Improving the quality of Essential Newborn Care in Solomon Islands
Document TypePhD thesis
Access StatusOpen Access
© 2019 Shidan Tosif
Gaps in the quality of hospital care in low- and middle-income countries contribute to neonatal death and morbidity. Most neonatal deaths occur in the first few days of life, many from preventable or treatable causes. Essential newborn care consists of low-cost interventions, such as basic resuscitation, early breastfeeding and skin-to-skin contact, which have been shown to improve outcomes. Successful essential newborn care implementation requires understanding of the setting in which it is being delivered and the contextual factors that enable healthcare workers to provide quality care for newborns. Solomon Islands is a low-resource country in the Western Pacific and a Small Island Developing State with high neonatal mortality rates, increasing births per capita and limited healthcare resources and personnel. The Ministry of Health and Medical Services (MHMS) and stakeholders implemented an intervention to improve newborn quality of care in Solomon Islands. This thesis evaluates the quality of care in hospitals of Solomon Islands and describes contextual factors that enabled successful implementation of a multifaceted intervention to improve essential newborn care. This thesis used a mixed methods design comprising the following sequential studies: (1) Quality of hospital care for newborns was described through a cross-sectional study using a structured assessment tool to identify strengths and limitations in structure and process components of existing care. (2) Three years of perinatal outcomes were audited to determine stillbirth, perinatal and neonatal mortality rates and the main causes of neonatal morbidity and mortality. (3) The impact of the World Health Organization Early Essential Newborn Care training program on knowledge and skills of healthcare workers was assessed, using a before-and-after study that identified the factors associated with improved retention of knowledge and skills. (4) The implementation process was described through interviews of healthcare workers, and interview data were triangulated with quantitative results to describe features of the intervention that supported implementation. This thesis demonstrated gaps in structure and process elements in quality of newborn care, which limited provision of appropriate, timely clinical care in the hospitals. Very high perinatal mortality rates, mainly owing to stillbirths, were identified. The provinces had higher rates of perinatal mortality than the National Referral Hospital. The main causes of neonatal mortality were complications of prematurity, birth asphyxia and infection. Knowledge and skills of healthcare workers significantly increased following the coaching program. At the time of evaluation, some loss of skills over time had occurred, particularly in cadres of healthcare workers that did not routinely use relevant skills. The evaluation of the implementation process reflected strengths of the intervention, specifically the training methods (content, short duration and practical approach) and the impact of a small training team of MHMS midwives and nurses who delivered the program independently. The challenges and sense of anxiety faced by healthcare workers in remote, isolated settings with infrequent exposure to resuscitation were highlighted. The barriers to establishing independent, ongoing quality improvement activities reflect the challenge of sustaining action across a large geographical area that has a dispersed health workforce when there is little capacity for regular oversight and support. This thesis highlights the potential impact from a multifaceted intervention to improve essential newborn care. Together with efforts to address stillbirths and improve intrapartum quality of care and quality of care in the neonatal period, essential newborn care may form an important part of a strategy to improve outcomes for newborns.
KeywordsNewborn; Neonatal; Quality improvement; Small Island Developing State; Essential newborn care; low- and middle-income country
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