\"Sec10\" class=\"Section4\"\u003e\u003ch2\u003eACU\u003c/h2\u003e\u003cp\u003eLabor suit\u003c/p\u003e\u003cp\u003eGynaecological emergencies\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eHDU\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eICU\u003c/h2\u003e\u003cp\u003e\u003cb\u003eEmergency procedures.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eEmergency caesarean sections.\u003c/p\u003e\u003cp\u003eExploratory Laparotomy\u003c/p\u003e\u003cp\u003eManual vacuum aspiration\u003c/p\u003e\u003cp\u003eSuction curettage\u003c/p\u003e\u003cp\u003eVaginal delivery\u003c/p\u003e\u003cp\u003eInstrumental delivery\u003c/p\u003e\u003cp\u003eRepair of 3\u003csup\u003erd\u0026minus;\u003c/sup\u003e and 4th -degree perineal tears\u003c/p\u003e\u003cp\u003eRepair of cervical tears\u003c/p\u003e\u003cp\u003e\u003cb\u003eElective procedures.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eElective cesarean section\u003c/p\u003e\u003cp\u003eCervical cerclage\u003c/p\u003e\u003cp\u003eMyomectomy\u003c/p\u003e\u003cp\u003eOvarian cystectomy\u003c/p\u003e\u003cp\u003eTotal abdominal hysterectomy\u003c/p\u003e\u003cp\u003ePerineorrhaphy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePatient outcomes\u003c/h2\u003e\u003cp\u003ePatient discharge\u003c/p\u003e\u003cp\u003eMaternal deaths\u003c/p\u003e\u003cp\u003eRefers\u003c/p\u003e\u003cp\u003eRunaway\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eDelivery outcomes\u003c/h2\u003e\u003cp\u003eFresh stillborns (FSB)\u003c/p\u003e\u003cp\u003eMacerated stillbirths (MSBs)\u003c/p\u003e\u003cp\u003eLive births\u003c/p\u003e\u003cp\u003eEarly neonatal death (ENND)\u003c/p\u003e\u003cp\u003eLate neonatal death (LNND).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eStudy procedures and data collection\u003c/h2\u003e\u003cp\u003eA data collection tool was designed to capture all the study-dependent variables and was piloted to ensure its appropriateness to the variables. Quantitative data for assessing patient care metrics, such as hospital admissions, number of outpatients, emergency and elective procedures, and patient and delivery outcomes, were extracted from hospital databases and monthly summaries via the developed tool. The monthly summaries were double-checked with the source tools at the corresponding departments to ensure correctness. Standardized data extraction forms ensure uniformity in data collection across the entire sample.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData management.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe medical records were entered into Microsoft Excel, reviewed to ensure accuracy, completeness, and correctness, and then exported into Stata 14, a statistical data package for data analysis. Data collected via the standardized extraction form were reviewed daily by an RA on a password-protected computer to ensure accuracy, completeness, and correctness.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis.\u003c/h2\u003e\u003cp\u003eStata 14 was used to analyse the data; descriptive data are presented as proportions.\u003c/p\u003e\u003cp\u003ePoisson regression was used to infer associations, and p-values less than 0.05 were considered statistically significant.\u003c/p\u003e\u003cp\u003e\u003cb\u003eQuality Assurance and Control.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe data collection tool was piloted to determine its Cronbach's alpha score for standardization. A set of standardized operating procedures (SOPs) was established. These SOPs guided the framework for systematically executing data collection, entry, and analysis. Research staff were provided training sessions and calibration exercises to mitigate potential variations in data collection practices. Data cleaning and validation procedures were implemented, involving a cross-referencing process against source documents to rectify discrepancies. Regular monitoring and internal audits were conducted.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eDescription of the results from the three different periods: the period preceding the interns\u0026rsquo; absence, the absence of interns, and the return of interns.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOutpatient attendance at the different departments in the hospital during the different periods varied, with Uroclinic having the biggest decline from 58.3% to 9.4% while ACU had an increase in the numbers by 3.5%. The oncology clinic remained with almost the same number of patients throughout the periods. (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\u003eOutpatient visits during the three different periods at the different departments.