Facilitating quality improvement activities related to newborn care in low- and middle-income countries: challenges and possible solutions

Abstract

Global strategies to improve newborn survival have expanded from basic Essential Newborn Care practices to more comprehensive approaches that address the specific needs of small and sick newborns. Despite advances, many low- and middle-income countries continue to face challenges in reducing neonatal mortality, necessitating supportive, evidence-based approaches such as quality improvement activities. Quality improvement focuses on empowering healthcare teams to identify and address gaps in care, with studies demonstrating its superior impact compared to traditional training and/or supervision. As we gain more experience applying it to improve newborn care, we need to learn from early efforts and adapt steps as required. This paper outlines four areas that program managers including teaching instructors can address to strengthen quality improvement efforts: (1) adapting quality improvement structures and training, (2) simplifying related tools and methods for ease of use at the frontline, (3) prioritising specific newborn health improvement goals with appropriate data and relevant indicators, and (4) strengthening health system elements to sustain the quality improvement initiatives. The paper describes challenges in each of these areas and proposes potential solutions. While point-of-care approaches are vital, it is equally essential to engage communities, foster leadership at all levels, promote equity and strengthen health systems, especially in low- and middle-income countries. This includes establishing regional and national technical bodies and strategies, working with ministries of health, stakeholders, and professional associations, to ensure sustainability, equity, and expansion of quality newborn care.

Introduction

Evolution of approaches to improve newborn survival

Initiatives to improve the newborn ‘survive and thrive’ agenda have evolved significantly. During the Millennium Development Goal (MDG) era (2000–2015), programs promoted skilled birth attendants delivering babies in facilities and basic Essential Newborn Care (ENC) [1–3]. These interventions reduced neonatal deaths, but not all countries achieved their MDG target, and now over 60 countries are at risk of not meeting their Sustainable Development Goals target [4]. Therefore, initiatives, including Every Newborn Action Plan (2014) [5], recommend focusing on quality of care, especially among preterm/ low-birthweight babies, and newborns with problems, collectively referred to as small and sick newborns (SSNBs), who contribute to a substantial share of neonatal deaths.

Evolution of quality improvement approaches

While many of the elements described in this article, in principle, apply to quality improvement (QI) activities related to other technical areas, the focus is on newborn health as it is related to high mortality rates, especially in low- and middle-income countries (LMICs). Approaches to improve health worker performance have evolved over time. Initially, the focus was on training health workers followed by external supervision by program staff in the government [6]. The assumption was that increased knowledge would lead to better care, but research revealed that just training and supervision have a limited impact on patient care outcomes [7]. In addition, as facility births increased and more complex care for SSNBs scaled up, the support provided by external government staff was insufficient to support clinicians in applying advanced clinical skills, resulting in the need for in-facility approaches to support more advanced newborn care practices. One such approach is the use of QI methodologies [8, 9]. QI focuses on teams of health workers identifying challenges and testing solutions using data-driven methods to enhance care at their facility. In a systematic review of over 800 studies in low- and middle-income countries (LMICs), QI approaches improved clinical practice by a median of 56% [7]. By comparison, training alone improved care by a median of 10% and supervision by a median of 15% [7].

While QI methodologies were initially established in high-income countries, their application in LMICs has grown significantly. Global partners, including the Gates Foundation, US Agency for International Development (USAID), World Health Organization (WHO), and United Nations Children’s Fund (UNICEF), have championed QI in newborn care [10–13]. Professional bodies, including the American Academy of Pediatrics (AAP), the National Neonatology Forum of India and, recently, the African Neonatal Association, have also promoted QI for essential interventions like neonatal resuscitation [14–16]. However, simply translating these approaches from high to low-income settings may be ineffective or not even fully feasible. This article explores the key challenges faced when implementing newborn QI in LMICs and proposes practical, potentially sustainable solutions.

Challenges with QI approaches for newborn care and strategies to enhance their effectiveness

QI efforts for newborn care in LMICs can be strengthened by focusing on four main areas: (1) developing and adapting existing QI structures and training as appropriate (2) simplifying QI tools and methods for ease of use at the frontline, (3) prioritizing specific newborn health improvement goals, 4.) adding QI components to teaching activities in facilities where they do not exist and 5) strengthening health system pillars to sustain QI initiatives.

