Reduced neonatal mortality in a regional hospital in Mozambique linked to a Quality Improvement intervention

Abstract

BackgroundNeonatal mortality remains a serious health issue especially in low resource countries, where 99% of neonatal deaths occur. Doctors with Africa CUAMM is an Italian non-governmental organization in the field of healthcare that has been working in Africa since 1955. In Mozambique, at the Central Beira Hospital (CBH), it has a project with the aim of supporting the neonatal intensive care unit (NICU) and the Obstetrical Department of the CBH through a multi-level intervention. Our aim was to evaluate the effectiveness of CUAMM continuous Quality Improvement intervention in terms of reduction of the overall neonatal mortality rate in the NICU of CBH.MethodsA baseline analysis was performed in order to assess the actual standard of neonatal care. Subsequently, the intervention was focused on three main areas: infrastructure, equipment and clinical protocols improvement. A retrospective pre- (2013)/post- (2014) implementation analysis of clinical outcomes was performed.ResultsTotal population included 4,276 newborns, 2,118 (50%) born in 2013 and 2158 (50%) born after implementation. Baseline characteristics of the two groups were similar apart from a higher incidence of outborn neonates (33% vs 30%, p = 0.02) and a lower incidence of Apgar score < 7 at 5 min (37% vs 43%, p < 0.01). The rates of admissions for asphyxia (22% vs 30%), sepsis (4% vs 7%) and prematurity (18% vs 28%) increased between the two study period. Mortality rate for each of these causes decreased from before to after the implementation: asphyxia (34% vs 19%, p < 0.01), sepsis (39% vs 28%, p = 0.06) and prematurity (43% vs 33%, p < 0.01).ConclusionWe found a reduction in mortality rate among newborns admitted to CBH’s NICU after the first year of CUAMM intervention. Most of this reduction can be attributed to the decrease in deaths for asphyxia, sepsis and prematurity. A Quality Improvement intervention based on infrastructural, equipment and clinical objectives was associated with a reduction of neonatal mortality rate in a low-resource NICU.

Effect of a Low-Dose/High-Frequency Training on Real-Life Neonatal Resuscitation in a Low-Resource Setting

“…Low proficiency with BMV immediately after training suggests that educational programmes should emphasize the learning of such a technique, including methods for improving ventilation when it is initially ineffective. Our data show a lower mortality rate after the low-dose/ high-frequency training, but this is likely associated with hospital-level quality improvements (including interventions regarding infrastructure, equipment and clinical protocols) that were implemented after the NRP course [25].…”

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

“…Similar observations were made following improved infrastructure, equipment and clinical protocols in an NNU in Mozambique where the mortality rate for asphyxia (34% vs 19%), sepsis (39% vs 28%) and prematurity (43% vs 33%) decreased significantly. 6 It is estimated that around one-quarter of neonatal deaths occur in the first day; therefore, emphasis on improving neonatal care needs to extend to the staff in the labour and postnatal ward to reduce neonatal mortality. 2 …”

“…Where hospital-based neonatal care has been implemented in LICs, significant impacts on mortality have been demonstrated. 6–9 If the unacceptable number of neonatal deaths are to be reduced, in addition to improving community neonatal care and emergency care at the time of delivery, hospital-based neonatal care needs to be developed to ensure a full cycle of care. Some frameworks already exist to evaluate and improve neonatal care, but they focus primarily on obstetric-led neonatal emergency management and not on ongoing specialised neonatal care.…”

Where technology does not go: specialised neonatal care in resource-poor and conflict-affected contexts

“…7 A group from India described how the creation of an SNCU, as opposed to treating neonates in the paediatric ward, in a West Bengal district hospital reduced intra-hospital neonatal mortality from 31% to 25% within 2 years. 19 SCNUs that are supported by other actors showed a reduction in intra-ward mortality: a Mozambican SNCU supported by Collegio Universitario Aspiranti Medici Missionari-Doctors for Africa brought mortality down from 26% to 13%, 8 and an MSF-managed SNCU in South Sudan (not included in this study), which excluded babies weighing 1250 g from admission, reported a reduction of mortality from 19% to 11% within 3 years. 10 Facility exit outcomes of neonatal units not only reflect the quality of nursing and medical care at the unit, they are also highly dependent on the patient population and on the quality of intrapartum and immediate post-partum interventions.…”

“…4 There are descriptions of SNCUs and outcomes of their patients in resource-limited, but mostly stable, settings. [5][6][7][8] Around 2009, Médecins Sans Frontières Operational Centre Brussels (MSF-OCB), an international non-governmental organisation providing humanitarian aid and free medical assistance to populations in distress, started offering specialised neonatal care in resource-limited settings, and has increased this activity over time. MSF-managed SNCUs are integrated into district or regional hospitals: some are located in conflict settings, and most operate in remote areas where no other supporting health actors are present.…”