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ORIGINAL ARTICLE
Open Access

The All Babies Count Initiative: Impact of a Health System Improvement Approach on Neonatal Care and Outcomes in Rwanda

Hema Magge, Evrard Nahimana, Jean Claude Mugunga, Fulgence Nkikabahizi, Elisabeth Tadiri, Felix Sayinzoga, Anatole Manzi, Merab Nyishime, Francois Biziyaremye, Hari Iyer, Bethany Hedt-Gauthier and Lisa R. Hirschhorn
Global Health: Science and Practice October 2020, 8(3):505-517; https://doi.org/10.9745/GHSP-D-20-00031
Hema Magge
aDivision of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, USA.
bDivision of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA.
cPartners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.
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  • For correspondence: Hema.magge@gmail.com
Evrard Nahimana
cPartners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.
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Jean Claude Mugunga
dPartners In Health, Boston, MA, USA.
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Fulgence Nkikabahizi
eMinistry of Health, Government of Rwanda, Kigali, Rwanda.
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Elisabeth Tadiri
fCenter for Global Health, Massachusetts General Hospital, Boston, MA, USA.
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Felix Sayinzoga
eMinistry of Health, Government of Rwanda, Kigali, Rwanda.
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Anatole Manzi
dPartners In Health, Boston, MA, USA.
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Merab Nyishime
cPartners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.
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Francois Biziyaremye
cPartners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.
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Hari Iyer
gDepartment of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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Bethany Hedt-Gauthier
hDepartment of Social Medicine, Harvard Medical School, Boston, MA, USA.
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Lisa R. Hirschhorn
iDepartment of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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    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.

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    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

    IndicatorNumeratorDenominatorData SourceFacility
    Antenatal carea1. ANC standard 4 visit coverageNumber of women who delivered in a HF who had 4 ANC visitsTotal number of health facility deliveries PLUS total number of referrals of laboring women from HC to hospital PLUS home deliveriesHMISHCs
    Delivery services2. Percentage of pregnant women with facility deliveryTotal number of health facility deliveriesTotal number of home deliveries PLUS total number of health facility deliveriesCommunity HMISHCs
    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 reviewbHospital
    4. Antenatal steroids for preterm laborNumber of women with preterm labor <34 weeks treated with dexamethasoneNumber of women with preterm labor (<34 weeks)Chart reviewHospital (HCs added later)
    Postnatal care5. Percentage of babies with immediate skin-to-skin after deliveryNumber of babies placed immediately skin to skinNumber of babies born vaginallyChart reviewHCs and hospital
    6. Danger sign assessment within 24 hoursNewborns checked for danger signs in postpartum ward within 24 hoursTotal deliveries MINUS stillbirths macerated MINUS stillbirths fresh MINUS death at birth of live born babiesHMISHC and hospitals
    Outcome7. Neonatal unit case fatalityNumber of deaths in neonatal unit (<28 days)Number of admissions to neonatal unit (<28 days)Chart reviewHospital
    8. District-wide neonatal mortalityHMIS neonatal deaths PLUS death at birth of live born babies PLUS number of neonatal deaths at communityLive births PLUS number of home deliveriesHMISHCs and hospital
    9. Facility neonatal mortality among preterm/LBWcHospital deaths due to prematurity PLUS HC deaths due to prematurityHospital LBW/non-preterm PLUS hospital preterm PLUS HC LBW/non-preterm PLUS HC pretermHMISHCs and hospital
    10. Facility neonatal mortality among non-preterm/LBWdHospital deaths of all causes except prematurity PLUS HC deaths of all causes except prematurityHospital and HC live births MINUS (hospital LBW/non-preterm PLUS hospital preterm PLUS HC LBW/non-preterm PLUS HC preterm)HMISHCs and hospitals
    11. Facility stillbirths (macerated and fresh)cStillbirths macerated PLUS stillbirths freshTotal deliveriesHMISHCs 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.

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    TABLE 2.

    Change in Maternal and Newborn Health Quality of Care Indicators in All Babies Count Initiative Implemented in 2 Districts in Rwanda