Adapting QI structures and training

Training programs for QI are often held separately from clinical training. A more effective approach would be to integrate specific QI training into relevant clinical training programs. For example, a neonatal resuscitation course can teach the required clinical skills to midwives, nurses and doctors in the first series of lessons and dedicate a session or a day, as appropriate, near the end of the same workshop to using QI approaches to promote application of these skills in their facility. Combining clinical training with refresher courses and QI activities addresses a wide range of potential barriers to good care in individual facilities and leads to better results than any one alone [7]. The authors have found that the QI sessions for newborn care work best when they include additional staff from obstetrics and gynaecology (ObGyn), hospital administration, and data management, who often work in the section that maintain records of case sheets and who consolidate data for the district/country health information system. Some potential advantages include:

1. Better collaboration between the Obstetric and Pediatric /Neonatology departments: Bringing together obstetric and neonatal staff in neutral QI workshop environments can facilitate teamwork, reduce gender inequity and “blame culture” seen in some facilities, and also help improve problem-solving [17].

2. Support from hospital administration: Involving facility managers may help promote QI efforts, reduce the hierarchy, motivate leadership, reduce frequent transfers of trained staff to other units and ensure better availability of suitable equipment and supplies.

3. Involving data management staff: In many LMICs, over-worked clinical staff may not be able to fully manage and analyse data related to QI. Involving the data management staff, where available, early in the program may help improve data quality and use [18]. At the same time, all facilities may not have well trained data management staff, as in smaller centers. Here some help may be sought from personnel in the medical record section or from those that are charged with sending data to the country’s health information system (HMIS). The importance of great care in collection, maintenance and utilization of data in itself, both for the HMIS and in quality improvement activities cannot be over-emphasized. These points must be repeatedly stressed during training programs, in reviews of QI exercises, in review of data used in QI activities and in maintaining the HMIS system. Without all this care, QI activities may become unreliable, and through the HMIS, lead to inaccurate information being disseminated by the country health system.

Simplifying QI tools and methods for ease of use at the frontline

Despite the diversity of QI approaches globally, many focus on similar concepts and key steps [8, 9]. This commentary, addressing LMICs, focuses on the four-step framework in the WHO Point of Care Quality Improvement (POCQI) training materials [8]. This model follows the steps noted below.

Identify a problem, establish a team, and write an aim statement

The care team needs to identify quality gaps that are important and feasible to improve. QI teams are frequently limited to clinical staff, often ignoring ancillary staff, who are involved in tasks that can influence the gaps being addressed. To mitigate this challenge, QI teams should include a range of personnel who are involved in the selected QI aim. Engaging these members helps ensure that all perspectives are considered, helps foster cooperation, and elevates the status of the category of staff who may be often overlooked. Identifying a specific, measurable, achievable, relevant, time-bound (SMART) aim with percentage of change over a specified period, can also be difficult as health care workers who are new to QI can struggle to identify what is possible over what period. Care should be taken to set targets that are practical and feasible. Writing a SMART aim also requires baseline data. Where this is not available, and a QI activity requiring such data is considered essential, one option is to commence collecting the necessary data for a period of, say, one to three months, before instituting activities for the specific QI process, that can then serve as the baseline data.

Another challenge is inadequate engagement with the families and local community. Communication strategies should be enhanced by connecting with families and local community leaders to establish trust and cooperation. These can potentially procure community support and family involvement to help solve some issues. While engagement and enhanced communication strategies with community health workers is vital, particularly for follow-up care, governments also must ensure that they are adequately compensated and supervised to maintain their knowledge, skills, efficiency, motivation and commitment [19].

Analyse the problem and measure quality of care

Sufficient attention must be paid to the underlying barriers experienced by providers in delivering good quality care, and improved quality in collection and in maintenance of data, and its utilization in monitoring QI. Senior staff often assume that poor care is due to junior staff not knowing the correct procedures, leading to increased focus on only repeated refresher training or giving instructions. While training of staff on problem analysis tools like flowcharts, ‘five whys’ and fishbone diagrams are useful, equally important is the vital step of a team-based approach of involving senior and junior personnel including frontline staff—the people directly delivering care, in identifying root causes of and steps to take to rectify poor care [8]. Senior staff should be counselled to appreciate the value of analysing problems with the team rather than just coming up with ready solutions, such as issuing instructions and providing additional clinical trainings. Initially, high-income partners can provide useful support through the country leadership teams to facilitate local QI implementers to improve relevant activities including careful plan-do-study-act (PDSA) cycles, ensuring that local country staff are involved consistently to make sure that interventions are appropriate for their requirements. The pictorial nature of these analysis tools, while useful, can, at times, be challenging, especially for some older frontline health workers, who may not be used to developing this type of visualization of data. For such staff, QI coaches can help them initially list problems in simple tables until they become comfortable in using visual formats.

