Essential Newborn Care (ENC) services - Bihar Experiences

Essential Newborn Care (ENC) services

- Bihar Experiences

State Health Society Bihar

National Review on Child Health

22-23 October 2012

BIHAR TEAM

Our Challenges


OUR CHALLANGES

Gaps in Infrastructure

(as per IPHS )

Health Institutions Required Present Shortfall

Medical Colleges 18 11 7 (39%)

District Hospitals 38 36 2 (6%)

Sub-Divisional

Hospitals 101 76 25(25%)

Referral Hospital 622 70 552 (88%)

PHC 2489 533 1956 (78%)

Additional PHC 2787 1243 1544 (55%)

Sub-Health

Centers 16576 8858 7718 (46%)

Source ; SHSB

Trend of IMR in Bihar

61 60

58

56

52

48

44

0

10

20

30

40

50

60

70

2005 2006 2007 2008 2009 2010 2011


Source ; SRS

Background

2010-Year of Newborn :

A defining YEAR for NB in Bihar

• A number of initiatives aimed at

improving the newborn care

facilities in the Bihar

• Setting up SNCU, NBSU, NBCC

has been a part of these initiatives

• KEY Initiative : All Health Facilities

in the state provide Essential

Newborn Care services through

NBCC and have Mamta workers

Declaration by Hon’ble Chief Minister Bihar,

Shri Nitish Kumarji on 25th Feb. 2010


So far there are 11 SCNUs, 1 NBSU and 464 NBCCs have been set up in

the state

27 SCNUs,41 NSUs and 50 NBCCs are in the process of getting set up by

the state government

Initiatives institutionalized

State level Newborn Care Committee

headed by Health Secretary and District

Newborn care Core Committees formed

in all districts for coordination of all

activities for newborn care.


State government provided Newborn

Kit to all mothers in government

hospitals(Baby Shirt; Baby Bed

Sheet; Baby Blanket; Baby Napkin;

Sanitary Pads for mother)

Initiatives institutionalized...cont..

Introduction of Labour Room Registers in all

Facilities conducting delivery to record the

information related to mother and newborns


MIS for SNCU set up and

SCNU Registers

Introduction of NBCC Registers in all

Facilities conducting delivery to record the

information related to newborns

Newborn Care Corner (NBCC) operational

status

46

164

464

0

100

200

300

400

500

600

2010 2011 2012 (April)

No of NBCC operational Expon. (No of NBCC operational)

Source: Monthly NBCC report

External Monitoring report

The Stepping Stones

2010 Year of Advocacy

State’s Year of Newborn

2011 Year of Establishment

Setting up of SNCU, NBSU

and NBCC

2012 Year of Consolidation

Quality Management

of FBNC


QM in FBNC

Immediate objective

– To provide quality services to newborn through FBNC in the state.

Long term goal

– Develop a pool of doctors, nurses and managers having the knowledge and

skill for running a FBNC.

– Develop a pool of Technical Quality Supervisors (TQS) capable of

providing monitoring and supervision support to FBNCs.

– Develop Medical colleges as the hub of newborn care and regional

centres of excellence for newborn care capable of training and mentoring

new generation of doctors, nurses and managers on newborn care.


Strategy: Quality Assurance Initiatives

Assuring quality with internal

intervention

• Internal QA by the practicing

staffs (MOs / Staff nurses /

ancillary staffs) themselves

using a protocol checklist –

Self-Assessment Tool (SAT)

This serves the dual purpose of on

the job capacity development of the

staff as well as monitoring and

reporting on QA.

Assuring quality with external

intervention

• External monitoring for QA done

using an External Assessment

Tool (ExAT) by RPMU, SIHFW,

MC who have been successfully

practicing the protocols of QA

This helps validation of the

protocols followed by the internal

staff as well as sharing of good

practices and cross learning.


Quality Assurance

Quality Assessment Quality

Improvement

Systematic

monitoring

Identify gaps –

recommend action Follow up on

recommendations

Quality Assurance Model


Protocol Indicators

INPUT PROCESSES OUTPUT

• Infrastructure

• Staff- training

• Posting incentives

• Equipment- O&M

• Drugs and

consumables

• Hand holding /

mentoring support

• Adherence to protocol and

guidelines

• Hand washing- before entering

and touching every baby

• Client provider interaction

• Record Keeping

• On the job training of staff

• Timely action for repair of the

equipment

• Breast feeding of admitted babies

• KMC

• Providers’ perspective-

(Quality)

Admission rates

Morbidit

Mortality

Referral to higher

centres

LAMA

• Clients’ perspective-

(Satisfaction)

Care provided by staff

Treatment

Behavior

Expenditure on

treatment


Scheme

SAT-based

Internal

assessment

Report

identifying action

points

Compilation of all SATs

generates action for

the CS/DHS

Action required at

the state level

intimated to SHS

Conduct Quarterly

visits to all facilities

using External

Assessment Tool

(ExAT)

Analyze and validate monthly SAT reports.

Provides mentoring support.

