Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App: Digital Perinatal Outcome Audit

Abstract

Background Mobile health (mHealth) is showing increasing potential to address health outcomes in underresourced settings as smartphone coverage increases. The NeoTree is an mHealth app codeveloped in Malawi to improve the quality of newborn care at the point of admission to neonatal units. When collecting vital demographic and clinical data, this interactive platform provides clinical decision support and training for the end users (health care professionals [HCPs]), according to evidence-based national and international guidelines. Objective This study aims to examine 1 month’s data collected using NeoTree in an outcome audit of babies admitted to a district-level neonatal nursery in Malawi and to demonstrate proof of concept of digital outcome audit data in this setting. Methods Using a phased approach over 1 month (November 21-December 19, 2016), frontline HCPs were trained and supported to use NeoTree to admit newborns. Discharge data were collected by the research team using a discharge form within NeoTree, called NeoDischarge. We conducted a descriptive analysis of the exported pseudoanonymized data and presented it to the newborn care department as a digital outcome audit. Results Of 191 total admissions, 134 (70.2%) admissions were completed using NeoTree, and 129 (67.5%) were exported and analyzed. Of 121 patients for whom outcome data were available, 102 (84.3%) were discharged alive. The overall case fatality rate was 93 per 1000 admitted babies. Prematurity with respiratory distress syndrome, birth asphyxia, and neonatal sepsis contributed to 25% (3/12), 58% (7/12), and 8% (1/12) of deaths, respectively. Data were more than 90% complete for all fields. Deaths may have been underreported because of phased implementation and some families of babies with imminent deaths self-discharging home. Detailed characterization of the data enabled departmental discussion of modifiable factors for quality improvement, for example, improved thermoregulation of infants. Conclusions This digital outcome audit demonstrates that data can be captured digitally at the bedside by HCPs in underresourced newborn facilities, and these data can contribute to a meaningful review of the quality of care, outcomes, and potential modifiable factors. Coverage may be improved during future implementation by streamlining the admission process to be solely via digital format. Our results present a new methodology for newborn audits in low-resource settings and are a proof of concept for a novel newborn data system in these settings.

The use of data in resource limited settings to improve quality of care

“…As they complete an admission, they receive prompts to respond appropriately to the data they have entered and manage patients according to evidence-based guidelines. Codevelopment of data capture on admission, embedded education in basic newborn care, and clinical decision support was completed in Zomba, Malawi where these functions were found to be highly useable, feasible, and acceptable to HCWs following implementation on the newborn care ward [30,31].…”

Admissions to a Low-Resource Neonatal Unit in Malawi Using a Mobile App and Dashboard: A 1-Year Digital Perinatal Outcome Audit

“…Whilst 91% of mothers were tested for HIV, only 78% were tested for syphilis antenatally. Although this is an improvement from 73% in the Zomba pilot ( 19 ), the opportunity to potentially prevent neonatal syphilis was missed in one fifth of mothers. This emphasises an enduring gap between antenatal HIV and syphilis screening across Africa due to lack of awareness, funding, and political will to address antenatal syphilis ( 35 ).…”

“…The NeoTree system ( Figure 2 ) has been and continues to be developed collaboratively with health workers in Bangladesh (2015), Malawi ( 19 ) (2016–2017 and 2019 onwards), and Zimbabwe ( 23 ) (2018 onwards) and has been shown to have good acceptability, feasibility, usability ( 19 ), and impact on measure of quality of care ( 22 , 23 ). Data collected on the app are printed in hard copy (including identifiable data) and filed in each patient's paper record.…”

“…A point-of-care, prospective electronic audit was conducted at Zomba Central Hospital (ZCH), another tertiary hospital in Malawi in 2016, using an early version of the NeoTree app. This showed promising results, achieving more than 90% completeness of data, and 70% coverage of admissions in a phased implementation where the NeoTree was done in addition to paper forms ( 19 ) (coverage here is defined as the proportion of admissions captured electronically compared to usual paper documentation). A larger 1-year audit of neonatal mortality rates has been conducted more recently at KCH; however, this utilised a data clerk to enter paper records into a database after admissions had taken place and did not report monthly trends in detail ( 20 ).…”

Usability-Focused Development and Usage of NeoTree-Beta, an App for Newborn Care in a Low-Resource Neonatal Unit, Malawi

“…The NeoTree ( Figure 1 ) is a recently developed, neonatal digital-health system, centred around an app which supports Health Care Professionals (HCP) working in low-resource neonatal units ( 20 , 21 ). NeoTree aims to improve neonatal care and reduce newborn mortality by bringing evidence-based guidelines, algorithms, and digital data capture to the bedside.…”