Uganda Pre-Eclampsia

Interventional
Framework
 Uganda Pre-Eclampsia
Interventional Framework
 Foreword

The pre-eclampsia
interventional framework
will provide a basis for
tracking implementation
and assessment of
achievements against
targets, with the overall
aim of reducing the
maternal and neonatal
morbidity and mortality
due to pre-eclampsia.

In Uganda pre-eclampsia is the second leading cause of maternal mortality at 15%, after postpartum
haemorrhage (PPH) that causes 45% of the maternal deaths (MPDSR Report 2020/2021). The Ministry of
Health (MoH) formed the National Safe Motherhood Expert Committee (NASMEC) with constituent sub-
committees that include the Pre-eclampsia subcommittee, to try and address the very high maternal and
perinatal morbidity and mortality due to pre-eclampsia and other hypertensive disorders in pregnancy. The
Pre-eclampsia subcommittee has since embarked on several activities including pre-eclampsia awareness
creation; participate in reviews and audits of pre-eclampsia related deaths nationally; conducted a national
survey on the prevention and management practices of pre-eclampsia as well as developing the pre-
eclampsia intervention frame work.

The pre-eclampsia interventional framework will provide a basis for tracking implementation and assessment
of achievements against targets, with the overall aim of reducing the maternal and neonatal morbidity
and mortality due to pre-eclampsia. The framework has been designed to provide updated, practical and
useful information in monitoring and evaluation, data collection, management and lastly implementation
arrangements for the prevention and management of pre-eclampsia and eclampsia. The frame work
requires active involvement of all stake holders right from policy and advocacy level to the clinical teams
involved in patient care.

I want to appreciate the NASMEC Pre-eclampsia subcommittee members, partners and all stakeholders that
contributed towards the development of this framework.

Dr. Olaro Charles

Director Health Curative Services, Ministry of Health

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 Acknowledgements

I would like to
acknowledge the
Ministry of Health
for supporting the
NASMEC Pre-eclampsia
subcommittee to deliver
its mandate and UNICEF
for funding the frame
work development
processes.

I would like to acknowledge the Ministry of Health for supporting the NASMEC Pre-eclampsia subcommittee to
deliver its mandate and UNICEF for funding the frame work development processes. In the same light, I would like to
appreciate and acknowledge the technical people who participated in the development of the frame work: Dr Jackline
Akello (Nebbi Hospital), Dr Sarah Nakubulwa (Makerere University), Dr Musa Sekikubo (Makerere Uinversity),
Dr Moses Adroma (Makerere University), Dr Charles Irumba (Bukuku Health Centre IV), Dr Agery Bameka
(Buwenge General Hospital), Ms Rehema Nabuufu (Kawempe National Referral Hospital), Mr Julius
Ssendiwala (Monitoring & Evaluation Specialist), Dr Patricia Pirio (UNICEF), Ms Grace Latigi (UNICEF) and
Dr. Atnafu Getachew Asfaw (UNICEF).

Finally, acknowledgements go to our regional pre-eclampsia champions across the country for their
contribution towards development of this frame work and for enthusiastically participating in all the subcommittee
activities.

Together we can significantly reduce maternal and perinatal deaths due to pre-eclampsia.

Prof Annettee Nakimuli, Obstetrician and Gynaecologist

Dean School of Medicine, Makerere University, College of Health Sciences
Chair, NASMEC Pre-eclampsia Sub Committee

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 Contents

FOREWORD i
ACKNOWLEDGEMENTS ii
ACRONYMS AND ABBREVIATIONS iv

1.0 INTRODUCTION 1
1.1 Background 1
1.2 Goal 1
1.3 Objectives 1

2.0 MONITORING AND EVALUATION 2

3.0 SCOPE 5

4.0 M&E MATRIX 6

5.0 DATA COLLECTION AND MANAGEMENT 21

5.1 Routine data sources 21
5.1.1Health Management Information System (HMIS) 21
5.1.2 Logistics management information system (LMIS) 21
5.1.3 The Integrated Human Resource Information System (iHRIS) 21
5.2 Non-routine Data Sources: 21
5.2.1Uganda Demographic and Health Survey Population survey (UDHS) 21
5.2.2 Periodic Cross-sectional surveys 21
5.2.3 The Annual Health Sector Performance Report (AHSPR) 22
5.3 Other data sources 22
5.4 Data Flow 23
5.5 Data Quality and management 24