    IndicatorAggregateSouth KayonzaKirehe
    BaselineEndpointP ValueMedian Difference (IQR)BaselineEndpointP ValueBaselineEndpointP Value
    Median (IQR)Median (IQR)Median (IQR)Median (IQR)Median (IQR)Median (IQR)
    1. Percentage of deliveries where mothers had 4 standard ANC visits13.7
    (6.7, 44.2)
    30.4
    (15.1, 43.1)
    .0413.6
    (−3.3, 26.4)
    42.4
    (19.9, 47.3)
    36.4
    (13.5, 66.3)
    .7810.2
    (2.8–26.8)
    29.6
    (18–34.2)
    .02
    2. Percentage of pregnant women delivering in facilities89.6
    (86.3, 94.9)
    92.6
    (86.8, 95.8)
    .257.8
    (−2.8, 5.1)
    92.2
    (87.2, 95.3)
    95.2
    (93.0, 96.3)
    .3388.4
    (86.3–96.7)
    91.0
    (86.2–94.6)
    .36
    3. Percentage of babies who are provided immediate skin-to-skin after birth53.6
    (0, 80.9)
    97.4
    (96.4, 99.3)
    <.00143.6
    (17.7, 95.7)
    91.2
    (75.9, 100)
    99.6
    (96.7, 100)
    .184.3
    (0, 53.6)
    97.2
    (96.1, 98.8)
    <.001
    4. Percentage of newborns checked for danger signs within 24 hours of birth46.6
    (31.1, 96.7)
    98.7
    (96.4, 100)
    <.00147.7
    (−1.4, 67.1)
    52.3
    (33.8, 98.6)
    100
    (93.8, 100)
    .0645.7
    (15.8, 82.1)
    98.6
    (97.4, 98.8)
    .003
    5. Average hospital time to emergency cesarean delivery (minutes)16750—8261—
    6. Percentage of women with preterm labor who are treated with antenatal steroids0
    (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 staff100100—15.1
    (4, 29.8)
    100100—100100—
    8. Percent availability of essential medications for MNH care61.2
    (45.0, 77.8)
    81.8
    (72.7, 81.8)
    <.00131.2
    (19.5, 37.8)
    35.0
    (25.0, 45.0)
    83.3
    (75.0, 87.5)
    .0166.7
    (55.6, 77.8)
    77.8
    (72.7, 81.8)
    .05
    9. Percent availability of functioning equipment essential for MNH care55.6
    (48.2, 61.1)
    86.6
    (77.8, 88.9)
    <.001—55.6
    (47.2, 56.6)
    88.9
    (88.9, 94.4)
    .0155.6
    (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)
    .113.3
    (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
    .953.5
    (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.

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    TABLE 3.

    Change in Neonatal Mortality Across 2 Districts in Rwanda Where All Babies Count Initiative Was Implemented

    IndicatorBaselineEndpointaOR (95% CI)a
    Neonatal mortality (deaths/1,000 live births)
    Aggregate30.1 (103/3,426)19.6 (57/2,902)0.54 (0.36, 0.83)
    Southern Kayonza35.4 (55/1,553)18.5 (24/1,295)
    Kirehe25.6 (48/1,873)20.5 (33/1,607)
    Facility neonatal deaths in preterm infants/1,000 preterm and LBW live births
    Aggregate198.8 (32/161)100.6 (18/179)0.47 (0.25, 0.90)
    Southern Kayonza290.3 (18/62)134.3 (9/67)
    Kirehe141.4 (14/99)80.4 (9/112)
    Facility neonatal deaths in non-preterm babies/1,000 non-preterm and LBW live births in district
    Aggregate10.4 (36/3,446)7.5 (24/3,181)0.60 (0.36, 1.02)
    Southern Kayonza7.9 (11/1,387)5.9 (7/1,177)
    Kirehe12.1 (25/2,059)8.5 (17/2,004)
    Facility stillborn rate (macerated and fresh)/total per 1,000 births  
    Aggregate23.4 (84/3,590)28.8 (99/3,436)
    Southern Kayonza20.7 (29/1,398)34.5 (44/1,274)1.71 (1.06, 2.75)
    Kirehe25.1 (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.

    • View popup
    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 Kayonza35.4 (55/1,553)18.5 (24/1,295)
    Kirehe25.6 (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 Kayonza28.725.3
    Kirehe18.310.7
    (3) Rural Rwanda comparison districtsa13.4 (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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The All Babies Count Initiative: Impact of a Health System Improvement Approach on Neonatal Care and Outcomes in Rwanda
Hema Magge, Evrard Nahimana, Jean Claude Mugunga, Fulgence Nkikabahizi, Elisabeth Tadiri, Felix Sayinzoga, Anatole Manzi, Merab Nyishime, Francois Biziyaremye, Hari Iyer, Bethany Hedt-Gauthier, Lisa R. Hirschhorn
Global Health: Science and Practice Oct 2020, 8 (3) 505-517; DOI: 10.9745/GHSP-D-20-00031

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The All Babies Count Initiative: Impact of a Health System Improvement Approach on Neonatal Care and Outcomes in Rwanda
Hema Magge, Evrard Nahimana, Jean Claude Mugunga, Fulgence Nkikabahizi, Elisabeth Tadiri, Felix Sayinzoga, Anatole Manzi, Merab Nyishime, Francois Biziyaremye, Hari Iyer, Bethany Hedt-Gauthier, Lisa R. Hirschhorn
Global Health: Science and Practice Oct 2020, 8 (3) 505-517; DOI: 10.9745/GHSP-D-20-00031
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