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Gato S, Biziyaremye F, Kirk CM, De Sousa CP, Mukuralinda A, Habineza H, Asir M, de Silva H, Manirakiza ML, Karangwa E, Nshimyiryo A, Tugume A, Beck K. Promotion of early and exclusive breastfeeding in neonatal care units in rural Rwanda: a pre- and post-intervention study. Int Breastfeed J 2022; 17:12. [PMID: 35193639 PMCID: PMC8864904 DOI: 10.1186/s13006-022-00458-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2022] [Indexed: 11/27/2022] Open
Abstract
Background Early initiation of breastfeeding after birth and exclusive breastfeeding for the first six months improves child survival, nutrition and health outcomes. However, only 42% of newborns worldwide are breastfed within the first hour of life. Small and sick newborns are at greater risk of not receiving breastmilk and often require additional support for feeding. This study compares breastfeeding practices in Rwandan neonatal care units (NCUs) before and after the implementation of a package of interventions aimed to improve breastfeeding. Methods This pre-post intervention study was conducted at two district hospital NCUs in rural Rwanda from October–December 2017 (pre-intervention) and September 2018–March 2019 (post-intervention). Only newborns admitted before their second day of life (DOL) were included. Data were extracted from patient charts for clinical and demographic characteristics, feeding, and patient outcomes. Exclusive breastfeeding at discharge was based on last recorded infant feeding on the day of discharge. Logistic regression analysis was used to evaluate factors associated with exclusive breastfeeding at discharge. Results Pre-intervention, 255 newborns were admitted in the NCUs and 793 were admitted in post-intervention. Exclusive breastfeeding on the day of birth (DOL0) increased from 5.4% (12/255) to 35.9% (249/793). At discharge, exclusive breastfeeding increased from 69.6% (149/214) to 87.0% (618/710). The mortality rate decreased from 16.1% (41/255) to 10.5% (83/793). Factors associated with greater odds of exclusive breastfeeding at discharge included admission during the post-intervention period (aOR 4.91; 95% CI 1.99, 12.11), and admission for infection (aOR 2.99; 95% CI 1.13, 7.93). Home deliveries (aOR 0.15; 95% CI 0.05, 0.47), preterm delivery (aOR 0.36; 95% CI 0.15, 0.87) and delayed first breastmilk feed (aOR 0.04 for DOL3 vs. DOL0; 95% CI 0.01, 0.35) reduced odds of exclusive breastfeeding at discharge. Conclusions Expansion and adoption of evidenced-based guidelines, using innovative approaches, aimed at the unique needs of small and sick newborns may help to improve earlier initiation of breastfeeding, decrease mortality, and improve exclusive breastfeeding on discharge from hospital among small and sick newborns. These interventions should be replicated in similar settings to determine their effectiveness.
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Affiliation(s)
- Saidath Gato
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.
| | | | | | - Chiquita Palha De Sousa
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Boston Children's Hospital, Boston, USA
| | | | | | | | | | | | | | | | - Alex Tugume
- Rwinkwavu District Hospital, Ministry of Health, Kigali, Rwanda
| | - Kathryn Beck
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
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Tuyisenge D, Byiringiro S, Manirakiza ML, Mutsinzi RG, Nshimyiryo A, Nyishime M, Hirschhorn LR, Biziyaremye F, Gitera J, Beck K, Kirk CM. Quality improvement strategies to improve inpatient management of small and sick newborns across All Babies Count supported hospitals in rural Rwanda. BMC Pediatr 2021; 21:89. [PMID: 33607961 PMCID: PMC7893907 DOI: 10.1186/s12887-021-02544-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 02/08/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Neonatal mortality contributes to nearly half of child deaths globally and the majority of these deaths are preventable. Poor quality of care is a major driver of neonatal mortality in low- and middle-income countries. The All Babies Count (ABC) intervention was designed to reduce neonatal mortality through provision of equipment and supplies, training, mentorship, and data-driven quality improvement (QI) with peer-to-peer learning through learning collaborative sessions (LCS). We aim to describe the ABC scale-up in seven rural district hospitals from 2017 to 2019 focusing on the QI strategies implemented in hospital neonatal care units (NCUs) and the resultant neonatal care outcomes. METHODS A pre-post quasi experimental study was conducted in 7 rural hospitals in Rwanda in two phases. The baseline periods were April-June 2017 for Phase I and July-September 2017 for Phase II; with