Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: a mixed methods case study.
ABSTRACT: BACKGROUND:Targeted clinical interventions have been associated with a decreased risk of neonatal morbidity and mortality. In conflict-affected countries such as South Sudan, however, implementation of lifesaving interventions face barriers and facilitators that are not well understood. We aimed to describe the factors that influence implementation of a package of facility- and community-based neonatal interventions in four displaced person camps in South Sudan using a health systems framework. METHODS:We used a mixed method case study design to document the implementation of neonatal interventions from June to November 2016 in one hospital, four primary health facilities, and four community health programs operated by International Medical Corps. We collected primary data using focus group discussions among health workers, in-depth interviews among program managers, and observations of health facility readiness. Secondary data were gathered from documents that were associated with the implementation of the intervention during our study period. RESULTS:Key bottlenecks for implementing interventions in our study sites were leadership and governance for comprehensive neonatal services, health workforce for skilled care, and service delivery for small and sick newborns. Program managers felt national policies failed to promote integration of key newborn interventions in donor funding and clinical training institutions, resulting in deprioritizing newborn health during humanitarian response. Participants confirmed that severe shortage of skilled care at birth was the main bottleneck for implementing quality newborn care. Solutions to this included authorizing the task-shifting of emergency newborn care to mid-level cadre, transitioning facility-based traditional birth attendants to community health workers, and scaling up institutions to upgrade community midwives into professional midwives. Additionally, ongoing supportive supervision, educational materials, and community acceptance of practices enabled community health workers to identify and refer small and sick newborns. CONCLUSIONS:Improving integration of newborn interventions into national policies, training institutions, health referral systems, and humanitarian supply chain can expand emergency care provided to women and their newborns in these contexts.
Project description:BACKGROUND:The neonatal period is only 1/60th of the first 5 years of life but it accounts for 63% of all infant deaths and 44% of all under-five deaths in Ethiopia. Most causes of neonatal death are preventable with clean cord care, temperature control by delaying first bath and initiation of early breastfeeding which has additional benefit of controlling hypothermia. Poor positive pressure ventilation (PPV) with ambubag is also another essential neborn care practice to reduce neonatal death even though it was not the focus of this study with the assumption that it cannot be measured only by exit interview (needs direct observation about the procedure). This study was aimed to assess the link between quality of ANC service and implementation of essential newborn care practices among pregnant women attending ANC at public health facilities of BDR City Administration. METHODS:A facility based prospective follow up study was conducted and 970 pregnant women with gestational age???16 weeks who came for their first ANC visit were enrolled. Women were followed from their first ANC visit until 6 weeks after delivery. Longitudinal data was collected during consultation with ANC providers using structured observation checklist and exit interview was also carried out at 6 weeks after birth when they came to immunize their child to assess the essential newborn care practices that their babies received. ANC service was considered as acceptable quality if women received ?75th percentile of the essential ANC services. Generalized Estimating Equation (GEE) was carried out to control cluster effect among women who received ANC in the same facility. RESULTS:The composite essential newborn care practice indices were 13.7%, with 95% CI (11.3%, 16.2%) and 86.3%, with 95% CI (83.8%, 88.7%) for good and poor essential new born care practices respectively. Of those who received acceptable ANC quality and un acceptable ANC quality 24.7% and 9.6% had good essential newborn care practice respectively (X2?=?31.668, p?<?0.000). CONCLUSIONS:Most neonatal interventions are not reaching newborns, indicating a "policy-to practice gap". It is crucial that maternal knowledge about essential newborn care need to start before the baby's birth with an effective educational plan. Quality ANC service is a facilitator for essential newborn care practice. To improve newborn survival, newborn care should be integrated into the current maternal and child health interventions, and should be promoted both at community and health facility level as part of a universal coverage strategy.
Project description:BACKGROUND: Globally, approximately 3 million babies die annually within their first month. Access to adequate care at birth is needed to reduce newborn as well as maternal deaths. We explore the influence of distance to delivery care and of level of care on early neonatal mortality in rural Zambia and Malawi, the influence of distance (and level of care) on facility delivery, and the influence of facility delivery on early neonatal mortality. METHODS AND FINDINGS: National Health Facility Censuses were used to classify the level of obstetric care for 1131 Zambian and 446 Malawian delivery facilities. Straight-line distances to facilities were calculated for 3771 newborns in the 2007 Zambia DHS and 8842 newborns in the 2004 Malawi DHS. There was no association between distance to care and early neonatal mortality in Malawi (OR 0.97, 95%CI 0.58-1.60), while in Zambia, further distance (per 10 km) was associated with lower mortality (OR 0.55, 95%CI 0.35-0.87). The level of care provided in the closest facility showed no association with early neonatal mortality in either Malawi (OR 1.02, 95%CI 0.90-1.16) or Zambia (OR 1.02, 95%CI 0.82-1.26). In both countries, distance to care was strongly associated with facility use for delivery (Malawi: OR 0.35 per 10km, 95%CI 0.26-0.46). All results are adjusted for available confounders. Early neonatal mortality did not differ by frequency of facility delivery in the community. CONCLUSIONS: While better geographic access and higher level of care were associated with more frequent facility delivery, there was no association with lower early neonatal mortality. This could be due to low quality of care for newborns at health facilities, but differential underreporting of early neonatal deaths in the DHS is an alternative explanation. Improved data sources are needed to monitor progress in the provision of obstetric and newborn care and its impact on mortality.
