Evaluation of criterion-based audit in improving quality of neonatal birth asphyxia care at Balaka district hospital in Malawi

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At Balaka district hospital, Birth asphyxia is the primary cause of neonatal mortality accounting for 37.3% of the district’s neonatal deaths. Although various quality improvement initiatives on birth asphyxia such as Helping Babies Breathe have been documented in Malawi, there is limited information on use of criterion based audit (CBA) to enhance the care of neonates with birth asphyxia. This study aimed to evaluate the effectiveness of criterion-based audit in improving quality of neonatal birth asphyxia care at Balaka district hospital in Malawi. Methods A CBA on the care of babies born with birth asphyxia was conducted at Balaka district hospital in Malawi. The care practices were assessed through a retrospective review of 110 cases notes and compared with a locally established standards, by a multidisciplinary team, based on the Malawi guidelines on care of the infant and newborn and World Health Organization manuals. The gaps in current practice were identified, reasons discussed, and recommendations made and implemented. A re-audit was conducted on 110 case notes six months after the initial audit. Results The re-audit showed significant improvements in many of the set criteria for quality care: Checking of vital signs (80% vs. 98.2%; p = 0.000), appropriate investigations check (0.9% vs. 74%; p = 0.000), Thermal support (82.7% vs. 91.8%; p = 0.041), Correct diagnosis (60% vs. 81%; p = 0.001), Correct treatment (18.7% vs. 81%; p = 0.000), Correct Feeding (12.7% vs. 56.4%; p = 0.000), Clinicians’ ward rounds (0% vs. 72%; p = 0.000), and Daily weight check (49.1% vs. 93%; p = 0.000). Additionally, neonatal death decreased from 11% in initial audit to 5% in the re-audit. Conclusion CBA is a low-cost tool that can significantly improve the care of neonates with birth asphyxia in resource-limited countries. Birth asphyxia Criterion-based audit Quality of care Balaka Malawi Figures Figure 1 1. Introduction Globally, 2.3 million newborns die every year during the first 28 days of life and the majority of all neonatal deaths (75%) occur during the first week of life and approximately one million newborns die within the first 24 hours [ 1 ]. Various initiatives such as safe motherhood programme, Helping Babies Breath (HBB), and Integrated Management of Childhood Illness (IMCI) have improved the health of children in Malawi in the last few decades [ 2 ]. The country achieved its fourth World Health Organization Millennium Development Goal to reduce childhood mortality by two-thirds in 2013 [ 3 ]. Despite these gains, Malawi still has a high neonatal mortality ratio of 27 per 1,000 live births [ 4 ]. The three main causes of neonatal deaths in Malawi are prematurity (33%), birth asphyxia (25.8%) and neonatal sepsis (18.6%) [ 5 ]. Similarly, at Balaka district hospital the leading causes of neonatal mortality are birth asphyxia (37.3%), prematurity and low birth weight (30.8%) and respiratory distress syndrome (15.4%) [ 6 ]. Birth asphyxia is defined as failure to initiate and sustain spontaneous breathing at birth [ 7 ]. It is characterized by marked impairment of exchange of respiratory gases (oxygen and carbon dioxide) resulting in progressive hypoxemia and hypercapnia, accompanied by marked metabolic acidosis [ 7 , 8 ]. The diagnosis of birth asphyxia can be made when a newborn has (i) Apgar score of < 7 at five minutes after birth; (ii) neonatal neurological manifestations (seizures, coma or hypotonia); and (iii) multisystem organ dysfunction [ 9 , 10 ]. The first minutes after birth are critical in reducing neonatal mortality. HBB is a simulation-based neonatal resuscitation programme for low resource settings. Larson et al. [ 11 ] indicated that HBB has made remarkable achievements in reducing newborn mortality in Malawi. According to the 2020 Malawi emergency obstetric and newborn care survey, Balaka district hospital conducted 100% resuscitation to asphyxiated neonates. However, birth asphyxia remains the leading cause of neonatal death at the facility. A number of studies in Malawi have been conducted to address the prevalence of birth asphyxia and its associated factors [ 12 – 14 ]. However, little is known on the quality improvement initiates to improve care of neonates with birth asphyxia. This study aimed to implement a criterion based audit (CBA) in order to improve quality of care for neonates with birth asphyxia through review of cases against explicit criteria and use findings to modify practice as necessary. CBA is a systematic and critical analysis that seeks to improve quality of care through review of cases against explicit criteria and use findings to modify practice as necessary [ 15 ]. The importance of CBA and its effectiveness in improving outcome of care has previously been demonstrated in other resource-limited settings in Uganda, Tanzania and Ethiopia [ 15 – 17 ]. In addition, to improving the quality of maternal and neonatal care, CBA was found to enable health care providers to reflect upon their clinical practice, explore their working environment, and give them the opportunity to think of locally applicable recommendations. The CBA was able to detect substandard diagnosis and management of foetal distress in Tanzania, consequently, leading to improved care by using feedback and available resources. Moreover, there was a significant improvement in the management of foetal distress between the baseline and the re-audit (p < 0.001) [ 17 ]. The study conducted in Ethiopia found that the prevailing quality of postpartum haemorrhage (PPH) management did not meet the majority of the standard criteria. Major areas of substandard care were identified (vital signs monitoring, IV-line setup and fluid administration, typing and cross-matching, and maintenance of a fluid intake/output chart) and locally appropriate recommendations were made to improve the care [ 15 ]. The extent to which CBA may improve the quality of care provided to patients is therefore dependent on having effective health systems, leadership and involvement of care providers even in low resource setting [ 16 ]. While several quality improvement initiatives on birth asphyxia in Malawi have been documented, for instance HBB there is limited information on CBA to improve care of neonates with birth asphyxia. Therefore, this study aimed to implement CBA as a quality improvement tool to systematically and critically evaluate the quality of care for neonates with birth asphyxia at Balaka district hospital in Malawi. 2. Methods 2.1. Study design We conducted criteria based audit at Balaka district hospital in Malawi. A retrospective quantitative approach was employed to assess and evaluate quality of care provided to neonates with birth asphyxia. The audit was implemented following the six steps of CBA cycle as shown in Fig. 1 . The initial CBA was executed in June 2023. The initial audit performance was discussed and interventions to improve neonatal care were implemented. After implementing the recommended changes the re-audit was performed in January 2024. 2.2. Setting The study took place in nursery ward at Balaka district hospital in Malawi. The country has a population of just over 17.6 million [ 18 ] and 28 districts, one of them being Balaka with a population of 438,379 people. The number of women of childbearing age for the district is about 100,828, representing 23% of the total district population and the expected annual number of deliveries is around 21,919, which is 5% of total district population. Balaka district has a fertility rate of 4.6 higher than the national fertility rate of 4.4. Balaka district hospital was selected as a site for implementation of this quality improvement study because it is one of busy district hospitals in Malawi with an average of 500 deliveries per month and recording high neonatal deaths. The report indicates that Balaka district hospital in fiscal year 2021/2022 had an average of 201 neonatal deaths out of 4732 live births of which birth asphyxia contributed to 37.3% of all deaths [ 6 ]. 2.3. Audit procedure The standard steps of a clinical audit cycle adopted from Mgaya et al. [ 17 ] were followed in this study (Figure. 1). The initial audit was conducted from 1 to 30 June 2023. The final audit was conducted six months after implementing the recommended changes. 2.3.1. Step 1: Set and agree on criteria of standard practice We used evidence from existing guidelines in Malawi on care of the infant and newborn [ 10 ]. Where necessary, this was supplemented by evidence from World Health Organization manuals and articles from peer reviewed journals. A multidisciplinary team of one doctor, two clinicians, six midwives and one policy maker established the criteria of standard practice during a 5-day workshop which was held in May, 2023. The first day of the workshop was dedicated to equipping the team with principles of CBA. The rest of the days were dedicated to developing criteria of standard practice. A set of 12 standards (Table 1 ) was developed which addressed quality issues related to the management of birth asphyxia. The standards were set according to the prevailing local setting and according to available resources. The developed criteria was pre-tested on ten files with diagnosis of birth asphyxia. Two meetings were conducted in May, 2023 to inform the department members on the standards. Each meeting involved doctors, nurses, midwives, clinicians and District Hospital Management Team (DHMT) members. In total, 35 members from maternity department and six DHMT were oriented on CBA and agreed standards. Table 1 List of agreed upon criteria for standard management of birth asphyxia at Balaka district hospital. 1. Adequate initial assessment Airway (secretions), Breathing (chest resections, apnoea attack), Circulation (skin colour, Coma (AVPU), Convulsions, Dehydration (urine, stool & vomiting), Vital signs (Temperature, respirations rate, pulse rate & oxygen saturation. (all should be assessed and documented during admission) 2. Appropriate Investigations Random Blood Sugar (RBS) checked 12 hourly, Full Blood Count (FBC), check if fever is 38.5 0 C for 2 consecutive readings. 3. Correct diagnosis Apgar < 7 at 5 minutes. For neonates not born at hospital should have the following on admission: cyanosis, floppy, convulsions & unable to suck. 4. Correct Treatment The treatment of birth asphyxia depends on the presenting signs, for example; Antibiotics based on FBC results/fever 39 0 C/rupture of membranes (ROM) > 18hours, Anticonvulsants (Phenobarbitone) given to neonate with convulsions, RBS 38.5 0 C (given antipyretic paracetamol), oxygen saturation < 90% (given oxygen therapy). NB: check indication for treatment, dose, frequency & route . 5. Vital signs monitoring 4 hourly Respirations, pulse rate, temperature & oxygen saturation checked at least 4 hourly. 6. Thermal support At least one of the following should be done to the neonate; drying, wrapping & putting a neonate on radiant warmer. 7. Airway management Suctioning of secretions if present. 8. Observations Skin colour, AVPU, convulsions, apneic attack, chest recessions & secretions checked at least 4 hourly. 9. Daily Weight check Checked once a day throughout admission period. 10. Correct Feeding Method: Breast/cup/orogastric tube, type of feed: EBM/formula, amount, interval: 2hrly 11. Ward rounds by Clinician Twice a day (Monday- Friday) & once a day (Saturday & Friday ) 12. Explain findings to guardian/parent Explained at least once a day throughout admission 2.3.2. Step 2: Collect baseline data to measure current practice The current practice was measured by a retrospective review of case notes. A multidisciplinary quality improvement team comprised of one medical doctor, one clinical officer, seven nurse/midwife officers, one clinical technician and two nurse/midwife technicians was established. A two day training was provided to the multidisciplinary team on data extraction. The team reviewed the cases of birth asphyxia from December, 2022 to May, 2023 and extracted the data into a data collection sheet. 