end-line data collected during the same periods in 2019. Data included facility audits of supplies and staffing, LCS surveys of QI skills, and reports of implemented QI change ideas. Data on NCU admissions and deaths were extracted from Health Management Information System (HMIS). Facility-reported change ideas were coded into common themes. Changes in post-post neonatal mortality were measured using Chi-squared tests. RESULTS NCUs were run by a median of 1 nurse [interquartile range (IQR):1-2] at baseline and endline. Median NCU admissions increased from 121 [IQR: 77-155] to 137 [IQR: 79-184]. Availability of advanced equipment improved (syringe pumps: 57-100 %, vital sign monitors: 51-100 % and CPAP machine: 14-100 %). There were significant improvements in QI skills among NCU staff. All 7 NCUs (100 %) addressed non-adherence to protocol as a priority gap, 5 NCUs (86 %) also improved communication with families. NCU case fatality rate declined from 12.4 to 7.8 % (p = 0.001). CONCLUSIONS The ABC package of interventions combining the provision of essential equipment to NCU, clinical training and strong mentorship, QI coaching, and the LCS approach for peer-to-peer learning was associated with significant neonatal mortality reduction and services utilization in the intervention hospitals.
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Affiliation(s)
- David Tuyisenge
- Partners In Health/Inshuti Mu Buzima, PO. Box 3432, Kigali, Rwanda.
| | | | | | | | | | - Merab Nyishime
- Partners In Health/Inshuti Mu Buzima, PO. Box 3432, Kigali, Rwanda
| | - Lisa R Hirschhorn
- Feinberg School of Medicine, Northwestern University, 625 N Michigan Avenue, 60611, Chicago, IL, USA
| | | | | | - Kathryn Beck
- Partners In Health/Inshuti Mu Buzima, PO. Box 3432, Kigali, Rwanda
| | - Catherine M Kirk
- Partners In Health/Inshuti Mu Buzima, PO. Box 3432, Kigali, Rwanda
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Sridhar S, Schmid A, Biziyaremye F, Hodge S, Patient N, Wilson K. Implementation of a Pediatric Early Warning Score to Improve Communication and Nursing Empowerment in a Rural District Hospital in Rwanda. Glob Health Sci Pract 2020; 8:838-845. [PMID: 33361246 PMCID: PMC7784060 DOI: 10.9745/ghsp-d-20-00075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/21/2020] [Indexed: 12/12/2022]
Abstract
Implementation of the Pediatric Early Warning Score for Resource-Limited Settings tool improved nurses’ competency and confidence in their triage capabilities. This tool has the potential to improve patient outcomes. However, staff turnover and limited physician buy-in were barriers to sustainability of the tool in low-resource settings. Background: Pediatric early warning (PEW) scores represent a “track-and-trigger system” that identifies clinical deterioration in a patient’s condition in the hours preceding a sentinel event. Before implementation, nurses reported feeling unprepared to identify and advocate for acutely ill patients owing to a lack of skills, vocabulary, and agency. We implemented a Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) with nurses in a rural district hospital in Rwanda. Although PEW scores can improve clinical outcomes, empowering nurses in resource-limited settings to discuss patient acuity with physicians is a critical first step. Our primary aims were to train nurses to obtain more accurate vital signs and assess their importance as early warning signs of clinical deterioration and use PEW scores to improve communication between nurses and physicians. Implementation: The PEWS-RL tool implementation began with a training program that was created through discussions with nurses, physicians, and the medical director of the hospital. The program included lectures and application of learned skills through direct clinical mentorship of nurses, as well as training of physicians regarding PEWS-RL as a communication tool. Evaluation: The PEWS-RL protocol was evaluated based on pre- and post-tests to assess improvement in nurses’ knowledge and skill, as well as skills assessments of accurate recognition of clinical deterioration. All 6 nurses passed skill testing with >80% accuracy. Nurses’ feelings of empowerment to advocate for patients and to escalate care were assessed through pre- and post-training interviews. Nurses described increased confidence in calling for physician support. Discussion: Implementation of PEW scores increased nurses’ technical skills and feelings of confidence and empowerment; however, the low-resource setting presented major challenges. Barriers to sustainable implementation include the rapid ward staff turnover as well as limited physician buy-in. Nevertheless, the PEWS-RL tool has the potential to empower nurses and improve patient outcomes if fully embraced by staff.
