Abstract:
Background: Effective coverage requires that those in need can access skilled care
supported by adequate resources. There are, however, few studies of effective coverage
of facility-based neonatal care in low-income settings, despite the recognition that
improving newborn survival is a global priority.
Methods: We used a detailed retrospective review of medical records for neonatal
admissions to public, private not-for-profit (mission) and private-for-profit (private)
sector facilities providing 24×7 inpatient neonatal care in Nairobi City County to
estimate the proportion of small and sick newborns receiving nationally recommended
care across six process domains. We used our findings to explore the relationship
between facility measures of structure and process and estimate effective coverage.
Results: Of 33 eligible facilities, 28 (four public, six mission and 18 private), providing
an estimated 98.7% of inpatient neonatal care in the county, agreed to partake. Data from
1184 admission episodes were collected. Overall performance was lowest (weighted
mean score 0.35 [95% confidence interval or CI: 0.22-0.48] out of 1) for correct
prescription of fluid and feed volumes and best (0.86 [95% CI: 0.80-0.93]) for
documentation of demographic characteristics. Doses of gentamicin, when prescribed,
were at least 20% higher than recommended in 11.7% cases. Larger (often public)
facilities tended to have higher process and structural quality scores compared with
smaller, predominantly private, facilities. We estimate effective coverage to be 25%
(estimate range: 21-31%). These newborns received high-quality inpatient care, while
almost half (44.5%) of newborns needed care but did not receive it and a further 30.4%
of newborns received an inadequate service.
Conclusions: Failure to receive services and gaps in quality of care both contribute to a
shortfall in effective coverage in Nairobi City County. Three-quarters of small and sick
newborns do not have access to high-quality facility-based care. Substantial
improvements in effective coverage will be required to tackle high neonatal mortality in
this urban setting with high levels of poverty.