Know-do gaps in obstetric and newborn care quality in Uganda: a cross-sectional study in rural health centers.

Objectives Variable and inadequate quality of maternity care is a critical factor in persistently high rates of maternal and neonatal mortality in Uganda. We investigated whether provider quality of care deviates from knowledge and the factors associated with these "know-do gaps" in Ugandan maternity facilities. Methods Data were collected from 109 providers in 40 facilities. Quality was measured using direct observations of intrapartum care and scores were based on the percentage of essential care actions provided out of a 20-item validated quality index. Knowledge was measured based on the percentage of items that providers reported knowing to do using vignette surveys. The know-do gap was the difference between knowledge and quality. Multivariable models were used to assess the association between provider- and facility-level characteristics and knowledge, quality, and know-do gaps. Results The average quality score was 45%, with quality varying widely within and across providers. Mean knowledge scores were 70%, yielding a mean know-do gap of 25%. Know-do gaps were largest for practices related to infection control, vitals monitoring, and prevention of postpartum hemorrhage. The association between quality and knowledge scores was positive but small (p=.08), so know-do gaps were largest for providers with the highest knowledge scores. Greater provider training was positively associated with knowledge (p=0.005) but not with quality (p=.60). Having 10 or more years of experience was associated with higher quality scores (5.3, 95%CI: 0.6 to 10.1), while higher patient volumes were associated with slightly lower quality scores (-2.2, 95%CI: -3.7 to -0.07). None of the factors of provider motivation, education, cadre, availability of essential medicines and supplies or facility staffing was associated with quality or know-do gaps. Conclusions Our results indicate that, in Uganda, gaps between knowledge and quality do not appear to be explained by factors such as lack of motivation, education, training, or supplies. Gaps are particularly large for essential practices related to prevention and early detection of conditions such as postpartum hemorrhage, pre-eclampsia and sepsis, the leading causes of maternal mortality in Uganda and similar settings.