2.3.3. Step 3: Compare current practice with agreed standards The baseline of current practice was compared with the agreed upon standards of diagnosis and management of birth asphyxia, and the results summarized. The audit evaluators then assessed the fulfilment of the criteria, evaluating the recorded practice against the agreed upon criteria for best practice. In case of disagreement, decisions were based on the consensus of the team members. The decision was also arrived at basing on the principal of not documented, not done. 2.3.4. Step 4: Feedback and decision to interventions to improve practice After analysis of data from the initial audit the results were presented to members of the department at a convened departmental meeting held in June, 2023. The gaps between current practice and standards were discussed and recommendations for improvements were made. Some of the recommendations were to conduct mentorship on Apgar score to midwives and clinicians in labour ward, post Apgar score chat on each and every delivery bed, let a colleague assist in conducting Apgar score, conduct supportive supervisions and mentorships to nurses and clinicians in nursery ward on management of birth asphyxia, have a team leader for each and every shift who can be allocating tasks to team members, conduct joint quarterly meetings between nurses and clinicians in nursery ward, strengthen team work and effective communication among team members and line managers (Table 2 ). The implementation of the recommendations commenced in July, 2023 and was run for six months. This involved assigning a special clinician to nursery ward, training nurses/midwives and clinicians on management of birth asphyxia, conducting supportive supervisions and mentorships. Table 2 Recommended interventions to improve birth asphyxia care 1. Post the list of agreed upon criteria for standard management of birth asphyxia in nursery ward 2. Conduct mentorship on Apgar score to midwives and clinicians in labour ward, post Apgar score chat on each and every delivery bed and let a colleague assist in conducting Apgar score 3. Conduct supportive supervisions and mentorships to nurses and clinicians in nursery ward on management of birth asphyxia 4. Allocate two Clinicians specific for Nursery ward 5. Have a team leader for each and every shift who can be allocating tasks to team members 6. Conduct joint quarterly meetings between nurses and clinicians in nursery ward 7. Clinicians should have a clear written duty roster for nursery ward 8. Disciplinary action should follow to clinicians/nurses who do not follow recommended criteria 9. Strengthen team work and effective communication among team members and line managers 10. DHMT and partners should provide more resource such as glucose strips, stationery and feeding cups 11. Commitment to appropriate stock inventory and make good predictions and timely ordering of drugs and supplies from the Central Medical Store in order to prevent unnecessary shortages of drugs and supplies. 12. Strengthen documentation through spot checks of files during handover 2.3.5. Step 5: Implementation of recommended interventions The summary of recommended interventions were presented to all cadre providing care at neonatal unit. The neonatal unit staff and management team worked jointly to implement the recommendations for a period of six months. The team were supported with basic resources to provide standard care based on identified needs. The resource included thermometers, heaters, suctioning machine, penguin suckers, glucometer, glucose strips and stationery. 2.3.6. Step 6: Re-evaluation of practice After implementation of the recommendations from the initial audit, a re-audit was conducted from January, 2024 to February, 2024 to assess the progress. The data collection procedure was done in the same way as in the initial audit. The outcome was evaluated by comparing the initial and re-audit results by percentage. 2.4. Study Population The study population was all neonates with birth asphyxia, born at gestation of 28 weeks and above, who received healthcare at Balaka district hospital. The sick neonatal register for Balaka district hospital shows that the institution admitted 483 neonates with birth asphyxia in fiscal year 2021/2022. 2.4.1. Inclusion criteria All neonates born at 28 weeks gestation and above who were admitted in nursery ward with a diagnosis of birth asphyxia. 2.4.2. Exclusion criteria Asphyxiated neonates born at 28 weeks gestation and above with extreme low birth weight of less than 1000g and neonates born with congenital abnormality were excluded as their chances for survival are minimal. 2.5. Sample size determination The sample size was determined by using Yamane Taro’s method (Yamane, 1967:886) of sample size determination which assumes a 95% level of confidence and p = 0.5. Yamane’s formula n \(=\frac{N}{1+N\left({e}^{2}\right)}\) where; n = sample size, N = total population which is 483. e = margin of error = 5% (0.05); the level of precision. The sample size for this study was calculated as follows: n \(=\frac{N}{1+N\left({e}^{2}\right)}\) , n \(=\frac{483}{1+483\left(0.05*0.05\right)}\) and n \(=\frac{483}{2.2075}\) = 219. Therefore, the calculated sample for the audit was 219 case files of neonates diagnosed with birth asphyxia. Audits were done twice (baseline and six months after interventions) and each time 110 files were selected. 2.6. Sampling Technique The case files were selected using a systematic random sampling technique with an interval of two, where the interval constant was obtained by dividing the total number of case files with diagnosis of asphyxia by the sample size. 2.7. Data Analysis Data were extracted using a data extraction sheet containing all variables of interest and entered into a data based created in Statistical Package for Social Sciences (SPSS) software. Analysis was performed using SPSS statistics version 22. Differences in neonatal characteristics between neonates participating in the initial audit and the re-audit were analysed using chi-square test and differences in the percentage of neonates that attained the recommended standard at the initial audit and the re-audit were analysed using Student t-test. Level of statistically significance was set at p < 0.05. 3. Results 3.1. Characteristics of the study participants A total of 220 neonatal cases of birth asphyxia were included in this study whereby 110 cases were analysed during each audit (initial and final audits). Table 3 shows the characteristics of the study participants, where there were no significant differences in the characteristics of participants in the two audits. The mean mother’s age of the participants in the initial audit was 23 ± 5.6 years while that of the final audit was 23 ± 6.4 years. The mean gestation age of participants at birth was 37.4 ± 1.5 weeks in the initial audit and 37.7 ± 1.4 weeks in the final audit. The mean birth weight of participant in the initial audit was 2943 ± 478 grams, while in final audit was 2865 ± 477 grams. The mean time interval between delivery and admission in nursery ward was 131 ± 26 minutes in the initial audit and 105 ± 14 minutes in the final audit. Most of the participants 50% (n = 50) and 56.4% (n = 62) were born through spontaneous vertex delivery in the initial and final audits respectively. Concerning the place of delivery, majority (97.3%, n = 107) were born at Balaka district hospital in both initial and final audits. Table 3 Characteristics of the study participants admitted in nursery ward due to birth asphyxia at Balaka district hospital Characteristic Initial CBA Final CBA Mean (SD) n (%) Mean (SD) n (%) Mothers’ age (years) 23(5.6) 23(6.4) Gestation age at birth (weeks) 37.4(1.5) 37.7(1.4) Birth weight (grams) 2943(478) 2865(477) Time interval between birth and admission in nursery ward (Minutes) 131(26) 105(14) Mode of delivery SVD Caesarean section Breech Vacuum extraction 55(50) 62(56.4) 40(36.4) 39(35.5) 6(5.5) 6(5.5) 9(8.1) 3(2.6) Delivery place Balaka district hospital Health centres 107(97.3) 107(97.3) 3(2.7) 3(2.7) 3.2. Attainment of standard criteria for management of birth asphyxia at Balaka district hospital Table 4 shows the results of the criteria-based audit of the clinical management before and after implementation of the interventions. The re-audit showed significant improvements in many of the set criteria for quality care of birth asphyxia as compared to the initial audit. The mean patient care increased from 54% in the initial audit to 86% (p = 0.000) in the re-audit. Neonatal deaths due to birth asphyxia reduced from 11% in initial audit to 5% in the final audit. The initial assessment on admission was adequate 100% (n = 110) in both initial and final audits (p = 1). Checking of vital signs improved from 80% (n = 88) to 98.2% (n = 108) (p = 0.000) from the initial audit to the final audit respectively. Percentage of neonates with appropriate investigations done increased from 0.9% (n = 1) in the initial audit to 74% (n = 81) in the re-audit (p = 0.000). There was a statistical significant improvement in conducting observations from 86.4% (n = 95) in the initial audit to 98.2% (n = 108) in the re-audit (p = 0.018). The provision of thermo support increased from 82.7% (n = 91) in the initial audit to 91.8% (n = 101) in the final audit (p = 0.041). There was a statistical significant improvement in making a correct diagnosis of birth asphyxia from 60% (n = 66) in the initial audit to 81% (n = 89) in the final audit (p = 0.001). The percentage of neonates who were given correct treatment improved from 18.7% (17/91) in the initial audit to 81% (71/88) in the re-audit (p = 0.000). The feeding of neonates born with birth asphyxia increased from 12.7% (n = 14) in the initial audit to 56.4% (n = 62) in the final audit (p = 0.000). Ward rounds conducted by clinicians improved from 0% (n = 0) in the baseline audit to 72% (n = 79) in the re-audit (p = 0.000). Weighing of neonates once daily increased from 49.1% (n = 54) in the initial audit to 93% (n = 102) in the final audit (p = 0.000). All neonatal conditions 100% (n = 110) (p = 1) were explained to their parents/guardians in both initial and final audits. There was no statistical significant improvement on suctioning the secretion in the initial audit 47.1% (8/17) and 77% (10/13) in the final audit (p = 0.183). Table 4 Attainment of standard criteria for management of birth asphyxia at Balaka district hospital SN Criteria Initial CBA Final CBA P-value (n = 110) (n = 110) 1 Adequate initial assessment 110(100%) 110(100%) 1 2 Checking vital signs 88(80%) 108(98.2%) 0.000 3 Observations 95(86.4%) 108(98.2%) 0.001 4 Thermo support 91(82.7%) 101(91.8%) 0.041 5 Explaining findings 110(100%) 110(100%) 1 6 Appropriate investigations 1(0.9%) 81(74%) 0.000 7 Correct diagnosis 66(60%) 89(81%) 0.001 8 Correct treatment 17/91 (18.7%) 71 / 88 (81%) 0.000 9 Feeding 14(12.7%) 62(56.4%) 0.000 10 Ward round by clinicians 0(0%) 79(72%) 0.000 11 Weight checked daily 54(49.1%) 102(93%) 0.000 12 Suctioning of secretions 8/17 (47.1%) 10/13 (77%) 0.183 4. Discussion This paper has presented the introduction of CBA on the management of birth asphyxia at Balaka district hospital in Malawi and lessons learned from the baseline assessment. This study reveals that using a CBA can be a valuable tool and a leading step in commencing the process of improving quality of care at hospital level. The introduction of the CBA created a chance to reflect on current practice, increased awareness, and motivated health care workers at the district hospital to be in control of improving future practice. There was a significant improvement in quality of patient care in the re-audit within the limited resources available. These improvements were observed within six months after implementation of the recommendations from the baseline audit. The improvements were seen in almost all aspects of care; in particular conducting the investigations, making correct diagnosis, correct treatment, feeding patients and ward rounds by clinicians. Self-initiatives to improve newborn quality care in resource limited countries which are self-driven without summoning external resources are crucial where neonatal mortality and morbidity is still high. Kidanto et al. [ 19 ] reported