Birth. 2024;51:783–794. wileyonlinelibrary.com/journal/birt   |  783© 2024 Wiley Periodicals LLC. Received: 17 July 2023  |  Revised: 24 January 2024  |  Accepted: 2 May 2024 DOI: 10.1111/birt.12837 O R I G I N A L A R T I C L E A case study analysis of a successful birth center in northern Uganda Michelle Telfer DNP, CNM, MPH, FACNM1   | Rachel Zaslow PhD, RM2  | Scovia Nalugo Mbalinda PhD, RM3  | Rachel Blatt MSN, CNM4  | Diane Kim MSN, CNM5  | Holly Powell Kennedy PhD, CNM, FACNM, FAAN6 1Yale School of Nursing, West Haven, Connecticut, USA 2Mother Health International & Yale School of Nursing, Gulu & West Haven, Uganda 3Department of Nursing, Makerere University, Kampala, Uganda 4Woodhull Hospital, Brooklyn, New York, USA 5Bronx Lebanon Hospital, The Bronx, New York, USA 6Varney Professor of Midwifery Emeritus, Yale School of Nursing, West Haven, Connecticut, USA Correspondence Michelle Telfer, Yale School of Nursing, PO Box 27399, West Haven, CT 06516- 7300, USA. Email: michelle.telfer@yale.edu Abstract Background: Mothers and infants continue to die at alarming rates through- out the Global South. Evidence suggests that high-quality midwifery care signifi- cantly reduces preventable maternal and neonatal morbidity and mortality. This paper uses a case study approach to describe the social and institutional model at one birth center in Northern Uganda where, in over 20,000 births, there have been no maternal deaths and the neonatal mortality rate is 11/1000—a rate that is lower than many high-resource countries. Methods: This case study combined institutional ethnographic and narrative methods to explore key maternal and neonatal outcomes. The sample included birthing people who intended to or had given birth at the center, as well as the midwives, staff, stakeholders, and community health workers affiliated with the center. Data were collected through individual and small group interviews, par- ticipant observation, field notes, data and document reviews. Iterative and sys- tematic analytical steps were followed, and all data were organized and managed with Atlas.ti software. Results: Findings describe the setting, an overview of the birth center's history, how it is situated within the community, its staffing, administration, clinical out- comes, and model of care. A synthesis of contextual variables and key outcomes as they relate to the components of the evidence-informed Quality Maternal and Newborn Care (QMNC) framework are presented. Three overarching themes were identified: (a) community knowledge and understanding, (b) community integrated care, and (c) quality care that is respectful, accessible, and available. Conclusions: This birth center is an example of care that embodies the findings and anticipated outcomes described in the QMNC framework. Replication of this model in other childbearing settings may help alleviate unnecessary perinatal morbidity and mortality. K E Y W O R D S birth center, ethnographic case study, midwifery, QMNC, respectful maternity care, Uganda www.wileyonlinelibrary.com/journal/birt mailto: https://orcid.org/0000-0002-8176-3936 https://orcid.org/0000-0001-7866-1552 mailto:michelle.telfer@yale.edu http://crossmark.crossref.org/dialog/?doi=10.1111%2Fbirt.12837&domain=pdf&date_stamp=2024-06-24 784  |     TELFER et al. 1   |   INTRODUCTION Despite considerable research into the reduction of peri- natal morbidity and mortality, mothers and newborns die at alarming rates throughout the Global South.1-4 In Sub-Saharan Africa, delays in receiving care lead to un- necessary perinatal mortality.5-10 Rural women often travel far to reach clinics that may be understaffed or un- dersupplied (Box 1). The three delays model asserts that addressing these delays would avert the majority of mor- tality.5-10 There is also evidence that community-based birth centers staffed by midwives improve outcomes,11-14 yet most clinics and midwifery education programs in the Global South do not follow the midwifery model.15-17 The evidence-informed Quality Maternal and Newborn (QMNC) framework presented in the 2014 Lancet Series on Midwifery18 identified key components that reflect what mothers and newborns need to assure the best out- comes (Figure 1). High-quality midwifery care described in the framework, when implemented at scale with family planning, has demonstrated power to avert over 80% of maternal and neonatal mortality.19 The framework holds promise to address the challenges faced in the Global South, yet until now there has not been an example of it in action in LMICs. In this paper, we present a case study of a birth cen- ter established in Northern Uganda in 2007. The maternal mortality rate in Uganda is 375/100,00020 and is markedly higher in the north after 23 years of war. The national neonatal mortality rate in Uganda is 30/1000, over five to six times higher than high-income countries (HICs).20 Remarkably, in over, 20,000 births at the center, there has been no maternal mortality and the neonatal mortality rate is 11/1000—substantially lower than the national rate and on par with outcomes in the Global North.20,21 We asked, “What cultural, clinical, and contextual fac- tors influence the outcomes at this center?” Specifically, we aimed to identify: (1) clinical factors that address criti- cal gaps in the care continuum and contribute to improved outcomes; (2) sociocultural factors that this center and its staff incorporate that may contribute to improved uptake of services and outcomes; and (3) to examine the findings alongside the QMNC framework. 