SCALING UP RMNCH+A PROJECT / USAID

Transcription

1 Maternal and Newborn Health Services in High Priority Districts in six states of INDIA FINDINGS: BASELINE ASSESSMENT With 4 maternal deaths and 4 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 effective implementation of high impact evidence based interventions at the health facilities is of paramount importance to help improve maternal and newborn care outcomes. Maternal Mortality Ratio $ 167 Infant Mortality Rate* 40 Neonatal Mortality Rate* 2 Perinatal Mortality Rate* 26 Early Neonatal Mortality Rate* 22 Under-5 Mortality Rate* 49 $ SRS *SRS To contribute towards the global goal of Ending Preventable Child and Maternal Deaths (EPCMD), USAID s flagship Scaling Up RMNCH+A Project, has designed a comprehensive and holistic Care around Birth Strategy to be implemented across 1 high case load delivery points in the 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. Baseline Assessment, in association with:

2 Delivery load (Oct- Dec, 2015) HPDs Total Facilities L3 facilities L2& L1 facilities Total deliveries $ 9,075 12,62 2,759,39,560 4,113 Vaginal delivery 9 7 Assisted vaginal delivery % Caesarian section 1 2% 2% $ Source: Facility records, Oct to Dec 2015 FACILITIES WITH BASIC AMENITIES Amenities, equipment and basic services 24 x 7 running water x 7 electricity 47% 9 Drinking water 7 Functional toilets 5 2% 9 7% Security services 5 Help desk Dietary services 7 7 Functional ambulance 7% Fire extinguisher 1 % 7 FACILITIES WITH LAB TESTS FOR ANC Hemoglobin Urine test for Albumin and sugar Urine test for pregnancy Screening for HIV Blood group MP Slide Blood Glucose Screening for Syphilis USG* % % * Assessed only for L3 facilities

3 QUALITY OF CARE AROUND BIRTH AVAILABILITY OF LABOUR TABLES Expected No. of LTs ## Actual No. of LTs Maternal Care Mattresses Mackintosh Functional Kellys 7 2% 2% % % FURNISHINGS AND EQUIPMENTS IN LABOUR ROOM Partition/ Screen for labour table Stepping stool for labour table Modular lights for labour table Clock with seconds hand/digital clock Moveable delivery trolley Room thermometer Refrigerator Room heater Autoclaved delivery sets % % 27% 5 # # Based on average number of deliveries as per MNH guidelines AVAILABILITY OF DRUGS AND SUPPLIES Delivery tray All items available Tray available 6 6 7% All items in tray 7% Medicine tray All items available Tray available All items in tray % 2 % 5% 1 % % Emergency drugs tray All items available Tray available % All items in tray % % 1 %

4 Maternal Care PROTOCOLS IN LABOR ROOM Partograph % AMTSL 9 % 5% 5 Vaginal bleeding <20 wk 6 4 Vaginal bleeding >20 wk 4 % Management of PPH % 5% 6 5 Management of atonic PPH 4 UPDATED DOCUMENTATION Labour Room Register Postnatal Care Register % 1 1 % % Referral Register (In) % 1 Referral Register (Out) Discharge Register 2% 3 Maternal Death Register 42% 37% % 1 TRAINED HUMAN RESOURCES BEmOC trained MOs CEmOC trained MOs SBA trained GNMs SBA trained ANMs % 1 2 7% 2 2 n= n= n= n= Delhi Haryana Himachal Pradesh Jharkhand Punjab Uttarakhand PARTOGRAPH COMPETENCY, USAGE AND COMPLETENESS Service provider s score < % 2% 3 7% 2 1 5% % 7 2

