Maternal and Newborn Health Services in High Priority...
Transcript of Maternal and Newborn Health Services in High Priority...
SCALING UP RMNCH+A PROJECT / USAID
Maternal and Newborn Health Services inHigh Priority Districts of UTTARAKHAND
With 46% maternal deaths and 40% neonatal deaths occurring during labor and the day of birth the impetus remains on improving the Quality of Care for Maternal and Newborn interventions at the time of birth. With a constant increase in institutional deliveries, the e�ective implementation of high impact evidence based interventions at the health facilities is of paramount importance to help improve maternal and newborn care outcomes.
To contribute towards the global goal of Ending Preventable Child and Maternal Deaths (EPCMD), USAID’s �agship Scaling Up RMNCH+A Project, has designed a comprehensive and holistic Care around Birth Strategy to be implemented across 141 high case load delivery points in the 25 project High Priority Districts (HPDs) spread across the 6 USAID supported states in the country.
The findings presented here are from a comprehensive baseline assessment conducted across the project HPDs as a part of the roll out of the Care around Birth Strategy.
L3 facilities. District/Sub-district hospitals/ FRU-CHCs
L2 facilities. Non-FRU CHCs/24 x 7 PHCs
Maternal Mortality Ratio$ 285
Infant Mortality Rate** 32
Neonatal Mortality Rate* 35
Perinatal Mortality Rate* 29
Early Neonatal Mortality Rate* 27
Under-5 Mortality Rate* 64*SRS 2012-13 (Uttarakhand/UP)**SRS 2012-13 (Uttarakhand)
$ SRS 2011-13 (Uttarakhand/ UP)
FINDINGS: BASELINE ASSESSMENT
Baseline Assessment, 2015-16 in association with:
DH Baurari
Narendranagar
CRW HospitalHaridwar
Srinagar
DWHPauri Pabo
Patisain
Satpuli
Kotdwar
Nandgaon
Beleshwar
Pilkhi
TEHRIGARHWAL
HARIDWAR
PAURIGARHWAL
Hindolakhal
BhagwanpurBahadrabad
JNL HospitalRoorkee
ManglaurLaksar
Methodology
The baseline assessment, which was conducted in 2015-16 by the RMNCH+A project team, encompassed a total of 748 data entry points.
The baseline assessment provides information on the three major components of labor room environment, staff competencies and practices.
The labor room environment component included information on facility profile, infrastructure and layout, human resources, drugs and consumables, recording and infection prevention practices. It assessed using a structured checklist , which drafted on the basis of Government of India’s Maternal and Newborn Health (MNH) Toolkit.
Of the 1140 staff nurses and ANMs posted at the facilities, competencies of 427 service providers were measured through knowledge assessment on Active Management of Third Stage of Labor (AMTSL), Post Natal Vital Monitoring and Infection Prevention Practices and skill assessment on Partograph through a case study and on Essential Newborn Care and Resuscitation (ENCR) using a neonatalie.
Assessment of practices was done for 93 identified service delivery indicators for the last quarter of 2015 using a structured checklist, drafted following a review of recording practices at the identified facilities.
The information presented in this document is collected from 18 facilities and 43 of the 105 service providers posted at these facilities in Uttarakhand.
