BackgroundGlobally, neonatal mortality remains high despite interventions known to reduce neonatal deaths. The All Babies Count (ABC) initiative was a comprehensive health systems strengthening intervention designed by Partners In Health in collaboration with the Rwanda Ministry of Health to improve neonatal care in rural public facilities. ABC included provision of training, essential equipment, and a quality improvement (QI) initiative which combined clinical and QI mentorship within a learning collaborative. We describe ABC implementation outcomes, including development of a QI change package.MethodsABC was implemented over 18 months from 2013 to 2015 in two Rwandan districts of Kirehe and Southern Kayonza, serving approximately 500,000 people with 24 nurse-led health centers and 2 district hospitals. A process evaluation of ABC implementation and its impact on healthcare worker (HCW) attitudes and QI practice was done using program documents, standardized surveys and focus groups with facility QI team members attending ABC Learning Sessions. The Change Package was developed using mixed methods to identify projects with significant change according to quantitative indicators and qualitative feedback obtained during focus group discussions. Outcome measures included ABC implementation process measures, HCW-reported impact on attitudes and practice of QI, and resulting change package developed for antenatal care, delivery management and postnatal care.ResultsABC was implemented across all 26 facilities with an average of 0.76 mentorship visits/facility/month and 118 tested QI change ideas. HCWs reported a reduction in barriers to quality care delivery related to training (p = 0.018); increased QI capacity (knowledge 37 to 89%, p <  0.001); confidence (47 to 89%, p <  0.001), QI leadership (59 to 91%, p <  0.001); and peer-to-peer learning (37 to 66%, p = 0.024). The final change package included 46 change ideas. Themes associated with higher impact changes included provision of mentorship and facility readiness support through equipment provision.ConclusionsABC provides a feasible model of an integrated approach to QI in rural Rwanda. This model resulted in increases in HCW and facility capacity to design and implement effective QI projects and facilitated peer-to-peer learning. ABC and the change package are being scaled to accelerate improvement in neonatal outcomes.

BackgroundAs care for preterm and low birth weight (LBW) infants improves in resource-limited settings, more infants are surviving the neonatal period. Preterm and (LBW) infants are at high-risk of nutritional and medical comorbidities, yet little is known about their developmental outcomes in low-income countries. This study evaluated the health, nutritional, and developmental status of preterm/LBW children at ages 1–3 years in Rwanda.MethodsCross-sectional study of preterm/LBW infants discharged between October 2011 and October 2013 from a hospital neonatal unit in rural Rwanda. Gestational age and birth weight were gathered from hospital records to classify small for gestational age (SGA) at birth and prematurity. Children were located in the community for household assessments in November–December 2014. Caregivers reported demographics, health status, and child development using locally-adapted Ages and Stages Questionnaires (ASQ-3). Anthropometrics were measured. Bivariate associations with continuous ASQ-3 scores were conducted using Wilcoxon Rank Sum and Kruskal Wallis tests.ResultsOf 158 eligible preterm/LBW children discharged from the neonatal unit, 86 (54.4%) were alive and located for follow-up. Median birth weight was 1650 grams, median gestational age was 33 weeks, and 50.5% were SGA at birth. At the time of household interviews, median age was 22.5 months, 46.5% of children had feeding difficulties and 39.5% reported signs of anemia. 78.3% of children were stunted and 8.8% wasted. 67.4% had abnormal developmental screening. Feeding difficulties (p = 0.008), anemia symptoms (p = 0.040), microcephaly (p = 0.004), stunting (p = 0.034), SGA (p = 0.023), very LBW (p = 0.043), lower caregiver education (p = 0.001), and more children in the household (p = 0.016) were associated with lower ASQ-3 scores.ConclusionsHigh levels of health, growth, and developmental abnormalities were seen in preterm/LBW children at age 1–3 years. As we achieve necessary gains in newborn survival in resource-limited settings, follow-up and early intervention services are critical for ensuring high-risk children reach their developmental potential.Electronic supplementary materialThe online version of this article doi: (10.1186/s12887-017-0946-1) contains supplementary material, which is available to authorized users.

A health system improvement program combining facility readiness support, clinical training/mentoring, and improvement collaboratives increased quality improvement capacity, improved maternal and newborn quality of care, and reduced neonatal mortality. These results can be used to inform system improvement approach design to transform quality of care and outcomes for newborns.