AdaraNewborn – halving newborn deaths in low resource settings
Summary
Adara is committing to invest US$10.6 million to scale AdaraNewborn to halve stillbirths and newborn deaths across seven facilities in Uganda. This model, pioneered at Kiwoko Hospital in Central Uganda over 25 years, has delivered strong results. In 2019, more than 89% of sick and vulnerable newborns survived, and since 2010 maternal deaths as a proportion of hospital births have fallen by 50%. The Adara team knows that to reduce newborn mortality, it is critical to address the quality and availability of services, across the continuum of care. By working in collaboration with others, including the Ugandan Ministry of Health, Adara believes it can support Uganda to meet the United Nations Sustainable Development Goals for maternal and newborn mortality.
Approach
AdaraNewborn aims to reduce newborn deaths and stillbirths by 50% in each partner facility. Adara Development commits to scale to seven new health facilities with the Ugandan Ministry of Health between 2024 and 2031 – reaching 350,000 mothers and babies and saving around 5,000 lives. They will also have a global reach through a publicly available AdaraNewborn package.
This work will span the continuum of care to improve outcomes across five arms of care: (1) antenatal, (2) intrapartum, (3) inpatient for small and sick newborns, (4) postnatal for mother and baby, and (5) follow up and early intervention. Along with strengthening facility-based care, the commitment will integrate community-based support.
Developed by Adara after working in Uganda for 25 years, the package will deliver targeted clinical training and Continuing Medical Education focused on the biggest contributors to maternal and newborn mortality, as well as leadership and governance training. It will mentor local champions in each facility to empower staff, even after exit, and help strengthen Quality Improvement systems, enhancing sustainability. The package will provide essential infrastructural upgrades and equipment, support biomedical engineering mentorship, and help strengthen medical supply chains. Finally, it will monitor and evaluate program implementation.
The commitment will cover two geographic regions through a ‘hub and spoke’ approach. They will be anchored by the referral hospital and surrounded by smaller hospitals and health centers that perform basic maternal and newborn care. They will be selected based on high mortality and referral rates. Smaller under-resourced health centers will also receive a basic package. The first hub will center around Kiwoko Hospital, a referral center providing higher levels of care – with whom Adara has partnered for 25 years. The second hub will be selected after close consultation with the Ministry of Health to improve outcomes and impact a high burden district.
Action Plan
In 2024, Adara will expand the neonatal intensive care unit (NICU) at Centre of Excellence, Kiwoko Hospital, and scale AdaraNewborn to two health centers within the first hub. In 2025, they will launch a second regional hub at a referral hospital. They will then partner with a surrounding hospital and three health centers from 2026. Adara’s commitment will end in 2031.
AdaraNewborn implementation spans seven years for a hospital and six for a health center.
Year one
Q1: Complete stakeholder meetings including Ministry of Health, and health facility baseline assessment to plan for equipment and infrastructure upgrade.
Q1: Commence leadership and governance training, ensuring local ownership and accountability.
Q2: Establish a Quality-of-Care Committee, providing framework for ongoing quality improvement, meeting quarterly.
Q3 to Q4: Start phase one of training and mentorship for newborn staff, starting with the basics of newborn care. Implement biomedical training in equipment maintenance and repair.
Year two
Q1: Establish Continuing Medical Education processes for staff’s ongoing professional development.
Q2: Commence advanced training for inpatient newborn and intrapartum care, building on skills and confidence.
Q2 to Q4: Distribute basic training package to smaller surrounding health centers on the basics of maternal and newborn care, focused on referrals.
Year three
Q1 to Q2: Commence advanced training for antenatal and postnatal care teams.
Year four
Q1 to Q2: Complete midpoint assessment to determine effectiveness and course correct as required.
Q3 to Q4: Conduct training on follow-up care for high-risk babies.
Year five
Q1 to Q4: Begin phase out between one-to-two years prior to exit, ensuring long term sustainability.
Year six
Q1 to Q2: Conduct end-point assessment for health centers, ensuring effectiveness of the model and determine next steps.
Year seven
Q3 to Q4: Conduct end-point assessment for hospitals to ensure effectiveness and determine next steps.
Adara will conduct clinical mentoring and monitoring and evaluation each quarter and share knowledge widely to expand the model.
