Rapid Assessment

07 Nov, 2013 to 9 Nov, 2013 & Rapid 13Nov,2013 to 14 Nov, 2013

Assessment

Facility Readiness Assessment for Essential Newborn Care and Resuscitation

Child Health Division, NRHM, Haryana in technical collaboration with

Table of Contents 1. Objectives: ...... 2 2. Materials and Methods ...... 2 3. General findings of district Panchkula are as follows: ...... 3 3. a. Overall Training Status ...... 4 3. b. Status of Newborn Corners ...... 4 3 c. Availability of equipment and instruments in NBCCs (n=19) ...... 4 3 d. Status of Designated Newborn Stabilization Units (NBSUs) ...... 5 4. Quantitative Analysis of various facilities (n= 19) ...... 5 5. Facility wise Qualitative Findings ...... 19 1. GH Panchkula ...... 19 2. CHC Kalka ...... 19 3. CHC Raipur Rani ...... 20 4. PHC Hangola ...... 21 5. PHC Kot ...... 21 6. PHC Morni ...... 21 7. PHC Barwala ...... 22 8. PHC Nanakpur ...... 22 9. PHC Punjore ...... 22 10. PHC Surajpur ...... 22 11. Urban Slum Dispensary, Sector- 19 ...... 23 12. SC Jaloli ...... 23 13. SC Maranwala ...... 24 14. SC Karanpur ...... 24 15. SC Bargodam ...... 24 16. SC Ramgarh ...... 25 17. SC Nadda Sahib ...... 25 18. SC Mauli ...... 25 19. Saketri ...... 25

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1. Objectives: 1. Qualitative and quantitative assessment of readiness of our health facilities for essential newborn care and resuscitation. 2. To assess the quality of essential newborn care provided to each and every neonate immediately after birth. 3. To understand the existing knowledge, skills, attitudes and practices of the health service providers. 4. On job trainings to the service providers on novelties in essential newborn care and resuscitation.

2. Materials and Methods 1. A structured and tested assessment tool has been used to assess the facilities on 8 parameters viz. facility identification and infrastructure, availability of services, human resource, Equipment and supplies, Register and client case records, protocols and guidelines, individual case records, knowledge and practices. 2. Knowledge and skill assessment has been done on the newborn simulators (mannequins). 3. The current and ideal practices in essential newborn care and resuscitation have been demonstrated to the service providers on the mannequins.

Our teams visited 19 facilities in the district, from 7th November, 2013 to 9st November, 2013 and 13th November 2013 to 14th November 2013, including General Hospital, all CHCs and PHCs and the delivery huts with monthly delivery load of 3 or more. Following is the list of facilities visited:

S.No. Name of Facility 1 GH Panchkula 2 CHC Kalka 3 CHC Raipur Rani 4 URCH sector 19 5 PHC Pinjore 6 PHC Kot 7 PHC Morni

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8 PHC Nanak pur 9 PHC Surajpur 10 PHC Hangola 11 PHC Barwala 12 SC Saketri 13 SC Nada Sahib 14 SC Karapur 15 SC Baadgodam 16 SC Maadwala 17 SC Mouli 18 SC Jalouly 19 SC Ramgarh

3. General findings of district Panchkula are as follows:

1. Effective hand washing not in practice.

2. Birth preparedness before delivery is still not in practice.

3. Skin to skin contact between mother and baby not in practice.

4. Milking of cord (in some facilities) still in practice.

5. Injection Vitamin K is not administered to every newborn.

6. Improper segregation of bio-medical waste. Yellow bags are not used.

7. Shifting of every baby to Newborn Corner is still in practice.

8. Case sheets are not available in the Sub-Centers.

9. Record keeping in delivery rooms has scope for improvement.

10. Partograph are filled but need quality improvement and proper interpretation.

11. Disinfection protocols are not followed as per guidelines. Non availability of regular disinfectant in many facilities.

