Health facility readiness to care for high risk newborn babies for early childhood development in eastern Uganda

Background: The neonatal mortality rate in Uganda has barely changed over the past decades, estimated at 28/1000 and 27/1000 live births in 2006 and 2016 respectively. The survivors have a higher risk of developing neurodevelopmental disabilities (NDD) due to brain insults from perinatal complications related to poor quality of health services during pregnancy, around the time of birth, and during the postnatal period. This study aimed to assess health facility readiness to care for high risk newborn babies in order to inform programming that fosters early childhood development in eastern Uganda. Methods: A cross sectional study of 6 hospitals and 10 higher level health centers that offer comprehensive maternal and newborn care was carried out in February 2020 in eastern Uganda. A World Health Organization Service Availability and Readiness Assessment tool (SARA) was adapted and used to assess the health facility readiness to manage maternal and neonatal conditions that are related to NDD. In addition, 201 mothers of high risk newborn babies were interviewed on their satisfaction with health services received. Readiness scores were derived from percentage average facilities with available infrastructure and essential medical commodities to manage neonatal complications. Descriptive statistics were computed for client satisfaction with service provision, and p values used to compare private not for profit to public health facilities. Results: There was limited availability in numbers and skilled human resource especially the neonatal nurses. Hospitals and health centers scored least in preterm and hypothermia care, with averages of 38% and 18% respectively. The highest scores were in essential newborn care, with readiness of 78% and 85% for hospitals and health centers, followed by resuscitation at 78% and 77%, respectively. There were no guidelines on positive interaction with newborn babies to foster neurodevelopment. The main cause of admission to neonatal care units was birth asphyxia followed by prematurity, indicative of intrapartum care challenges. The overall client satisfaction with health services was higher in private not for profit facilities at 91% compared to public hospitals at 73%, p = 0.017. Conclusion: Health facility readiness was inadequate in management of preterm complications. Efforts should, therefore, be geared to improving availability of inputs and quality of emergency obstetric and newborn care in order to manage high risk newborns and reduce the burden of NDD in this setting.

