Maternal and Newborn Health

Transcription

1 we do not have adequate support staff for 4X7 functioning of IPD Paediatrician is not there, doctors shoud be there we have.1 staff nurse shoud be there but we have ony 6 ( permanent 4 deputation) There is no data entry person. The previous one eft for capita hospita so pharmacist has to record data in the computer - Medica Officer at Unit 4 CHC beds aocated to the maternity ward but the same is not enough due to scarcity of beds, many of them are getting treated just on the foor. - Medica Officer at BMC Hospita CAPITAL HOSPITAL: Overcrowding: The hospita had a daiy OPD attendance of about patients in OPD a day (6, patients a month). To cater to this, there were ony 6 functiona beds atogether. Deficiencies at the PHCs & CHCs had ed to increasing patient oad at the Capita Hospita over the years. However, the resources (medica personne, paramedics and support staff, ogistics and infrastructure) at the hospita had not increased commensuratey. Incidents of deivering babies on foor or on mattresses had been reported. Patient overcrowding had increased demands on staff time ( more patients, more paperwork ) resuting in ong queues and significant waiting time. Referra from a eves (incuding informa referra system ead by ASHAs, key infuencers, community and oca practitioners) were made directy and ony to the Capita Hospita, surpassing a other heath faciities avaiabe within the system. This combined with the usua patient oad at the hospita, caused much overcrowding at the hospita and overwhemed capacity and quaity of care therein. Beneficiaries compained that ambuance services for accessing the hospita [Hepines: 1 (Janani Express) and 18] were inadequate. Avaiabiity of Drugs and Suppies: The service providers expressed satisfaction with the avaiabiity of medicines at the Capita Hospita. Working towards.... Based on the study resuts, deiberations and a series of consutative meetings with the Bhubaneswar Municipa Corporation (BMC), Government of Odisha and the Urban Heath Advisory Committee for Bhubaneswar city, Save the Chidren, BMC and the NHM, Government of Odisha are cosey working together on the foowing: a. Deveopment of City Heath Panprioritizing heath system strengthening for MNH b. Formuating a framework for the operationaization of City Heath Pan c. Deveoping a too-kit for morbidity surveiance at the community eve We have 1 beds in tota for Gynaecoogy ward and 13 beds for paediatric and extra beds in SNC ward. But that ward is aways over crowded patients are in the ward aways in this faciity. So by compusion we manage them on the foor. In order to manage the fow of patients daiy, we need more doctors and more staff to manage the crowd of the patients. We need 3 more staff nurse, 14 pharmacists, radiographers. Posts have remained vacant. Practicay it (stock out) does not happen. We pace orders sufficienty in advance. We are procuring about 11 items of medicines from outside source. The ine department is providing 161 items of medicines to us. -Service Provider at Capita Hospita d. Estabishment of appropriate referra mechanism for deivering heath services to mothers and newborns e. Formuation of capacity buiding strategy and package for the heath staff at the BMC Situation of Materna and Newborn Heath in Urban Sums of Bhubaneswar Summary Report 16 Saving Newborn Lives, Save the Chidren 1st & nd Foor, Pot No. 91, Sector 44, Gurugram- 13, Haryana Phone : E-mai: sn@savethechidren.in Website:

