Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns

PLoS ONE, Volume 17, No. 11 November, Year 2022

Interpretation

Background Evidence shows that delivery of prompt and appropriate in-patient newborn care (IPNC) through health facility (HF)-based neonatal care and stabilization units (NCU/NSUs) reduce preventable newborn mortalities (NMs). This study investigated the HFs for availability and performance of NCU/NSUs in providing quality IPNC, and explored factors influencing the observed performance outcomes in Mtwara region, Tanzania. Methods A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach. HF-based records and characteristics allowing for delivery of quality IPNC were reviewed first to establish the overall HF performance. The review findings were clarified by healthcare staff and managers through in-depth interviews (IDIs) and focus group discussions (FGDs). Results About 70.6% (12/17) of surveyed HFs had at least one NCU/NSU room dedicated for delivery of IPNC but none had a fully established NCUs/NSU, and 74.7% (3,600/4,819) of needy newborns were admitted/transferred in for management. Essential medicines such as tetracycline eye ointment were unavailable in 75% (3/4) of the district hospitals (DHs). A disparity existed between the availability and functioning of equipment including infant radiant warmers (92% vs 73%). Governance, support from implementing patterns (IPs), and access to healthcare commodities were identified from qualitative inquiries as factors influencing the establishment and running of NCUs/NSUs at the HFs in Mtwara region, Tanzania. Conclusion Despite the positive progress, the establishment and performance of NCUs/NSUs in providing quality IPNC in HFs in Mtwara region is lagging behind the Tanzania neonatal care guideline requirements, particularly after the IPs of newborn health interventions completed their terms in 2016. This study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower avoidable NMs. The study was conducted in Mtwara region in Tanzania because, between 2010 and 2015, NMs in Mtwara region was higher (47 deaths per 1000 live births) above the national average of 26 deaths per 1000 live births [32]. About 17 HFs that met inclusion criteria (operating for not less than three years and also providing EmONC services) from among 36 HFs mandated to deliver IPNC were included in this study. Of all HFs included in the study, 76.5% (13/17) were publicly owned while 23.5% (4/17) were non-public. The majority 64.7% (11/17) of study HFs were HCs, and 35.3% (6/17) were hospitals. Mtwara region is bordered on the north by the Lindi region, on the East by the Indian Ocean, on the South by Mozambique, and on the West by the Ruvuma region. It has a population of approximately 1,507,426 people (according to 2021 projections of the 2012 national census). A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach (Fig 1). Quantitative data was collected and analyzed first to establish the overall HF status on availability and functionality of NCUs/NSUs followed by qualitative data collection and analysis that obtained clarifications of the quantitative findings [33]. Quantitative data was collected on HF-based newborn records and characteristics that allow for the delivery of quality IPNC such as; newborn birth, admission, management h records, the availability and functioning of newborn care infrastructure and equipment, the availability of medicines and supplies, referral systems, recording and reporting systems, and evidence of newborn data use in decision making as well as healthcare staff training on in-patient newborn care. The investigation was guided by a framework for maternal and newborn care quality [27, 34] as indicated in (Fig 2). The data was collected in three ways: 1) review of newborn records updated in health management information system (HMIS) and newborn registers from January to December 2020, 2) health facility-based assessment of factors for delivery of IPNC services, and 3) interviews (IDIs and FGDs) with healthcare staff and managers to clarify the review and assessment findings in 1 and 2. In the HF-based assessment, a standardized electronic checklist embedded in the tablets was used after being piloted at two (2) non-study facilities for validation and improvement. Indicators for facility delivery of quality IPNC included in the checklist were extracted from the survive and thrive report [16], WHO-Early Essential Newborn Care (EENC) guideline [25], Tanzania neonatal care guideline [29], the WHO standards for improving quality of maternal and newborn care in HFs [27], and the UNICEF tool kit for settling up special NCUs and NSUs [35]. The HF-based assessment was done through an observational and interview schedule. Two field investigators with prior experience in public health research were oriented for one day to conduct HF assessment and interviews. The data collection process was supervised by the principal investigator between June and August 2021. After preliminary analysis of quantitative data, outcomes within each HF indicator for delivery of quality IPNC were clarified through FGDs and IDIs. The IDIs were conducted with regional and council health managers having experience in newborn care and with some healthcare staff (midwives, nurses, and doctors) working in NCUs/NSUs at HFs with insufficient staff, while FGD only involved similar healthcare staff at HFs that had suitable numbers of staff. After being validated for completeness, quantitative data was exported to Stata version 14 for statistical analysis. Proportional means and overall scores were used to summarize the results, which were then displayed in tables for comparison. The primary outcome of the analysis was an HFs’ availability and functionality of NCUs/NSUs. Recording audios for IDIs and FGDs from representative HFs (8 with and 4 without any form of NCU/NSU) were transcribed, read, and analyzed manually by 4 authors of this work. Contents describing each quantitative finding were manually summarized on a Microsoft Excel spreadsheet based on the similarity of responses from interviewees. Only important quotes from contents summarized in each quantitative finding were translated into the English language for reporting. Ethical approval for this study was obtained from the Ifakara Health Institute Ethical Review Board with permit No. IHI/IRB/No.22-2021. All participants provided written informed consent before they participated in the interviews. A letter introducing investigators to the study HFs was obtained at a respective administrative council.

