Situational Assessment of Inpatient Care

of Newborns and Young Infants in Rwanda

Joanne Thomas, MIPH

Presentation outline

• Background

• Rwanda assessment

• Key findings from the assessment and

recommendations

• Next steps

Inpatient newborn care – why now?

Top 3 causes of newborn deaths

1. Prematurity(35%) – “born too soon”

2. Intrapartum complications (24%) – “birth asphyxia”

3. Neonatal infections (23%) – sepsis, meningitis and pneumonia

Inpatient newborn care – why now?

• 41% of neonatal deaths averted by interventions during

labor and childbirth; 30% by care of small and sick

newborns, 12% by care of healthy newborns and 10% by

immediate newborn care

• Essential newborn care mainstreamed in national newborn

programs

• Inpatient care of small and sick newborns – nascent

Inpatient Care for Newborns and

Young Infants in Rwanda

Background: Mortality trends (RDHS 2015)

Neonatal mortality as proportion of infants 62.5%

Healthcare indicators

(RDHS 2015)

• ANC One: 99%

• ANC Four: 44%

• SBA & Institutional Delivery: 91%

• PNC mothers: 43%

• PNC newborns: 19%

• BEmONC services: 100% (509 facilities)

• CEmONC services: 100% (47 facilities)

Methodology

• Data collection (9 globally endorsed tools, adapted for Rwanda)

• Desk review

• National and sub-national interviews

• Facility assessment

• Facility interviews

• Data entry: electronic and paper

• Data analysis: SPSS

• September 2018 MOH and RPA led workshop

Levels of 15 facilities assessed

• One national referral hospital: Southern province

• Two provincial referral hospitals: Northern & Eastern

provinces

• Ten district hospitals

• Two private hospitals: Kigali

Findings & recommendations

1. Improving capacity and motivation of human

resources providing in-patient newborn care

National staff need and availability

Qualification # Needed # Available

Neonatologist N/A 1

Pediatrician N/A 71

Pediatric ophthalmologist/retinal specialist

N/A Not available

Other medical doctor 1209 507

Neonatal surgeon N/A Not available

Other medical non-physician staff

N/A Not available

Neonatal nurse specialist N/A 18

Nurse 7843 1290

Midwife 4030 952

Ratio of staff and patients on day shift

(day of assessment)

Nurse & midwife staff on day shift

# of patients todayRatio of patients to

nurse & midwife staff on day shift

National referral hospital (n=1)

4 6 1.5

Provincial referral hospital (n=2)

5 41 8.1

District hospital (n=10)

17 169 10.4

Private clinic (n=2) 6 2 1

Staff shortages and management practices

0%

25%

50%

75%

100%

> 4 times inpast 4weeks

1-3 timespast 4weeks

Happenedpreviously

Never Staff pulledfrom other

units

Off duty unitstaff called

in

Continuewith staffpresent

Other (usebreak time)

Addressing staff shortagesRecommendations from the September 2018 workshop

• Neonatology is equivalent to intensive care -

standards for neonatology units should incorporate

recommendations of nurse and doctors to patient

ratios

Improving staff skills Recommendations from the September 2018 workshop

• Harmonize preservice curriculum with updated guidelines

• Staff orientation package with certification - link with

probation period (6 months)

• Mentorship and on-site training for building and retaining

skills

• Annual “updates” on clinical skills for all staff

Improving staff motivationRecommendations from the September 2018 workshop

• Recognize neonatal unit nurses & doctors as “specialized staff”

• Create individual professional development opportunities

• Opportunities to participate in events (conferences, off-site workshops)

• Champions should get opportunities to teach others (mentorship at

health centers, peer trainings)

Findings & recommendations

II. Implementing family centered and developmentally supportive in-patient newborn

care in Rwanda

8

17

0

8

100

8

25

50

0 10 20 30 40 50 60 70 80 90 100

Trace through phone call/text

Trace through / CBWs

Facility focal point for follow up

Community support person for parent

Appointment systems

Appointment reminder system

Follow-up missed appointments

Infant record kept with infant

Percentage

Methods of improving adherence to follow-up care among facilities promoting any methods for promoting adherence (n=12)

