When Partners In Health first began working in Rwanda in 2005, the rate of children who died before reaching the age of five was among the highest in the world. In the last decade, Rwanda has made incredible progress in improving child survival, reducing the under five mortality rate by 67% from 152 per 1,000 live births in 2005 to 50 in 2015.
Every child deserves the opportunity to reach their full potential. We work to decrease child mortality further by ensuring children have access to high quality health services. We provide mentorship focused on newborn and child health and our innovative Pediatric Development Clinics provide routine checks to children born with increased medical risks. We work to create a culture of data-driven quality improvement for newborn and child health and in partnership with the government design and implement improved protocols nationally.
All Babies Count
Although the rate of newborn deaths in Rwanda has decreased by 46% in the last ten years, deaths in the first month of life now account for the largest portion of under five deaths. This is because neonatal mortality did not fall as quickly as child mortality. Premature births continue to be a large contributor to overall under five mortality in Rwanda. In order to address this slower decline, we developed a program to specifically target improving the quality care to save newborn lives. While 91% of women give birth in health facilities, nearly half of newborn deaths occur in the first 24 hours of life while most mothers and babies are still in a health facility. The All Babies Count (ABC) program is an 18-month intensive clinical mentorship and quality improvement intervention created with funding support from the Doris Duke Charitable Foundation and the World Bank.
The ABC program accelerates systemic change by intensely focusing on maternal and newborn health care processes, promoting data driven decisions, and ensuring health facilities have the essential equipment and supplies needed to provide care. Through clinical mentorship and system improvements we employ techniques that have already been proven to build clinical skills and improve patient outcomes. We organize learning collaboratives that include clinicians such as doctors, nurses and midwives, as well as non-clinical staff such as data managers and administrative personnel, and also government officials. These learning collaboratives create a community to review recent data, develop quality improvement projects focused on improving key indicators, and share successes and challenges.
Scaling-Up All Babies Count
After demonstrating the effectiveness of the program in two pilot districts we support, we are working in partnership with the Rwanda Ministry of Health to scale-up ABC to seven district hospital catchment areas across the country. Through a three year grant from Saving Lives at Birth, we will support 76 new health facilities, train 326 health care providers and reach a population of over 1.8 million people with the goal of reducing newborn mortality by at least one third before 2019.
Pediatric Development Clinics
The Pediatric Development Clinics (PDC) were created in 2014 to complement the ABC program. With more vulnerable children surviving the neonatal period due to the interventions made as part of the ABC program, more follow-up attention is required for children born with increased health risks to ensure they survive and thrive. Children born prematurely, at low birth weight, or with other conditions such as Down syndrome, birth asphyxia, cerebral infections, or severe malnutrition are entered into this program. This is the only program of its kind in Rwanda, and to our knowledge in sub-Saharan Africa that provides important follow-up care to at-risk infants, which is the standard in higher income settings. We achieve this, by sharing tasks that would traditionally be provided by a team of specialists with an interdisciplinary team of nurses, social workers, and a general practitioner.
Children enrolled in the PDC receive routine checks at the health center to ensure they are healthy. During these routine checks, a nurse examines the child’s vitals, asses their growth, and checks for clinical danger signs. If the examination shows that the child is sick or malnourished they are immediately referred for specific care. At the same visit, a social worker provides play and communication coaching and well as early childhood development education in group sessions. Additionally, the social worker meets one-on-one with the mothers to discuss their social and economic concerns. Depending on the individual's needs, the mother may be provided with food, transportation cost compensation, or a follow-up home visit. Home visits and social support groups aim to engage fathers in the care of these young children.
The frequency of checks depends on the condition of the child but is usually about once a month for children under one then decreases as the child gets older. These checks provide an opportunity for healthcare providers to quickly and preemptively intervene if any potential problems arise, rather than waiting until the child is already sick or developmentally delayed. We utilize our community health workers to track down patients that miss their appointments and learn what obstacles might stand in their way of attending. To date, there are six Pediatric Development Clinics serving over 500 medically at-risk children.
Innovating to keep babies warm
Premature and low birth weight newborns are at high risk of hypothermia which impairs growth and can cause long term negative outcomes. Traditional methods of regulating a baby’s temperature such as incubators and warming tables are problematic especially in low-resource settings. These tools require electricity, are difficult to repair, and can be complicated to use effectively. We promote the use of Kangaroo Mother Care which is the the practice of providing continuous skin-to-skin contact between mother and baby. This practice has been shown to decrease mortality and morbidity in preterm and low birthweight infants by providing protection from infection; regulating temperature, breathing, and brain activity; and encouraging mother-baby bonding.
Kangaroo Mother Care is an effective, location appropriate solution for keeping babies warm. However, in some cases it is not possible such as with twins or very sick newborns. Therefore, we sought out to create an innovative solution in collaboration with Boston Children’s Hospital, Lawrence Berkeley National Laboratory and the Rwanda Ministry of Health. After three years of development, we now have begun using our Infant Warming Mat in Rwanda. The mat is made of a special wax that changes from liquid to solid at skin temperature and keeps that temperature for up to six hours. Boiling water is the only input needed to use the mat. The Infant Warming Mat is an electricity-free, simple to use, inexpensive solution that safely keeps newborns warm.
Developing and implementing protocols
As co-chair of the National Neonatal sub-Technical Working Group we work with the Rwandan Government to develop evidence based protocols to improve the quality of neonatal care. In 2015 we finalized a new protocol for neonatal care at hospitals and then conducted a nationwide training of the trainers to put it into action. One doctor and one nurse from all 42 district hospitals participated in the training program. They will go on to train their colleagues at their respective hospitals and we will provide follow-up training for them in the future.
Through our mentorship program we work to build the capacity of nurses at the health center and hospital levels on a broad array of protocols that affect child health. We provide mentorship in essential newborn care, acute child care (IMCI), and nutrition. We promote an approach to child care that focuses on the well-being of the whole child. Since children often suffer from more than one condition, we promote an integrated strategy which takes into account the variety of factors that put children at serious risk. Much of our training and mentorship is supported by the All Mothers and Children Count project.
Through our partnerships with Boston Children’s Hospital and other institutions, specialists such as pediatricians come from the United States to provide high level mentorship to doctors and nurses at the district hospitals we support.
Creating opportunities for play and learning in pediatric wards
No child enjoys going to the hospital, but we work to improve the experience of staying in a pediatric ward. We hire and train local young women to play with children at the hospitals in order to create a more enjoyable and stimulating environment. The opportunity allows young women who have just graduated from high school to build skills in leadership and early childhood development.
We envision a future in which every child born in Rwanda survives and thrives. We actively conduct research on all of our programs to evaluate the implementation and benefits to young children and their families. By working closely with the government to scale up these child-focused initiatives, we are coming closer to making our vision a reality.