Changes that improved maternal and neonatal health in ... · Changes that improved maternal and neonatal health ... interventions in antenatal, perinatal, postnatal care of mothers

Changes that improved maternal and neonatal health in Uttarakhand

January 2015

The ‘needle and syringe’ represents health service delivery or a health product change ideas

The ‘classroom’ icon represents change ideas that were primarily related to classroom or on-the-job trainings, orientation and sensitization sessions.

The ‘notice’ icon represents change ideas where materials were created for ready reference or as reminders for action.

The ‘checklist’ icon represents change ideas that improved services by enhancing quality of reporting, recordkeeping and review.

The ‘box’ icon represents change ideas that improved procurement of products and services.

The ‘two bustheads’ icon represents change ideas which were either task shifting or was undertaken by introduction of a new health professional.

The ‘clock’ icon represents change ideas that were related to either increasing or reducing time of a service or product administration.

The ‘cart with goods’ icon represents change ideas that were related to relocation or creation of a facility.

The ‘crossing arrow signs’ icon represents change ideas that were related to supportive supervision.

The ‘people across a table’ icon represents change ideas that were related to counseling practices.

Icons used in the change package andhow to read them

General/District/Sub-District Hospital

Primary HealthCenter

Sub-Center

Health facilities inUttarakhand

where e�orts to improve care led to

this change package

Community Health Center

BaurariNew TehriChamba

Chopadiyal Gaon

Gaza Srinagar

ThalisainPauri

Pabau

Patisain

KotdwarBahadarabad

SohalpurGarhJwalapur Haridwar

Lal Dhang

The USAID ASSIST Project also acknowledges contribution of facility managers and health service providers who, as members of the quality improvement teams, initiated and implemented change ideas to improve quality of healthcare services in their facilities.

The USAID ASSIST Project acknowledges the unwavering support of Dr. Rakesh Kumar, Joint Secretary (RCH), Minstry of Health and Family Welfare, Government of India in development of this change package.

Uttarakhand is the second fastest growing state in India economically1. Of the 13 districts in the state, three – Haridwar, Pauri and Tehri – have been identified high-priority districts for the National Health Mission. Maternal mortality ratio for the state was 292 per 100,000 live births (2010-12) 2, down from 445 per 100,000 live births in 2001-033. The Infant mortality rate fell from 50 per 1000 live births in 20004 to 32 per 1000 live births in 20135. The neonatal mortality declined two basis points to 28 per 1000 live births in 2012-136 from 30 per 1000 live births in 2010-117. The Annual Health Survey in the state shows that only 58.2 % of all deliveries take place in an institution8. Of remaining child birth that took place at home, only 33.2% had a skilled birth attendant9 facilitating delivery10.

93 percent of the 53,484 square kilometers of the state is mountainous and of the remaining, nearly two thirds is covered by forest11. The challenge of providing quality, reliable and timely health services in the state is accentuated by the difficult terrain, sparse road and rail network and unstable geological conditions. The public health system is often constrained to explore innovations not only within the limited resources available at its disposal but also with the extenuating circumstances.

In order to accelerate reduction in maternal, neonatal and infant deaths in the state, there was an immediate need to improve quality of maternal and newborn health (MNH) services. The USAID ASSIST Project in Uttarakhand is conceived with a mandate to improve quality of maternal and newborn care services by strengthening the public health system in the state. The quality improvement12 (QI) teams from the USAID ASSIST Project, in consultation with public health facility managers and key health professionals in the state, selected a set of catalytic, high impact interventions in antenatal, perinatal, postnatal care of mothers and essential care of newborns that would accelerate further reduction in maternal and infant deaths in Uttarakhand. These change ideas were introduced at district, block and sub-centers levels in three high priority districts of the state.

CONTEXT

The QI teams used a mix of observations techniques and in-depth interviews on the maternal and newborn health interventions being practiced at select public health facilities in the state and identified the following gaps in provision of quality maternal and newborn health services.