\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=\"left\" 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\u003eDepartment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeriod preceding interns\u0026rsquo; absence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAbsence of interns\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReturn of interns\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACU\u003c/p\u003e\u003cp\u003eGYN E\u003c/p\u003e\u003cp\u003eONCOLOGY\u003c/p\u003e\u003cp\u003eANC\u003c/p\u003e\u003cp\u003eGYN CLINIC\u003c/p\u003e\u003cp\u003eURO CLINIC\u003c/p\u003e\u003cp\u003eFP CLINIC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5107(34.5%)\u003c/p\u003e\u003cp\u003e1531(47.7%)\u003c/p\u003e\u003cp\u003e1447(33.9%)\u003c/p\u003e\u003cp\u003e9606(35.5%)\u003c/p\u003e\u003cp\u003e578(32.1%)\u003c/p\u003e\u003cp\u003e105(58.3%)\u003c/p\u003e\u003cp\u003e2175(31.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4762(32.2%)\u003c/p\u003e\u003cp\u003e936(29.1%)\u003c/p\u003e\u003cp\u003e1283(30.1%)\u003c/p\u003e\u003cp\u003e8558(31.6%)\u003c/p\u003e\u003cp\u003e660(36.6%)\u003c/p\u003e\u003cp\u003e58(32.2%)\u003c/p\u003e\u003cp\u003e1970(28.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4922(38.4%)\u003c/p\u003e\u003cp\u003e744(23.2%)\u003c/p\u003e\u003cp\u003e1526(34.5%)\u003c/p\u003e\u003cp\u003e8893(32.9%)\u003c/p\u003e\u003cp\u003e564(31.3%)\u003c/p\u003e\u003cp\u003e17(9.4%)\u003c/p\u003e\u003cp\u003e2854(40.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e% percentage\u003c/h2\u003e\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\u003ch2\u003eAdmissions of patients at different points in the hospital\u003c/h2\u003e\u003cp\u003eThe hospital has four general admission points and one private admission point. During the study, it was found that NICU had 32.8%, 34% and 33.2% admissions, ACU had 27.9% admissions to 32.2% to 37.5% and labor suite had 34.1% to 33.2% to 32.7%. This is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below.\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\u003eAdmissions at the different wards in the three periods of time\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=\"left\" 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\u003eDepartment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeriod preceding interns\u0026rsquo; absence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAbsence of interns\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReturn of interns\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\u003eNICU\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eACU\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLabour suite\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eGyn E\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eHDU\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eICU\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2541(32.8%)\u003c/p\u003e\u003cp\u003e1137(27.9%)\u003c/p\u003e\u003cp\u003e10556(34.1%)\u003c/p\u003e\u003cp\u003e1513(33.3%)\u003c/p\u003e\u003cp\u003e881(35.6%)\u003c/p\u003e\u003cp\u003e124(31.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2634(34.0%)\u003c/p\u003e\u003cp\u003e1314(32.25%)\u003c/p\u003e\u003cp\u003e10279(33.2%)\u003c/p\u003e\u003cp\u003e1516(33.4%)\u003c/p\u003e\u003cp\u003e782(31.6%)\u003c/p\u003e\u003cp\u003e127(32.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2567(33.2%)\u003c/p\u003e\u003cp\u003e1526(37.5%)\u003c/p\u003e\u003cp\u003e10108(32.7%)\u003c/p\u003e\u003cp\u003e1513(33.3%)\u003c/p\u003e\u003cp\u003e811(32.8%)\u003c/p\u003e\u003cp\u003e143(36.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e% percentage\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003eEmergency procedures\u003c/h2\u003e\u003cp\u003eThe hospital performs several emergency procedures, especially in obstetrics and gynecology, and paediatrics. In the three time periods, EM C/S were 31.3%, 33.8% and 34.8% while EXLAP were 30.9%, 34.5% and 34.8% and Cervical tears were 27.1%, 40.5% and 32.4% in the different time periods. This is shown in the table below (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\u003eEmergency procedures performed in the three different periods\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=\"left\" 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\u003eProcedure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeriod preceding interns\u0026rsquo; absence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAbsence of interns\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReturn of interns\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEM C/S\u003c/p\u003e\u003cp\u003eEXLAP\u003c/p\u003e\u003cp\u003eMVA\u003c/p\u003e\u003cp\u003eSVD\u003c/p\u003e\u003cp\u003eVacuum\u003c/p\u003e\u003cp\u003ePerineal tear\u003c/p\u003e\u003cp\u003eCervical tear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2835(31.3%)\u003c/p\u003e\u003cp\u003e352(30.9%)\u003c/p\u003e\u003cp\u003e580(33.1%)\u003c/p\u003e\u003cp\u003e4579(39.9%)\u003c/p\u003e\u003cp\u003e61(52.1%)\u003c/p\u003e\u003cp\u003e34(28.8%)\u003c/p\u003e\u003cp\u003e30(27.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3064(33.8%)\u003c/p\u003e\u003cp\u003e393(34.5%)\u003c/p\u003e\u003cp\u003e533(30.5%)\u003c/p\u003e\u003cp\u003e3551(30.2%)\u003c/p\u003e\u003cp\u003e17(14.5%)\u003c/p\u003e\u003cp\u003e47(39.8%)\u003c/p\u003e\u003cp\u003e45(40.