A post from the Stillbirth Advocacy Working Group stillbirths series by Alka Dev
In 1804, Haiti defeated its French colonizers to become the first Black nation to gain independence due to a large and successful slave rebellion. While the country was free to promote human rights, universal citizenship, and participation in government, development in Haiti has been a broad challenge. It has the highest neonatal mortality rate in the Latin America and Caribbean region; of every 1,000 livebirths, 32 babies Haitian babies die in the first month of life. A majority of Haitian women, especially rural women, deliver at home where there is no provision for emergency obstetrical or neonatal care.
For facility births, neonatal care services are not always available at high volume maternity wards. In August 2017, the Dartmouth College and GHESKIO Centers established the first neonatal ward at a tertiary care hospital in southern Haiti, serving a rural population of approximately 790,000 people. Staffed by two pediatricians and eight nurses, the ward has cared for over 1,200 neonates since its creation, including premature neonates, those with congenital malformations, sepsis, respiratory distress, and other perinatal complications. Funding was provided by the WK Kellogg Foundation and The Children’s Prize.
To improve quality of care, we set out to train our team in several neonatal care areas, beginning with a focus on neonatal resuscitation during the ‘golden minute’ of life using the Helping Babies Breathe (HBB) curriculum. Two Haitian pediatricians came to the Dartmouth-Hitchcock Medical Center for one month, attended daily neonatology rounds, and received one-on-one education sessions with our neonatologists, including a Master training on HBB.
The pediatricians next assisted with a nurses’ training in HBB in Haiti – focusing on both neonatal nurses and midwives. The training also included Essential Care for Every Baby and trained over 40 participants. This was a start but more was needed! As the neonatal ward began to admit more and more babies, we identified a need for continuing nursing education. We carried out an in-depth nursing skills assessment and identified several areas for improvement – first self-rated by the nurses and then discussed in small groups with nurses and expert trainers.
“I gave birth in the countryside and the fanm chay [birth attendant]
took the child and hung him over the fire. She always does that…
Every country has its customs, but now I do not practice this kind
of custom. When they are sick I take them to the hospital”
– Haitian mother in Port-au-Prince (2018)
Two neonatal nurses (one American and one Haitian) joined the team as trainers, helped to complete the nursing skills assessment, and developed the first set of trainings. Nurses told us that they were keen to learn a complete head-to-toe assessment and important steps to take during admission. They also identified jaundice as an important condition for further training as they were seeing quite some premature, jaundiced babies. For example, they did not know how to use the one phototherapy machine on the ward. During site visits, we also observed a sense of disorganization on the ward and explored their understanding of patient handoff and shift workflow. Informed by a complete list of their training needs and a better understanding of their workflow, we supplemented their HBB training with a 2-day session on head-to-toe assessment protocols, danger signs to look for at admission, taking vital signs, and organizing their workday. Handoff training using the I-PASS system as well as phototherapy training were also provided by a Dartmouth pediatric resident who rotated on the ward for a month.
Additionally, to support their workflow, we updated and improved medical charting tools such as shift notes to reduce repetitive writing tasks, ensure signoff on doctors’ orders, and make it easier to document nursing observations and carry out an effective handoff. Communication with parents was also a focus so that nursing duties could be carried out with parents’ participation. Hand washing before handling the baby was an urgent concern, so nurses were asked to take initiative in asking parents to wash their hands when entering the ward or handling the baby.
The training was so well received that we had requests from all pediatric nurses to include them in future trainings. Neonatal nurses reported an increase in confidence in working with premature neonates and pediatricians noted better quality of care, communication with nurses, and lower mortality after the training. Unfortunately, due to political unrest and the eventual end of our grants, we were not able to continue with the next set of trainings and we are actively seeking funding to carry out four additional trainings. All of our materials are developed in English and French and will be available free of charge.
Nurses are essential to high quality of care in a clinical setting and we found that investing in our neonatal nurses was a layered and urgent part of our program. Nurses are the only staff who are with the patients and families 24h per day and can be trained to identify and manage potential problems, especially if a doctor is not immediately available. We found that beyond HBB, nurses who care of neonates in a hospital setting need targeted trainings on a number of complications and interventions that should be prioritized on neonatal wards.
The Stillbirth Advocacy Working Group was founded by the Partnership for Maternal, Newborn and Child Health, and is co-chaired by the International Stillbirth Alliance and the London School of Hygiene & Tropical Medicine. Email co-chairs Hannah Blencowe or Susannah Leisher at firstname.lastname@example.org or email@example.com to learn more, or sign up to join the group here!