Figures & Tables
Figures
- FIGURE.
All Babies Count Initiative Design Implemented in 2 Districts in Rwanda
Abbreviations: ABC, All Babies Count; LS, learning session; MOH, Ministry of Health; QI, quality improvement.
Tables
- TABLE 1.
Selection of Maternal and Newborn Health Core Improvement Collaborative Indicators and Outcome Measures Used in Evaluating an All Babies Count Initiative Implemented in Rwanda
Indicator Numerator Denominator Data Source Facility Antenatal carea 1. ANC standard 4 visit coverage Number of women who delivered in a HF who had 4 ANC visits Total number of health facility deliveries PLUS total number of referrals of laboring women from HC to hospital PLUS home deliveries HMIS HCs Delivery services 2. Percentage of pregnant women with facility delivery Total number of health facility deliveries Total number of home deliveries PLUS total number of health facility deliveries Community HMIS HCs 3. Time to cesarean delivery for emergency (from determination of need at hospital to time of delivery) Average time to cesarean delivery for emergency (from determination of need by doctor at hospital to time of cesarean delivery incision) Chart reviewb Hospital 4. Antenatal steroids for preterm labor Number of women with preterm labor <34 weeks treated with dexamethasone Number of women with preterm labor (<34 weeks) Chart review Hospital (HCs added later) Postnatal care 5. Percentage of babies with immediate skin-to-skin after delivery Number of babies placed immediately skin to skin Number of babies born vaginally Chart review HCs and hospital 6. Danger sign assessment within 24 hours Newborns checked for danger signs in postpartum ward within 24 hours Total deliveries MINUS stillbirths macerated MINUS stillbirths fresh MINUS death at birth of live born babies HMIS HC and hospitals Outcome 7. Neonatal unit case fatality Number of deaths in neonatal unit (<28 days) Number of admissions to neonatal unit (<28 days) Chart review Hospital 8. District-wide neonatal mortality HMIS neonatal deaths PLUS death at birth of live born babies PLUS number of neonatal deaths at community Live births PLUS number of home deliveries HMIS HCs and hospital 9. Facility neonatal mortality among preterm/LBWc Hospital deaths due to prematurity PLUS HC deaths due to prematurity Hospital LBW/non-preterm PLUS hospital preterm PLUS HC LBW/non-preterm PLUS HC preterm HMIS HCs and hospital 10. Facility neonatal mortality among non-preterm/LBWd Hospital deaths of all causes except prematurity PLUS HC deaths of all causes except prematurity Hospital and HC live births MINUS (hospital LBW/non-preterm PLUS hospital preterm PLUS HC LBW/non-preterm PLUS HC preterm) HMIS HCs and hospitals 11. Facility stillbirths (macerated and fresh)c Stillbirths macerated PLUS stillbirths fresh Total deliveries HMIS HCs and hospital Abbreviations: ANC, antenatal care; HC, health center; HF, health facility; HMIS, health management information system; LBW, low birth weight.
↵a Rwinkwavu health center did not have delivery services, so the denominator was changed to number of community HMIS health facility deliveries at district hospital plus number of community HMIS home deliveries.
↵b Chart review indicators were newly introduced at the start of the intervention.
↵c Prematurity defined as gestational age ≤37 weeks, and low birth weight defined as birth weight < 2500 g per World Health Organization standard definition.
↵d Stillbirths defined in national HMIS data dictionary as a baby born with no signs of life at or after 22 weeks gestation and with birth weight greater than or equal to 500 g. Stillbirth analysis restricted to facility level given the absence of community-based recording of stillbirths.
- TABLE 2.