2   |   METHODS In this empirical study, we used a case-study approach informed by ethnographic and narrative methods for data collection and analysis focused on one specific birth center with better-than-expected outcomes for the region and population served.22,23 Understanding a model of care requires robust research methods that explore the com- plexities of the setting, practitioners, and systems in which it is situated. We employed institutional ethnography to describe the social and institutional forces that organize and shape the environment of this birth center.20-24 It is especially effective in examining organizational and in- stitutional practices to learn how patient experiences and outcomes can be improved.25 We added narrative analy- sis to learn from the discourses of those who provide and those who receive care.26 Ethical approval was received from Yale University and the Uganda National Council for Science and Technology. 2.1  |  Setting The birth center is on an 11-acre compound in Atiak sub- county in Northern Uganda. It is 18 miles (29 km) from the border of South Sudan and 45 miles (72 km) from the referral hospital where emergency obstetric services are available. The region is recovering from 23 years of armed conflict that resulted in a breakdown of health systems. In Uganda, healthcare is delivered in health centers (HCs) that range in classification from 1 to 5.27 HC1 uses com- munity health workers (CHWs) who are deployed by the government to deliver education and preventative care. HC2 provides focused rural care with nurses. HC3 has both maternity and outpatient services and HC4 has a doctor and an operating theater.28 HC5 is classified as hospitals.27 HCs are designed to work in coordination with one another with each level referring to higher levels of care that exceeds the scope of practice. Serious break- downs in this system are reported: long distances between facilities, lack of essential medicines, and understaffing that contribute to delays and poor outcomes.29-31 The birth center in this study is classified as a HC3 and serves eight villages with a population of 76,985.32 The region is rural and the community relies on subsistence farming. The birth center is centrally located, with an av- erage travel distance of 4 miles to villages. The roads that connect the villages to the main road are not paved. In the dry season, these are navigable but can be treacherous due BOX 1  Note on gendered language A note on gender language We recognize that not all people who are assigned female at birth and have reproductive experiences identify as women. In this case study, all participants and those accessing the birth center identified as women; therefore, our language will use that term generally throughout. 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense      |  785TELFER et al. to flooding during the rainy season. Most transportation is by motorcycle, bicycle, or on foot. 2.2  |  Sample and data collection Researchers developed the study methods alongside the birth center community in 2018. Interviews, participant observation, and record reviews were collected over 6 weeks in June and July of 2019, with ongoing communi- cation throughout 2020 and 2021. The sample was drawn from staff, patients, and key stakeholders. 2.2.1  |  Interviews Interviews were conducted with patients of the birth center, traditional midwives (TM; also called community health workers), nurse–midwives (NM), the district health officer, and additional staff. We conducted individual and small- group interviews in English or Acholi (depending on prefer- ence), and recorded for transcription. Interviews followed a guide developed collaboratively with local NMs and TMs, to ensure cultural appropriateness and relevance (Table 1). A hired interpreter was used that had no relationship to the birth center but was culturally acceptable to participants as a local woman. Participants who were illiterate provided verbal assent after a script was read to them and questions were answered. Those who were literate signed a written consent form. Consents included permissions for the use of participant-approved photographs. Participants received sugar, which was evaluated as a culturally appropriate meas- ure of compensation. Interviews continued until saturation was achieved and no new concepts were identified.33 Participant observation was conducted at the birth cen- ter, outreach clinics, the referral hospital, and community events. Detailed field notes were taken and verified with staff. We developed a timeline of the birth center and its context. Documents reviewed included annual reports from 2009 to 2021, care ledgers, and medical charts. 