P2B103: Improving the Quality of Essential Newborn Care and Care of Small Babies Though Neonatal Curriculum Implementation in Borama, Somaliland

Background: The first Neonatal Intensive Care Unit (NICU) in Borama, Somaliland was established in 2017 at the Borama Regional Hospital (BRH) to address a growing need for improved care delivery at birth. A majority of under-five deaths in Somaliland occur within the first 28 days of life, and the current neonatal mortality rate of 36% remains above the 2030 Sustainable Development Goal of < 12 neonatal deaths per 1,000 live births. The BRH NICU is staffed by Family Medicine (FM) physicians, who sought out collaboration with US-based Neonatal-Perinatal Medicine subspecialists to strengthen their care of small and sick babies, standardize essential newborn care (ENC) and identify gaps in best practice for targeted quality improvement (QI) to reduce preventable neonatal deaths.

Methods: A mixed method study design was employed with 3 implementation phases. In phase 1, FM residents and maternity ward nurses (Figure 1) completed training in the Helping Babies Breathe (HBB) curriculum, a skills-based ENC course developed for low-resource settings. Baseline knowledge was assessed, followed by a 1-day HBB training, and post-assessment evaluation by Objective Structured Clinical Evaluation (OSCE). In phase 2, learners were observed in the delivery room to characterize barriers to effective curriculum implementation and assess skill performance utilizing a clinical checklist tool. In phase 3, education sessions in core neonatal topics were conducted, including 16 (1-hr) lecture-based sessions, 4 (1.5-hr) procedure workshops, 1 (1.5-hr) journal club and 1 (1-hr) morbidity and mortality case review.

Results: 15/16 (94%) FM residents and 2/6 (33%) nurses had previously completed HBB training prior to the study period. Table 1 displays score reports for the pre- and post-HBB assessments. 16/16 (100%) FM residents and 4/6 (67%) of nurses passed the course. Despite the high pass rate, a number of barriers to HBB were identified during clinical observations, including equipment barriers (e.g., absence of radiant warmer, thermometer), infection prevention deficiencies (e.g., no bag-mask disinfection between use), and systems-based barriers (e.g., no delayed cord clamping, no immediate skin-to-skin, no temperature measurement and outdoor environmental exposure for NICU transfer). In phase 2, multi-disciplinary focus groups identified four best practice gaps to improve rates of admission normothermia, hand hygiene, delayed cord clamping and effective non-invasive ventilation. In phase 3, we observed an average pass rate of 90% for lecture-based sessions and 95% for procedure workshops with the lowest performance scores on neonatal sepsis and fluids, electrolytes and nutrition (Table 1).

Conclusion: Despite the high pass rate on the OSCE, a number of barriers to effective ENC and resuscitation were identified during direct clinical observations. The identified knowledge and best practice gaps are now the focus of ongoing QI initiatives to supplement curriculum training and standardized care provision to reduce site-specific neonatal morbidity and mortality.