abwao: quality of care at the time of birth

7/28/2019 Abwao: Quality of Care at the Time of Birth

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Quality of Care

At the Time of Birth

Selected Multi-Country Findings

Dr. Stella Abwao, Advisor Newborn Health - MCHIP/Save the Children

Global Newborn Health Conference

April 16, 2013

Johannesburg, South Africa


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Acknowledgments

Country Ministries of Health and staff at the study health facilities inEthiopia, Madagascar, Rwanda, United Republic of Tanzania, Kenya,

Mozambique and Malawi

Data collection teams in each country

MCHIP QOC research team & Malawi HBB research team: Jim Ricca,

Barbara Rawlins, Linda Bartlett, David Cantor, Patricia Gomez,

Heather Rosen, Bob Bozsa, Joseph de Graft Johnson, Shivam Gupta,

Angela Mtimi, Abigail Kazembe, Evelyn Zimba, Reena Sethi

MCHIP\Jhpiego headquarters and in-country staff, research firms in

Madagascar & Kenya

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Presentation Outline

Summary of QOC study sample

Inventory findings - newborn care equipment & supplies

Findings on immediate newborn care and practice

Newborn resuscitation findings

Malawi Helping Babies Breathe(HBB) performance evaluation

Conclusion & Recommendations


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Summary of QOC Study Sample

Surveyed 643 facilities in 6 countries; Observed ~5600 deliveries andANC consultations, and Interviewed ~1000 health workers

4

Sample Kenya Ethiopia Tanzania Zanzibar Rwanda Mada-

gascar

Mozam-

bique

Total

Facilities 409 19 52 9 72 36 46 643

-Hospital 52% 100% 23% 56% 58% 75% 46% 53%

-Health Center/dispensary 48% 0% 77% 44% 42% 25% 54% 47%

Observations of care 2035 318 880 274 604 670 828 5609

-Deliveries 626 192 489 217 293 347 525 2689

*newborn & postpartum care 571 115 419 203 225 336 508 2377

-Intrapartum complications

*newborn resuscitation 42 18 37 12 44 49 28 230

-ANC consultations 1409 126 391 57 311 323 303 2920

Health workers interviewed 249 79 206 51 146 140 186 1057


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Observation of Immediate Newborn Care

5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Immediately dries baby

with towel

Discards wet towel and

covers with dry towel

Cuts cord with clean

blade

Assists the mother to

initiate breastfeeding

within the first hour

Places newborn skin to

skin

Ties/clamps cord when

pulsations stop or by 2-

3min after birth

Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar Mozambique

81%63%

37% 43%

67%93%


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Inventory of Supplies for Immediate

Newborn Care

6

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Disposable cord ties or clamps Towel or blanket to wrap baby Sterile scissors or blade Mean score essential supplies


69%

36%

89%65% (48%

to 81%)


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Inventory of Supplies for Management of

Newborn Complications

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Mean High Low

Bag and mask (infant size) 79.9% 100.0% 57.1%

Suction bulb 66.2% 95.1% 26.7%

Suction apparatus for use with catheter 77.0% 100.0% 60.9%

Resuscitation table for newborn 68.3% 88.9% 51.4%

Gentamycin 61.8% 78.0% 40.0%

Ampicillin 54.5% 73.7% 22.2%

Functioning incubator or other heat source 52.7% 83.3% 26.0%

Mean score supplies for complications 66.0% 81.2% 42.9%


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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Equipment Immediate newborn care Signs of sepsis in the

newborn

Care of LBW newborn Newborn resuscitation


Health Worker Knowledge of Immediate Newborn

Care and Management of Complications

8

* Values are mean score

(1) no data for Madagascar; (2) case study for Kenya and Ethiopia, simulation for Tanzania, Zanzibar, Rwanda, Madagascar

38%

54%61%

43% 28% 53%


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Essential Newborn Care Cascade from Policy

to Practice

9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Policy (ENC in SDGs) Skilled birth attendance Supervised last 3/6

months

Score for essential

supplies

Score for immediate

care knowledge

Received all essential

newborn care elements


100% 92%

61% 65%

51%

23%


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Non-beneficial and Non-indicated

Newborn Care Practices - Observation

10

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Slap newborn Hold newborn upside down Milk newborns chest Routine aspiration of newborn

mouth and nose at birth


5% 10%


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0% 20% 40% 60% 80% 100%

Dry/position

Suction

Ventilation

Adjustment

Tanzania Zanzibar Rwanda Madagascar

Newborn Resuscitation Simulation

34%

53%

84%

74%

Dry/position: drying, place on

warm clean surface, head in

slightly extended position (all

items)