2.3  |  Data analysis All data (interview transcripts, field notes, photographs) were entered into Atlas.ti. which permits explorations of qualitative textual and image data and permits complex mapping through its networking capability.34 Systematic data analytic steps were both iterative and interpretative, allowing for repeated questioning and examination of the question: What cultural, clinical, and contextual fac- tors influence the outcomes documented at this center?35 F I G U R E 1   The framework for quality maternal and newborn care: maternal and newborn health components of a health system needed by childbearing women and newborn infants (Renfrew et al.1). [Colour figure can be viewed at wileyonlinelibrary.com] 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com 786  |     TELFER et al. Researchers achieved consensus on code development and categorization through iterative coding and team meetings. A priori codes reflected the components of the QMNC framework. Emergent codes were developed throughout the analysis. Researchers independently identified three prevalent themes and reviewed them for alignment with the QMNC framework's five overarching components,19,36 developing a gestalt of the findings that were examined across all codes and coding categories. 3   |   RESULTS Description of the sample: Patients interviewed represented all the villages (N = 21). Their average age was 22 with a range of 15–39 and parity from P0–P10. We interviewed most staff including 37 TMs (years in practice 1.5–60), 5 NMs (years in practice 5–20); the district health officer and additional sup- port staff (lab technician, drivers, cook, engineer). We de- scribe the birth center's history, community integration, and clinical outcomes and present a synthesis of central themes identified likely related to the birth center's outcomes using the components of the QMNC framework.19 Photographs illustrate some findings. The timeline of the birth center establishment (Table 2) provides a historical overview and a summary of community engagement while mapping the development of outreach clinics and outcomes. 3.1  |  Historical establishment The center was established as a non-profit, Mother Health International (MHI), in 2007 by a midwife who worked in a government hospital during the war. Observing many pre- ventable perinatal deaths, she made connections between the lack of coordinated care, trauma, war, and displace- ment.37 Although 80% of the regions' mothers were giving birth at home with TMs, there was no collaborative care between TMs and hospitals.38 This lack of collaboration led to dialogue with TMs called “lucolo” (“push helpers” in Acholi). TMs described the need to confront entrenched ob- stetric violence within hospitals, discrimination, discounting of traditional knowledge, poor understanding, and recog- nition of community barriers to facility birth. At the time, Atiak was home to Uganda's largest Internally Displaced Persons (IDP) camp, where TMs were attending most births with minimal supplies and support. The nearest doctor was 72 km away with no paved roads or ambulances. The mid- wife and TMs formed a collective and opened a temporary birth center in the camp. They had 13 births within the first 2 days. Over 2 years, they fundraised, bought land, and built a physical birth cente. Table 2 describes the timeline for the establishment and growth of the birth center. T A B L E 1   Semi-structured interview guides. Template of interview questions Midwives and the community 1. When did you become a midwife? What made you decide to become a midwife? 2. Can you tell me about the first birth you ever saw or attended? How did you feel? 3. Is there a birth that is particularly memorable you would like to share about? 4. What do you like about being a midwife? 5. What is hard about being a midwife? 6. What is it like working for the MHI birth center? 7. If you have worked in other facilities, what is the difference between those clinics or hospitals and MHI? 8. What do you think the role of the midwife should be throughout a woman's pregnancy and delivery? 9. What is it like working with Lucolo community health workers? What do you think their role should be with pregnant women? 10. What do you think this birth center has done for the community? Is there anything you would change? 11. What advice would you give to a new mother who has never given birth before? 