Appropriate selection of indicators is important for analysis of quality gaps. Reliance on process indicators alone is insufficient. While they are very important in documenting that staff are compliant in following standard protocols, outcome indicators are essential, to stay focused on the major objective(s) [20]. Inadequate availability of some relevant data and indicators in LMICs is yet another significant issue that can hinder monitoring and add to the cost if surveys have to carried out [21]. To address the lack of appropriate indicators for newborn health that are essential to document and monitor key outcome measures, a global core list for essential care has been prioritized [22]. These include key indicators related to common components of level I and level II care that provide special care components for SSNBs, but which, for many facilities in LMICs, are below those in intensive care units (level III) [23–26]. For example, India has established newborn care with data monitoring covering some key indicators relevant to both level I and II care across district hospitals [26].

In addition to the process and outcome indicators, QI teams should also anticipate unintended consequences during QI activities and use ‘balancing’ indicators. These are often overlooked in LMICs but they are crucial to anticipate, measure and address. For example, counselling to promote early care-seeking for neonatal jaundice can reduce severe hyperbilirubinemia and its consequences [27]. However, such counselling can also lead to families bringing babies in too early to the hospital resulting in over-crowding, increased workload for the limited staff and at times, needless admissions. Hence, QI projects should anticipate and plan for suitable balancing measures to look out for such events early and to take necessary actions to mitigate adverse consequences, including proper counselling of parents and family members [27].

A variant of application of a balancing measure to be considered would be to monitor infections associated with procedures, that is often not taken into account. Hospital acquired infections are common in LMICs, especially in the vulnerable newborns leading to preventable deaths. It is, therefore, essential to ensure (through training, QI activities and evaluation) that clinical procedures are not only performed appropriately, but also in a manner that does not lead to infections. Additionally, health education to mothers and families related to steps that they can take to reduce infections, starting with handwashing and use of human milk and breastfeeding are equally important. This can support broader efforts to ensure patient safety and reduce the needless use of antimicrobials which are driving antimicrobial resistance [28].

Careful review of data and outcome(s) can also lead to valuable lessons, especially when QI projects do not yield expected results and when set goals are not achieved (Box 1).

Box 1 Lessons Learned from Lack of Response to QI Activities Initiated for Improving Outcome following Neonatal Resuscitation at Birth [29]

A collaborative QI project involving four hospitals in Ghana failed to improve neonatal resuscitation outcomes despite multiple clinical trainings and repeated virtual interactions with the facilitating group in the USA and the relevant country QI teams [29]. A more in-depth analysis of the data revealed that over 10% of babies born in these hospitals had an APGAR score ≤ 3 at one minute. One of the challenges in resuscitating babies with score of ≤ 3 at one minute associated with a more highly depressed status at birth, especially with basic resuscitation as with Helping Babies Breathe, is that the final short term and long-term outcomes are poorer. This finding highlights the need for hospitals to expand their QI work to additionally focus on improving the status of the baby at birth resulting in better Apgar scores. These include strengthening of antenatal education of mothers on seeking timely care during labor along with appropriate management of the 2nd stage of labor with optimal use of the partograph [29]. Proper use of suitable checklists can be useful both for effective documentation of activities that have taken place both on the clinical side and as a part of QI activities [30].

Develop and test changes

While PDSA cycles are seen by some as tools to test whether a change directly leads to improved care, it is equally important to use PDSAs for testing more ambitious changes to learn if a change is really feasible. These ‘feasibility’ PDSAs give teams the freedom to try out changes that might be met with uncertainty or disagreement, fostering a more creative approach to problem-solving where required [18].

Another challenge arises when several evidence-based interventions are clearly required to solve certain problems and, where evaluating them one at a time, may be excessively time consuming. Here, testing multiple changes simultaneously in a single PDSA cycle (bundle approach) can save time. However, care must be taken to ensure that such actions do not compromise the interpretation of the results [27, 31].

Sustain the successful change idea

After a remedial approach has been found feasible and successful in achieving the expected improvement in health outcome, it needs to be sustained in the routine work. Some type of hardwiring the new way of working is essential by including it in the standard procedures and policies of the unit and hospital. This must also be communicated to all existing team members and to any new staff members that join over time.

Prioritizing specific newborn health improvement goals

While many known evidence-based interventions are required for the care of newborns, especially SSNBs, both immediate and long-term outcomes can be strongly influenced by additional interventions listed below, that are often underutilised.

