operations research to improve 24/7 delivery and emonc services in public facilities by health...
TRANSCRIPT
Operations research to improve 24/7 delivery and EmONC
services in public facilities by health systems strengthening in
Bangladesh
A collaborative study among ICDDR,B,
DGHS, DGFP, EngenderHealth, MCHIP/Save the Children,
JHSPH
Date:13.07.2015
Principal Investigator
Mahbub Elahi Chowdhury
Scientist, ICDDR,B
Conceptual framework of the study
Health system input
(filling up the gaps in
infrastructure and
logistical supports
Increased
availability of
providers
Improved
quality of care
Increased
utilization of
delivery and
EmONC services
Policy advocacy to fill
up HR gap
Standard based
monitoring and
recognition (SBM-R)
Sharing of public
providers
Input Output
indicatorOutcome
indicator
Outline of the presentation• Specific objectives
• Methodology
• Preliminary findings of the baseline assessment
Availability of Infrastructure, Essential drugs and Equipment for MNH services
Availability of human resources (HR) based on sanctioned post
Quantity of careService record of last 6 month Daily service statistics (30 days observation)
Quality of care
Scores obtained by the providers of DH in different MNH care services
Availability of providers for MNH care services in 30 days’ observation period Percentage of days with availability of providers by type for MNH care in each
shift (morning, evening, night) Availability of mean number of other support staff for MNH care per shift per day Scoring on availability of providers
• Objective 1a. To test effectiveness of a health system strengthening intervention package (filling up the gaps in infrastructure and logistical supports; sharing/hiring of providers; policy advocacy to fill-up human resource gaps; strengthening of the monitoring and supervision; provision of non-financial group incentives to attain the set targets) in
• Increased availability of providers for offering MNH and
EmONC services at public health facilities
• Increased utilization of delivery and EmONC services • Improved quality of care for different components of EmONC services
Specific objectives
Methodology
Habiganj
1 District Hospital
& 1 MCWC
Study design & sites
Pre-post study design
Study sites
• A four member data collection team divided into two groups is engaged in quantitative data collection. Each data collection group consists of one female medical officer and one person with quantitative background trained in respective field
• Another medical officer was responsible for co-coordinating the overall quantitative data collection activities in the field.
• A team of two members were engaged in qualitative data collection.
Data collection team
• A monitoring and supervision team, consisting of the ICDDR,B investigators made unscheduled field visits to supervise the field activities.
• The qualitative investigator of the study was responsible for overall data collection, monitoring and supervision of the qualitative team.
Monitoring team
Monitoring visit
Data collection procedureBoth baseline and 1st periodic assessments were done in 3 phases for a duration of 30 days
Data collection tools
• EmONC needs assessment (cross-sectional)
− Face-to-face interview by using semi structured questionnaire
− Extraction of service record of last 6 months from registers
• 30 days prospective assessment on HR availability, admission and referral and services
• Assessment of quality of MNH care through observation (using checklist)
− ANC, NVD, PNC, FP services, Sick newborn care, C-section delivery, Maternal complications management, Blood transfusion, Infection prevention
• In depth interviews of program managers, providers and support staffs
Baseline Assessment Phase-1 Assessment
1st phase April 29-May o8, 2014 April 15-April24, 2015
2nd phase May 18-May 27, 2014 May 01-May 10, 2015
3rd phase June 07-June18, 2014 May 15-May 24, 2015
Snap shot of data collection
Human resources (HR)
Availability of HR in DH : Medical doctors (No.)
Medical doctorsSanctioned
post
In positionComment
Baseline Phase-1
Sr.Consultant (Obs/Gynae)
1 0 0Jr. Consultants of two UHCs are working through local management
Jr.Consultant (Anaesthesia)
1 0 1
Jr.Consuntant (Paediatrics)
1 2 2One consultant is placed against the post of Jr. Consultant (Eye)
RMO 2 2 1
Medical officer (Pathology)
1 1 1
Anaesthetist 1 1 1
Medical officer (BT) 2 0 0
Medical officer (MO) 14 8 8 One Obs/Gynae specialist One is trained in Obs/Gynae
EMO 3 1 1 Trained in Anaesthesia
Availability of HR in DH : Nurses and other technical staff (No.)
