BackgroundA health partnership to improve hospital based neonatal care in Rwanda to reduce neonatal mortality was requested by the Rwandan Ministry of Health. Although many health system improvements have been made, there is a severe shortage of health professionals with neonatal training.MethodsFollowing a needs assessment, a health partnership grant for 2 years was obtained. A team of volunteer neonatologists and paediatricians, neonatal nurses, lactation consultants and technicians with experience in Rwanda or low-income countries was assembled.A neonatal training program was provided in four hospitals (the 2 University hospitals and 2 district hospitals), which focused on nutrition, provision of basic respiratory support with nasal CPAP (Continuous Positive Airway Pressure), enhanced record keeping, thermoregulation, vital signs monitoring and infection control. To identify if care delivery improved, audits of nutritional support, CPAP use and its complications, and documentation in newly developed neonatal medical records were conducted. Mortality data of neonatal admissions was obtained.ResultsIntensive neonatal training was provided on 27 short-term visits by 10 specialist health professionals. In addition, a paediatric doctor spent 3 months and two spent 6 months each providing training. A total of 472 training days was conducted in the neonatal units.For nutritional support, significant improvements were demonstrated in reduction in time to initiation of enteral feeds and to achieve full milk feeds, in reduction in maximum postnatal weight loss, but not in days for regaining birth weight. Respiratory support with bubble CPAP was applied to 365 infants in the first 18 months. There were no significant technical problems, but tissue damage, usually transient, to the nose and face was recorded in 13%. New medical records improved documentation by doctors, but nursing staff were reluctant to use them. Mortality for University teaching hospital admissions was reduced from 23.6% in the 18 months before the project to 21.7%. For the two district hospitals, mortality reduced from 10% to 8.1%. A major barrier to training and improved care was low number of nurses working on neonatal units and staff turnover.ConclusionThis health partnership delivered an intensive program of capacity building by volunteer specialists. Improved care and documentation were demonstrated. CPAP was successfully introduced. Mortality was reduced. This format can be adapted for further training and improvement programs to improve the quality of facility-based care.

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ISRCTN22578364.

The majority of the 2.4 million neonates (infants<28 days) who died in 2020 were born weighing <2500g i.e. low birth weight (LBW). In Africa, approximately 1 in 10 neonates are LBW. The majority of those who survive beyond the neonatal period are undernourished, have neuro-developmental impairment, or die before their second birthday. Unaddressed feeding difficulties contribute significantly to these adverse outcomes. This study assessed the feasibility and acceptability of using trained mother-to-mother peers (peer-mothers) to deliver breastfeeding support to mothers of LBW infants in healthcare facilities in rural Kenya.A mixed methods approach was employed, using structured observations, and pre- and post-intervention semi-structured interviews, with mothers, healthcare providers and peer-mothers. Six trained peer-mothers delivered the interventions to the mother-LBW infant pairs across eight healthcare facilities in Homa Bay County. Descriptive statistics were used to analyse the quantitative data and thematic analysis for the qualitative data.From September-November 2021, 23 mothers and 26 LBW infants were recruited and received the intervention. All infants were born in a hospital, the median age of the infants was 1 day (Interquartile range, IQR 1,3), birth weight 2100g (IQR 1900, 2260) and recorded gestation 34 weeks (IQR 34,36). Although all mothers looked well, 4 (17%) showed no signs of bonding with their infant. One infant was too weak to suckle and was referred to healthcare providers. Key themes were challenges with infant feeding decision-making among mothers of LBW infants, community misconceptions of recommended infant feeding practices for LBW infants, and the integral role of peer-mothers in maternity units.Facility-based, breastfeeding peer support for LBW infants was feasible and acceptable in the context of resource constraints. It could improve uptake of appropriate infant feeding practices among these vulnerable infants and enhance their post-discharge survival and growth outcomes. This strategy warrants further evaluation in a larger study.

Aims To assess feasibility of introducing bubble CPAP into three neonatal units in a low-income country. We determined if, by regular training visits by UK health professionals, bubble CPAP could be established, and its short-term complications and neonatal outcome. Method A bubble CPAP system was designed using an air compressor, with additional cylinder oxygen. Gases are warmed and humidified, pass via an oxygen analyser to the baby and delivered with nasal prongs or mask. Expiratory circuit contains a water pressure manometer. Circuits are reused, after cleaning. Oxygen saturation monitors were provided for each machine. Eight CPAP machines were provided, six to the university teaching hospitals and two to a large provincial hospital. Regular intensive staff training was provided. Data on babies receiving CPAP was recorded prospectively. Results Between March 2012-September 2013 a total of 482 staff training days were provided; 63 days by 3 neonatologists (6 visits), 172 days by neonatal nurses (18 visits), 17 days by a medical technician (3 visits), 230 days by two paediatric specialist registrars. All were volunteers. 319 babies received CPAP. There were no equipment failures or malfunctions. It was commenced on the first day of birth in 71% of babies, for a median of 2 days. Although surfactant therapy is unavailable, only 16% needed >40% oxygen and none were transferred for ventilator care. No babies developed a pneumothorax, however 13% experienced significant nasal trauma. Retinopathy of prematurity screening was not available. In the university hospitals, 45 babies had a birthweight <1 kg (mortality 67%), 139 birthweight 1.0 – 2.49 kg (mortality 37%), and 21 birthweight >2.5 kg (mortality 11%). This contrasted with the provincial hospital where only 8 babies had a birthweight <1 kg (mortality 43%), 56 birthweight 1.0 – 2.49 kg (mortality 8%) and 50 birthweight >2.5 kg (mortality 10%). Conclusion Bubble CPAP was established in this low resource country. It provided adequate respiratory support for most babies currently admitted for neonatal care. However, in spite of intensive staff training, nasal trauma was problematic.