that self-assessment of an institution before and after auditing is important because it helps to identify underutilised existing resources by reorganisation before calling for external help. In addition, Pinedo [ 20 ] found that transparency in the self-evaluation process positively influenced stakeholder involvement and commitment to the process, as well as the efficiency and effectiveness of the process. The care of neonates with birth asphyxia improved from 54% in initial audit to 86% in re-audit. The key to improvement of quality care for neonates with birth asphyxia using CBA were provision of locally available resources, good leadership and support from hospital management, supportive mentorships and team work among healthcare workers. Other studies have also reported that the level to which CBA may improve the quality of care provided to patients depends on having effective health systems, leadership and involvement of care providers even in low resource setting [ 15 , 16 ]. There was a significant improvement in making a correct diagnosis of birth asphyxia from 60% in baseline audit to 81% in re-audit. During the meeting where baseline results were shared, healthcare workers admitted that there was knowledge and skill gap to diagnose birth asphyxia. The argument was that in our local setting, the diagnosis of birth asphyxia solely depends on Apgar score which is a conventional method subjected to many errors. Ahearne [ 21 ] indicated that Apgar score has subjective nature, which leads to high levels of inter-observer variability. Unlike in developed countries where an Apgar score of < 7 depicts asphyxia, there is an add-on of umbilical cord pH value of < 7 that gives evidence of neurologic involvement (e.g., seizures, altered tone, coma) which is more objective and accurate as recommended by the American College of Obstetricians and Gynaecologists and American Academy of Paediatrics [ 22 ]. Similarly, Dr. Virginia Apgar, the founder of Apgar score recommended that the person carrying out the delivery should not be the one assigning the Apgar score as they could have a vested interest in the neonatal outcome, and also have divided attention in view of the need for continual maternal management [ 23 ]. Furthermore, Njie et al. [ 22 ] found that healthcare professionals without access to an Apgar scoring chart were more likely to inaccurately classify asphyxia compared to their counterparts with access to an Apgar scoring chart. The team at Balaka district hospital during the meeting agreed to have sessions of supportive mentorship on how to conduct Apgar score among midwives and clinicians working in labour ward, post Apgar score chat on each and every delivery bed and let a colleague assist in conducting Apgar score. After six months of implementation of these interventions, the Apgar scoring improved, consequently the process of making a diagnosis of birth asphyxia improved as well. The percentage of neonates with appropriate investigations (full blood count and random blood sugar) done increased from 0.9% in the initial audit to 74% in re-audit. Glucose is an essential source of energy for the neonate. It has been recognized for many years that both high and low blood glucose levels may be dangerous to the newborn baby [ 24 ]. Therefore, it is essential to have accurate and regular monitoring of blood glucose concentrations so that prolonged periods of disordered blood glucose homeostasis may be prevented. Blood sugar should be maintained in the normal range. If need arises a dextrose infusion should be initiated [ 25 ]. Hypoglycaemia should be treated as soon as possible to prevent complications of neurologic damage in sick neonates [ 26 ]. Early feeding of the newborn with breast milk or formula is encouraged. In this study, feeding of neonates born with birth asphyxia increased from 12.7% in the initial audit to 56.4% in the final audit. Neonates born with birth asphyxia have breastfeeding difficulties. Therefore, efforts to initiate feeding through cup or orogastric tube with expressed breast milk should commence as soon as possible. Niermeyer et al. [ 27 ] documented the importance of starting tube feeding early among sick neonates with expressed breast milk in order to avoid hypoglycaemia. It should be noted that feeding of sick neonates with expressed milk is weight dependent, as such, it is important that sick neonates are weighed daily. This study shows that weighing of sick neonates improved from 49.1% in initial audit to 93% in re-audit. There is need of interprofessional team role in assessing and treating neonates with birth asphyxia in order to avoid disordered blood glucose homeostasis. The CBA in this study improved interprofessional team role as ward rounds conducted by Clinicians increased from 0% in baseline audit to 72% in re-audit. Nyikuri et al. [ 28 ] indicated that team work among healthcare providers improve quality of care for the patients through joint ward rounds and regular consultation between clinicians and nurses. The provision of thermo support increased from 82.7% in the initial audit to 91.8% in the final audit. Neonatal hypothermia is not only a universal health problem but also a common condition on admission. Long-term hypothermia will cause cell metabolism disorder, increased oxygen consumption, hypoglycaemia, acidosis and circulatory and respiratory problems in neonates, which can lead to various severe complications and even death [ 29 ]. Therefore, it important that healthcare providers use locally available resources to keep asphyxiated neonates warm and prevent hypothermia. The midwives should thoroughly dry the babies soon after birth, properly wrap the babies in a dry cloths and keep babies warm when transporting them to nursery ward. Shikuku et al. [ 30 ] showed that even in resource limited settings, many babies with birth asphyxia only require simple interventions such as drying and airway clearance in cases of airway obstruction due to secretions and ensuring that the babies are kept warm and that may be all required to prevent most of the neonatal deaths due to birth asphyxia. Although not all asphyxiated neonates need suctioning of secretions, the CBA in current study improved the skills of nurses and clinicians in performing suctioning of secretions from 47.1–77% by conducting supportive mentorship sessions. The percentage of neonates who were given correct treatment improved from 18.7% in the initial audit to 81% in re-audit. According to care of the infant and newborn guidelines in Malawi, the treatment for birth asphyxia will depend on when and how the condition is presenting. Some strategies medical providers use to treat birth asphyxia include oxygen supplementation and breathing support among infants with signs of oxygen deprivation. The neonate who have gasping respiration or absence of respiration, immediate assisted ventilation should be provided. Drugs like Phenobarbitone can be considered in case of seizures [ 25 ]. Antibiotics are not indicated to all neonates with birth asphyxia, instead a proper assessment should be conducted if antibiotics are to be given such as neonates born to mothers who had prolonged rupture of membrane more than 18 hours which is a risk of neonatal sepsis [ 31 ]. During the audit exercise, the evaluators made sure that the indication for treatment, dosage of the drugs, frequency & route of the drugs was documented in case notes of the patient. Although, there was a successful CBA implementation through involvement of all key stakeholders and selection of realistic interventions, some challenges were observed, These included; poor quality of some selected cases notes, transfer and rotation of mentored staffs to other facilities or wards within the study facility and inadequate knowledge and skills to properly identify a neonate who needed Continuous Positive Airway Pressure (CPAP). Most of these challenges were resolved by the very process of criterion based audit. One limitation of this study is that the study period was short to detect significant reduction of case fatality rate. However, there was enough sample power to detect significant improvement in quality care. 4.1. Conclusion The criterion based audit improved the quality of care for neonates with birth asphyxia at Balaka district hospital in Malawi. Criterion based audit is a low-cost tool that can improve the care of neonates with birth asphyxia in resource-limited countries. In order to have a successful CBA, there is need of involvement of all key stakeholders and selection of realistic interventions. Sensitization of staff on the recommended birth asphyxia care guidelines, provision of locally available resources, good leadership and support from hospital management, supportive mentorships and team work among healthcare workers were all key intervention strategies to improving quality care for neonates with birth asphyxia. Abbreviations CBA Criterion-Based Audit CPAP Continuous Positive Airway Pressure DHIS District Health Information Software DHMT District Hospital Management Team EBM Exclusive Breast Feeding HBB Helping Babies Breathe HIMS Health Information Management System IMCI Integrated Management of Childhood Illness PPH Postpartum Haemorrhage SPSS Statistical Package for Social Sciences UNICEF United Nations Children's Fund WHO World Health Organisation Declarations Ethics approval and consent to participate Ethical approval was sought from University of Malawi College of Medicine research and ethics committee with reference number P.02/23/3991. Institutional clearance was granted by Balaka district hospital research and ethics committee. Participant’s identification information such as name and address were delinked from the case files before data collection to ensure anonymity. To achieve this, the data clerks were requested to photocopy all eligible case files having hidden the name and the address. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare no competing interests. Funding Laerdal foundation ( grant number: 2022-0200 ). The funder had no role in the design, execution, analysis of data, or decision to publish. Author Contributions CM: Writing - review & editing, writing original draft, visualization, validation, software, project administration, methodology, investigation, formal analysis, data curation and conceptualization. EMC: Validation, supervision, review, investigation, funding acquisition, resources. EBC: Validation, supervision, investigation and review. MWS: Validation, supervision, investigation and review. LL: Data curation and investigation. LK: Data curation and investigation. CKM: Data curation and investigation Acknowledgments We would like to thank our audit panel members (Maurice Mponda, Evelyn Taibu, Mbalendo Msisya, Samuel Mwale, Piliran Adini, Charity Khobwe, Chancy Phiri, Alfred Ulambo, Ivy Kalinde and Funny Kawawa) and Balaka District Hospital Managers for their support during the study. Authors’ information Chank Mwalweni; MSc in Reproductive Health & BSc in Nursing and Midwifery Professor Ellen Mbweza Chirwa; PhD in Nursing, MSc in Nursing & BSs. Nursing Eveles Banda Chimala; MSc in Reproductive Health & BSc in Nursing Mirriam Window Shaba; MSc in Global Health Implementation & BSc in Nursing and Midwifery Leone Lowole; Medical Doctor (MBBS) Lucia Kasawala; BSc in Child Health Nursing Christina Kalawa Mwakhundi;BSc in Nursing and Midwifery References World Health Organization. New-borns: improving survival and well-being. 2024; https://www.who.int/news-room/fact-sheets/detail/newborn-mortality . Fitzgerald E, Mlotha-Mitole R, Ciccone EJ, Tilly AE, Montijo JM, Lang HJ et al. A pediatric death audit in a large referral hospital in Malawi. BMC Pediatr [Internet]. 2018 Dec [cited 2024 Jun 17];18(1):75. https://bmcpediatr.biomedcentral.com/articles/ 10.1186/s12887-018-1051-9 . Kanyuka M, Ndawala J, Mleme T, Chisesa L, Makwemba M, Amouzou A, et al. Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study. Lancet Glob Health. 2016;4(3):e201–214. National Statistical Office. Malawi Demographic and Health Survey [Internet]. 2015. https://dhsprogram.com/publications/publication-fr319-dhs-final-reports.cfm . UNICEF. Maternal and New-born Health Disparities in Malawi [Internet]. 