Enhancing perinatal care in Rwanda: building quality improvement into system strengthening.

Rwanda has achieved substantial gains in maternal, newborn and child health over the last two decades. But reduction in neonatal mortality has slowed, with most deaths now occurring in hospitals and health centres. Mortality is mainly caused by prematurity, perinatal asphyxia, infection and gaps in quality of care. From 2017 to 2023, the Rwanda Pediatric Association and the Royal College of Paediatrics and Child Health Global, in partnership with UNICEF, the Ministry of Health and Rwanda Biomedical Center, implemented a multiphase programme across 21 hospitals designed to enhance perinatal care, working intensively with nurses, midwives and doctors, integrating in situ clinical training and mentorship with hospital-led quality improvement (QI) processes. Using structured facility baseline assessments, programme-specific quality indicators and Health Management Information System data, we evaluated changes specifically in neonatal quality of care and mortality at 12 hospitals (selected for the original programme phase) where continuous neonatal data were available for the whole period. Substantial improvements were observed in core indicators of quality of care and mortality among newborns admitted to neonatal units decreased from 11.8% in 2017 to 6.2% in 2023 (a 47.5% reduction). QI processes also exposed systemic constraints-including workforce rotation, drug and equipment procurement variability, infrastructure limitations, deficiencies in equipment maintenance and gaps in referral coordination-that shape the feasibility and sustainability of clinical improvements.