Towards achieving the Newborn SGDs targets, What can hospitals offer?

1. Towards achieving the Newborn SGDs targets, What can hospitals offer? Prof Grace Irimu, PhD, MMed Paediatrician/Implementation Scientist Kenya Paediatric Association Annual Scientific Conference Mombasa, 12th April 2019

2. SDG Target Neonatal mortality rate 12/1000 by 2030 2050

3. SURVIVE: learning from history to accelerate change Global Neonatal Mortality (NMR) trends USA and UK trends since 1900 PHASE 1: Public Health Approaches PHASE 1 25% relative reduction NMR NMR Sub-Saharan Africa & Central & Southern Asia now PHASE 2 50% relative reduction PHASE 2: Improved pregnancy, birth and essential newborn care 27 26 18 PHASE 3 75% relative reduction PHASE 3: Special and intensive neonatal care 12 SDG 3.2 national target (NMR=12) Data sources: Born Too Soon, BMC RH Lawn et al 2013, UN IGME 2018 estimates

4. Health systems need to develop the capacity to measure and use data to learn.

5. Defining Clinical information Network 16 Hospitals CIN Mission:“To generate hospital data we trust to inform our decisions, plans, monitor and evaluate our actions” CIN Vision : To become leaders in the use of information to improve paediatric hospital care in Kenya and the region

6. Aim of Clinical Information Network • To support hospitals to improve documentation practices and utilize data to inform policies, quality initiatives and performance evaluation • To improve uptake of evidence-based paediatric clinical guidelines by regular audit-feedback. • To build leadership skills of the mid-level managers to introduce & sustain change • To embed research in routine clinical work.

9. CIN Data Flow • Data collected using Standard operating procedures: • Biomedical data • Key history & examination • Diagnosis • Investigation • Treatment • Outcomes • Nursing care Source : NBU & Paediatric Wards Single data clerk in each hospital All care provided by existing hospital staff A Research assistant keeps a log of events in each hospital each day

10. RESULTS Admissions and mortalities in all 16 Hospitals April'18 - March’19

11. Under 5’s admissions in 13 County Hospitals

13. Variation of mortalities across hospitals (April 2018-March 2019 Average mortality 2578/20782 = 12% * Data collection started in Dec2018

14. Variation of mortalities per birth weight across hospitals

15. Variation of mortalities per birth weight across hospitals

16. Variation of mortalities per birth weight across hospitals

17. % Admissions and mortalities Apr 2018-Mar 2019

18. DISEASE PATTERNS – (disease episodes) AT DISCHARGE(April ’18 to March ‘19)

19. RESULTS NBU XXX Hospital October '18 - December '18

21. Temperature ranges on the day of admission

23. LENGTH OF STAY for MORTALITY CASES

24. Nurses monitoring vital signs, feeds and fluids

25. Stevie wonderBlind due to retinopathy of prematurity - yet was only 6 weeks preterm Major issue was unsafe oxygen (high and unmonitored) Marker of quality of care Important need for pulse oximeters

26. Frequency of dehydration among neonates in the CIN Hospitals • 11 636 neonates admitted from Dec 2015 to Nov 2016 • Prevalence of dehydration was 19.7% (2293). Range across hospitals was 9.4% to 27.0%. • 85% had birth weight more than 2.5kg • Only 4% had history of diarrhoea • Diagnosis of neonate sepsis made in half of them • 7% died Breastfeeding May 2017

27. Access to Emergency Obstetric & Newborn Care (EmNOC) has a critical role to play : Basic and comprehensive.

28. Newborn Essential Solutions and Technologies (NEST) programme • NEST Programme is a multi-country program • The program’s main goal is to halve newborn mortality in target countries by 2030. • NEST program will achieve this by : • Making robust high impact low cost technologies for comprehensive newborn care accessible • Bundle approach • Capacity building clinicians, biotechnicians and innovators in newborn health.

29. NEST: Newborn Essential Solutions & Technologies Bundles of Care Hydration & Nutrition Prevent & Treat Infections Will NEST have significant impact on the outcomes ? Breathing Support Monitor & Treat Jaundice Separate Neonatal Ward Point-of-care Diagnostics Temperature Stability

30. Learning from others–redesign service delivery • Interventions –care along continuum of care • Quality data • Improved access & improved care in County hospitals – large numbers – inefficient services • Need to improve referral system • Human resource for health - Task shifting • Equipment – suitability & sustainability • KPA to consider establishing accreditation norms for quality newborn care at health facility. MPNDSR • Newborn corners • in • Health centres • Newborn units in subcounty/county • Newborn intensive care units

31. Continuum of care

32. Are there modifiable risk factors of unfavourable outcomes? • Favourable outcome (ENC) • Prematurity (KMC+) • Asphyxia (Breathing) • Neonatal infections (antibiotics) Maternal, perinatal and neonatal death surveillance and response (MPDSR)

33. Thanks………….