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Background: Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. Methods: We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. Results: Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40-0.58; infection: RR 1.28 [1.11-1.47]; feeding: RR 0.49 [0.40-0.58]; postnatal: RR 3.17 [2.01-5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2.32]), but other practices were not statistically different. Mothers’ knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). Conclusions: Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries.
A cross-sectional descriptive design was employed using health facility assessments, direct observation of midwife time-use, clinical observation of the labor and delivery period, and exit interviews with recently delivered mothers. The study population consisted of mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities operated by International Medical Corps (IMC) in displacement camps located in South Sudan: Maban (Gendrassa and Kaya), Juba, and Malakal. Maban hosts refugee camps, whereas Juba and Malakal have internally displaced person (IDP) camps. One hospital and four PHCCs that conduct the majority of deliveries in the camps agreed to participate in the study. The hospital, located in Juba, operated 24/7 with skilled attendants, an in-patient department and comprehensive emergency obstetric care, while the PHCCs have midwives and traditional birth attendants (TBA) conducting deliveries. Health facilities in the camps were selected based on: (1) provision of delivery care, (2) delivery of at least 20 births per month, and (3) management by IMC. The sample size for these current analyses of baseline data was based on power calculations conducted to ensure that the planned pre-post evaluation would be sufficiently powered to detect changes as a result of the intervention components. Male and female midwives, aged 18 and older, who were working a daytime shift on the date of data collection at one of the study facilities were eligible for time-use observation. A midwife was observed every ten minutes over an eight-hour shift for a four-day period at each facility to reach the necessary sample size. We estimated that midwives spend about 40 min of an eight-hour working day on postnatal care. To detect a 5% difference post-intervention in the proportion of time spent on postnatal care (e.g. 8% to 13%) with an alpha of 0.05, 0.8 power and 5% non-response rate, we required a total sample size of 620 observations at baseline and end line. Women, aged 15 and older, arriving at a study facility for delivery during the 9-week enrollment period were eligible for recruitment for observation of the labour and delivery period and an exit interview. Similarly, the sample size calculated to see a change in baseline was 185 deliveries based on a two-sample comparison of the primary outcome—proportion of newborns that receive the components of essential newborn care (Table 1). This assumed a 50% baseline prevalence of the primary outcome, a conservative estimate due to a lack of data from similar settings, and a 15% detectable difference with an alpha of 0.05 and power of 0.8. The sample size accounted for a non-response rate of 8% based on a 3% stillbirth rate and 5% referral for complications. The sample was doubled to allow for analyses stratified by facility type: hospital and PHCC. Women delivering a stillbirth were subsequently excluded from analysis of observation data. Recently delivered mothers who participated in a clinical observation and did not have a stillbirth or neonatal death were asked to participate in an exit interview. Components of essential newborn care measured in the clinical observations Locally-based non-clinicians were hired as research assistants and trained jointly to standardize data collection procedures across the health facilities. The three research teams consisted of three to five research assistants and one site supervisor. A ten-day training was conducted by study co-investigators to orient the teams to newborn clinical practices, research ethics and procedures, and the study instruments. Researchers practiced the interview aloud in both Arabic and Nuer languages to ensure the translation was standard between researchers. To improve reliability, a two-day pilot session was held to standardize observations between researchers, with one day in the classroom observing videos as a group and one day in a facility observing live births with researchers from the same site. Site supervisors received additional training to conduct the health facility assessment. Data collection occurred at the five study facilities, starting with a health facility assessment. In April 2016, study health facilities were assessed for readiness to provide intrapartum and postnatal services using a structured questionnaire and checklist on the mobile device. The site supervisor interviewed the midwife in-charge about the availability of skilled birth attendants, running water, and electricity over the past month. Medical equipment, supplies and drugs for intrapartum and