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Affiliation(s)
| | | | | | | | | | - Kim Wilson
- Boston Children's Hospital, Boston, MA, USA
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Magge H, Nahimana E, Mugunga JC, Nkikabahizi F, Tadiri E, Sayinzoga F, Manzi A, Nyishime M, Biziyaremye F, Iyer H, Hedt-Gauthier B, Hirschhorn LR. The All Babies Count Initiative: Impact of a Health System Improvement Approach on Neonatal Care and Outcomes in Rwanda. Glob Health Sci Pract 2020; 8:0. [PMID: 33008847 PMCID: PMC7541121 DOI: 10.9745/ghsp-d-20-00031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 08/05/2020] [Indexed: 01/29/2023]
Abstract
A health system improvement program combining facility readiness support, clinical training/mentoring, and improvement collaboratives increased quality improvement capacity, improved maternal and newborn quality of care, and reduced neonatal mortality. These results can be used to inform system improvement approach design to transform quality of care and outcomes for newborns. Introduction: Poor-quality care contributes to a significant portion of neonatal deaths globally. The All Babies Count (ABC) initiative was an 18-month district-wide approach designed to improve clinical and system performance across 2 rural Rwandan districts. Methods: This pre-post intervention study measured change in maternal and newborn health (MNH) quality of care and neonatal mortality. Data from the facility and community health management information system and newly introduced indicators were extracted from facility registers. Medians and interquartile ranges were calculated for the health facility to assess changes over time, and a mixed-effects logistic regression model was created for neonatal mortality. A difference-in-differences analysis was conducted to compare the change in district neonatal mortality with the rest of rural Rwanda. Results: Improvements were seen in multiple measures of facility readiness and MNH quality of care, including antenatal care coverage, preterm labor management, and postnatal care quality. District hospital case fatality decreased, with a statistically significant reduction in district neonatal mortality (odds ratio [OR]=0.54; 95% confidence interval [CI]=0.36, 0.83) and among preterm/low birth weight neonates (OR=0.47; 95% CI=0.25, 0.90). Neonatal mortality was reduced from 30.1 to 19.6 deaths/1,000 live births in the intervention districts and remained relatively stable in the rest of rural Rwanda (difference in differences −12.9). Conclusion: The ABC initiative contributed to improved MNH quality of care and outcomes in rural Rwanda. A combined clinical and health system improvement approach could be an effective strategy to improve quality and reduce neonatal mortality.
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Affiliation(s)
- Hema Magge
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA. .,Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | - Elisabeth Tadiri
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | | | - Hari Iyer
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Mutaganzwa C, Wibecan L, Iyer HS, Nahimana E, Manzi A, Biziyaremye F, Nyishime M, Nkikabahizi F, Hirschhorn LR, Magge H. Advancing the health of women and newborns: predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda. Int J Qual Health Care 2019; 30:793-801. [PMID: 29767725 DOI: 10.1093/intqhc/mzy103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 04/24/2018] [Indexed: 11/14/2022] Open
Abstract
Objective Identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda. Design Cross-sectional. Setting Twenty-six health facilities in Southern Kayonza (SK) and Kirehe districts. Participants Sample of women ≥ 16 years old receiving antenatal and delivery care between November and December 2013. Intervention Survey of patient satisfaction with antenatal and delivery care to inform quality improvement (QI) initiatives aimed at reducing neonatal mortality. Main Outcome Measure Overall satisfaction with antenatal and delivery care (reported as excellent or very good). Results In multivariate logistic regression analysis, high perceived quality [odds ratio (OR) = 3.03, 95% confidence intervals (CI): 1.565.88], respect [OR = 4.13, 95% CI: 2.16-7.89], and confidentiality [SK: OR = 7.50, 95% CI: 2.16-26.01], [Kirehe: OR = 1.54, 95% CI: 0.60-3.94] were associated with higher overall satisfaction with ANC, while having ≥1 child compared to none [OR = 0.46, 95% CI: 0.25-0.84] was associated with lower satisfaction. For maternity services, <5 years of school versus ≥5 years [OR = 0.13, 95% CI: 0.026-0.69] and higher cleanliness [OR = 19.23, 95% CI: 2.22-166.83], self-reported quality [OR = 10.52, 95% CI: 1.81-61.22], communication [OR = 8.78, 95%CI: 1.95-39.59], and confidentiality [OR = 8.66, 95% CI: 1.20-62.64] were all positively associated with high satisfaction. Higher comfort [OR: 0.050, 95% CI: 0.0034-0.71] and Kirehe vs. SK district [OR: 0.21, 95% CI: 0.042-1.01] were associated with lower satisfaction. Conclusions Patient-centeredness (including interpersonal relationships), organizational factors, and location are important individual determinants of satisfaction for women seeking maternal care at study facilities. Understanding variation in these factors should inform QI efforts in maternal and newborn health programs.