Gaps in quality of maternal and newborn health services

● The health workers were measuring blood pressure (BP) of pregnant women only during the first ANC visit instead of measuring and recording BP during every one of the four ANC visits to identify pregnancy induced hypertension

● The health providers were assessing hemoglobin levels (Hb) of pregnant women only during the first ANC visit instead of measuring and recording Hb during every one of the four ANC visits to identify severely anemic women.

Gaps in maternal health services during ante-natal period

● There was inconsistency across the state in administration of oxytocin, both in terms of timing and in appropriateness of dosage as suggested by the skilled birth attendance guidelines from the Government of India.

● Partograph was not being plotted correctly and consistently by the skilled birth attendants (SBAs) across several facilities in the state.

Gaps in maternal health services during intra-natal period

● The practice of repeatedly monitoring vital parameters during the immediate postpartum period was inconsistent across the selected facilities and was not happening as per the guidelines of the Government of India.

Gaps in maternal health services during post-natal period

● Vitamin K injection was administered only to low birth weight babies or to pre-term babies than to all newborns. ● Health providers were not counseling mothers on early initiation of breastfeeding resulting in delay in initiating breastfeeding by many mothers.

Gaps in newborn health services

ASSIST coaches trainingmembers of quality improvement team

Orientation learning sessionfacilitated by quality improvement teams

Measuring and recording blood pressure levels during all antenatal check-ups and their timely referral to in-house specialists or to higher facilities.AIM#1

Delivering change in maternal and newborn health services

Change idea Logic for change How the change happenedChange site

Orientation to health staff at the facility on the importance and correct method of measuring BP in for women during all ANC visits.

Maintaining with healthcare providers record of BP levels in taken during ANC services.

Relocation of ANC room to the ground floor and adjacent to female outpatient department (OPD) in the health facility.

Redistribution of out-patient department (OPD) hours to make for a separate timeslot dedicated only to ANC services.

Enabling ASHAs to measure BP using digital BP machines when pregnant women came with them for ANC services to health facility.

In some health facilities, BP was measured only during first visit ANC visit of the pregnant woman and was not measured during other visits.

Blood pressure was getting recorded in the prescription slip that was being given back to the patient, resulting in non availability of BP records taken during ANC visits with the health staff.

There were some health facilities where female OPD was on the ground floor and the ANC room was on a different floor. It was observed that the pregnant women went home after consulting the medical officer in the female OPD, without getting their vitals checked with staffs in the ANC room.

Pregnant women coming to the health facility were not getting the full complement of ANC services due to high patient load and clash of timing of ANC and immunization services.

In health facilities with high load and shortage of staffs, it was observed that BP could not be measured for all women coming for ANC services. It was observed that ASHAs, who often accompanied pregnant women to health facilities, could be engaged for assisting ANC services.

Medical officer in-charge (MOIC) trained all the healthcare staff of the facility on importance of measuring BP in all ANC visits of a pregnant woman. The health staffs were further trained on the correct way to measure blood pressure.

ANC register available with healthcare providers was revised to include columns for recording blood pressure for all four ANC visits.

The hospital administration shifted the ANC room from the first floor to the ground floor adjacent to the female OPD so that all the patients would receive ANC services as well as a gynecology consultation.

The MOIC of the facility changed timings of ANC services during the OPD. OPD staffs first provided immunization services from 8 AM to 11 AM daily and ANC services from 11 AM to 2 PM every day. This change freed up time of the nursing staff to measure blood pressure of all women coming for ANC services.

The task of measuring BP in high load health facilities and in cases where ASHAs accompanied pregnant women to ANC clinics was shifted to ASHAs, with better skill sets. Medical Officer In-Charge of the facility trained the identified ASHAs during their monthly meeting on measuring blood pressure using the digital BP machine in the facilities and shifted the tasks to ASHAs.

