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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.
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