Aiming to improve the quality of early essential newborn care (EENC) in Burkina Faso, Alive & Thrive has implemented a multi-pronged approach that is now being applied in a selected set of health facilities in the country’s Centre Nord Region.
“The Ministry of Health’s Family Health and Nutrition directorates solicited our support to implement quality improvement for EENC and lay the basis for Baby-Friendly Hospital Initiative (BFHI) norms and standards in Burkina after we shared findings of a rapid assessment and offered our support,” explained Maurice Zafimanjaka, country director of the Alive & Thrive program in Burkina Faso. “Despite a national protocol, newborn nutrition interventions, like counseling on the early initiation of breastfeeding and exclusive breastfeeding, delayed umbilical cord clamping and prolonged skin-to-skin contact were not being systematically delivered.”
The approach specifically focuses on integrating the 10 steps for successful breastfeeding into relevant national policies and standards of care; implementing a quality improvement process on a small scale in the Centre Nord Region; and then gathering evidence from the experience to develop a scaling-up plan. Alive & Thrive also supported the Ministry of Health to develop training modules, tools, and materials, including a training video on early essential newborn care for health facility personnel.
WATCH the training video here (IN FRENCH ONLY)
The approach began by assessing the integration of maternal and newborn nutrition services in the standards for improving quality of maternal and newborn care in health facilities.
“Ensuring maternal, infant and young child nutrition (MIYCN) is sufficiently covered in national guidelines is key to supporting optimal maternal, infant, and young child health and nutrition,” Zafimanjaka said. “We noticed that maternal and newborn nutrition concepts were not well developed in the draft Burkina Faso document on standards for improving the quality of maternal and neonatal care in health facilities as per WHO guidance, and successfully advocated for the reinforcement of maternal and newborn nutrition.”
A key element of the support has been ensuring health personnel have sufficient knowledge, competence, and skills to support newborn nutrition, including breastfeeding. Since launching the intervention in July, Alive & Thrive has supported the training of 262 health workers in maternal and newborn nutrition.
The health workers received training on newborn nutrition/early essential newborn care, including Kangaroo Mother Care and the provision of quality inter-personal communication (IPC), and were updated on the International Code of Marketing of Breast-milk Substitutes. Participants were required to practice using their newly acquired knowledge, during interactive practice sessions.
A comparison of pre- and post-test scores showed that the training sessions were effective: The percentage of participants with a score equal or above 75% increased from 3% to 49%.
The trainings also emphasized the “Plan-Do-Study-Act” quality improvement process and a collaborative model for quality improvement.
“The collaborative approach we introduced is a collective learning process that allows capacity building of service providers within a large number of facilities at the same time and geared to go to scale,” Zafimanjaka explained. “We brought together personnel from several health facilities who were experiencing similar problems, to develop and implement similar quality improvement plans and they attacked the problems – they discussed the issues together and exchanged experiences during learning sessions.”
The quality improvement intervention focused on EENC practices by using data to reinforce practices within the health system through internal health facility coaching and external coaching from supervisors at higher levels of the system (health district, region, and center). A&T plays a facilitator role, Zafimanjaka explained. As a pilot intervention, the local health system is collecting and utilizing extra national Health Management Information Systems (HMIS) data from coaching and exit interviews.
“It’s easier for people to accept the idea of change when they see that the same problem is resolved in other, similar contexts and the intervention is integrated into their routine tasks using the same platforms,” he said.
After reviewing data on EENC and discussing where there were difficulties, the teams proposed improvements to foster adoption of ENNC practices that worked, and then shared them further.
For example, initially, service providers and A&T technical experts observed that the practice of skin-to-skin contact and early initiation of breastfeeding were not systematic, said Leonard Bassole, the A&T HMIS technical advisor, who, with Dr. Robert Karama, the A&T technical coordinator, is supervising the quality improvement process.
“In particular, the problem was that skin-to-skin contact would be initiated but not sustained for the recommended 90 minutes,” Bassolet said. “We noticed that as soon as a baby is born, the service providers would put the baby on the mother’s chest but not for the recommended time. After 1-3 minutes, the umbilical cord was cut and the baby taken from the mother.”
“Service providers recognized the gap in the application of this directive,” said Dr. Karama. “We discussed this in theory and used the training video as well to illustrate the practice. Then, they put this into practice, which we observed. Afterward, we discussed how to organize the work so that as soon as the mother gives birth” the standard and protocol are applied.
One simple modification was to put a clock in the delivery room, he said, but they identified others, as well. Much of the change involved increasing awareness and understanding of the directive, he said.
Subsequently, each health center developed an action plan to ensure that each step in the early essential newborn care process is implemented. The personnel set objectives for the plan with each team member’s input. As part of the collaborative learning approach, which is ongoing, the personnel of several health centers meet monthly to compare how they have addressed issues of common concern.
“We are about to evaluate progress on these objectives,” Dr. Karama said, referring to upcoming field visits. “These visits will allow us to all come together to share the experiences and discuss, ‘What did we do to improve this?’ and ‘What else can we do now to improve?’”
While this experience is still in process, four regions (Boucle du Mouhoun, Cascades, Hauts Bassins, and Sud Ouest) chose to go forward to implement EENC with an emphasis on newborn nutrition within their pilot health districts (Solenzo, Sindou, Houndé, and Batié). A&T supported these four regions to conduct a light version of the EENC training (which still included the same technical training, and used readily available national data systems rather than local EENC data reporting): 269 (136 men and 192 women) participants from 87 CSPS and four district hospitals have participated. The experience from these regions will add to the overall understanding of how to improve the quality of EENC in Burkina Faso.