5 QUALITY OF CARE AROUND BIRTH Maternal Care PARTOGRAPH PRACTICES Total cases 9,075 12,62 2,759,39,560 4,113 Filled partograph $ Total partographs assessed Completely filled partograph # % 20 2 % 115 # Based on samples of partographs reviewed between October and December, 2015 $ Source: Facility records, Oct to Dec 2015 ACTIVE MANAGEMENT OF THIRD STAGE LABOR (AMTSL) COMPETENCY Service provider s score < % 42% 2 2% 27% 45% % % 4 5% ACTIVE MANAGEMENT OF THIRD STAGE LABOR (AMTSL) PRACTICES $ Total cases Oxytocin administered in AMTSL Oxytocin administered within one minute 9,075 12,62 2,759,39,560 4,113 POSTNATAL MONITORING COMPETENCY 95% 6 97% 2% % 7 57% $ Source: Facility records, Oct to Dec 2015 Service provider s score < % % 7% 15% 2 5% POSTNATAL MONITORING PRACTICES Total Cases sheets* Mother s vitals monitored within 6hrs Mother s vital monitored at discharge 5% 1 ** 2%*** No. of times mother s vitals monitored within 6 hrs $$ $$ Mother expected to be monitored at least nine (9) times within six hours of delivery * Based on samples of case sheets reviewed between October and December, 2015 **Based on a sample of 210 case sheets reviewed between October and December, 2015 ***Based on a sample of 45 case sheets reviewed between October and December, 2015

6 Essential Newborn Care AVAILABILITY OF ESSENTIAL EQUIPMENT FOR NEWBORN CARE Functional suction apparatus 7 9 Functional Oxygen cylinder 9 9 2% Fetoscope 5 95% 5 Bag and mask 9 95% Pediatric stethoscope % 2 Baby weighing scale 95% Radiant warmer NEWBORN TRAY All items available Tray available 2% STOCK OUT OF CONSUMABLES AND SUPPLIES 42 Vitamin K1 5% 3 BCG Vaccine 1 Oral Polio Vaccine 5% Hepatitis B Vaccine PROTOCOLS FOR NEWBORN CARE Newborn resuscitation Kangaroo Mother Care Breastfeeding 97% % Delhi (n=) Haryana (n=) Himachal Pradesh (n=) Jharkhand (n=) Punjab (n=) Uttarakhand (n=)

7 QUALITY OF CARE AROUND BIRTH Essential Newborn Care TRAINED HUMAN RESOURCES NSSK trained MOs NSSK trained GNMs NSSK trained ANMs 6 47% n = n = % 2% n = 2% 57% Delhi Haryana Himachal Pradesh Jharkhand Punjab Uttarakhand NEWBORN CARE COMPETENCIES (SCORE > 0 PER CENT) Preparation of the labour room % 5 1 Essential immediate newborn care 3 27% 1 2 Counselling on care of newborn at discharge 2 2 % Counselling on danger signs in newborns 7% Newborn resuscitation Newborn vaccination 7 7 COMPETENCIES IN ESSENTIAL IMMEDIATE NEWBORN CARE AND ACTION POST-BIRTH Called out time of birth Delivered over mother s abdomen Checked for meconium Checked for crying and breathing Dried the baby Skin to skin contact Cord clamping Initiation of breastfeeding Administered Inj. Vit K1 <1hr of birth Newborn examinations % % 2 3 5% 45% 7% % % 67 2% 15% 2%

8 Essential Newborn Care NEWBORN RESUSCITATION COMPETENCY Felt pressure 1 % 2 Pop off valve checked 37% 2 Bag re- inflates 27% % % 1 1 Ventilation started Checked chest rise 4 3 Ventilation cycle 15% 27% 3 Ventilated 30 seconds IMMEDIATE NEWBORN CARE PRACTICES $ No. of live births,954 12,561 2,746 16,996,560 4,113 Weighed at birth % 9 97% Temp recorded at birth 6 % 9 Dried after birth 95% 2 1 Delayed cord clamping 2 Vit K1 administered 57% 9 Immediate breastfeeding 9 9 5% 1 LOW BIRTH WEIGHT NEWBORNS: Delhi, with % of all newborns registered as LBW(<2.5kgs), had the highest proportion VERY LOW BIRTH WEIGHT NEWBORNS: 4 per cent of all newborns in Delhi, Himachal Pradesh and Punjab were registered as VLBW(<2.0kgs) KANGAROO MOTHER CARE: Only Haryana recorded giving KMC to VLBW newborns, with 27% of VLBW newborns receiving it. $ Source: Facility records, Oct- Dec, 2015 NEWBORN VACCINATION PRACTICES $ No. of live births,954 12,561 2,746 16,996,560 4,113 All three vaccines 15% 7 % BCG only 15% 4 % 2% 7% % % OPV only 15% 9 Hep-B Only 2% 9 2% 3 $ Source: Facility records, Oct to Dec 2015 POSTNATAL MONITORING OF NEWBORN PRACTICES 42 Within 1 hr of birth 1 % hrs post birth % % % On discharge 3 1 Monitored for breathing 2 Monitored for vitals, breastfeeding, passage of urine and stool 3 Monitored for vitals, breathing and feeding.