Background
Despite significant gains in reducing mortality since 1990, and a clear commitment to newborns, Uganda is not on track to reach the Sustainable Development Goals (SDGs) target of only 12 newborn deaths per 1,000 live births. A recent paper (Lancet 2021 398:870–905) suggests Uganda experiences around 25.6 neonatal deaths per 1,000 livebirths each year, and by 2030, the rate will only drop to an estimated 21.9.
Uganda’s health system is understaffed and under resourced. In newborn care, of the required 20 neonatal intensive units (NICU) , Uganda only has four units that provide high level care – three are in the capital, Kampala. The fourth is at Adara’s partner hospital, Kiwoko Hospital – their NICU is considered a Centre of Excellence and is the only of its kind located in a rural setting.
The long-term impact of COVID-19 on maternal and newborn mortality and morbidity is not fully known, but preliminary research (PLOSONE 2021 0260006) suggests the impact on health outcomes will be severe. Over the next decade, Uganda needs to prevent the deaths of 80,000 newborns to achieve the SDGs (Lancet 2021 398:870–905) . The Ministry of Health is urgently calling for a collaborative approach to take serious and targeted action to bend the curve and save these lives.
There is an immediate need for increased investment in workforce, training, critical infrastructure and equipment to improve maternal and newborn care.
Evidence shows (PMID:33956641) that improvements in the quality of care provided during pregnancy and at the time of childbirth, especially to sick and vulnerable newborns, coupled with access to high quality postnatal care and family-centered inpatient neonatal care, can dramatically improve survival in the next decade. Investment in the health and development of the next generation, will help Uganda to build human capital and accelerate economic development.
Progress Update
Since Adara Development’s commitment, they have accomplished some important milestones.
They continued to strengthen their Centre of Excellence, Kiwoko Hospital in a number of ways. Adara started a project to expand their congested newborn unit and maternity wards. Working in partnership with Build Health International, they are currently concept planning, master planning and schematic architectural designs. They addressed the need for nursing accommodation by adding 10 new rooms and a septic system to the existing accommodation. Adara also explored new ways Kiwoko Hospital can continue to be a training and mentorship hub, including through installing a simulation lab at the Kiwoko Nursing School.
Adara continued providing quality follow-up and early intervention care through their Hospital to Home and Baby Ubuntu programmes.
At second AdaraNewborn site, Nakaseke Hospital, they strengthened maternal care across antenatal, intrapartum and postnatal care through equipping the facility and running phased training across basic and intermediate training.
Adara also started adapting their Hospital to Home programme for a public setting, which will be piloted at Nakaseke.
This means mothers will receive comprehensive education on how to care for their new baby and receive regular athome follow up support from a community health worker for six months.
At third site, Luwero Hospital, Adara helped open their newly constructed newborn unit. This unit is designed to care for up to 20 babies. With support from their partner, the DAK Foundation, they have equipped the unit with critical lifesaving equipment, including incubators, kangaroo mother care chairs, phototherapy lights and radiant warmers. It has six nurses who have already begun training and mentoring in newborn care. It also has a committed pediatrician.
Across all sites, Adara is using their newly developed Quality of Care tool to ensure facilities are maintaining quality across all components of the AdaraNewborn model.
Partnership Opportunities
Adara is seeking financial resources totaling US$6.6 million over the next eight years to scale AdaraNewborn into seven new sites. They need advocates and influencers to spread the work about AdaraNewborn to their networks and beyond. They will also select new implementing facilities hand in hand with the Ugandan Ministry of Health, and Knowledge Sharing partners to share AdaraNewborn resources and scale beyond Uganda., The resources Adara can offer funding partners as part of this commitment include rigorous and regular reporting and impact measurement across a matrix of indictors, outputs, activities and outcomes.
A mutually beneficial partnership package will include various communication, marketing and engagement activities, including Adara’s new documentary featuring AdaraNewborn, to be released in September 2023. It may also include program visits, as appropriate, for significant investors.
All potential implementors will be able to access the full AdaraNewborn package on their website. Already, Adara’s Hospital to Home package has been uploaded, guiding facilities and communities on how to save lives through this simple intervention.
Adara will select the seven new AdaraNewborn facility partners in Uganda in collaboration with the Ministry of Health. Facilities will receive the full package including infrastructure, resources, training, mentorship, systems and processes.