Maternal and Newborn Health Services in High Priority ...rmncha.in/wp-content/uploads/data_img/1477041243.pdfSCALING UP RMNCH+A PROJECT / USAID Maternal and Newborn Health Services

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


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


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


had updated Labor Room Sterilization

register


(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


had all recommended

biomedical waste

management methods

11%had updated Labor Room Sterilization

register


(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%


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%


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%


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


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


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)


89%facilities had

radiant warmers


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


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)


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


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


NEWBORN RESUSCITATION (n =43)

IMMEDIATE NEWBORN CARE (n= 4113$)

NEWBORN VACCINATION (n = 4113$) POSTNATAL MONITORING OF NEWBORN (n = 18)


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


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




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

Documents

Maternal and Newborn Health Services in High Priority ...rmncha.in/wp-content/uploads/data_img/1477041243.pdfSCALING UP RMNCH+A PROJECT / USAID Maternal and Newborn Health Services