2021. file:///C:/Users/Al%20Muzdhar%20Computers/Downloads/country%20profile_MWI%20(9).pdf . Malawi Ministry of Health. DHIS2 [Internet]. 2022. https://dhis2.health.gov.mw/dhis-web-commons/security/login.action . Organization WH. Guidelines on basic newborn resuscitation [Internet]. World Health Organization; 2012 [cited 2024 Jun 17]. https://iris.who.int/handle/10665/75157 . Russ JB, Simmons R, Glass HC. Neonatal Encephalopathy: Beyond Hypoxic-Ischemic Encephalopathy. NeoReviews [Internet]. 2021 Mar 1 [cited 2024 Jun 17];22(3):e148–62. https://publications.aap.org/neoreviews/article/22/3/e148/92297/Neonatal-Encephalopathy-Beyond-Hypoxic-Ischemic . Kriebs JM. Guidelines for Perinatal Care, Sixth Edition: By the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Journal of Midwifery & Women’s Health [Internet]. 2010 [cited 2024 May 18];55(2):e37–e37. https://onlinelibrary.wiley.com/doi/abs/ 10.1016/j.jmwh.2009.12.013 . O’Hare BAM, Kawaza K, Mzikamanda R, Molyneux L. Care of the infant and newborn in Malawi (2017): the COIN Course - Participants Manual [Internet]. University of St Andrews; 2016 [cited 2024 May 18]. https://research-repository.st-andrews.ac.uk/handle/10023/12839 . Larson A, McPherson R, Posner J, LaFond A, Ricca J. Scaling Up High-Impact Health Interventions in Complex Adaptive Systems: Lessons from MCHIP. 2015. Haraldsdóttir I, Milanzi Faque B, Thorkelsson T, Gunnlaugsson G. Assessment of improved neonatal ward infrastructure on neonatal health outcomes in southern Malawi. Journal of Global Health Reports [Internet]. 2021 Jul 6 [cited 2024 Jun 11];5. https://www.joghr.org/article/24587-assessment-of-improved-neonatal-ward-infrastructure-on-neonatal-health-outcomes-in-southern-malawi . Löwensteyn YN, Housseine N, Masina T, Browne JL, Rijken MJ. Birth asphyxia following delayed recognition and response to abnormal labour progress and fetal distress in a 31-year-old multiparous Malawian woman. BMJ Case Rep [Internet]. 2019 Sep [cited 2024 Jun 11];12(9):e227973. https://casereports.bmj.com/lookup/doi/ 10.1136/bcr-2018-227973 . Tewesa E, Chirwa E, Majamanda MD, Maluwa A, Chimwaza A. Associative Factors for Birth Asphyxia at Queen Elizabeth Central Hospital—Malawi. JBM [Internet]. 2017 [cited 2024 Jun 11];05(05):22–31. http://www.scirp.org/journal/doi.aspx?DOI=10.4236/jbm .2017.55003. Tura AK, Aboul-Ela Y, Fage SG, Ahmed SS, Scherjon S, van Roosmalen J et al. Introduction of Criterion-Based Audit of Postpartum Hemorrhage in a University Hospital in Eastern Ethiopia: Implementation and Considerations. Int J Environ Res Public Health [Internet]. 2020 Dec [cited 2022 Mar 19];17(24):9281. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7764538/ . Kayiga H, Ajeani J, Kiondo P, Kaye DK. Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit. BMC Pregnancy Childbirth [Internet]. 2016 Dec [cited 2022 Mar 13];16(1):152. http://bmcpregnancychildbirth.biomedcentral.com/articles/ 10.1186/s12884-016-0949-1 . Mgaya AH, Litorp H, Kidanto HL, Nyström L, Essén B. Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania. BMC Pregnancy and Childbirth [Internet]. 2016 Nov 8 [cited 2022 Mar 13];16(1):343. https://doi.org/10.1186/s12884-016-1137-z . National Statistical Office. Malawi Population and Housing Census [Internet]. 2018. https://malawi.unfpa.org/sites/default/files/resource-pdf/2018%20Malawi%20Population%20and%20Housing%20Census%20Main%20Report%20%281%29.pdf . Kidanto HL, Wangwe P, Kilewo CD, Nystrom L, Lindmark G. Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. Bridging the quality gap. BMC Pregnancy Childbirth [Internet]. 2012 Dec [cited 2024 Jun 17];12(1):134. https://bmcpregnancychildbirth.biomedcentral.com/articles/ 10.1186/1471-2393-12-134 . Pinedo M, Chiyón I, Pérez F. The Influence of Transparency on Self-Evaluation as Part of the University Accreditation Process in Peru. Procedia - Social and Behavioral Sciences [Internet]. 2012 [cited 2024 Jun 17];46:1069–76. https://linkinghub.elsevier.com/retrieve/pii/S1877042812013791 . Ahearne CE. Short and long term prognosis in perinatal asphyxia: An update. WJCP [Internet]. 2016 [cited 2024 Jun 17];5(1):67. http://www.wjgnet.com/2219-2808/full/v5/i1/67.htm . Njie AE, Nyandiko WM, Ahoya PA, Moutchia JS. A comparative analysis of APGAR score and the gold standard in the diagnosis of birth asphyxia at a tertiary health facility in Kenya. PLOS ONE [Internet]. 2023 May 24 [cited 2024 May 14];18(5):e0285828. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0285828 . Apgar V. The Newborn (APGAR) Scoring System: Reflections and Advice. Pediatric Clinics of North America [Internet]. 1966 Aug 1 [cited 2024 May 14];13(3):645–50. https://www.sciencedirect.com/science/article/pii/S0031395516318740 . Balasundaram P, Dumpa V. Neonatal Hyperglycemia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 May 18]. http://www.ncbi.nlm.nih.gov/books/NBK567769/ . Datta V. Therapeutic Hypothermia for Birth Asphyxia in Neonates. Indian J Pediatr [Internet]. 2017 Mar [cited 2024 May 14];84(3):219–26. http://link.springer.com/ 10.1007/s12098-016-2266-0 . Cranmer H. Neonatal Hypoglycemia: Practice Essentials, Background, Etiology. 2024 Jan 25 [cited 2024 May 18]; https://emedicine.medscape.com/article/802334-overview?form=fpf . Niermeyer S, Robertson NJ, Ersdal HL. Beyond basic resuscitation: What are the next steps to improve the outcomes of resuscitation at birth when resources are limited? Seminars in Fetal and Neonatal Medicine [Internet]. 2018 Oct [cited 2024 Jun 17];23(5):361–8. https://linkinghub.elsevier.com/retrieve/pii/S1744165X18300763 . Nyikuri M, Kumar P, Jones C, English M. But you have to start somewhere… Nurses’ perceptions of what is required to provide quality neonatal care in selected hospitals, Kenya. Wellcome Open Res [Internet]. 2019 Dec 6 [cited 2024 Jun 17];4:195. https://wellcomeopenresearch.org/articles/4-195/v1 . Ting JY, Synnes AR, Lee SK, Shah PS, Canadian Neonatal Network and Canadian Neonatal Follow-Up Network. Association of admission temperature and death or adverse neurodevelopmental outcomes in extremely low-gestational age neonates. J Perinatol. 2018;38(7):844–9. Shikuku DN, Milimo B, Ayebare E, Gisore P, Nalwadda G. Practice and outcomes of neonatal resuscitation for newborns with birth asphyxia at Kakamega County General Hospital, Kenya: a direct observation study. BMC Pediatr [Internet]. 2018 Dec [cited 2024 Jun 17];18(1):167. https://bmcpediatr.biomedcentral.com/articles/ 10.1186/s12887-018-1127-6 . Manan MM, Ibrahim NA, Aziz NA, Zulkifly HH, Al-Worafi YMA, Long CM. Empirical use of antibiotic therapy in the prevention of early onset sepsis in neonates: a pilot study. Arch Med Sci [Internet]. 2016 Jun 1 [cited 2024 May 18];12(3):603–13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889677/ . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Nov, 2024 Read the published version in Maternal Health, Neonatology and Perinatology → Version 1 posted Reviews received at journal 07 Jul, 2024 Reviews received at journal 03 Jul, 2024 Reviews received at journal 26 Jun, 2024 Reviewers agreed at journal 26 Jun, 2024 Reviewers agreed at journal 24 Jun, 2024 Reviewers agreed at journal 23 Jun, 2024 Reviewers agreed at journal 20 Jun, 2024 Reviewers invited by journal 19 Jun, 2024 Editor assigned by journal 17 Jun, 2024 Submission checks completed at journal 17 Jun, 2024 First submitted to journal 17 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4594213","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321697480,"identity":"53eda136-9ddb-4b82-a892-626bbfd283e3","order_by":0,"name":"Chank Mwalweni","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYHACxgNAgodBAshqqAAymZkbCOpB0nIGpIWROC0MYC2NbWBr8WvRnZH84DBPxR0Z/tnNzx7OnFcbzd8O1PKjYhtOLWY30gwO85x5xiNx55i54cZtx3NnHGZsYOw5cxu3ltsJBodz2w7zGEgkmEk+3HYstwGohZmxDZ+W9A+Hc/+BtKR/k3w451jufMJacoC2NIC05JhJbmyoyd1AUMv9NwWH/xw7zCNxI6dMcsaxA7kbgVoO4vXLmeMbH86oOWzPPyN9m2RPTV3uvPOHDz74UYFbCzo4DCYPEK0eCOpIUTwKRsEoGAUjBAAAMKFkTynY55kAAAAASUVORK5CYII=","orcid":"","institution":"Balaka District Hospital","correspondingAuthor":true,"prefix":"","firstName":"Chank","middleName":"","lastName":"Mwalweni","suffix":""},{"id":321697481,"identity":"7342b190-a016-475d-bf54-1d75230c4c48","order_by":1,"name":"Ellen Mbweza Chirwa","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ellen","middleName":"Mbweza","lastName":"Chirwa","suffix":""},{"id":321697482,"identity":"82a01dce-0ca1-48e4-9c3d-4bb184d3d592","order_by":2,"name":"Eveles Banda Chimala","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Eveles","middleName":"Banda","lastName":"Chimala","suffix":""},{"id":321697483,"identity":"e10d480d-e60c-4b81-bb25-c3e368ddb6b2","order_by":3,"name":"Mirriam Window Shaba","email":"","orcid":"","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mirriam","middleName":"Window","lastName":"Shaba","suffix":""},{"id":321697484,"identity":"9c690115-3db8-4ce7-a308-180c585b153d","order_by":4,"name":"Leone Lowole","email":"","orcid":"","institution":"Balaka District Hospital","correspondingAuthor":false,"prefix":"","firstName":"Leone","middleName":"","lastName":"Lowole","suffix":""},{"id":321697485,"identity":"af7116c8-29da-411a-9a08-4c92bf31ea48","order_by":5,"name":"Lucia Kasawala","email":"","orcid":"","institution":"Balaka District Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lucia","middleName":"","lastName":"Kasawala","suffix":""},{"id":321697486,"identity":"2b438742-23bb-473e-bc56-51f5ff4e9a5e","order_by":6,"name":"Christina Kalawa Mwakhundi","email":"","orcid":"","institution":"Balaka District Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christina","middleName":"Kalawa","lastName":"Mwakhundi","suffix":""}],"badges":[],"createdAt":"2024-06-17 12:44:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4594213/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4594213/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40748-024-00191-7","type":"published","date":"2024-11-04T15:57:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60019818,"identity":"a96e36b5-6126-4a79-b29d-dc52c1b1a504","added_by":"auto","created_at":"2024-07-10 15:29:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":85646,"visible":true,"origin":"","legend":"\u003cp\u003eCriterion Based Audit Cycle Adopted from Mgaya et al. [17]\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4594213/v1/340990e7109121b17c4089b4.png"},{"id":68749791,"identity":"7f68a746-01ad-4022-a80f-5c370dc76308","added_by":"auto","created_at":"2024-11-11 16:04:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":877205,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4594213/v1/172a8d90-1186-4c7a-8b8c-59af133c635f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of criterion-based audit in improving quality of neonatal birth asphyxia care at Balaka district hospital in Malawi","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eGlobally, 2.3\u0026nbsp;million newborns die every year during the first 28 days of life and the majority of all neonatal deaths (75%) occur during the first week of life and approximately one million newborns die within the first 24 hours [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Various initiatives such as safe motherhood programme, Helping Babies Breath (HBB), and Integrated Management of Childhood Illness (IMCI) have improved the health of children in Malawi in the last few decades [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The country achieved its fourth World Health Organization Millennium Development Goal to reduce childhood mortality by two-thirds in 2013 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite these gains, Malawi still has a high neonatal mortality ratio of 27 per 1,000 live births [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe three main causes of neonatal deaths in Malawi are prematurity (33%), birth asphyxia (25.8%) and neonatal sepsis (18.6%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Similarly, at Balaka district hospital the leading causes of neonatal mortality are birth asphyxia (37.3%), prematurity and low birth weight (30.8%) and respiratory distress syndrome (15.4%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Birth asphyxia is defined as failure to initiate and sustain spontaneous breathing at birth [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It is characterized by marked impairment of exchange of respiratory gases (oxygen and carbon dioxide) resulting in progressive hypoxemia and hypercapnia, accompanied by marked metabolic acidosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The diagnosis of birth asphyxia can be made when a newborn has (i) Apgar score of \u0026lt;\u0026thinsp;7 at five minutes after birth; (ii) neonatal neurological manifestations (seizures, coma or hypotonia); and (iii) multisystem organ dysfunction [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe first minutes after birth are critical in reducing neonatal mortality. HBB is a simulation-based neonatal resuscitation programme for low resource settings. Larson et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] indicated that HBB has made remarkable achievements in reducing newborn mortality in Malawi. According to the 2020 Malawi emergency obstetric and newborn care survey, Balaka district hospital conducted 100% resuscitation to asphyxiated neonates. However, birth asphyxia remains the leading cause of neonatal death at the facility.