6.0 IMPLEMENTATION ARRANGEMENTS 25

6.1 Stakeholder roles and responsibilities 25
6.2 Dissemination and information use 26

APPENDIX 1: PROFORMA FOR PREECLAMPSIA /ECLAMPSIA / OTHER

HYPERTENSIVE DISORDERS OF PREGNANCY FOR 8 HOUR SHIFT 27

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 Acronyms & Abbreviations

AHSPR Annual Health Sector Performance Report

ANC Antenatal Care
AO Anaesthetic Officer
APH Antepartum Haemorrhage
AMSTL Active Management of the Third Stage Labour
BEMONC Basic Emergency Obstetric and Newborn Care
BIS Blood Information System
CEMONC Comprehensive Emergency Obstetric and Newborn Care
CFR Case Fatality Rate
CHAI Clinton Health Access Initiative
CPD Continuous Professional Development
CSO Community Service Organization
DDM Data decision making
DHIS2 District Health Information System 2
EMHSLU Essential Medicines and Health Supplies List for Uganda
EML Essential Medical List
EMONC Emergency Obstetric and Newborn Care
ETOO Essential Training in Operative Obstetrics
GH General Hospitals
HC Health Centre
HELLP Hemolysis, Elevated Liver enzymes, Low Platelets
HF Health Facility
HRH Human Resources for Health
HW Health Worker
HMIS Health Management Information System
IEC Information, Education, and Communication
iHRIS Integrated Human Resource Information System
IP Implementing Partner
IR Intended Result
M&E Monitoring and Evaluation
MMR Maternal Mortality Ratio
MNAH Maternal Neonatal Adolescent Health
MNH Maternal Neonatal Health
MO Medical Officer
MOH Ministry of Health
MPDSR Maternal Perinatal Death Surveillance Response
NASMEC National Safe-Motherhood Expert Committee
NDA National Drug Authority
NMS National Medical Stores
NASG Non-Pneumatic Anti-Shock Garment
OH Obstetric Haemorrhage
PET Pre-eclampsia
QI Quality Improvement
RMNCAH Reproductive Maternal Neonatal Child Adolescent Health
SDP Service Delivery Point
SF Signal Function
sPET Pre-eclampsia with severe features
SO Strategic Objective
SOP Standard Operating Procedure
TBD To Be Determined
TOR Terms of Reference
TXA Tranexamic Acid
UBTS Uganda Blood Transfusion Services
UDHS Uganda Demographic and Health Survey
UMA Uganda Manufacturers’ Association
UNHLS Uganda National Health Laboratories
USAID United States Agency for International Development
UN United Nations
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund

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1.0
Introduction

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1.1 Background

Uganda’s maternal mortality ratio reduced from 438 (UDHS2011) to 336 per 100,000 live births (UDHS
2016) while perinatal mortality has stagnated and contributes 42% of all under-5 mortality. The leading
causes of maternal mortality are; post-partum haemorrhage (PPH), hypertensive disorders of pregnancy
(HDP) and puerperal infections. Conversely, birth asphyxia, complications of prematurity and infections are
the leading causes of perinatal mortality. In Uganda pre-eclampsia is the second leading cause of maternal
mortality at 15%, after PPH that causes 45% of maternal deaths (MPDSR Report 2020/2021).

The burden of pre-eclampsia has been demonstrated in several studies in Uganda. A prospective cohort
study among 403 women with hypertensive disorders of pregnancy found that the case-specific maternal
mortality ratio was 780 per 100,000 live births for all hypertensive disorders;1940 per 100,000 live births
for severe pre-eclampsia and 501 per 100,000 live births for eclampsia (Nakimuli et al, 2016). The case-
fatality ratio was 5.1 % for all hypertensive disorders in pregnancy and this was 8 times higher for eclampsia
compared to severe pre-eclampsia. Kiondo et al, 2012, documented risk factors for pre-eclampsia in
Uganda which included chronic hypertension, low education levels, primi parity and parity of five or more.
A study in southwestern Uganda (Nabulo et al, 2021) found that myths and misconceptions about pre-
eclampsia and eclampsia, late antenatal attendance, low awareness and limited or no surveillance of pre-
eclampsia as the main contributing factors to mortality due to pre-eclampsia.

Several interventions have been proposed to prevent and manage pre-eclampsia and eclampsia. These
include improving community awareness and prevention, early diagnosis and timely intervention, early
detection and management of any complications, availability and administration of life saving drugs,
deciding on delivery plan and early referrals where necessary (Lassi, 2015). There is a need to monitor the
implementation of these interventions and how they contribute to maternal and perinatal outcomes. This
interventional framework will provide the basis for tracking implementation and assessment of achievements
against the targets (Micha, 2017).

1.2 Goal

To reduce maternal and perinatal morbidity and mortality attributed to pre-eclampsia and other hypertensive
disorders in pregnancy in Uganda

1.3 Objectives

1. To improve leadership, accountability, advocacy and policy environment for the management of maternal
and new-born health with focus on Pre-eclampsia and other hypertensive disorders of pregnancy.
2. To institute preventive mechanisms for Pre-eclampsia and other hypertensive disorders of pregnancy at
all levels of the health care system.
3. To improve access to essential commodities and supplies for the management of Pre-eclampsia and
other hypertensive disorders of pregnancy.
4. To improve overall clinical management of pre-eclampsia and other hypertensive disorders of pregnancy.
5. To create community awareness of Pre-eclampsia and other hypertensive disorders of pregnancy

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2.0
Monitoring & Evaluation

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Monitoring and auditing of interventions allow health care providers to ascertain the extent to which standards
are being met, goals accomplished, activities performed according to requirements, and to identify aspects
that may need improvement. This includes the regular evaluation of facility compliance with regulations and
set standards, and identification of actions that need reinforcement or a change in strategies, as well as
successful experiences at all levels of the healthcare system. Doing this helps to create a “monitoring and
learning” culture.

Monitoring, evaluation and feedback will provide information required to effectively track and guide the pre-
eclampsia program implementation, improving effectiveness and efficiency of programs, promote learning
and guide decision making. This will include documentation of successful interventions, challenges, gaps in
implementation of pre-eclampsia and other HDP interventions. To conduct effective monitoring, evaluation
and feedback, there is need to establish benchmarks upon which monitoring, and evaluations will be based.
Data for key performance indicators should be routinely collected and analysed to monitor pre-eclampsia
program outputs at all levels of the monitoring and evaluation (M&E) result chain as shown in figure 1 below.