DH PHC SCCHC

Proportion of ANCs during which BP was checked and recorded

QI team reviewing clinical recordsand providing feedback to facility staffs

Measuring and recording bloodpressure levels during every ANC visit

A senior staff made responsible toensure that no service is missed to a pregnant woman

Measuring and recording hemoglobin (Hb) levels in all four antenatal check-ups and their timely referral of anemic cases to in-house specialists or to higher facilities.AIM#2



Orientation to Lab Technicians (LT) and ANMs on importance of checking Hb level in all ANC visits.

Addition of a column in the existing ANC register for recording Hb levels during all ANC visits

Relocation of ANC room to the ground floor and adjacent to female outpatient department (OPD) in the health facility.

Extension of sample collection time in the facility from 3 hours in the morning (8-11 AM) to 6 hours in the day (8 AM – 2 PM) so that blood samples of all women coming for ANC services can be collected for Hb testing.

Provision of Hb testing kits in the labor room.

Planned procurement (in time and in adequate quantity) of Hb testing kits to ensure 24 x 7 availability

A large number of women coming for ANC services were not screened routinely for anemia with Hb testing

There was no defined column to record the Hb levels in the ANC register available with the nursing staff.

There were some health facilities where female OPD was on the ground floor and the ANC room was on a different floor. It was observed that the pregnant women went home after consulting the medical officer in the female OPD, without getting their Hb checked with staffs in the ANC room.

The pathology laboratory in the health facility collected samples till 11 am and then prepared reports from 11 am to 2 pm. The laboratory technicians would stop collecting samples after 11 am and ask the women to return next day. This resulted in the facility missing Hb testing for many women.

In absence of laboratory technician, Hb levels were not being tested for women coming for delivery.

The procurement was being done only on report of stock-out, which caused delays, sometimes as long as a couple of weeks, in replenishment of Hb testing kits. This was resulting in failure to check Hb levels for many pregnant women.

The MOIC oriented the nursing staffs of the facilities on importance of Hb testing for all pregnant women in each of their ANC visits and tracking her Hb levels for anemia detection.

A separate column for documenting Hb levels was added to the ANC register and staff nurses on duty were instructed to record Hb levels for all ANC patients in that column

The hospital administration shifted the ANC room from the first floor to the ground floor adjacent to the female OPD so that all the patients would receive ANC services as well as a gynecology consultation.

The Medical Superintendant issued an order to the laboratory to collect blood samples for Hb testing of all women coming for ANC services until 2 pm and not to return any woman without collecting the sample. The ANMs were assigned the responsibility of collecting the Hb reports from the laboratory and updating the ANC register prior to subsequent visits.

Hb testing kits were made available in the labor room and labor room staffs were oriented on its use. The labor room staffs tested the Hb levels of the women coming for delivery when laboratory technician was not available in the facility.

The staffs involved in procurement were oriented to keep buffer stock of Hb testing kits based on average monthly consumption and a benchmark level when they shall place order for fresh stock. The staffs updated utilization status of the Hb testing kits on regular basis and orders were placed once stocks reached the reorder level.

DH PHC SCCHC

Proportion of ANCs during which Hb was checked and recorded.

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Proportion of ANCs during which haemoglobin ofpregnant woman was checked & documented in

DH Baurari, January – November, 2014

Total no. of ANCs reviewed

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Provision of Hb testing kits in labor room

Addition of a column in existing ANC register for recording Hb levels during all ANC visits

Orientation of lab technicians and ANMs on importance of checking Hb level in all ANC visits

Checking and recordinghemoglobin levels during all ANC visits

Line listing of severely anemiccases in ANC clinics of the maternity homes

Delivering change in maternal and newborn health servicesUse of partograph in early identi�cation and management of complications during labor.AIM#3


DH PHC SCCHC

Training of health staff on the correct filling of partograph

Compliance of labor room staffs to use of the simplified version of partograph, developed by WHO and as recommended by the Government of India for use.

Weekly review of plotted partograph by the Medical Officers to check for its completeness and correctness, and provide support as needed.