Family-centred care/family involved care

Maternal involvement and Kangaroo Mother Care (KMC), including immediate KMC, are some of the components of Family Centred Care (FCC)/Family Involved Care (FIC) [32–35]. Besides numerous advantages including improved bonding and better outcome, including both immediate effects and long-term neurological impact, there is also an element of task-sharing by parents/surrogates, covering some of the non-specialized care of the baby, especially useful in LMICs where nurse-bed ratios may range from 1:15 in the daytime to 1:30 at night [36]. This can permit nurses to allocate time to other responsibilities including major QI activities. It is essential that health facility management and QI teams support this approach. This also highlights the need to consider the high work load and, where feasible, implement some key QI meetings and activities in the day shift with more staff. All relevant staff must be trained and motivated, as FCC/FIC may not be readily accepted by everyone. Initially, nurses may find it challenging to integrate it into their workflows [37]. However, when properly implemented with appropriate counselling and motivation of the health care providers, FCC/FIC can relieve nurses of some non-specialized care duties, increase bonding between the mother and baby and maternal confidence, without increasing infections, promote earlier discharge and enhance postnatal care at home [32, 35] Ultimately, the aim is to promote zero separation of the maternal and newborn dyad to the extent possible [38]. For this to happen, facilities should provide more support and resources to the mothers/mother figures to better support their stay in the facility.

Compassionate quality of care

Compassionate care must be a consistent part of QI activities. Since the mother-baby dyad is central to newborn care, this includes the principles of respectful maternal care and the nurturing care of newborns [39, 40]. Some examples of the latter include proper positioning of the baby, appropriate pain management and adjusting lighting to support restful sleep [40].

Addressing very early discharge of low-risk mother-baby dyads

It is recommended that all mother-baby dyads remain in the facility for at least 24 h after delivery [41]. However, due to bed shortages or the families’ desire to return home, some mothers are discharged within a few hours after birth. This short, immediate postnatal period may not be the suitable time to initiate counselling for the first time as mothers are often exhausted and overwhelmed after giving birth and may not be so receptive. To improve care, we suggest initiating counselling during the antenatal period, on optimal maternal and newborn care, early recognition of danger signs and prompt care-seeking, focusing on newborn care in the first week of life, when 75% of newborn deaths occur [27, 42]. This health education should then be reinforced after birth along with maternal and newborn assessments, before discharge and, again, during the subsequent postnatal follow-up visits [27].

Taking feedback from mothers/families

It is essential, although often overlooked, that neonatal units should aim to try and procure feedback from mothers and families on quality of care they received and level of satisfaction. Such steps can further help ensure better healthcare outcomes [43].

Strengthening health system pillars to sustain QI initiatives

Ongoing support to QI teams is important for sustaining momentum. Follow-up virtual interactions with external QI trainers through online platforms (e.g. Zoom and/or WhatsApp) along with workshops and in-person support where feasible may be more affordable [27]. QI activities in the facilities are often decreased or, actually discontinued after external (project) support is over. Therefore, representatives of district / regional health authorities for maternal and newborn care should be included from the beginning to guide and motivate for early and long-term support to sustain QI activities at hospital level, and, additionally, to strengthen relevant health system pillars.

Ultimately, more so in the larger programs, it is important that the national government takes the leadership role and involves key stakeholders including professional bodies early in the activities. Establishing a national and, ideally, regional technical support groups for the newborn can be helpful. It is also critical to develop a specific, budgeted national level strategy for newborn care to ensure that key, essential interventions, including data driven QI actions are included and funds set aside specifically for the newborn care components in the Maternal and Child Health (MCH) programmes. This can result in greater commitment and a better implementation, especially when the strategy is periodically updated to suit the changing needs. The national newborn strategy must include QI as a routine in-country activity and not be dependent on donor driven, externally facilitated projects.

Recent guidance from the World Health Organization also emphasizes the importance of building systems that support QI over the long term. WHO’s approach focuses on strengthening five key foundations for sustaining QI: onsite support for QI teams; peer-to-peer support between facilities; measurement to monitor both activities and their effects on patient care; engaging communities and stakeholders; and integrating QI efforts into the routine health system management [44, 45]. A collaborative approach between hospitals can also be very supportive [16, 46].

Box 2 summarises one such study [47].

Box 2 Improving the Quality of Health Care in Special Neonatal Care Units of India [47]

A collaborative cross-learning quality improvement approach was found successful across a network of 3 special newborn care units providing care to small and/or sick newborns. A novel strategy was successfully used under which clinical training to improve the knowledge and skills of health care workers in managing sick and preterm neonates was combined with point- of -care quality improvement (POCQI) skills. A total of 156 doctors and nurses were trained in teams in the POCQI methodology and preterm newborn care package. The trained teams received on-the-job coaching by QI experts from a nearby medical college and successfully completed sixteen quality improvement projects. QI teams assigned a nurse to collect data from the bedside patient records prospectively and a mixed-effects regression model was used to estimate the effect of the intervention. It was observed that care across these newborn units was successfully standardized and reduced the use of oxygen, antibiotics (without any inadvertent increase in mortality) and phototherapy while increasing the use of enteral feeds. However, the short duration of the study that was limited only to care of newborn complications in the newborn units did not lead to any improvement in neonatal survival.

