Findings obtained from the interviews are grouped under two broad themes; (1) Barriers contributing to the poor quality of inpatient care for small and sick newborn care. This includes perceived bottlenecks and challenges impeding the quality of small and sick newborn care, and (2) Enablers contributing to improved inpatient care for small and sick newborns. This theme identified one factor potentially contributing to improved care for small and sick newborns. These two themes are explained in the following sections.
Theme I: Barriers contributing to the poor quality of inpatient care for small and sick newborns across Pakistan
Category 1: Lack of essential neonatal care standards
Both groups of respondents (health care providers and planners) expressed their dissatisfaction over the quality of care provided to small and sick newborns at the district and tertiary care units across Pakistan. Among the underlying reasons, the non-availability and use of essential newborn care guidelines/standards at the facility by front line service delivery staff were highlighted as the major concern. A group of pediatricians and senior representatives at the MNCH Provincial Directorate voiced their concerns by highlighting the non-availability of standards protocols for preventing intrapartum stillbirths and neonatal deaths and common childhood illnesses and recommended for the development of these standards at the provincial and district level.
“There are no protocols. No standard protocols are being followed for newborn and neonatal care.” (MNCH Assistant Director, 005-01)
“They (district and the provincial department of health officials) should make proper guidelines for the management of major issues such as birth asphyxia, preterm infections, etc.” (Pediatrician, 003-05)
A respondent while reflecting the current practice of keeping 3-4 neonates in a single cot, stated;
“Now high standard means one child per bed. In that room (nursery), there are four newborns in one bed. So, what kind of standard we are fulfilling?” (Pediatrician, 001-02)
An obstetrician expressed concerns that the absence of set guidelines encouraged malpractices related to the care of a newborn;
“There is no newborn care as such. An obstetrician will try to save the woman during delivery and will hand over the baby to TBA (Dai/ Aya), and they will turn the baby upside down and slap her to make her cry. No vitals, no APGAR score, no explanation regarding the danger signs is carried out. Even at the tertiary level, the system is not up to the mark. So, what can you expect from Rural Health Center, Basic Health Units, and DHQs?” (MS, 001-03)
While respondents shared their grievances about the absence of neonatal care standards, they also acknowledged World Health Organization (WHO) protocols of essential maternal and neonatal care and highlighted the need for implementing the same at SNCUs.
Category 2: Inadequate infrastructure and equipment for the care of small and sick newborn
Health care providers including the MS, obstetricians/ gynecologists, and pediatricians also expressed concerns about the inadequacy of infrastructure and equipment in health facilities as an important reason for the poor quality of neonatal care. Infrastructural deficiencies included unavailability or non-functionality of neonatal intensive care units (NICU), labor room, ventilators, life-saving medications, shortage of the required number of infant cots and ultrasound facility, non-functional operation theaters, etc. The resulting poor quality of care contributed to neonatal deaths at these facilities.
“There are a lot of neonatal deaths in the facility as well. The reasons are that we have a shortage of manpower, the need for electricity is not fulfilled. ………If the incubator is required, it’s not provided ……..there are few medicines……..these are the problems due to which neonatal deaths are reported”. (Obstetrician, 001-04)
“A preterm baby, less than 28 weeks needs ventilator support, which we are unable to provide. So, what do you expect? How can we make progress in this situation?” (Gynecologist, 002-03)
Frontline care providers believed that an early discharge of preterm neonates is due to limited bed capacity at the DHQ hospitals.
“One issue is the unavailability of space, because of which at times we are compelled to discharge preterm neonates (Gynecologist, 002-03)
Furthermore, the pediatricians also shared their views about the compromised quality of care in the absence of required logistics and essential lifesaving medications for sick newborn;
“..........If a child is presented with fits and I don’t have valium or when newborn is not breathing, I don’t have an ambu bag to resuscitate, the baby will die. This equipment should be made available”. (Pediatrician, 007-09)
Furthermore, both groups of respondents also highlighted the scarcity of incubators and ventilators in rural areas.