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 Inputs & processes Outputs Outcomes Impact

Improved Reduced
Medical Intervention
management Maternal
supplies Health access & Service
of and Perinatal
Indicator Workforce SOPs readiness.
preeclampsia/ Morbidity
IEC materials Quality, safety,

Financing
eclampsia and and Mortality

Governance
Information and Efficiency
other HDP due to PET

Data
Health facility / community assessments
Collection

Analysis
and Service and data quality assessments and program evaluations
synthesis

Figure 1: M&E Result Chain

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The following steps will guide in monitoring/auditing and providing feedback on the performance of the
PET program.

a) Planning: This will involve identifying key elements for monitoring and the indicators which will be
used to effectively track and guide program implementation, improve efficiency and effectiveness of
programs. The indicators for monitoring inputs, processes, outputs and outcomes have been developed.

b) Monitoring: The key elements for monitoring of program implementation will include (i) Inputs as well as
their efficient and effective use in the various program areas; (ii) Processes/activities being implemented
vis-à-vis the planned activities and timeliness of implementation of the various program activities and
(iii) Level of involvement of various stakeholders along the continuum of health care delivery. To monitor
performance, routine data collection and reporting will be guided by the REAP strategic framework.
Data sources will include National HMIS, support supervision and mentorship reports and evaluation
results.

c) Evaluation: Periodic evaluations will examine questions related to activity implementation. Programmatic
success will be analyzed using routinely collected data and feedback from stakeholders. The identified
best practices and lessons learnt will form a basis for recommendations and scale-up of interventions.
The evaluation questions will include (i) To what extent are planned activities actually realized, (ii) How
well are the PET interventions implemented, (iii) What outcomes were observed, (iv) Do PET interventions
make a difference? To answer some of these questions, the program will conduct baseline assessments
and follow-on periodic re-assessments.

d) Information dissemination: At all levels, quarterly performance review meetings will be held to review
progress of program implementation. Data from the various sources will be aggregated and analyzed
periodically to produce program reports which will be shared with all key stakeholders and implementing
partner.

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3.0
Scope

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 The framework will streamline and monitor activities implemented at the various levels of the health care delivery system. The impact of these strategies will
be monitored and evaluated at all levels to ascertain their relevancy and contribution to the reduction of maternal and perinatal morbidity and mortality due
to pre-eclampsia and other hypertensive disorders.

3.1 Result Framework

Reduced maternal and perinatal morbidity and mortality attributed to preeclampsia and other hypertensive disorders of pregnancy in Uganda

Improved leadership, advocacy Established preventive Improved access to essential Improved management of Improved community awareness
accountability, and policy mechanisms for PET commodities and supplies for pre-eclampsia of PET
environment for management of management of PET
maternal and new-born health
with focus on PET

• Functional national, • Improved Risk assessment • Availability of supplies and • Improved availability of • Improved community
regional and HF • Administration of low dose commodities for the up-to-date clinical protocols awareness initiatives
subcommittee on PET aspirin to high-risk management of • Improved in-service Strengthen
• Incorporate PET prevention mothers pre-eclampsia training for Health workers in • Community health workers
and management into • Integration of hypertensive • Availability of essential PET management Improved capacity to identify and refer
sexual and reproductive disorders and PET into preventive medicines referral mechanisms high-risk pregnant mothers
health policy health education sessions during pregnancy • Improved management of
• Availability of updated • Availability of nationally pre-eclampsia Improved
guidelines on the adopted eclampsia kit for management of
management of PET the management of PET complications of
• Institute Supportive • Functional laboratory and pre-eclampsia
supervision mechanisms ultra-sound scan to • Establish QI initiatives on PET
• Increased support of data investigate complications related death and near miss
system to monitor PET at of PET reviews. Improved
all levels • Improved advocacy for postpartum follow-up for
• Functionalize all CEMONC health care financing for long term sequelae
sites to enhance PET commodities and
management of PET supplies

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Figure 2: Result Framework
4.0
M&E Matrix

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
Reduced maternal and perinatal morbidity and mortality attributed to pre-eclampsia and other hypertensive disorders of pregnancy in Uganda
Reduced Maternal mortality Number of Count the deaths 336 70 SDG UDHS every 5 Reduce PET PI, MOH,
maternal ratio per 100,000 maternal deaths from hospital 3.1 by years and other related deaths by RRH and all
and perinatal live births per 100,000 live records, DHSI2, 2030 data sources 50% by 2030 champions
morbidity and births. MPDSR, UDHS annually
mortality

Proportion of Num: Number of Review all 15% of all 7% of Midterm survey Reduce PET PI, MOH,
Maternal deaths Maternal death MPDSR reports maternal Maternal (2.5 years) related deaths by RRH and all
attributed to pre- due to Pre- to ascertain the deaths deaths by 50% champions
eclampsia eclampsia cause of death 2030
Den: Total
number of
maternal deaths.
Perinatal mortality Number of still Count the deaths 38 19 UDHS every 5 Reduce perinatal PI, MOH, RRH
rate per 1,000 births and early from hospital years and other deaths by at least and champions
births neonatal deaths records, DHSI2, data sources 50%
per 1000 births MPDSR, UDHS annually
1. To strengthen leadership, accountability, advocacy and policy environment for management of maternal and new-born health with focus on Hypertensive disorders in
pregnancy.

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
1.1 Functional Existence of Existence of Minutes 1 1 Monthly NASMEC-PET NASMEC
national, functional national functional
regional and HF PET committee national
subcommittee on committee
PET that meets on
quarterly basis
with specified TOR
Proportion of Existence of Quarterly All regions Director-RRH
regions with functional should have a
functional Safe regional Safe 0 18 committee led by
motherhood/PET motherhood/PET an obstetrician in
Minutes
committees committees that the region with
meet quarterly representation
with specified TOR from other
hospitals in the
region.