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Affiliation(s)
- Christine Mutaganzwa
- Partners In Health/Inshuti Mu Buzima, Department of Maternal and Child Health, KG 9 Ave, 46 Nyarutarama, Kigali, Rwanda
| | - Leah Wibecan
- Harvard Medical School, Department of Global Health and Social Medicine, 55 Shattuck Street, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Department of Epidemiology, 677 Huntington Ave, Boston, MA, USA
| | - Hari S Iyer
- Partners In Health/Inshuti Mu Buzima, Department of Maternal and Child Health, KG 9 Ave, 46 Nyarutarama, Kigali, Rwanda.,Harvard T.H. Chan School of Public Health, Department of Epidemiology, 677 Huntington Ave, Boston, MA, USA.,Brigham and Women's Hospital, Department of Global Health Equity, 75 Francis Street, Boston, MA, USA
| | - Evrard Nahimana
- Partners In Health/Inshuti Mu Buzima, Department of Maternal and Child Health, KG 9 Ave, 46 Nyarutarama, Kigali, Rwanda
| | | | - Francois Biziyaremye
- Partners In Health/Inshuti Mu Buzima, Department of Maternal and Child Health, KG 9 Ave, 46 Nyarutarama, Kigali, Rwanda
| | - Merab Nyishime
- Partners In Health/Inshuti Mu Buzima, Department of Maternal and Child Health, KG 9 Ave, 46 Nyarutarama, Kigali, Rwanda
| | | | - Lisa R Hirschhorn
- Harvard Medical School, Department of Global Health and Social Medicine, 55 Shattuck Street, Boston, MA, USA.,Brigham and Women's Hospital, Department of Global Health Equity, 75 Francis Street, Boston, MA, USA.,Ariadne Laboratories, 405 Park Drive 3E, Boston, MA, USA
| | - Hema Magge
- Partners In Health/Inshuti Mu Buzima, Department of Maternal and Child Health, KG 9 Ave, 46 Nyarutarama, Kigali, Rwanda.,Brigham and Women's Hospital, Department of Global Health Equity, 75 Francis Street, Boston, MA, USA.,Boston Children's Hospital, Division of General Pediatrics, 300 Longwood Ave, Boston, MA, USA
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6
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Werdenberg J, Biziyaremye F, Nyishime M, Nahimana E, Mutaganzwa C, Tugizimana D, Manzi A, Navale S, Hirschhorn LR, Magge H. Successful implementation of a combined learning collaborative and mentoring intervention to improve neonatal quality of care in rural Rwanda. BMC Health Serv Res 2018; 18:941. [PMID: 30514294 PMCID: PMC6280472 DOI: 10.1186/s12913-018-3752-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 11/21/2018] [Indexed: 11/30/2022] Open
Abstract
Background Globally, neonatal mortality remains high despite interventions known to reduce neonatal deaths. The All Babies Count (ABC) initiative was a comprehensive health systems strengthening intervention designed by Partners In Health in collaboration with the Rwanda Ministry of Health to improve neonatal care in rural public facilities. ABC included provision of training, essential equipment, and a quality improvement (QI) initiative which combined clinical and QI mentorship within a learning collaborative. We describe ABC implementation outcomes, including development of a QI change package. Methods ABC was implemented over 18 months from 2013 to 2015 in two Rwandan districts of Kirehe and Southern Kayonza, serving approximately 500,000 people with 24 nurse-led health centers and 2 district hospitals. A process evaluation of ABC implementation and its impact on healthcare worker (HCW) attitudes and QI practice was done using program documents, standardized surveys and focus groups with facility QI team members attending ABC Learning Sessions. The Change Package was developed using mixed methods to identify projects with significant change according to quantitative indicators and qualitative feedback obtained during focus group discussions. Outcome measures included ABC implementation process measures, HCW-reported impact on attitudes and practice of QI, and resulting change package developed for antenatal care, delivery management and postnatal care. Results ABC was implemented across all 26 facilities with an average of 0.76 mentorship visits/facility/month and 118 tested QI change ideas. HCWs reported a reduction in barriers to quality care delivery related to training (p = 0.018); increased QI capacity (knowledge 37 to 89%, p < 0.001); confidence (47 to 89%, p < 0.001), QI leadership (59 to 91%, p < 0.001); and peer-to-peer learning (37 to 66%, p = 0.024). The final change package included 46 change ideas. Themes associated with higher impact changes included provision of mentorship and facility readiness support through equipment provision. Conclusions ABC provides a feasible model of an integrated approach to QI in rural Rwanda. This model resulted in increases in HCW and facility capacity to design and implement effective QI projects and facilitated peer-to-peer learning. ABC and the change package are being scaled to accelerate improvement in neonatal outcomes.