Annexing partograph to the Bed Head Ticket (BHT) as soon as a woman is admitted in labor.

Establishing a process of handing over and taking over of partograph between the nursing staffs of two consecutive shifts, with the more experienced nurse acting as mentor to the less experienced one.

Health care providers did not know the correct method of plotting partograph and its relevance in identifying early danger signs.

The labor room staffs were plotting the older version of partograph incorrectly and incompletely. The facilities also experienced frequent stock outs of partograph.

The use and interpretation of partograph was not being done in some cases, in spite of the labor room staffs having undergone the training. They needed more hands on support and supportive supervision.

Plotting of partograph was being missed by some of the labor room staffs even after training because partograph was not readily available when the woman was brought in labor.

The information plotted on the partograph was not being detailed when labor room staffs of one shift were handing over the charge to the nursing staffs for the next shift, which resulted in the early danger signs getting missed for some women in labor.

On-site training by the MOIC was provided to the health staff on plotting of partograph and identifying danger signs based on correctly plotted partographs.

Health facility staffs were trained in plotting the simplified version of partograph. The partograph was printed in bulk and given to the nursing staff to avoid stock outs.

The gynecologist, the medical officer or a senior nursing staff reviewed the partographs on weekly basis and provided feedback, orientation and mentoring support as needed to the labor room staff.

The labor room staffs attached the partograph to the Bed Head Ticket at the time of admission of woman in labor. The attached partograph provided a reminder to the staff to plot it during active labor.

Sharing of information on partographs was included in the handover of duties by nurses during shift changes so as to ensure early danger signs of labor are not missed.

Proportion of pregnant women identi�ed as high risk by use of partograph

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Proportion of pregnant women for whom partograph was filled in DWH Pauri, April – November, 2014

Total no. of women admitted in labor in the last month

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Weekly review of plotted partograph by the Medical Officers to check for its completeness and correctness, and provide support as needed

Training of health staff on correct filling of partograph

Annexing partograph to the Bed Head Ticket (BHT) as soon as a woman is admitted in labor room

Administration of InjectionOxytocin within one minute of delivery

Labelled drug tray

Administration of Injection Oxytocin 10 International Units/intramuscular within one minute of delivery to all the women delivering in labor room for active management of third stage of labor (AMTSL)13AIM#4


DH PHC SCCHC

Orientation to facility based health providers on administration of Injection Oxytocin (IM) within one minute of delivery

Load syringes with oxytocin at the time of perineal bulging and keep them ready for use.

Planned procurement (in time and in adequate quantity) of oxytocin to ensure 24 x 7 availability

Addition of a column in the delivery register to record administration of Injection Oxytocin within one minute of delivery.

Handwritten and printed notes on action points for oxytocin administration placed in line of sight, like wall in front of the labor table, to act as visual reminders for nursing staffs in the labor room.

Little or no knowledge amongst most health providers on the active management of third stage of labor, especially on using Injection Oxytocin within one minute of delivery

The labor room staffs in the facilities were not able to administer oxytocin within one minute of delivery because often the injection was not ready for use.

The procurement was being done only on report of stock-out, which caused delays, sometimes as long as a couple of weeks, in replenishment of Injection Oxytocin. This led to Oxytocin not being administered to a number of women immediately post delivery.

Oxytocin administration was not recorded in the delivery register resulting not only in miscalculation of quantity of future procurement but also incomplete documentation of the delivery procedure.

The labor room staffs missed administering oxytocin within one minute in some cases as there was no mechanism to remind them of this practice.

MOIC of the facility/the QI team members oriented staffs conducting deliveries on guidelines related to administration of Injection Oxytocin intramuscularly within one minute of delivery, highlighting the importance, the dosage and timeliness of administering injection oxytocin

Staff nurses/ ANMs were trained to use the time of perineal bulging to load oxytocin into syringes and keep them ready in the surgical tray or on a sterile surface for administration.