The committee
should monitor
PET and other
safe motherhood
issues
Proportion of Existence of Minutes 0 2,259 All health In-charges of
health facilities functional Health facilities facilities
with a functional facility Safe managing
safe motherhood/ motherhood/ PET should
PET committee PET committees have a PET
meet monthly with subcommittee.
specified TOR These include all
HC IIIs and IVs,
Gen hospitals, RR
Hospitals and NR
Hospitals

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
1.2 Integrate PET Revised and Evidence based Updated and 0 1 Every 2 years A comprehensive MoH
into sexual and approved SRH interventions approved SRH policy
reproductive policy with PET in regarding PET to guidelines should include
health policy place be incorporated a section on
PET NASMEC
will work closely
with the SRH
department
to review and
integrate PET into
the SRH policy
and guidelines.
Number of MPDSR MPDSR reports 0 52 weekly NASMEC-PET
reports with focus with focus on PET committee
on PET

Number of PET Policy brief Policy briefs with

focused policy should provide focus on PET
brief published progress on the 0 4 annually Dissemination of NASMEC-PET
annually implementation PET guidelines, committee
of PET prevention reports and
and management policy briefs in
guidelines, SMH conference,
challenges and PET awareness
recommendations month and
AOGU
conference,
midwives’ day
and any other
opportunities

1.3 Availability Revised and The guideline will Revised and 0 1 Once in 5 years The current MOH and
of updated approved include all aspects approved with midterm guideline is NASMEC –PET
guidelines on the guidelines in place of prevention, guidelines in review undergoing committee
management of treatment of PET, place review to include
PET and sequelae management of
complications

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
1.4 Institute Support Trained regional A team of Training report 15 18 Annually Obstetrician, MOH, NASMEC
supervision PET champion health workers and training data MO and midwife and Partners
mechanisms teams (obstetrician, MO set available for
and midwife) training/ capacity
who have had building
a refresher
TOR for regional Frequent health
training in the PET
champions worker transfers
guidelines
Number of Meet, review, Minutes, support 01 18 Quarterly All regions NASMEC
functional regional supervise and supervision and should have a
teams of PET mentor their mentorship regional team of
champions regions reports PET champions
Number of Quarterly support Support 0 4 Quarterly Quarterly MOH,
quarterly support supervision should supervision supervisions NASMEC-PET,
supervisions be instituted reports, should occur PET Champions,
conducted to lower to strengthen across the health MCH partners
level capacity for PET care delivery
management cascade

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
1.5 Support of Revised HMIS data Revision of HMIS Updated HMIS 0 3 Every 5 years with All the HMIS tools MOH, NASMEC-
data systems to tools to capture data tools to data tools which midterm review should capture PET, PARTNERS
monitor PET at all PET data (ANC, capture PET data capture PET data a minimum PET
levels Maternity and (ANC, Maternity (ANC, Maternity data set .
PNC Registers) and PNC and PNC
Registers) Registers)

Weekly reporting PET/HDP reported Revised MTRAC 0 52 weekly MOH, NASMEC-

of PET and HDP in the weekly form and report PET, PARTNERS
surveillance e
reports on MTRAC

National PET National PET 0 1 Once with possible MTRAC form NASMEC-PET,
Proforma has Proforma review after 2 will be revised to
a checklist with (Appendix 1) years track PET/HDP
variables obtained Developed and cases
Development
from history, disseminated
of a National
examination,
Proforma for PET
medications
management A National
and time of
Proforma for PET
administration,
management will
investigations
help standardize
care

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
1.6 Functionalize Proportion of Pregnant Number of health 50% 100% Annual Functional MoH
all CEMONC HC IVs providing women with center IVs that are CEMONC HC
sites to enhance CEMONC pre-eclampsia functional IVs will improve
management of managed as per accessibility
PET guidelines and timely
intervention

1.7 Advocate for Number of Advocacy meeting Policy briefs, ND 4 Quarterly Advocacy MOH
improved health advocacy will create minutes (take meeting will
financing for PET meetings held with awareness and it up as 1st inform decision NASMEC-PET
programs stakeholders. magnitude of indicator) makers about the
morbidity and need to prevent
• Parliamentary mortality due and mitigate the
committee on to PET. Costed effects of PET
health interventional and thus allocate
• Uganda women plans will be resources to
parliamentary shared with all support PET
association stakeholders to activities
• Development solicit funding
partners for the critical
(UNICEF, WHO, activities.
CDC, USAID)
Implementing
partners

2. To strengthen prevention of pre-eclampsia and eclampsia

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
2.1 Improved Risk Proportion of Pregnant women Register ND 100% Biannual Health workers Regional PET
assessment Pregnant women with any of the and are trained and champions and
assessed for PET categorizations patient can identify risk health workers
risk factors in as per guideline records factors, signs (Medical officers
antenatal. should be and symptoms and midwives)
identified and of PET
develop a
prevention plan.

Proportion of All pregnant Register ND 100% Biannual

pregnant women women with and
assessed for features of severe patient
PET signs and PET should records
symptoms be identified
and treated
appropriately
2.2 Administration of Proportion of high- All high-risk Registers and 19% 75% Bi-annual Low dose aspirin MOH NASMEC
low dose aspirin risk mothers that mothers should patient files will be supplied PET, NMS
during pregnancy received low dose receive low dose by NMS as
aspirin aspirin as per the essential ANC
guidelines medicines

2.3 Integration of Proportion of All health talks Health education 64% 100% Bi-annual IEC material will MOH NASMEC
hypertensive group health given to pregnant schedules /book be available for PET, health
disorders and education sessions women should health workers facility in
PET into health conducted in include the PET and patients charges.
education session which PET is topics
discussed
Proportion of All health talks Health education 43% 100% Bi-annual
women given given to post- schedules/book
discharge partum women
instructions and should include the
IEC materials PET topics
on signs and
symptoms of PET

