Working to save babies – and mothers – in Uganda

Faith* was seven months pregnant with triplets when she arrived at Kiwoko Hospital in premature labor. She had come to the hospital in Central Uganda's Nakaseke District for a simple reason: it’s famous for the quality care it provides sick and small newborns. Shortly after arriving, Faith delivered the babies. Three weeks later – after the infants had escaped danger, growing and developing under the watchful eye of Kiwoko’s expert staff – Faith was able to take her healthy babies home.

When facilities are able to provide quality maternal and newborn care, stories of success like Faith’s become the norm. Women are provided with the care they need before, during, and after birth; newborns have access to high-quality interventions through dedicated newborn units; parents receive support when taking their newborns home; and families and communities thrive. But because not all hospitals are like Kiwoko, not all stories are like Faith’s.

At Adara, we understand the acute need to innovate, so we can save the lives of women and children. In Uganda, we began focusing on newborn care when very few neonatal units even existed. In our last two decades doing this work, we have seen significant improvements in newborn health. But despite this progress, Uganda is not on track to reach the Sustainable Development Goal (SDG) target of only 12 deaths per 1,000 births by 2030. Instead, the most recent data from The Lancet predicts that by then, Uganda will still experience 21.9 deaths for every 1,000 births. The question, then, must become: how can organizations, governments, and individuals support Uganda and other countries with a similar trajectory to achieve the SDG? How can we have more stories that are like Faith’s?

Health workers like Sister Christine Otai know the answer. When she first began working with Kiwoko Hospital in 1989, the hospital had a small maternity ward with a handful of beds and no specialized newborn unit. Now, the hospital has a newborn unit that is recognized by the Ugandan Ministry of Health as a Center of Excellence for maintaining high survival rates while admissions have grown exponentially. As Sister Christine says, “This work has saved the lives of many mothers and babies.”

The secret to its success is an evidence-based model that provides support to mother and baby from the time of pregnancy through the moment they return home after birth. It includes everything a nurse needs to provide quality care: appropriate staff-to-patient ratios, training and mentorship, equipment, supplies, biomedical engineering, and infrastructure. It also encompasses processes and procedures to maintain focus on quality of care through quality of care committees and continuing medical education.

Since 1999, we have partnered with Kiwoko Hospital to significantly improve maternal and child survival throughout Uganda. At Kiwoko Hospital, we worked together to introduce, in 2000, a newborn unit that was later expanded to accommodate increasing admissions. In the nine years following its expansion, maternity ward admissions rose by almost 50 percent, and admissions in the newborn unit rose by 168 percent, including the admission of many babies born outside the hospital who were at greater risk of death. Despite this rapid growth, maternal deaths as a proportion of births fell by 50 percent and newborn survival rates remained above 89 percent over this period. Also during this time, babies born weighing less than 2.5kg have consistently maintained an 88 percent survival rate or better, except for a period during COVID-19, when survival rates decreased (the reasons for this decrease were recently explored in a research article, here.)

The model we have pioneered at Kiwoko Hospital – called AdaraNewborn – includes five arms of care: antenatal, intrapartum, inpatient, postpartum, and follow-up. We deliver ongoing comprehensive training programmes and mentorship for staff, as well as quality improvement systems and governance strengthening. Our clinical training begins with the essentials of care, ensuring that nurses always understand the “why” behind the care they are providing, and building incrementally as the basics are mastered. Our global team of nurses and clinicians have contributed to the establishment of clinical guidelines and comprehensive training programs that provide practical guidance for the provision of quality care. In rolling out these programs, we have learnt the importance of keeping staff with the right skills in the right place. This means not continuously rotating nurses after receiving specialized training, as is a common practice in Ugandan health facilities, and developing and delivering continuing medical education programs.

We have also ensured the Kiwoko newborn unit has the right infrastructure to enable stable power for life-saving machines and equipment. As is the case with any rural hospital, this is critical, and goes hand-in-hand with biomedical engineering, to facilitate proper maintenance and uninterrupted operation of vital equipment.

By using this holistic approach, staff feel well-supported and begin to see positive outcomes. This, in turn, builds confidence, hope, and the knowledge that they can save lives and truly make a difference. By inspiring nurses and midwives to become champions of newborn health, we can drive continued, sustainable change. According to Adara’s Senior Clinical Advisor, Heidi Nakamura, the combination of these interventions is powerful. “Together, they create a sense of hope,” she says. “The first time a nurse sees a small baby survive and go home in their mother’s arms, they begin to have hope. It’s hope that builds passionate staff, and it’s passionate staff that save lives.”

Dr James Nyonyintono, Surgeon and Clinical Programs Manager at Kiwoko Hospital, agrees a hopeful and dedicated staff are key: “There are many reasons for Kiwoko’s success but one of the biggest is the committed, passionate and available staff we have. They love looking after babies. We have good teamwork and staff are encouraged to participate in decision making regarding their work. Training is another factor – especially training focused on problem solving. When we identify gaps, we carry out frequent training and this motivates staff; they can see how it benefits not only themselves but their patients. We also have a culture of continuous improvement. We provide constructive feedback which promotes accountability, and we review every perinatal death. As well as that, we analyze the newborn unit data to identify trends and see how we can do better.”

Facilities in Uganda are looking to Kiwoko Hospital as an example of what is possible in newborn health. In recent years, health workers and organizations have traveled to the hospital to learn about the newborn unit and receive training from their experienced and knowledgeable staff. After visiting the unit, one health worker commented: “When we visited Kiwoko, we got so challenged by the high standard of infection control, staff commitment, and good patient management [that] we returned with determination to make a difference!"

For the past five years, we have also worked with our second AdaraNewborn site, the public hospital Nakaseke Hospital, demonstrating impressive improvements in survival rates. We now have ambitious plans to expand our AdaraNewborn model across 10 facilities in Uganda over the next decade, with the goal of halving newborn mortality and stillbirths in these facilities.

In partnership with the Government of Uganda and other implementation partners, we will strengthen two regional Centers of Excellence that will work with surrounding target hospitals, health centers and community health systems. We will also continue to work closely with the National Newborn Steering Committee who champion newborn health throughout Uganda. To facilitate the adoption of best practices across the 10 AdaraNewborn sites, and to encourage the uptake of the model in other health facilities beyond these sites, we will maintain an open-access online knowledge sharing platform for the duration of the program. The platform will include curriculum, program packages, and guidelines of care.

Through AdaraNewborn, we will strengthen the Ugandan health system and support sustainable systems change. This will save lives now and help reduce maternal and newborn deaths and morbidity into the future. With excellence, with hope, and with passion, we will continue working to help Ugandans deliver stories like Faith's.

*Name has been changed.