\u003c/p\u003e \u003cp\u003eA number of studies in Malawi have been conducted to address the prevalence of birth asphyxia and its associated factors [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, little is known on the quality improvement initiates to improve care of neonates with birth asphyxia. This study aimed to implement a criterion based audit (CBA) in order to improve quality of care for neonates with birth asphyxia through review of cases against explicit criteria and use findings to modify practice as necessary. CBA is a systematic and critical analysis that seeks to improve quality of care through review of cases against explicit criteria and use findings to modify practice as necessary [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe importance of CBA and its effectiveness in improving outcome of care has previously been demonstrated in other resource-limited settings in Uganda, Tanzania and Ethiopia [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In addition, to improving the quality of maternal and neonatal care, CBA was found to enable health care providers to reflect upon their clinical practice, explore their working environment, and give them the opportunity to think of locally applicable recommendations. The CBA was able to detect substandard diagnosis and management of foetal distress in Tanzania, consequently, leading to improved care by using feedback and available resources. Moreover, there was a significant improvement in the management of foetal distress between the baseline and the re-audit (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The study conducted in Ethiopia found that the prevailing quality of postpartum haemorrhage (PPH) management did not meet the majority of the standard criteria. Major areas of substandard care were identified (vital signs monitoring, IV-line setup and fluid administration, typing and cross-matching, and maintenance of a fluid intake/output chart) and locally appropriate recommendations were made to improve the care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The extent to which CBA may improve the quality of care provided to patients is therefore dependent on having effective health systems, leadership and involvement of care providers even in low resource setting [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. While several quality improvement initiatives on birth asphyxia in Malawi have been documented, for instance HBB there is limited information on CBA to improve care of neonates with birth asphyxia. Therefore, this study aimed to implement CBA as a quality improvement tool to systematically and critically evaluate the quality of care for neonates with birth asphyxia at Balaka district hospital in Malawi.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design\u003c/h2\u003e \u003cp\u003eWe conducted criteria based audit at Balaka district hospital in Malawi. A retrospective quantitative approach was employed to assess and evaluate quality of care provided to neonates with birth asphyxia. The audit was implemented following the six steps of CBA cycle as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The initial CBA was executed in June 2023. The initial audit performance was discussed and interventions to improve neonatal care were implemented. After implementing the recommended changes the re-audit was performed in January 2024.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Setting\u003c/h2\u003e \u003cp\u003eThe study took place in nursery ward at Balaka district hospital in Malawi. The country has a population of just over 17.6\u0026nbsp;million [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and 28 districts, one of them being Balaka with a population of 438,379 people. The number of women of childbearing age for the district is about 100,828, representing 23% of the total district population and the expected annual number of deliveries is around 21,919, which is 5% of total district population. Balaka district has a fertility rate of 4.6 higher than the national fertility rate of 4.4. Balaka district hospital was selected as a site for implementation of this quality improvement study because it is one of busy district hospitals in Malawi with an average of 500 deliveries per month and recording high neonatal deaths. The report indicates that Balaka district hospital in fiscal year 2021/2022 had an average of 201 neonatal deaths out of 4732 live births of which birth asphyxia contributed to 37.3% of all deaths [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Audit procedure\u003c/h2\u003e \u003cp\u003eThe standard steps of a clinical audit cycle adopted from Mgaya et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] were followed in this study (Figure. 1). The initial audit was conducted from 1 to 30 June 2023. The final audit was conducted six months after implementing the recommended changes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1. Step 1: Set and agree on criteria of standard practice\u003c/h2\u003e \u003cp\u003eWe used evidence from existing guidelines in Malawi on care of the infant and newborn [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Where necessary, this was supplemented by evidence from World Health Organization manuals and articles from peer reviewed journals. A multidisciplinary team of one doctor, two clinicians, six midwives and one policy maker established the criteria of standard practice during a 5-day workshop which was held in May, 2023. The first day of the workshop was dedicated to equipping the team with principles of CBA. The rest of the days were dedicated to developing criteria of standard practice. A set of 12 standards (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was developed which addressed quality issues related to the management of birth asphyxia. The standards were set according to the prevailing local setting and according to available resources. The developed criteria was pre-tested on ten files with diagnosis of birth asphyxia. Two meetings were conducted in May, 2023 to inform the department members on the standards. Each meeting involved doctors, nurses, midwives, clinicians and District Hospital Management Team (DHMT) members. In total, 35 members from maternity department and six DHMT were oriented on CBA and agreed standards.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of agreed upon criteria for standard management of birth asphyxia at Balaka district hospital.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Adequate initial assessment\u003c/p\u003e \u003cp\u003e\u003cem\u003eAirway (secretions), Breathing (chest resections, apnoea attack), Circulation (skin colour, Coma (AVPU), Convulsions, Dehydration (urine, stool \u0026amp; vomiting), Vital signs (Temperature, respirations rate, pulse rate \u0026amp; oxygen saturation. (all should be assessed and documented during admission)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Appropriate Investigations\u003c/p\u003e \u003cp\u003e\u003cem\u003eRandom Blood Sugar (RBS) checked 12 hourly, Full Blood Count (FBC), check if fever is 38.5\u003c/em\u003e\u003csup\u003e\u003cem\u003e0\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eC for 2 consecutive readings.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Correct diagnosis\u003c/p\u003e \u003cp\u003e\u003cem\u003eApgar\u0026thinsp;\u0026lt;\u0026thinsp;7 at 5 minutes. For neonates not born at hospital should have the following on admission: cyanosis, floppy, convulsions \u0026amp; unable to suck.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Correct Treatment\u003c/p\u003e \u003cp\u003e\u003cem\u003eThe treatment of birth asphyxia depends on the presenting signs, for example; Antibiotics based on FBC results/fever 39\u003c/em\u003e\u003csup\u003e\u003cem\u003e0\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eC/rupture of membranes (ROM)\u0026thinsp;\u0026gt;\u0026thinsp;18hours, Anticonvulsants (Phenobarbitone) given to neonate with convulsions, RBS\u0026thinsp;\u0026lt;\u0026thinsp;45mg/dl (given glucose 10%), Fever\u0026thinsp;\u0026gt;\u0026thinsp;38.5\u003c/em\u003e\u003csup\u003e\u003cem\u003e0\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eC (given antipyretic paracetamol), oxygen saturation\u0026thinsp;\u0026lt;\u0026thinsp;90% (given oxygen therapy). NB: check indication for treatment, dose, frequency \u0026amp; route\u003c/em\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Vital signs monitoring 4 hourly\u003c/p\u003e \u003cp\u003e\u003cem\u003eRespirations, pulse rate, temperature \u0026amp; oxygen saturation checked at least 4 hourly.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Thermal support\u003c/p\u003e \u003cp\u003e\u003cem\u003eAt least one of the following should be done to the neonate; drying, wrapping \u0026amp; putting a neonate on radiant warmer.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Airway management\u003c/p\u003e \u003cp\u003e\u003cem\u003eSuctioning of secretions if present.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Observations\u003c/p\u003e \u003cp\u003e\u003cem\u003eSkin colour, AVPU, convulsions, apneic attack, chest recessions \u0026amp; secretions checked at least 4 hourly.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Daily Weight check\u003c/p\u003e \u003cp\u003e\u003cem\u003eChecked once a day throughout admission period.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Correct Feeding\u003c/p\u003e \u003cp\u003eMethod: Breast/cup/orogastric tube, type of feed: EBM/formula, amount, interval: 2hrly\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Ward rounds by Clinician\u003c/p\u003e \u003cp\u003e\u003cem\u003eTwice a day (Monday- Friday) \u0026amp; once a day (Saturday \u0026amp; Friday\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Explain findings to guardian/parent\u003c/p\u003e \u003cp\u003e\u003cem\u003eExplained at least once a day throughout admission\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2. Step 2: Collect baseline data to measure current practice\u003c/h2\u003e \u003cp\u003eThe current practice was measured by a retrospective review of case notes. A multidisciplinary quality improvement team comprised of one medical doctor, one clinical officer, seven nurse/midwife officers, one clinical technician and two nurse/midwife technicians was established. A two day training was provided to the multidisciplinary team on data extraction. The team reviewed the cases of birth asphyxia from December, 2022 to May, 2023 and extracted the data into a data collection sheet.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3. Step 3: Compare current practice with agreed standards\u003c/h2\u003e \u003cp\u003eThe baseline of current practice was compared with the agreed upon standards of diagnosis and management of birth asphyxia, and the results summarized. The audit evaluators then assessed the fulfilment of the criteria, evaluating the recorded practice against the agreed upon criteria for best practice. In case of disagreement, decisions were based on the consensus of the team members. The decision was also arrived at basing on the principal of not documented, not done.