Improving Rates of Delayed Cord Clamping in Ethiopian Hospitals: A Virtual Quality Collaborative

Although curricula to teach quality improvement (QI) methodology exist for global settings, ongoing mentorship and support to implement QI practices have not been well established. Leveraging the ECHO methodology, we taught a basic QI curriculum and established a learning community to improve a chosen gap in essential newborn care, delayed cord clamping (DCC).

The Ethiopian Neonatal Quality Improvement (EN-QI) Project was conducted from February 2021 to January 2022 across 8 delivery centers selected by the Ethiopian Pediatrics Society. Each site set a SMART (Specific-Measurable-Attainable-Relevant-Time bound) aim for improvement in DCC. Virtual QI training sessions were held monthly, and site-specific progress was tracked. The primary outcome was the percentage of deliveries at each site that achieved DCC. The process measure was defined as setting an institutional SMART aim, which all sites were able to complete. Each site represented their progress via DCC% line graphs. Post hoc balancing measures included time to first breath and time to skin-to-skin. Outcome measures were analyzed using control charts, with a post hoc analysis assessing average time to cord clamping across all sites.

SMART aim targets ranged from 50% to 90% DCC across sites. Initial rates ranged from 7% to 72%, with 6 of the 8 sites having initial DCC rates at or below 50%. Six months into the project, 7 of the 8 sites had DCC rates above 50%. A combined analysis of all sites included over 3500 observed deliveries and an end-of-project DCC rate above 90%.

Implementation of a remote, virtual peer-led, QI initiative increased the rate of DCC at the 8 participating sites in Addis Ababa. Local QI teams demonstrated the ability to adopt and sustain DCC within their delivery room settings. EN-QI may serve as a model for other QI initiatives in low-resource settings.