12. Is there anything I have not asked you that you would like to tell me? The birth center and the community (non-clinicians) 1. What is your role or relationship to the clinic? 2. Do you know anyone personally who has delivered there? What did they share with you about their experience? 3. If you have seen or worked in other maternity centers, what is the difference between those clinics or hospitals and MHI? 4. What do you think the role of the Birth Center should be throughout a woman's pregnancy and delivery? 5. How do you feel about Lucolo (traditional midwives)? What do you think their role should be with pregnant women? 6. What do you think this birth center has done for the community? Is there anything you would change? 7. What advice would you give to a new mother who has never given birth before? 8. Is there anything I have not asked you that you would like to tell me? Mothers who have given birth at the birth center 1. Can you tell me about your birth history? How many babies have you had? 2. Did all of your babies survive delivery? 3. Did you have any fear about going into labor with your last baby? 4. Tell me about your last birth at Maraam (local word for birth center)? What happened? a. Was the birth what you expected it would be? b. What helped you get through labor? c. Who helped you the most? d. Is there anything you would change? 5. Did you come to the center for prenatal care or receive prenatal care from the outreach team? What was that like? 6. Have you also delivered babies in other health facilities? What was that experience like? 7. What do you think the midwife's job is in caring for you? How do you know if she is doing a good job? 8. Did you have a Lucolo (traditional midwife) working with you? What did she do for you? 9. What do you think this birth center has done for the community? 10. What advice would you give to a new mother who has never given birth before? 11. Is there anything I have not asked you that you would like to tell me? Probes: Can you tell me more about that? Could you give me an example? 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense      |  787TELFER et al. 3.2  |  Description of the birth center and services The birth center is a large building with a circular com- mon area and eight round rooms surrounding it. Private birth rooms have low accessible beds, birth tubs, birth stools, and yoga balls. The central room has hammocks T A B L E 2   Ti m el in e of th e bi rt h ce nt er e st ab lis hm en t a nd g ro w th . 19 96 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 M SF d ep ar te d w ith ou t a go ve rn m en t p la n in p la ce to re op en he al th fa ci lit ie s w ith U ga nd an st af f Fu tu re b ir th ce nt er d ir ec to r w or ke d in G ul u H os pi ta l N ee ds a ss es sm en t ov er 6  m on th s w ith 54 9 w om en a nd 6 0 tr ad iti on al m id w iv es 20 08 : P re si de nt K on y fle es U ga nd a; 5 00 ,0 00 pe op le st ill li vi ng in ID P C am ps w ith m in im al he al th c ar e W or ld F oo d Pr og ra m , ID P ca m ps di sb an de d M ob ile M id w iv es of fic ia lly st ar te d w ith e ve ry m id w ife re ce iv in g a bi ke C om pl et io n of th e pa vi ng of th e G ul u- N im ul e R oa d A tia k 2 ro om b ir th ce nt er o pe ne d O t N yw al M e K uc B ir th C en te r o pe ne d M H I e st ab lis he d as a n N G O La nd p ur ch as ed a nd co ns tr uc tio n be gu n on n ew p os tp ar tu m w ar d N ew po st pa rt um w ar d op en ed M od es o f t ra ns po rt at io n 1 SU V , 1 m ot or cy cl e & b ic yc le s ( 20 10 ) M ot or iz ed tr ic yc le s, m ot or cy cl es , S U V , b ic yc le s # nu rs e– m id w iv es 2 2 4 4 3 3 5 5 5 6 6 6 5 5 # tr ad iti on al m id w iv es 27 29 32 30 36 60 58 55 59 59 60 59 59 59 # bi rt hs 60 0 62 5 98 2 88 9 90 0 99 9 10 36 11 18 11 54 11 27 12 47 16 77 17 39 21 18 # ne on at al d ea th s 6 7 12 9 9 10 11 12 11 12 10 13 18 21 # m at er na l d ea th s 0 0 0 0 0 0 0 0 0 0 0 0 0 0 # ho sp ita l t ra ns fe rs 51 47 86 82 79 89 96 88 93 99 10 1 99 10 0 97 # ce sa re an d el iv er ie s 33 29 51 57 61 70 76 73 81 74 97 89 92 83 T A B L E 3   Birth center demographics (2020). Types of services provided N Comments Primary care Malaria 1479 Family planning 769 Surgical sterilization 52 On-site clinic held 2 × a year with visiting consultant Antenatal visits 8729 Labor and birth 1247 1026 births in the birth center Nulliparous births 415 Multiparous births 832 Singleton births 1220 Multiple 27 Twins Breech 31 Vacuum assisted 57 Transfer to regional hospital 221 Failure to progress (87), Obstructed Labor (22), Malposition (9), Cord prolapse (1), Placenta Previa (2), Malaria in labor (10), Fetal distress (39), PPH (19), Neonatal care (27), other (5) Cesarean deliveries 107 At referral hospital 1 hour away (0.8%) Apgar <7 at 5 min 229 Postnatal visits 5988 12-year infant mortality rate 11/1000 12-year maternal mortality rate 0 in 13,000 births T A B L E 4   Contributions to neonatal demise over 10 