Scaling up newborn care technologies from tertiary- to secondary-level hospitals in Malawi: an implementation case study of health professional perspectives on bubble CPAP

Abstract

Background While Malawi has achieved success in reducing overall under-five mortality, reduction of neonatal mortality remains a persistent challenge. There has, therefore, been a push to strengthen the capacity for quality newborn care at district hospitals through the implementation of innovative neonatal technologies such as bubble continuous positive airway pressure (CPAP). This study investigates tertiary- versus secondary-level hospital differences in capacities for bubble CPAP use and implications for implementation policies. Methods A secondary analysis of interviews was conducted with 46 health workers at one tertiary hospital and three secondary hospitals in rural Southern Malawi. Grounded theory was utilized to explore the emerging themes according to health worker cadres (nurse, clinician, district health management) and facility level (tertiary- and secondary-level facilities), which were managed using NVivo 12 (QSR International, Melbourne, Australia). Results We identified frequent CPAP use and the availability of neonatal nurses, physicians, and reliable electricity as facilitators for CPAP use at the tertiary hospital. Barriers at the tertiary hospital included initiation eligibility disagreements between clinicians and nurses and insufficient availability of the CPAP machines. At secondary-level hospitals, the use was supported by decision-making and initiation by nurses, involving caretakers to assist in monitoring and reliable availability of CPAP machines. Bubble CPAP was hindered by unreliable electricity, staffing shortages and rotation policies, and poor systems of accountability. Conclusion While this study looked at the implementation of bubble CPAP in Malawi, the findings may be applicable for scaling up other novel neonatal technologies in low-resource settings. Implementation policies must consider staffing and management structures at different health services levels for effective scale-up.

Training on the Silverman and Andersen score improved how special care unit nurses assessed neonatal respiratory distress in a low‐resource setting

“…This could have had a negative impact on resource allocation, in terms of equipment, staff and time 6 . A recent review stated that correctly identifying the severity of neonatal RD was one of the factors that facilitate successful CPAP in low‐resource settings 16 . After they received training, the nurses improved how accurately they identified mild or moderate RD by using the Silverman and Andersen score.…”

“…6 A recent review stated that correctly identifying the severity of neonatal RD was one of the factors that facilitate successful CPAP in low-resource settings. 16 After they received training, the nurses improved how accurately they identified mild or moderate RD by using the Silverman and Andersen score. We can speculate that this change may have positive implications for the selection of eligible patients who may benefit more from CPAP treatment and greater staff attention.…”

“…The disagreement between nurses and clinicians on patient eligibility has been identified as a barrier to CPAP implementation in low-resource settings. 16…”

“…The disagreement between nurses and clinicians on patient eligibility has been identified as a barrier to CPAP implementation in low‐resource settings 16 . McAdams et al reported good agreement between how the doctors and nurses quantified RD using the Silverman and Andersen score in a rural Ugandan NICU 15 .…”