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3160(34.8%)\u003c/p\u003e\u003cp\u003e395(34.6%)\u003c/p\u003e\u003cp\u003e637(36.4%)\u003c/p\u003e\u003cp\u003e3643(30.9%)\u003c/p\u003e\u003cp\u003e39(33.3%)\u003c/p\u003e\u003cp\u003e37(31.4%)\u003c/p\u003e\u003cp\u003e36(32.4%)\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\u003eElective procedures.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe elective procedures performed in the three different periods included ELC/S at 24.1%, 35.8% to 40.1%; Myomectomy was 47.3% to 23.7% to 29.0% and Cystectomy was 34.2%,31.6% and 11.1%. These are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e below.\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\u003eElective procedures performed in the three different periods\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=\"left\" 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\u003eProcedure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeriod preceding interns\u0026rsquo; absence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAbsence of interns\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReturn of interns\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eELC/S\u003c/p\u003e\u003cp\u003eMyomectomy\u003c/p\u003e\u003cp\u003eCystectomy\u003c/p\u003e\u003cp\u003eTAH\u003c/p\u003e\u003cp\u003ePerineorrhaphy\u003c/p\u003e\u003cp\u003eVasectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138(24.1%)\u003c/p\u003e\u003cp\u003e44(47.3%)\u003c/p\u003e\u003cp\u003e13(34.2%)\u003c/p\u003e\u003cp\u003e24(23.8%)\u003c/p\u003e\u003cp\u003e7(50.0%)\u003c/p\u003e\u003cp\u003e0(0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e205(35.8%)\u003c/p\u003e\u003cp\u003e22(23.7%)\u003c/p\u003e\u003cp\u003e12(31.6%)\u003c/p\u003e\u003cp\u003e52(51.5%)\u003c/p\u003e\u003cp\u003e3(21.4%)\u003c/p\u003e\u003cp\u003e1(100.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e572(40.1%)\u003c/p\u003e\u003cp\u003e27(29.0%)\u003c/p\u003e\u003cp\u003e13(11.1%)\u003c/p\u003e\u003cp\u003e25(24.8%)\u003c/p\u003e\u003cp\u003e4(28.6%)\u003c/p\u003e\u003cp\u003e0(0.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003ePatient outcomes\u003c/h2\u003e\u003cp\u003eThere are several outcomes when patients are admitted to the hospital across the three different periods. In this study, it was found that pediatric discharges were 35.7%, 28.5% and 35.8% in the 3 time periods, OBGYN discharges were 37.0%, 30.4% and 32.6% in the same periods. These are shown in the table below. (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\u003eOutcomes recorded in the three periods.\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=\"left\" 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\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeriod preceding interns\u0026rsquo; absence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAbsence of interns\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReturn of interns\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePead discharges\u003c/p\u003e\u003cp\u003eObgyn discharges\u003c/p\u003e\u003cp\u003eReferrals out\u003c/p\u003e\u003cp\u003eRunaways\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3743(35.7%)\u003c/p\u003e\u003cp\u003e10427(37.0%)\u003c/p\u003e\u003cp\u003e409(35.0%)\u003c/p\u003e\u003cp\u003e28(37.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2987(28.5%)\u003c/p\u003e\u003cp\u003e8581(30.4%)\u003c/p\u003e\u003cp\u003e440(37.7%)\u003c/p\u003e\u003cp\u003e16(21.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3759(35.8%)\u003c/p\u003e\u003cp\u003e9192(32.6%)\u003c/p\u003e\u003cp\u003e319(27.3%)\u003c/p\u003e\u003cp\u003e31(41.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eDelivery outcomes\u003c/h2\u003e\u003cp\u003eMothers admitted for obstetric management have several outcomes, and these included FSB went from 42.2% to 29.5% to 28.3%, ENND went from 30.8% to 31.8% to37.4% and Maternal deaths went from 27.4% to 24.1% to 48.5%. The table below (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e) illustrates the results.\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\u003eDelivery outcomes in the three time periods\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=\"left\" 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\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePeriod preceding interns\u0026rsquo; absence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAbsence of interns\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReturn of interns\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFSB\u003c/p\u003e\u003cp\u003eMSB\u003c/p\u003e\u003cp\u003eENND\u003c/p\u003e\u003cp\u003eLNND\u003c/p\u003e\u003cp\u003eMaternal deaths\u003c/p\u003e\u003cp\u003eLive births\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e296(42.2%)\u003c/p\u003e\u003cp\u003e366(45.3%)\u003c/p\u003e\u003cp\u003e555(30.8%)\u003c/p\u003e\u003cp\u003e64(38.6%)\u003c/p\u003e\u003cp\u003e109(27.4%)\u003c/p\u003e\u003cp\u003e6271(34.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e207(29.5%)\u003c/p\u003e\u003cp\u003e272(33.7%)\u003c/p\u003e\u003cp\u003e572(31.8%)\u003c/p\u003e\u003cp\u003e43(25.9%)\u003c/p\u003e\u003cp\u003e96(24.1%)\u003c/p\u003e\u003cp\u003e5726(31.