Gerald and Patricia Turpanjian School of Public Health Avedisian Onanian Center for Health Services Research and Development Institutional consultancy on Assessing Neonatal Care Services at Maternity and Primary Healthcare Levels in Armenia Study Team: Anahit Demirchyan, MD, MPH Dzovinar Melkom Melkomian, DVM, MPH, MBA Gohar Abelyan, MS, MPH Varduhi Petrosyan, MS, PhD October, 2017 Yerevan Table of Content ABBREVAITONS ........................................................................................................................................ v EXECUTIVE SUMMARY ........................................................................................................................ vii ԱՄՓՈՓՈՒՄ .............................................................................................................................................. x 1. INTRODUCTION ................................................................................................................................ 1 1.1 Study rationale ................................................................................................................................... 1 1.2 Study objectives................................................................................................................................. 2 2. DESK REVIEW OF AVAILABLE SOURCES ................................................................................... 3 2.1 Neonatal mortality as a global target ................................................................................................ 3 2.2 Effective strategies to reduce neonatal mortality .............................................................................. 4 2.3 Current situation with neonatal mortality and neonatal services in Armenia ................................... 9 2.4 Recent initiatives in the field of neonatal care in Armenia ............................................................. 14 2.5 Neonatal care in selected countries that achieved notable reduction of neonatal mortality ............ 16 2.6 The recommended structural features of neonatal services proved to be effective in reducing neonatal mortality ....................................................................................................................................... 21 3. METHODS ......................................................................................................................................... 25 3.1 Study design .................................................................................................................................... 25 3.2 Study setting .................................................................................................................................... 25 3.3 Study participants ............................................................................................................................ 26 3.4 Research instruments ....................................................................................................................... 26 3.5 Data collection and analysis ............................................................................................................ 27 3.6 Categorization of study participants ................................................................................................ 30 3.7 Ethical considerations ...................................................................................................................... 30 4. RESULTS ........................................................................................................................................... 31 4.1 Needs in trainings and clinical guidelines ....................................................................................... 31 4.2 Needs in material and human resources in selected regional neonatal units ................................... 34 4.3 Qualitative study results .................................................................................................................. 41 4.3.1 Organization and adequacy of neonatal services ........................................................................ 41 4.3.1.1 Equity of access to quality maternity and neonatal services in Armenia .................................... 41 4.3.1.2 Selection of a delivery hospital ................................................................................................... 45 4.3.1.3 Availability of equipment at neonatal units of Armenia .............................................................. 48 4.3.1.4 Issues with operating the available equipment ........................................................................... 55 i 4.3.1.5 Referrals between different level neonatal units ......................................................................... 58 4.3.1.6 Need in neonatal services restructuring ..................................................................................... 61 4.3.2 Medical staff of neonatal services ............................................................................................... 64 4.3.2.1 Qualification standards for neonatal nurses and neonatologists in Armenia ............................ 64 4.3.2.2 Issues with current qualification of neonatologists and neonatal nurses in Armenia ................ 66 4.3.2.3 Staff-per-patient rate in different-level neonatal units ................................................................ 70 4.3.2.4 Around-the-clock availability of specialists in maternity hospitals ............................................ 73 4.3.3 Providers’ knowledge, educational needs and quality of inpatient neonatal care ....................... 80 4.3.3.1 Current system of continuous trainings for neonatologists and neonatal nurses ....................... 80 4.3.3.2 Some issues related to the current system of specialty trainings in neonatology ....................... 83 4.3.3.3 Providers’ knowledge and skills on neonatal resuscitation ........................................................ 88 4.3.3.4 Areas for continuing education of neonatal nurses .................................................................... 90 4.3.3.5 Areas for continuous education and information sources for neonatologists ............................ 92 4.3.3.6 Need in clinical guidelines in neonatology ................................................................................. 95 4.3.3.7 Quality of care indicators and work organization in neonatal units of Armenia ....................... 97 4.3.3.8 Fetal antenatal diagnosis and ways for its improvement .......................................................... 102 4.3.3.9 Financial issues, motivation of providers and quality of care .................................................. 106 4.3.4 Family involvement in neonatal care ........................................................................................ 110 4.3.4.1 Family members’ access to their newborn baby in maternity hospitals of Armenia ................ 110 4.3.4.2 Care environment and family centered care in the NICUs of Armenia .................................... 112 4.3.4.3 Conditions for breast milk pumping, storing and feeding at neonatal units ............................. 117 4.3.4.4 Availability of information for parents whose neonates are placed in NICUs ......................... 121 4.3.5 Organizing the transfer of sick newborns ................................................................................. 123 4.3.5.1 The need in ex utero and in utero transfer guidelines .............................................................. 123 4.3.5.2 Vehicles for newborns’ transfer: equipment, staff, and existing problems ............................... 126 4.3.6 Donor projects on neonatal care in Armenia since 2010 .......................................................... 131 4.3.6.1 Content and coverage of the projects ....................................................................................... 131 4.3.6.2 Monitoring and effectiveness of the projects ............................................................................ 134 4.3.6.3 Problems and barriers encountered during the projects .......................................................... 138 4.3.6.4 Future projects by the donors ................................................................................................... 140 4.3.7 Outpatient neonatal care............................................................................................................ 141 4.3.7.1 Ensuring continuity of newborns’ care ..................................................................................... 141 ii 4.3.7.2 Maternal knowledge on newborn care and feeding .................................................................. 148 4.3.7.3 Newborns’ primary healthcare after discharge from maternity hospital ................................. 151 4.3.7.4 Indications for and issues with newborn hospitalization .......................................................... 160 4.3.8 Educational needs of PHC providers on newborn care ............................................................. 162 4.3.8.1 Information sources on neonatal care for PHC providers ....................................................... 162 4.3.8.2 Opportunities for continuous education of pediatricians and pediatric nurses ........................ 163 4.3.8.3 Obstacles for participating in training courses ........................................................................ 166 4.3.8.4