Scaling up Ghana's national newborn care initiative: integrating 'helping babies breathe' (HBB), 'essential care for every baby' (ECEB), and newborn 'infection prevention' (IP) trainings.

BACKGROUND: Responding to stagnating neonatal mortality rates in Ghana, a five-year collaboration called Making Every Baby Count Initiative (MEBCI) was undertaken to improve the quality of newborn care provided around the time of birth. A multi-pronged approach was used to build health worker (HW) capacity in resuscitation, essential newborn care, and infection prevention using a curriculum built on the American Academy of Pediatric's (AAP) Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) modules with an added section on infection prevention (IP). METHODS: MEBCI used a training of trainer's approach to train 3688 health workers from district-level facilities in four regions in Ghana between June 2015 and July 2017. Prior to training, HWs familiarized themselves with the learning materials. Concurrently, MEBCI worked to improve enabling environments that would sustain the increased capacity of trained health workers. Knowledge and skills gained were tested using AAP's Knowledge checklist and validated single-scenario Objective Structured Clinical Examinations (OSCEs) tools. FINDINGS: Majority of HWs trained were midwives (58.8%) and came from district-level hospitals (88.4%). Most HWs passed the HBB OSCE (99.9%, 3436/3440). Age of doctors was negatively associated with HBB scores (r = - 0.16, p = 0.0312). Similarly, older midwives had lower HBB scores (r = - 0.33, p value < 0.001). Initiating ventilation within the Golden Minute was challenging for HWs (78.5% passed) across all regions. Overall, the pass rate for ECEB OSCEs was 99.9% in all regions. Classify newborn for further care and communicate plan to family were frequent challenges observed in Volta Region (69.5% and 72.0% pass rate respectively). HWs less than 40 years of age performed significantly better than health workers older than 40 years (p = 0.023). Age of only paediatricians was positively associated with ECEB scores (r = 0.77, p < 0.001) while age of midwives was negatively associated with ECEB scores (r = - 0.08, p < 0.001). CONCLUSION: MEBCI's integrated HBB-ECEB-IP training resulted in significant mastery of the clinical knowledge and skills of HWs. Harmonization and standardization of the course delivery by trainers and having a core team to ensure training fidelity are essential to maintaining high quality while scaling a program nationally. FUNDING: Children's Investment Fund Foundation (CIFF).

Evaluating a novel neonatal-care assessment tool among trained delivery attendants in a resource-limited setting.

OBJECTIVE: To validate a novel objective structured clinical examination (OSCE) tool for assessing neonatal care skills among delivery attendants trained as part of the Essential Care for Every Baby (ECEB) program and to assess ECEB training effectiveness. METHODS: Between August 1 and September 30, 2015, a cross-sectional study enrolled ECEB-trained healthcare providers who attended deliveries from the Brong Ahafo and Eastern regions of Ghana. Participants completed a previously developed 21-item OSCE tool that assessed neonatal-care competency. Participant performance was scored independently by regional trainers and national master trainers. The inter-rater scoring reliability was assessed using the Cohen kappa coefficient and performance was compared across participant characteristics. RESULTS: The study enrolled 57 trained delivery attendants from 12 district hospitals. Inter-rater agreement was perfect (kappa 1.00) or almost perfect (kappa 0.81-0.99) for nine OSCE items, substantial (kappa 0.61-0.80) or moderate (kappa 0.41-0.60) for 11 items, and fair (kappa 0.21-0.40) for one item. Differences in OSCE-item performance were recorded based on participants' regions, facility type, age, and education level (P<0.05). CONCLUSIONS: In a resource-limited setting, the OSCE tool demonstrated substantial reliability and ECEB-trained healthcare practitioners exhibited satisfactory performance. The OSCE tool could be useful in similar settings and could have potential for up-scaled use in assessing neonatal-management skills.

Oxytocin in Uniject Disposable Auto-Disable Injection System versus Standard Use for the Prevention of Postpartum Hemorrhage in Latin America and the Caribbean: A Cost-Effectiveness Analysis.

Postpartum hemorrhage (PPH) is a leading cause of maternal death. Despite strong evidence showing the efficacy of routine oxytocin in preventing PPH, the proportion of women receiving it after delivery is still below 100%. The Uniject injection system prefilled with oxytocin (Uniject) has the potential advantage, due to its ease of use, to increase oxytocin utilization rates. We aimed to assess its cost-effectiveness in Latin America and the Caribbean (LAC). We used an epidemiological model to estimate: a) the impact of replacing oxytocin in ampoules with Uniject on the incidence of PPH, quality-adjusted life years (QALYs) and costs from a health care system perspective, and b) the minimum increment in oxytocin utilization rates required to make Uniject a cost-effective strategy. A consensus panel of LAC experts was convened to quantify the expected increase in oxytocin rates as a consequence of making Uniject available. Deterministic and probabilistic sensitivity analyses were performed. In the base case, the incremental cost of Uniject with respect to oxytocin in ampoules was estimated to be USD 1.00 (2013 US dollars). In the cost-effectiveness analysis, Uniject ranged from being cost-saving (in 8 out of 30 countries) to having an incremental cost-effectiveness ratio (ICER) of USD 8,990 per QALY gained. In most countries these ICERs were below one GDP per capita. The minimum required increment in oxytocin rates to make Uniject a cost-effective strategy ranged from 1.3% in Suriname to 16.2% in Haiti. Switching to Uniject could prevent more than 40,000 PPH events annually in LAC. Uniject was cost-saving or very cost-effective in almost all countries. Even if countries can achieve only small increases in oxytocin rates by incorporating Uniject, this strategy could be considered a highly efficient use of resources. These results were robust in the sensitivity analysis under a wide range of assumptions.