The staffs involved in procurement were oriented to estimate average monthly use of Injection Oxytocin in their facility based on utilization of preceding months. They were oriented to use this information for establishing a buffer stock of one month for Injection Oxytocin in their facility and a benchmark level when they shall place order for fresh stock. This strengthened the stock ordering mechanism in their facility and minimized delays in stock replenishment.

A column was introduced in the delivery register and labor room staffs attending deliveries were instructed to record oxytocin administration in that column.

Details of oxytocin dosage, timing and method of administration were translated into Hindi, hand written or printed and posted at key locations, like wall in front of the labor table and at the nurses’ duty station. This served as a ready reckoner for staffs on duty.

Proportion of ANCs during which Hb was checked and recorded.


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Total no. of vaginal deliveries observed/reviewed/C-section where only this is done

Proportion of vaginal deliveries for which uterotonic was administered within one minute

of birth of baby in DH Haridwar, January – November, 2014

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Handwritten and printed notes on action points for oxytocin administration placed in line of sight.

Addition of a column in delivery register to record administration of oxytocin 1. Planned procurement of oxytocin to ensure 24*7 availability.

2. Placement, on rotational basis, of Auxiliary Nurse Midwives (ANMs) from feeding sub centres to assist labor room staff in assisting delivery.

1. Orientation of staff regarding administration of oxytocin within one minute.2. Load syringes with oxytocin at the time of perineal bulging and keep them ready for use.

Monitoring vital parameters (BP and Pulse) in the postpartum period

Recording of postpartum vitalparameters (BP and Pulse) in the delivery register

Appropriate management of biomedicalwaste after BMV visits and other interventions

Administration of Injection Oxytocin 10 International Units/intramuscular within one minute of delivery to all the women delivering in labor room for active management of third stage of labor (AMTSL)13AIM#4


DH PHC SCCHC

Orientation to emergency medical technician, placed in National Health Mission’s (NHM) Emergency Medical Transport Service (ambulance) (EMTS), on administration of Injection Oxytocin to women delivering in transit.

Placement, on rotational basis, of Auxiliary Nurse Midwives (ANMs) from feeding sub-centers to assist labor room staff in assisting delivery.

The labor room staffs were asked to mention any and all reason for not administering Oxytocin on one page format pasted on a wall inside the labor room. Evidence from this exercise showed that women delivering in transit were not being administered Injection Oxytocin as per guidelines as staffs on EMTS were not trained in AMTSL.

Most facilities had only one nursing staff to assist delivery as well as take care of newborn care services. Staff nurses would often miss administering Injection Oxytocin within one minute of delivery to women when she had to handle a neonatal emergency.

The QI teams identified the Emergency Medical Technician in EMTS, who is a pharmacist by qualification in Uttarakhand, to be trained in administration of Injection Oxytocin to women who deliver in transit. The EMTS coordinator trained the Emergency Medical Technician(s) of the district on Government of India guidelines related to administration of Injection Oxytocin.

The ANMs attached to a facility and working in the peripheral sub centers were placed on rotation basis to the facility labor room in order to assist the primary staff nurse in handling deliveries and administer Injection Oxytocin within one minute of birth when the nursing staff was busy with neonatal emergencies.

Proportion of vaginal deliveries for which uterotonic was administered within one minute of birth

Early identi�cation and management of post-partum complications by monitoring vital parameters (blood pressure and pulse) in the �rst six hours after delivery.

AIM#5


DH PHC SCCHC

Orientation to health facility staffs on importance of monitoring and recording vital parameters of the woman periodically during the first six hours after birth.

Annexing the Vitals Monitoring Sheet to the Bed Head Ticket (BHT) of woman admitted for delivery to record post partum vital parameters (BP and pulse).

The staffs used to measure and record the vital parameters only once or twice after delivery as they were not sensitized on the value of checking vital signs repeatedly during the immediate postpartum period. This resulted in their missing many cases of postpartum complications.