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3. a. Overall Training Status

No. of Birth attendants SBA NSSK IMNCI

63 57 50 49

Total Percentage 90 79 77

3. b. Status of Newborn Corners No. of Newborn Corners Newborn Total NBCCs still not Facilities with Radiant Corners with NBCCs established Visited Warmer 200 W bulb Established 19 9 8 15 4 (SC Bargodam, Marawala, USD 19 and Karanpur)

3 c. Availability of equipment and instruments in NBCCs (n=19) Sr. Equipment/Instrument Available (No. of Not available (No. of No. Facilities) Facilities) 1. Self-Inflating Bag 19 0 2. Mask Size ‘1’ 19 0 3. Mask Size ‘0’ 19 0 4. Shoulder Roll 16 3 5. Suction Catheter 13 6 6. Disposable Mucus Extractors 17 2 7. Suction Machine 18 1 8. Oxygen Cylinder 12 7 9. Baby Sheets 18 1 10. Disinfectant 18 1 11. Vitamin K 17 2 12. NBCC at appropriate place 12 7

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3 d. Status of Designated Newborn Stabilization Units (NBSUs) Sr. No. Name of Institution Status

CHC Kalka Functional

CHC RaipurRani Established but Not Functional

4. Quantitative Analysis of various facilities (n= 19)

Score 75% and Above Score 51% to 74% Score 50% and less

DELIVER ESSENTIA KNOWLEDG REGISTER Y AND PROTOCOL PROVIDER FACILITY’ L DRUGS, E ABOUT S AND NAME OF THE INFRASTRUCT NEWBOR S AND K0WLEDG S EQUIPMEN INFECTION CLIENT FACILITIES URE N CARE GUIDELINE E AND OVERALL T AND PREVENTIO CASE SERVICE S SKILLS AVERAGE SUPPLIES N RECORDS S

GH 90 89 80 70 57 52 56 71 PANCHKULA

PHC 69 83 72 80 57 62 58 69 BARWALA

PHC 76 83 70 60 86 51 56 69 NANAKPUR

CHC KALKA 92 100 79 40 57 57 44 67

PHC PINJORE 78 89 68 60 43 54 66 65

PHC KOT 76 78 70 60 57 55 55 64

PHC 76 83 68 60 43 55 66 64 SURAJPUR

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PHC MORNI 69 78 69 80 43 59 52 64

PHC 67 78 74 70 57 45 46 62 HANGOLA

URCH SEC 19 65 83 64 50 57 58 55 62

District 67 80 65 59 44 51 32 57 Average

SC SAKETRI 59 83 58 60 43 57 6 52

CHC RAIPUR 71 83 67 70 0 40 29 52 RANI

SC 59 78 51 70 29 49 0 48 RAMGARH

SC JALOULY 59 78 59 40 43 47 10 48

SC 59 78 59 40 43 47 10 48 MARWALA

SC NADDA 53 67 53 80 29 54 0 48 SAHIB

SC MOULI 57 67 53 60 43 47 0 47

SC 57 78 61 40 43 44 0 46 KARANPUR

SC BAR 47 67 46 30 14 40 0 35

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Figure 1. KNOWLEDGE ABOUT EFFECTIVE ANC

MINIMUM 4 VISITS 100 80 60 PROMOTE EBF BIRTH PLAN 40 20 0

DANGER SIGN TT AND IFA

HIGH RISK MOTHER DETECTION ROUND 1

Figure 2. KNOWLEDGE OF DETECTION OF HIGH RISK MOTHERS

PREVIOUS CS H/O 100 5 OR MORE 80 NEONATAL/INFA… DELIVERIES 60 40 H/O ABORTIONS LESS THEN 2 20 OR OTHER… 0 YEARS BIRTH…

PREVIOUS AGE OF PRIMI <18 INSTRUMENTAL… OR >30 YEARS PREVIOUS PREVIOUS STILL NEONATAL DEATH BIRTH

ROUND 1

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Figure 3. KNOWLEDGE ABOUT LABOUR PROGRESS

REGULAR UTRINE CONTRACTION 100 80 60 40 BREAKING OF 20 WATERS AND DILATION OF 0 RUPTIOR CERVIX MEMBRANE

DISCHARGE OF BLOOD AND MUCUS ROUND 1

Figure 4. LABOUR PROGRESS MONITORING KNOWLEDGE

FETAL HEARTBEAT 100 MATERNAL PULSE 80 COLOUR OF… 60 40 MATERNAL… 20 DEGREE OF MOLDING 0

MATERNAL BP DILATION OF CERVIX UTERINE… DESCENT OF HEAD

ROUND 1

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Figure 5. RECORDING OF OBSERVATIONS ON PARTOGR APH 100 80 60 40 20 0 ON ON PIECE PATIENT OF PAPER CLINICAL RECORDS

ROUND 1

Figure 6. KNOWLEDGE ABOUT 3 STAGE OF LABOUR MANAGEMENT

IMMEDIAT E OXYTOCIN 100

UTRINE CCT MASSAGE

ROUND 1

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Figure 7. KNOWLEDGE ABOUT IMMEDIATE CARE TO NEWBORN WITHIN 1 Hr

BREATHING OF BABY 100 ADMINISTER VIT K 80 DRY THE BABY 60 40 20 EXAMIN NEWBORN OBSERVE FOR COLOR OF 0 WITHIN 1 HRS BABY

INITIATE BF WITH IN 30 WEIGHT THE BABY MIN

CARE ROUNDFOR UMBLICAL 1 CORD

Figure 8. KNOWLEDGE ABOUT SIGN AND SYMPTOMS OF SEPSIS/INFECTION IN NEWBORN LESS MOVEMENT (POOR MUSCLE TONE) 100 SEVERE ABDOMINAL 80 POOR OR NO BF DISTENTION 60 40 20 HYPO/HYPERTHER DEEPJAUNDICE 0 MIA

INFECTION ON RESTLESSNESS/IRRI EYE/THROAT/SKIN TABILITY

DIFFICULTY/FAST BREATHING ROUND 1

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Figure 9. KNOWLEDGE OF MANAGEMENT ABOUT INFECTION IN NEWBORN

EXPLAIN SITUATION TO MOTHER 100 80 60 REFER 40 CONTINUE TO BF 20 0

BEGIN ANTIBIOTICS KEEP AIRWAYS OPEN

ROUND 1

Figure 10. KNOWLEDGE ABOUT MANAGEMENT OF LBW (<2.5 KG) BABIES

WARMTH OF BABY 100 80 PROVIDE EXTRA 60 REFER SUPPORT TO MOTHER 40 FOR BF 20 0

MONITOR ABLITY TO ENSURE INFCETION BF/SUCKING CAPACITY PREVENTION OF BABY

MONITOR BABY FOR FIRST 24 Hr

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Figure 11. KNOWLEDGE ABOUT SIGN AND SYMPTOMS OF BIRTH ASPHYXIA

DEPRESSED BREATHING 100 80 CENTRAL CYNANOSIS 60 FLOPPINESS 40 20 0

HEART RATE BELOW NOT CRIED AT BIRTH 100

DELAYED CRYING AT BIRTH ROUND 1

Figure 12. KNOWLEDGE ABOUT STEPS OF RESUSCITATION

CALL FOR HELP 100 START VENTILATION 80 EXPLAIN SITUATION TO USING BAG AND MASK 60 MOTHER 40 20 SUCTION MOUTH THEN 0 PLACE NEWBORN FACE NOSE UP EXTENDED POSITION OF WRAP OR COVER BABY NECK OF NEWBORN EXCEPT FACE AND…

ROUND 1

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Figure 13. KNOWLEDGE ABOUT RESUSCITATION STEP CONT…

PLACE BABY MASK AND FORM SEAL 100 80 60 DETERMINE 40 ENSURE APPROPRIATE SPONTINIOUS SEAL BREATHING 20 0

VENTILATE 1 OR 2 VENTILATE 40-60 PER TIMES FOR CHEST MINUTE RISING ROUND 1

Figure 14. Knowledge about what to do if newborn start breathing after initial resuscitation

KEEP BABY WARM 100 80 60 40 20 0

MONITORING THE INITIATE BF BABY

ROUND 1

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Figure 15. What to do ? If Newborn is not breathing after initial Resuscitation

CONTINUE TO VENTILATE 100 80 60 ADMINIST REFER 40 ER BABY 20 OXYGEN 0

ASCESS INTUBATE NEED FOR BABY SPECIAL CARE ROUND 1

Figure 16. Over all Readiness of facilities in Infrastructure

100 92 90 78 80 76 76 76 71 69 69 67 67 65 59 59 59 59 57 57 60 53 47 40

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Figure 17. Availability of Protocols Guideline at Facilities

100 80 80 80 80 70 70 70 70 60 60 60 60 60 60 59 60 50 40 40 40 40 40 30

Figure 18. Knowledge of Infection Prevention

100 80 80 80 80 70 70 70 70 60 60 60 60 60 60 59 60 50 40 40 40 40 40 30 20 0

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Figure 19. Registers and Client Case records

100

80 66 66 58 56 56 55 60 55 52 46 44 40 32 29

20 10 10 6 0 0 0 0 0

SCBAR

PHCKOT

SCMOULI

CHCKALKA

SCSAKETRI

SCJALOULY

PHCMORNI

URCH SEC19

PHCPINJORE

SCRAMGARH

SCMARWALA

SCKARANPUR

PHCBARWALA

PHCHANGOLA

PHCSURAJPUR

District Average

GHPANCHKULA

PHCNANAKPUR SCNADDA SAHIB CHCRAIPUR RANI

Figure 20. ESSENTIAL DRUGS, EQUIPMENT AND SUPPLIES

100 80 79 74 80 72 70 70 69 68 68 67 65 64 61 59 59 58 60 53 53 51 46 40

SCBAR

PHCKOT

SCMOULI

CHCKALKA

SCSAKETRI

SCJALOULY

PHCMORNI

URCH SEC19

PHCPINJORE

SCRAMGARH

SCMARWALA

SCKARANPUR

PHCBARWALA

PHCHANGOLA

PHCSURAJPUR

District Average

GHPANCHKULA

PHCNANAKPUR SCNADDA SAHIB CHCRAIPUR RANI

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Figure 21. Over All Status of facilities for ENBC/R Skills

100

80 62 59 58 57 57 60 55 55 54 54 52 51 51 49 47 47 47 45 44 40 40 40

Figure 22. Over All Status of facilities for ENBC/R

100

80 71 69 69 67 65 64 64 64 62 62 57 52 52 60 48 48 48 48 47 46 40 35

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Figure 23. FACILITIES CLASSIFICATION FOR ENBC/R FACILITY READINESS

GOOD (75 AND ABOVE) AVERAGE (51 TO 74 ) POOR (BELOW 50)

Figure 24. Essential Newborn Care District Average

NNL 39 41 SNP 43 45 FTB 47 47 GUR 49 49 YNR 49 ROUND 1 51 JND 52 52 KKR 54 56 PKL 57 59 HSR 61 0 10 20 30 40 50 60 70

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5. Facility wise Qualitative Findings

1. GH Panchkula a) Labour room running along with PNC ward/construction going on for new labour room b) RW available at labour room : Unhygenic sheets on RW, Bag of Ambu meconium stained, 0 size mask not available, Shoulder role not as standard protocol, Thermometer not available at NBCC

2. CHC Kalka a) Shoulder role not as per guideline b) Two Bag and mask available at labour room but one payer of 0 and 1 size mask not available c) Tube lights and bulb in labour room out of order d) No lightning in toilet and hand washing area e) Thermometer dipped in solution need to kept in dry bottle f) Chittel dipped in solution need to kept in dry bottle g) Feeding tubes used for suction h) Bio medical waste disposal contractor visit facility twice a week need to rationalize as per contract i) Room thermometer not available in labour room j) Only yellow and red bag available in labour room for Bio medical waste segregation need to put black and bag bucket too. k) Towel available at hand washing area of labour room need to discourage towel uses should promote air dry l) NBSU established need to available Syringe Hub cutter, weight machine, Laryngoscope set neonate, digital thermometer, room heater, room thermometer, concealed lights, Stethoscope with neonatal chest piece, shoe rack

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3. CHC Raipur Rani a) Training of staff nurses not completed. b) Mucus extractors expired in May-13. c) Distilled water level in O₂ humidifier not maintained. d) Good practice of keeping vaccines in labour room to ensure administration of birth doses. OPV and Hep. B vaccines should have date of opening mentioned on it. e) Disinfection of Radiant warmer, AMBU bag, suction apparatus not done regularly. f) DHIS 2 reporting of labour room needs improvements. Records in delivery register and reported data do not match. g) Knowledge of staff nurses is average for, i. ANC ii. Identification of high risk pregnancies iii. Identification of true labour pains iv. Monitoring of labour progress v. AMTSL vi. Immediate care for new-born vii. Special care for low birth weight new-borns h) Knowledge of staff nurses is not adequate for, i. Neonatal Resuscitation ii. Identification of infection/sepsis in new-born i) Shoulder roll is not available. j) Wall clock with seconds hand not available at NBCC. k) Case records need improvements, i. Details of at birth immunisation ii. Care provided to new-born iii. Details of resuscitation if done iv. Vital signs of new-born

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4. PHC Hangola

a) One staff nurse not trained in SBA and NSSK b) GPLAD, term preterm and maternal complications not mentioned in the maternal case sheets c) Cord cutting with blade, breastfeeding initiation timings not mentioned in the baby case sheets d) New Born Care Corner was not located appropriately. NBCC relocated in the labour room e) Breast feeding not initiated within half an hour after birth, hand washing not in practice, Skin to skin contact not initiated f) Resuscitation chronology not practiced (Position suction stimulation and repositioning not followed as per protocols) g) Milking of cord is in practice h) Every baby is shifted to new born care corner i) Disinfectants not available j) Yellow colour coded bag not used for placenta segregation k) Filling of partograph need improvement

5. PHC Kot

a) Some essential drugs are out of stock b) Colour coded buckets and bags not available c) Skills for high risk detection not as per protocols d) Baby not dried after delivery e) Spot lamp not functional f) Case sheets need improvements in term of baby notes on essential new born care and resuscitation.

6. PHC Morni a) NBCC well established with radiant warmer, shoulder roll, mucous extractor, oxygen cylinder, concentrator, bag and mask of both sizes b) Double gloving in practice c) Skin to skin contact in practice d) Practice of re-clamping the cord e) Immediate cord cutting in practice f) Inj vitamin K not available and not in practice

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7. PHC Barwala a) NBCC well established with bag and mask, radiant warmer, shoulder roll, oxygen cylinder, suction apparatus b) Practice of skin to skin contact c) Double gloving in practice d) Immunization of newborn with BCG, OPV and Hep B in practice e) Vitamin K in practice f) Facility having delivery load of about 35-40 deliveries a month. Single delivery table available and 3 inpatient beds are available g) Space constraint in facility h) Case sheets are being prepared for delivery cases. Delivery notes and baby notes are being recorded i) Record keeping very good.

8. PHC Nanakpur a) Well maintained Labour room with well-established NBCC with 200 W bulb as heat source. b) Record keeping is good. c) Knowledge of staff nurse about essential newborn care and resuscitation is good. d) Skills of staff nurse about essential newborn care and resuscitation is average.

9. PHC Punjore a) Well maintained PHC b) Skills and practices for ENCR need regular follow up c) Promotion of Infection prevention protocols is strictly required d) Documentation need few improvements regarding baby notes

10. PHC Surajpur a) PHC running in another SC building b) No Staff nurse c) No Hand washing station inside labour room d) Promotion of Infection prevention protocols is strictly required Skills and practices for ENCR need regular follow up e) Documentation need few improvements regarding baby notes

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11. Urban Slum Dispensary, Sector- 19 a) Bleaching powder for disinfection is not available. b) Baby sheets are not available. c) NBCC not established. d) Baby mask of size ‘0’ is not available. e) Colour coded bags for biomedical waste segregation and disposal are not available. f) Disposable surgical blades for cord cutting are not available. g) Case records are well maintained but notes on essential newborn care are incomplete. h) There are issues related to procurement of articles and items required for delivery and newborn care. Cord clamps, baby sheets, mucus extractors, surgical blades, disinfectants (bleaching powder) etc. are not available and these items are difficult to procure in small quantities, moreover, there are no vendors for such items in local market. Also, medicines are in very limited supply and need to be purchased locally. i) Milking of cord is still in practice. j) Knowledge of one staff nurse about essential newborn care and resuscitation is good but for other two it is average. k) Skills of staff nurses for essential newborn care and resuscitation are average

Recommendations

a) Resolve procurement issues related to medicines and other items with Civil Surgeon’s office. Ensure regular supply of required items and medicines to the dispensary. b) Write complete notes on essential newborn care as described during the visit. c) Promote peer learning to improve knowledge and skills of service providers.

12. SC Jaloli a) Sub centre running in damaged building b) Toilet available but not usable c) Promotion of Infection prevention protocols is strictly required d) Skills and practices for ENCR need regular follow up e) Documentation need few improvements regarding baby notes

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13. SC Maranwala a) Well maintained Sub Centre b) Inappropriate Hand washing station c) Promotion of Infection prevention protocols is strictly required d) Skills and practices for ENCR need regular follow up e) Documentation need few improvements regarding baby notes

14. SC Karanpur

a) Case sheets and partographs not available b) Delivery register with only address/ male female/ weight and time of birth mentioned c) Active management of third stage of labour not done (Inj oxytocin after delivery not administered) d) Two hundred watt bulb not available e) Invertors not functional f) Oral pills and condom contraceptive not available

15. SC Bargodam a) NBCC not established at facility b) Shoulder roll to be prepared as directed c) Baby sheets are not available d) Toilet non-functional since 2007 e) Facility having delivery load of about 4-5 deliveries a month f) Case sheets are not being prepared g) Partographs are not available and are not being filled h) Kelly’s pad not available on delivery table i) Yellow bags not available j) Biomedical waste segregation not being done k) Spot lamp non-functional since 3 months l) Practice of separating newborn and mother despite good cry m) Practice of re-clamping the cord n) Immediate cord cutting in practice o) Inj vitamin K not available

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16. SC Ramgarh a) Shoulder roll to be prepared as directed b) Case sheets are not being prepared c) Partographs are not available and are not being filled d) Kelly’s pad not available on delivery table e) Practice of separating newborn and mother despite good cry f) Practice of re-clamping the cord g) Immediate cord cutting in practice h) Mask of size 0 not available i) Inj vitamin K not available

17. SC Nadda Sahib a) NBCC not established. It was established as onsite correction with 200 W bulb, bag and mask of both sizes b) Shoulder roll to be prepared as directed c) Case sheets are not being prepared d) Practice of separating newborn and mother despite good cry e) Practice of re-clamping the cord f) Immediate cord cutting in practice g) IEC material not displayed at appropriate places h) Hand washing station not appropriate

18. SC Mauli a) Well maintained labour room, but no NBCC. b) Immediate cord cutting and milking of cord still in practice. c) Case sheets for delivery cases are not available. d) Knowledge of ANM about essential newborn care and resuscitation is average. e) Skills of staff nurse about essential newborn care and resuscitation are average.

19. Saketri a) Well maintained labour room with NBCC in a small room adjoining it. NBCC has all the articles and equipment necessary for newborn resuscitation. b) Knowledge of ANMs about essential newborn care and resuscitation is good. c) Skills of ANMs about essential newborn care and resuscitation are average.

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