KINC: KwaZulu-Natal Initiative for Newborn Care
A sad reality in South Africa is that a large number of our newborn babies die. Many of these deaths are due to avoidable factors, with most deaths happening in district hospitals.
In 2013, researchers at the Centre for Rural Health embarked on a three-year project (2013-2016) that aimed to improve newborn care in all 39 district hospitals in KwaZulu-Natal (KZN).
Funded by ELMA Philanthropies, the KwaZulu-Natal Initiative for Newborn Care (KINC) was a multipronged intervention which aimed to address the complex factors associated with poor newborn care in district hospitals. These included poor management skills, inadequate equipment, and poor health worker skills.
Over the course of the project, KINC task teams were established in each of the 11 districts in KZN. These task teams were responsible for not only overseeing the project interventions, but also to train health professionals (doctors, nurses and maternity managers) and to mentor health workers in neonatal units. Finally the teams were responsible for the accreditation of district hospitals for excellence in newborn care.
Working in close collaboration with the KwaZulu-Natal Department of Health, 339 health workers (136 enrolled nurses, 97 professional nurses, 53 doctors) from all 39 district hospitals in the 11 districts received training. Of the 39 hospitals, 33 had a full team of health workers trained in KINC including at least one enrolled nurse, professional nurse and doctor.
KINC training materials were adapted from those developed by the Limpopo Department of Health (known as Limpopo initiative for newborn care or LINC).
Mentoring was undertaken by an advanced midwife working closely with district supervisors to monitor the neonatal unit environment including equipment and personnel, compliance with guidelines through case audits, and infection control practices. Each district hospital neonatal unit received four mentoring visits.
In the quest to assist health managers directly responsible for the neonatal units and to improve their skills, action learning groups were established. Over the course of one year, groups of maternity/neonatal unit managers from different hospitals were brought together for monthly meetings. This presented them with the opportunity to share their complex issues with each other. The group combined their knowledge and experience to clarify the problems and to ultimately generate innovative and creative ways of dealing with these issues. Researchers found that the approach improved participants’ confidence and empowered them to be more proactive in finding solutions to the many complex challenges in their units. (Masango-Muzindutsi Z, Haskins L, Wilford A and Horwood C. Using an action learning methodology to develop skills of health managers: experiences from KwaZulu-Natal, South Africa. BMC Health Services Research (2018) 18:907 https://doi.org/10.1186/s12913-018-3693-6)
A combination of well performing and poorly performing neonatal units in 7 hospitals were selected to participate in case studies (based on their performance in quantitative surveys conducted at baseline and midpoint).
An observer sat in the nursery for five days observing activities and taking notes before interviewing mothers and health workers to explore the challenges they experienced. These case studies highlighted poor communication between health workers and mothers as a key barrier to the provisioning of high quality care. Communication between mothers and health workers is important for quality of newborn care: a qualitative study in neonatal units in district hospitals in South Africa. BMC Pediatrics (2019) 19:496 https://doi.org/10.1186/s12887-019-1874-z)
Evaluation: Did the intervention improve quality of care for newborn babies in district hospitals in KZN?
- To evaluate whether the KINC intervention improved quality of care for newborn babies in district hospitals in KZN, a series of three cross-sectional quantitative surveys were undertaken at project baseline, mid-point and end-point.
- Indicators were developed, based on KZN norms and standards, to measure aspects of care at each of the timepoints.
- Care elements were categorised into domains including human resources, infrastructure, equipment, availability of guidelines, care practices and resuscitation readiness. A composite score was developed to track changes in each of the domains over the three-year project implementation period.
- Demonstrable improvements to many elements contributing to the quality of newborn care were shown, suggesting that the KINC approach was effective in improving measurable elements of care for small and sick newborns. (Horwood C, Haskins L, Phakathi S and McKerrow N. 2019. A health-systems strengthening intervention to improve quality of care for sick and small newborn infants: results from an evaluation in district hospitals in KwaZulu-Natal, South Africa. BMC Pediatrics (2019) 19:29 https://doi.org/10.1186/s12887-019-1396-8)
In the final year of the three year project, an accreditation process was undertaken in the neonatal units in each of the 39 district hospitals.
Accreditation teams visited hospitals and undertook comprehensive assessments of care provision. Teams comprised a minimum of four members including senior managers from the district, external representatives from another district, a paediatrician and a midwife with extensive experience of newborn care, who also served as team leader. Prior to the accreditation process, accreditation tools were shared with the district hospitals to explain the standards required to achieve silver, gold or platinum accreditation.
Although no district hospitals were awarded platinum status, eight district hospitals were awarded silver accreditation status and five received gold accreditation status. (Haskins L, Nyasulu D, Davidge R, McKerrow N, Horwood C. First experiences of accrediting district hospitals for excellence in newborn care in KwaZulu-Natal, South Africa: Successes and challenges. Journal of Hospital Administration 2018, Vol. 7, No. 3 https://doi.org/10.5430/jha.v7n3p25)