Delivery load (Oct-Dec, 2015)
Amenities, equipment and basic services
AVERAGE DELIVERY PER MONTH DELIVERIES BY CAESARIAN SECTION LIVE BIRTHS IN TOTAL BIRTHS*
(n=4113$) (n=4113$)
* Number of births may exceed number of deliveries$Source: Facility records, Oct-Dec, 2015 $ Source: Facility records, Oct-Dec, 2015
78%facilitieshad JSY
entitlementsdisplayed
94%facilities
had JSSKentitlements
displayed
67%facilities
had Citizen’sCharterdisplayed
FACILITIES WITH BASIC AMENITIES (n = 18) FACILITIES WITH LAB TESTS FOR ANC (n = 18)
L2 AND L3 FACILITIESL3 facilities L2 facilities
L3 facilities L2 facilities
SCALING UP RMNCH+A PROJECT / USAID
58
85
25% 50% 75% 100%
83%
89%
6%
78%
0%
89%
61%
Hemoglobin
78%
Blood group
MP slide
25% USG*
94% Urine test for pregnancy
Urine test forAlbumin and sugar
Screening for HIV94%
Blood Glucose
Screening forSyphilis - RPR
*Assessed only for L3 facilities (n=12)
25%50%75%100%
89%
72%
24 x 7 runningwater
24 x 7electricity
Drinking water
Functionaltoilets
Securityservices
Help desk
Dietaryservices
Functionalambulance
Fireextinguisher
78%
72%
94%
22%
83%
12
6 2% 99%
Methodology
The baseline assessment, which was conducted in 2015-16 by the RMNCH+A project team, encompassed a total of 748 data entry points.
The baseline assessment provides information on the three major components of labor room environment, staff competencies and practices.
The labor room environment component included information on facility profile, infrastructure and layout, human resources, drugs and consumables, recording and infection prevention practices. It assessed using a structured checklist , which drafted on the basis of Government of India’s Maternal and Newborn Health (MNH) Toolkit.
Of the 1140 staff nurses and ANMs posted at the facilities, competencies of 427 service providers were measured through knowledge assessment on Active Management of Third Stage of Labor (AMTSL), Post Natal Vital Monitoring and Infection Prevention Practices and skill assessment on Partograph through a case study and on Essential Newborn Care and Resuscitation (ENCR) using a neonatalie.
Assessment of practices was done for 93 identified service delivery indicators for the last quarter of 2015 using a structured checklist, drafted following a review of recording practices at the identified facilities.
The information presented in this document is collected from 18 facilities and 43 of the 105 service providers posted at these facilities in Uttarakhand.
Delivery load (Oct-Dec, 2015)
Amenities, equipment and basic services
AVERAGE DELIVERY PER MONTH DELIVERIES BY CAESARIAN SECTION LIVE BIRTHS IN TOTAL BIRTHS*
(n=4113$)
* Number of births may exceed number of deliveries$Source: Facility records, Oct-Dec, 2015 $ Source: Facility records, Oct-Dec, 2015
78%facilitieshad JSY
entitlementsdisplayed
94%facilities
had JSSKentitlements
displayed
67%facilities
had Citizen’sCharterdisplayed
FACILITIES WITH BASIC AMENITIES (n = 18) FACILITIES WITH LAB TESTS FOR ANC (n = 18)
L2 AND L3 FACILITIESL3 facilities L2 facilities
L3 facilities L2 facilities
SCALING UP RMNCH+A PROJECT / USAID
58
85
25% 50% 75% 100%
83%
89%
6%
78%
0%
89%
61%
78%
25%
94%
94%
*Assessed only for L3 facilities (n=12)
50%75%100%
89%
72%
24 x 7 runningwater
24 x 7electricity
Drinking water
Functionaltoilets
Securityservices
Help desk
Dietaryservices
Functionalambulance
Fireextinguisher
78%
72%
94%
22%
83%
12
6 2%
