In this study we used observations made by trained survey staff to examine fundamental structural components required to provide care for sick newborns with the most common causes of newborn mortality in line with WHO and national guidelines in eight Kenyan government district hospitals. These hospitals represent a relatively small, non-random sample of all Kenyan hospitals and therefore our results should not be used in any specific, quantitative sense to describe the situation in Kenyan hospitals generally. However, we feel our results do illustrate some of the likely areas in which structural aspects of care for newborns are deficient, a view supported by non-survey visits by some of the authors to many other hospitals in Kenya. Our findings suggest that important, structural components for providing newborn care were often unavailable at the time of baseline surveys in the eight sites (). Specific problem areas were noted; for example with regard to infection prevention where inability to separate out-born infants from those born within the hospital, lack of appropriate cleaning materials on the wards and inadequate toilets and washing facilities for the mothers were common. Oxygen supply and delivery systems, resuscitaires and bag-valve-mask devices are vital equipment in facilities expected to provide emergency obstetric and newborn care, these too were often unavailable although some of these resource shortfalls have since been tackled. Such physical problems were commonly linked to very limited availability of guidelines for care and inadequacies in systems or organisation of care. For example, no hospital had clinical management guidelines for common causes of serious illness in newborns; in most hospitals no clinician provided routine review of sick newborns and although available in seven hospitals, no hospital was adhering to the government policy to provide routine Vitamin K at birth, perhaps because of the formulation of Vitamin K supplied.
Cross-sectional observations such as these may be criticised for providing an estimate of point-prevalence in availability only, arguably a problematic measure when trying to assess a dynamic, working hospital environment. It is therefore useful to examine the context of care from more than one perspective and compare the findings. We attempted to examine the credibility of our findings by using health workers’ opinions of availability for some items as an estimate of recent period-prevalence. An alternative or complimentary approach might be to seek caretaker opinions on availability of resources even though their lack of technical knowledge might make this problematic. Although measuring somewhat different aspects of availability there was some agreement between the survey observations and health worker opinions, providing some reassurance that our findings are reasonably indicative of the reality and in general health worker reports of availability, on a scale of 0–10, were relatively low (). However, there were also sometimes discrepancies for which several explanations other than the different periods of measurement are possible. Thus, there may be differences in interpretation of ‘availability’. For example in one case the survey workers observed a drug to be available but health workers reported the same drug as not being available because mothers had to pay for the drug before it was provided. It is also possible that the relatively small (especially in some sites) and convenience sample of 81 respondents lead to chance misclassification. Different assessment practises of the team supervisors, as suggested by the (non-significant) lower agreement between approaches in one of the three teams, and reluctance of health workers to give high scores could also contribute to apparent disagreement between data obtained by observation and health worker response.
Availability of essential items for provision of care is a widely used indicator of quality of care (Litvack & Bodart 1993
; Gilson et al. 1995
; Kamat 1995
). It is based on the assumption that given the proper resources and organisational structure, health care workers are enabled to provide good quality services; conversely, poor organisation, resources and infrastructure are likely to be associated with poor quality of care. The latter concern is of especial relevance to low-income settings where inadequate resources are often reported (UNDP 2007
) and where, in our experience, there are few local ‘champions’ advocating for the needs of newborns.