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e199(28.3%)\u003c/p\u003e\u003cp\u003e170(21.0%)\u003c/p\u003e\u003cp\u003e674(37.4%)\u003c/p\u003e\u003cp\u003e59(35.5%)\u003c/p\u003e\u003cp\u003e193(48.5%)\u003c/p\u003e\u003cp\u003e6336(34.6%)\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\u003cb\u003eGraphical representations of the trends across the periods.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAcross the time periods, there was a change in the trends in OPD, Inpatients, electives and emergencies, is shown in the figure below (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe changes in the outcomes of obstetric and paediatric admissions over the three time periods were also displayed in a figure below (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) to show the changes.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAnalysis of the results collected in the three periods.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe period before the interns left was considered the baseline, and the two time periods were compared. It was found that there was a 11.3% ( p-value 0.01) negative change in outpatient attendance, 0.6% in admissions, and 9.7% in emergency procedures. This is shown in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eShowing the observed impact versus the expected impact of the absence of interns\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eObserved\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExpected\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%change\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\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\u003eOutpatients\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eAdmissions\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eElectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eEmergencies\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaternal deaths\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDelivery outcomes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18227\u003c/p\u003e\u003cp\u003e16652\u003c/p\u003e\u003cp\u003e295\u003c/p\u003e\u003cp\u003e7650\u003c/p\u003e\u003cp\u003e96\u003c/p\u003e\u003cp\u003e1051\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20549\u003c/p\u003e\u003cp\u003e16752\u003c/p\u003e\u003cp\u003e227\u003c/p\u003e\u003cp\u003e8471\u003c/p\u003e\u003cp\u003e109\u003c/p\u003e\u003cp\u003e1217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-11.3%\u003c/p\u003e\u003cp\u003e-0.6%\u003c/p\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003cp\u003e-9.7%\u003c/p\u003e\u003cp\u003e-11.9%\u003c/p\u003e\u003cp\u003e-13.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.002\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\u003eIn the period after the return of interns, there was a decline in outpatients, 43.9% (0.001), inpatients, 0.5% (0.001), and an increase in maternal death at 77.1% (0.15). The parameters showed that maternal death (p value 0.15) and delivery outcomes (0.16) did not significantly change between the baseline period and when the interns returned. Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e below shows the findings.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChanges when the interns returned\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eObserved\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExpected\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%change\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\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\u003eOutpatients\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInpatients\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eElectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eEmergencies\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaternal Death\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eDelivery outcomes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11510\u003c/p\u003e\u003cp\u003e16668\u003c/p\u003e\u003cp\u003e641\u003c/p\u003e\u003cp\u003e7947\u003c/p\u003e\u003cp\u003e193\u003c/p\u003e\u003cp\u003e1043\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20549\u003c/p\u003e\u003cp\u003e16752\u003c/p\u003e\u003cp\u003e227\u003c/p\u003e\u003cp\u003e8471\u003c/p\u003e\u003cp\u003e109\u003c/p\u003e\u003cp\u003e1217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-43.9%\u003c/p\u003e\u003cp\u003e-0.5%\u003c/p\u003e\u003cp\u003e182.4%\u003c/p\u003e\u003cp\u003e-6.2%\u003c/p\u003e\u003cp\u003e77.1%\u003c/p\u003e\u003cp\u003e-14.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.150\u003c/p\u003e\u003cp\u003e0.159\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\u003eIn the analysis of the mean number of interns' presence and absence, it was found that there was a significant negative change in all the parameters when interns were present: OPD 19.51% (0.001), IPD 0.35% (0.001), Emergencies 7.31% (0.001), and Maternal death 57.29% (0.001). This is shown in Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTable showing the impact of interns on the relationship between the mean number of interns present and their absence.