How Mbale Regional Hospital reduced newborn mortality from 52 to 11% in under 3 years
Ms Barbara Auma (right) of Tororo would now be in her final two weeks of pregnancy but her baby came almost three months earlier, writes Kakaire Ayub Kirunda. Prior to her ‘delivery’ Barbara bled for two days and the attending doctor had already written off the viability of the pregnancy outcome, documenting it as an abortion. When Barbara’s baby came out at 700 grammes after two days, the doctor told her she was too small to survive.
A 2014 report of the UK’s Telegraph newspaper, quoting Dr Mike Smith, a paediatric consultant, indicated that in 1974 the outlook for a baby born before 26 weeks – two thirds of the way through a normal pregnancy – was poor. “They almost certainly wouldn’t have survived.” Could this the same thinking that Barbara’s doctor had when he wrote off her baby? May be yes. May be no.
None-the-less, Barbara was not about to give up. She asked the doctor for the nearest hospital where she could try her luck even though her baby looked extremely feeble. She was told to try Mbale Regional Referral Hospital and advised to move fast where upon arrival was booked into the Neonatal Unit (NNU). The baby was initiated on fluids, kangaroo care (for warmth) and put on continuous positive airway pressure (CPAP) to support the baby’s breathing, a routine that lasted for close to two months in hospital, punctuated with sleepless nights, physical and financial exhaustion, among the many challenges.
But when Barbara returned in late August to honour a Preterm Follow-Up Clinic appointment following her discharge a few weeks earlier, she was a happy woman. Her baby was progressing well and now weighed 1.8 kilogrammes, up from 700 grammes at birth. “I never lost faith. The staff in the newborn unit was so supportive. One time my baby was dying late in the night. I called Dr Kathy who called another doctor who came immediately. I am happy that my baby is developing well.”
It is Barbara’s story and other such success stories that are fast making the two-year old neonatal unit at the Mbale Regional Referral Hospital a centre of excellence in newborn care in Eastern Uganda, 220 kilometres away from the capital Kampala.
The Neonatal Care Programme (NCP) began operating from the Paediatric Acute Care Unit that was admitting all sick children from prematures and sick neonates to older children with pneumonia and diarrhoea. The initiation of Level 1 neonatal care in October 2014 saw newborn mortality reduce from 52 percent to 36 percent by May 2015. In May 2015 a dedicated neonatal unit was opened in the hospital allowing Level 2 neonatal care to be implemented and newborn mortality now stands at 11 percent as at the end of July 2017.
Level 1 care entails: Routine data collection on neonatal admissions; regular monthly audit of neonatal admissions, outcomes and mortality; maternal education, involvement and empowerment; protocols and guidelines to aid neonatal case management; and Staff training in neonatology. This level also comes with guidelines and training in the administration of neonatal medications; guidelines and training in administration of neonatal feeds and intravenous fluids; dedicated area for neonatal patients and improved infection control policies; and a neonatal follow-up clinic
Under Level 2 care, there is dedicated neonatal unit with reliable water supply, hand-washing facilities, infection control policies and stable power source; investment in appropriate technology for neonatal care (Oxygen concentrators, phototherapy, pulse oximetry, Continuous Positive Airways Pressure –CPAP); and dedicated neonatal staff including a paediatrician and neonatal nurses
British Paediatrician, Dr Kathy Burgoine (above), who is the head of the neonatal unit says with such a mix up of children of different ages and diseases in the Acute Care Unit, it was not surprising that mortality was high.
“There were also no guidelines and no training in neonatal care. So we identified 12 key areas for quality improvement and began to implement Level 1 Neonatal Care within the existing paediatric ward with limited funding,” Dr Burgoine explains. “So we focussed then on training and education of our nurses. In order to replicate one-on-one nursing, the ‘Mbale Mother-Centered Model’ was developed where mothers and attendants were empowered to undertake the basic ‘nursing’ care of their babies. We taught them to weigh the babies, to take the temperatures and feed their babies. We focussed on infection control, hand washing. But we also developed neonatal guidelines based on WHO standards and evidence from similar settings. We also developed a neonatal drug formulary that helps all of our nurses, new and old, to know how to mix drugs and give the correct dose to the babies.”
The Neonatal Unit (NNU) now operates in room carved out of the maternity ward and although it was initially designed for ten patients at any one time, it now has up to 45 newborns on any one day. Their admissions grew from just over 100 patients a month up to 220 admissions per month. A bed is now shared by six to seven babies. Segmented into three sections for preterm babies, term babies, and a High Dependency Unit for the five sickest babies, the unit has five CPAP machines made by Diamedica, three oxygen concentrators and two phototherapy machines. There are no incubators in the unit because Kangaroo care is highly promoted here. To minimise infections, attendants are required to leave their belongings outside of the room and are provided with hospital gowns while inside. There are strict rules requiring hand washing on entry and inside the NNU. The NNU admits babies born in MRRH as well as those referred from other facilities and from home. Babies with skin infections and diarrhoea are not admitted inside the unit.
The neonatal team also realised that there was need to work on the then negative attitude of mothers and the community as a whole regarding interventions such as kangaroo care if success was to be realised, as Neonatal Clinical Officer Juliet Ikiror explains:
“Mothers also did not want feeding tubes in their babies. To insert a feeding tube was a very big challenge that we experienced. But as time went by and the community started realising that there was an improvement, and babies were being saved, the attitudes started changing and the numbers are overwhelming.”
A 15-module Newborn Care Training Course covering basic newborn care and management of complex cases which has now been delivered four times is also a major contributing factor to the reduced newborn mortality, according to Dr Burgoine. “We have also run that course in two other district hospitals. That helps with the quality of referrals that we get here.”
A non-bureaucratic leadership at the hospital that joined hands with the charity Born on the Edge run by Dr Burgoine and her husband to set up the neonatal unit has been monumental to the successful operation of the unit. According to Dr Burgoine, this partnership has seen the improvements in neonatal skills, systems development and infrastructure support to improve service delivery.
“We also have a great partnership with Diamedica who built our CPAP machines; they regularly come and service them for us for free and give us training. These machines have really helped us to reduce mortality for the tiny prematures,” adds Dr Burgoine.
While the big numbers are welcome, Dr Burgoine explains that space remains a big impediment to quality service delivery: “If we had more space we would be able to reduce hospital acquired infections. The mothers would have enough space to rest and also practice kangaroo care for those whose babies require it.”
She further shares that although the neonatal unit has some power back up, it lasts only three hours when grid based electricity is off. Sometimes that is not long enough. Occasionally, babies who are dependent on oxygen and CPAP machines lose their lives.
It is apparent from Mbale that improving newborn health outcomes is possible in both referral and general hospitals if the right clinical skills are passed on to the available staff especially nurses, midwives and clinical officers, who are more available compared to the elusive medical officers. Partnerships are critical in order to register successful ventures such as the one between Born on the Edge and Mbale Regional Referral Hospital. A learning visit by staff from other public hospitals would yield a lesson or two on how to revolutionise newborn care.