Uganda Pre-Eclampsia Interventional Framework

3. Improved access to essential commodities and supplies for management of PET

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
3.1 Improved access Proportion of Sufficient stock Stock cards 18% 75 % Biannually The drugs will MOH, NMS,
to essential health facilities that can last for 3 be delivered by JMS, HF in-
preventive with sufficient months Rx Solutions, NMS, JMS a part charge
medicines during stock of low dispensing logs of the essential
pregnancy dose aspirin for medicines for
supplementation ANC
(75-150mg)

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
3.2 Availability Proportion of A pre-eclampsia Presence of the 68% 100% Biannually The components NMS, JMS and
of nationally health facilities kit should have kit in labor ward of the kit will be Maternity in-
adopted pre- with an approved magnesium supplied by NMS, charges
eclampsia kit for pre- eclampsia kit sulphate [at JMS
the management at all times least 44g (10
of PET ampoules of 5g
each)], syringes
[20mls (2),10mls
(6) and 5mls(10)],
nifedipine [at
least 80 mgs (4
tablets of 20mg)],
methyldopa [1500
mg (6 tablets
of 250mg)],
IV hydralazine
[60mg (3 vials
of 20mg)] OR
IV labetalol
[200mg (10
vials of 20mg)],
calcium gluconate
(10g), 2%
lignocaine, water
for injection, 2
urethral catheters,
1 urine bag, 3
canulae (1pink,
1 green and 1
grey), alcohol
swabs, gloves
[2pairs sterile
and 10 pairs
examination] and
plaster which
could last for at
least 24 hours.

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
3.3 Functional Proportion of all Urine dipsticks Patient treatment ND 100% Biannual The equipment MOH, NMS,
laboratory to facilities with Urine should be records to look and reagents are JMS, UNHLS,
investigate PET dipsticks at all available in all for the of results supplied by NMS Facility in-
times. ANC, labor wards and JMS and charges
and post-natal are managed
wards at all times by laboratory
(zero stock outs). personnel.

CEMONC facilities A functional 49.2% 100% Biannual

to have functional laboratory is one
laboratories that can perform
able to do basic all the basic
investigations investigations
(CBC, RFT, LFT) at related to PET at
all times all times

3.4 Functional Proportion of Emergency Presence of a ND 70% Annual Ultrasound MOH, UNHLS,
ultra-sound scan CEMONC facilities obstetric scan sonographer machines are Facility in-
to investigate able to perform should be able to & a functional supplied by NMS charges
complications of basic emergency give you a report ultrasound scan and JMS and
PET obstetric on maternal – machine. are managed by
Ultrasound Scans fetal parameters sonographer

Patient medical
records
3.5 Advocate for Number of Advocacy meeting Minutes 0 4 Quarterly Regular MoH,
improved health advocacy will create engagement of NASMEC –PET
financing for PET meetings held with awareness and Policy briefs stakeholders by subcommittee,
commodities and stakeholders. magnitude of NASMEC-PET hospital
supplies morbidity and subcommittee directors,
• Parliamentary mortality due and regional professional
Reports
committee on to PET. Costed champions bodies
health interventional may result
• Uganda women plans will be into increased
parliamentary shared with all funding.
association stakeholders to
• Development solicit funding
partners for the critical
(UNICEF, WHO, activities.
CDC, USAID)

Uganda Pre-Eclampsia Interventional Framework

• Implementing
partners

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
4. Improved management of pre-eclampsia
4.1 Revision of MOH Updated clinical 0 1 Five years with MOH/
clinical protocols guideline and midterm review NASMEC-PET
and guidelines protocol for PET subcommittee
for management management
of PET
4.2 Revised protocols Proportion of Revised protocols Survey 48% 100% Annually There should MOH/
disseminated health facilities and Flow chart be a revised NASMEC-PET
with updated should be protocol with flow subcommittee,
protocols in ANC available in all chart awaiting partners
antenatal clinics printing that can
be printed and
placed in the
antenatal clinic
4.3 Disseminate Proportion of Protocol and Flow Survey 69% 100% Annually There should a MOH/
revised clinical health facilities chart present in revised protocol NASMEC-PET
protocols on the with revised the labor ward with flow chart subcommittee
management clinical protocols and postnatal awaiting printing
of PET that are on management units that can be
available in the of PET in maternity printed and
labor ward and and postnatal placed in the
postnatal areas areas. labour ward and
of the maternity postnatal units
consistent with
MOH guidelines
4.4 Strengthen in- Proportion of HF Health workers Evidence in 54.7% 90% Annually All maternity MOH/
service training with maternity should attend training book staff should NASMEC-PET
for Health and ANC staff training/CPD in the unit, have refresher subcommittee,
workers in PET that received sessions on the minutes and CPD on PET and HDP RRH team and
management training in PET components of handbook once a year as implementing
management in the protocol plus part of CPD partners
the last 12 months physical copies in requirements
the HFs