The Global Fund has developed training materials to help governments institutionalize these support structures [48]. QI activities must be linked to the responsibilities of newborn health technical groups, professional bodies for obstetricians, paediatricians/neonatologists, and nurses/midwives, at the national and regional levels to ensure alignment of QI with clinical training and monitoring mechanisms. It is also essential to establish and acknowledge the importance of leadership at all levels, within individual QI teams and the management at the facility level, and at district, regional and national levels. Its value can further increase when a system is in place where such leaders also take on roles to mentor additional personnel who are potential leaders with a view to building follow-on leaders to ensure long-term sustainability [49, 50]. Equally important for sustainability is an additional focus on equity in provision of improved quality of care [51].

In addition, there may be several advantages in promoting the basic principles of compassionate quality of care into pre-service training with additional components being covered in continuing medical education for healthcare workers. By these interventions, countries can, hopefully, prepare the next generation of health professionals to deliver both technically sound and compassionate quality of care in a sustained, equitable and efficient manner for all newborns.

Conclusion

The evolution of approaches to improve newborn survival globally highlights the importance of adapting QI strategies in LMICs to suit local requirements. While significant progress has been made through initiatives such as ENAP and advances in newborn care, challenges remain. These include the complexity of supporting SSNBs, inadequate staff with high workload, limitations of training-focused interventions, and the need for integrated, equitable and sustainable compassionate QI efforts.

Suggested changes include integrating QI training activities with traditional clinical trainings and refresher courses, simplifying QI tools, and prioritizing appropriate, measurable, data-based actionable QI goals. Fostering teamwork in health facilities by involving all levels of staff, from clinical to relevant non-clinical members and mothers and families, is critical for ensuring continuous, effective quality improvement of newborn healthcare.

While point of care QI activities are essential, the importance of embedding these in the health system approaches at all levels cannot be overstated. As external funding gets more limited, effective leadership within the health system at all levels and early involvement of the ministry of health and key stakeholders in shouldering the responsibility and maintaining QI momentum is critical. Establishing national and regional level committees on newborn health and quality of care, and up-to-date national newborn health strategies with dedicated budget are important. Sustainability depends on building strong organizational foundations that align QI activities with system-wide enhanced support for financing, other necessary resources, and governance. Additionally, ensuring collaboration across Obstetrics/Gynaecology and Pediatrics/Neonatology, nurses/midwives facility managers, administrative staff and data personnel will further help enhance the effectiveness, sustainability and expansion of QI initiatives.

Lastly, it is important to involve family members and the broader community and integrate their feedback on their experience of care to ensure good quality compassionate maternal-newborn care towards achieving desired health outcomes and emotional well-being of mother-baby dyads. Incorporating key QI principles in a holistic manner into pre-service and continuing medical education would help foster a generation of healthcare workers equipped not only with technical skills but also with a deeper commitment to deliver high-quality, compassionate care to every mother-baby dyad every time.

Abbreviations

AAP

American Academy of Pediatrics

ENC

Essential newborn care

ENAP

Every newborn action plan

FCC

Family centered care

FIC

Family involved care

KMC

Kangaroo mother care

LMICs

Low- and middle-income countries

MDG

Millenium development goal

ObGyn

Obstetrics and Gynaecology

PDSA

Plan-do-study-act

POCQI

Point of care quality improvement

QI

Quality improvement

SSNBs

Small and sick newborns

USAID

United States Agency for International Development

WHO

World Health Organization

UNICEF

United Nations Children’s Emergency Fund

Author contributions

Dr. Indira Narayanan conceptualized the idea and drafted the initial manuscript, critically reviewed and revised the manuscript. Dr. Rajesh Mehta, Dr. Nigel Livesley and Dr. Tamar Chitashvili contributed to framing the concepts for the manuscript, critically reviewed and suggested revisions. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Funding

Funding was provided for publishing this review as open access through the Global Health Initiative Seed Grant, Georgetown University Medical Center, Washington DC, USA.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Use of large language models such as chat GPT

Large Language Models, such as Chat GPT, were not used in the preparation of this document.

Competing interests

The authors declare no competing interests.