Post-discharge follow-upRecommendations from the September 2018 workshop

• Phone (SMS) handoff from facility to community health

worker or follow-up clinic

• Standardize written/verbal discharge form

• Pediatric Development Clinic

Caregivers’ perception of respectful care

98%

51%

49%

44%

93%

76%

44%

93%

83%

83%

0% 25% 50% 75% 100%

Clean

Quiet during day

Quiet during night

Privacy for self has been sufficient

Sees infant as often as want

Touches / holds infant as often as want

Baby had pain and staff responsive

Medical care good

Nursing care good

Staff gentle/comforting with infant

Improving respectful careRecommendations from the September 2018 workshop

• Integrate structured communication as part of care provision

• Initiate “peer to peer” communications by mothers (“Expert

Mothers”) or Community Health Workers

• Pain management

• Privacy for caregivers

• Policy on unit environment

Family Centered CareRecommendations from the September 2018 workshop

• Mothers/caregivers engaged in activities of daily living

• Handling, positioning, talking with babies

Caregivers’ description of available amenities

0 10 20 30 40 50 60 70 80 90 100

Number of functional toilets for caregivers

Cleanliness of toilets for caregivers

Availability of hand cleaning items near toilet

Access to shower/bathing facilities

Cleanliness of shower/bathing area

Access to water for washing

Access to water for drinking

Sleeping accommodations

Cooking area

Availability and quality of prepared food

Laundry area

No experience Good

Improving facilities for families in hospitalsRecommendations from the September 2018 workshop

• Handwashing and toilet facilities

• Kettle to boil water for drinking

• Food for mothers – 2 simple meals provided by social services or for

low weekly fee (Fr 1000) or by volunteers (scheduled activities by

church or civic groups)

• Place for discharged mothers to keep their belongings

• Involving fathers

• Examine accreditation standards relative to specific needs of family-

centered care

• Include in hospital budgets

Findings & recommendations

III. Ensuring appropriate supplies, timely procurement and maintenance of equipment for

inpatient newborn care

53 53

50

58

% PREVENTIVE MANAGEMENT:

INCUBATOR

% PREVENTIVE MANAGEMENT

RADIANT WARMER

% PREVENTIVE MANAGEMENT PHOTO

THERAPY

% PREVENTIVE MANAGEMENT MICRO-

INFUSION PUMPS

EQUIPMENT: PREVENTIVE MANAGEMENT

Preventive management of equipmentRecommendations from the September 2018 workshop

• Hospital technicians should have a preventive maintenance

plan

• MTI to develop a plan to train technicians

• Exchange of skilled maintenance technicians between hospitals

• Look for external contractors for maintenance of equipment

(private companies)

• All new equipment should have a user manual and a training

manual available at the facility

Key takeaway messages

• Service delivery of inpatient care of NYI is largely unexplored

• Findings from Rwanda and recommendations

▪ Staffing shortages – improve neonatal care standards and ensure continuous steady coverage of services

▪ Improve staff skills through training and mentorship

▪ Boost staff motivation through special recognition and growth opportunities

▪ Coordinated efforts to strengthen post-discharge follow up

▪ Emphasizing respectful newborn care

▪ Making provision for family centered care and improving available amenities in facilities

▪ Preventative management of equipment and inpatient supplies

Next steps

• Preparations underway for situational assessment in Nepal

• Workshops to generate recommendations and action plans – Nepal and Tanzania

• Publication of a multi-country analysis report to inform policy, government efforts and future programming

For more information, please visit

www.mcsprogram.org

This presentation was made possible by the generous support of the American people through the

United States Agency for International Development (USAID), under the terms of the Cooperative

Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not

necessarily reflect the views of USAID or the United States Government.

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