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Affiliation(s)
- Jennifer Werdenberg
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.,Harvard TH Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | | | - Merab Nyishime
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,University of Global Health Equity, 800 Boylston St. Suite 300, Boston, MA, 02199, USA
| | | | | | | | - Anatole Manzi
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,University of Rwanda School of Medicine and Health Sciences, PO box 3286, Kigali, Rwanda
| | - Shalini Navale
- Widener University Center for Human and Sexuality Studies, One University Place, Chester, PA, 19013, USA
| | - Lisa R Hirschhorn
- Northwestern University Feinberg School of Medicine, 420 E Superior St, Chicago, IL, 60611, USA
| | - Hema Magge
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.,Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Institute for Healthcare Improvement, 20 University Rd, Cambridge, MA, 02138, USA
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7
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Nyishime M, Borg R, Ingabire W, Hedt-Gauthier B, Nahimana E, Gupta N, Hansen A, Labrecque M, Nkikabahizi F, Mutaganzwa C, Biziyaremye F, Mukayiranga C, Mwamini F, Magge H. A retrospective study of neonatal case management and outcomes in rural Rwanda post implementation of a national neonatal care package for sick and small infants. BMC Pediatr 2018; 18:353. [PMID: 30419867 PMCID: PMC6233583 DOI: 10.1186/s12887-018-1334-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 10/31/2018] [Indexed: 11/23/2022] Open
Abstract
Background Despite worldwide efforts to reduce neonatal mortality, 44% of under-five deaths occur in the first 28 days of life. The primary causes of neonatal death are preventable or treatable. This study describes the presentation, management and outcomes of hospitalized newborns admitted to the neonatal units of two rural district hospitals in Rwanda after the 2012 launch of a national neonatal protocol and standards. Methods We retrospectively reviewed routinely collected data for all neonates (0 to 28 days) admitted to the neonatal units at Rwinkwavu and Kirehe District Hospitals from January 1, 2013 to December 31, 2014. Data on demographic and clinical characteristics, clinical management, and outcomes were analyzed using median and interquartile ranges for continuous data and frequencies and proportions for categorical data. Clinical management and outcome variables were stratified by birth weight and differences between low birth weight (LBW) and normal birth weight (NBW) neonates were assessed using Fisher’s exact or Wilcoxon rank-sum tests at the α = 0.05 significance level. Results A total of 1723 neonates were hospitalized over the two-year study period; 88.7% were admitted within the first 48 h of life, 58.4% were male, 53.8% had normal birth weight and 36.4% were born premature. Prematurity (27.8%), neonatal infection (23.6%) and asphyxia (20.2%) were the top three primary diagnoses. Per national protocol, vital signs were assessed every 3 h within the first 48 h for 82.6% of neonates (n = 965/1168) and 93.4% (n = 312/334) of neonates with infection received antibiotics. The overall mortality rate was 13.3% (n = 185/1386) and preterm/LBW infants had similar mortality rate to NBW infants (14.7 and 12.2% respectively, p = 0.131). The average length of stay in the neonatal unit was 5 days. Conclusions Our results suggest that it is possible to provide specialized neonatal care for both LBW and NBW high-risk neonates in resource-limited settings. Despite implementation challenges, with the introduction of the neonatal care package and defined clinical standards these most vulnerable patients showed survival rates comparable to or higher than neighboring countries.