Recording of vital parameters post partum was being missed by some of the labor room staffs even after training because Vitals Monitoring Sheet was not readily available for use.

Staffs of the labor room and post natal ward were oriented on the importance of repeatedly monitoring vital parameters during the postpartum period and how to use the collected data for identifying and managing complications. MOICs of the facility did these orientations.

The MOIC of the facilities instituted a practice among labor room staffs of attaching the Vitals Monitoring Sheet with the Bed Head Ticket. The Medical Officers In-charge also got the Vitals Monitoring Sheet printed in bulk to avoid stock outs.


Training to nursing staffs on administration ofInjection Vitamin K to all newborns within 24 hours of birth

Baby tray kept ready infacilities for emergency newborn careChange idea Logic for change How the change happened

Change siteDH PHC SCCHC

Setting a schedule of monitoring vital parameters in Vitals Monitoring Sheet and documenting vital parameters (blood pressure and pulse) taken during postpartum period.

Informing ASHAs and family members accompanying the mother about the post partum check schedule and engaging them to remind post natal ward staffs to check vitals as per schedule.

Procuring new BP instrument and thermometer for postnatal ward.

The time and frequency of checking and recording vital parameters postpartum was not consistent. Advance recording of the time on Vitals Monitoring Sheet informed the nursing staffs of time for subsequent check.

Due to high caseload and shortage of staffs in postnatal ward, the nursing staffs at times missed measuring vital parameters despite setting the schedule for it. ASHAs and family members were available beside the mother to facilitate a reminder system.

BP instrument was not available in post-natal ward. In some facilities, an extra BP instrument was required as a back-up. Inadequate number of BP instruments in the postnatal ward was resulting in the staffs not measuring BP for many mothers.

Vitals Monitoring Sheet was provided in the labor room/postnatal ward for recording vital parameters, based on a pre-determined schedule, which was made from the time of delivery. Abnormal readings were checked again by a senior nursing staff before proceeding to case management.

QI team advised nursing staffs in postnatal ward to inform ASHAs and family members accompanying the mother about post partum vitals monitoring schedule. Family members and ASHAs reminded the nursing staff to monitor post partum vitals as per schedule in case the staff was busy on another case.

BP instrument and thermometer were procured by the MOIC of the facility specifically for use in postnatal ward.

Average number of times vital signs (BP and pulse) were checked and recorded within the �rst six hours of delivery.

Administration of Vitamin K to all newborns within six hours of birth to prevent Vitamin K de�ciency bleeding.AIM#6


DH PHC SCCHC

Orientation to nursing staffs on GOI guidelines on Injection Vitamin K administration to all newborns.

Planned procurement (in time and in adequate quantity) of Injection Vitamin K, Insulin syringes and 26 gauge needles to ensure 24 x 7 availability

Vitamin K was being administered only to a select few newborns because staffs in the facility had limited knowledge on GOI guidelines on Injection Vitamin K for newborns

Injection Vitamin K was in short supply in some facilities because they were not procured on the basis of delivery load at the facility. Frequent stock outs lasting as long as 2-3 weeks, were observed in some facilities that resulted in non-

The MOIC oriented the nursing staffs in labor room and in postnatal ward on importance of Vitamin K administration, the correct dosage, syringe specifications, time of administration and procurement of Vitamin K.

The staffs involved in procurement were oriented to project supply requirements of Vitamin K, 26 gauge needles and insulin syringes based on utilization in preceding months. The MOIC issued instructions to maintain at least 30 days of stock as buffer,

Delivering change in maternal and newborn health servicesEarly identi�cation and management of post-partum complications by monitoring vital parameters (blood pressure and pulse) in the �rst six hours after delivery.

