Impact of Solar Light and Electricity on the Quality and Timeliness of Maternity Care: A Stepped-Wedge Cluster-Randomized Trial in Uganda

BACKGROUND: We evaluated the impact of solar light installation in Ugandan maternity facilities on implementation processes, reliability of light, and quality of intrapartum care. METHODS: We conducted a stepped-wedge cluster-randomized trial of the We Care Solar Suitcase, a complete solar electric system providing lighting and power for charging phones and small medical devices, in 30 rural Ugandan maternity facilities with unreliable lighting. Facilities were randomly assigned to receive the intervention in the first or second sequence in a 1:1 ratio. We collected data from June 2018 to April 2019. The intervention was installed in September 2018 (first sequence) and in December 2018 (second sequence). The primary effectiveness outcomes were a 20-item and a 36-item index of quality of intrapartum care, a 6-item index of delays in care provision, and the percentage of deliveries with bright light, satisfactory light, and adequate light. RESULTS: We observed 1,118 births across 30 facilities. The intervention was successfully installed in 100% of facilities. After installation, the intervention was used in 83% of nighttime deliveries. Before the intervention, providers on average performed 42% of essential care actions and accumulated 76 minutes of delays during nighttime deliveries. After installation, quality increased by 4 percentage points (95% confidence interval [CI]=1,8) and delays in care decreased by 10 minutes (95% CI=−16,−3), with the largest impacts on infection control, prevention of postpartum hemorrhage, and newborn care practices. One year after the end of the trial, 90% of facilities had LED lights in operation and 60% of facilities had all components in operation. CONCLUSIONS: Reliable light is an important driver of timely and adequate health care. Policy makers should invest in renewable energy systems for health facilities; however, even when reliable lighting is present, quality of care may remain low without a broader approach to quality improvements.