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.

Results of the assessment following the intervention showed many significant improvements in the quality of newborn care, including skin-to-skin care, delayed cord clamping, breastfeeding within one hour of birth, and the overall index score for quality of newborn care. The results of health workers' skills in newborn resuscitation, however, were disappointing; scores of providers conducting resuscitation scenarios using a newborn mannequin remained stagnant or even dropped at endline.

Some indicators, notably initiation of breastfeeding, showed a more pronounced improvement in lower-level health facilities than in regional hospitals, but the overall quality of care index score at endline was not significantly different between the levels. Breastfeeding of newborns within one hour is among the interventions with the greatest potential positive impact on child survival [1]. While an impressive increase of 32 percentage points in initiating breastfeeding was achieved among lower-level facilities, this critical, cost-effective intervention was still not universal (seen in 87% of deliveries) at endline.

According to the findings from the health worker knowledge and skills assessments, there were modest but significant increases in knowledge, but no increase in skills for newborn resuscitation using a mannequin. One possible explanation is that providers were unfamiliar with the skills assessment methodology (simulated resuscitation using a newborn mannequin). However, providers were supposed to be exposed to the mannequin during regular on-the-job practice and as part of the program's strengthening of supportive supervision for quality assurance. It is quite possible that the findings reflect real, poor resuscitation skills of health care providers in maternity wards. Indeed, findings from Msemo et al. indicate that skills and practice of the steps of care related to the Helping Babies Breathe (HBB) program (stimulation, suction, and ventilation) were poorly performed at baseline in 9 facilities in Tanzania [15]. Other studies from low- and middle-income countries have shown similar barriers to newborn resuscitation, including limited provider knowledge and skills, inadequate training, and poor availability of equipment [25-28].

The low performance and lack of improvement in newborn resuscitation raises the question of what needs to be done to improve providers' skills in newborn resuscitation, especially at lower-level health facilities with low delivery volume, where providers may not have the occasion to perform resuscitation frequently. To help address some of these deficiencies, the MOHSW and partners are currently implementing HBB and a clinical mentorship program throughout Tanzania to improve newborn resuscitation skills and provide essential equipment. These efforts include supportive supervision, refresher trainings, guided on-the-job practice, and SMS text reminders to providers.

According to the WHO, skin-to-skin contact for at least an hour immediately following birth and breastfeeding during this period is a high-impact intervention that supports the establishment of exclusive breastfeeding, assists with appropriate thermal care, and promotes bonding between mother and newborn [12]. While improvements in skin-to-skin care were notable - with the practice almost doubling overall - in the end, only 77% of newborns were being provided with this important, no-cost practice. A recent study of newborn care in Ethiopia also identified skin-to-skin care as a major gap in immediate newborn care [29].

Separating mothers and newborns, which was noted but not quantified in this study, is a particularly dangerous practice. Leaving newborns unobserved and unmonitored in the first critical few hours of life can significantly increase their risk for inappropriate thermoregulation and nutrition. Limiting maternal-newborn separation is particularly pertinent in light of critical shortages of health care providers at all levels of health facilities in Tanzania.

Although newborn resuscitation equipment was almost universally available at regional hospitals at both baseline and endline, this was not the case in the lower-level health facilities, where only one-third had the necessary equipment at baseline. Lower-level health facilities saw an increase in the availability of equipment - up to 70% - which is dramatic but not yet sufficient. The importance of having newborn resuscitation equipment cannot be overstated. The United Nations Commission on Life-Saving Commodities for Women and Children includes a bag-and-mask device for newborn resuscitation on its list of 13 affordable and effective but underutilized lifesaving commodities [30].

Recent findings by Ajaari et al. confirm that newborns delivered outside a health facility are more likely to die compared to newborns delivering in health facilities [31]. Findings from our current study confirm that improvements in facility-based newborn care can be achieved, but there are areas of persistent gaps, including newborn resuscitation and proper skin-to-skin care. As Tanzania continues to promote facility-based births with skilled attendants, investment in competent human resources and necessary infrastructure and supplies is urgently needed to ensure improved newborn survival. Training should continue to emphasize skin-to-skin care and initiation of breastfeeding within the first hour of life, with consideration for implementing UNICEF Baby-Friendly Hospital Initiative [32]. Meanwhile, the HBB program should help address gaps in training and equipment for newborn resuscitation during the Golden Minute after birth.

Over the course of these two years, this newborn care quality improvement program was successful in raising the quality of essential newborn care services in the program facilities. Some gaps in newborn care were persistent, notably practical skills in newborn resuscitation. Current efforts to roll out HBB nationally, which involves training and equipment, including newborn mannequins for health care providers to practice resuscitation, may help in addressing these gaps. Continued investment in life-saving improvements to newborn care is a priority for reduction of newborn mortality in Tanzania.