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eObserved\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExpected\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%change\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\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\u003eOPD\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eIPD\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eElectives\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eEmergencies\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMD\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eOB outcomes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18227\u003c/p\u003e\u003cp\u003e16652\u003c/p\u003e\u003cp\u003e295\u003c/p\u003e\u003cp\u003e7650\u003c/p\u003e\u003cp\u003e96\u003c/p\u003e\u003cp\u003e1051\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21784\u003c/p\u003e\u003cp\u003e16710\u003c/p\u003e\u003cp\u003e754\u003c/p\u003e\u003cp\u003e8209\u003c/p\u003e\u003cp\u003e151\u003c/p\u003e\u003cp\u003e1130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-19.51%\u003c/p\u003e\u003cp\u003e-0.35%\u003c/p\u003e\u003cp\u003e-155.59%\u003c/p\u003e\u003cp\u003e-7.31%\u003c/p\u003e\u003cp\u003e-57.29%\u003c/p\u003e\u003cp\u003e-7.52%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003eOutpatient services\u003c/h2\u003e\u003cp\u003eWhile studying outpatient attendance, a general decline in total outpatient attendance was noted compared with the mean of the two periods with interns present. This could have been due to the redistribution of the workforce (specialists, residents, medical officers) to attend inpatients and emergencies, cancellation of elective outpatient visits, and all mitigation strategies to reduce the adverse effects of strikes(Stoye \u0026amp; Warner, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Ruiz reported a similar finding in the UK(Ruiz, Bottle, \u0026amp; Aylin, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The intern strike was nationally publicized, which could have deterred clients from attending elective clinics.(Scanlon et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)However, we noted only a slight decline in patient attendance at the different clinics: the ACU, the oncology clinic, ANC, and the Gyn Clinic. This could be attributed to the fact that these clinics were primarily run by midwives, residents, and medical officers, so the absence of intern doctors did not affect their operations.\u003c/p\u003e\u003cp\u003eAdmissions in the hospital registered a slight decline of 0.35%. The slight decline could have been due to the cancellation of elective admissions and prompt review and definitive management of those who attended the emergency unit by the specialist residents and medical officers, reducing unnecessary and inappropriate admissions(San Jose-Saras et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). A study in Kenya also revealed that pregnant patients during strikes were more likely to deliver in private centres and at home, another possible explanation for the slight decline(Coughtrey-Davenport, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Notably, the special care unit, labor suite, and gynecological emergency did not significantly change across the periods; however, there was a gradual increase in admissions in the acute care ward from 27.9 to 32.3 to 37.5 and a decrease in admissions in the HDU from 35.6 to 31.6. This could be attributed to the fact that patients still access obstetric and neonatal services entirely, as this is independent of staff availability. The increase in the ACU is attributed to the sensitization of the service to the public, as it was not fully utilized earlier. At the same time, the decrease in the HDU was due to prompt and appropriate management of patients at different care points, mitigating adverse conditions that could warrant HDU admission.\u003c/p\u003e\u003cp\u003eElective procedures had a significant decline of over 155%. This could have been due to the suspension of outpatient booking clinics and the cancellation of elective admissions. Additionally, the workforce was redistributed to cater to emergencies. This finding was similar to that of a study performed after a one-day strike in NHS hospitals in 2012(Ruiz et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe hospital registered a decline in emergency procedures performed by 7.31%. The strike of the country-wide interns could have prompted medical officers and specialists to increase their presence, reducing referral admissions at Kawempe National Referral Hospital. The decline in elective procedures did not translate into increased emergency procedures, probably because clients decided to seek care in private institutions. This was highlighted in a study by Coughtrey-Davenport, which reported an increase in delivery services during strike periods in private facilities, while the increase was realized in public facilities upon the end of the strike and full operationalization (Coughtrey-Davenport, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The