Electricity Access and Maternal Care in Rural Health Facilities in Uganda

Scale is scored as 1: Very Bright; 2: Somewhat Bright; 3: Dim; 4: Pitch Black. Variable is binary indicator for "very bright" or "somewhat bright" throughout delivery

Satisfactory light source is a variable equal to 1 if observation occurs without daylight and facility is using grid, solar or functional generator and zero if using kerosene, candle, torch, etc. Variable is always equal to 1 during daylight.

Binary variable equal to 1 if light is from a satisfactory source and is "bright" ("very bright" or "somewhat bright") for duration of delivery observation.

Quality of care index is based on essential actions providers must perform during the course of labor and delivery, as described in Tripathi et al. (2015). Score is the fraction of 20 items, yielding a range of 0 to 1, with higher scores indicating better quality of maternal care.

Quality of care index is based on the essential actions providers must perform during the course of labor and delivery, derived from the Maternal and Child Health Integrated Program (MCHIP). It includes the 20 items from Tripathi et al. (2015) plus an additional 17 quality of care items from MCHIP (2013). Score is fraction of the 37 items, yielding a range of 0 to 1, with higher scores indicating better quality of maternal care.

Index including:

i) Time between facility arrival and first contact with health worker (mins) ii) Time between facility arrival and first assessment (mins) iii) Time between delivery and uterotonic (mins) iv) Time between delivery and assessment of perineal and vaginal lacerations (mins) v) Time between delivery and drying baby with towel (mins) vi) Time between delivery and initiation of breastfeeding (mins) Score is average of the 6 items measured in minutes, with lower values indicating reduced delays in quality of maternal care. Range from 0 to 120 minutes.

Responses on a 1-5 scale with 1: Strongly Disagree, 2: Disagree, 3: Neutral (Neither Agree nor Disagree), 4: Agree, 5: Strongly Agree

Worker Satisfaction with Electricity is a binary variable equal to 1 if strongly agree with both:

i) I am satisfied with the availability and brightness of light in this facility.

ii) I am satisfied with the availability of electricity in this facility

Responses on a 1-5 scale with 1: Strongly Disagree, 2: Disagree, 3: Neutral (Neither Agree nor Disagree), 4: Agree, 5: Strongly Agree

Overall job satisfaction index is the mean score (1-5) of the 4 below components:

i) These days, I feel motivated to work as hard as I can. ii) Overall, I am satisfied with my job. iii) Overall, the morale level at my department is good iv) I plan on staying at this position for the next year.

Scale is scored as 1: Very Bright; 2: Somewhat Bright; 3: Dim; 4: Pitch Black

Satisfactory light source defined in Primary Outcome 2.

Variable equal to 1 if no interruptions of > 2 hours in satisfactory light source during observed deliveries.

Number of times the provider used a fetal doppler during labor and delivery

Phone is available and on for deliveries

Provider assigns any APGAR score (binary variable equal to 1 if provider assigns an APGAR score (range of 0-10), and equal to 0 if no APGAR score is assigned.

Facility reported performance of basic emergency obstetric care signal functions in the past three months. Measure includes the number of signal functions performed from:

• Removal of retained products of conception
• Parenteral oxytocin for maternal hemorrhage
• Parenteral magnesium sulfate for (pre-) eclampsia
• Manual removal of placenta
• Parenteral antibiotics for maternal infection
• Assisted vaginal delivery

Facility reported performance of basic emergency newborn care signal functions in the past three months. Measure includes the number of signal functions performed from:

• Antibiotics for preterm or prolonged PROM
• Corticosteroids in preterm labor
• Resuscitation with bag and mask for non-breathing baby
• Kangaroo Mother Care for premature/very small babies
• Alternative feeding if baby unable to breastfeed
• Injectable antibiotics for neonatal sepsis
• PMTCT if HIV-positive mother

Facility reported universal practice of routine obstetric care signal functions. Measure includes the number of signal functions performed from:

• Infection control (provider hand-washing before patient exam in labor, new sterile gloves before every vaginal examination)
• Use of partograph to monitor labor
• Routine practice of active management of the third stage of labor

Facility reported universal practice of routine newborn care signal functions. Measure includes the number of signal functions performed from:

• Thermal protection (newborn dried immediately, skin-to-skin, no bath/delayed>6 hours)
• Exclusive breastfeeding initiated within 1 hour of birth
• Hygienic cord care (cord cut with sterile blade/scissors; chlorhexidine or nothing applied to stump)

Observed time between delivery and when provider began suturing lacerations, if needed.

Index constructed from the following variables:

• Health worker explains to woman what is happening (binary)
• Health worker cleans area prior to suturing with antiseptic solution (binary)
• Health worker prepares instruments/sutures on a sterile surface (binary)
• Health worker sutures episiotomy or tears appropriately in layers. (binary) Score is fraction of 4 items, yielding a range of 0-1, with higher score indicating better quality of suturing.

Patient treatment/inter-personal quality care index, based on Kruk et al. (2014) including whether health worker: shouted/scolded patient, threatened to withhold treatment, ignored/left patient, did not answer questions, was not present when delivery began, slapped/beat mother, stitched episiotomy without anesthesia, demanded payment inappropriately, requested bribe, did not provide privacy to mother. Fraction of items that were NOT performed, yielding a range of 0-1, with higher scores indicating better treatment of patients.