2 1. Background 1 The sum popuation in Indian cities is rapidy expanding (.1% decada growth Census 11). This urban poor popuation offers compex chaenges of vunerabiity for adverse materna and newborn heath (MNH) outcomes. Pubic heath care provisioning for MNH in urban sums is mosty unstructured, 3 fragie and with amost non-existent outreach. Heath service utiization is compromised due to imited capacity for decision making, negigent and deayed care seeking, issues to access and affordabiity, and the 4 pethora of unorganized private providers. This is compounded by socio-behaviora, spatia and economic inequities that define the context of disempowerment and constraint for this popuation. The Nationa Urban Heath Mission (NUHM), aunched in 13, advises for improving the heath of the urban sum popuations through a needs-based, city-specific urban heath care system that incudes a refurbished primary care system, targeted outreach, equitabe access, and invovement of the community 6 and urban oca bodies (ULBs). The ack of formative information and disaggregated data impedes efficient urban heath poicy-making and programming. 7 Fig. : Conceptua Framework for the Study. Study Goa and Objectives Save the Chidren in coaboration with the Bhubaneswar Municipa Corporation (BMC) and the state Nationa Heath Mission (NHM) undertook this study in the urban sums of Bhubaneswar city (profie given in Fig. 1) to generate earnings for designing a city-specific pubic heath approach to improve MNH services for the urban poor. The specific objectives were: a) To understand the community needs, behaviors and perceptions for MNH in urban poor settings. b) To expore various factors (both demand and suppy side, and environmenta factors) affecting care seeking for MNH. c) To assess the preparedness of the urban heath system for providing MNH services at various eves of care in terms of infrastructure, HR avaiabiity and capacity, ogistics, drugs & equipment, referra, recording & reporting, supervision, governance and financia modaities. Fig. 1: Map and Profie of Bhubaneswar City Demography (Census 11) Popuation:.9 m Area: 4 km Popuation Density:.1K/Km Sex Ratio: 89 Literacy: 91.7% Annua Popuation Growth Rate: 3.% Sums in Bhubaneswar Number of Sums: 377 (99 Notified) Popuation: 36% of Bhubaneswar Density: 6.K/Km Annua Popuation Growth Rate: 7.7% Medica Units 1 Tertiary Hospita UCHC 1 Urban PHC (UPHC) 3 Dispensaries 1 AWC 18 Bawadis 96 MAS 16 ASHA 1 Primary Census Abstract for Sum, 11. Office of the Registrar Genera & Census Commissioner, India. Accessed on 16 Jun 13. Avaiabe from: Internationa Institute for Popuation Sciences (IIPS) and Macro Internationa. Nationa Famiy Heath Survey (NFHS-3), 6: India: Voume I. Mumbai: IIPS Madhiwaa N. Heathcare in urban sums in India. Nationa Medica Journa of India. 8; (3): Gupta I, Guin P. Heath Status and Access to Heath Services in Indian Sums. Heath. 1;7():4. Hazarika I. Women's Reproductive Heath in Urban Sum Popuations in India: Evidence from NFHS-3. Journa of Urban Heath. 1, 87 (): Nationa Urban Heath Mission: Framework for Impementation. Ministry of Heath and Famiy Wefare. Government of India. May 13 7 Ministry of Heath and Famiy Wefare. Integrated HMIS Reporting Formats: Information At a Gance (version 1.). Government of India. Ju Methodoogy Method of Quaitative Data Coection Transect wak Focus Group Discussions (for resource mapping) Infuentia persons from the community Husbands of RDWs Mothers-in-aw (MIL; Not members of MAS/SHGs) of RDWs In-depth Interviews Members of sef-hep groups (SHG) incuding MAS Community Link Workers ANMs/ AWWs Informa Doctor/ heath provider from sum Forma Doctor/ heath provider from nearby primary pubic heath faciity Private service provider Key officias (NHM, BMC) Heath Faciities: Peds, O&G, MO, SNs Case Studies Quaitative Component Famiy with sick newborn Famiy of deceased newborn The sums were purposivey seected [criteria used: popuation density (of RDWs), incusivity of sums from across the city, proximity to heath faciity (pubic or private), notification status and coherence with the quantitative survey]. 