Change in Maternal and Newborn Health Quality of Care Indicators in All Babies Count Initiative Implemented in 2 Districts in Rwanda
Indicator Aggregate South Kayonza Kirehe Baseline Endpoint P Value Median Difference (IQR) Baseline Endpoint P Value Baseline Endpoint P Value Median (IQR) Median (IQR) Median (IQR) Median (IQR) Median (IQR) Median (IQR) 1. Percentage of deliveries where mothers had 4 standard ANC visits 13.7
(6.7, 44.2)30.4
(15.1, 43.1).04 13.6
(−3.3, 26.4)42.4
(19.9, 47.3)36.4
(13.5, 66.3).78 10.2
(2.8–26.8)29.6
(18–34.2).02 2. Percentage of pregnant women delivering in facilities 89.6
(86.3, 94.9)92.6
(86.8, 95.8).25 7.8
(−2.8, 5.1)92.2
(87.2, 95.3)95.2
(93.0, 96.3).33 88.4
(86.3–96.7)91.0
(86.2–94.6).36 3. Percentage of babies who are provided immediate skin-to-skin after birth 53.6
(0, 80.9)97.4
(96.4, 99.3)<.001 43.6
(17.7, 95.7)91.2
(75.9, 100)99.6
(96.7, 100).18 4.3
(0, 53.6)97.2
(96.1, 98.8)<.001 4. Percentage of newborns checked for danger signs within 24 hours of birth 46.6
(31.1, 96.7)98.7
(96.4, 100)<.001 47.7
(−1.4, 67.1)52.3
(33.8, 98.6)100
(93.8, 100).06 45.7
(15.8, 82.1)98.6
(97.4, 98.8).003 5. Average hospital time to emergency cesarean delivery (minutes) 167 50 — 82 61 — 6. Percentage of women with preterm labor who are treated with antenatal steroids 0
(0, 0)41.7
(0, 100).32 — 0
(0, 0)16.7
(0, 33.3)— 0
(0–0)75
(0, 100).32 7. Percentage of facilities with at least 2 MNH clinically trained staff 100 100 — 15.1
(4, 29.8)100 100 — 100 100 — 8. Percent availability of essential medications for MNH care 61.2
(45.0, 77.8)81.8
(72.7, 81.8)<.001 31.2
(19.5, 37.8)35.0
(25.0, 45.0)83.3
(75.0, 87.5).01 66.7
(55.6, 77.8)77.8
(72.7, 81.8).05 9. Percent availability of functioning equipment essential for MNH care 55.6
(48.2, 61.1)86.6
(77.8, 88.9)<.001 — 55.6
(47.2, 56.6)88.9
(88.9, 94.4).01 55.6
(48.2, 63.9)81.1
(77.8, 88.6)<.001 10. Patient satisfactiona: average satisfaction with ANC — — — — 2.8
(SD: 1.57)3.1
(SD: 1.53).11 3.3
(SD: 1.62)3.6
(SD: 1.52).01 11. Patient satisfaction: average satisfaction with maternity care — — — — 2.4
(SD: 1.67)2.3
(SD: 1.160.95 3.5
(SD: 1.59)3.4
(SD: 1.52).61 Abbreviations: ANC, antenatal care; IQR, interquartile range; MNH, maternal and newborn health; SD, standard deviation.
↵a Patient satisfaction scores on a Likert scale: 1=excellent; 2=very good; 3=good; 4=fair; 5=poor.
- TABLE 3.
Change in Neonatal Mortality Across 2 Districts in Rwanda Where All Babies Count Initiative Was Implemented
Indicator Baseline Endpoint aOR (95% CI)a Neonatal mortality (deaths/1,000 live births) Aggregate 30.1 (103/3,426) 19.6 (57/2,902) 0.54 (0.36, 0.83) Southern Kayonza 35.4 (55/1,553) 18.5 (24/1,295) Kirehe 25.6 (48/1,873) 20.5 (33/1,607) Facility neonatal deaths in preterm infants/1,000 preterm and LBW live births Aggregate 198.8 (32/161) 100.6 (18/179) 0.47 (0.25, 0.90) Southern Kayonza 290.3 (18/62) 134.3 (9/67) Kirehe 141.4 (14/99) 80.4 (9/112) Facility neonatal deaths in non-preterm babies/1,000 non-preterm and LBW live births in district Aggregate 10.4 (36/3,446) 7.5 (24/3,181) 0.60 (0.36, 1.02) Southern Kayonza 7.9 (11/1,387) 5.9 (7/1,177) Kirehe 12.1 (25/2,059) 8.5 (17/2,004) Facility stillborn rate (macerated and fresh)/total per 1,000 births Aggregate 23.4 (84/3,590) 28.8 (99/3,436) Southern Kayonza 20.7 (29/1,398) 34.5 (44/1,274) 1.71 (1.06, 2.75) Kirehe 25.1 (55/2,192) 25.4 (55/2,162) 0.90 (0.61, 1.32) Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; LBW, low birth weight.
↵a Odds estimates from models stratified by district only provided if test for interaction between district and time in regression was statistically significant at 0.05 level.
- TABLE 4.
Change in Neonatal Mortality in All Babies Count Intervention Area in 2 Districts Compared With the Rest of Rural Rwanda
Pre-intervention (Deaths/1,000 Live Births) Post-intervention (Deaths/1,000 Live Births) Per 1,000 Change (1) Southern Kayonza/Kirehe (ABC) 30.1 (103/3,426) 19.6 (57/2,902) −10.4 Southern Kayonza 35.4 (55/1,553) 18.5 (24/1,295) Kirehe 25.6 (48/1,873) 20.5 (33/1,607) (2) Southern Kayonza/Kirehe (HMIS) 22.3 (87/3,896) 15.6 (59/3,785) −6.7 Southern Kayonza 28.7 25.3 Kirehe 18.3 10.7 (3) Rural Rwanda comparison districtsa 13.4 (834/62,382) 15.9 (958/60,225) 2.5 Difference Difference 1 − 3 −13.0 Difference 2 − 3 −9.2 Abbreviations: ABC, All Babies Count; HMIS, health management information system.
↵a Bugesera, Gakenke, Gatsibo, Gicumbi, Gisagara, Huye, Kamonyi, Karongi, Muhanga, Musanze, Ngoma, Ngororero, Nyabihu, Nyagatare, Nyamagabe, Nyamasheke, Nyanza, Nyaruguru, Rubavu, Ruhango, Rulindo, Rusizi, Rutsiro, Rwamagana Districts HMIS reported data.
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