CONSUMABLES AND AMENITIES FOR INFECTION PREVENTION (n = 18)
READY REFERENCE TO INFECTION PREVENTION PROTOCOLS (n = 18)
TRAINING, COMPETENCY AND PRACTICES IN INFECTION PREVENTION
Infection prevention and control
56%facilities had all
recommended amenities and consumables
for infection prevention
6%facilities had
all infection prevention protocols displayed in labor room
None of the facilities
had all recommended
biomedical waste
management methods
None of the facilities
had updated Labor Room Sterilization
register
None of the facilities
(n=18) had all sta� trained
on different infection
prevention practices
35%providers (n=43)
scored more than 80% oninfection
control during competency assessment
Disinfectants Antisepticsolution
Handwashingfacility at
point of use
Elbowoperated
tap
Sterilegloves
Autoclave Colorcoded bins
Color codedplastic bags
Needle/hub cutter
Punctureproof box
Processing ofinstruments used
Infectionprevention
Bleachingsolution
Labor roomsterilization
Preparing0.5% Chlorine
solution
(n=18)
40%
60%
20%
0%Externalfootwearrestrictedin patientcare area
Sharpsdisinfected
beforedisposal
(n=18)
Patient carearea cleaned
with detergent
80%
100%
QUALITY OF CARE AROUND BIRTH
89%
100%
61%
50%
94% 94%
44%
78% 83%
22%
22%
44%
6%
39%
78%
39% 44%
67%
CONSUMABLES AND AMENITIES FOR INFECTION PREVENTION (n = 18)
READY REFERENCE TO INFECTION PREVENTION PROTOCOLS (n = 18)
TRAINING, COMPETENCY AND PRACTICES IN INFECTION PREVENTION
Infection prevention and control
56%facilities had all
recommended amenities and consumables
for infection prevention
6%facilities had
all infection prevention protocols displayed in labor room
None of the facilities
had all recommended
biomedical waste
management methods
11%had updated Labor Room Sterilization
register
None of the facilities
(n=18) had all sta� trained
on different infection
prevention practices
35%providers (n=43)
scored more than 80% oninfection
control during competency assessment
40%
60%
80%
100%
20%
Cleaningagents
Disinfectants Antiseptic solution
Handwashingfacility at
point of use
Elbowoperated
tap
Sterilegloves
Autoclave Colorcoded bins
Color codedplastic bags
Needle/hub cutter
Punctureproof box
40%
60%
80%
100%
20%
Handwashing
Processing ofinstruments used
Infectionprevention
Bleachingsolution
Labor roomsterilization
40%
60%
20%
0%Spill
management
80%
100%
Preparing 0.5% Chlorine
solution
(n=18)
40%
60%
20%
0%Externalfootwearrestrictedin patientcare area
Sharpsdisinfected
beforedisposal
(n=18)
Patient carearea cleaned
with detergent
80%
100%
QUALITY OF CARE AROUND BIRTH
89% 89%
100%
61%
50%
94% 94%
44%
78% 83%
22%
67%
22%
44%
6%
39%
0%
78%
39% 44%
67%
LABOR TABLE (n=18)
AVAILABILITY OF DRUGS AND SUPPLIES (n =18)
AMENITIES IN LABOR ROOM (n=18)
PROTOCOLS IN LABOR ROOM (n=18) UPDATED DOCUMENTATION (n =18)
11%facilities had
reportedstock out of
Inj. Oxytocin
10 IU
72%facilities had
autoclaved delivery sets
22%facilities had stock out of
Inj. Magnesium
Sulfate
Maternal Care
40%
60%
80%
100%
20%
Adequacy Partition/screen
Adequatefurnishings
100%
Steppingstool
Modularlight
Clock withsecondshand/
Digital Clock
40%
60%
80%
100%
20%
Roomthermometer
Refrigerator Roomheater
40%
60%
80%
100%
20%
LaborRoom
Register
ReferralRegister
(out)
ReferralRegister
(in)
MaternalDeath
Register
PostNatalCare
Register
DischargeRegister
40%
60%
20%
Management ofPostpartumHemorrhage
PartographManagement ofAntepartumHemorrhage