3 notified (Jokaandi, Dhirikutti, Gandamunda), and 1 non-notified (Saia Sahi) sums were seected. Quantitative Component Samping for househod Interviews: Two-staged samping was used to seect the respondents. A tota of 3 sum custers were seected using Probabiity Proportiona to Size (PPS) method: 6 were identified from amongst authorized sums and 4 from unauthorised sums. From each custer, recenty deivered women (RDW; who deivered within -6 months) were seected using systematic random samping foowing extensive house-to-house enumeration. Ony one eigibe woman was seected per househod. 9 RDWs were identified (93 from authorized sums and 499 RDWs from unauthorized sums). Samping For Faciity Assessment: 1 UPHCs, UCHCs (BMC Hospita, Unit 4 Hospita), and District eve (Capita Hospita)were assessed. Data Management (Quaitative and Quantitative) A data was anonymized using unique identification numbers and codes. Quantitative data was managed and anaysed using Epi-data version 3. and SPSS v11. Quaitative data was both inductivey and deductivey coded and thematicay anaysed using MS Exce 1. The socia-cum-resource maps were studied in detai to understand the distribution of community resources and sociodemographic distribution of the residing popuation. Period of Data Coection: January and Apri 16 Ethics Approva: Sigma Research and Consuting, India and Save the Chidren-US Ethics Review Committee 3

3 4 4. Study Findings Overarching Situation in the Sums Source: Transect wak The sums examined had -1 househods (4 had >1 househods, 9 had 1 househods). Interaction with the sum dweers suggested that annua popuation growth in these sums hovers around 1%. Major occupations among the sum dweers were construction work (both men and women) and private sector jobs (men: driver, sweeper, etc.; women: domestic hep). Househods had access to mutipe sources of drinking water; each sum had a minimum of one BMC water stand-post which served as the primary source of drinking water. The sums had poor drainage systems, bad roads and inadequate toiet faciities. Each sum had an Anganwadi Centre(AWC). ASHAs were working in sums, had aopathic dispensary, 1 had a homeopathic dispensary, and 3 had Mahia Aarogya Samitis (MAS). In times of medica probems reated to materna and chid heath, dweers preferred to go to the Capita Hospita whie they sought care from a various other BMC faciities and even oca chemists and practitioners for genera inesses. Tabe 1: Profie of the Participants and Househods (HH) [N=9] Reigion Median age of the women (Range) Contact with Frontine workers (FLWs; ANM/ ASHA/ AWW/ Link Worker/ etc): Majority of the RDWs (1.%) had not been visited by any FLW at home in the ast 6 months prior to the survey. Ony 3.6% (N=1) of the RDWs (N=9) reported that they had ever attended an outreach heath session in their sums. Onethird (N=7) of the sessions reported had been organized by AWWs foowed by Mahia Arogya Samiti (MAS) members (N= ). Support System for MNH Care: There seems to be dotted ines of a system estabished for providing support and faciitating materna and newborn care among the urban poor of Bhubaneswar. Whie Sef Hep Groups (SHGs) members across sums reported to be engaged in providing economic support to its members and sum-dweers in case of emergency, Mahia Aarogya Samiti (MAS), and Ward Kayan Samiti (WKS) reported to focus more on ensuring sanitation in the sum and enroment of chidren in the schoo. MAS and WKS members aso reported to provide support in mobiizing communities to visit AWCs to avai services, and coectivey keep a check on services provided at the AWCs. The FLWs however reported ack of concrete support by these groups, they have never provided us any kind of equipment or even the first aid box, said ANMs. Aso, not a MAS were active (e.g., in Jokaandi, a MAS had been constituted but some paper work was pending and the bank account was yet to be activated). Overa, it was reaized that the MAS, WKS & SHGs were under-utiized in faciitating MNH care in the sums. Decision-making power (Source: FGDs with Husbands and MILs): Husbands in case of nucear famiy, and Mother-in-Laws (MILs) in joint or extended famiies were the key decision-makers with