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Affiliation(s)
- Merab Nyishime
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda.
| | - Ryan Borg
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda
| | - Willy Ingabire
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda
| | - Bethany Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Evrard Nahimana
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda
| | - Neil Gupta
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda.,Brigham and Women's Hospital, Boston, USA
| | | | | | | | | | | | | | | | - Hema Magge
- Partners In Health/Inshuti Mu Buzima (PIH/IMB), P.O. Box 3432, Kigali, Rwanda.,Brigham and Women's Hospital, Boston, USA.,Boston Children's Hospital, Boston, USA.,Institute for Healthcare Improvement, Addis Ababa, Ethiopia
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8
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Bayitondere S, Biziyaremye F, Kirk CM, Magge H, Hann K, Wilson K, Mutaganzwa C, Ngabireyimana E, Nkikabahizi F, Shema E, Tugizimana DB, Miller AC. Assessing retention in care after 12 months of the Pediatric Development Clinic implementation in rural Rwanda: a retrospective cohort study. BMC Pediatr 2018; 18:65. [PMID: 29452576 PMCID: PMC5815233 DOI: 10.1186/s12887-018-1007-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 01/23/2018] [Indexed: 11/10/2022] Open
Abstract
Background In Africa, a high proportion of children are at risk for developmental delay. Early interventions are known to improve outcomes, but they are not routinely available. The Rwandan Ministry of Health with Partners In Health/Inshuti Mu Buzima created the Pediatric Development Clinic (PDC) model for providing interdisciplinary developmental care for high-risk infants in rural settings. As retention for chronic care has proven challenging in many settings, this study assesses factors related to retention to care after 12 months of clinic enrollment. Methods This study describes a retrospective cohort of children enrolled for 12 months in the PDC program in Southern Kayonza district between April 2014–March 2015. We reviewed routinely collected data from electronic medical records and patient charts. We described patient characteristics and the proportion of patients retained, died, transferred out or lost to follow up (LTFU) at 12 months. We used Fisher’s exact test and multivariable logistic regression to identify factors associated with retention in care. Results 228 children enrolled in PDC from 1 April 2014–31 March 2015, with prematurity/low birth weight (62.2%) and hypoxic ischemic encephalopathy (34.5%) as the most frequent referral diagnoses. 64.5% of children were retained in care and 32.5% were LTFU after 12 months. In the unadjusted analysis, we found male sex (p = 0.189), having more children at home (p = 0.027), health facility of first visit (p = 0.006), having a PDC in the nearest health facility (p = 0.136), referral in second six months of PDC operation (p = 0.006), and social support to be associated (100%, p < 0.001) with retention after 12 months. In adjusted analysis, referral in second six months of PDC operation (Odds Ratio (OR) 2.56, 95% CI 1.36, 4.80) was associated with increased retention, and being diagnosed with more complex conditions (trisomy 21, cleft lip/palate, hydrocephalus, other developmental delay) was associated with LTFU (OR 0.34, 95% CI 0.15, 0.76). As 100% of those receiving social support were retained in care, this was not able to be assessed in adjusted analysis. Conclusions PDC retention in care is encouraging. Provision of social assistance and decentralization of the program are major components of the delivery of services related to retention in care.
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Affiliation(s)
| | | | | | - Hema Magge
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Boston Children's Hospital, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Katrina Hann
- Partners In Health Sierra Leone, Freetown, Sierra Leone
| | - Kim Wilson
- Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | - Evelyne Shema
- Ministry of Health, Rwinkwavu District Hospital, Rwinkwavu, Rwanda
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