One mother described how the constant beeping of medical machines made her fearful: “All the time the machines beep, if you just hear that sound ‘twitwitwi’ that baby is gone [dead]."
A sick or premature baby in a Kenyan hospital receives only
30 minutes of a nurse’s attention during a 12-hour shift, researchers have
found.
That is due to a critical shortage of neonatal nurses in public hospitals. The researchers said one nurse is often responsible for nearly 20 infants, and sometimes more than 25. By contrast, private hospitals limit nurses to no more than seven babies each.
The researchers, from the Kemri-Wellcome Trust Research Programme (KWTRP) and the Kenya Paediatric Research Consortium (Keprecon), observed nearly 600 babies for more than 1,800 hours in eight public hospitals to capture the reality of missed nursing care.
They observed that overwhelmed nurses often offload their duties to mothers of these babies and nursing students doing rotation in the neonatal wards.
“Nurses deliver roughly one-third of the care a sick newborn needs, while mothers or student nurses provide another third, and about 40 per cent of required care goes completely undone,” said Prof Fred Were, the CEO and chief executive researcher at Keprecon.
The findings were presented in six briefs based on the Harnessing Innovation in Global Health for Quality Care (High-Q) project by Keprecon and Kemri-Wellcome Trust, and related research.
High-Q evaluates how new technologies and workforce innovations influence the quality of care in newborn units (NBUs).
The research team also piloted interventions in four county hospitals, where three additional nurses and three ward assistants (WAs) were introduced to newborn units for periods of up to 15 months.
Kenya Medical Research Institute (Kemri) Director General Prof Elijah Songok said the findings expose a major bottleneck in Kenya’s quest to reduce newborn deaths.
“Nurse shortages and high patient loads can affect the delivery of this care,” he said. “Nurses remain the primary providers of essential care for sick and premature newborns, responsible for managing breathing support, monitoring, feeding, administering medications, providing hygiene, and emergency interventions.”
The briefs indicate that nurses spend a significant portion of their already limited time on non-clinical tasks. Instead of feeding, monitoring and soothing babies, they often end up cleaning equipment, changing linens or fetching supplies. The High-Q observations found that routine tasks such as feeding, monitoring, and repositioning are informally delegated to mothers when nurses are overwhelmed.
One mother described how the constant beeping of medical machines made her fearful: “All the time the machines beep, if you just hear that sound ‘twitwitwi’ that baby is gone [dead]. It gave me a heavy burden in the heart.”
Another recalled being scolded after asking a question: “When I asked something, she [a nurse] answered me harshly. From then on, I just kept quiet. I feared asking again.”
These accounts underline how thinly stretched nurses cannot offer mothers the guidance or reassurance that is essential for family-centred care.
Nurses themselves admitted that under pressure, they prioritised the sickest babies, focusing on life-saving interventions like oxygen therapy, resuscitation or IV medications, while other important tasks (including educating mothers on feeding, hygiene and emotional support) were pushed aside.
A nurse explained, “Sometimes, even the calculation of these doses, we help each other. I appreciate it. The workload, like you used to go in a shift alone [before the intervention], now she [new nurse] has come, you see the workload now is shared.”
The High-Q team tested whether adding more hands on deck could help. They introduced three extra nurses and three trained ward assistants (WAs) to each of the four public newborn units. Adding nurses had only a modest effect: nursing time per baby rose from 34 to 43 minutes per 12-hour shift, a 25 per cent jump, but still far below high-income-country standards. More importantly, it freed some nurses from their isolation and allowed for breaks, mentoring, and better teamwork.
Ward Assistants, however, proved especially impactful. They were trained for a week to focus on non-clinical tasks such as changing diapers, cleaning equipment, preparing feeds, managing waste and guiding mothers.
“By handling non-nursing tasks, WAs enabled nurses to focus on technical tasks,” one brief reports.
The research team found “improved work efficiency among nurses, a sense of support among some nurses, more substantial support for mothers, and better hygiene and infection control” after WAs started work.
Staff reported that WAs helping with laundry, equipment cleaning and basic feeding meant nurses could return to patients sooner and attend medical rounds. Nurses also found they could take breaks and leave when needed, improving morale.
One policy brief titled “Mothers’ experiences and caregiving responsibilities in newborn units”, said mothers felt the difference. It describes WAs guiding new mothers through the unfamiliar ward: “[They] guided new mothers around the unit, helped with tasks like baby cleaning and feeding, and were often more available than nurses to answer questions and give practical help.”
One mother remembered: “The ward assistant showed me how to cup-feed my baby. I had feared I might choke him, but she held my hand and told me not to worry.” Another added, “The ward assistant reminded me to wash my hands every time I touched the baby. She was not harsh, she was kind.”
The evidence shows that shifting such support tasks away from nurses works. For instance, nurses in units with WAs reported smoother teamwork and could focus more on monitoring vital signs, adjusting oxygen and other life-saving duties. Better hygiene followed – wards were cleaner and infection control improved once WAs took over waste disposal and cleaning routines.
Dr Michuki Maina, a paediatrician and health systems researcher at the KEMRI-Wellcome Trust Programme (KWTRP) in Nairobi, said that adding three nurses to already-understaffed units made a difference, but nowhere near what’s needed to close the care gap.
“Meaningful increases in nursing care will require much more significant increases in nurse staffing than the pilot intervention achieved, but these small steps are also important,” he said.
Prof Songok said the findings show that continuous investment is required to achieve the third Sustainable Development Goal on reducing deaths in the first 28 days of life (neonatal mortality) to below 12 deaths per 1,000 live births.
“In Kenya, reducing neonatal mortality from an average 22/1000 live births is part of the government’s efforts to achieve Universal Health Coverage (UHC) and key to this is the role of nursing in neonatal care,” he said.
He urged policymakers to greatly expand the number of neonatal nurses and to formalise the role of ward assistants in every newborn unit.