“After delivery, if the baby gets hypothermia, fever or asphyxia then there is no neonatal set up in the rural areas to manage such cases. Our ambulances are not equipped with ventilator services. They do not have the incubator or the warmer…” (MNCH Assistant Director, 005-01)
Moreover, some of the respondents at the facility level also shared their grievances about the inadequacy of oxygen supply and related equipment (ambulatory bags, oxygen flow meters, etc.).
Category 3: Issues with neonatal health care workforce
Sub-category 3.1: Deficiency of specialized workforce for neonatal case management
Inadequate availability of the specialized workforce for neonatal case management was perceived as another hurdle in delivering optimum quality of care. Both groups of respondents equally identified the shortage of neonatologists, pediatricians, and nurses in the neonatal units.
A pediatrician while highlighting the dearth of required workforce exclaimed;
“…….We do not have a single neonatologist in the entire province. Pediatricians deal with neonates. They are not present in every DHQ. The staff is not enough across different units of the hospital.…” (Paediatrician, 007-04)
Respondents while reflecting the unavailability of a specialized workforce round the clock at the inpatient care units, shared that evening and night shifts are mostly observed without nurses. Alongside the unavailability of nurses, pediatricians were reported to be on call and were only reported to be accessible in the daytime; resulting in the delay of essential newborn care.
“The patient care is affected because of the shortage of staff in shifts. Let’s suppose cesarean has been done and now they need a child specialist, but the child specialist is on call…. During this calling process, the golden minutes are wasted. And when the pediatrician arrives, the baby has died already, or he has been resuscitated.” (MNCH Assistant Director, 005-01)
Dialogues with the MNCH program planners and managers unfolded the reasons contributing to the dearth of the specialized workforce at inpatient care units. A commonly reported reason was the budgetary constraints at the provincial level; restricting recruitment of skilled workforce. While highlighting the inadequacy of the specialized neonatal care workforce across DHQs, suggestions were proposed for in-service training of residents in neonatology.
“There should be more people sent for the capacity building. Those who have done house jobs in the pediatrics should be sent to neonatology units. They should learn and build their capacity and then get appointed in the districts.” (DG Health, 007-02)
Sub-category: 3.2. Inadequate thermal care management for newborns
While respondents highlighted multiple aspects of poor quality of newborn care at the facility level, it came under discussion from one province that newborns are handled by the traditional birth attendants (TBAs); resulting in inadequate thermal care, which leads to neonatal deaths at the facility.
“…….. So, what I’ve observed is that the child is handed over to the TBA, she takes the child somewhere and doesn’t keep him warm…. They just dry the child with a cloth and the child remains cold later. A lot of children die because they remain cold.” (Pediatrician,001-01)
One of the senior officials at the Provincial Department of Health also shared similar malpractice after childbirth.
“Soon after the delivery, if the male baby is born, he is handed over to ward servants who then handover him to family. They wander all-around taking the baby thus causing hypothermia. This has been strictly mentioned a lot of times that baby should be placed in front of the heater or the baby warmer should be switched on at least half an hour before the delivery.”
(DG Health, 001-01)
Category 4: Inadequate referral system
Across the regions, the inadequate referral system in general and in particular to neonatal cases was repeatedly emphasized. While unfolding the issues in the referral system, participants reported a lack of pre-referral care and treatment by attending physicians reflecting incompetency of front-line staff in managing emergency cases requiring urgent referrals.
“….. The doctors are incapable of resuscitation and proper referrals, this leads to a situation where a critically ill patient arrives with no proper referral or support, so we must send him forward.” (DG Health, 001-01)
Another official in the Department of Heath straightforwardly ascribed stillbirths and neonatal deaths in the country to a poor referral system.
“One of the challenges in preventing stillbirths and neonatal deaths in the poor referral system and poor transportation.” (MNCH Coordinator, 004-01)
In the views of pediatricians, the absence of follow-up after the referral was also highlighted, especially when the sick child is referred from peripheries to the tertiary care hospitals.
