‘Sometimes you are forced to play God…’: a qualitative study of healthcare worker experiences of using continuous positive airway pressure in newborn care in Kenya

Helen M Nabwera,Fiona Dickinson,Mercy K Sammy,Jemma L Wright,Matthews Mathai,Osman H Warfa,Bridget C Naimoi,Pamela Godia,Florence Murila,Judith Maua,Manasi Patil,Helen Smith,Juan Emmanuel Dewez,Alexander Manu

doi:10.1136/bmjopen-2019-034668

Abstract

ObjectiveTo explore the experiences of using continuous positive airway pressure (CPAP) in newborn care among healthcare workers in Kenya, and to identify factors that would promote successful scale-up.Design and settingA qualitative study using key informant interviews and focus group discussions, based at secondary and tertiary level hospitals in Kenya.ParticipantsHealthcare workers in the newborn units providing CPAP.Primary and secondary outcome measureFacilitators and barriers of CPAP use in newborn care in Kenya.Results16 key informant interviews and 15 focus group discussions were conducted across 19 hospitals from September 2017 to February 2018. Main barriers reported were: (1) inadequate infrastructure to support the effective delivery of CPAP, (2) shortage of skilled staff rendering it difficult for the available staff to initiate or monitor infants on CPAP and (3) inadequate knowledge and training of staff that inhibited the safe care of infants on CPAP. Key facilitators reported were positive patient outcomes after CPAP use that increased staff confidence and partnership with caregivers in the management of newborns on CPAP. Healthcare workers in private/mission hospitals had more positive experiences of using CPAP in newborn care as the relevant support and infrastructure were available.ConclusionCPAP use in newborn care is valued by healthcare workers in Kenya. However, we identified key challenges that threaten its safe use and sustainability. Further scale-up of CPAP in newborn care should ensure that staff members have ready access to optimal training on CPAP and that there are enough resources and infrastructure to support its use.EthicsThis study was approved through the appropriate ethics committees in Kenya and the UK (see in text) with written informed consent for each participant.

Highlights

Healthcare workers felt that the use of continuous positiveairway pressure (CPAP) had the potential to enhance newborn care in Kenya, there were multiple challenges with the implementation predominantly in the public sector
The key barriers were provision of inadequate infrastructure for effective delivery of CPAP; shortages of skilled staff that hindered CPAP initiation and management; and inadequate knowledge and training of CPAP among staff limiting its safe use. These barriers were sometimes mitigated by positive patient outcomes that increased staff confidence in CPAP use and promoted partnership between caregivers and healthcare workers when initiating CPAP
This is consistent with findings from an observational study in a rural Ugandan neonatal intensive care unit (NICU), which found that training using the Silverman-A nderson respiratory severity score made it feasible to implement CPAP in newborn care safely in a resource-limited setting.[35]

Summary

Introduction

The neonatal period (ie, first 28 days after birth) is well recognised globally as the Strengths and limitations of this study►► First study in Kenya that has explored the experiences of healthcare workers using continuous positiveairway pressure (CPAP) in newborn care in-d epth, obtaining data from multiple departments with a diverse range of available services and different levels of access to resources.►► The study was timely as it was conducted approximately 2 years after an intense implementation programme of CPAP in Newborn Units in public hospitals, providing key information on the sustainability of this exercise.►► The study was conducted at a time when there were several healthcare workers’ strikes that significantly disrupted healthcare services in Kenya, the healthcare worker perspectives in this study may reflect the views of the subset who returned to work after the strikes.most vulnerable time of childhood.[1]. ►► First study in Kenya that has explored the experiences of healthcare workers using continuous positiveairway pressure (CPAP) in newborn care in-d epth, obtaining data from multiple departments with a diverse range of available services and different levels of access to resources. Severe respiratory distress is a serious complication of the three leading causes of neonatal death (ie, preterm birth, intrapartum related events and sepsis) with a case fatality rate of up to 20% in LMICs.[4 5] The provision of respiratory support is a key requirement for the care of hospitalised small and sick newborns, but is often inaccessible in many LMICs.[4 6]

Results

Discussion

Conclusion