Staged implementation of a two-tiered hospital-based neonatal care package in a resource-limited setting in Eastern Uganda

Abstract

Neonatal mortality remains a major global challenge. Most neonatal deaths occur in low-income countries, but it is estimated that over two-thirds of these deaths could be prevented if achievable interventions are scaled up. To date, initiatives have focused on community and obstetric interventions, and there has been limited simultaneous drive to improve neonatal care in the health facilities where the sick neonates are being referred. Few data exist on the process of implementing of neonatal care packages and their impact. Evidence-based guidelines for neonatal care in health facilities in low-resource settings and direction on how to achieve these standards of neonatal care are therefore urgently needed. We used the WHO-Recommended Quality of Care Framework to build a strategy for quality improvement of neonatal care in a busy government hospital in Eastern Uganda. Twelve key interventions were designed to improve infrastructure, equipment, protocols and training to provide two levels of neonatal care. We implemented this low-cost, hospital-based neonatal care package over an 18-month period. This data-driven analysis paper illustrates how simple changes in practice, provision of basic equipment and protocols, ongoing training and dedicated neonatal staff can reduce neonatal mortality substantially even without specialist equipment. Neonatal mortality decreased from 48% to 40% (P=0.25) after level 1 care was implemented and dropped further to 21% (P<0.01) with level 2 care. In our experience, a dramatic impact on neonatal mortality can be made through modest and cost-effective interventions. We recommend that stakeholders seeking to improve neonatal care in low-resource settings adopt a similar approach.

Intraventricular haemorrhage in a Ugandan cohort of low birth weight neonates: The IVHU study

“…Neonates are admitted from the labour ward, surrounding health facilities and home. MRRH-NNU saw signi cant reduction in preterm mortality following implementation of a two-tiered hospital-based neonatal care package (3). Further reduction in preterm mortality was achieved with the introduction of bubble CPAP (bCPAP) (19) .…”

Reducing preterm mortality in eastern Uganda: The impact of introducing low-cost bubble CPAP on neonates &lt;1500g

“…Since 11 May 2015, MRRH has had a dedicated NNU that admits over 2000 neonates a year including around 140 VLBW infants. (18) Neonates are admitted directly from the labour ward, referred from surrounding health facilities and, due to a high rate of home deliveries, some neonates are brought directly from home. (6) The MRRH-NNU is staffed by one full-time neonatal doctor, two neonatal clinicians, 6 specially trained neonatal nurses and a rotating intern.…”

“…Every nurse working in the neonatal unit attended the Newborn Care Training Course, which included a 2-hour module on the recognition and treatment of respiratory illness in neonates. (18) Each nurse was also given one-on-one bedside training from a senior member of the team in the recognition of respiratory distress, how to correctly set-up the bCPAP and how to select and apply the correct interface. The distending pressure was initiated at 5cmH 2 O and adjusted between 2-8cmH 2 O depending on the level of respiratory distress observed.…”

Health workers’ views on factors affecting caregiver engagement with bubble CPAP

“…Though nearly all neonatal deaths are preventable [1], there are still 3,600,000 newborn deaths a year worldwide, 99% of which occur in low-and middle-income settings [2]. Sub-Saharan Africa (SSA) alone contributes 39% of all global neonatal death and includes eight of the ten countries with the worst indicators globally [3,4]. The goal towards elimination of preventable infant mortality is reaffirmed in the Sustainable Development Goal 3.2 and aims at reducing neonatal mortality to 12 per 1000 live births by 2030 [5].…”