1. Health Services that Deliver for Newborns Post-Doctoral Researcher
Effective coverage of essential in-patient newborn services in Nairobi County
David Gathara
Post-Doctoral Researcher
KEMRI Wellcome Trust
Work developed in collaboration with the county

2. Background
Despite the progress in reducing U-5 mortality, neonatal mortality still accounts for 45% of all child deaths deaths
“estimates suggest the greatest effect [on newborn survival] would come from a focus on the care of small and ill neonates,
Much of this effect is potentially achievable through newborn care services in subdistrict and district level hospitals.”
In Kenya we don’t have a good understanding of what care is currently being provided for sick newborns and what the quality of that care is
Nairobi County has NN mortality of 39 per 1000 live births (national average 22/1000).
Nairobi has 89% hospital delivery and 14% of the health facilities nationally
With mothers being increasingly encouraged to deliver in facilities, it is important that these facilities are able to deal with any complications that may arise for the newborn, even if this is just to have a good referral system in place to other facilities with high quality care.
Without a clear understanding of how care is currently delivered and what the gaps are, it becomes difficult to discuss how improvements can be made.

3. Nairobi Newborn Study Estimating the need Identify facilities
Estimate admissions
Structural assessment
Examine process of care
Assess knowledge of nurses

4. METHODS Access gap Quality scores Structure Process Knowledge
Estimating need
Literature review
Admission register review
All neonatal admissions for one year
Structural assessment
Check list for infrastructure, staffing, equipment, drugs
Medical record review
1183 records sampled: proportional sampling/weighting
Correct’ defined a priori by national guidelines
Nursing knowledge questionnaire
125 maternity and newborn unit nurses sampled
Vignettes and direct questions
Access gap
Quality scores
Structure
Process
Knowledge

5. Need inpatient services: 18% of live births BMJ Global Health, Murphy et al, 2017
Newborns needing care
<200
>
>700
The 183 sick newborns/1000 live births estimate was applied to the live births population- calculated by taking 2009 census population, adjusting for population growth in last 7 years, applying the CBR of 3.1 from the KDHS2014.

6. 34 facilities providing 24/7 inpatient service
Legend G
FBO
Military
Private
Public
Newborns needing care
<200
>
>700

7. What is the need for neonatal inpatient care?
Using population projections to 2015 we estimate the need for INC services during study period (mid-2014 to mid-2015) = 21,966
18% of all live births will require inpatient newborn care
12,202 admissions were registered across 31 facilities in the same period

8. Where is inpatient neonatal care (INC) provided?
34 facilities
1 excluded & 2 declined
 31 participated (30 with maternity)
Define INC; Registers for one year and structural assessment
Just 5 facilities = 84% of admissions
Range of settings: discrete NBU v room on maternity
A: Facilities providing 24/7 inpatient newborn services (INC facilities) in Nairobi City County.
B: Annual (1st July 2014 – 30th June 2015) admissions among 31 INC facilities.
C: Cost of one overnight accommodation in a newborn unit (NBU) across 28 INC facilities.
D: Percentage occupancy of NBUs across 29 INC facilities.

9. Summary structure score per facility

10. Summary process score per facility

11. Knowledge scores
Here scores for sets of questions. Also explored these by level of training and whether nurses were dedicated or not.

12. What is the quality of care of provided?

13. What quality of care is being accessed?

14. Relationship between summary process score and structural capacity score
Bubble size= patient volume
Blue=public
Orange=mission
Yellow=private
Note that the x- and y-axes do not begin at zero.

15. EFFECTIVE COVERAGE
Low quality:
process ≤0.5 or structure <80 or knowledge ≤0.6
High quality:
process >0.6 and structure ≥80 and knowledge >0.8
Quality of care received by all babies estimated requiring inpatient care

16. Almost 1 in 5 live births requires inpatient neonatal care in NCC
There is poor effective coverage of essential inpatient neonatal services with barriers to care being:
Inadequate provision - about 45% on newborns have no access
Quality – only 25% of newborns access high quality care
Cost - only 4 public health facilities
Physical barriers – maldistribution of facilities with need
Improving neonatal care requires an expansion of appropriate human resources for health but also improvement on the availability of resources and quality provision
To Improve access to high quality for all and especially the poor, the county should consider
Upgrading some facilities to provide standard of care category neonatal care
Strengthening existing hospitals to reliably provide intermediate category of care
Establish a country wide referral strategy and system

17. Health Services that Deliver for Newborns
Stakeholder engagement and dissemination
Ministry of Health
Nairobi City County
Chief nursing officer
Nursing Council of Kenya
National Nurses Association of Kenya
Universities and training institutions
Hospital managers
Neonatal nurses
They are very engaged. Everyone knows that there is a problem with newborns services but there is an increasing feeling that you need to bring evidence in your argument to have resources and focus to your issue. It starts a dialogue and shows where changes could be made.

18. Funders:
Joint Health Systems Research Initiative
Wellcome Trust
MRC
UKAID
ESRC
KEMRI-Wellcome Trust team
Nurses Expert Group
HSD-N Advisory Group
Participating hospitals
Mothers and Nurses that consented to the study