reference to materna and newborn heath. In both the cases, ASHAs appeared to have a major infuence on decisions taken. Whie in nucear famiies, the husband woud usuay consut with the wife and parents, MILs were more ikey to be infuenced by members of MAS and SHGs. Source of Information on Materna & Chid Heath Services: Interpersona communication was considered most effective. A vast majority of respondents had aso received MNH information from FLWs (commony AWWs). Teevision and radio were aso cited as common sources. Of the 9 RDWs, 43.6% had been pregnant for the first time. Pregnancy at a young age was commony seen with 6.3% RDW in the teenage years having aready experienced more than one pregnancy (Fig. 3). Caste Education Notification status of the sum of residence Duration of residence in the sum (Range) Type of house 91.4% Hindu; 7.1% Musim; 1.% Christian 4yrs (16-yrs) 18% SC, 6.4% ST, 43.4% OBC, 3.% No forma education: 14.9% Upto th Grade: 4.% Above 1 th Grade: 6.7% Non-notified: 8% Median=36 months 18.6% Pucca, 7.8% semi-pucca HHs with mobie phone 89% Access to piped drinking water 86.7% Access to fush toiet faciity 37.8% HH with eectricity 9.4% Distance to nearest Pubic Heath Faciity (waking) (n=331) 94.%: < 3 mins Median: 1mins their Fig. 3: Number of times the RDWs in the study had been pregnant N = Years (n=48) -4 Years (n=6) -9 Years (n=193) By the age 4 years, over 39% RDWs have aready had more than one pregnancy About 1% of the RDWs had first pregnancy beyond 9 year age 1. Care Seeking for MNH (source: various FGDs and Quantitative Survey): Care-seeking for MNH was mosty sef-driven and conditioned by prevaent socio-behaviora beiefs and preferences (Fig. 4 and ). In both notified and non-notified sums, the District Hospita (Capita Hospita) was the most preferred. However, husbands and mother-in-aws of RDWs across sums criticized it for the ack of infrastructure and services, apathy among nurses, ack of avaiabiity of beds, unceaniness, ong waiting time, and high out-ofpocket expenses (pathoogica and radioogica tests, erratic avaiabiity of ambuances for transportation). MILs were found to be more critica and opined that treatment at Capita Hospita was dependent on persona references and contacts and to some extent on the presence of ASHA with the patient. Preference for private providers were sedom conditioned by distance and was more among RDWs with higher education eve and residing in pucca houses (signifying reative affuence). Reiance on the RMPs was reported ony for genera aiments, and rarey for MNH reated issues. The RMPs aso reported to treat patients ony for genera iness and confirmed referring MNH cases to Capita hospita. Antenata Care Practices No of times pregnant Once Twice Three & more >9 Years (n=89) Fig. : Reasons for Preference of Private over the Pubic faciities for MNH care N= Short Distance Avaiabiity at a times Affordabe Fees Comfort Leves Fig. 4: Preference among the RDWs regarding care seeking for pregnancy and deivery Registration of Pregnancy: Registration of pregnancy was near universa (99%), majority (96.1%) RDWs st came to know about their pregnancy in the 1 trimester itsef; 3 (9.%) had registered their pregnancy st in the 1 trimester (.% at private faciities; 9.9% by FLWs). Around 14.8% of the women got registered within same month when they came to know that they were pregnant, whie 48.% registered in the foowing month. Of the 6 RDWs who had not registered their ast pregnancy, of them were from nonnotified sums, 4 of them had never received forma education, and a resided in semi-pucca houses. Though registration rates were reported high, ambiguity regarding the term 'registration' was observed. From peope's perspective, the day ASHA wrote name of the pregnant woman in a register was considered as 'registration'. Besides procedura deays in registration, ASHAs reported to defer forma registration to be abe to meet their monthy quota of registration. The deay reportedy heped ASHAs maintain an average number to be abe to receive incentives towards registration and institutiona deiveries. ASHAs aso compained that pregnant women with two existing chidren tend to hide their pregnancies to be abe to avai reevant government schemes and faciities Private Hospita/ Nursing 14. Private Doctor.1 Pharmacy/ Chemist Dispensary/ Maternity District Hospita/ Medica Coege N = 9 About 4% of the RDWs prefer consuting at the District hospita for any pregnancy and deivery reated condition. Amost 3. woud seek care from a private doctor