postnatal care were observed for availability in the delivery and postnatal care wards, and in relevant cases for functionality or expiration. The checklist for medical commodities was based on the recommended newborn supplies outlined in the Newborn Health in Humanitarian Settings Field Guide. Following the assessment, we conducted the time-use observations. At each facility, for a four-day period, one midwife was randomly selected each day for time-use observation. Every ten minutes over an eight-hour period, the researcher recorded the main activity in which the midwife was engaged using a structured checklist; activities were categorized into eighteen general tasks for midwives such as postnatal care, intrapartum care, antenatal care (ANC), documentation, supervision, cleaning, and other tasks. Patient census data in the maternity unit was noted on every observation day. Informed consent was attained from each midwife. For clinical observations, one researcher was assigned per shift to ensure continuous coverage during facility operating hours. Data collectors rotated every eight to twelve-hour shift, depending on the security guidance in each site. Each mother-newborn pair was observed for at least one and no more than 6 h before starting a new observation. The observation was documented using a structured checklist, based on the Maternal and Child Health Integrated Program (MCHIP) Quality of Care Surveys [15]. We observed the following clinical practices: (i) partograph use, (ii) preparation for delivery, (iii) immediate postnatal care, (iv) bag and mask resuscitation for non-breathing babies, and (v) kangaroo mother care (KMC) for low birth weight babies. Additional information on the outcome of the mother and newborn, gravidity, parity and birth weight was extracted from clinical records. Following observation and before the mother was discharged, researchers administered an exit interview using a structured questionnaire (in either Arabic or Nuer, according to the mother’s preference). Information was gathered on the mother’s demographic characteristics and her knowledge of six newborn danger signs without prompting response options. Verbal consent was obtained for both clinical observations and exit interviews from all participating mothers. Data were entered on Android tablets using Magpi mobile data software (DataDyne Group LLC, Version 3.2.2). Data were monitored daily for quality checks and uploaded to an online server by site supervisors, reviewed for consistency, and exported to Stata (StataCorp LP, Version 13.1) for analysis. Descriptive analyses were performed to explore frequencies, means and interval estimation. Missing and “don’t know” responses were analyzed as missing and excluded from analysis. The activities measured in the time-use observations were classified into three categories: contact time for newborn care (by antenatal, delivery and postnatal care), non-contact productive time (i.e. documentation, meetings, training, supervision and cleaning) and non-productive time (i.e. waiting for patients, break time and socializing). Proportion of the total amount of observed time spent on each activity was estimated and a regression analysis was conducted to estimate associations with facility type. In the clinical observations, we conducted descriptive analyses of up to 65 practices for partograph use, delivery preparation, immediate postnatal care, neonatal resuscitation, and KMC. The primary outcome was defined by the proportion of newborns who received the essential components of immediate postnatal care: (i) thermal care, (ii) infection prevention, (iii) feeding support, and (iv) postnatal monitoring; individual sub-items contributing to these composite components are shown in Table 1. Partograph use was not analyzed among women who were admitted immediately to the labor room because they were assumed to be in the second stage of labour. For the exit interviews, the pre-defined response options for knowledge of newborn danger signs were entered as a binary (yes/no) variable. One point was assigned for each answer that was coded as ‘yes’, giving a maximum score of six. The overall knowledge score was categorized as ‘poor’ (zero to one danger signs), ‘moderate’ (two to three), and ‘adequate’ (four to six). Mother’s age, parity and years living in the camp were measured as a continuous variable and categorized as a binary variable for analysis. A chi-squared statistic was used to examine differences in newborn care practices by type of health worker and facility. Multiple logistic regression, in a stepwise backward manner with a 0.05 cutoff, was used to identify factors associated with newborn practices and maternal knowledge including maternal, newborn and health worker characteristics. In each step, variables that are least significant are removed until all variables in the regression model have a p-value of less than or equal to 0.05. Associations were examined by relative risks (RR), using a modified Poisson approach with a robust variance estimator, and 95% confidence intervals [16].
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