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.3.4. Step 4: Feedback and decision to interventions to improve practice\u003c/h2\u003e \u003cp\u003eAfter analysis of data from the initial audit the results were presented to members of the department at a convened departmental meeting held in June, 2023. The gaps between current practice and standards were discussed and recommendations for improvements were made. Some of the recommendations were to conduct mentorship on Apgar score to midwives and clinicians in labour ward, post Apgar score chat on each and every delivery bed, let a colleague assist in conducting Apgar score, conduct supportive supervisions and mentorships to nurses and clinicians in nursery ward on management of birth asphyxia, have a team leader for each and every shift who can be allocating tasks to team members, conduct joint quarterly meetings between nurses and clinicians in nursery ward, strengthen team work and effective communication among team members and line managers (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The implementation of the recommendations commenced in July, 2023 and was run for six months. This involved assigning a special clinician to nursery ward, training nurses/midwives and clinicians on management of birth asphyxia, conducting supportive supervisions and mentorships.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eRecommended interventions to improve birth asphyxia care\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Post the list of agreed upon criteria for standard management of birth asphyxia in nursery ward\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Conduct mentorship on Apgar score to midwives and clinicians in labour ward, post Apgar score chat on each and every delivery bed and let a colleague assist in conducting Apgar score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Conduct supportive supervisions and mentorships to nurses and clinicians in nursery ward on management of birth asphyxia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Allocate two Clinicians specific for Nursery ward\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Have a team leader for each and every shift who can be allocating tasks to team members\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Conduct joint quarterly meetings between nurses and clinicians in nursery ward\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Clinicians should have a clear written duty roster for nursery ward\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Disciplinary action should follow to clinicians/nurses who do not follow recommended criteria\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Strengthen team work and effective communication among team members and line managers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. DHMT and partners should provide more resource such as glucose strips, stationery and feeding cups\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Commitment to appropriate stock inventory and make good predictions and timely ordering of drugs and supplies from the Central Medical Store in order to prevent unnecessary shortages of drugs and supplies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Strengthen documentation through spot checks of files during handover\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.3.5. Step 5: Implementation of recommended interventions\u003c/h2\u003e \u003cp\u003eThe summary of recommended interventions were presented to all cadre providing care at neonatal unit. The neonatal unit staff and management team worked jointly to implement the recommendations for a period of six months. The team were supported with basic resources to provide standard care based on identified needs. The resource included thermometers, heaters, suctioning machine, penguin suckers, glucometer, glucose strips and stationery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.3.6. Step 6: Re-evaluation of practice\u003c/h2\u003e \u003cp\u003eAfter implementation of the recommendations from the initial audit, a re-audit was conducted from January, 2024 to February, 2024 to assess the progress. The data collection procedure was done in the same way as in the initial audit. The outcome was evaluated by comparing the initial and re-audit results by percentage.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Study Population\u003c/h2\u003e \u003cp\u003eThe study population was all neonates with birth asphyxia, born at gestation of 28 weeks and above, who received healthcare at Balaka district hospital. The sick neonatal register for Balaka district hospital shows that the institution admitted 483 neonates with birth asphyxia in fiscal year 2021/2022.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1. Inclusion criteria\u003c/h2\u003e \u003cp\u003eAll neonates born at 28 weeks gestation and above who were admitted in nursery ward with a diagnosis of birth asphyxia.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.4.2. Exclusion criteria\u003c/h2\u003e \u003cp\u003eAsphyxiated neonates born at 28 weeks gestation and above with extreme low birth weight of less than 1000g and neonates born with congenital abnormality were excluded as their chances for survival are minimal.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Sample size determination\u003c/h2\u003e \u003cp\u003eThe sample size was determined by using Yamane Taro\u0026rsquo;s method (Yamane, 1967:886) of sample size determination which assumes a 95% level of confidence and p\u0026thinsp;=\u0026thinsp;0.5. Yamane\u0026rsquo;s formula n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(=\\frac{N}{1+N\\left({e}^{2}\\right)}\\)\u003c/span\u003e\u003c/span\u003e where; n\u0026thinsp;=\u0026thinsp;sample size, N\u0026thinsp;=\u0026thinsp;total population which is 483. e\u0026thinsp;=\u0026thinsp;margin of error\u0026thinsp;=\u0026thinsp;5% (0.05); the level of precision. The sample size for this study was calculated as follows: n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(=\\frac{N}{1+N\\left({e}^{2}\\right)}\\)\u003c/span\u003e\u003c/span\u003e, n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(=\\frac{483}{1+483\\left(0.05*0.05\\right)}\\)\u003c/span\u003e\u003c/span\u003e and n\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(=\\frac{483}{2.2075}\\)\u003c/span\u003e\u003c/span\u003e = 219. Therefore, the calculated sample for the audit was 219 case files of neonates diagnosed with birth asphyxia. Audits were done twice (baseline and six months after interventions) and each time 110 files were selected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Sampling Technique\u003c/h2\u003e \u003cp\u003eThe case files were selected using a systematic random sampling technique with an interval of two, where the interval constant was obtained by dividing the total number of case files with diagnosis of asphyxia by the sample size.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Data Analysis\u003c/h2\u003e \u003cp\u003eData were extracted using a data extraction sheet containing all variables of interest and entered into a data based created in Statistical Package for Social Sciences (SPSS) software. Analysis was performed using SPSS statistics version 22. Differences in neonatal characteristics between neonates participating in the initial audit and the re-audit were analysed using chi-square test and differences in the percentage of neonates that attained the recommended standard at the initial audit and the re-audit were analysed using Student t-test. Level of statistically significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Characteristics of the study participants\u003c/h2\u003e \u003cp\u003eA total of 220 neonatal cases of birth asphyxia were included in this study whereby 110 cases were analysed during each audit (initial and final audits). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the characteristics of the study participants, where there were no significant differences in the characteristics of participants in the two audits. The mean mother\u0026rsquo;s age of the participants in the initial audit was 23\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 years while that of the final audit was 23\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4 years. The mean gestation age of participants at birth was 37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 weeks in the initial audit and 37.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 weeks in the final audit. The mean birth weight of participant in the initial audit was 2943\u0026thinsp;\u0026plusmn;\u0026thinsp;478 grams, while in final audit was 2865\u0026thinsp;\u0026plusmn;\u0026thinsp;477 grams. The mean time interval between delivery and admission in nursery ward was 131\u0026thinsp;\u0026plusmn;\u0026thinsp;26 minutes in the initial audit and 105\u0026thinsp;\u0026plusmn;\u0026thinsp;14 minutes in the final audit. Most of the participants 50% (n\u0026thinsp;=\u0026thinsp;50) and 56.4% (n\u0026thinsp;=\u0026thinsp;62) were born through spontaneous vertex delivery in the initial and final audits respectively. Concerning the place of delivery, majority (97.3%, n\u0026thinsp;=\u0026thinsp;107) were born at Balaka district hospital in both initial and final audits.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the study participants admitted in nursery ward due to birth asphyxia at Balaka district hospital\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInitial CBA Final CBA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD) n (%) Mean (SD) n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMothers\u0026rsquo; age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23(5.6) 23(6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestation age at birth (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.4(1.5) 37.7(1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth weight (grams)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2943(478) 2865(477)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime interval between birth\u003c/p\u003e \u003cp\u003eand admission in nursery ward (Minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131(26) 105(14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode of delivery\u003c/p\u003e \u003cp\u003eSVD\u003c/p\u003e \u003cp\u003eCaesarean section\u003c/p\u003e \u003cp\u003eBreech\u003c/p\u003e \u003cp\u003eVacuum extraction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55(50) 62(56.4)\u003c/p\u003e \u003cp\u003e40(36.4) 39(35.5)\u003c/p\u003e \u003cp\u003e6(5.5) 6(5.5)\u003c/p\u003e \u003cp\u003e9(8.1) 3(2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelivery place\u003c/p\u003e \u003cp\u003eBalaka district hospital\u003c/p\u003e \u003cp\u003eHealth centres\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107(97.3) 107(97.3)\u003c/p\u003e \u003cp\u003e3(2.7) 3(2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Attainment of standard criteria for management of birth asphyxia at Balaka district hospital\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the results of the criteria-based audit of the clinical management before and after implementation of the interventions. The re-audit showed significant improvements in many of the set criteria for quality care of birth asphyxia as compared to the initial audit. The mean patient care increased from 54% in the initial audit to 86% (p\u0026thinsp;=\u0026thinsp;0.000) in the re-audit. Neonatal deaths due to birth asphyxia reduced from 11% in initial audit to 5% in the final audit.