Inpatient care of small and sick newborns: A multi-country analysis of health system bottlenecks and potential solutions

Background: Preterm birth is the leading cause of child death worldwide. Small and sick newborns require timely, high-quality inpatient care to survive. This includes provision of warmth, feeding support, safe oxygen therapy and effective phototherapy with prevention and treatment of infections. Inpatient care for newborns requires dedicated ward space, staffed by health workers with specialist training and skills. Many of the estimated 2.8 million newborns that die every year do not have access to such specialised care. Methods: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system “bottlenecks” (or factors that hinder the scale up) of maternal-newborn intervention packages. For this paper, we used quantitative and qualitative methods to analyse the bottleneck data, and combined these with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for inpatient care of small and sick newborns. Results: Inpatient care of small and sick newborns is an intervention package highlighted by all country workshop participants as having critical health system challenges. Health system building blocks with the highest graded (significant or major) bottlenecks were health workforce (10 out of 12 countries) and health financing (10 out of 12 countries), followed by community ownership and partnership (9 out of 12 countries). Priority actions based on solution themes for these bottlenecks are discussed. Conclusions: Whilst major bottlenecks to the scale-up of quality inpatient newborn care are present, effective solutions exist. For all countries included, there is a critical need for a neonatal nursing cadre. Small and sick newborns require increased, sustained funding with specific insurance schemes to cover inpatient care and avoid catastrophic out-of-pocket payments. Core competencies, by level of care, should be defined for monitoring of newborn inpatient care, as with emergency obstetric care. Rather than fatalism that small and sick newborns will die, community interventions need to create demand for accessible, high-quality, family-centred inpatient care, including kangaroo mother care, so that every newborn can survive and thrive. This study used quantitative and qualitative research methods to collect information, assess health system bottlenecks and identify solutions to scale up of maternal and newborn care interventions in 12 countries: Afghanistan, Cameroon, Democratic Republic of Congo (DRC), Kenya, Malawi, Nigeria, Uganda, Bangladesh, India, Nepal, Pakistan and Vietnam. The maternal-newborn bottleneck analysis tool (additional file 1) was developed to assist countries in the identification of bottlenecks to the scale up and provision of nine maternal and newborn health interventions across the seven health system building blocks as described previously [16,20]. The tool was utilised during a series of national consultations supported by the global Every Newborn Steering Group between July 1st and December 31st, 2013. The workshops for each country included participants from national ministries of health, UN agencies, the private sector, non-governmental organisations (NGOs), professional bodies, academia, bilateral agencies and other stakeholders. For each workshop, a facilitator oriented on the tool coordinated the process and guided groups to reach consensus on the specific bottlenecks for each health system building block. This paper, seventh in the series, focuses on the provision of inpatient care of small and sick newborns. Tracer interventions were defined for each package to focus the workshop discussion. For the purpose of this bottleneck analysis, three interventions required for the treatment of common neonatal conditions were included as tracer items for the package of inpatient care: safe oxygen administration, intragastric tube feeding (IGTF) and the provision of intravenous (IV) fluids (Figure ​(Figure3).3). Oxygen therapy is a mainstay treatment for small and sick babies, with respiratory compromise commonly seen in RDS (following preterm birth, neonatal pneumonia and neonatal sepsis) and respiratory failure being an important mechanism in most neonatal deaths [3]. Developmental immaturity of the preterm newborn (especially those born before 34 weeks gestation), or severe illness in a more mature neonate, may limit their ability to coordinate sucking and swallowing required for successful exclusive breastfeeding. In these instances, intragastric feeding is a commonly used low-tech intervention to deliver nutrition, using expressed breast milk where possible. In addition, many of the most small and sick newborns will require administration of IV fluids to prevent dehydration as a result of insensible water loss, and to manage the delicate fluid, electrolyte and glucose balance, especially in the first days after birth [21,22]. Definitions of tracer indicators for inpatient care of small and sick newborn bottleneck analysis tool. For more details see the complete bottleneck analysis in the additional file 2. Safe implementation and monitoring of these interventions can be challenging, especially in low-resource settings. The list of tracers is not exhaustive and other important interventions, notably, effective phototherapy for the treatment of hyperbilirubinaemia (Figure S2, additional file 2), basic newborn care and resuscitation [12], KMC [13] and management of neonatal sepsis [14] are covered by other sections of the bottleneck analysis tool. Data received from each country were analysed and the graded health system building blocks were converted into heat maps (Figures ​(Figures44 and ​and5).5). Bottlenecks for each health system building block were graded using one of the following options: not a bottleneck (=1), minor bottleneck (=2), significant bottleneck (=3), or very major bottleneck (=4) (Figure ​(Figure5).5). We first present the number of countries from which workshops participants categorised health system bottlenecks as significant or very major, by mortality contexts (Neonatal Mortality Rate (NMR) <30 deaths per 1000 live births and NMR ≥30 deaths per 1000 live births) and region (countries in Africa and countries in Asia) (Figure ​(Figure4).4). We then developed a second heat map showing the specific grading of health system bottlenecks for each country (Figure ​(Figure55). Very major or significant health system bottlenecks for inpatient care of small and sick newborns. NMR: Neonatal Mortality Rate. *Cameroon, Kenya, Malawi, Uganda, Bangladesh, Nepal, Vietnam. **Democratic Republic of Congo, Nigeria, Afghanistan, India, Pakistan. See additional file 2 for more details. Individual country grading of health system bottlenecks for inpatient care of small and sick newborns. Part A: Heat map showing individual country grading of health system bottlenecks for inpatient care of small and sick newborns. Part B: Table showing total number of countries grading significant or major for calculating priority building blocks. DRC: Democratic Republic of the Congo. Context specific solutions to overcome challenges to scaling up inpatient care identified in all countries were categorised into thematic areas and then linked to the specific bottlenecks in the results section (Table ​(Table1/1/ Table S1, additional file 2). We undertook a literature review to identify further case studies and evidence-based solutions for each defined thematic area (Additional file 2). For more detailed analysis of the steps taken to analyse the intervention specific bottlenecks, please refer to the overview paper [20]. Summary of solution themes and proposed actions for inpatient care for small and sick newborns.