(APH)
ActiveManagementof Third Stage
of Labor
100%
80%
SCALING UP RMNCH+A PROJECT / USAID
61%72%
56%56%
94%
61%
50%
83%
67% had designated delivery tray 17% had all items of
the medicine tray
78% had all items of the delivery tray
6% had medicine trays with all items
39% had all items of the emergency tray
17% had emergency trays with all items
39% had designated medicine tray
67% had designated
emergency tray
50%56%
17%
61%
89%
56%
0%
17%33%
11%
None of the facilities had delivery trays with all items
LABOR TABLE (n=18)
AVAILABILITY OF DRUGS AND SUPPLIES (n =18)
AMENITIES IN LABOR ROOM (n=18)
PROTOCOLS IN LABOR ROOM (n=18) UPDATED DOCUMENTATION (n =18)
Maternal Care
40%
60%
80%
100%
20%
Adequacy Partition/screen
Adequatefurnishings
100%
Steppingstool
Modularlight
Clock withsecondshand/
Digital Clock
40%
60%
80%
100%
20%
Roomthermometer
Refrigerator Roomheater
40%
60%
80%
100%
20%
LaborRoom
Register
ReferralRegister
(out)
ReferralRegister
(in)
PostNatalCare
Register
40%
60%
20%
Management ofPostpartumHemorrhage
PartographManagement ofAntepartumHemorrhage
(APH)
ActiveManagementof Third Stage
of Labor
100%
80%
SCALING UP RMNCH+A PROJECT / USAID
61%72%
56%56%
94%
61%
50%
83%
67% had designated delivery tray 17% had all items of
the medicine tray
78% had all items of the delivery tray
6% had medicine trays with all items
39% had all items of the emergency tray
17% had emergency trays with all items
39% had designated medicine tray
67% had designated
emergency tray
50%56%
17%
61%
89%
56%
0%
17%
None of the facilities had delivery trays with all items
AVAILABILITY OF ESSENTIAL EQUIPMENT FOR NEWBORN CARE (n=18)
AVAILABILITY OF ESSENTIAL DRUGS AND SUPPLIES (n =18)
PREPAREDNESS OF SERVICE PROVIDERS FOR ESSENTIAL NEWBORN CARE
COMPETENCIES IN ESSENTIAL IMMEDIATE NEWBORN CARE AND ACTION POST-BIRTH
PROTOCOLS FOR NEWBORN CARE (n =18)
Essential Newborn Care
89%facilities had
radiant warmers
None of the facilities
had dedicated stabilizers
for radiant warmers
22%facilities had stock out of Oral Polio
Vaccine (OPV)
6% facilities had stock out of
Hepatitis B Vaccine
(HBV)
28%facilities
displayed all the protocols
for newborn care
53%providers (n=43)
scored more than 80 per cent on vaccination schedule for
newborns during
competency assessment
20%
40%
60%
Fetoscope Bagand
mask
Pediatricstethoscope
Babyweighing
scale
80%
100%
Functionalsuction
apparatus
Functionaloxygencylinder
10%
20%
30%
40%
Vitamin K1 BCG vaccine
33%
0%
40%
60%
80%
Newbornresuscitation
KangarooMother Care
Breastfeeding
20%
67%
33% 33%
60%
90%
30%
0%
29%
57%
NSSK trainedmedicalofficers(n=35)
NSSKtrainedANMs(n=7)
41%
NSSKtrainedGNMs(n=98)
20%
30%
10%
0%
(n=43)
Preparationof the
labor room
19% 21%
Essentialimmediate
newborn care
Counseling on careof newbornat discharge
12%
Counseling onidentification of
danger signsin newborns
0%Newborn
Resuscitation
9%
40%
60%
20%
0%
80%
100%
9%14%
67% 79% 74%
30%
86%77%
(n=43)84%
Calledout timeof birth
Delivered over mother’s
abdomen
Checkedfor
meconium
Checked for crying and breathing
Driedthe
baby
Skin to skin
contact
Cord clamping
Initiation of breastfeeding
AdministeredInj. Vit K1
<1hr of birth
53%
Newborn examinations
SCALING UP RMNCH+A PROJECT / USAID
50%61%
44%
61%
28%
100%
None of the facilities had all items of the newborn tray
50% facilities had a designated newborn tray
AVAILABILITY OF ESSENTIAL EQUIPMENT FOR NEWBORN CARE (n=18)
