A rapid assessment of the quality of neonatal healthcare in Kilimanjaro region, northeast Tanzania

The World Health Organization estimates that 4 million children under 1 month of age die each year [1, 2] and more than 90% of these deaths occur in developing countries [3, 4]. Neonatal mortality rates have remained high despite a decline of infant mortality rates [5]. The highest neonatal mortality rates are documented in sub-Saharan Africa [1, 6–9]. Tanzania is among the five countries in sub-Saharan Africa recording the highest neonatal mortality rates, [8, 10] with birth asphyxia, prematurity and infection as prime causes, all of which are preventable [11].

The relative lack of progress in reducing neonatal mortality may be at least in part due to a gap between national or international standards of good care of neonates and the actual delivery of care health facilities [12–14]. However, the lack of quantitative and qualitative data, including an absence of stable and accurate vital registration systems [15–18] and retrieval systems, constitute constraints in making a useful judgment of the quality of care [10, 19].

A study conducted in 2002 in the Kilimanjaro region of Tanzania found that only one-third of all inpatientdeaths were properly documented in the case notes, and the cause of death could only be determined in 38% of the these [20]. Most of the neonatal deaths in northern Tanzania are preventable, [21, 22] and an audit of records in a Dar es Salaam teaching hospital showed quality neonatal care was often suboptimal even within the context of available resources [23].

This study aimed to provide an overview of the quality of neonatal health care in district hospitals and health centres offering obstetric services in the Kilimanjaro region in north-eastern Tanzania. We anticipate that the results may suggest priority areas for improvement of neonatal care nationally and in sub-Saharan Africa generally.

The study was conducted in Kilimanjaro region of north-eastern Tanzania where data were collected from the northern zonal referral hospital and 13 referring peripheral hospitals by a purposive sampling technique. Of the 13 peripheral facilities included, 1 was the Kilimanjaro regional hospital, 4 were government-supported district hospitals, 6 were missionary-supported hospitals designated as district hospitals, and 2 were health centres with inpatient facilities servingurban Moshi’s two largest wards. Each health care facility was visited unannounced and data were collected in a single day or at most over two days.

In each facility, staffing numbers were recorded from nationally standardized system i.e. Health Management Information Systems (HMIS), used for collection of data regarding health care workers in Tanzania; these data were verified in discussion with senior administrative staff in each hospital. Vital registration records and antenatal cards, records care and referral records were reviewed at each facility as well as at the zonal referral hospital from 26^th November, 2010 to 25^th April, 2011.

Maternity and paediatric wards were inspected for the presence of basic supplies and equipment using a pre-prepared standard check-list. In addition, health workers were requested, again using a standardized list, to estimate the availability of essential supplies in terms of the number of months per year a supply was typically available. In each hospital the senior nurse or clinician who was present in each of the relevant paediatric or maternity wards was asked to identify any neonate less than or equal to 30 days of age currently on the ward who had been admitted or retained post-delivery for a medical problem, including prematurity. In each case, the record of the last menstrual period (LMP) as recorded on the antenatal card was used to calculate gestational age. The case notes were inspected and standard informationwas extracted regarding the presence or absence of a list of 13 features judged to be essential to the record of a sick neonate, as shown in Figure 1. A record of Rh factorand blood group, syphilis and HIV screening, APGAR score and birth weight were extracted from all antenatal cards.

Care of neonates in Kilimanjaro region is characterized by poor documentation and a lack of common systems for documentation across facilities; in addition many of our findings suggest substandard care even within the context of available resources. These findings are apparently similar to those in Kenya [26] and those found among older children in the same region [14]. While the neonatal mortality rates recorded at these facilities are lower than what might be expected given the conditions, the high mortality rate at the zonal referral hospital raises concern since many high risk women and neonates are transferred there.Substantial discrepancies noted between recorded referrals to thezonal referralhospital and records of received neonates at the zonal referral hospital demonstrate some of the challenges faced inhealth systems management, evaluation process and outcome of care.