Technical and support staff Sanctioned post
In position EOC training
Baseline Phase-1 Baseline Phase-1
Nursing staffNursing supervisor 2 0 0 - -Senior staff nurse 38 31 28 4 2Staff nurse 16 0 1 - -Staff nurse (MaMoni) 10 10 - -Assistant nurse 5 4 4 - -
Technical staffSACMO 0 1 4 - -Medical Technologist (Lab.) 1 2 2 - -Medical Technologist (Rad.) 1 1 1 - -Medical Technologist (BT) 0 - -Pharmacist 3 2 2 - -
Other support staffDriver 2 2 2 - -MLSS 17 18 18 - -Ward Master 2 0 0 - -Stretcher bearer 4 2 2 - -Guard 4 1 5 - -Aya 10 7 8 - -Sweeper 19 13 14 - -
Quality of care
• Technical competency of the providers for providing commonly performed maternal and newborn health care services were assessed by observation of the related medical procedures using standardized checklists of SBM-R
• These checklists were filled-up by trained female medical officer/paramedic
• In each of the health facilities these observation were done if respective procedure was available within 30 days
• For each of the procedures, the total target was estimated purposively
• Scoring was done as percentage of activities achieved among total number of activities in each procedure
Methodology
Total number of activities observed by procedure
Type of careNumber of activities
observed per procedure (Total score)
ANC 81NVD 253PNC 103Sick newborn care
Preterm/LBW neoenate 20Neonatal sepsis 14Neonatal jaundice 14Umbilical infection
C-section delivery 152Maternal complications management
Incomplete abortion 54Pre-eclampsia/Eclampsia 58PPH 71
Blood transfusion 24Infection prevention 156
Total number of procedures observed by type
Type of careNumber of procedure
observedBaseline Phase-1
ANC 36 36NVD 20 20PNC 20 20Sick newborn care
Preterm/LBW neoenate 4 9Neonatal sepsis 7 7Neonatal jaundice 3 3Umbilical infection - -
C-section delivery 15 15Maternal complications management
Incomplete abortion 6 5Pre-eclampsia/Eclampsia 4 6PPH 5 4
Blood transfusion 10 15Infection prevention 5 5
Level of quality of care for different types of MNH-FP care services in DH
FP serviceANC
NVD
C-section delivery
PNC
Maternal comp. management
Sick newborn care
Blood transfusion
Infection preventio
n
All procedures
0102030405060708090
100
Baseline Phase-1
Per
cent
age
of s
core
Percentage of score obtained in different components of antenatal care by the providers of DH
Component of Antenatal CareDH
Baseline Phase-1
Initial evaluation by the receiver 15.5 9.3
Cordial and respectful receiving by the provider 57.1 33.1
Obstetrical history taking 57.1 54.3
General medical history taking 30.2 24.7
Physical and obstetric examination 15.3 35.4
Individualized care based on findings and protocols 32.7 60.0
Birth planning 1.5 19.9
Care planning 36.1 48.5
Total 25.6 35.6
Percentage of score obtained in different components of normal vaginal delivery by the providers of DH
Components of Normal Vaginal DeliveryDH
Baseline Phase-1Initial assessment 45.6 57.2Explanation of services to be provided 67.9 79.8Review and filling-up the clinical history 55.3 67.3Physical examinations between contractions if time allows 40.1 59.4Obstetric examination between contractions if time allows 58.0 61.0Vaginal examination 62.8 83.5Use of partograph and make adjustments to the birth plan 9.7 17.9Preparation to assist birth 42.7 64.1Assist the woman to have a safe and clean birth 80.8 87.0Initial assessment of the newborn and provides immediate newborn resuscitation if needed 78.6 88.1
Active management of the third stage of labor 63.0 69.4Immediate postpartum care 68.7 90.3Disposal of used instruments and medical waste 43.5 44.0Monitoring of newborn in immediate postpartum period 32.8 53.9Close monitoring of the woman for at least two hours after the birth 49.5 57.7Neonatal resuscitation if needed 86.7 97.5Total 52.6 65.2
Percentage of score obtained in different components of C-section delivery by the providers of DH
Components of C-Section DeliveryDH
Baseline Phase-1
Information to the clients regarding indication, risks and benefit of caesarean section delivery 51.7 75.6
Ensure fitness for surgery through physical and laboratory examinations 52.0 60.0