number of emergency procedures performed increased with the number of perineal and cervical tears (28.8\u0026ndash;39.8 and 27.1\u0026ndash;40.5, respectively). This could have been directly related to the absence of interns, which led to gaps in obstetric monitoring of the mothers in labour. This was also the finding of Atuyambe et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) that intern students were compassionate and caring as they participated in patient care, leading to better patient care (Atuyambe et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). There was an increase in the number of emergency caesarian sections (31.3\u0026ndash;34.8), which could be explained by the fact that specialists were quick at making delivery decisions for mothers. There was a decrease in vacuum deliveries (52.1\u0026ndash;14.5), which could be because of the improvement in quick decision-making for delivering mothers and avoiding the need for vacuum extraction. This finding is comparable to that of a study by Salazar, which revealed a shorter length of stay in the emergency department when serious residents were replaced by physicians(Salazar et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThere was an increase in the performance of elective procedures such as TAH (23.8\u0026ndash;51.5), vasectomy (1\u0026ndash;99), and elective c-section (24.1\u0026ndash;35.8). The specialists fully managed the wards; hence, they were able to identify in a timely manner the mothers and patients who needed the elective procedure and prescribed it.\u003c/p\u003e\u003cp\u003eFor patient outcomes such as discharge, the difference was minimal in line with admissions; however, there was a decrease in maternal deaths during the period with no interns, and the number increased after return (27.4 to 24.1 to 48.5). This could be because specialists provided timely interventions. However, they did not mentor the interns well enough to manage the mitigation of the outcome, which sided with the findings of Capinpuyan et al., who reported that internship programs sometimes leave interns unsupervised by the seniors, leading to medical errors and gaps in quality health care delivered(Capinpuyan \u0026amp; Miguel, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) because they are seen as supplements to low staff solutions, forgetting that they are still learning. Other studies have highlighted clinical teachers' challenges, such as Wilkerson (1998), who reported that specialists who are expected to engage in clinical teaching may not have received prior formal teaching training(Olasoji, Mu'azu, \u0026amp; Garba, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and that the heavy workload associated with emergency departments(Quinn et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) hinders their capacity to teach their interns, affecting patient care adequately. There was an increase in referrals (35\u0026ndash;37.7), which could have been a way of managing the overwhelming number of patients who attended Kawempe National Referral Hospital at the time; hence, more mothers were sent to Mulago Specialized Women\u0026rsquo;s and Neonatal Hospital and other specialized centers.\u003c/p\u003e\u003cp\u003eDelivery outcomes significantly decreased in FSB (42.2\u0026ndash;29.5), MSB (45.3\u0026ndash;33.7), and LNND (38.6\u0026ndash;25.9), and no significant changes in ENND were detected. This was attributed to better obstetric management of the mothers during labour, which improved outcomes. This was in line with a study by Nakibuuka et al. (2012) that showed that the level of knowledge and expertise of human resources contributed to the number of perinatal deaths in hospitals; thus, interns may have had limited knowledge, which could have caused the increase in the number of perinatal deaths. The specialists have more expertise, hence decreasing their presence.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe presence or absence of medical interns affected the hospital metrics during the study periods at Kawempe National Referral Hospital.\u003c/p\u003e\u003cp\u003eThe presence or absence of medical interns affected patient outcomes at Kawempe National Referral Hospital.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe Ministry of Health, the National Internship Committee, and the Ministry of Finance should develop policies that ensure the uninterrupted deployment of medical interns in public facilities.\u003c/p\u003e\u003cp\u003eThe Ministry of Health and the National Internship Committee should collaborate with medical training institutions and the Federation of Uganda Medical Interns to develop sustainable strategies for ensuring the continued deployment of medical interns at public facilities.\u003c/p\u003e\u003cp\u003eFollow-up studies to determine whether the presence or absence of medical interns affects the quality of care of patients and those that explain the observed changes in this study should be carried out.