One of our findings was the lack of a universal system for recording medical assessments and care provided to sick neonates, aside from the antenatal care card, which has very limited space for such evaluations. Neonatal care records were often difficult to locate and information provided within them was scant, with key diagnoses such as prematurity notably lacking in a substantial proportion of cases. Although absence of a record does not imply absence of examination, a poor record of care inevitably damages prospects for good continuity of care between staff and local systematic audits are difficult to perform. This is particularly important in neonatal care where clinical states change rapidly. Given the complexities that are unique to the care of neonates (high likelihood of hypothermia, hypoglycaemia, differences in “cut-off” for empiric antibiotics in the case of fever, need for different types of intravenous fluids), the availability of standard care forms which guide health care workers through the process of a typical neonatal admission could prove useful.

The fact that birth weight was missing from nearly one-fifth of universally filled antenatal cardsindicates poor motivation and/or oversight of clinical staff attending neonates delivered in health facilities. In addition to poor documentation, evidence of suboptimal care was prevalent. Incorrect dosing of antibiotics occurred in a substantial proportion of cases. Improbable diagnoses such as “gastroenteritis” were found on more than one occasion in chart notes, the latter being a highly unlikely diagnosis in neonates, especially in this setting where exclusive breastfeeding is almost universal through the neonatal period of one month; this is concerning since feeding intolerance and vomiting at this age could portend a much more serious diagnosis such as trachea-oesophageal fistula. The notably higher proportion of antenatal cards with HIV test results compared with other test results suggests that training, motivation, and efforts to make tests kits available on the ground can result in improved performance; there have been concerted efforts to promote prevention of maternal to child transmission in Kilimanjaro in recent years with highly successful results [27].

Missing laboratory tests, such as blood group and Rh factor in mothers and bilirubin in neonates is likely explained by lack of assay availability in many cases. The absence of anything beyond the most basic laboratory facilities at most of the hospitals in this study prevents proper diagnosis and management of key frequently encountered conditions. Since prematurity and infections contributed to most of the hospitalizations, availability of blood culture systems and measurement of full blood picture are critical to appropriate management of these neonates, but most often unavailable [28–30].

However, we showed that even when supplies and diagnostics are available, they are not utilized appropriately, as in the case of glucometers, oxygen and intravenous fluids. The relative lack of expertise in neonatal care almost certainly contributes to these challenges; WISN for nurses tended to be high, but for clinicians was much lower, indicating a need for more specialized training in this area [31]. Similar lack of expertise in managing antenatal care as well as in managing sick children in hospital has previously been documented in Tanzania [14, 32–35]; therefore it may not be surprising that neonatal care faces similar challenges.

While declines in child mortality rates in sub-Saharan Africa are encouraging, these declines are likely to stagnate if quality of neonatal care is not addressed. Achieving MDG 4 remains a challenging task in rural Tanzania, [36, 37] and sub-Saharan Africa [38]. Over the last 5 years declines in infant and child mortality rates have stagnated [39, 40]. Our data demonstrate that improvements will need to cover several areas, but that better care may be delivered even within the confines of currently available staff and equipment if there are improvements in training, motivation and standard operating procedures/guidelines to address key issues in neonatal care.

Documentation of care for sick neonates hospitalized in peripheral health facilities in Kilimanjaro demonstrates significant deficits in areas which could have major health implications, not only for infant outcomes but also for program assessment and planning. Lack of regular auditing, few highly trained staff,and low availability of equipment and laboratory facilities all contribute to these challenges.

BM is a Tanzanian medical doctor and clinical researcher at Kilimanjaro Clinical Research Institute of Kilimanjaro Christian Medical Centre, Moshi Tanzania. HR is faculty at the London school of Hygiene and Tropical Medicine and he is a project leader at the Joint Malaria Programme in Moshi, Tanzania. He was the organiser and the overall supervisor for proposal writing and report designs. ER is a paediatrician, internist and researcher who directs collaborative research programs between Duke University and Kilimanjaro Christian Medical Centre.