4 Fig. 6: Pace of Registration of Last Pregnancy Fig. 7: Type of Faciity Visited for ANC Services Fig. 9: Pace of Deivery Fig. 1: Mode of Trave to Faciity for Deivery (N=33) Tertiary Hospita/ Medica Coege Hospita Secondary/ Maternity UHP/ Dispensry Pregnancies were most frequenty registered with the frontine workers (91.7%). st Antenata care (ANC) check-ups: About 48% women received first ANC check-up in the 1 trimester; 99% nd had received at east one ANC by the end of the trimester. 7.7% had received at east 4 ANC checkups. Roe of FLWs: About 9% RDWs reported that FLW (ASHA/ AWW/ ANM/ LW) had visited them at home during their ast pregnancy. Of those who did, th mean month of first visit was 4 month of pregnancy and an average of 3.9 times during the Fig. 8: Awareness (%) of Danger Signs in Pregnancy among RDWs fu course of pregnancy. Antenata Counseing: ANC counseing was mosty regarding pace of deivery (71.8%) and eary initiation of breast feeding (67.4%). About 37% had been counseed on materna danger signs of which 6% had been informed on where to seek care for the same. Ony 9% had received advice on neonata danger signs of which about 7% had been counseed on where to go if any neonata danger signs were found. Awareness among RDWs on danger signs in pregnancy has been depicted in Fig. 8. Concerns regarding quaity of ANC provided by the FLWs were aso raised by the service providers at the pubic hospitas as they reported inadequacy in skis and trainings. Key Observations: Pvt. Hospita/ Cinic/ Nursing 91.7 Frontine Workers N = 9 Not Registered Anywhere Tertiary Hospita/ Medica Coege Hospita Secondary /Maternity 3.3 UHP/ Dispensry Pvt. Hospita /Cinic /Nursing N= Pvt. Pharmacy Doctor ANC services were commony sought from FLWs (83.8%) and tertiary care pubic heath faciity (46%) RDWs accessed more than 1 faciities for ANC. Any 3 or more danger signs Any or more danger signs Ony 1 danger sign Own N = 9 Frontine Workers 1. Registration of pregnancy was near universa (99%); however, there was time ag between woman knowing knowing about her pregnancy and her registration for ANC. FLWs were commony invoved in rendering ANC services 3. Quaity of antenata counseing and ANC services provided by the FLWs was questionabe and danger signs (both materna and neonata) were usuay ignored Capita Hospita. 3. UCHC UPHC Pvt. Hospita Deivery and Immediate Newborn Care Out-of-Pocket expenses (Source: FGD with MILs and Husbands): The respondents spent about INR - on transportation and pathoogica tests in case of institutiona deiveries at pubic faciity. They reported that a other expenses were covered under various their out-of-pocket expenses At N=61. The popuation reported 9% institutiona deivery rate. deiveries were majory due to deay in identification of abor and miscacuation of Expected Date of Deivery; 17% of RDWs < years age had deivered at home About 9%of the home deiveries had skied attendance 3% deiveries were Cesarean section (~Govt: 19%, Pvt: %); 64.