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACU: Acute Care Clinic\u003c/p\u003e\n\u003cp\u003eANC: Antenatal Clinic\u003c/p\u003e\n\u003cp\u003eENND: Early neonatal death\u003c/p\u003e\n\u003cp\u003eFSB: fresh still birth\u003c/p\u003e\n\u003cp\u003eKNRH \u0026nbsp; \u0026nbsp; Kawempe National Reference Hospital\u003c/p\u003e\n\u003cp\u003eLNND: late neonatal death\u003c/p\u003e\n\u003cp\u003eL/S: Labour suite\u003c/p\u003e\n\u003cp\u003eMD: Maternal death\u003c/p\u003e\n\u003cp\u003eMOH \u0026nbsp; \u0026nbsp; \u0026nbsp;Ministry of Health\u003c/p\u003e\n\u003cp\u003eMSB: Macerated Still Birth\u003c/p\u003e\n\u003cp\u003eSCU: Special Care Unit\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e\n\u003cp\u003eNICU: Neonatal intensive care unit\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSource of funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by Kawempe National Referral Hospital Kampala.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this study are available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eauthor's contribution.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJLN and MNM designed the study, conducted the data collection, cleaned and analysed the data, and drafted the manuscript. MGN and HS supervised all stages of the study, from conceptualization of the topic to manuscript writing and submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval and a waiver of consent were obtained from the Mildmay Uganda Research and Ethics Committee (MUREC). Approval was sought from the Uganda National Council of Science and Technology (UNCST). Administrative clearance was obtained from Kawempe National Referral Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA consent form was filled out by the respondents after they explained the purpose of the study to them. Anonymity and confidentiality were strictly observed during data collection, description, and reporting of findings. Written informed consent forms were provided, and the confidentiality of all the information about the respondents was communicated and maintained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor biography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Joel Lwasa Njagala is a medical doctor at Kawempe National Referral Hospital Kampala.\u003c/p\u003e\n\u003cp\u003eDr. Mabel Nekesa Mirembe, a medical doctor at Kawempe National Referral Hospital Kampala.\u003c/p\u003e\n\u003cp\u003eDr. Henry Ssenyondo is a medical doctor at Kawempe National Referral Hospital Kampala.\u003c/p\u003e\n\u003cp\u003eMs. Mary GraceNaggita is a nurse at Kawempe National Referral Hospital Kampala.\u003c/p\u003e\n\u003cp\u003eDr Emmanuel K Byaruhanga. is the Executive Director at Kawempe National Referral Hospital Kampala.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAtuyambe, L. M., Baingana, R. K., Kibira, S. P., Katahoire, A., Okello, E., Mafigiri, D. K., . . . Muggaga, K. (2016). Undergraduate students\u0026rsquo; contributions to health service delivery through community-based education: A qualitative study by the MESAU Consortium in Uganda. \u003cem\u003eBMC medical education, 16\u003c/em\u003e, 1-11.\u003c/li\u003e\n \u003cli\u003eCapinpuyan, A. L. C., \u0026amp; Miguel, R. T. D. (2019). Ethical Challenges in Medical Community Internships: Perspectives from Medical Interns in the Philippines. \u003cem\u003eHealth Hum Rights, 21\u003c/em\u003e(1), 141-147.\u003c/li\u003e\n \u003cli\u003eCoughtrey-Davenport, T. (2017). When the Health System Fails You: Maternal Care Under Kenya\u0026rsquo;s 2017 Nurses\u0026apos; Strike.\u003c/li\u003e\n \u003cli\u003eIbrahim, J. E., Jeffcott, S., Davis, M. C., \u0026amp; Chadwick, L. (2013). Recognizing junior doctors\u0026apos; potential contribution to patient safety and health care quality improvement. \u003cem\u003eJournal of health organization and management, 27\u003c/em\u003e(2), 273-286.\u003c/li\u003e\n \u003cli\u003eKisling, L. A., \u0026amp; Das, J. M. (2022). Prevention strategies. In \u003cem\u003eStatPearls [internet]\u003c/em\u003e: StatPearls Publishing.\u003c/li\u003e\n \u003cli\u003eOlasoji, H. O., Mu\u0026apos;azu, A. B., \u0026amp; Garba, M. H. (2019). A study of clinical teachers\u0026apos; attitude to teaching and perceived learning needs in a medical college in Nigeria. \u003cem\u003eAdv Med Educ Pract, 10\u003c/em\u003e, 605-617. doi:10.2147/amep.S171550\u003c/li\u003e\n \u003cli\u003eQuinn, A., Gottlieb, M., Chan, T. M., Nickson, C. P., Mitzman, J., Natesan, S., . . . Messman, A. (2019). Curated Collections for Educators: Five Key Papers on Clinical Teaching.\u0026nbsp;\u003cem\u003eCureus, 11\u003c/em\u003e(11), e6084. doi:10.7759/cureus.6084\u003c/li\u003e\n \u003cli\u003eRuiz, M., Bottle, A., \u0026amp; Aylin, P. (2013). A retrospective study of the impact of the doctors\u0026apos; strike in England on 21 June 2012. \u003cem\u003eJ R Soc Med, 106\u003c/em\u003e(9), 362-369. doi:10.1177/0141076813490685\u003c/li\u003e\n \u003cli\u003eSalazar, A., Corbella, X., Onaga, H., Ramon, R., Pallares, R., \u0026amp; Escarrabill, J. (2001). Impact of a resident strike on emergency department quality indicators at an urban teaching hospital.