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Background: High-quality essential newborn care (ENC) can improve newborn health and reduce preventable newborn mortality. The World Health Organization recommends specific ENC interventions. Video recordings have potential as a tool for assessment of clinical care also in low and middle-income countries. Objective: To use video observations of healthy newborns to describe ENC practices in a low-income setting and compare actual clinical practice with WHO recommendations. Method: This is a cross-sectional observational study. Video records of neonatal interventions to 324 healthy newborns were assessed. They were obtained at baseline of a pre-post intervention study during a 10-week study period in Pemba, Tanzania. Data also included postnatal structured questionnaires. Eight ENC interventions and quality indicators were defined as per the WHO recommendations. Descriptive statistics were used to summarize ENC practices and maternal and neonatal characteristics. Results: None of the newborns received all eight recommended ENC interventions. The median duration of separation from the mother was 25 minutes and 15 seconds (ranging from 22 seconds to 3 hours and 36 minutes), 51% of the newborns received proper thermal care during the separation. Twenty-one percent had sufficient umbilical cord care, 8% were stimulated for breathing, 69% were observed at least once by healthcare staff and 9% did undergo suctioning. None of the newborns received antibiotic ointments or vitamin K. Conclusion: Video recording of healthy newborns was feasible. The study identified omission of key ENC practices including proper thermal care, skin-to-skin contact and establishment of breastfeeding within the first hour of life, vitamin K administration as well as application of unnecessary practices such as excessive suctioning of breathing newborns.
This cross-sectional observational study drew on data obtained during the baseline period of a pre-post intervention ‘Newborn Emergency Outcome study’ (clinicaltrials.gov:{“type”:”clinical-trial”,”attrs”:{“text”:”NCT04093778″,”term_id”:”NCT04093778″}}NCT04093778, Zanzibar Health Research Institute: NO.ZAHREC/2 August 2019/30) in Pemba, Tanzania with the aim of reducing neonatal mortality. Motion-triggered video cameras mounted on top of resuscitation tables in the delivery room of each district hospital were used to collect data presented in this paper during a 10-week period from 13 September 2019 to 22 November 2019. The Strengthening the Reporting of Observational studies in Epidemiology checklist was used to apply the methodology used in the current study. Pemba has a population of about 400,000 and four district hospitals [19]. This study included data collected at Chake Chake District Hospital, a secondary level hospital with a catchment population of about 100,000 [19] and with approximately 4–5,000 annual deliveries [20]. The stillbirth rate is estimated at 27.7 per 1,000 live births, and the neonatal mortality rate is approximately 16 per 1,000 live births [21]. There are no tertiary hospitals in Pemba, so in case of an emergency transfer is made to the closest tertiary hospital in Unguja which is reached by air or ferry. The main delivery room has three delivery beds and one resuscitation table. In addition, the hospital has a movable table for resuscitations in the operating theatre. The resuscitation tables are also used for the post-delivery observations of healthy newborns not undergoing resuscitation. At Chake Chake Hospital, midwives are responsible for the postnatal care of all neonates, with 3–4 midwifes at work during daytime and 2 during the night. The available equipment for ENC care consists of gloves, umbilical cord clamps, stethoscopes, oximeters, and bulb suction. Furthermore, a traditional cloth called a Kanga was brought by the women for wrapping, drying, and securing sufficient thermal care for the newborn after delivery. Healthy newborns delivered at Chake Chake District Hospital during the 10-week study period and their mothers were eligible for participation. Newborns undergoing neonatal resuscitation or showing danger signs were included in a different analysis, and these data will be presented elsewhere. Prior to the delivery the participants provided written consent to participate in the study. Women in the maternity and delivery wards were enrolled as soon as possible after admission; until the expulsion phase of the second stage of labour. Women in an obstetric emergency or with late presentation was not approached. After delivery consent could be obtained for the postnatal questionnaire. Research assistants asked the women for informed consent to video record the post-delivery care of their newborns and to complete a postnatal questionnaire, which was completed in cooperation with them. The research assistants were present in the maternity and delivery wards 24 hours a day to enrol women in the study, obtain their consent and complete the postnatal questionnaire. The health worker in charge of each birth, assisted by a research assistant, also completed a postnatal questionnaire as soon as possible after the delivery. Prior to the beginning of the study period the healthcare workers provided their consent to participate. A motion-triggered camera (Oco II Smart Cam Pro®, Oco Group Inc., Irvine, California, USA) was used to record the videos; it was installed on top of the resuscitation table and recorded all instances of newborns being placed on the table. The newborn was placed on the resuscitation table immediate after the health worker cut the umbilical cord and before active management of third stage of labour. A research assistant would cover the camera if any woman, who did not provide consent, was in the delivery room since the table was shared. Only newborns, the resuscitation table with surrounding floor and the hands and feet of the healthcare provider were in the field of vision to ensure the confidentiality of staff. The parents, obstetric procedures and caregivers faces where not visible. The research assistant placed each individually assigned identification card on the resuscitation table prior to or after placement of the newborn. The videos contained time stamps and identification numbers. The identification number was applied to each woman and her newborn until discharge. The recorded videos were stored on an encrypted micro-SD card in the camera, and the data were uploaded to a secure database that could only be assessed by the international PI with an encryption code and key. All videos are deleted after the final analyses from the study. The video recordings were only for research purposes and only the international study team had access to the video recordings to ensure the individual health workers’ anonymity. The postnatal questionnaires and data on the participants’ sociodemographic, obstetric, delivery and neonatal characteristics were collected and directly entered into Lenovo® (version 7) tablets using secure data collection software (i.e. RedCap® version 5.12.1). Birthweight was cross matched with the data from the hospital registers owing to inconsistencies for a small number of observations. Eight WHO essential newborn care interventions were observed on the video recordings. For each ENC indicator corresponding actions in video recordings i.e. video indicators and their subcategories, were defined by a team comprising two doctors specialized in paediatrics and a paediatric resident (Table 1) [5]. Some ENC recommendations like immediate drying, removing of the wet towel, APGAR scores, administration of vaccines and weighing of the newborns were not included in the analysis because they were out of view of the camera and/or most likely happened either before the newborn was placed on the table or after it was removed. Definition of essential newborn care indicators and their corresponding actions in video recordings *Note: Defined as healthcare worker observing the newborn, with no other interactions **Note: Defined as uncovering of the newborn’s chest for examination of breathing and colour The video recordings were analysed according to the ENC video indicators defined in Table 1 by two independent researchers. In the event of a lack of consensus, the researchers consulted another member of the study team. The evaluation took place from the placement of the newborn on the resuscitation table and considered subsequent events until the newborn was removed from the table, as per the ENC video indicators and subcategories (Table 1). Data from the video observations were transferred from Excel® (2011 version) (Microsoft® Corporation, Redmond, Washington, USA), and the quantitative variable data were transferred from REDcap®, to SPSS® (version 27) (IBM, New York, USA) to perform descriptive statistical analysis. The continuous variables were categorised according to common medical standards and the risk factors for newborns. The median time for each quality indicator was calculated and presented as the minimum/maximum period and interquartile range (IQR). The number of observations for each qualitative indicator per newborn was grouped and specified. The indicators were furthermore compared with number of births per week. To determine any correlation between the quality indicators, a two-sample t-test was performed. Video indicators regarding suctioning, stimulation and administration of vitamin K and antibiotic eye ointment were afterwards compared with the postnatal questionnaires to account for findings possibly not captured on video.
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