AI Digest

Study Justification:

– The study aimed to investigate the availability and functionality of neonatal care units (NCUs/NSUs) in healthcare facilities (HFs) in Mtwara region, Tanzania.
– The study was justified by the need to improve the quality of in-patient newborn care (IPNC) and reduce preventable newborn mortalities (NMs).
– The study focused on Mtwara region because it had a higher NM rate compared to the national average.

Study Highlights:

– 70.6% of surveyed HFs had at least one NCU/NSU room, but none had a fully established unit.
– 74.7% of needy newborns were admitted/transferred for management.
– Essential medicines were unavailable in 75% of district hospitals.
– There was a disparity between the availability and functioning of equipment.
– Factors influencing the establishment and running of NCUs/NSUs included governance, support from implementing partners, and access to healthcare commodities.

Recommendations for Lay Reader and Policy Maker:

– Additional improvement plans are needed to optimize the provision of quality IPNC and lower avoidable NMs.
– The establishment and performance of NCUs/NSUs in HFs in Mtwara region need to align with Tanzania neonatal care guideline requirements.
– Governance, support from implementing partners, and access to healthcare commodities should be strengthened to improve the establishment and running of NCUs/NSUs.

Key Role Players:

– Healthcare staff and managers in HFs
– Regional and council health managers
– Implementing partners

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare staff
– Procurement of essential medicines and supplies
– Infrastructure and equipment improvement
– Monitoring and evaluation activities
– Stakeholder engagement and coordination efforts
Please note that the cost items provided are general categories and not actual cost estimates.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted a cross-sectional investigation using a mixed-methods approach, which included quantitative data collection and analysis, as well as qualitative interviews with healthcare staff and managers. The study provides specific findings on the availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania. However, the abstract does not provide information on the sample size or representativeness of the healthcare facilities included in the study. To improve the strength of the evidence, the abstract could include more details on the methodology, such as the sampling strategy and the number of participants in the qualitative interviews. Additionally, providing information on the statistical analysis conducted for the quantitative data would enhance the credibility of the findings.