\u0026nbsp;\u003cem\u003eAcad Emerg Med, 8\u003c/em\u003e(8), 804-808. doi:10.1111/j.1553-2712.2001.tb00210.x\u003c/li\u003e\n \u003cli\u003eSan Jose-Saras, D., Vicente-Guijarro, J., Sousa, P., Moreno-Nunez, P., Espejo-Mambi\u0026eacute;, M., \u0026amp; Aranaz-Andres, J. M. (2023). Inappropriate Hospital Admission According to Patient Intrinsic Risk Factors: an Epidemiological Approach. \u003cem\u003eJ Gen Intern Med, 38\u003c/em\u003e(7), 1655-1663. doi:10.1007/s11606-022-07998-0\u003c/li\u003e\n \u003cli\u003eScanlon, M. L., Maldonado, L. Y., Ikemeri, J. E., Jumah, A., Anusu, G., Bone, J. N., . . . Christoffersen-Deb, A. (2021). A retrospective study of the impact of health worker strikes on maternal and child health care utilization in western Kenya. \u003cem\u003eBMC Health Serv Res, 21\u003c/em\u003e(1), 898. doi:10.1186/s12913-021-06939-7\u003c/li\u003e\n \u003cli\u003eStoye, G., \u0026amp; Warner, M. (2023). The effects of doctor strikes on patient outcomes: Evidence from the English NHS. \u003cem\u003eJournal of Economic Behavior \u0026amp; Organization, 212\u003c/em\u003e, 689-707. doi:https://doi.org/10.1016/j.jebo.2023.06.011\u003c/li\u003e\n \u003cli\u003eVance, G., Jandial, S., Scott, J., \u0026amp; Burford, B. (2019). What are junior doctors for? The work of Foundation doctors in the UK: a mixed methods study. \u003cem\u003eBMJ Open, 9\u003c/em\u003e(4), e027522. doi:10.1136/bmjopen-2018-027522\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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical interns, Healthcare delivery, Internship program, Kawempe National Referral Hospital","lastPublishedDoi":"10.21203/rs.3.rs-7922459/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7922459/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the World Health Organization (WHO), quality of care is how health services in a given population yield desirable outcomes and align with evidence-based professional knowledge. This study aimed to assess the impact of medical interns on healthcare delivery at Kawempe National Referral Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a cross-sectional study with three time points at Kawempe National Referral Hospital (KNRH), a national referral hospital for obstetrics and gynaecology. All patient records for the two time periods were reviewed, and the data were exported for statistical analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdmissions in the hospital registered a slight decline of 0.35%, whereas the hospital register registered a decline in emergency procedures performed by 7.31%. There was an increase in the performance of elective procedures such as TAH (23.8 to 51.5%), vasectomy (1 to 99%), and elective c-section (24.1 to 35.8%). There was a decrease in maternal deaths during the period with no interns, and the number increased after return (27.4% to 24.1% to 48.5%). There was an increase in referrals (35 to 37.7%). Delivery outcomes included a significant decrease in FSB (42.2% to 29.5%), MSB (45.3% to 33.7%), and LNND (38.6% to 25.9%). Delivery outcomes included a significant decrease in FSB (42.2% to 29.5%), MSB (45.3% to 33.7%), and LNND (38.6% to 25.9%), and a decrease in vacuum deliveries (52.1 to 14.5%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe presence or absence of medical interns affected the hospital metrics during the study periods at Kawempe National Referral Hospital.\u003c/p\u003e\n\u003cp\u003eThe presence or absence of medical interns affected patient outcomes at Kawempe National Referral Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ministry of Health, the National Internship Committee, and the Ministry of Finance should develop policies that ensure the uninterrupted deployment of medical interns in public facilities.\u003c/p\u003e","manuscriptTitle":"Assessing the Impact of Medical Interns on Healthcare Delivery at Kawempe National Referral Hospital. A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-03 11:32:52","doi":"10.21203/rs.3.rs-7922459/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-01T19:13:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-21T20:42:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-12T05:17:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315162832575315955109319032420212361255","date":"2025-12-03T15:29:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241249141389219382000197927227576307290","date":"2025-12-02T06:48:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-01T13:52:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-01T15:25:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-30T03:39:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-30T03:38:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-10-22T10:18:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d92baa62-d0ff-466d-a5b6-82912e0740ee","owner":[],"postedDate":"December 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-01T19:23:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-03 11:32:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7922459","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7922459","identity":"rs-7922459","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}