AVAILABILITY OF ESSENTIAL DRUGS AND SUPPLIES (n =18)
PREPAREDNESS OF SERVICE PROVIDERS FOR ESSENTIAL NEWBORN CARE
COMPETENCIES IN ESSENTIAL IMMEDIATE NEWBORN CARE AND ACTION POST-BIRTH
PROTOCOLS FOR NEWBORN CARE (n =18)
Essential Newborn Care
89%facilities had
radiant warmers
None of the facilities
had dedicated stabilizers
for radiant warmers
22%facilities had stock out of Oral Polio
Vaccine (OPV)
6% facilities had stock out of
Hepatitis B Vaccine
(HBV)
28%facilities
displayed all the protocols
for newborn care
53%providers (n=43)
scored more than 80 per cent on vaccination schedule for
newborns during
competency assessment
20%
40%
60%
Fetoscope Bagand
mask
Pediatricstethoscope
Babyweighing
scale
80%
100%
Functionalsuction
apparatus
Functionaloxygencylinder
10%
20%
30%
40%
Vitamin K1 BCG vaccine
33%
0%
40%
60%
80%
Newbornresuscitation
KangarooMother Care
Breastfeeding
20%
67%
33% 33%
60%
90%
30%
0%
29%
57%
NSSK trainedmedicalofficers(n=35)
NSSKtrainedANMs(n=7)
41%
NSSKtrainedGNMs(n=98)
20%
30%
10%
0%
(n=43)
Preparationof the
labor room
19% 21%
Essentialimmediate
newborn care
Counseling on careof newbornat discharge
12%
Counseling onidentification of
danger signsin newborns
0%Newborn
Resuscitation
9%
40%
60%
20%
0%
80%
100%
9%14%
67% 79% 74%
30%
86%77%
(n=43)84%
Calledout timeof birth
Delivered over mother’s
abdomen
Checkedfor
meconium
Checked forcrying and breathing
Driedthe
baby
Skin to skin
contact
Cord clamping
Initiation of breastfeeding
AdministeredInj. Vit K1
<1hr of birth
53%
Newborn examinations
SCALING UP RMNCH+A PROJECT / USAID
50%61%
44%
61%
28%
100%
None of the facilities had all items of the newborn tray
50% facilities had a designated newborn tray
NEWBORN RESUSCITATION (n =43)
IMMEDIATE NEWBORN CARE (n= 4113$)
NEWBORN VACCINATION (n = 4113$) POSTNATAL MONITORING OF NEWBORN (n = 18)
Essential Newborn Care
None of the facilities (n=18) were
providing Kangaroo
Mother Care to VLBW
newborns
22%newborns (n=4113$)
received all three
vaccines
11%facilities(n=18)
record information on
still birth
None of thefacilities(n=18) were
monitoringthe
newbornat the time of
discharge
Feltpressure
Pop offvalve checked
Bagre-inflates
Ventilationstarted
Checkedchest rise
Ventilationcycle
Ventilated30 seconds
21%12% 14%
40%
60%
20%
0%
80%
100%79%
33% 30% 21%
3% 3%
24%
35%
10%
Temperature at birth
Driedafter birth
Delayed cord
clamping
Received Injection
Vit K1
Breastfeeding <1 hour of
birth
Breathing rate of newborns monitored in
one hour in 6% facilities
Newborns monitored between 1
to 6 hours in 6% facilities
QUALITY OF CARE AROUND BIRTH
97% newborns were weighed at the time of birth
2% newborns weighed had
very low birth weight
(<2.0kgs)
15% newborns weighed had low birth
weight (<2.5kgs)
38% newborns received OPV
36% newborns received Hepatitis B vaccine
25% newborns received BCG vaccine
$ Source: Facility records, Oct-Dec, 2015
$ Source: Facility records, Oct-Dec, 2015
NEWBORN RESUSCITATION (n =43)
IMMEDIATE NEWBORN CARE (n= 4113$)
NEWBORN VACCINATION (n = 4113$) POSTNATAL MONITORING OF NEWBORN (n = 18)
Essential Newborn Care
None of the facilities (n=18) were
providing Kangaroo
Mother Care to VLBW
newborns
22%newborns (n=4113$)
received all three
vaccines
11%facilities(n=18)
record information on
still birth
None of thefacilities(n=18) were
monitoringthe
newbornat the time of
discharge
Feltpressure
Pop offvalve checked
Bagre-inflates
Ventilationstarted
Checkedchest rise