years. Contribution (n) Contributory cause 34 Obstructed labor 33 Prematurity 25 Unknown 21 Fetal anomaly 19 Infection 14 Meconium 12 Cord prolapse or accident 7 Breech Total: 165 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense 788  |     TELFER et al. and grass mats for families and is used by the TMs for weekly education and peer review. There is an antenatal room, laboratory, and pharmacy. There is solar power and running water from a well. A thatched canopy outside has a charcoal stove for families or TMs to prepare food for laboring women and a wash area with clotheslines. Staff housing is on the compound. There is a kitchen/din- ing area and family-style meals are provided to all staff. Motorcycle ambulances, a van, and drivers are on-call to take the team for outreach, bring laboring women to the birth center and for emergency transfers. Clinical records are both written and image based so that illiterate TMs can also chart events such as rupture of membranes or fever. During the founding, the collective created protocols re- flexive to the needs of a displaced community and a system where TMs mobilized women for antenatal care and enrolled them to birth at the center. Before the birth center, 73% of women birthed at home either alone or with a TM, and 90% of women had fewer than three antenatal visits.38 By 2019, 92% of women birthed at the center, attended by both a NM and a TM and 81% of women had eight antenatal visits.21,39 During 2019, there were a total of 1247 births recorded in Atiak, of those, 1026 were at the center.21 Table 3 provides an overview of services and outcomes. Table 4 provides an overview of contributors to perinatal demise. The center is community owned. Services are supported by donations, grants, and some government support; no one is turned away. To subsidize fees, a collection drive occurs biannually with community members giving the equivalent of 1–3 U.S. dollars each. Donors become stake- holders and are invited to take part in the annual meeting. Additional funding is raised through the non-profit MHI. 3.3  |  Results of the thematic analysis Using an institutional ethnographic lens, we exam- ined the social and institutional forces that organize and shape the environment and narratives told by partici- pants in the study. In the process of examining our find- ings, we identified three prevalent themes that correlate to the QMNC framework. (a) Community knowledge and understanding: Care is deeply rooted in the context of northern Uganda. Intrinsic to the model is respect for the TMs' knowledge and cultural fluency. The TMs, chosen by community elders, worked in the community throughout the war. Many attended work- shops provided by the government or NGOs. The TMs named the center Ot Nywal Me Kuc, “House of Birth and Peace” in Acholi. “It was founded when the war in northern Uganda was still ongoing, and the TMs felt it was important to convey that peace begins with birth, especially when con- ception has occurred as a result of rape or trauma and where women's bodies are used as tools of war. Being born in love holds promise to improve women's and children's lives in the future as they survive the trauma of conflict” (staff NM). This community lived through decades of war and re- turned to subsistence farming after a generation of displace- ment and reliance on the World Food Program.40 In 2009, IDP camps abruptly closed. Daily life for women suddenly included long walks to collect water and farm. To miss even 1 day for antenatal care might destroy a family's food secu- rity. Women described being chastised in other settings for not seeking care. At the birth center, it was recognized that lack of attendance was often the result of prioritizing more immediate needs and organized bringing care to women through a “Mobile Midwives” outreach program. (b) Community integrated care: TMs were made ille- gal in Uganda in 2010 yet women still sought their care. It was noted that many women are more comfortable with TMs so having them integrated as care navigators within a government-approved health clinic is central to the center's success. Women birth legally with licensed practitioners but have the support and community knowledge from TMs. This integration is reflected by the nickname, Yala Yala, which means to “come together in community.” “Yala Yala has changed the community by mobilizing TMs to bring women to deliver, and they are nicer to women in comparison to Health Center 4” (staff [Picture 1 of TM reviewing prenatal records in birth center common space with adjoining rooms] [Colour figure can be viewed at wileyonlinelibrary.com] 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com      |  789TELFER et al. TM). The outreach program recognizes the mobilizing power of TMs alongside the need for clinical care from NMs brought to women's homes. Each village hosts a clinic twice per month. One of