PhD defence Brian Turigye

Supervisors

• Prof. dr. Lenka Benova (ITM)

• Dr. Peter M. Macharia (ITM)

• Prof. dr. Edgar Mugema Mulogo (Mbarara University of Science and Technology, (MUST), Uganda)

• Prof. dr. Joseph Ngonzi (MUST, Uganda)

Abstract

Despite major gains in facility-based childbirth in Uganda, maternal and newborn mortality remain unacceptably high, suggesting that increased service utilisation has not been matched by sufficient improvements in quality of care. This thesis assessed the quality of obstetric and newborn care in Uganda, with a specific focus on effective coverage, evidence-based intrapartum care, facility readiness, and geographic accessibility to childbirth services in Midwestern Uganda.

The thesis used a multi-method quantitative design organised in two phases. The first phase generated national-level evidence through a scoping review of published studies on the quality of maternal and newborn care in Uganda and an effective coverage analysis linking the 2022 Uganda Demographic and Health Survey with the 2023 Harmonised Health Facility Assessment. The second phase generated subnational evidence from Kasese and Bundibugyo districts through a retrospective review of childbirth records, a census facility readiness assessment of 42 public facilities, and geospatial modelling of travel time to nearest, utilised, and referral childbirth facilities.

Findings show that Uganda’s high facility birth coverage masks substantial deficits in quality of care. Although 85.9% of women gave birth in health facilities, only 47.8% delivered in facilities classified as ready, and only 14.0% received all ten selected recommended maternal and newborn interventions. Evidence from the scoping review showed persistent quality gaps over two decades, especially in lower-level public facilities, including inadequate staffing, weak referral systems, poor infrastructure, stock-outs, incomplete documentation, and deficits in respectful care. At the subnational level, in Kasese and Bundibugyo, overall facility readiness was 53.3%, while availability of emergency obstetric and newborn signal functions was low (42.3%). Evidence-based intrapartum practices were inconsistently documented, with particularly low coverage of blood pressure monitoring and newborn examination before discharge. Geographic modelling showed that only about half of women were within 30 minutes of a childbirth facility, 34.9% bypassed the nearest facility, and referral pathways increased travel time, with poorer and rural women experiencing the greatest access disadvantage.

This thesis demonstrates that facility birth alone is an insufficient marker of maternal and newborn health system performance. Improving outcomes requires strengthening lower-level public facilities, functionalising referral systems, improving workforce capacity and supplies, embedding effective coverage metrics into routine monitoring, and using equity-sensitive spatial planning to ensure timely access to high-quality childbirth care.