Abstract

The study was conducted in Mtwara region in Tanzania because, between 2010 and 2015, NMs in Mtwara region was higher (47 deaths per 1000 live births) above the national average of 26 deaths per 1000 live births [32]. About 17 HFs that met inclusion criteria (operating for not less than three years and also providing EmONC services) from among 36 HFs mandated to deliver IPNC were included in this study. Of all HFs included in the study, 76.5% (13/17) were publicly owned while 23.5% (4/17) were non-public. The majority 64.7% (11/17) of study HFs were HCs, and 35.3% (6/17) were hospitals. Mtwara region is bordered on the north by the Lindi region, on the East by the Indian Ocean, on the South by Mozambique, and on the West by the Ruvuma region. It has a population of approximately 1,507,426 people (according to 2021 projections of the 2012 national census). A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach (Fig 1). Quantitative data was collected and analyzed first to establish the overall HF status on availability and functionality of NCUs/NSUs followed by qualitative data collection and analysis that obtained clarifications of the quantitative findings [33]. Quantitative data was collected on HF-based newborn records and characteristics that allow for the delivery of quality IPNC such as; newborn birth, admission, management h records, the availability and functioning of newborn care infrastructure and equipment, the availability of medicines and supplies, referral systems, recording and reporting systems, and evidence of newborn data use in decision making as well as healthcare staff training on in-patient newborn care. The investigation was guided by a framework for maternal and newborn care quality [27, 34] as indicated in (Fig 2). The data was collected in three ways: 1) review of newborn records updated in health management information system (HMIS) and newborn registers from January to December 2020, 2) health facility-based assessment of factors for delivery of IPNC services, and 3) interviews (IDIs and FGDs) with healthcare staff and managers to clarify the review and assessment findings in 1 and 2. In the HF-based assessment, a standardized electronic checklist embedded in the tablets was used after being piloted at two (2) non-study facilities for validation and improvement. Indicators for facility delivery of quality IPNC included in the checklist were extracted from the survive and thrive report [16], WHO-Early Essential Newborn Care (EENC) guideline [25], Tanzania neonatal care guideline [29], the WHO standards for improving quality of maternal and newborn care in HFs [27], and the UNICEF tool kit for settling up special NCUs and NSUs [35]. The HF-based assessment was done through an observational and interview schedule. Two field investigators with prior experience in public health research were oriented for one day to conduct HF assessment and interviews. The data collection process was supervised by the principal investigator between June and August 2021. After preliminary analysis of quantitative data, outcomes within each HF indicator for delivery of quality IPNC were clarified through FGDs and IDIs. The IDIs were conducted with regional and council health managers having experience in newborn care and with some healthcare staff (midwives, nurses, and doctors) working in NCUs/NSUs at HFs with insufficient staff, while FGD only involved similar healthcare staff at HFs that had suitable numbers of staff. After being validated for completeness, quantitative data was exported to Stata version 14 for statistical analysis. Proportional means and overall scores were used to summarize the results, which were then displayed in tables for comparison. The primary outcome of the analysis was an HFs’ availability and functionality of NCUs/NSUs. Recording audios for IDIs and FGDs from representative HFs (8 with and 4 without any form of NCU/NSU) were transcribed, read, and analyzed manually by 4 authors of this work. Contents describing each quantitative finding were manually summarized on a Microsoft Excel spreadsheet based on the similarity of responses from interviewees. Only important quotes from contents summarized in each quantitative finding were translated into the English language for reporting. Ethical approval for this study was obtained from the Ifakara Health Institute Ethical Review Board with permit No. IHI/IRB/No.22-2021. All participants provided written informed consent before they participated in the interviews. A letter introducing investigators to the study HFs was obtained at a respective administrative council.

Materials

N/A

Innovations

Based on the provided description, here are some potential innovations that could be recommended to improve access to maternal health:

1. Establish fully equipped neonatal care units (NCUs) and neonatal stabilization units (NSUs) in healthcare facilities: This would ensure that healthcare facilities have the necessary infrastructure and equipment to provide quality in-patient newborn care (IPNC) to small and sick newborns.

2. Improve availability of essential medicines and supplies: Ensuring that healthcare facilities have a consistent supply of essential medicines, such as tetracycline eye ointment, can contribute to better IPNC outcomes.

3. Strengthen governance and support from implementing partners (IPs): Enhancing governance structures and strengthening support from IPs can help in the establishment and running of NCUs/NSUs in healthcare facilities.

4. Enhance access to healthcare commodities: Improving access to healthcare commodities, such as equipment like infant radiant warmers, can contribute to the functionality of NCUs/NSUs.

5. Strengthen healthcare staff training on in-patient newborn care: Providing comprehensive training to healthcare staff, including midwives, nurses, and doctors, on in-patient newborn care can improve the quality of IPNC provided in healthcare facilities.

These innovations can help optimize the provision of quality IPNC and lower preventable newborn mortalities in Mtwara region, Tanzania, and other comparable settings.

AI Innovations Description

The study titled “Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns” aimed to investigate the availability and performance of neonatal care units (NCU/NSU) in providing quality in-patient newborn care (IPNC) in Mtwara region, Tanzania. The study also explored factors influencing the observed performance outcomes.

The study found that 70.6% of surveyed healthcare facilities (HFs) had at least one NCU/NSU room dedicated to IPNC, but none had a fully established unit. Additionally, essential medicines such as tetracycline eye ointment were unavailable in 75% of the district hospitals. There was also a disparity between the availability and functioning of equipment, including infant radiant warmers.