“We don’t have a system of follow-up after referral at all. When a child from a small village is referred to a hospital in the city, there is no follow-up; whether the child was given the service or not, whether the ambulance was arranged on their own or by the government or by some NGO, we do not have such system right now.” (Pediatrician, 003-01)
While the existence of emergency transportation arrangements for maternal and sick newborn cases in the form of emergency helpline numbers was acknowledged by MNCH managers and planners. However, the non-availability of ambulance service for patients in general and particularly related to sick newborns remain cited as a concern.
Category 5: Absence of a multidisciplinary approach in neonatal case management
Narratives from stakeholders’ interviews also alluded to the lack of coordination mechanism among three different specialties i. e., neonatology, pediatrics, and gynecology in inpatient care units. During emergency events such as fetal distress, the absence of a neonatologist exhibited a lack of coordination among attending staff, which can risk newborn life.
“Now the protocol in the case of fetal distress is that when an obstetrician is in OT to deliver the baby, there should be a neonatologist present there too. We call them… but they do not reach on time.” (Gynecologist, 006-01)
The underlying reasons that surfaced for the lack of coordination between the specialist cadres were indicative of wrongly perceived role and responsibilities by the respondents;
“A Gynecologist is more interested in maternal health and stillbirths; whereas a pediatrician is only interested in neonatal deaths. There is a lack of coordination between these two cadres.” (MNCH Coordinator, 004-01)
The respondents while sharing their concerns about the lack of coordination between the diverse group of providers rebuked the hospital governance, and strongly emphasized the culture of teamwork while providing care for sick neonates;
“…..There are communication gaps between the departments…... It is not only the administration or the government who is responsible. Responsibility, of course, lies upon the gynecologists, obstetricians, and pediatricians as well. We should build an environment where there is teamwork.” (Gynecologist, 006-01)
Category 6: Need to institute monitoring system to prevent neonatal deaths and stillbirths
Alongside the above-mentioned issues associated with the poor quality of neonatal care at the facility level, respondents also discussed instituting and strengthening monitoring systems. This includes careful reviews of patient case records, verbal autopsies, perinatology meetings, etc. While highlighting the need for reviewing the patient reports and undertaking verbal autopsies for neonatal deaths and stillbirths, a pediatrician stated;
“Reviewing of reports can give us data, for example, if we report 10 deaths in a month, then we can review to see what were the causes and check if it was a mistake on our part or from the parents’ side so that we can prevent it from happening again and we can save child’s life.” (Pediatrician, 003-01)
Participants indicated a culture where facility-based supervision is nearly non-existent. In this regard, pediatricians suggested monthly audits by the provincial health department representative and instituting a formal mechanism at the facility and district level to ascertain the causes of neonatal deaths.
“Formal mechanisms with standardized forms can help identify causes and prevent stillbirths and neonatal deaths. If we recommend these forms to the government, then it will get you data about the causes of stillbirths and neonatal deaths.” (Pediatrician, 001-02)
Furthermore, a few of the respondents also highlighted the need for supervisory visits (audits) by the respective provincial health department to ensure correct utilization of the logistic support received from UNICEF at SNCUs.
“Whichever hospital we are working in, whatever equipment we are getting from UNICEF etc. or the training received, there should be a follow-up to see if all of that is provided is being utilized. We don’t have a system for audits.” (Pediatrician, 003-01)
Theme II: Enablers contributing to improved inpatient care for small sick newborns
Category 1: Improved federal and provincial oversight for reproductive, maternal, and newborn (RMNCH) care
The existence of the RMNCH technical group at the federal and provincial levels was positively viewed by the stakeholders with the potential to improve reproductive, maternal, and newborn care. The respondents viewed that the technical committee is actively working to improve the MNCH across Pakistan. The group comprised of government, non-government, and International Non-Government Organizations (INGOs) with the representation of Health Secretaries, Director General Health (National and Provincial), planning & finance representatives, WHO, and UNICEF. Health care professionals including obstetricians and pediatricians are also reported to be part of the said group. The committee is to promote evidence-based MNCH interventions across the country, alongside advocacy for essential newborn interventions such as umbilical cord care by chlorhexidine at the facility level.