\u003c/p\u003e \u003cp\u003eThe initial assessment on admission was adequate 100% (n\u0026thinsp;=\u0026thinsp;110) in both initial and final audits (p\u0026thinsp;=\u0026thinsp;1). Checking of vital signs improved from 80% (n\u0026thinsp;=\u0026thinsp;88) to 98.2% (n\u0026thinsp;=\u0026thinsp;108) (p\u0026thinsp;=\u0026thinsp;0.000) from the initial audit to the final audit respectively. Percentage of neonates with appropriate investigations done increased from 0.9% (n\u0026thinsp;=\u0026thinsp;1) in the initial audit to 74% (n\u0026thinsp;=\u0026thinsp;81) in the re-audit (p\u0026thinsp;=\u0026thinsp;0.000). There was a statistical significant improvement in conducting observations from 86.4% (n\u0026thinsp;=\u0026thinsp;95) in the initial audit to 98.2% (n\u0026thinsp;=\u0026thinsp;108) in the re-audit (p\u0026thinsp;=\u0026thinsp;0.018). The provision of thermo support increased from 82.7% (n\u0026thinsp;=\u0026thinsp;91) in the initial audit to 91.8% (n\u0026thinsp;=\u0026thinsp;101) in the final audit (p\u0026thinsp;=\u0026thinsp;0.041). There was a statistical significant improvement in making a correct diagnosis of birth asphyxia from 60% (n\u0026thinsp;=\u0026thinsp;66) in the initial audit to 81% (n\u0026thinsp;=\u0026thinsp;89) in the final audit (p\u0026thinsp;=\u0026thinsp;0.001). The percentage of neonates who were given correct treatment improved from 18.7% (17/91) in the initial audit to 81% (71/88) in the re-audit (p\u0026thinsp;=\u0026thinsp;0.000). The feeding of neonates born with birth asphyxia increased from 12.7% (n\u0026thinsp;=\u0026thinsp;14) in the initial audit to 56.4% (n\u0026thinsp;=\u0026thinsp;62) in the final audit (p\u0026thinsp;=\u0026thinsp;0.000). Ward rounds conducted by clinicians improved from 0% (n\u0026thinsp;=\u0026thinsp;0) in the baseline audit to 72% (n\u0026thinsp;=\u0026thinsp;79) in the re-audit (p\u0026thinsp;=\u0026thinsp;0.000). Weighing of neonates once daily increased from 49.1% (n\u0026thinsp;=\u0026thinsp;54) in the initial audit to 93% (n\u0026thinsp;=\u0026thinsp;102) in the final audit (p\u0026thinsp;=\u0026thinsp;0.000). All neonatal conditions 100% (n\u0026thinsp;=\u0026thinsp;110) (p\u0026thinsp;=\u0026thinsp;1) were explained to their parents/guardians in both initial and final audits. There was no statistical significant improvement on suctioning the secretion in the initial audit 47.1% (8/17) and 77% (10/13) in the final audit (p\u0026thinsp;=\u0026thinsp;0.183).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAttainment of standard criteria for management of birth asphyxia at Balaka district hospital\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCriteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInitial CBA Final CBA P-value\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;110) (n\u0026thinsp;=\u0026thinsp;110)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdequate initial assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110(100%) 110(100%) 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChecking vital signs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88(80%) 108(98.2%) 0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95(86.4%) 108(98.2%) 0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThermo support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91(82.7%) 101(91.8%) 0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplaining findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110(100%) 110(100%) 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAppropriate investigations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(0.9%) 81(74%) 0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrect diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66(60%) 89(81%) 0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrect treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e17/91\u003c/b\u003e(18.7%) \u003cb\u003e71\u003c/b\u003e/\u003cb\u003e88\u003c/b\u003e(81%) 0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(12.7%) 62(56.4%) 0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWard round by clinicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0%) 79(72%) 0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeight checked daily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54(49.1%) 102(93%) 0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuctioning of secretions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e8/17\u003c/b\u003e(47.1%) \u003cb\u003e10/13\u003c/b\u003e(77%) 0.183\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis paper has presented the introduction of CBA on the management of birth asphyxia at Balaka district hospital in Malawi and lessons learned from the baseline assessment. This study reveals that using a CBA can be a valuable tool and a leading step in commencing the process of improving quality of care at hospital level. The introduction of the CBA created a chance to reflect on current practice, increased awareness, and motivated health care workers at the district hospital to be in control of improving future practice.\u003c/p\u003e \u003cp\u003eThere was a significant improvement in quality of patient care in the re-audit within the limited resources available. These improvements were observed within six months after implementation of the recommendations from the baseline audit. The improvements were seen in almost all aspects of care; in particular conducting the investigations, making correct diagnosis, correct treatment, feeding patients and ward rounds by clinicians. Self-initiatives to improve newborn quality care in resource limited countries which are self-driven without summoning external resources are crucial where neonatal mortality and morbidity is still high. Kidanto et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported that self-assessment of an institution before and after auditing is important because it helps to identify underutilised existing resources by reorganisation before calling for external help. In addition, Pinedo [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] found that transparency in the self-evaluation process positively influenced stakeholder involvement and commitment to the process, as well as the efficiency and effectiveness of the process.\u003c/p\u003e \u003cp\u003eThe care of neonates with birth asphyxia improved from 54% in initial audit to 86% in re-audit. The key to improvement of quality care for neonates with birth asphyxia using CBA were provision of locally available resources, good leadership and support from hospital management, supportive mentorships and team work among healthcare workers. Other studies have also reported that the level to which CBA may improve the quality of care provided to patients depends on having effective health systems, leadership and involvement of care providers even in low resource setting [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere was a significant improvement in making a correct diagnosis of birth asphyxia from 60% in baseline audit to 81% in re-audit. During the meeting where baseline results were shared, healthcare workers admitted that there was knowledge and skill gap to diagnose birth asphyxia. The argument was that in our local setting, the diagnosis of birth asphyxia solely depends on Apgar score which is a conventional method subjected to many errors. Ahearne [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] indicated that Apgar score has subjective nature, which leads to high levels of inter-observer variability. Unlike in developed countries where an Apgar score of \u0026lt;\u0026thinsp;7 depicts asphyxia, there is an add-on of umbilical cord pH value of \u0026lt;\u0026thinsp;7 that gives evidence of neurologic involvement (e.g., seizures, altered tone, coma) which is more objective and accurate as recommended by the American College of Obstetricians and Gynaecologists and American Academy of Paediatrics [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similarly, Dr. Virginia Apgar, the founder of Apgar score recommended that the person carrying out the delivery should not be the one assigning the Apgar score as they could have a vested interest in the neonatal outcome, and also have divided attention in view of the need for continual maternal management [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, Njie et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] found that healthcare professionals without access to an Apgar scoring chart were more likely to inaccurately classify asphyxia compared to their counterparts with access to an Apgar scoring chart. The team at Balaka district hospital during the meeting agreed to have sessions of supportive mentorship on how to conduct Apgar score among midwives and clinicians working in labour ward, post Apgar score chat on each and every delivery bed and let a colleague assist in conducting Apgar score. After six months of implementation of these interventions, the Apgar scoring improved, consequently the process of making a diagnosis of birth asphyxia improved as well.\u003c/p\u003e \u003cp\u003eThe percentage of neonates with appropriate investigations (full blood count and random blood sugar) done increased from 0.9% in the initial audit to 74% in re-audit. Glucose is an essential source of energy for the neonate. It has been recognized for many years that both high and low blood glucose levels may be dangerous to the newborn baby [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, it is essential to have accurate and regular monitoring of blood glucose concentrations so that prolonged periods of disordered blood glucose homeostasis may be prevented. Blood sugar should be maintained in the normal range. If need arises a dextrose infusion should be initiated [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Hypoglycaemia should be treated as soon as possible to prevent complications of neurologic damage in sick neonates [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Early feeding of the newborn with breast milk or formula is encouraged. In this study, feeding of neonates born with birth asphyxia increased from 12.7% in the initial audit to 56.4% in the final audit. Neonates born with birth asphyxia have breastfeeding difficulties. Therefore, efforts to initiate feeding through cup or orogastric tube with expressed breast milk should commence as soon as possible. Niermeyer et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] documented the importance of starting tube feeding early among sick neonates with expressed breast milk in order to avoid hypoglycaemia. It should be noted that feeding of sick neonates with expressed milk is weight dependent, as such, it is important that sick neonates are weighed daily. This study shows that weighing of sick neonates improved from 49.1% in initial audit to 93% in re-audit. There is need of interprofessional team role in assessing and treating neonates with birth asphyxia in order to avoid disordered blood glucose homeostasis. The CBA in this study improved interprofessional team role as ward rounds conducted by Clinicians increased from 0% in baseline audit to 72% in re-audit. Nyikuri et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] indicated that team work among healthcare providers improve quality of care for the patients through joint ward rounds and regular consultation between clinicians and nurses.\u003c/p\u003e \u003cp\u003eThe provision of thermo support increased from 82.7% in the initial audit to 91.8% in the final audit. Neonatal hypothermia is not only a universal health problem but also a common condition on admission. Long-term hypothermia will cause cell metabolism disorder, increased oxygen consumption, hypoglycaemia, acidosis and circulatory and respiratory problems in neonates, which can lead to various severe complications and even death [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Therefore, it important that healthcare providers use locally available resources to keep asphyxiated neonates warm and prevent hypothermia. The midwives should thoroughly dry the babies soon after birth, properly wrap the babies in a dry cloths and keep babies warm when transporting them to nursery ward. Shikuku et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] showed that even in resource limited settings, many babies with birth asphyxia only require simple interventions such as drying and airway clearance in cases of airway obstruction due to secretions and ensuring that the babies are kept warm and that may be all required to prevent most of the neonatal deaths due to birth asphyxia. Although not all asphyxiated neonates need suctioning of secretions, the CBA in current study improved the skills of nurses and clinicians in performing suctioning of secretions from 47.1\u0026ndash;77% by conducting supportive mentorship sessions.