A cross sectional study was carried out in February 2020 in six hospitals and ten higher level health centers (HC IVs) in Busoga region in eastern Uganda. This was before the first Covid-19 case had been identified in the country. In Uganda Health Centres (HC) vary in their care provision across three levels – HC II, HC III, and HC IV. The higher level HC IVs offer comprehensive maternal and newborn care for HRBs. Busoga region has a population of about four million people, with a NMR estimated at 30/1000 live births in 2015[32]. The region is served by eleven hospitals [33]. The hospitals included in this study were 4 public and 2 ‘private not for profit’ health facilities (PNFP). All the HCIVs were government owned health facilities. One of the public hospitals was a regional referral hospital to which the rest of the general hospitals refer complicated cases. All the six hospitals were sites for the Preterm Birth Initiative (PTBi) study which was conducted between 2016 and 2019. The PTBi study aimed at reducing preterm morbidity and mortality through four intervention components: Data strengthening, use of the modified WHO Safe Childbirth Checklist, health provider training and mentorship, and use of collaborative quality improvement approach [34]. The PTBi study also provided some equipment and supplies at the start of implementation to address the critical gaps identified during the baseline study. In the current study, the facilities were assessed to determine their readiness for care of HRBs: availability of inputs based on standards and clients’ experiences of the maternal and newborn care received. The health facilities were selected on the basis of being high volume facilities that are mandated to offer emergency obstetric and newborn care. We selected public and PNFP hospitals, and health centers IVs. This allowed us to assess the facility readiness based on the variation of the type of facilities in the region. The WHO Services Availability and Readiness Assessment (SARA) tool, previously used by the PTBi study, was adapted based on the matrix developed by Moxon et al. 2018 [35], and used to assess the readiness of included facilities to care for HRBs. The adaptation of the SARA tool involved adding infrastructure for thermoregulation beyond KMC, and management of jaundice, use of a continuous positive airway pressure (CPAP) ventilation, and neurodevelopmental support. The inputs for neurodevelopmental support included: availability of cyclic lights, sound control measures, and guidelines for positive interactions with newborns and communication with carers. The infrastructure assessed included space for special care and resuscitation, stabilization and KMC. The staffing levels and availability of the skilled cadres were determined. An inventory was taken of equipment and commodities including nasal gastric tubes for feeding, availability of antibiotics for treatment of neonatal bacterial infection, intravenous fluids, oxygen, use of pulse oximetry, and use of a phototherapy machine for effective case management of pathological jaundice. The inventory data were collected by the first author, with the support of one research assistant, using a paper checklist written in English. The experience of service provision for HRBs from the client perspective was assessed through client exit interviews in the hospitals. The HRBs were defined as: babies with APGAR score of less than 7 five minutes after birth, preterms with a gestation age of less than 37 weeks at birth, babies with a birth weight of less than 2500 g at birth, and infections characterized by either convulsions, failure or cessation of feeding, fast breathing of > 60 breaths per minute, severe chest in-drawing, temperature > 37.5 °C or < 35.5 °C, movement only when stimulated or no movement at all. Additionally, HRBs included those with pathological jaundice: a condition where a term newborn baby presents with jaundice within 24 h after birth, or the total serum bilirubin level is higher than 17 mg/dl in infants 25 to 48 h old, and the infant has signs and symptoms of serious illness. On average, 250 HRBs were admitted in the SNCU on a monthly basis from the six hospitals [36]. After excluding 10 runaway cases, 14 patients referred to other facilities and 25 deaths, 201 mothers with HRBs were included in the study. Proportionate to size sampling methods were used to distribute the sample size across the six hospitals. Six research assistants with medical background who were trained for two days and supervised by the first author, were attached to the hospitals (one per hospital) for a month. The research assistants liaised with the nurses working in the maternity and special newborn care units of the respective hospital and were informed of the potential discharges to enable interviews to be conducted immediately after discharge. On discharge, mothers with HRBs were interviewed on the care their babies received and how it was provided using the exit interview tool in Lusoga, the local language. Satisfaction with the services mothers received was captured by questions regarding the attitude of health providers, consultation time given to them, waiting time, general cleanness of the premises and on specific care during the delivery and postnatal period. In addition, mothers were asked whether they were given information on how to care for their babies after discharge, any counselling on danger signs and feeding, and details on when to come back for review of the babies. We ensured that participants did not wait for more than 10 min before interviews following discharge from the SNCU. Facility readiness to manage maternal and neonatal conditions that result in NDD was determined by the availability of infrastructure, medical commodities, skilled providers and client satisfaction with service provision. These were based on the list of evidence-based treatments (inclusive of items for diagnosis, treatment, and monitoring) for the common neonatal conditions developed by Morgan and team (essential routine newborn care; neonatal resuscitation; feeding and hypothermia; respiratory distress/apnea of prematurity; infection, convulsions and jaundice) [20], and on the WHO quality of care standards on developmental support for sick and small newborn babies [6]. Neonatal complications are known to be the main causes of neonatal deaths and also responsible for neonatal developmental disabilities among survivors. In addition, availability of resources for antenatal and emergency obstetric care (EmOC) were included given their critical role in neonatal survival and developmental potential during prenatal and intrapartum period. Data from the SARA tool and exit interviews were entered in ACCESS with consistence checks and later exported to STATA version 15 for analysis. Descriptive statistics using frequencies, percentages, means, and standard deviations were used to summarize the data stratified by type of facility. Readiness scores were derived from proportions of facilities with availability of essential equipment, supplies and medicines for care of HRBs. The scores were then compared across the public hospitals, PNFP, and HCIV facilities. The satisfaction of mothers of HRBs was assessed on several services received. We considered satisfaction to include those who mentioned ‘very satisfied’ and ‘satisfied’ for each variable. Chi square test statistic was computed to determine whether there was any difference in satisfaction between the Public and PNFP hospitals. Ethical approval to conduct the study was obtained from the Higher Degrees and Research Ethical Committee (HDREC) of Makerere University School of Health Sciences (Ref. 2017- 011) and Uganda National Council of Science and Technology (#SS4600). Permission to access the health facilities was obtained from the district health authorities and the hospital administration prior to facility assessment and exit interviews. Written informed consent was obtained from all mothers of HRBs before data collection.

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• namazzi, gertrude
• hildenwall, helena
• ndeezi, grace
• mubiri, paul
• nalwadda, christine
• kakooza-mwesige, angelina
• waiswa, peter
• tumwine, james k.