the NMs described collaborative care with the TMs: “… they [TMs] are the ones always helping us by bring- ing these mothers to the birth center. Most of this population is used to delivering at home. So, they help mobilize these mothers, so they know to come to us, either in labor or in antenatal. Some lucolos [TMs] are very knowledgeable and know how to identify high risk mothers on their own – this makes things safer, and we can refer quickly when neces- sary” (staff NM). The NMs and TMs collaboratively provide continuity of care from the antenatal period through the first year. A TM noted, “you find them (pregnant women) when you are collecting water together; you always know who is preg- nant.” She described pulling women aside to talk to them, encouraging them to come for care. The NMs and TMs consult one another in follow-up care. They described that this means that families “do not get lost” or slip through the cracks. The staff knows where each woman lives, her home circumstances, and history (i.e., if she is food in- secure, experiencing intimate partner violence, or previ- ously lost a child). TMs each have a mobile phone provided by the center so at the onset of labor, women contact their TM, who call for transport. A driver is dispatched to bring them to the birth center. The TM stays with the woman through labor, offers support, and accompanies her home postpartum or to the hospital if the mother is transferred. The integration within the community extends to the re- ferral hospital; our observations indicated that the NMs had a good relationship and provided an in-person detailed re- port when referring to ensure timely and effective treatment. They have a strong relationship with the District Medical Officer. He remarked on the strong referral system contrib- uting to good outcomes – “they use it well” – compared with the government system that has limited emergency medical services and few working ambulances. With the center's dedicated ambulance and drivers, a patient in need of higher level care is taken immediately, eliminating delays in care. (c) Quality care that is respectful, accessible, and avail- able: Our observations indicated a highly competent work- force within a rural area. NMs receive additional training at orientation so they are not only clinically excellent but value a culture of respectful care. About 70% of women who present in labor come with their local TM; others are assigned support from an on-call TM at the birth center. The TMs are self-governed by elected leadership, attend weekly meetings to peer review cases, discuss concerns, and learn from the NMs. Many are illiterate; thus, the birth [Picture 2: women waiting for antenatal/postnatal/infant checks in an outreach setting with the motorcycle ambu- lance used for team transport in the background]. [Colour figure can be viewed at wileyonlinelibrary.com] [Picture 4 – TMs training for a birth at the birth center, hands show clapping as they sing the protocol] [Colour figure can be viewed at wileyonlinelibrary.com] [Picture  3 – arrival in labor-motorcycle in background] [Colour figure can be viewed at wileyonlinelibrary.com] 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com https://onlinelibrary.wiley.com https://onlinelibrary.wiley.com 790  |     TELFER et al. center protocols were developed using song and dance; a traditional means of sharing information. The songs cover everything from warning signs in pregnancy, labor support, signs of infection, and when to seek higher level care. In addition to care that is clinically excellent, we ob- served interpersonal and cultural fluency. For example, belief in possession by evil spirits in pregnancy is com- mon. One of the NMs who had worked in other settings believed honoring this was important. “In most allopathic settings, these would be brushed off as beliefs that do not cor- relate to outcomes. In reality, what a woman believes about her labor impacts the physical outcomes and so having care providers who understand the nuances and are able to pro- vide care where the client is, will have an impact not only on outcomes but on women's perceptions of care in labor and willingness to share perhaps other critical information” (staff NM). Another NM described how past experiences of trauma could present during labor and birth. “Sometimes she can be in denial of the whole labor; there was a time with a mother who was deeply traumatized and didn't want to accept the labor. She was angry and cutting herself and say- ing the family members bewitched her, but in reality, it was her trauma. I was able to counsel her and eventually she accepted the labor and the whole purpose of labor. It was long; it was hard” (staff NM). One of the staff TMs described births in the IDPs, where “there were too many to count.” She noted that the government moved to stop home births because TMs were not formally trained. She