Quarterly consolidated report prepared

containing the recommendations of SAT and QAT

reports

Tagging of local Health

Officials with the TQS

resulted in their gradual

capacity development

Medical College as Hub of Newborn

Care (operate as the Secretariat of

QAFBNC, training, verbal autopsy)

Internal exercise

The journey so far

• QA being practiced internally in 11 SNCUs, 1 NBSU and 464 NBCCs

• A pool of TQS created (RPMU/MC/SIHFW/SHS/STF)- 82 State & 150

District (2 MOs & 2 SNs /district)

• All these facilities being monitored externally for validation of

adherence to protocols and providing hand holding support

– Cross sharing and learning across the state through quarterly documentation of

outcome of internal and external QA mechanisms.

– Quarterly grading of facilities (one of the key indicator for ranking of districts in

Bihar)

• Hub in MC

• UNICEF supported State Task Force for QA-FBNC providing technical

support at all levels.


Essential criteria for Grading of NBCC

Functional status of

equipment

Following five neonatal equipment along with Voltage Stabilizer need to be

in working condition

1. Radiant Warmer

2. Oxygen Concentrator

3. Suction Machine

4. AMBU Bag

5. Weighing Scale

Availability of Trained and

Skilled staff

All staff need to be trained on NSSK/NBCC training and Possess the required

skill for handling newborn babies

(Skills are assessed by direct observation & demonstration on mannequin)

Asepsis maintained &

Adherence to protocols

Cleansing of labor room and NBCC areas at least 3 times daily and NBCC

equipment once daily

Staff need to practice at least the following 5 protocols:

1. Hand wash

2. Resuscitation

3. KMC

4. Breast Feeding (EBF, position)

5. BMW management

Proper Record keeping

Timely &Complete reporting to

SHS

Maintaining and updating NBCC register & sending report monthly to

SHS

Care of Baby (Essential

Newborn Care)

1. Early initiation of breastfeeding

2. Weighing the newborn

3. Provision of Warmth (Drying & wrapping, KMC, delayed bathing)

4. Prevention of infection (hygienic cord care/eye care)

5. Immunization (Birth dose Polio, BCG and Hepatitis-B)

Availability of Essential Life

Saving drugs

NBCCs should have at least these 5 essential drugs

1.Adrenaline

2. Normal Saline

3. Inj. Vitamin-K

4. Dextrose 5% or 10%

5.Inj. Antibiotics

Availability of Consumables

NBCCs need to have the following items

1. Sterile Gloves

2. Disposable Syringes & Needle

3.Baby Wrapping towel

4. Soap & Towel for wash basin

5. Color coded bags & bins

Essential criteria for Grading of NBCCs…..cont…

Grading of NBCCs/Facilities -

3 categories with color coding

Fully Functional

(Fulfilling all 5 criteria)

A. Newborn Care: Newborn babies provided with Essential

Newborn Care

B. Other parameters

1. Equipment : All equipment are functional

2. Human Resources :All staff are trained & skilled

3. Adherence to Protocol :Asepsis maintained & Protocols

followed strictly

4. Records & reports :Record keeping good & report sent to SHS

regularly

Partially Functional

A. Newborn Care: Newborn babies provided with Essential Newborn

Care

B. Problem in anyone of the above B criteria.

Non-Functional Babies NOT provided with ENC

But equipment/ trained HR/ other logistics available

Grading: 1st Quarter Vs 2nd Quarter of 2012

Sl.

No. Status April 2012 Sept 2012 Change

1 Fully Functional 125 (27%) 167(36%)

2 Partially Functional 311 (67%) 288 (62%)

3 Non-Functional 28 (6%) 9 (2%)

Total 464 464


Overall changes-Functional Status

Sr

No

Major changes in Functional Status Number of

NBCC

comment

1 Upgraded from Partial to Fully

functional NBCC 48

2 Upgraded from Non-functional to

Partial Functional NBCC 19

3 Downgraded from Fully to Partial

functional NBCC 6 Mainly due to non-

functional neonatal

equipment

4 Downgraded to Non-Functional NBCCs

0


Findings: 1st Quarter Vs 2nd Quarter

Newborns reached


1 Total number of Live Birth 1,53,152

a

No. of Babies received Initial Steps of

Resuscitation56200 (36%)

b

No. of Babies received Bag and Mask

Ventilation11704 (7.6%)

c No. of Babies referred to higher facility 1169

2 Total number of Still Birth 2835

3 Total number of Newborn Death 363

Source : MPR-NBCC , SHSB

Newborn Care at NBCCs- Apr to June 2012

Source: Reported data (YNB format) for 2010

NBCC Monitoring & Mentoring Report

Early Initiation of breastfeeding

….within one hour of birth

39

72 79

0

10

20

30

40

50

60

70

80

90

2010-11 Q1 (April 2012) Q2 (Sept 2012)

Early initiation of Breastfeeding

Correct weight recording of Newborn at

Health Facilities

11%

22%

25%

2011 2012 (1st Quarter) 2012 (2nd Quarter)

Correct weight recording at health facility

NBCC Monitoring & Mentoring Report

N- 2918 newborn

Web Based NBCC reporting

State Health Society Bihar UNICEF

Challenges

– Managing facilities where staff nurses are not

available and only ANMs are present.

– Weak O&M support from the suppliers of the

equipment – challenge of spread – 464 NBCC/38

districts/connectivity challenges

– Changing behaviour and age-old practices of staff

– Timely replenishment of Drugs, consumables and

supplies


State Health Society Bihar UNICEF

Documents

Essential Newborn Care (ENC) services - Bihar Experiences