Index of variables (from MCHIP (2013) tool capturing completeness of recording on partograph). Fraction of 14 items completed on partograph (all binary variables), yielding a range of 0-1, with higher values indicating more completeness.

Time between contractions at first exam (mins)

Degree of dilation at woman's first exam (cm)

Average Number of Monthly Deliveries

Average Number of Nighttime Deliveries per Month

Average Number of Antenatal Clients per Month

Average Number of Monthly Referrals Out of Facility for Mothers and Newborns

Recorded brightness at sensor sight in the two hours around delivery of baby.

Average difference between solar suitcase load voltage in evening and morning (based on sensor)

Average time between morning and when the solar suitcase is fully charged, based on sensor

Fraction of deliveries in which enumerator recorded usage of suitcase

Health worker response (1-5) on the following scale: 1: No overhead light; 2: Very poor; 3: Poor; 4: Good; 5: Very Good to the question:

"In general, how would you rate the availability of overhead light for maternal and newborn care (deliveries) in this facility at night?"

Health worker response (1-5) on the following scale: 1: No procedure/task light; 2: Very poor; 3: Poor; 4: Good; 5: Very Good to the question:

"In general, how would you rate the availability of procedure/task light for maternal and newborn care (deliveries) in this facility at night?"

Health worker response (1-5) on the following scale: 1: No overhead light; 2: Very poor; 3: Poor; 4: Good; 5: Very Good to the question: "In general, when the overhead light is on, how would you rate the quality of light (brightness) for maternal and newborn care (deliveries) in this facility at night?"

Health worker response (1-5) on the following scale: 1: No procedure/task light; 2: Very poor; 3: Poor; 4: Good; 5: Very Good to the question: "In general, when the procedure/task light is on, how would you rate the quality of light (brightness) for maternal and newborn care (deliveries) in this facility at night?"

Index of items measuring health worker assessment of impact of blackouts in facility on ability to conduct their job, including how often health worker: conducted deliveries without overhead light; had to hold torch in hand to see patient; experienced lack of light that affected normal care provided; delayed care; feared to move around facility; was affected in ability to suture, find/use equipment, conduct examinations of mother, provide emergency care, provide newborn care, monitor fetal heartrate, administer medication, clean up after delivery, manage infection control. Response to items scored (1-5) on following scale: 1. Every delivery, 2. Most, 3. Some, 4. Few, or 5. Never. Overall score measured as average of 14 items, yielding a range of 1-5.

Provider asks whether woman has experienced vaginal bleeding during current pregnancy (binary)

Provider asks whether woman has experienced headaches and/or blurred vision during current pregnancy (binary)

Provider offers woman an HIV test or checks her HIV status (binary)

Provider takes pulse of mother during initial exam (binary)

Provider takes both systolic and diastolic blood pressure measurements of mother during initial exam (binary)

Provider wears sterile gloves for initial vaginal exam (binary)

At least once, explains what will happen in labour to woman and/or her support person. (binary)

Provider starts partograph to monitor progress of labour. (binary)

Provider washes his/her hands with soap and water or uses alcohol hand rub prior to every examination of woman. (binary)

Uterotonic is prepared for Active Management of the Third Stage of Labor (AMTSL). (binary)

Prepares self-inflating ventilation bag and newborn face mask. (binary)

After delivery, provider administers 10 IU of IM oxytocin, OR:

• 5 IU slow push if IV in place
• 600μg of misoprostol sublingually
• 600μg misoprostol rectally (binary)

Provider assesses completeness of the placenta and membranes. (binary)

Assesses completeness of the placenta and membranes. (binary)

Provider places baby on mother's abdomen or chest skin-to-skin. (binary)

Provider immediately dries baby with towel. (binary)

Provider ties or clamps cord. (binary)

Provider takes mother's vital signs after delivery. (binary)

Provider palpates uterus after delivery of placenta. (binary)

Breastfeeding is initiated within one hour of delivery. (binary)

Provider asks about complications during previous pregnancies. (binary)

Provider washes his/her hands with soap and water or uses alcohol hand rub before initial examination. (binary)

Provider takes mother's temperature during initial exam. (binary)

Provider checks fundal height during initial exam. (binary)

Provider checks fetal presentation by palpation of abdomen. (binary)

Provider checks fetal heart rate with fetoscope/Doppler/ultrasound. (binary)

Provider performs vaginal examination at initial exam. (binary)

Provider wears sterile gloves for all vaginal examinations. (binary)

Prepares disposable cord ties/clamps AND sterile scissors/blade. (binary)

Provider supports perineum after baby's head is delivered. (binary)

Applies traction to the cord while applying suprapubic counter traction. (binary)

Provider performs uterine massage immediately following the delivery of the placenta. (binary)

Provider checks newborn's temperature. (binary)

Provider assists mother with breastfeeding. (binary)

Provider sterilizes or uses high-level disinfection for all reusable instruments. (binary)

Provider disposes of all contaminated waste in leak-proof containers. (binary)

Provider washes his/her hands with soap and water or uses alcohol hand rub after cleaning up. (binary)

Time between facility arrival and first contact with health worker (mins)

Time between facility arrival and first assessment (mins)

Time between delivery and uterotonic (mins)

Time between delivery and assessment of perineal and vaginal lacerations (mins)

Time between delivery and drying baby with towel (mins)

Time between delivery and initiation of breastfeeding (mins)