described a government train- ing where she was given a fetoscope but never taught how to use it. She has since gained confidence in assessing vital signs and fetal well-being by working at the center. One previous government training insisted that TMs use razor blades to cut umbilical cords. However, there were no resupply mechanisms, so many TMs reused rusty or unsanitized blades and unknowingly put infants at risk for infection. TMs described using straw grass to cut cords before the razor blades were introduced. Straw grass is sterilized by the hot sun, sharp enough to cut through a cord and is renewable. The ripple effects of these kinds of “one off” trainings were addressed by the collective in order to define a set of best practices that honored local knowledge. Women described experiencing violence in other health settings, but when they walked into the birth cen- ter, they felt like they were cared for as if “being taken like a baby.” They said this jokingly, but the culture of respect was well known. Women said they knew they would be believed, cared for, not shamed, hit, or abused. Almost universally, when we interviewed women who had given birth in other settings, they described how their experi- ence differed at the birth center. They described a good midwife as one who “asks what you are feeling, asks what is needed, asks about pain, and stays close” (patient). One woman described how she had experienced birth in the hospital: “The nurses left me alone, and I ended up deliv- ering my baby by myself, and then the nurses came in and slapped me when they found out. At the birth center they stay and check you and will not leave” (patient). 4   |   DISCUSSION The purpose of this case study was to ask the question: What cultural, clinical, and contextual factors influence the outcomes documented at this center? Specifically, we aimed to identify: (1) clinical factors in place that address critical gaps in the care continuum and contribute to im- proved outcomes; and (2) sociocultural factors that this center and its staff incorporate that may contribute to im- proved uptake of services and outcomes. We set out to understand “what is happening here?”. The case-study analysis reflects components of the QMNC framework and the critical importance of safe, accessible, and respectful care. The women interviewed did not trust the government health workers or the medical system. Almost every woman who had given birth in a hospital re- ported being hit, strangled, or verbally berated by medical staff. Respectful maternity care (RMC) is described by the World Health Organization as “the care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth”.41 RMC has become a critical global goal, but especially in the Global South where the impact may be the greatest.42 Without RMC in a supported healthcare system, women may avoid healthcare facilities.43 In contrast, care at the birth center was described as respectful and loving, with critical components like transport and emergency care integrated into the organization. Local beliefs were addressed respectfully and incorporated into decision- making and clinical care. It is important to note that RMC can only be provided in a health system that supports its healthcare workers with safe staffing and critical sup- plies.44 The birth center NMs and TMs are supported by staff, supplies, competitive salaries, and good living condi- tions. They do not work alone in a facility lacking in sup- plies or transport, which can be a terrifying prospect for a NM in a remote posting. This fear and lack of support often translates into disrespectful care to patients.43 The birth center organizes care around the “three de- lays”5 which highlights key barriers to accessing maternal health services: (1) delay in the decision to seek care; (2) delay in reaching a facility; and (3) delay in receiving ade- quate care once at a facility.5 This model has been widely reported on, yet it has not been studied alongside the 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense      |  791TELFER et al. QMNC framework in a clinical setting.7,8,11,13,45 The birth center sets an example for care that responds to the delays and integrates the QMNC framework. As discussed, the center sends NMs to remote villages to bring direct care, thus eliminating the first delay and increasing overall an- tenatal attendance which is known to reduce perinatal mortality.46,47 The second delay is access to care: Once the decision to seek care has been made (often at a time of emer- gency), transport can be a huge barrier. In rural areas, many women give birth alongside the road while walk- ing to seek help. In response, the birth center uses am- bulances to pick up women, bring them to the center for birth, and then drive them home postpartum, eliminating several delays. The third delay is receiving care once reaching a health center. It