PC2116: Quality Indicators for Essential Newborn Care in Low- and Middle-income Countries

Purpose/Objectives: In striving to achieve the Sustainable Development Goal of neonatal mortality reduction, many low- and middle-income countries (LMICs) are encouraging implementation of quality improvement (QI) methodology. Although impact measures, such as mortality rates, are recommended at national levels, facility-level quality indicators for Essential Newborn Care are better suited to local QI efforts. To date, facility-level indicators have been variably defined and recommended. We developed a directory of indicators to assist LMICs and annotated the directory with guidelines to aid in indicator selection.

Design/Methods: We employed a mixed method study design with four implementation phases (Figure 1). During Phase 1, we performed a systematic review to generate an indicator directory with corresponding definitions. Each indicator was assigned a score for scientific evidence, importance and usability. An overall rating was then generated as a product of the three sub-scores. During Phase 2, we employed a modified Delphi technique utilizing a 91-item survey and 90-minute virtual sessions to modify scores and obtain consensus-based approval for indicator inclusion from members of the Helping Babies Survive Planning Group (HBSPG). During Phase 3, we conducted a secondary survey of international partners for appraisal and broad scope review of selected indicators. During Phase 4, we generated implementation guidelines for site-specific indicator selection and use as all indicators will not be appropriate for use within every facility given variability in clinical context and goals.

Results: During Phase 1, we developed a list of 57 indicators which were categorized into three domains: outcomes, processes and educational indicators. During Phase 2, 10 of 14 HBSPG members (majority representation from North America) completed the survey and 12 of 14 members attended Delphi sessions. During Phase 3, a convenience sample of 16 international partners from 4 leading intergovernmental public health organizations and 1 non-governmental organization were surveyed. In this phase, 81% (13/16) of responses were collected using the survey tool, and 19% (3/16) as free text responses. A total of 49 indicators met inclusion criteria (17 outcome, 21 process and 11 educational) and 8 were rejected. Among the 49 included, 28 were recommended for use, meaning that indicators should be selected preferentially from this group when appropriate; an additional 10 were recommended for selective use primarily because of data collection challenges; 11 were recommended with reservations because of limitations in scientific evidence or usability (Figure 2).

Conclusion/Discussion: As healthcare governing bodies aim to reduce global disparities in neonatal mortality, guidance for data tracking is needed to evaluate facility-level clinical practice and ascertain where gaps in quality occur. This open-access directory of quality indicators was developed by leading experts in essential newborn care to enable appraisal of care provision, track progress toward improvement goals and provide a standard for benchmarking care delivery among LMIC sites.