Using Quality Improvement Collaborative Approach to Improve

newborn outcomes in Malawi Dr Mercy Jere

International Forum London

Thursday, 27 April 2017

Background

• Malawi

– Population: 17.2 million (2015)

– Maternal mortality Rate: 439 per 100,000 live births

– Neonatal Mortality Rate: 27 per 1000 live births

• Prematurity 31%

• Asphyxia 28%

• Neonatal Sepsis 19%

– 18% deliveries are preterm

Background of the preterm project • Started as a scale-up plan on increasing uptake of Antenatal Corticosteroids in

Malawi following successful results in 4 hospitals (increase from 6% to 80%)

• Following study findings from Althabe et al, the Global ACS TWG recommended that ACS should only be used where the following three conditions can be met:

1. Ability to accurately assess gestational age (GA) and determine risk of imminent preterm birth.

2. Adequate care available for preterm newborns (e.g. resuscitation, Kangaroo Mother Care, adequate feeding support, treatment of infection, etc.)

3. Reliable, timely and appropriate identification and treatment of maternal infection

Theory of Change• Primary Aim: decrease mortality in low birth weight babies (1000 – 2000g) by

30% in 2 years across 12 District hospitals through reliable application of evidence based facility interventions

• Secondary Aims: Decrease all Newborn Mortality, Maternal Mortality, Stillbirths

Admission:

Assess fetal size

Screen and manage risk factors e.g. infection, eclampsia

Intrapartum:

Monitor with Partograph

Act if baby or mother at risk

Early Postpartum:

AMTSL

Clean birth

HBB

Skin to skin

Early breastfeeding

Late Postpartum:

Kangaroo Mother Care (KMC)

Manage Infection (mother/baby)

Activated leadership who can champion an improvement system for neonatal survival 15 Leaders & 24 District mentors trained in QI Leaders making decisions based on gaps identified (Staffing, medical equipment,

generators etc.)

Immediate access to essential commodities needed for preterm neonatal survival Hospitals established nursery and KMC units separate from the general postnatal ward Essential equipment provided

A bundle of key interventions that are reliably applied to every mother in labour and every preterm new-born infant Antenatal, Intrapartum and Postpartum

Patient & Family Centred Care from antenatal care through neonate’s discharge

Knowledgeable health workers who can expertly deliver preterm new-born care Clinical training on labour and management of the new-born In-situ trainings (parto-graph scoring, resuscitation, KMC) Introduction to Quality Improvement and Collaborative Learning Sessions

Reducing deaths of Low Birth Weight Babies in 12 Hospitals in

Malawi

Drivers of Success

Reliable Data systems Real time chart reviews and scoring processes of care against standards Hospitals using their data

Reduced deaths of Low Birth Weight Babies by 25% in 12 hospitals

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Run Chart: Low Birth Weight Deaths per 1000 live births in 12 Hospitals

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Run Chart: % of KMC Babies managed as per protocol or standard

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Run Chart: % Eligible LBW babies (weight ≤2000g admitted into KMC

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Learning Session 4 Key Interventions Immediate Skin to skin for all babies National neonatal monitoring tools provided to all hospitals Scoring of KMC processes of care

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37% Reduction in Maternal Mortality in 12 Hospitals

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U Chart: Maternal Deaths per 100,000 Live births across 12 facilities

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No change in Stillbirths and Neonatal Mortality

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Run Chart: Percentage of Fresh Still Births in 12 Hospital Collaborative

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Run Chart: Neonatal Mortality Rate per 1000 Live Births

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1 hospital reduced Stillbirths by 42% by:

improving on monitoring of pregnant women in latent phase of labor

Improving monitoring of active phase of labor using the partograph (≥90% correct use)

Fortnightly chart reviews and scoring of partographs

This theory has to be tested further

Limitations• Most District Hospitals have very small

KMC rooms and Nursery units

• District Referral systems

• Many babies dying due to complications of birth asphyxia in the collaborative – Complex processes

10 mothers and guardians in a ≈9m2 KMC Room

District Collaborative

• A small scale demonstration of implementation of this QI model across a District, including birthing facilities located in primary care sites

• Focus on Maternal Newborn Health

Activated leadership who can champion an improvement system for maternal and neonatal survival 6 Leaders and 24 District mentors trained in QI District leaders in-charge of District QI activities

Immediate access to essential commodities needed for maternal and neonatal survival Provide essential equipment and drugs

A bundle of key interventionsthat are reliably applied to every mother in labour and new-born infant Antenatal Intrapartum Postpartum

Patient & Family Cantered Carefrom antenatal care through neonate’s discharge

Knowledgeable health workerswho can expertly deliver preterm new-born care Introduction to Quality

Improvement Clinical mentorship at

primary care site In-situ trainings (parto-graph

scoring, resuscitation, KMC) Clinical Mentorship of

primary care midwives at the District Hospital

Improving outcomes of mothers and newborns at District level

District Prototype

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Run Chart: Neonatal Mortality at Kasungu District Hospital

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Too early to see improvement in the outcome measures

…But there have been improvements in KMC process indicators