9 QUALITY OF CARE AROUND BIRTH FAMILY PLANNING - TRAINED HUMAN RESOURCES Family Planning, Child and Adolescent Health PPIUCD trained MOs 6 4 % 2 % 1 n = PPIUCD trained GNMs n = PPIUCD trained ANMs 6 45% n = Delhi Haryana Himachal Pradesh Jharkhand Punjab Uttarakhand FAMILY PLANNING - CONSUMABLES, SUPPLIES AND UPDATED RECORDS PPIUCD tray All items available 7% % Tray available 5% 7 All items in tray 7% PPIUCD Register Available 7% 3 7% Updated FP Register Available 5 Updated 4 FAMILY PLANNING SERVICES $ Total cases 9,075 12,62 2,759,39,560 4,113 % of of women accepting post partum family planning method % 2 7% 15% % CHILD HEALTH - STOCK OUT OF CONSUMABLES AND SUPPLIES ORS Zinc % 7% 2 $ Source: Facility records, Oct Dec 2015 % 5 OPERATIONAL AFHCs AND BENEFICIARIES Sanctioned AFHCs Functional AFHCs Beneficiaries 4 7,629 1,111 4, ,269 Boys/ girls break-up 72/2 3,690/3, /59 1,594/ /206 92/1377

10 CONSUMABLES AND AMENITIES FOR INFECTION PREVENTION Infection prevention and control Cleaning agent Disinfectant 9 6 Antiseptic solution 9 Hand washing at point of use 97% 9 Elbow operated tap % Color coded bins 97% 7% Color coded plastic bags Needle/ hub cutter 9 95% Puncture proof box 5 Autoclave AVAILABILITY OF ITEMS FOR PERSONAL PROTECTION Heavy duty gloves & gumboots 2 % Masks 97% 4 7% Sterile gloves in labour room Gown/ apron 9 7% Shoe cover/ gum boots in LR 15% 2 Caps Protective kit for HIV 5 1 % % COMPETENCIES IN INFECTION PREVENTION Service provider s score < % 47% % 5 4 2% 37%

11 QUALITY OF CARE AROUND BIRTH AVAILABILITY OF VARIOUS INFECTION PREVENTION PROTOCOLS IN LABOUR ROOM Hand washing Preparing 1 litre bleaching powder Infection prevention Processing of used instruments LR Sterilization 9 4 % Infection prevention and control % % DOCUMENTATION LR STERILIZATION REGISTER Available 5 42% 2% 1 Updated 5 2 2% % 1 BIOMEDICAL WASTE MANAGEMENT PRACTICES Sharps disinfected BMW in closed container FACILITIES WITH TRAINED HUMAN RESOURCES Spill management Preparing 0.5% chlorine solution % % Delhi (n=) Haryana (n=) Himachal Pradesh (n=) Jharkhand (n=) Punjab (n=) Uttarakhand (n = ) INFECTION PREVENTION PRACTICES Care area cleaned with disinfectant 47% 5% External footwear restricted 5 % 6

12 Methodology The baseline assessment, which was conducted in by the RMNCH+A project team, encompassed a total of 74 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 1 facilities and 427 service providers posted at these facilities in six states. SELECTED HIGH PRIORITY DISTRICTS NORTH WEST CHAMBA GODDA SAHIBGANJ GURDASPUR NORTH EAST HISAR JIND PANIPAT MANDI KINNAUR LOHARDAGA GUMLA SARAIKELA- KHARSAWAN SIMDEGA DUMKA MUKTASAR BARNALA SANGRUR HARIDWAR TEHRI GARHWAL PAURI GARHWAL MEWAT PALWAL MANSA Impact at Scale Adoptive Learning Comprehensive Baseline The NINE Pillars 1. 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, staff competencies and practices Robust Management Information System Sustained Quality Improvement Structured Mentoring Visits CARE AROUND BIRTH STRATEGY Experiential Training Advocacy for Implementation Holistic Technical Intervention Packages 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. 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 4, Defence Colony, New Delhi Ph: rmncha@ipeglobal.com Disclaimer This 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 reflect 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-36-A