is common for women to exhaust all resources to reach a health center only to find that there are no skilled staff, supplies, or essential medicine. Staff may berate women for waiting too long to arrive, and send them away for lack of plastic to birth on or ability to pay. At the center, once in labor, women are brought to an always staffed and stocked clinic with access to emergency medicine, trans- port, and skilled respectful practitioners. The organization of care in this way is the embodiment of midwifery as de- scribed in the QMNC framework. The focus on access in the hardest-to-reach areas, the importance of respectful relationships, and the value of quality care becomes in- trinsic to the culture and well-being of a community. By mapping the QMNC framework to the structure of the birth center (Figure 2), it is clear how each element is ad- dressed and integrated achieving a significant reduction in mortality.48-51 A recent case study of four low-income countries (LMICs) demonstrated that midwife-led birth centers, when adequately supported and staffed, can have similar improved outcomes in HICs.52 More research is needed to determine the scalability of such models, with special focus on difficult to reach and underserved areas. This case study provides a glimpse into how birth centers using F I G U R E 2   Birth center interventions mapped to three delays model and QMNC framework. [Colour figure can be viewed at wileyonlinelibrary.com] 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com 792  |     TELFER et al. the midwifery model of care and QMNC framework can improve outcomes. Case studies are inherently limited by their focus. By looking at one birth center, the regional, cultural, or social influencers on outcomes may not apply in other settings. Simultaneously, a case study is strengthened by in-depth engagement with the community, multiple data sources, and participant observation. Therefore, these findings may be helpful in evaluating current models and develop- ing future policies and proposals to put the QMNC frame- work into action.53,54 5   |   CONCLUSION This birth center is an example of perinatal care that addresses the three delays while embodying the QMNC framework. It reflects organized care that integrates different systems working together to support the practice of midwifery with subsequent excellent outcomes. Scaling up the model of care with skilled midwives organized around the unique needs of women within the community could be a pathway for signifi- cant change in many settings. Future research may consider replication of a similar collaborative community birth center model that invokes the QMNC framework for both method development and evaluation of outcomes. CONFLICT OF INTEREST STATEMENT We have no conflict of interest to declare. The Director of MHI did not participate in any of the research interviews, coding or data analysis. They participated in providing background information, cultural context and in writing of the final paper. DATA AVAILABILITY STATEMENT The data that support the findings of this study are avail- able on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. ORCID Michelle Telfer  https://orcid.org/0000-0002-8176-3936 Holly Powell Kennedy  https://orcid. org/0000-0001-7866-1552 REFERENCES 1. Onambele L, Ortega-Leon W, Guillen-Aguinaga S, et  al. Maternal mortality in Africa: regional trends (2000-2017). Int J Environ Res Public Health. 2022;19(20):13146. doi:10.3390/ ijerph192013146 2. Moller AB, Newby H, Hanson C, et  al. Measures matter: a scoping review of maternal and newborn indicators. 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Midwifery. 2019;73:26-34. doi:10.1016/j. midw.2019.03.002 54. Symon A, Pringle J, Cheyne H, et al. Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and charac- teristics of care. BMC Pregnancy Childbirth. 2016;16(1):168. doi:10.1186/s12884-016-0944-6 How to cite this article: Telfer M, Zaslow R, Nalugo Mbalinda S, Blatt R, Kim D, Kennedy HP. A case study analysis of a successful birth center in northern Uganda. Birth. 2024;51:783-794. doi:10.1111/birt.12837 1523536x, 2024, 4, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/birt.12837 by M akerere U niversity, W iley O nline L ibrary on [23/03/2026]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://doi.org//10.1016/j.midw.2019.03.002 https://doi.org//10.1016/j.midw.2019.03.002 https://doi.org//10.1186/s12884-016-0944-6 https://doi.org/10.1111/birt.12837 A case study analysis of a successful birth center in northern Uganda Abstract 1 | INTRODUCTION 2 | METHODS 2.1 | Setting 2.2 | Sample and data collection 2.2.1 | Interviews 2.3 | Data analysis 3 | RESULTS 3.1 | Historical establishment 3.2 | Description of the birth center and services 3.3 | Results of the thematic analysis 4 | DISCUSSION 5 | CONCLUSION CONFLICT OF INTEREST STATEMENT DATA AVAILABILITY STATEMENT ORCID REFERENCES