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
4.5 Improved Proportion of An appropriate Referral ND 100% annually All mothers MOH/
pre referral women referred referral is one documents/ being referred NASMEC-PET
treatment and with documented which is indicated records due to PET are subcommittee
documentation prereferral and has obtained given pre referral
treatment initial treatment Registers treatments as per
(Magnesium (antihypertensive guidelines
sulphate and anti- and loading dose
hypertensives) of Magnesium
4.6 Improved referral Proportion of sulphate Referral ND 100% annually All women with MOH-EMS,
transportation women referred and taken in documents / PET referred
in the ambulance ambulance with documents / are taken by Ambulance
and escorted by HCW. registers ambulance and coordinators,
ambulance escorted by facility in
health workers charges
4.7 Establish QI Proportion of Implementation Documentation ND 75% Bi annually QI activities Health workers
initiatives on PET Health facilities of one of the journals will lead to in the HFs and
implementing QI recommendations improvement Regional PET
projects related to from death and in care of PET champions lead
PET near miss review patients the team
sessions
4.8 Improved Proportion of All women without Patient records, 29.5% 100% Bi annually The guidelines NASMEC
management of women with mild features of severe registers are available at PET SUB
pre-eclampsia pre-eclampsia pre-eclampsia are service delivery COMMITTEE
without severe followed-up as per followed up as points to guide
features (mild protocol per protocol management.
pre-eclampsia)

Proportion of All women Patient records, 26% 100% Bi annually Guidelines for MoH,
women with with mild pre- registers management of NASMEC PET
mild pre- eclampsia at term pre-eclampsia subcommittee
eclampsia at term (37weeks and and induction and Health
recommended above) without of labor are facility in
for induction as contraindication disseminated to charges
appropriate. for induction of all units
labor.

Uganda Pre-Eclampsia Interventional Framework

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
4.9 Improved Proportion of All women Patient records, 67% 100% Bi annually All facilities have MoH, NMS, JMS,
management women diagnosed diagnosed registers sufficient stock NASMEC PET
of severe pre- with severe pre- with severe of magnesium subcommittee
eclampsia eclampsia that pre-eclampsia sulphate and and Health
were administered should receive guidelines of facility in
with magnesium magnesium management of charges
sulphate (full IV or sulphate pre-eclampsia
IM regimen) are available in
the facility.

Proportion of All women Patient records,

women diagnosed diagnosed with registers
with severe pre- severe pre-
eclampsia that eclampsia should
were administered receive
antihypertensives
as per guidelines

Proportion of Maternal and Patient records, 54% 100% Bi annually A standardized MoH,
women diagnosed fetal well-being registers monitoring tool NASMEC PET
with severe pre- of all women for PET will be subcommittee
eclampsia whose with severe pre- utilized at all and Health
vital signs, reflexes eclampsia should levels facility incharges
and fetal heart be monitored
rate are monitored regularly for at
based on the least 72 hours
protocol after delivery.

Proportion of All women Patient records, Bi-annually CEMONC MoH, IPs and
women diagnosed diagnosed with registers facilities should Health facility in
with pre- pre-eclampsia 49% 100% have functional charges
eclampsia that should have laboratories.
had laboratory laboratory
investigations like investigations

Uganda Pre-Eclampsia Interventional Framework

CBC, LFTs and done e.g., CBC,
RFTs done to guide LFTs, RFTs, blood
management grouping, e.t.c

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 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
4.10 Improved Proportion of All women with Patient records, 64% 100% Bi-annually Mothers and DHT, Health
management of women with severe severe pre- registers health workers facility in
pre-eclampsia pre-eclampsia eclampsia should will follow the charges
in postpartum that are monitored be monitored Post-partum
period immediately after immediately after schedules
birth (first 72 delivery, at 1
hours) week, 6 weeks
Proportion of and 12 weeks Patient records, ND 100% Bi-annually
women with severe after birth. registers
pre-eclampsia that
were monitored at
1 week after birth.

Proportion of Patient records, ND 70% Bi-annually

women with severe registers
pre-eclampsia that
were monitored
at 6 weeks after
birth.

Proportion of Patient records, ND 50% Bi-annually

women with severe registers
pre-eclampsia that
were monitored
at 12 weeks after
birth.
5. To improve community awareness of pre-eclampsia and eclampsia
5.1 Improved Number of Nation-wide awareness ND 1 annually Airtime is MoH, NASMEC
community country-wide community campaigns available for both
awareness community awareness conducted on Televisions and
initiatives through awareness campaigns on radios and Tele Radios
radio talk shows, campaigns PET should be visions
IEC materials conducted conducted.
annually
Number of At least one of all Outreach reports ND 4 Bi-annual There is an MoH, DHT,
community the community existing outreach health facility
outreaches outreaches schedule at all incharges

Uganda Pre-Eclampsia Interventional Framework

focusing on PET conducted per facilities.
conducted by quarter should
health facilities. focus on PET

| 31
 Objective/ Indicator Definition Means of Baseline Target Frequency Assumptions Responsible
Strategy verification person/entity
5.2 Integrate PET Number of Appropriate Reports ND 6 Annually Celebrations of MoH, NASMEC
awareness awareness PET awareness women’s day,
campaigns in campaigns materials and international
critical national conducted on platforms will be midwifery day,
celebrations. select national and utilized to enable Mother’s Day,
international days dissemination of Father’s Day,
PET warning signs doctor’s day, etc
and management.
5.3 Strengthen Proportion of CHWs will be List of trained 0 40% annually Health care MoH, DHT,
Community health facilities trained in signs CHWs facilities already Regional
health workers with at least 3 and symptoms of have CHWs champions and
capacity to community health PET system in place health facility in
identify and workers trained in charges
refer high- danger signs of
risk pregnant PET
mothers

Proportion of CHWs will refer Carbon copies CHWs will be Health facility in
pregnant women mothers from of referred cases trained and refer charges, CHWs
suspected/ community to from community 0 100% Annually mothers to the
diagnosed with health care to health facilities, health facility
PET who were facilities for care VHT registers
referred by
community health
workers

Proportion of Women will be Women 43% 100% Quarterly There will be IEC MoH, NASM
women given discharged with with written information on
discharge clearly written information on cards given to
instructions and instructions with pet patients
IEC materials PET information
on signs and
symptoms of PET

Uganda Pre-Eclampsia Interventional Framework

| 32
5.0
Data Collection &
Management

Uganda Pre-Eclampsia Interventional Framework | 33

Monitoring data for this framework will be collected through the nationally approved structures and data
sources. These sources will provide routine data for monitoring outputs, outcomes, and impacts of the pro-
gram. If the non-routine data is required to answer some of the indicators, secondary sources will be utilized,
or surveys will be designed to support the collection of this data.