Building alliances for improving newborn health in Latin America and the Caribbean.

The regional Latin American and Caribbean (LAC) Neonatal Alliance and national neonatal alliances in Bolivia, El Salvador, and Peru were studied through in-depth interviews and a review of publications. Findings were analyzed to distill successful strategies, structures, and tools for improving neonatal health by working through alliances that can be replicated at the regional or national level. The studies found the following factors were the most critical for successful outcomes from alliance work: inclusion of the Ministry of Health as a leader or primary stakeholder; a committed, diverse, technically expert, and horizontal membership; the presence of champions for neonatal health at the national level; development of a shared work plan based on feasible objectives; the use of shared financing mechanisms; the use of informal and dynamic organizational structures; and a commitment to scientific evidence-based programming. The relationship between the regional and national alliances was found to be mutually beneficial.

Building alliances for improving newborn health in Latin America and the Caribbean / Alianzas para mejorar la salud de los recién nacidos en América Latina y el Caribe

The regional Latin American and Caribbean (LAC) Neonatal Alliance and national neonatal alliances in Bolivia, El Salvador, and Peru were studied through in-depth interviews and a review of publications. Findings were analyzed to distill successful strategies, structures, and tools for improving neonatal health by working through alliances that can be replicated at the regional or national level. The studies found the following factors were the most critical for successful outcomes from alliance work: inclusion of the Ministry of Health as a leader or primary stakeholder; a committed, diverse, technically expert, and horizontal membership; the presence of champions for neonatal health at the national level; development of a shared work plan based on feasible objectives; the use of shared financing mechanisms; the use of informal and dynamic organizational structures; and a commitment to scientific evidence-based programming. The relationship between the regional and national alliances was found to be mutually beneficial.

Se estudiaron la Alianza de Salud Neonatal para América Latina y el Caribe a escala regional, y las alianzas nacionales de salud neonatal de Bolivia, El Salvador y Perú, mediante entrevistas exhaustivas y un análisis de las publicaciones. Se analizaron los resultados para extraer las estrategias, las estructuras y las herramientas eficaces para mejorar la salud neonatal trabajando mediante alianzas que puedan repetirse a escala regional o nacional. Los estudios descubrieron que los factores más decisivos para obtener resultados exitosos del trabajo mediante alianzas fueron los siguientes: la inclusión de los ministerios de salud como líderes o interesados directos principales; una afiliación comprometida, diversa, técnicamente experta y horizontal; la presencia de promotores de la salud neonatal a escala nacional; la formulación de un plan de trabajo compartido basado en objetivos factibles; la utilización de mecanismos de financiamiento compartido; el uso de estructuras organizativas informales y dinámicas; y un compromiso con la programación científica basada en datos probatorios. Se observó que la relación entre las alianzas regionales y nacionales resultaba mutuamente beneficiosa.

Economic evaluation of oxytocin in uniject injection system versus standard use of oxytocin for the prevention of postpartum hemorrhage in the active management of the third stage of labor in Latin America and the Caribbean

BACKGROUND: Postpartum hemorrhage (PPH) is a leading cause of maternal death. Despite strong evidence showing the efficacy of oxytocin in preventing PPH, use of the drug for this purpose remains suboptimal. The Uniject injection system prefilled with oxytocin (OiU) has the potential advantage, due to its ease of use, to increase oxytocin coverage rates (OCR). OBJECTIVES: To evaluate the cost-effectiveness of OiU in Latin America and the Caribbean (LAC). METHODS: An epidemiological model was built to estimate the impact of replacing oxytocin in ampoules with OiU on the incidence of PPH, quality-adjusted life years (QALYs), and costs, from a health care perspective. A systematic search for data on epidemiology and cost studies was undertaken. A consensus panel among LAC experts was performed to quantify the expected increase in OCR as a consequence of making OiU available. Deterministic and probabilistic sensitivity analyses were performed. RESULTS In the threshold analysis the minimum required increment in the OCR to make OiU a costeffective strategy ranged from 1.3% in Suriname to 15.8% in Haiti. In more than 60% of the countries, the required increment was below 5%. OiU could prevent more than 40,000 PPH episodes annually in LAC. In 27% of the countries, OiU was found to be cost saving. In the remaining 22 countries, OiU was associated with a net cost increment (0.005 to 0.847 2013 US dollars per delivery). OiU strategy ranged from being dominant to having an incremental costeffectiveness ratio (ICER) of US$ 8,990 per QALY gained. In the great majority of countries these ICERs were below one GDP per capita. CONCLUSIONS OiU was cost-saving or very cost-effective in almost all countries. Even if countries can achieve only small increases in OCR by incorporating OiU, this strategy could be considered an efficient use of resources. These results were robust in the sensitivity analysis under a wide range of assumptions and scenarios. (AU)