Ventilationcycle
Ventilated30 seconds
30%
45%
15%
0%
60%
75%
21%12% 14%
40%
60%
20%
0%
80%
100%79%
33% 30% 21%
40%
60%
3% 3%
24%
35%
80%
100%
10%20%
Temperature at birth
Driedafter birth
Delayed cord
clamping
Received Injection
Vit K1
Breastfeeding <1 hour of
birth
Breathing rate of newborns monitored in
one hour in 6% facilities
Newborns monitored for vital
between 1 to 6 hours in 6% facilities
QUALITY OF CARE AROUND BIRTH
97% newborns were weighed at the time of birth
2% newborns weighed had
very low birth weight
(<2.0kgs)
15% newborns weighed had low birth
weight (<2.5kgs)
38% newborns received OPV
36% newborns received Hepatitis B vaccine
25% newborns received BCG vaccine
$ Source: Facility records, Oct-Dec, 2015
$ Source: Facility records, Oct-Dec, 2015
SCALING UP RMNCH+A PROJECT / USAID
The ‘NINE’ Pillars1. Adoptive Learning - By adapting lessons from successful models on quality of care at
health facilities
2. Comprehensive Baseline - For maternal and newborn care covering labor room environment, sta� competencies and practices
3. Advocacy for Implementation - Consistent engagement with national and state government at all available platforms
4. Holistic Technical Intervention Packages - To strengthen evidence based, high impact interventions for mothers and newborns
5. Experiential Training - By using participatory methods to facilitate ‘learning-by-doing’
6. Structured Mentoring Visits – Regular, planned onsite mentoring to sustain learning
7. Sustained Quality Improvement - A multipronged approach including facility QI teams, champions and Experience Sharing Platforms
8. Robust Management Information System - For continuing comprehensive measurement of the progress and outcomes.
9. Impact at Scale - Planned and organized transfer of successful interventions to more facilities, districts and states
For additional information & queries, contact –
Scaling Up RMNCH+A Project/ USAID,IPE Global Limited, IPE Global House, B – 84, Defence Colony, New Delhi – 110 024Ph: +91.11.4075.5900 | email: [email protected] DisclaimerThis document is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of IPE Global Limited and do not necessarily re�ect the views of USAID or the United States Government. The RMNCH+A Project is managed by IPE Global Limited under the terms of USAID Cooperative Agreement Number AID-386-A-14-00001.
Family Planning, Child and Adolescent HealthFAMILY PLANNING
CHILD HEALTH (n = 18) ADOLESCENT HEALTH
22%
72%
PPIUCDRegister
FamilyPlanningRegister
% o
f fac
ilitie
s 17%women
(n=4113*) accepted a
post partum family
planning method
50%facilities reported
stock out of
Zinc
17%facilities reported
stock out of
ORS
1377
892
Boys Girls
AFHS
ben
eficia
ries (
Oct –
Dec
’15)
CONSUMABLES AND SUPPLIES UPDATED RECORDS SERVICES
CAREAROUND
BIRTHSTRATEGY
AdoptiveLearning
ComprehensiveBaseline
Advocacy forImplementation
Holistic TechnicalIntervention
Packages
ExperientialTraining
StructuredMentoring
Visits
SustainedQuality
Improvement
RobustManagementInformation
System
Impact atScale
(n=18) (n=18)78% facilitieshad all individualitems ofPPIUCDtray
77% of sanctionedAdolescent Friendly
Health Clinics (n=13)are operational
67% facilities had adesignated PPIUCD tray
TRAINED HUMAN RESOURCES
43% GNMs(n=98) aretrained in PPIUCD
31% medicalofficers (n=35)are trained inPPIUCD
14% ANMs (n=7)are trained in PPIUCD
*Source: Facility records, Oct-Dec, 2015