‘All Babies Count’: Caring for Newborns in Rwanda

Photo: Partners in Health. Data Manager Jean Napal Manirahari, in the cream shirt, works with a small group, including a community health supervisor at Gashongora Health Center, at the recent training session.

“When you reduce child mortality, you increase life expectancy. We should therefore collaborate to ensure that no baby dies, because all babies count,” said Dr. Christian Rusangwa, the southern Kayonza district clinical director for Partners In Health’s Rwandan sister organization, Inshuti Mu Buzima (PIH/IMB).

Rusangwa delivered this remark during the initial session of the All Babies Count (ABC) Neonatal Learning Collaborative. In the language of Kinyarwanda, the ABC initiative is known as Impinja Ntizigapfe, which comes from a community folk song about a mother’s wish that no baby ever die.

Launched in October 2013, ABC is a collaboration between IMB and the Rwandan Ministry of Health to reduce the country’s neonatal death rate through training and mentorship, systems-strengthening initiatives, and quality improvement strategies. This holistic approach is creating change throughout the health care system, from the community to the hospital level. The program was first implemented in two rural Rwandan districts, with two district hospitals and 23 health centers serving approximately 500,000 people.

Although Rwanda has achieved unprecedented reductions in under 5 mortality and is on track to meet all health-related Millennium Development Goals, the neonatal death remains stubbornly high. In 2013 there were 20 neonatal deaths for every 1,000 live births in Rwanda, according to World Bank data. For comparison, the neonatal death rate in the U.S. is four of every 1,000 live births.

At one of the first two-day ABC learning sessions, Rusangwa urged the approximately 50 nurses, community health workers, data managers, and other health workers to do everything in their power to reduce the death rate as a team. The participants, who included nurses, data officers and community health supervisors, had come from PIH/IMB-supported Rwinkwavu District Hospital, as well as from eight other health centers.

In seminars and training sessions, participants discussed best practices and examined specific ways they can contribute to preventing needless newborn deaths. There was a strong emphasis on strengthening neonatal care processes such as bolstering antenatal care services, improving delivery management and post-natal care for all infants, with an emphasis on improving care for preterm infants and preventing birth asphyxia, two leading causes of neonatal deaths.

“We can change the health of our babies if we keep active, share knowledge and skills, and intensify our efforts to save babies by coming up with creative solutions from the real experts in this area—you as health care providers in the field every day in your communities,” Dr. Hema Magge, director of pediatrics at PIH/IMB, told the group. “We should utilize the chance to learn the best practices from this training and from one another. This will pay off in the long run.”

Virginia Uwingabire, a line manager in the pediatric unit at Rwinkwavu Hospital, said she picked up several new skills through the trainings and was eager, albeit a tad nervous, to apply the newfound tools in a clinical setting.

“We have learned so much that will enable us to save lives, but putting this into practice is the challenge,” Uwingabire said. “There is a need for commitment to put into action what is taught in the trainings. We also need continuous trainings to build our capacity and help us achieve our goal of saving babies.”

Fortunately, the ABC initiative was designed with that sentiment in mind. The skills taught in the classroom will be reinforced at the bedside through ongoing clinical mentorship and quality improvement coaching to help the teams implement their new ideas, measure the impact, and effect change. To further build capacity, future training sessions will focus on sharing lessons learned from each facility’s quality improvement efforts, communicating across levels of the health system to tackle issues such as transport and referrals, and provide clinical updates in topics such as essential newborn care and kangaroo mother care.

After nine months the program has yielded measurable results in the two districts it was first implemented. The percentage of newborns screened for danger signs within 24 hours of birth increased from 48 to 97 percent and immediate skin-to-skin care after delivery jumped from 11 to 81 percent.

Most importantly, district hospital case fatality has decreased significantly from 18% to 6% and district-wide neonatal mortality has dropped from 25.8 to 17.6 per 1000 live births in only nine months. Weaving individual clinical mentorship with systems-level quality-improvement initiatives has shown promising results, and discussions have begun regarding expansion and scale-up after the 18-month intensive phase is complete.

“Through supporting each other and learning from one another, we will surely reduce child mortality and save the lives of babies,” concluded Dr. Fulgence Nkikabahizi, the medical director of Rwinkwavu District Hospital.

Acknowledgements: The All Babies Count Initiative was supported in part by the Doris Duke Charitable Foundation African Health Initiative and the World Bank.

Dr. Hema Magge is director of pediatrics for Partners In Health/Rwanda.

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