Suction: suction mouth then nose

with bulb or with catheter (either)

Ventilation: place correct size

mask covering chin, mouth and

nose, squeeze bag with 2 fingers

or hand, ventilate at 40 breaths/min

(all items)

Adjustment: reposition head/neck,

check seal, repeat suction,

reposition mask, squeeze harder

(any item)

M t f N b A h i


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Management of Newborn Asphyxia

Observations

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Item Number

(n)

Cases of resuscitation observed 230

Steps performed correctly-Drying and positioning 91

-Suction 92

-Ventilation 29

-Adjustment head position, mask

seal

92

Outcome of newborn

-Alive 208

-Dead 22Steps are as described on previous page;


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Malawi: Helping Babies Breathe

Performance Evaluation

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2012 Performance evaluation: conducted by MCHIP and

Malawi MOH

Findings are available from the first phase of datacollection for HBB-newborn resuscitation

81 facilities were sampled in Malawi

Inventory of ENC/HBB supplies and equipments

Assessment of health worker skills and simulation of bag & maskventilation

Observation of immediate essential newborn care

Management of newborn asphyxia


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Inventory of Equipment for Newborn Care

EquipmentTotal facilities (n=81)

Observedn(%)

Reported,not seen

n(%)

Notavailable

n(%)

Bag and mask (infant size) for

resuscitation 55 (67.9) 5 (6.2) 21 (25.9)

Tube and mask 50 (61.7) 4 (4.9) 25 (30.9)

Incubator 15 (18.5) 4 (4.9) 62 (76.5)

Other source of heat for premature

newborn 24 (30.0)-

55 (68.8)

Newborn weighing scale 77 (95.1) 1 (1.2) 3 (3.7)

Suction bulb for mucus extraction 49 (60.5) 3 (3.7) 28 (34.6)

Suction apparatus for use with catheter 66 (81.5) 2 (2.5) 12 (14.8)

Resuscitation table for newborn 59 (72.8) - 21 (25.9)

Disposable cord ties or clamps 71 (87.7) 3 (3.7) 7 (8.6)

Towel or blanket to wrap newborn 20 (25.0) 5 (6.2) 56 (69.1)

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Respondents who completed each step (N=177) PercentChecks equipment and selects the correct mask

Tests function of bag and mask 43.3

Makes sure mask fits the babys face 64.4

Applies the mask to make a firm seal

Extends the head 88.2

Places mask on the chin then mouth and nose 84.3A firm seal permits chest movement when the bag is

squeezed66.3

Ventilates at 40 breaths per minute 51.7

Looks for chest movement 74.2

Improves ventilation if the chest does not move

Head- reapplies mask and repositions head 59

Mouth- clears secretions and opens the mouth 50.6

Bag- squeezes the bag harder 28.1

Mean Number of steps done correctly 6.1

SD 2.4Range 0-10

Assessment of Health Worker Skills

Bag & Mask Ventilation (Simulation)

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Observation of Immediate Newborn Care

16

0

20

40

60

80

100

120

Immediately driesbaby with towel

Discards wet towel Places newbornskin-to-skin with

mother

Ties/clamps cordwhen pulsations

stop, or within 23minutes after birth

(but not immediatelyafter birth)

Cuts cord with cleanblade

Initiate breastfeeding within the

first hour

P

e

r

ce

n

t

Performance of ENC tasks among newborns breathing at birth (N = 1327)


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231 not breathing at birth

164 received stimulation

13 missing data

89 breathing 75 not breathing

54 received no

stimulation

2 w/o

data

68 with

bag &mask

5 w/o

bag &mask

62

breathing

6

unsuccess

ful

4

breathing

1unsuccessfu

l

1 w/odata

47breathing

6unsuccessful

Preliminary Findings for Management of Newborn

Asphyxia

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Conclusions

Assumption:

Skilled birth attendance equals quality newborn care

This is not exactly true

There is still much to be done to improve the quality of newborncare for babies delivered at health facilities

A sizable proportion of health facilities included in the study havenewborn resuscitation equipment but provider skills need furtherstrengthening


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Although countries are committed to making QOCimprovements, additional efforts are needed to:

Strengthen health provider skills, competence and practice ongoing mentorship, in-service/pre-service training

Avail necessary life saving commodities - including supply and logisticsmanagement

Have appropriate policies, service delivery guidelines/protocols

Strengthen supervision and monitoring

Recommendations


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