Project description:BACKGROUND:Identification of maternal and newborn illness and the decision-making and subsequent care-seeking patterns are poorly understood in Nepal. We aimed to characterize the process and factors influencing recognition of complications, the decision-making process, and care-seeking behavior among families and communities who experienced a maternal complication, death, neonatal illness, or death in a rural setting of Nepal. METHODS:Thirty-two event narratives (six maternal/newborn deaths each and 10 maternal/newborn illnesses each) were collected using in-depth interviews and small group interviews. We purposively sampled across specific illness and complication definitions, using data collected prospectively from a cohort of women and newborns followed from pregnancy through the first 28 days postpartum. The event narratives were coded and analyzed for common themes corresponding to three main domains of illness recognition, decision-making, and care-seeking; detailed event timelines were created for each. RESULTS:While signs were typically recognized early, delays in perceiving the severity of illness compromised prompt care-seeking in both maternal and newborn cases. Further, care was often sought initially from informal health providers such as traditional birth attendants, traditional healers, and village doctors. Key decision-makers were usually female family members; husbands played limited roles in decisions related to care-seeking, with broader family involvement in decision-making for newborns. Barriers to seeking care at any type of health facility included transport problems, lack of money, night-time illness events, low perceived severity, and distance to facility. Facility care was often sought only after referral or following treatment failure from an informal provider and private facilities were sought for newborn care. Respondents characterized government facility-based care as low quality and reported staff rudeness and drug type and/or supply stock shortages. CONCLUSION:Delaying the decision to seek skilled care was common in both newborn and maternal cases. Among maternal cases, delays in receiving appropriate care when at a facility were also seen. Improved recognition of danger signs and increased demand for skilled care, motivated through community level interventions and health worker mobilization, needs to be encouraged. Engaging informal providers through training in improved danger sign identification and prompt referral, especially for newborn illnesses, is recommended.
Project description:Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (?90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.
Project description:BACKGROUND: Reducing preventable medical causes of neonatal death for faster progress toward the MGD4 will require Cameroon to adequately address the social factors contributing to these deaths. The objective of this paper is to explore the social, behavioral and health systems determinants of newborn death in Doume, Nguelemendouka and Abong-Mbang health districts, in Eastern Region of Cameroon, from 2007-2010. METHODS: Data come from the 2012 Verbal/Social Autopsy (VASA) study, which aimed to determine the biological causes and social, behavioral and health systems determinants of under-five deaths in Doume, Nguelemendouka and Abong-Mbang health districts in Eastern Region of Cameroon. The analysis of the data was guided by the review of the coverage of key interventions along the continuum of normal maternal and newborn care and by the description of breakdowns in the care provided for severe neonatal illnesses within the Pathway to Survival conceptual framework. RESULTS: One hundred sixty-four newborn deaths were confirmed from the VASA survey. The majority of the deceased newborns were living in households with poor socio-economic conditions. Most (60-80%) neonates were born to mothers who had one or more pregnancy or labor and delivery complications. Only 23% of the deceased newborns benefited from hygienic cord care after birth. Half received appropriate thermal care and only 6% were breastfed within one hour after birth. Sixty percent of the deaths occurred during the first day of life. Fifty-five percent of the babies were born at home. More than half of the deaths (57%) occurred at home. Of the 64 neonates born at a health facility, about 63% died in the health facility without leaving. Careseeking was delayed for several neonates who became sick after the first week of life and whose illnesses were less serious at the onset until they became more severely ill. Cost, including for transport, health care and other expenses, emerged as main barriers to formal care-seeking both for the mothers and their newborns. CONCLUSIONS: This study presents an opportunity to strengthen maternal and newborn health by increasing the coverage of essential and low cost interventions that could have saved the lives of many newborns in eastern Cameroon.
