Every year, more than a million of the world's newborns die on their first day of life [1]. Although significant progress has been made over the past two decades in child survival, less progress is evident in reducing newborn mortality, especially in sub-Saharan Africa. Neonatal deaths account for 43% of under-five child deaths globally and account for 40% of under-five mortality in Tanzania [2],[3]. Two-thirds of all newborn mortality (deaths in the first 28 days of life) occurs in 12 countries, six of which are in sub-Saharan Africa, and this includes Tanzania [4]. In Tanzania, infant mortality (deaths in the first year of life) has seen dramatic reduction in the past 13 years, falling from 71/1,000 to 51/1,000 live births, but neonatal mortality has remained more constant in the same period, from 30/1000 to 26/1,000 [5]. Helping newborns survive their first day is a priority in the work of the Tanzanian Ministry of Health and Social Welfare (MOHSW) and of other key partners working to accelerate progress toward Millennium Development Goal (MDG) 4 for child survival [6].
Most causes of newborn mortality are preventable or treatable. Cost-effective, evidence-based interventions for prevention and treatment of the major causes of newborn mortality - prematurity, birth asphyxia, and infections - are well established [7-10] and as well, studies have shown that use of quality improvement initiatives can be effective in applying these interventions to cause at least a moderate reduction in newborn mortality [11]. However, massive gaps remain in the quality and coverage of these interventions both through the health care infrastructure and at community level. Good quality care during labor and birth and following childbirth is particularly important, as this is the period in which most lives are saved. Key essential newborn care interventions to reduce morbidity and mortality include immediate drying and warming including skin-to-skin care, clean cord care, resuscitation for newborns with birth asphyxia, and early and exclusive breastfeeding for all newborns [12].
Birth asphyxia, or intrapartum-related hypoxic events, is a major contributor to newborn mortality, causing an estimated 23% of newborn deaths globally [13]. As many as two-thirds of the 3 - 6% of newborns who are born with birth asphyxia could be saved with interventions at birth, including clearing of the airway, tactile stimulation, and assisted ventilation with a bag-and-mask device. Assisting newborns with ventilation can reduce mortality among neonates by approximately 30% [14]. A 2013 study by Msemo et al. in nine Tanzanian hospitals showed that provision of newborn resuscitation - specifically, by skilled birth attendants trained in Helping Babies Breathe (HBB) - reduced neonatal mortality by 47% [15]. HBB is an evidence-based educational programme to teach newborn resuscitation techniques in resource-limited areas [16].
According to van den Broek, the provision of quality care should be the central focus of efforts to achieve MDG targets for maternal and newborn health [17]. The Tanzanian MOHSW has endorsed various quality improvement initiatives, including, in 2009, the 5S Approach, which focuses on facility-based infrastructure and attitude improvements, as well as quality improvement for maternal and newborn care using nationally approved basic emergency obstetric and newborn care (BEmONC) performance standards [18]. Our current study conducted an evaluation of the quality of newborn care associated with a USAID-funded program to improve maternal and newborn health services in Tanzania, run collaboratively between a university-affiliated non-governmental organization and the MOHSW of Tanzania. Key programmatic approaches included training for health care providers (nurses, midwives, clinical officers, and assistant medical officers) in BEmONC and routine delivery care, provision of essential equipment (e.g., bag-and-mask device, suction), supportive supervision of BEmONC in health care facilities, a quality improvement approach in facilities based on national BEmONC standards, and improvements to national health information systems for maternal and newborn health. BEmONC training is conducted using a nationally approved learning package: the training is a 13-day competency-based in-service training, which utilizes didactic approaches, simulation, actual clinical practice and proficiency assessment. (The HBB-specific newborn resuscitation curriculum was not yet available at the time of this program but is since being implemented through a training program which is being rolled out to health care providers nationally). While prematurity is notably a leading cause of death of newborns in Tanzania, the MAISHA program focused more heavily on the management of birth asphyxia, as well as supporting care of low birth weight or pre-term babies through kangaroo mother care.
The program trained and provided quality improvement support to more than 1,593 providers and supervisors from 251 facilities nationwide (including mainland Tanzania and Zanzibar) from 2009 to 2013. The quality improvement process utilized the Standards Based Management and Recognition (SBM-R) approach, in which facility-based quality improvement teams are brought together, trained, and subsequently conduct internal quality assessments utilizing national BEmONC standards. Facilities are externally assessed annually or upon request, and facilities reaching an 80% score are recognized by the MOHSW.
In the 52 facilities assessed, the program trained a total of 243 service providers in newborn care (average 3 providers in lower level facilities, 11 providers in regional hospitals). Not all providers of maternity services in these facilities, and thus providers assessed in the study, had been trained by the program. However, onsite coaching and quality improvement initiatives involved all providers working in maternity at time of coaching.
The program aimed at decongesting hospitals by improving quality of care at lower level health facilities, which are closer to communities. Quality MNH services at dispensary and health center would encourage women to seek services from those sites, and reduce referral of to overcrowded hospitals. The program thus worked to improve quality of care in regional hospitals, as training centers for the region, and lower level health facilities (health centers and dispensaries).
This article reports on the changes in quality of newborn care before and two years following the implementation of this program. The study was conducted in facilities in 12 of Tanzania's 30 regions, which were the regions reached in Year 1 and 2 rollout of the program.
Internationally, there are relatively few widely used, standardized assessments of the quality of maternal and newborn health care [19],[20]. The quality-of-care surveys that do exist largely focus on facility readiness, based on facility audits of human resources, availability of equipment and commodities, and self-reported practices of health care workers [17],[21]. This study is among few that are based on direct observations of maternal and newborn care and, as such, provides important new insight into the quality of newborn health care services in a developing country.