The All Babies Count Initiative: Improving Quality of Newborn Care to

Eliminate Newborn Deaths

Rwandan Trends: Neonatal Mortality

25%

decline

4%

decline

District Overview for ABC Implementation

32012 Rwanda Census

Population: 529,346

Community Health Workers:

2,765

Health Centers: 24

District Hospitals: 2

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Section Title

All Babies Count (ABC) Initiative

Key Processes and Indicators

• Antenatal Care

– 4 visit ANC

• Delivery Management

– % skilled delivery

– % antenatal corticosteroid

– % PPROM antibiotics*

– Time to c-section (hospital)

• Postnatal Care

– Immediate skin-to-skin

– Postnatal care within 24 hours

– Number with asphyxia*

• Primary Outcome: district neonatal mortality

A mother with her baby and Kangaroo Mother

Care with a neonatal nurse at Rwinkwavu District

Hospital, July 2013. Permission for educational

use granted.

*Not reported due to inadequate data quality.

Methods• Data extraction: chart review, routine data, and programmatic records

• Aggregate monthly data were measured and validated across 26 district facilities

– Baseline: July 2013-Sept 2013

– 21 mo endpoint: July 2015-Sept 2015

– Sustainability (12 months later): July 2016-Sept 2016

• Qualitative assessment using focus group discussions and in-depth individual interviews with key implementers

– inductive, content analytic approach to capture experiences of neonatal practice, change over time, and factors important to sustainability

Quality Improvement ProjectsTotalNumberofQIProjectsandChangeIdeasOver18monthImplementationPeriod

CAREAREATARGETED #QIPROJECTS #CHANGEIDEAS

AntenatalCare 23 74

DeliveryCare 17 32

PostnatalCare 12 12

Total 52 118

Consolidation of relevant, high impact

change ideas to support spread

Improved Data Quality: Neonatal Mortality Routine Reporting

27.7 27.7

18.6 19

24.5

17.419.3 18.6

16.5

12.7

18.0

9.1 9.910.8

11.7 12.110.3 10.8

0

5

10

15

20

25

30

Jul-Sep 13 Oct-Dec 13 Jan-Mar 14 Apr-Jun 14 Jul-Sep 14 Oct-Dec 14 Jan-Mar 15 Apr-Jun 15 Jul-Sep 15

Validated HMIS Routine HMIS

Core Collaborative Process Measures

Indicator

Baseline Endpoint

P-value

12 Month Sustainability

P-value comparing 12 months

sustainability to ABC endpointMedian (IQR) Median (IQR) Median (IQR)

Percent of deliveries where mothers had 4

ANC visits

12.7(6.7-42.2)

30.2(15-46)

0.06 30.9(23-47)

0.76

Percent of pregnant women with early

ANC1

22.0(12.3-37.8)

27.4(18.5-37.2)

0.2 39.3(32.8-48.6)

0.006

Percent of pregnant women delivering in

facilities

89.7(86.3-95)

93 (87-95) 0.2

95.8(93-97.4) 0.01

Percent of babies who are provided

immediate skin-to-skin after birth

63.4(18-82.3)

98.2 (96.3-100) <0.001

96.3(86-100) 0.2

Percent of newborns checked for danger

signs within 24 hrs of birth

46.5(31-96.7)

98.7 (96.3-100) <0.001

99.3(89-100) 0.72

Indicator

Baseline Endpoint

P-value

12 Month Sustainability

P-valueMedian (IQR) Median (IQR) Median (IQR)Average time to emergency

caesarian-section (minutes)*

124.5 56 53

Percent of women with preterm labor who are treated with antenatal

steroids* 0 45 58 N/APercent availability of

essential medications for maternal/newborn care

61.1(45-77.8)

81.8(72.7-81.8) <0.001

83(83-92) 0.006

Percent availability of functioning equipment

essential for maternal/newborn care

55.6(48.2-61)

86.6(77.8-88.9)

<0.001 89(89-94) 0.01

District Hospital neonatal unit case fatality (%)* 25.7 11.0 14.8

*p value unable to be calculated due to sample size and distribution

Relative Change in Neonatal Mortality

Outcome

South

Kayonza /

Kirehe

(ABC)

Rest of Rural

Rwanda

Districts1

Difference of Differences

total (SE) total (SE)

Difference

(SE)95% CI

p-

value

Baseline

(deaths/1000

live births)

30.1 14.9

Endpoint

(deaths/1000

live births)

19.6 15.3

Change (per

1000 live

births)

-10.4

(3.9)

0.4

(0.5)

-9.5

(4.0)(-17.6, -1.5) 0.02

Factors Related to Sustainability

• Leadership ownership

• Internally-generated solutions

• Benefits/drawbacks of young leadership

• Staff turnover

• Impact of unplanned contextual events

• Gap between high MNH service demand and available staff

Next Steps

Testing change packages in 7 new districts with Saving Lives at Birth Transition to Scale award (2016-2019)

Continue monitoring and iterative improvement in currently supported areas

National scale-up planning and coordination with quality planning efforts

Conclusions: Lessons From the Field

• Able to create sustainable impact through a comprehensive, integrated health system improvement approach

• Addition of a district-wide learning collaborative to mentoring accelerates change

• Create culture of improvement and data utilization to drive and track change

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