% of these conducted in Govt. faciities Retention rates from ANC to deivery for Private set ups was 76.9%. Waked Government Vehice Private Vehice Cyce Rickshaw government schemes and entitements. In private faciities, about INR 6-8 woud be spent for norma deivery and up to INR 1- for caesarean deiveries. Access to Program Entitements: Dissonances were reported across groups in sums with respect to incentives and benefits provided under various government schemes such as JSSY, JSSK etc. Though many respondents reported to have received money in instaments, majority compained deay and difficuty in receiving it due to compex paper work, need to produce proof of identity and pace of residence (especiay for immigrants), and frequent transfers of appropriate approving authority. Most beneficiaries reported having received food suppements such as egg, sattu, etc from the Anganwadi Centre (AWC) during ante-nata period. Unavaiabiity of ambuance during deivery appeared to be one of the key disappointments among beneficiaries as it added consideraby to Respondents aso reported inabiity to utiize cash benefits towards unforeseen caesarean deiveries and compicated cases due to deay in payments. In view of this, many respondents reported to save cash as a birth preparedness measure to be abe to bear the cost of transportation and other medicines and suppies. Most (9.1%) of the RDWs had reached the institution for deivery using a private vehice. 9% had used government ambuance services. Transportation for deivery was considered as a major out-of-pocket expenditure (Source: FGD with beneficiaries) Beneficiaries were frequenty advised to arrange transportation on their own (Source: FGD with ASHA) "We do not get money at that time and get it after months. I caed the ambuance and they gave me the number of the contro room. I rang to the contro room and got repy that there was no ambuance and it woud be ate by haf an hour. I waited, but it didn't come within haf an hour. So, I was bound to hire a vehice to go to hospita and that too, after much deay - Husband of RDW

5 1 Immediate Newborn Care: The newborn was paced on the bare skin of the mother or someone ese in 11.8% of the deiveries. Recording of the Birth Weight: 91.9%newborns were weighed at birth. About 9.6% (N=44) were of ow birth weight (LBW; <. kg)[13% from birth documents as avaiabe e.g., mother's card (N=3), 7.% from reca by RDWs (N=31)]. Incidence of LBW babies in RDWs from notified sums was 7.8% and from nonnotified sums was 9.9%. Breast feeding: Amost a (98.3%) the RDWs had ever breastfed their newborns (N=9). 9.4% had initiated breast feeding on Day 1 and 4.9% within the critica first hour after birth (eary initiation) (N=74). 91.1% of the RDWs said that they had fed their first mik to the newborn. Cord care: Reca rates were poor when the RDWs were asked whether a new bade was used to cut the cord or not (73.3% RDWs coud not reca), and whether anything was appied on the cord after cutting (3.8% suggested that something was appied most commony an ointment;.4% were unaware). About 3% said that they had appied something on the cord unti it fe off (4.9% of these had appied ointment and 4.% had appied oi) Fig. 11: Person accompanying at the Time of Deivery Mother Husband Mother in Law Sister Other Famiy Member Severa famiy members and acquaintances accompanied the RDWs at the time of deivery, the mother being the most frequent accompaniment Ony 8% of the RDWs said that they had a frontine worker (ASHA/ AWW or a ink worker from some NGO) aongside at the time of deivery to take care of the newborn Friend 6. Line Worker/ ASHA Fig. 13: Compications Experienced during Deivery (N=9) 18.4 Heavy Beeding 3.3 Labour More than 1 Hours Loss of Conciousness Premature Labour Fou Fig. 14: Reasons Cited by RDW for not going to the Referred Pace for Compications during Deivery (N=17) Cost too much/ too expensive Fig. 1: Reason for not seeking FLW escort during Labor N = 9 N = AWW 1.1 Baby in Abnorma Position About 64.8% (N=384) of the RDWs reported having experienced some compication during deivery with.8% reporting more than one compication. Fou vagina discharge was reported as a frequent compication (%) foowed by abor asting beyond 1 hours Deivery at night.9 Husband/ Famiy didn,t Aow About 7.