Physicians' Industrial Action: An Interrupted Time Series Analysis Assessing Impact in 11 Kenyan Neonatal Units

In the fragile early days of life, a newborn's survival often depends on the steady presence of skilled medical staff. In many parts of the world, including Kenya, public hospitals are the primary safety net for these vulnerable infants, yet they frequently face a unique and severe threat: the absence of doctors. When physicians go on strike to demand better working conditions or resolve compensation disputes, the ripple effects extend far beyond the hospital walls. For newborns, who require constant monitoring and rapid decision-making for complications like infection or breathing difficulties, the removal of the medical team creates a critical gap. The question is not just whether the hospitals remain open, but what happens to the babies who need care when the doctors are gone. Do the most vulnerable infants simply stay home, or do those who do arrive face a different, perhaps more dangerous, reality?

To answer this, researchers turned to a rare and precise moment in time: a 56-day nationwide strike by physicians in Kenya during the spring of 2024. This event involved roughly 4,000 doctors, nearly half of the country's registered medical workforce, and provided a clear window to observe how a health system reacts when its leadership vanishes. The team analyzed records from 11 neonatal units across the country, tracking over 12,000 admissions of sick newborns before, during, and after the walkout. By comparing the flow of patients and their outcomes against what usually happens in those same weeks, the researchers could isolate the specific impact of the strike, separating the effects of the doctors' absence from other seasonal changes in health.

The first and most dramatic change was a sudden, steep drop in the number of babies arriving at these hospitals. Before the strike, the units saw an average of 413 admissions per week. During the 56 days of the walkout, that number plummeted to 189, a decline of more than half. The researchers estimated that approximately 1,700 fewer babies were admitted than would have been expected if the doctors had been working. This drop was not uniform; in some hospitals where the staff was most severely affected, admissions fell by nearly 90 percent. Crucially, once the strike ended and the doctors returned, the number of admissions immediately bounced back to normal levels, confirming that the drop was directly tied to the industrial action and not a long-term shift in the population's health.

The babies who did manage to reach the hospitals during the strike were different from those who arrived before or after. They were, on average, smaller, more likely to be born prematurely, and more likely to have been born outside the hospital and brought in later. This suggests that the strike acted as a filter, where only the most critical cases or those with the most urgent need were able to navigate the barriers to care. In the hospitals where admissions dropped the most, the average weight of admitted newborns fell significantly, and the proportion of babies born outside the facility more than doubled. It appears that families either delayed seeking help until a condition became life-threatening or were turned away, leaving the sickest infants to be the only ones who successfully entered the system.

Despite this drastic change in who was being admitted, the overall death rate among the babies who did receive care did not show a measurable increase. The percentage of newborns who died while in the hospital remained roughly the same before, during, and after the strike. This finding might seem surprising given the shortage of doctors, but it points to a specific dynamic in neonatal care. In these units, nurses are the backbone of daily care, managing feeding, warmth, and routine monitoring. With far fewer babies in the wards, the remaining nurses may have had more time to attend to each child, potentially maintaining the quality of basic care even without a physician present. The data showed that nurses continued to perform essential tasks like checking oxygen levels and providing warmth at rates that were often higher during the strike than before it.

However, a closer look at specific groups of babies revealed a more troubling story. While the overall death rate held steady, the risk of death for babies admitted with a primary diagnosis of infection doubled during the strike. Before the walkout, about 4.7 percent of babies with recorded infections died; during the strike, that figure rose to 9.6 percent. This sharp increase suggests that the absence of doctors had a specific and devastating impact on treating sick newborns. Infections in newborns require precise medical judgment to diagnose and treat with the right antibiotics, a task that is difficult to manage without a physician. The delay in seeking care, the potential for misdiagnosis, or the inability to prescribe the correct medication likely turned manageable infections into fatal ones.

The study also highlighted a significant limitation in what the data could tell us. Because the researchers only looked at records from inside the hospitals, they could not see what happened to the estimated 1,700 babies who never made it through the doors. These infants may have died at home, in transit, or in other facilities, and their deaths are invisible in this dataset. Previous research in Kenya and other countries suggests that when health services are disrupted, the most vulnerable often suffer the most, with families turning to home remedies or traditional healers when hospitals are inaccessible. Therefore, while the hospitals themselves did not see a rise in mortality among the patients they treated, the true toll of the strike on the newborn population was likely much higher than the numbers show.

The findings paint a complex picture of a health system under pressure. The strike caused a severe disruption in access, filtering out the less urgent cases and concentrating the sickest, most vulnerable infants in the wards. While the dedicated nursing staff managed to keep the overall death rate stable for those who arrived, the system failed to protect the most fragile group: those fighting infection. The study concludes that to protect newborns during future labor disputes, health systems need more than just a return to normal operations; they require resilient plans that ensure essential care continues even when doctors are absent. This might include formalizing roles for nurses to handle more complex tasks or creating agreements with private and faith-based hospitals to absorb overflow, ensuring that no baby is left without a chance at survival when the lights go out in the public wards.