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Beneath the Surface: A Comparison of Methods for Assessment of Quality of Care for Maternal and Neonatal Health Care in Rural Uganda



Efforts to improve access to healthcare in low-income countries will not achieve the maternal and child health (MCH) Sustainable Development Goals unless a concomitant improvement in the quality of care (QoC) occurs. This study measures infrastructure and QoC indicators in rural Ugandan health facilities. Valid measure of the quality of current clinical practices in resource-limited settings are critical for effectively intervening to reduce adverse maternal and neonatal outcomes.


Facility-based assessments of infrastructure and clinical quality during labor and delivery were conducted in six primary care health facilities in the greater Masaka area, Uganda in 2017. Data were collected using direct observation of clinical encounters and facility checklists. Direct observation comprised the entire delivery process, from initial client assessment to discharge, and included emergency management (e.g. postpartum hemorrhage, neonatal resuscitation). Health providers were assessed on their adherence to best practice standards of care.


The quality of facility infrastructure was relatively high in facilities, with little variation in availability of equipment and supplies. However, heterogeneity in adherence to best clinical practices was noted across procedure type and facility. Adherence to crude measures of clinical quality were relatively high but more sensitive measures of the same clinical practice were found to be much lower.

Conclusions for Practice

Standard indicators of clinical practice may be insufficient to validly measure clinical quality for maternal and newborn care if we want to document evidence of impact.

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The authors would like to thank the staff at LifeNet International for their generosity and cooperation in carrying out this study.


The study was funded by LifeNet International.

Author information

The authors report a grant from LifeNet International during the conduct of the study. Three of the authors of this publication (JK, LA, SW) were paid employees of LifeNet International, the funder, at the time this study was carried out and assisted with study design, data collection and manuscript preparation. However, no LifeNet author had access to aggregate study data during data collection, nor was any LifeNet employee involved with data analysis or in the initial presentation of study results.

Correspondence to Joseph R. Egger.

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Egger, J.R., Headley, J., Li, Y. et al. Beneath the Surface: A Comparison of Methods for Assessment of Quality of Care for Maternal and Neonatal Health Care in Rural Uganda. Matern Child Health J 24, 328–339 (2020).

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  • Adherence
  • Clinical
  • Quality of care
  • Maternal and child health
  • Direct clinical observation
  • Low-income countries