\u003c/p\u003e \u003cp\u003eThe percentage of neonates who were given correct treatment improved from 18.7% in the initial audit to 81% in re-audit. According to care of the infant and newborn guidelines in Malawi, the treatment for birth asphyxia will depend on when and how the condition is presenting. Some strategies medical providers use to treat birth asphyxia include oxygen supplementation and breathing support among infants with signs of oxygen deprivation. The neonate who have gasping respiration or absence of respiration, immediate assisted ventilation should be provided. Drugs like Phenobarbitone can be considered in case of seizures [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Antibiotics are not indicated to all neonates with birth asphyxia, instead a proper assessment should be conducted if antibiotics are to be given such as neonates born to mothers who had prolonged rupture of membrane more than 18 hours which is a risk of neonatal sepsis [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. During the audit exercise, the evaluators made sure that the indication for treatment, dosage of the drugs, frequency \u0026amp; route of the drugs was documented in case notes of the patient.\u003c/p\u003e \u003cp\u003eAlthough, there was a successful CBA implementation through involvement of all key stakeholders and selection of realistic interventions, some challenges were observed, These included; poor quality of some selected cases notes, transfer and rotation of mentored staffs to other facilities or wards within the study facility and inadequate knowledge and skills to properly identify a neonate who needed Continuous Positive Airway Pressure (CPAP). Most of these challenges were resolved by the very process of criterion based audit. One limitation of this study is that the study period was short to detect significant reduction of case fatality rate. However, there was enough sample power to detect significant improvement in quality care.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Conclusion\u003c/h2\u003e \u003cp\u003eThe criterion based audit improved the quality of care for neonates with birth asphyxia at Balaka district hospital in Malawi. Criterion based audit is a low-cost tool that can improve the care of neonates with birth asphyxia in resource-limited countries. In order to have a successful CBA, there is need of involvement of all key stakeholders and selection of realistic interventions. Sensitization of staff on the recommended birth asphyxia care guidelines, provision of locally available resources, good leadership and support from hospital management, supportive mentorships and team work among healthcare workers were all key intervention strategies to improving quality care for neonates with birth asphyxia.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Criterion-Based Audit\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCPAP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Continuous Positive Airway Pressure\u003c/p\u003e\n\u003cp\u003eDHIS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;District Health Information Software\u003c/p\u003e\n\u003cp\u003eDHMT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;District Hospital Management Team\u003c/p\u003e\n\u003cp\u003eEBM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Exclusive Breast Feeding\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHBB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Helping Babies Breathe\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIMS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Health Information Management System\u003c/p\u003e\n\u003cp\u003eIMCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Integrated Management of Childhood Illness\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePPH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Postpartum Haemorrhage\u003c/p\u003e\n\u003cp\u003eSPSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Statistical Package for Social Sciences\u003c/p\u003e\n\u003cp\u003eUNICEF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;United Nations Children\u0026apos;s Fund\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organisation\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was sought from University of Malawi College of Medicine research and ethics committee with reference number\u0026nbsp;P.02/23/3991. Institutional clearance was granted by Balaka district hospital\u0026nbsp;research and ethics committee. Participant\u0026rsquo;s identification information such as name and address were delinked from the case files before data collection to ensure anonymity. To achieve this, the data clerks were requested to photocopy all eligible case files having hidden the name and the address.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLaerdal foundation (\u003cstrong\u003egrant number: 2022-0200\u003c/strong\u003e). The funder had no role in the design, execution, analysis of data, or decision to publish.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCM: Writing - review \u0026amp; editing, writing original draft, visualization, validation, software, project administration, methodology, investigation, formal analysis, data curation and conceptualization. EMC: Validation, supervision, review, investigation, funding acquisition, resources. \u0026nbsp;EBC: Validation, supervision, investigation and review. MWS: Validation, supervision, investigation and review. LL: Data curation and investigation. LK: Data curation and investigation. CKM: Data curation and investigation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank our audit panel members (Maurice Mponda, Evelyn Taibu, Mbalendo Msisya, Samuel Mwale, Piliran Adini, Charity Khobwe, Chancy Phiri, Alfred Ulambo, Ivy Kalinde and Funny Kawawa) and Balaka District Hospital Managers for their support during the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; information\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eChank Mwalweni; MSc in Reproductive Health \u0026amp; BSc in Nursing and Midwifery\u003c/li\u003e\n \u003cli\u003eProfessor Ellen Mbweza Chirwa; PhD in Nursing, MSc in Nursing \u0026amp; BSs. Nursing\u003c/li\u003e\n \u003cli\u003eEveles Banda Chimala; MSc in Reproductive Health \u0026amp; BSc in Nursing\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMirriam Window Shaba; MSc in Global Health Implementation \u0026amp; BSc in Nursing and Midwifery\u003c/li\u003e\n \u003cli\u003eLeone Lowole; Medical Doctor (MBBS)\u003c/li\u003e\n \u003cli\u003eLucia Kasawala; BSc in Child Health Nursing\u003c/li\u003e\n \u003cli\u003eChristina Kalawa Mwakhundi;BSc in Nursing and Midwifery\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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Arch Med Sci [Internet]. 2016 Jun 1 [cited 2024 May 18];12(3):603\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889677/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889677/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"maternal-health-neonatology-and-perinatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mhnp","sideBox":"Learn more about [Maternal Health, Neonatology and Perinatology](http://mhnpjournal.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/mhnp/default.aspx","title":"Maternal Health, Neonatology and Perinatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Birth asphyxia, Criterion-based audit, Quality of care, Balaka, Malawi","lastPublishedDoi":"10.21203/rs.3.rs-4594213/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4594213/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBirth asphyxia remains one of the leading causes of neonatal deaths worldwide with a higher incidence in resource limited countries such as Malawi. At Balaka district hospital, Birth asphyxia is the primary cause of neonatal mortality accounting for 37.3% of the district\u0026rsquo;s neonatal deaths. Although various quality improvement initiatives on birth asphyxia such as Helping Babies Breathe have been documented in Malawi, there is limited information on use of criterion based audit (CBA) to enhance the care of neonates with birth asphyxia. This study aimed to evaluate the effectiveness of criterion-based audit in improving quality of neonatal birth asphyxia care at Balaka district hospital in Malawi.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA CBA on the care of babies born with birth asphyxia was conducted at Balaka district hospital in Malawi. The care practices were assessed through a retrospective review of 110 cases notes and compared with a locally established standards, by a multidisciplinary team, based on the Malawi guidelines on care of the infant and newborn and World Health Organization manuals. The gaps in current practice were identified, reasons discussed, and recommendations made and implemented. A re-audit was conducted on 110 case notes six months after the initial audit.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e The re-audit showed significant improvements in many of the set criteria for quality care: Checking of vital signs (80% vs. 98.2%; p\u0026thinsp;=\u0026thinsp;0.000), appropriate investigations check (0.9% vs. 74%; p\u0026thinsp;=\u0026thinsp;0.000), Thermal support (82.7% vs. 91.8%; p\u0026thinsp;=\u0026thinsp;0.041), Correct diagnosis (60% vs. 81%; p\u0026thinsp;=\u0026thinsp;0.001), Correct treatment (18.7% vs. 81%; p\u0026thinsp;=\u0026thinsp;0.000), Correct Feeding (12.7% vs. 56.4%; p\u0026thinsp;=\u0026thinsp;0.000), Clinicians\u0026rsquo; ward rounds (0% vs. 72%; p\u0026thinsp;=\u0026thinsp;0.000), and Daily weight check (49.1% vs. 93%; p\u0026thinsp;=\u0026thinsp;0.000). Additionally, neonatal death decreased from 11% in initial audit to 5% in the re-audit.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCBA is a low-cost tool that can significantly improve the care of neonates with birth asphyxia in resource-limited countries.\u003c/p\u003e","manuscriptTitle":"Evaluation of criterion-based audit in improving quality of neonatal birth asphyxia care at Balaka district hospital in Malawi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-10 15:29:23","doi":"10.21203/rs.3.rs-4594213/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-07-07T12:22:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-03T18:01:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-26T07:17:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312270078625663694048242090934042195324","date":"2024-06-26T04:05:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77704698414672861265348991812776423527","date":"2024-06-24T21:46:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167522002640313661063151701044389331239","date":"2024-06-23T07:07:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260607779297059929452452573010338464271","date":"2024-06-20T11:50:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-19T14:10:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-18T02:53:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-18T02:52:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Maternal Health, Neonatology and Perinatology","date":"2024-06-17T12:41:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"maternal-health-neonatology-and-perinatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mhnp","sideBox":"Learn more about [Maternal Health, Neonatology and Perinatology](http://mhnpjournal.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/mhnp/default.aspx","title":"Maternal Health, Neonatology and Perinatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9bf2100b-2d2b-4327-8f4e-ea5183a49b0b","owner":[],"postedDate":"July 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-11T15:59:06+00:00","versionOfRecord":{"articleIdentity":"rs-4594213","link":"https://doi.org/10.1186/s40748-024-00191-7","journal":{"identity":"maternal-health-neonatology-and-perinatology","isVorOnly":false,"title":"Maternal Health, Neonatology and Perinatology"},"publishedOn":"2024-11-04 15:57:00","publishedOnDateReadable":"November 4th, 2024"},"versionCreatedAt":"2024-07-10 15:29:23","video":"","vorDoi":"10.1186/s40748-024-00191-7","vorDoiUrl":"https://doi.org/10.1186/s40748-024-00191-7","workflowStages":[]},"version":"v1","identity":"rs-4594213","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4594213","identity":"rs-4594213","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}