Project description:AIMS:To assess the knowledge of nurses of national guidelines for emergency maternity, routine newborn and small and sick newborn care in Nairobi County, Kenya. BACKGROUND:The vast majority of women deliver in a health facility in Nairobi. Yet, maternal and neonatal mortality remain high. Ensuring competency of health workers, in providing essential maternal and newborn interventions in health facilities will be key if further progress is to be made in reducing maternal and neonatal mortality in low-resource settings. DESIGN:Cross-sectional survey. METHODS:Questionnaires comprised of clinical vignettes and direct questions and were administered in 2015-2016 to nurses (n = 125 in 31 facilities) on duty in maternity and newborn units in public and private facilities providing 24/7 inpatient neonatal services. Composite knowledge scores were calculated and presented as weighted means. Associations were explored using regression. STROBE guidelines were followed. RESULTS:Nurses scored best for knowledge on active management of the mother after birth and immediate routine newborn care. Performance was worst for questions on infant resuscitation, checking signs and symptoms of sick newborns, and managing hypertension in pregnancy. Overall knowledge of care for sick newborns was particularly low (score 0.62 of 1). Across all areas assessed, nurses who had received training since qualifying performed better than those who had not. Poorly resourced and low case-load facilities had lower average knowledge scores compared with better-resourced and busier facilities. CONCLUSION:Overall, we estimate that 31% of maternity patients, 3% of newborns and 39% of small and sick newborns are being cared for in an environment where nursing knowledge is very low (score <0.6). RELEVANCE TO CLINICAL PRACTICE:Focus on periodic training, ensuring retention of knowledge and skills among health workers in low-case load setting, and bridging the know-do gap may help to improve the quality of care delivered to mothers and newborns in Kenya.
Project description:Despite progress in recent years, an estimated 273,500 women died as a result of maternal causes in 2010. The burden of these deaths is disproportionately bourne by women who reside in low income countries or belong to the poorest sectors of the population of middle or high income ones, and it is particularly acute in regions where access to and utilization of facility-based services for childbirth and newborn care is lowest. Evidence has shown that poor quality of facility-based care for these women and newborns is one of the major contributing factors for their elevated rates of morbidity and mortality. In addition, women who perceive the quality of facilty-based care to be poor,may choose to avoid facility-based deliveries, where life-saving interventions could be availble. In this context, understanding the underlying factors that impact the quality of facility-based services and assessing the effectiveness of interventions to improve the quality of care represent critical inputs for the improvement of maternal and newborn health. This series of five papers assesses and summarizes information from relevant systematic reviews on the impact of various approaches to improve the quality of care for women and newborns. The first paper outlines the conceptual framework that guided this study and the methodology used for selecting the reviews and for the analysis. The results are described in the following three papers, which highlight the evidence of interventions to improve the quality of maternal and newborn care at the community, district, and facility level. In the fifth and final paper of the series, the overall findings of the review are discussed, research gaps are identified, and recommendations proposed to impove the quality of maternal and newborn health care in resource-poor settings.
Project description:Newborn feeding practices are important to neonatal health and survival, but understudied in sub-Saharan Africa. We assessed the prevalence and determinants of newborn feeding practices in Burkina Faso.An 18?000 household survey was conducted in rural Burkina Faso in 2010 to 2011. Women of reproductive age were asked about antenatal, delivery and newborn care practices for their most recent live birth. Coverage of newborn feeding practices was estimated and multivariate regression was used to assess determinants of these practices.Seventy-six percent of live births were breastfed within 24?h of birth, 84% were given colostrum and 21% received prelacteals. Facility delivery and antenatal care attendance were associated with positive feeding practices.Positive newborn feeding practices were common in rural Burkina Faso, relative to other low-income settings. Interventions are needed to improve feeding practices among home-born babies, and to encourage earlier initiation of breastfeeding among facility-born newborns.
Project description:A World Health Organization (WHO)/United Nations Children's Fund (UNICEF) (2009) joint statement recommended home visits by community-based agents as a strategy to improve newborn survival, based on promising results from Asia. This article presents detailed evaluation of community volunteer assessment and referral implemented within the Ghana Newhints home visits cluster-Randomized Controlled Trial (RCT). It highlights the lessons learned to inform implementation/scale-up of this model in similar settings. The evaluation used a conceptual framework adopted for increasing access to care for sick newborns and involves three main steps, each with a specific goal and key requirements to achieving this. These steps are: sick newborns are identified within communities and referred; families comply with referrals and referred babies receive appropriate management at health facilities. Evaluation data included interviews with 4006 recently delivered mothers; records on 759 directly observed volunteer assessments and 52 validation of supervisors' assessments; newborn care quality assessment in 86 health facilities and in-depth interviews (IDIs) with 55 mothers, 21 volunteers and 15 health professionals. Assessment accuracy of volunteers against supervisors and physician was assessed using Kappa (agreement coefficient). IDIs were analysed by generating and indexing into themes, and exploring relationships between themes and their contextual interpretations. This evaluation demonstrated that identifying, understanding and implementing the key requirements for success in each step of volunteer assessment and referrals was pivotal to success. In Newhints, volunteers (CBSVs) were trusted by families, their visits were acceptable and they engaged mothers/families in decisions, resulting in unprecedented 86% referral compliance and increased (55-77%) care seeking for sick newborns. Poor facility care quality, characterized by poor health worker attitudes, limited the mortality reduction. The important implication for future implementation of home visits in similar settings is that, with 100% specificity but 80% sensitivity of referral decisions, volunteers might miss some danger signs but if successful implementation must translate into mortality reductions, concurrent improvement in facility newborn care quality is imperative.
Project description:The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick.The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns.The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems.Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.