Qualitative inquiries identified governance, support from implementing partners, and access to healthcare commodities as factors influencing the establishment and running of NCUs/NSUs in the region.

The study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower preventable newborn mortalities (NMs).

To improve access to maternal health in Mtwara region and similar settings, the following recommendations can be considered:

1. Strengthening Neonatal Care Units: Efforts should be made to establish fully functional neonatal care units in healthcare facilities. This includes ensuring the availability of essential equipment, medicines, and supplies necessary for providing quality IPNC.

2. Enhancing Governance and Support: Improve governance structures and support from implementing partners to facilitate the establishment and running of neonatal care units. This can involve strengthening coordination mechanisms, providing technical assistance, and allocating adequate resources.

3. Addressing Healthcare Commodities: Ensure the availability and accessibility of essential medicines and supplies, such as tetracycline eye ointment, in healthcare facilities. This may require improving supply chain management systems and addressing any existing gaps in the procurement and distribution of healthcare commodities.

4. Training and Capacity Building: Provide training and capacity building opportunities for healthcare staff involved in in-patient newborn care. This can include training on neonatal care guidelines, early essential newborn care, and other relevant topics to enhance their skills and knowledge.

5. Monitoring and Evaluation: Establish robust monitoring and evaluation systems to track the performance and outcomes of neonatal care units. This can help identify areas for improvement and ensure the delivery of quality IPNC.

6. Collaboration and Partnerships: Foster collaboration and partnerships between healthcare facilities, government agencies, non-governmental organizations, and other stakeholders involved in maternal and newborn health. This can facilitate knowledge sharing, resource mobilization, and the implementation of innovative approaches to improve access to maternal health.

By implementing these recommendations, it is expected that access to maternal health, particularly in terms of quality in-patient newborn care, can be improved in Mtwara region and similar settings.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Establish fully functional neonatal care units (NCUs) and neonatal stabilization units (NSUs) in healthcare facilities: This recommendation involves ensuring that all healthcare facilities have dedicated rooms and equipment for providing in-patient newborn care. This includes having adequate staff, essential medicines, and equipment such as infant radiant warmers.

2. Improve access to essential medicines and supplies: It is important to ensure that healthcare facilities have a consistent supply of essential medicines and supplies needed for maternal and newborn care. This includes medications like tetracycline eye ointment, which should be readily available to prevent neonatal infections.

3. Strengthen governance and support from implementing partners: Effective governance and support from implementing partners play a crucial role in the establishment and running of neonatal care units. This recommendation involves strengthening coordination, collaboration, and support from relevant stakeholders to ensure the provision of quality in-patient newborn care.

4. Enhance healthcare staff training on in-patient newborn care: Training healthcare staff, including midwives, nurses, and doctors, on in-patient newborn care is essential for improving access to maternal health. This includes providing regular training and updates on evidence-based practices for newborn care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify specific indicators that can measure the impact of the recommendations on improving access to maternal health. These indicators could include the availability and functionality of neonatal care units, the availability of essential medicines and supplies, and the knowledge and skills of healthcare staff.

2. Collect baseline data: Gather data on the current status of the indicators before implementing the recommendations. This could involve reviewing healthcare facility records, conducting interviews and focus group discussions with healthcare staff and managers, and using standardized checklists to assess the availability and functionality of neonatal care units.

3. Implement the recommendations: Introduce the recommended interventions, such as establishing fully functional neonatal care units, improving access to essential medicines and supplies, strengthening governance and support, and providing healthcare staff training.

4. Collect post-intervention data: After implementing the recommendations, collect data on the indicators again to assess the impact of the interventions. This could involve repeating the data collection methods used in the baseline assessment.

5. Analyze and compare the data: Analyze the baseline and post-intervention data to determine the changes in the indicators. Compare the results to evaluate the impact of the recommendations on improving access to maternal health. This could be done using statistical analysis techniques and presenting the findings in tables or graphs.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the recommendations in improving access to maternal health. Identify any gaps or areas for further improvement and make recommendations for future interventions.

It is important to note that the methodology described above is a general framework and can be adapted and customized based on the specific context and resources available for the study.

Author

Dima Health

Identifiers:

DOI: 10.1371/journal.pone.0269151

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Mozambique, Multi-Countries, Tanzania

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative