Quality of Care for Essential Newborn Care and Neonatal Resuscitation

in selected districts Jharkhand Experience

Dr. Anju Puri, Senior Advisor, Newborn Health

USAID- MCHIP

Uttar Pradesh

Gonda

Deoghar

Jamtara

Jharkhand

Giridih Simdega

Chaibasa

Lucknow

Knowledge base posts

ENCR - Essential and Universal

Technical focus: Essential newborn care: Immediate newborn care and neonatal resuscitation (QOC) Approach that has been used to analyse the delivery of service; understand the

performance of the providers during training; and thereafter using systematic effort to

improve the competence for the skill proficiency on ENC/R for improved outcomes.

Core of our understanding is direct implementation and observation to assess

quality of care at the select facilities, both for delivery and newborn care

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NSSK

2 day training Neonatal Resuscitation Basic newborn care - Care of the baby at birth, Prevention of infection, Thermal

protection, Feeding of normal & LBW, transport of neonates

NO CHANGE IN PRACTICE ? Who got trained? Plan? Provider mapping? ? How was training conducted? Block/ district? Complete or

Incomplete? ? What did the training result? ? What was missing? ? What can be done to improve?

4

During Training - adaption Quality Assurance Checklist Been used to assess and

adhere to a minimum standard for quality of process during the training.

10 observation questions Score less than 80,

training is repeated.

Ensure Pre-Post Performance checklist shared with each participant

Pre-post test scores are used to rate the training and provide feed-back to the providers.

Measure changes in both the knowledge and skill acquisition by the health providers as a result of the training.

S no

Field for scoring. Scoring by observer/participants Total

score Average

score Ideal score Trainee 1 2 3 4 5 6

1 Facilitator to participants ratio

District A 5 5 5 5 5 - 25 4.2 5

District AI 0 0 0 0 0 0 0 0.0 5

District B 5 5 5 5 5 5 30 5.0 5

District BI 5 5 5 5 5 25 4.2 5

2 Whether planning session conducted before the start of the training?

District A 0 NA NA NA NA 0 0.0 5

District AI 5 NA NA NA NA NA 5 0.8 5

District B 5 0 NA NA NA NA 5 0.8 5

District BI 5 NA NA NA NA 5 0.8 5

3 Items present at the training

District A 2 2 2 2 2 10 1.7 5

District AI 2 2 2 2 2 2 12 2.0 5

District B 2 2 2 5 5 5 21 3.5 5

District BI 2 2 2 2 2 10 1.7 5

4 Number of participant’s for whom both pre & post test was conducted

District A 5 5 5 5 5 25 4.2 5

District AI 5 5 5 5 5 5 30 5.0 5

District B 5 5 5 5 5 5 30 5.0 5

District BI 5 5 5 5 5 25 4.2 5

5 Whether the performance list was correctly used

District A 5 0 5 5 5 20 3.3 5

District AI 5 5 5 5 5 5 30 5.0 5

District B 5 0 5 5 5 5 25 4.2 5

District BI 5 5 5 0 5 20 3.3 5

6 Feedback given using performance checklist

District A 0 0 5 5 5 15 2.5 5

District AI 5 5 0 5 5 5 25 4.2 5

District B 5 0 5 5 5 5 25 4.2 5

District BI 5 5 5 0 5 20 3.3 5

7 List of skill demonstrations

District A 45 35 45 50 50 225 37.5 50

District AI 40 35 40 40 40 40 235 39.2 50

District B 40 45 45 50 50 45 275 45.8 50

District BI 45 45 45 40 40 215 35.8 50

8 Good quality video used in the training (Thermal protection and feeding)

District A 10 10 10 10 10 50 8.3 10

District AI 5 5 5 5 5 5 30 5.0 10

District B 10 10 10 0 10 10 50 8.3 10

District BI 0 0 0 0 0 0 0.0 10

9 Mega code score conducted correctly (Performed for all 5 bold items)

District A - 10 10 - - - 20 3.3 10

District AI 10 10 - 10 10 10 50 8.3 10

District B - - - - 10 10 20 3.3 10

District BI 10 0 - 10 - - 20 3.3 10

10 Number of participant’s with less than minimum passing score (optional)

District A 4 4

District AI 3 3

District B 3 3

District BI 3

Total score

District A 72 67 87 82 82 - 390 65 100

District AI 77 72 62 77 77 82 447 70 100

District B 72 62 72 70 90 85 451 80 100

District BI 82 77 70 85 72 386 57 100

Gear Changers : Capacity Building Approach

Modified cascade approach used to promote continuity & quality

Quality care at key times during delivery and postpartum care, integrating components (assessment, care and counseling) care and follow up a) core group of trainers/supervisors and nurses,

b) physicians - orientation sessions

Basic Care of NSSK adapted to improved action based components: Immediate essential care (within the first 6 hours of

delivery)

Pre-discharge care (including providing appointment for 1st visit)

Early postnatal visit (within 1 week as recommended for visit within 3 days)

Subsequent PN visits during next 4 weeks

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B. Organizational Changes

Physical space (room) and basic equipment/supplies

Introduction of record and review mechanism

Appropriate organization of the labor room

C. Supportive Supervision and M & E

Baseline and mid line readiness evaluations by observations of client-provider interactions and the job-corrections and capacity building

Findings from on-going monitoring during monthly supportive supervisory visits facilitated by MCHIP staff

Modeling with in facilities

District Supportive supervision

A structured guide & training methodology for supportive supervision was prepared

An “yes and no “simple checklist” is being used for regular supervision & feedback.

Each skill is only scored, if all the steps is followed for the skill.

The checklist has two copies, one for the health provider being supervised and the other for the one who supervises the activity. By this mean we assured that the provider who was supervised knows the misses and can be motivated to improve his performance.

55

82

100

64

100

82

45

55

73

73

73

100

73

73

Preparation of birth

Hand washing

Drying

Cord clamping & cutting

Skin to Skin

Breast feeding with in 1 hr

Vitamin K

Examination of the newborn

Temperature recording

Weighing

Neonatal immunization

Cheking of B & M

Steps of resuscitation

Vetilation by Bag & mask

Supportive supervision

Newborn Resuscitation Simulations

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(1) Adjustment is any proper adjustment: check neck position, check seal, repeat suction, squeeze harder (2) Ventilation: place correct size mask covering chin, moth and nose, squeeze bag with 2 fingers or hand – appropriately, ventilate at 40 breathes/min (all items) (3) Initial steps: drying, place on warm clean surface, head in slightly extended position, suction with bulb or catheter in mouth or nose (all items)

Dip-stick tests – Regular and measurable

Questionnaire and exercise methodology developed to focus on the “preparedness” of the health facilities to deliver newborn care services as per the national guidelines.

The results framework is quantifiable in operational terms rather than health systems framework.

The analysis tool works on 75 broad indicators to generate color- codes to map the status of 8 parameters – Infrastructure, Delivery and Newborn Care services, Human resource, Essential drugs, equipment and supply, Register and client case record, Protocols and guidelines, universal precautions & infection prevention and Provider‟s knowledge & competency on core skills.

A computerized SQL based analysis system has been developed to generate score based color-codes.

Implementing a planning exercise based after this exercise is found very useful and allowed us to bench mark the health facilities over a period of time.

Score-card and improvement scores

37 43 43

57

67 64

54

75

Palajori Pabia Sadar Jamtara Mahupur

Facility readiness scores of the demo sites

Oct-2010 Feb-2012

Reporting and recording system

Simple, coded, integrated maternal and newborn register 94% percent of the total deliveries are live born and 3% are neonatal and still

births. 9.38% increase in the institutional delivery load between Oct 2011 and Sept

2012 There is 4.57% reduction in the reported neonatal deaths from 5.68% of all

live births in October 2011 to 1.12% in September 2012

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Reported Data Reduction in still birth

rates is 5.44% from 6.53% of all deliveries to 1.09% in September 2012

On an average 21% newborns were low birth weight, 10.9% newborns had birth asphyxia and 0.9% newborns were preterm.

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Resuscitation at NBCC D

istri

ct N

ame

Faci

lity

Nam

e

Num

ber o

f stil

l bor

ns re

susc

itate

d (X

)

Stil

l bor

ns b

roug

ht b

ack

to li

fe (B

V-C

U)

Num

ber o

f ne

wbo

rns

with

asp

hyxi

a (A

J)

Num

ber o

f ne

wbo

rns

with

mec

oniu

m

(AI)

Num

ber o

f ne

wbo

rns

who

had

flo

ppin

ess

(AK

)

Num

ber r

esus

cita

ted

by s

timul

atio

n on

ly

Num

ber r

esus

cita

ted

by s

timul

atio

n an

d su

ctio

n

Num

ber r

esus

cita

ted

by s

timul

atio

n ,s

uctio

n an

d ba

g an

d m

ask

Num

ber r

esus

cita

ted

by s

timul

atio

n ,s

uctio

n an

d ba

g an

d m

ask

and

oxyg

en

Tota

l num

ber o

f new

born

s on

who

m b

ag

and

mas

k ha

s be

en u

sed

Tota

l num

ber o

f new

born

s w

ith a

sphy

xia

or m

econ

ium

or f

lopp

ines

s (A

J+AI

+AK

)

JAM DH 33 2 43 75 11 3 37 13 14 27 67

JAM Pabia 36 0 8 10 0 0 4 8 0 8 10

DEO Palajori 7 1 8 18 12 0 1 5 2 7 29

DEO Madhupur 30 0 6 15 3 4 2 3 2 5 18

All sites total 84 3 82 125 36 8 44 29 18 47 124

Tracked newborn care at NBCC resuscitation data

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Out of a total of 369 birth asphyxia newborns 189 newborns were reported to be have managed by bag and mask. While it is encouraging finding of increase in use of bag and mask; the proportion remains very high*

So what?

Community follow up; Birth asphyxia children were followed with at least three visits- Visit 1 on day3, Visit 2 on day 7, and visit 3 on day 28 and an extra visit „4‟ and an additional visit is made on day 14 if the newborn is found sick or reported ill by Sahiya‟s.

477 facility delivered newborn have been tracked with all the 3 follow ups completed in the community. Highest mortality 58.3% were found within 1st 3 days of birth.

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Mortality up-to 28 days on the community follow up visit

Change in knowledge on diagnosis of birth asphyxia

67.9

0.0

71.4

0.0 3.6

53.6

89.3

78.6

100.0

89.3

78.6

67.9

Depressed

breathing

Floppiness

Not cried at birth

Delayed crying (1

or 5 minutes)

Heart rate below 100 beats per minutes

Central cyanosis

(blue tongue)

Deoghar Oct 10

Deoghar Jan 12

Change in provider’s knowledge & practice in using chronology of steps during resuscitation process

0.0 0.0

16.7 4.2

70.2

4.2

0.0

40.0 70.0

44.0

66.0

90.0

80.0

60.0

Explain to mother

condition of baby

Place the newborn face

up

Wrap or cover baby except for face and

chest

Position baby’s head so neck is

slightly extended

Suction mouth then

nose

Start ventilation using using

bag and mask

Were the steps in

sequential order

Deoghar Oct 10

Deoghar Jan 12

0.0

50.0

22.2 5.6

83.3

61.1

0.0

80.0

90.0

62.0

74.0

94.0

98.0

88.0

Explain to mother

condition of baby

Place the newborn face

up

Wrap or cover baby except for face and

chest

Position baby’s head so neck is

slightly extended

Suction mouth then

nose

Start ventilation using using

bag and mask

Were the steps in

sequential order

Jamtara Oct 10

Jamtara Jan 12

Sustaining and scaling efforts

Resuscitation indicators

Non - breathing

Non - breathing or meconium or floppiness

% newborns with birth asphyxia 3.5 5.3

Proportion of "Non - breathing" newborns resuscitated with stimulation alone 9.8 6.5

Proportion of "Non - breathing " newborns resuscitated with stimulation and suction 53.7 42.2

Proportion of " Non- Breathing" resuscitated with stimulation, suction and bag and mask 35.4 48.2

Proportion of "Non-breathing" newborns resuscitated successfully 98.8 96.9

Landscape of program inputs

Facility readiness assessment using 8 parameters was conducted in

Oct 2010 using a structured questionnaire and 75 indicators generated. KAP performance for maternal and newborn care especially neonatal

resuscitation was mapped. District mapping of the gaps generated and facility wise plan made for

realistic program. Based on this implementation included provider

mapping, 3- Day skill based training in essential newborn care and resuscitation

skills of all district level primary providers conducted (250) Job-aides and skill lab of key providers (28) in the demo-facilities. Supportive supervision involving quantitative and qualitative checklists

was used to provide on-going hand holding. Involving district authorities

at each step was critical to success of the program. Strengthening of health information systems by improved reporting and

feedback mechanism,

Follow up of facility births of birth asphyxia newborns conducted in the

community.

ENCR program Operational Model Framework

Tools Key Management Cycle Needs assessment

Planning Monitoring Evaluation

Basic Information Basic Data x x x x Facility Needs Facility Readiness x x Planning Facility Plan x Implementation Training, Supportive Supervision,

Information Management x x

Service & Management quality*

Training QA, logistic management, Quality of Care, Neonatal death audit

x

Surveillance Management information system x Monitoring indicators & feedback x x Cost analysis Not Included x Sustainability Key Parameters x x X x

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Conclusions

Assumption that skilled birth attendance equals quality newborn care is obviously not true

There is a need to improve the quality of newborn care for infants delivered at health facilities

No ENC R program in place Training is not synonymous with practice Supportive national policies absent Lack of supplies for immediate newborn care A sizable percentage of health facilities had newborn

resuscitation equipment Routine monitoring of newborn care in health facilities, in addition

to periodic comprehensive health facility assessments, will assist in addressing some of the observed deficiencies

State and district ownership

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Self learning tools – Rotating mentors

Practice exercises at skill labs

Leaders and excellence within the districts – cross learning

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6

CROSS-LEARNING -ENCR

Practical skill station and peer learning and supervision

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ASKS

SIGNATURE PROGRAM FOR ENCR Operational plan for roll-out of ENCR

–District as a unit (perinatal network) Adaptation of current training guidelines –

NSSK to ENCR ( at least 3 days) Supportive supervision Neonatal task groups in ALL states Linkages with Maternal Health especially

Intra-partum care

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