% of the RDWs did not contact the FLW for escorting during abor. Among those who did not contact the FLW, 38% said that they did not have the time to ca and 1% said that their husband/ famiy did not aow them to ca. Of 9 RDWs, 8% said that the FLW did not inform them that they shoud ca them for accompaniment for deivery Don t trust famiy/ poor quaity service 11. I was out of Town Husband/ Famiy did not aow 6.1 Don t Trust No Time to Ca Not necessary Don t Know 9 (7.6%) of 384 RDWs with compications at deivery had received referra advice of which 17 did not compy. 3% fet that it was not necessary to foow the referra advice. Ony 6% respondents mentioned costs as the cause. Distance to referred faciity and ack of transportation did not emerge as important reasons. Post Nata Care (PNC) Duration of stay in the heath faciity: Of 33 institutiona deiveries, 76.6% had stayed at the faciity for at east 4 hours (7.4% for norma vagina deiveries, 96.8% for caesarean deiveries). 3.4% had eft the faciity within 6 hours of deivery Breast Feeding 89. Fig. 1: Components of Pre-discharge Counseing 81.6 Nutritious Food for Mother 7.3 Umbiica Cord Care Deayed Bathing Immunization 3.6 Skin-to-skin Kangaroo Method 93.% of the RDWs had received pre-discharge counseing (for home deiveries, advice given by FLW before she eft the beneficiaries home post-deivery). Counseing was ess frequenty provided on famiy panning. 3. Keep Baby Warm (not STS or KMC 44.4 Materna Danger Signs Neonata Danger Signs N = Birth Contro/ Famiy Panning Breastfeeding counseing incuded advice on excusive breastfeeding in 6.4% cases. Ony 16.9% had been educated on how to breastfeed and 1.% had been tod about need to feed the coostrum to the baby Pre-discharge check-up: Among institutiona deiveries (N=33), 7% of the RDWs and 79.7% newborns had received physica check-up before discharge, commony by the doctor (in more than 9% cases). 8 6 Fig. 16: Components of Pre-discharge Counseing on Breast Feeding N = Give Breast Breast How to Benefits of Breast/ Coostrum feed feeding Breast Breast Nippe care Nutrition Mother s Excusivey improves feed Mik actation Fig. 17: Profie of Post-nata care for Mother 16 Mother received any PNC (N=9) more than PNC visits(n=9) first check up within 4 Hrs (N=9) PNC at the Heath Faciity (N=9) PNC at the UNHD/ AWC (N=9) Fig. 19: Components of Post-nata care for Mother 86.3 Examined Body 33.7 Breasts 1.8 for heavy beeding Counseed on Famiy Panning 7. Counseed on Nutrition 4 Keep Baby Warm (not STS or KMC Neonata Danger Signs N= Materna Danger Signs Fig. 18: Profie of Post-nata care for Newborn Newborn received any neonata care (N=9) 73.1 Examined Weighed Body the new born 3.6 more than PNC visits the umbiicus first check up within 4 Hrs 49.1 Counseed on breast feeding 16.6 PNC at the heath faciity 3.4 Observed Counseed breast on STS/ feeding KMC Counseed on danger signs 9 9 PNC at temparature N=17 breathing. Other PNC at the UHND/ AWC Fig. : Components of Post-nata care for Newborn 1.3 heartbeat

6 Check up after discharge from the faciity: Ony 16% of the RDWs and 3% of newborns had received postnata heath check-up after discharge (mosty at heath faciities with negigibe PNC at community/ Key Observations: 1. Pre-discharge counseing was reported by 9.3% RDWs of which ony 6.4% reported that they had been counseed on Excusive Breastfeeding. Care was mosty centered around deivery PNC was frequenty overooked 3. Ony 16% of the RDWs and 3% of the newborns had received post-nata check up Of 9 RDWs, 98.3% coud mention of at east one danger sign in the newborn without probing Fever was the most frequenty reported neonata danger symptom (87.7%).3% of the RDWs reported that their newborn had at east one danger sign in the first month of ife. Fever and poor sucking/ feeding were the most frequenty reported Convusion 6.7 Convusion 87.7 Fever.7 Poor Sucking or Feeding Fever Poor Sucking or Feeding 38. Difficut/ 3. Difficut/ Difficut/ Difficut/ 8.6 Too sma or born too eary 4.7 Too sma or born too eary 1.9 Cord Redness/ 1. Cord Redness/ 1.3 Red swoen eyes/ discharge 19.1 Yeow Pams/ Soes/ Eyes Red swoen eyes/ discharge Yeow Pams/ Soes/ Eyes N= Lethargy.3 Lethargy Unconsciousness N=1 3.3 Unconsciousness.3.7 Care had been sought for 96% of sick neonata (Fig. 3). Newborns of three of the 9 RDWs were dead one deivered at home and died on Day 1, 1 deivered in pubic faciity and died on Day, and 1 deivered in a private hospita and died on Day 1 in a pubic faciity. Care of the LBW newborn: 8.3% of RDWs perceived that their baby was born smaer than average (n=41)/ very sma (n=8). Of those who reported that their baby was very sma (n=8), a reported that they had provided extra care to their baby viz., frequent breast feeding and skin-to-skin care (n=7) and newborn heath check-up at a heath faciity (n=3); had been visited at home by FLW. Faciity Survey (Source : FGDs and IDIs faciity assessments) URBAN PRIMARY HEALTH CENTRES (UPHCs) Constraints of Space: Most PHCs operated in rented government residentia quarters and acked architectura suitabiity and space for patient care. Inconvenience and ack of privacy dissuaded cients. Unavaiabiity of Speciaists: Speciaists were either not posted or were not reguary avaiabe. Those avaiabe were imited in efficiency due to inadequacies in infrastructure, instruments and devices. Doctors had to see patients beyond their area of speciaization. Issues Reated to Human Resource Management: Frequent transfers of Medica Officers reportedy hampered day-to-day management and created an image of service inconsistency among communities. Roe rationaization, carity on reporting ines, accountabiity frameworks and confidence in MNH care were acking among PHC staff. The pharmacist was the one in a cerica staff, manageria staff and data manager. IT personne/data entry operators were not posted despite avaiabiity of computers. NHM officias highighted shortage of staff nurses at PHCs. High Referra Rates for Sick Newborns: Care seekers were often referred to the Capita Hospita, adding to their out-of-pocket expenses and dissatisfaction. Unavaiabiity of Essentia Drugs and Consumabes: NHM officias expressed chaenges with suppy chains as Bhubaneswar was undergoing transition of drug management authority from the State Drug Management Unit to Odisha State Medica Corporation. Providers at the PHCs aso reported inconsistency in suppy of consumabes such as needes and reagents, and aboratory instruments (urine pregnancy test, hemogobinometry, bood tests, etc). URBAN COMMUNITY HEALTH CENTRE (CHCs) A tota of 4 CHCS have been panned to be set-up in the city. Two centres namey the BMC Hospita and the Unit 4 faciity were upgraded in as CHCs. Lack of space and shortage of beds was noted. Unit 4 had ony 7 beds for IPD, whie ony beds had been aocated in BMC's Maternity Ward. Stretcher and whee chairs were not avaiabe in maternity ward. The BMC Hospita did not have Specia Newborn Care Units (SNCU). Aso, issues regarding ventiation, ighting etc were observed in PNC ward at BMC. The service providers aso reported ack of necessary equipment and instruments to be abe to provide MNH services. Inadequacy of critica personne manpower incuding doctors, speciaists, staff nurses made CHCs unattractive to avai MNH services. Lack of essentia drugs and consumabes was reported. Medicines were insufficient for the cient oad Fig. 3: Profie of sick newborn who sought care 4. Convusion 43.1 Fever 37. Poor Sucking or Feeding 9. Difficut/. Difficut/.6 Too sma or born too eary Cord Redness/ Red swoen eyes/ discharge 14.6 Yeow Pams/ Soes/ Eyes.6 Lethargy N=144.8 Unconsciousness 16.7 Earier peope used to compain that they had to wait outside and there were no chairs or benches. We have recenty bought some but need more space The BP instrument and water fiter are my own, said a service provider. -Medica Officers at the PHCs