5.1 Routine data sources provide data that are collected on a continuous basis, such as information
that health facilities collect on the patients utilizing their services. Although these data are collected
continuously with patient encounters, processing, aggregation and reporting on the data usually
takes place on a weekly, monthly or quarterly basis. This data is available more frequently and can
be used effectively to monitor the implementation of the framework. However, due to incomplete
documentation and poor record keeping the quality of the data from these sources may be poor.

5.1.1 Health Management Information System (HMIS) is a Ministry of Health driven platform which provides
tools for monitoring health services provided at each health facility and district in the country. It
provides paper tools in form of registers, proformas, prescription forms and reporting forms. Data
from the registers at service delivery levels are aggregated on paper-based forms that are submitted
to the district or entered directly in the electronic platform (District Health Information software 2
(DHIS2)) which is accessible at both district and MoH headquarters.

5.1.2 Logistics management information system (LMIS) is a platform which monitors the distribution of
health commodities across the country. LMIS is mostly paper based although efforts are in place to
scaleup electronic LMIS across all healthcare units in the country. LMIS captures data on procurement,
storage, and dispensing of medicines and health supplies. Thus, it manages medicines and health
supplies from start to finish, from the planning stages of procurement to the point when the product
is given to the patient. All data related to health commodities including PET and MNCH commodities
will be generated from this system.

5.1.3 The Integrated Human Resource Information System (iHRIS) will provide data on the health work
force. The system tracks the number of health workers by cadre, qualifications, licenses and practice
requirements. The system will provide data which will guide in deciding where capacity building
efforts should be focused and advocacy data for the recruitment of more health workers.

5.2 Non-routine Data Sources: Non-routine data sources provide data that are collected on a periodic
basis, usually annually, biennially or every five years. Using non-routine data minimizes the problem
of incorrectly estimating the target population when calculating coverage indicators although they
are often expensive thus irregular. These include.

5.2.1 Uganda Demographic and Health Survey Population survey (UDHS) provides statistical data on the
Ugandan population’s demographic characteristics, family planning initiatives, maternal mortality,
and infant and child mortality. It also provides data other healthcare services and activities including
antenatal, delivery, and postnatal care, children’s immunisations, and management of childhood
diseases among others. UDHS will provide data for the monitoring changes in impact indicators
which include maternal mortality ratio per 100,000 live births and perinatal mortality rate per 1,000
births.

5.2.2 Periodic Cross-sectional surveys will be designed to provide data which will monitor the outcomes
and short-term outputs of the program which cannot be obtained through the conventional routine
or non-routine systems. These surveys will be guided by the Ministry of Health under the NASMEC
Senior Leadership Team. The surveys will specifically provide data which will be used to measure the
following indicators.

Uganda Pre-Eclampsia Interventional Framework | 34

 Indicator Frequency of reporting
i) Proportion of Maternal deaths attributed to pre-eclampsia Two and half years
ii) Proportion of health facilities with updated protocols in ANC Annually
iii) Proportion of health facilities with revised clinical protocols on Annually
management of PET in maternity and postnatal areas.

5.2.3 The Annual Health Sector Performance Report (AHSPR) summarizes progress made in the health
sector, challenges and lessons learnt each financial year (FY). The AHSPR focuses on the overall
sectoral performance against the targets set for the FY and trends in performance for selected
indicators over the previous years. This report will provide data on the interim outputs of the program

5.3 Other data sources

Data for most of the indicators will be collected from other data sources which are not necessary
collected on routine basis. Some of these sources include the following
• Health facility documentation journals which will show if health facilities are implementing
quality improvement projects on PET.
• Support supervision reports which will assess various competencies at the facility, district and
regional levels.
• Clinical mentorship reports which will provide information on the competencies of the various
health workers.
• Meeting Minutes at various levels will inform the program if the various technical working
groups are constituted and functional.
• Training and activity report will provide evidence on the implementation of the activities.

5.4 Data Flow

The figure 3 below shows the flow of data from community through the Village health team reports
submitted through health facilities. Health facility reports submitted on weekly, monthly, or quarterly
basis to the district health office which are reviewed and then submitted to MOH headquarters. This
data is eventually made available through the national DHIS for decision making. Similarly, there is
feedback from MoH to the lower facilities which is in form of national health assembly, district health
offices performance review meetings for health facility teams as well as meetings held by health
facilities together with community health workers in which feedback is provided.

Uganda Pre-Eclampsia Interventional Framework | 35

 Uganda Bureau
Ministry of Health of statistics

Professional
Academia Bodies
Regional Referral
Hospital

District Health Office

Health Facility

Community Health Workers

Figure 3: Data flow Chart

Uganda Pre-Eclampsia Interventional Framework | 36

5.5 Data Quality and management

Data quality needs to be monitored and maintained throughout the data collection process. The
following strategies should be utilized at national, regional, district and health facility level to ensure
high quality data:
• Ensuring availability of standardized data collection and reporting tools with job aides to
guide data collectors.
• Regular data cleaning at all levels of data entry that is at the facility before data is entered in
the registers and at the district before data is entered into DHIS.
• Regular supportive supervision and data verification exercises using standardized tools to
establish the extent of variation and support teams to collect high quality data.
• Regular capacity building of health workers, record officers and personnel with data
management roles at all levels.
• Strengthening the information feedback mechanism to ensure that any data quality issues
identified at any level are communicated through the system.
• Conduct regular performance review to discuss data quality issues by all stakeholders in the
health sector.

