Background: In 2017, the Ministry of Health in Gaza introduced Early Essential Newborn Care (EENC) as its primary maternal and neonatal care strategy. EENC comprises a package of simple evidence-based interventions that are delivered during labour and delivery, and in the early post-partum period, to prevent or treat the most important causes of morbidity and mortality in newborn babies. Four public maternity hospitals in Gaza, responsible for approximately 75% of all deliveries, began implementation of EENC in June, 2017. Clinical coaching was delivered by national facilitators over 2 days, and targeted all clinical staff in maternity and neonatal units. Subsequently, EENC quality improvement teams were formed to address contextual factors that influence practice. This study aimed to determine whether introduction of EENC resulted in changes in clinical practices for vaginal births.
Methods: A pre-intervention and post-intervention design was used to review key clinical practices before and after EENC introduction in the four hospitals. Trained data collection staff visited each hospital for 1 day in each of the months of March and June, 2017 (before EENC implementation), January and April, 2018 (in the early stages of EENC implementation), September, 2018, and June, 2019 (after full EENC implementation). Standard WHO data collection methods and tools were used to gather practice data using exit interviews and chart reviews of 10-15 randomly selected post-partum mothers who had delivered vaginally in the previous 2-24 h and had not experienced a newborn death or stillbirth. Delivery observations were conducted for five to ten randomly selected vaginal deliveries using a standard clinical skills observation checklist, beginning at the second stage of labour. The Ministry of Health in Gaza approved EENC assessments for programme use, and informed verbal consent was obtained before maternal interviews. No personal identifiers were used in assessments.
Findings: 259 maternal post-partum interviews and 139 observations of birth practices were done across the four maternity hospitals, representing 8·8% (259 of 2940) and 4·7% (139) of expected vaginal births during the observation periods, respectively. Comparing practices at baseline, early implementation, and after full implementation, significant trend improvements were noted for proportion of babies receiving thorough drying (0% [0 of 12], 49% [32 of 66], 72% [43 of 60], respectively, p<0·0004), immediate skin-to-skin contact (SSC) for less than 1 min (0% [0 of 14], 33% [43 of 127], 66% [72 of 110], p<0·0001), uninterrupted SSC for at least 60 min (0% [0 of 14], 21% [27 of 129], 48% [53 of 111], p<0·0001), uninterrupted SSC for at least 90 min (0% [0 of 14], 10% [13 of 129], 36% [39 of 110], p<0·0001), early breastfeeding (15-90 min after birth) (0% [0 of 15], 39% [50 of 130], 61% [65 of 107], p<0·0001), breastfeeding before separation (0% [0 of 15], 28% [36 of 131], 52% [56 of 108], p<0·0001), and exclusive breastfeeding before discharge (33% [5 of 15], 68% [89 of 131], 81% [87 of 107], p=0·0010). Average clinical practice scores rose from five of 42 (12%) to 16 of 42 (38%) and 24 of 42 (57%). Practice improvements were supported by updated clinical guidelines, hospital policies, and routines, by reorganisation of work, and by the provision of simple supplies, including gowns for mothers and caps for newborn babies.
Interpretation: The EENC clinical coaching approach coupled with regular self-assessments and action by hospital teams has significantly improved care practices during delivery and in the early post-partum period. It is possible that periodic cross-sectional practice reviews were not representative of routine practices, which may have varied with time of day, case load, and case complexity. Limitations were mitigated by assessing a systematic random sample of post-partum women delivering throughout the previous 24 h, and by measuring practices in two different time periods in each phase of implementation. Post-partum interviews were used to limit the Hawthorne effect. No other maternal or newborn initiatives were introduced during the study period, and no additional staff training was available, therefore the EENC approach was the primary influence on health worker practices.
Funding: Support for this work was provided by WHO, occupied Palestinian territory.
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