Contribution of improved quality of early essential newborn care to neonatal mortality decline in Cambodia, 2010-2022: a retrospective observational study.

Abstract

Between 2005 and 2010, reductions in newborn mortality fell behind those for maternal and under-five child mortality in Cambodia. To improve newborn outcomes, we developed and scaled-up early essential newborn care (EENC) nationally using a new clinical coaching and data-based quality improvement approach. This study aimed to determine EENC's contribution to Cambodia's observed neonatal mortality decline between 2010 and 2022. Standard indicators in the EENC monitoring and evaluation framework were calculated from programme records, nationally representative population-based surveys and facility-based assessments using standardised methods. The Lives Saved Tool (LiST) was used to model newborn lives saved 2010-2022 using facility estimates of care quality. Newborn mortality declined from 27 to 8/1000 live births (70.4%) comparing 2010 and 2022. The average annual rate of newborn mortality decline accelerated by 33% after EENC introduction in 2012 compared with the previous 10 years, with greatest declines among high-risk groups (poorest, rural, uneducated and with low birth interval). Between 2010 and 2022, EENC was integrated into national and subnational policies, standards and implementation plans and introduced to 87.6% of birth facilities. The average birth practice score rose to 72.9% (95% CI 59.0% to 83.4%) in 2022, from 6% (95% CI 1.7% to 20.1%) in 2011. Significant improvements were seen in application of clean birth environments, immediate drying and stimulation, thermal protection (immediate and prolonged skin to skin contact), delayed cord clamping and clean cord care. LiST modelling estimated that EENC interventions averted 21 704 Cambodian newborn deaths (range 17 694-26 450) during 2010-2022 and were responsible for 75.3% (range 69.5%-80.5%) of the observed national mortality reduction. A new approach to EENC programme implementation led to sustained country-wide improvements in evidence-based practices around birth. Improved care quality was associated with 69.5-80.5% of the observed neonatal mortality decline in Cambodia between 2010 and 2022.