Improving the quality of health facility care for neonates in low- and middle-income countries.

The neonatal period (1–28 days) encompasses the newborn’s transition to independent extra-uterine life. Rapid adaptations in immune, physiological and biochemical functioning occur during this time, as the infant is exposed to multiple environmental influences. The infant is most vulnerable and dependent during these weeks, and this is also a critical period for postnatal intervention and nutritional programming [1]. There has been slow improvement in rates of neonatal mortality despite major reductions in overall child mortality in lowand middleincome countries. Just <4 million infants die each year before reaching 1 month of age, and neonatal deaths now account for 38% of the 10.9 million deaths among children aged <5 years [2]. Tackling neonatal mortality is essential if the fourth millennium development goal to reduce by 2015 overall child mortality by two-thirds from its levels in 1990 is to be achieved. Neonatal mortality rates are likely to remain static at just >40% for the period to 2015 unless there are significant changes in child health interventions and policies. The lack of progress in reducing neonatal mortality is largely because of the difficulties in reducing early neonatal mortality rates. Global reports from 1980 indicated that only 23% of all deaths in children aged <5 years arose in the first week of life; by the year 2000, this figure had risen to an estimated 38% (3 million deaths) [3]. Reducing early neonatal mortality requires both communityand facility-driven approaches, including improving access to health facilities and improving the quality of health service provider care. There has been much work on indicators to measure the effectiveness and quality of health facility obstetric care [4, 5]. A World Health Organization (WHO) publication in 1997 ‘Guidelines for monitoring the availability and use of obstetric services’ [4], described key interventions to manage the main causes of maternal mortality (haemorrhage, hypertensive diseases of pregnancy, sepsis, obstructed labour and unsafe abortion). This document described the need for quality emergency obstetric care (EmOC), which was subdivided into basic and comprehensive. A facility that provided basic EmOC was defined as one that could provide parenteral antibiotics, parenteral oxytocic drugs, parenteral anticonvulsants, manual removal of placenta, removal of retained products and assisted vaginal delivery. This was generally provided in a health centre staffed by midwives without the assistance of a medical practitioner. A comprehensive EmOC facility was defined as a facility that could provide all basic interventions but also Caesarean section and blood transfusion. This was generally considered to be a district, regional or tertiary hospital and required staffing by midwives and medical practitioners. The WHO work led to the development of EmOC indicators (commonly called signal functions) for both basic and comprehensive facility functioning. They were thought to reflect responsiveness of the health services to the main obstetric complications at basic and comprehensive level [4, 5]. There have been attempts to develop similar indicators of the ability of health facilities to provide emergency care newborn care, but no indicators have been widely agreed for newborns, except for newborn resuscitation [4, 6]. In mid 2012, new indicators to measure the ability of health facilities to provide routine and emergency neonatal care were proposed and published (Table 1) [7]. These indicators were developed after an extensive systematic review of published and unpublished literature and a Delphi consensus approach involving 39 international experts. The authors (Gabrysch, et al.) concluded that these routine and emergency neonatal care indicators should be collected in future country-level facility assessments, and that they should be used to set and test benchmarks for routine and emergency neonatal care provision. However, evaluating quality of care in health facilities involves the assessment of many different components. Quality of care can be defined as the quality of the interaction between the individual and the health systems’ attributes [8]. It does require consideration of organizational implementation, but it also requires understanding of the processes of care, the training of health service providers and the effects on health outcomes [8]. It includes contributions from the organizers of care, processes of care, practitioners and clients [9]. Gabrysch, et al. do state it is important to understand staffing levels, work load and the provision of supplies and drugs in health centres and hospitals [7]. However, more studies are urgently needed that focus on the optimal methods of improving neonatal health service provider skills and whether these interventions improve health outcomes. Recent studies from Kenya [10, 11] are excellent examples, but more studies are needed from other countries and regions with different organizational structures. JOURNAL OF TROPICAL PEDIATRICS, VOL. 59, NO. 2, 2013