AIM#5

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Proportion of newborns given injection of vitamin Kat birth in PHC Chamba, January – November, 2014

Total no. of newborns observed

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Recording of Injection Vitamin K administration in either Bed Head Ticket or Labor Admission Register

Orientation of nursing staff on GOI guidelines on administration of Vitamin K to all newborns

Trained nursing staffadministering Injection Vitamin K to a newborn

Poster reminding nursing staff to inject Vitamin K after initiating breastfeeding to the newborns

Early initiation of breastfeeding in all newbornsAIM#7


DH PHC SCCHC

Orientation of QI team and other labor room staffs on IYCF practices and importance of early initiation of breastfeeding to newborns.

Documentation of the early initiation of breastfeeding to be done in the post natal register of the mother.

The nursing staffs were not fully aware of the guidelines on IYCF practices, advantages of early initiation and exclusive breastfeeding and ways to motivate mothers and their families for it.

Whether or not breastfeeding was initiated in time early to a newborn could not be verified in absence of it’s record.

Medical Officer In-charge oriented the health staffs on the significance for early initiation of breastfeeding and its benefits to the mother and child.

Additional columns were created in the post natal register by the nursing staff on duty to record cases in which breastfeeding was initiated within one hour of birth.

Proportion of newborns who were breast fed within one hour of birth


DH PHC SCCHC

Placement of posters on guidelines related to Injection Vitamin K administration pasted at key locations, like NBCC and NBSU in the facility.

Recording of Injection Vitamin K administration in either Bed Head Ticket (BHT) or in Labor Admission Register

administration of Vitamin K to newborns. In addition, the Insulin syringes, which are used for administering Injection Vitamin K, were not available in the district.

Nursing staffs in the facility missed administering Injection Vitamin K to newborns as per the Government of India guidelines, which states ‘soon after delivery and no later than 24 hours’.

It was not a practice to keep record of Injection Vitamin K administration to newborn. Whether or not Vitamin K has been administered to a newborn could not be verified in absence of record.

and establish a system to requisition new supplies. This strengthened the stock ordering mechanism in the facility. The MOIC in PHCs, who also supervise ANMs working in sub-centers, instructed them to utilize untied fund to purchase Injection Vitamin K, insulin syringes and 26 gauge needles from the local chemists to meet any stock requirements in the period intervening between their placing the order and receiving fresh supplies.

Key points in the GOI guidelines mentioning dosage and timing of injection Vitamin K administration for all newborns, were translated to Hindi and posted on the wall of labor room, newborn care corner (NBCC) and newborn stabilization unit (NBSU).

Nursing staffs in the labor room were instructed to add an additional column in the Labor Admission Register for recording of Vitamin K administration newborns and also record it on the BHT of all mothers.

Proportion of newborns administered Injection Vitamin K within 24 hours of birth


Administration of Vitamin K to all newborns within six hours of birth to prevent Vitamin K de�ciency bleeding.AIM#6

Keeping drugs, materials and apparatusready in preparation of deliveries in the facility

References1. http://indianexpress.com/article/business/business-others/madhya-pradesh-now-fastest-growing-state-uttarakhand-pips-bihar-to-reach-second. Accessed on 09 January 20152. Special Bulletin on Maternal Mortality in India 2010-12. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.3. Sample Registration Estimates (2001-03). Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.4. SRS Bulletin, Volume 36 No.2, October 2002. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.5. SRS Bulletin, Volume 49 No.1, September 2014. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.6. Annual Health Survey, Factsheet Uttarakhand, 2012-13. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.7. Annual Health Survey, Factsheet Uttarakhand, 2010-11. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.8. Ibid reference 79. The Government of India considers the skilled birth attendant as a person who can handle common and major obstetric and neonatal emergencies as well and recognizes when the situation reaches a

point beyond his/her capability and refers the woman or the newborn to a First Referral Unit/appropriate facility without delay. GOI. Handbook for ANMs, LHVs and staff nurses as a skilled birth attendant. New Delhi: Department of Family Welfare, Ministry of Health and Family Welfare; 2006. Accessed http://mohfw.nic.in/NRHM/MH/Facilitors_Guide.pdf on 12 December 2014

