Sustainability Assessment of a District-Wide Quality Improvement on Newborn Care Program in Rural Rwanda: A Mixed-Method Study

Evrard Nahimana,Felix Sayinzoga,Merab Nishimwe,Hema Magge,Christina Thompson Lively,Bethany Hedt Gauthier,Lisa R Hirschhorn,Hannay Gilbert,Francois Bizimana,Fulgence Nkikabahizi

doi:10.5334/aogh.3205

Abstract

Background:Neonatal mortality continues to be a global challenge, particularly in low- and middle-income countries. There is growing work to reduce mortality through improving quality of systems and care, but less is known about sustainability of improvements in the setting post initial implementation. We conducted a 12-month sustainability assessment of All Babies Count (ABC), a district-wide quality improvement project including mentoring and improvement collaborative designed to improve quality and reduce neonatal mortality in two districts in rural Rwanda.Methods:We measured changes in key neonatal process, coverage, and outcome indicators between the completion of ABC implementation and 12 months after the completion. In addition, we conducted 4 focus group discussions and 15 individual in-depth interviews with health providers and facility and district leaders to understand factors that influenced sustainability of improvements. We used an inductive, content analytic approach to derive six themes related to the ABC sustainability to explain quantitative results.Findings:Twelve months after the completion of ABC implementation, we found continued improvements in core quality, coverage, and neonatal outcomes. During ABC, the percentage of women with 4 antenatal visits increased from 12% to 30% and remained stable 12 months post-ABC (30%, p = 0.7) with an increase in facility-based delivery from 92.6% at the end of ABC to 95.8% (p = 0.01) at 12-month post-ABC. During ABC intervention, the 2 districts decreased neonatal mortality from 30.1 to 19.4 deaths per 1,000 live births with maintenance of the lower mortality 12 months post-ABC (19.4 deaths per 1,000 live births, p = 0.7). Leadership buy-in and development of self-reliance encouraging internally generated solutions emerged as key factors to sustain improvements while staff turnover, famine, influx of refugees, and unintended consequences of new national newborn care policies threatened sustainability.Interpretation:Despite discontinuity of key ABC support, health facilities kept the momentum of good practices and were able to maintain or increase the level of prenatal, neonatal quality of care and outcomes over a period of 12 months following the end of initial ABC implementation. Additional studies are needed to determine the longer-term sustainability beyond one year.

Highlights

Over the past two decades, countries across the globe have made substantial improvements reducing under-five mortality overall, yet 3 million newborn deaths and 2.6 stillbirths [1] still occur every year
Most (99%) of these deaths occur in low- and middle-income countries (LMICs) where high neonatal mortality rates are often associated with poor quality of maternal and neonatal care services [1, 2]
Training related to neonatal care were given to facilities after the 12-month completion of All Babies Count (ABC) by Partners In Health/Inshuti Mu Buzima (PIH/IMB), and all health facilities in the two districts continued to be managed by the MOH

Summary

Introduction

Over the past two decades, countries across the globe have made substantial improvements reducing under-five mortality overall, yet 3 million newborn deaths and 2.6 stillbirths [1] still occur every year. To achieve the health-related sustainable development goal (SDG) of reducing preventable deaths of newborns to at most 12 per 1,000 live births by 2030, high burden countries must effectively and sustainably implement evidence-based interventions in maternal and newborn care that could reduce neonatal deaths by as much as 71% annually [5, 4]. Governments and their partners are currently implementing programs to achieve these goals, but little is known of how these improvements can be sustained beyond the intervention period and factors related to their shortand long-term sustainability. We conducted a 12-month sustainability assessment of All Babies Count (ABC), a district-wide quality improvement project including mentoring and improvement collaborative designed to improve quality and reduce neonatal mortality in two districts in rural Rwanda

Methods

Results

Conclusion