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6.0
Implementation Arrangements

Uganda Pre-Eclampsia Interventional Framework | 38

6.1 Stakeholder roles and responsibilities

To establish an effective monitoring and evaluation system, there is a need to clarify the roles and respon-
sibilities of different stakeholders, and who requires what information and for what purpose. The MoH will
require a coherent information flow system that is developed through regular consultations. The table below
gives a broad outline of roles and responsibilities of each stakeholder.

Stakeholder Roles Responsibilities

MoH • Provide technical guidance and quality assurance
• Policy development and review for the PET Framework interventions
• Mobilization and advocacy for resources implementation of the PET
framework.
• Coordination and dialogue with health development partners
• Strategic planning
• Advocacy for increased health financing
• Adequate health worker recruitment
• Supervision of health sector activities
NASMEC-PET • Develop and Review PET management guidelines
• Develop and review PET interventional framework
• Monitor and track implementation of the PET framework
• Coordinate national PET awareness activities
• Advocacy for reduction in PET related morbidity and mortality
Health development part- • Mobilize and provide human and financial resources for the Implemen-
ners tation of the framework.
Implementing partners and • Fund and implement interventions from the Framework
development partners
Academic institutions • Conduct surveys
• Draft and review guidelines
• Participate in grand rounds, webinars and seminars
• Knowledge production and dissemination
• Training and mentoring health work force
UNHLS • Supervise and ensure functionality of laboratory services across the
country
NMS/JMS • Ensure timely delivery of supplies for PET management
Regional Champions • Coordinate regional PET related activities
• Trainings and mentorships on PET
• Create PET awareness
DHT • Monitor and supervise of PET related activities
• Initiate recruitment of health workers
• Quality assurance
In-charges of facilities and • Provide infrastructure for quality maternal care
other Health workers • Provide evidence-based maternal care
CSOs, Religious Institutions, • Support advocacy at the subnational and national levels, provide
Parliament accountability for services provided
Community health workers • Create awareness about PET
• Demand creation for PET services
• Demand accountability
Community • Demand accountability

Uganda Pre-Eclampsia Interventional Framework | 39

6.2 Dissemination and information use

The Ministry of Health is responsible for the compilation, management and dissemination of all data
collected through the national HMIS and subsystems. All information products on the program will be
cleared by the Maternal and Child Health Technical Working Group. These products include: Policy Briefs,
MPDSR reports, bulletins, quarterly reports and annual health sector performance report. These products
will be disseminated through various for a such as meetings, print media, electronically on the MoH website
and digital media.

Uganda Pre-Eclampsia Interventional Framework | 40

APPENDIX 1: PROFORMA FOR PREECLAMPSIA /ECLAMPSIA / OTHER HYPERTENSIVE
DISORDERS OF PREGNANCY FOR 8 HOUR SHIFT

Location: Postnatal ward / Labor ward/ Theatre (Please circle)

Date: / / Time of Admission _ _: _ _ (24hr clock)
Date: / / Time of delivery _ _: _ _ (24hr clock)

Midwife attending for PET:

Name: ............................................... Designation: ............................ Time arrived _ _: _ _ (24hr clock)
Name: ............................................... Designation: ............................ Time arrived _ _: _ _ (24hr clock)
Name: ............................................... Designation: ............................ Time arrived _ _: _ _ (24hr clock)

Specialist on duty: Names: ........................................................... Date: ...............................................

Specialist/ Senior House Officer and/or Medical Officer assigned on duty PET Room/area/bed
Name: ............................................... Designation: ............................ Time arrived _ _: _ _ (24hr clock)
Name: ............................................... Designation: ............................ Time arrived _ _: _ _ (24hr clock)

Actions Taken Time Result/Comment (If many comments write overleaf in

notes.
(24hr clock)
Initial BP, pulse , RR & saturation __:__ BP PR RR SPO2
Urine protein __:__
Urinary catheter inserted __:__ Urine Output
Complete blood count __:__ Platelet Count Hb

Renal Function tests __:__ Creatinine Urea

Liver function tests __:__ AST ALT Bilirubin
IV access placed __:__
Foetal heart rate __:__
Ultrasound + Doppler studies __:__

Drug Dose and Route Time if given _ _: _ _

Hydralazine 5mg q 30 mins IV
Labetalol, Q 10mins 20/40/80
Nifedipine 20mg oral
Methyldopa 250/500/750mg 8 hourly
Magnesium sulphate Load 4g 20% IV & 10g 50% IM
Magnesium sulphate 5g 4hourly
Other (eg for induction)

Uganda Pre-Eclampsia Interventional Framework | 41

Fluids Volume Tick if given Time initiated
Normal Saline __:__
Other __:__

Communication Time
Cross matched blood requested from haematology __:__
Specialist on duty informed __:__
Anaesthetist /anesthesiologist informed __:__
Theatre informed where applicable __:__
Time transferred to Theatre __:__
Time transferred to HDU/ICU : circle where applicable __:__
Table subsequent observations

Time of observations Blood pressure Pulse SPO2 Respiratory rate

__:__
__:__
__:__
__:__
__:__
__:__
__:__
__:__
__:__
__:__
__:__
__:__
__:__

Uganda Pre-Eclampsia Interventional Framework | 42

Designed and printed with UNICEF support