10. Ibid reference 711. Accessed http://health.uk.gov.in/pages/display/111-introduction on 07 January 201512. Quality Improvement team consisted of select medical and paramedical staffs of the participating public health facility.13. Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/ LHVs/SNs, 2010. Maternal Health Division, Ministry of Health & Family Welfare, Government of India.14. Langley GJ et al. the Improvement Guide – a Practical Approach to Enhancing Organizational Performance. Second Edition. 2009

List of contributors (in alphabetical order)

The USAID Applying Science to Strengthen and Improve Systems (ASSIST) is a USAID funded project managed by University Research Co., LLC (URC) to support the government and to strengthen and improve the health system so that the quality of maternal & newborn care becomes better and more lives are saved. URC’s global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard University School of Public Health; Health Research, Inc.; Institute for Healthcare Improvement; Initiatives Inc.; Johns Hopkins University Center for Communication Programs; and Women Influencing Health Education and Rule of Law, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write [email protected].

• Anisha Singh, District Improvement Coordinator, Pauri, USAID ASSIST Project, URC CHS• Enisha Sarin, Senior Advisor, Research and Evaluation, the USAID ASSIST Project, URC CHS• Kovid Sharma, State Improvement Coordinator, USAID ASSIST Project, URC CHS• Mehtab Singh, Acting State Improvement Coordinator, USAID ASSIST Project, URC CHS• Mirwais Rahimzai, Deputy Project Director, USAID ASSIST Project, URC CHS

• Nadeem Javed, District Improvement Coordinator, Tehri, USAID ASSIST Project, URC CHS• Nigel Livesley Project Director, USAID ASSIST Project, URC CHS• Prashant Soni, Acting State Improvement Coordinator, USAID ASSIST Project, URC CHS• Raghavendra Kumar, District Improvement Coordinator, Haridwar, USAID ASSIST Project, URC CHS• Subir Kole, Data and Research Manager, the USAID ASSIST Project, URC CHS

QualityImprovementApproach

The QI approach used in the USAID ASSIST Project consists of seven steps14:1. Defining the improvement aim2. Forming the improvement team3. Understanding the current system4. Developing a measurement system5. Developing changes6. Testing changes7. Implementing and sustaining changes

What are we trying toaccomplish?

What change can we make thatwill result in improvement?

How will we know that a change is an improvement

DoStudy

PlanAct

Model for improvement

AbbreviationsAMTSL Active Management of Third Stage of LaborANC Antenatal careANM Auxiliary Nurse MidwifeASHA Accredited Social Health ActivistASSIST Applying Science to Strengthen and Improve SystemsBHT Bed Head TicketBP Blood PressureCHC Community Health CenterDH District HospitalDLHS District Level Household SurveyEMTS Emergency Medical Transport SystemGOI Government of IndiaHb Hemoglobin

IM IntramuscularIMR Infant Mortality RateIU International UnitsIYCF Infant and Young Child FeedingLT Lab TechnicianMMR Maternal Mortality RatioMOIC Medical Officer In-ChargeOPD Outpatient DepartmentPHC Primary Health CenterPPH Postpartum HemorrhageQI Quality ImprovementSC Sub CenterUSAID United States Assistance for International Development

For more information, contact: Dr Mirwais Rahimzai, Deputy Country DirectorUSAID ASSIST India. University Research Co., LLC

Alps Building, 1st Floor, 56 Janpath, New Delhi - 110001. TEL 91-11-48987700www.usaidassist.org / www.urc-chs.com / [email protected]

Disclaimers This ‘Change Package’ is made possible by the generous support of the American people through USAID’s Bureau for Global Health, Office of Health Systems. The contents are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of USAID or the United States Government. The

USAID ASSIST Project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101.

Many change ideas mentioned in this change package were context and facility specific. They may not necessarily be applicable across the board in their current form and may require modifications to achieve desired results.

Documents

Changes that improved maternal and neonatal health in ... · Changes that improved maternal and neonatal health ... interventions in antenatal, perinatal, postnatal care of mothers