Preparation of operation theatre and provider for surgery 70.9 77.5Preparation of the patient for surgery 62.9 70.5Provide anaesthesia 84.0 92.4Opening of abdominal layer 84.2 100.0Opening of uterus 90.0 100.0Delivery of baby 80.0 100.0Delivery of the placenta and exploration of the peritoneal cavity 58.1 95.0Closure of the uterus 88.5 86.7Closure of the abdominal wall 98.9 100.0Completion of all post-procedure tasks 55.8 62.7Post-operative monitoring and ensure postnatal care 71.2 64.8Monitoring of newborn in immediate postpartum period 34.1 55.1Resuscitation of newborn if needed - 100.0Total 65.6 76.9
Percentage of score obtained in different components of postnatal care by the providers of DH
Components of Postnatal CareDH
Baseline Phase-1
Initial assessment 35.3 37.0
Cordial and respectful receiving by the provider 40.0 66.7
Verification of existed clinical records or opening of new one by appropriate history taking 41.3 13.5
Routine physical examination 13.6 11.7
Individualized care based on findings and protocols 28.1 50.7
Advices on danger signs of postpartum period 6.1 21.6
Referral of mother if needed 50.0 83.3
Assessment of the condition of newborn 25.9 40.1
Management of neonates and show breast feeding position 0.0 0.0
Counseling on care of baby 7.2 22.3
Advices on baby's danger signs 0.0 15.8
Total 19.0 28.1
Percentage of score obtained in different components of maternal complications management by the providers of DH
Components of Maternal Complications Management DH
Baseline Phase-1
General
management
Availability of drugs, equipment and supplies 89.5 82.4
Management of hypovolumic shock 81.9 83.8
Evaluation of patient's response and next step 67.7 70.0
Incomplete abortion Diagnosis of incomplete abortion 90.5 97.6
Management of incomplete abortion 68.8 83.9
Pre-eclampsia/
Eclampsia
Diagnosis of pre-eclampsia/Eclampsia 91.7 100.0
Management of severe pre-eclampsia and/or
eclampsia 76.0 82.4
PPH
Diagnosis of PPH 100.0 100.0
General management of PPH 62.3 86.9
Cause-specific management of PPH 49.0 100.0
Follow-up of the PPH patient 59.9 79.2
Total 77.0 85.0
Percentage of score obtained in different components of sick newborn care by the providers of DH
Sick newborn careDH
Baseline Phase-1
Receiving of the patient and explanation of the condition after history taking
70.0 75.3
Appropriate diagnosis of a pre-term/low birth weight neonate
31.7 75.9
If neonatal sepsis, proper diagnosis and appropriate referral
53.0 81.2
If neonatal jaundice, proper diagnosis and appropriate referral if required
51.9 76.4
If umbilical infection, proper diagnosis and appropriate treatment
- -
Total 54.1 78.4
Percentage of score obtained in different components of blood transfusion by the providers of DH
Components of Blood Transfusion ServicesDH
Baseline Phase-1
Cordial receive of the patient and response to any query 55.0 73.3
Assessment of the donor for fitness of blood donation 75.0 86.7
Blood collection procedure 91.7 91.1
Appropriate blood transfusion procedure 86.8 78.6
Total 80.3 82.3
Percentage of score obtained in different components of infection prevention by the providers of DH
Components of infection preventionDH
Baseline Phase-1Cleanliness of the facility and availability of clean running water 52.6 72.5Process to clean rooms wards and clinical areas 41.7 66.1
Labour room
Storage of equipment for reuse 48.0 76.0
Using of antiseptics 40.0 82.4Instrument cleaning area and prevention of cross-contamination 77.8 91.1
Decontamination of instruments and other articles 56.0 72.0
Process of cleaning instruments and other items 77.1 88.6
OT
Storage of equipment for reuse 80.0 80.0Using of antiseptics 60.0 94.3
Instrument cleaning area and prevention of cross-contamination 86.7 97.8
Decontamination of instruments and other articles 72.0 72.0Process of cleaning instruments and other items 80.0 82.9
Area for wrapping and packing instruments 60.0 100.0Process of packaging instruments and other items to be sterilized 80.0 100.0Sterilization process 71.8 93.2High level disinfection process 90.0 100.0Availability of antiseptics, disinfectants and other supplies 61.4 94.1Collection of soiled linen 26.7 66.7Following of general biosafety and infection prevention practices in the laboratory 97.1 79.5
Total 64.3 83.2
Round the clock availability of provider for
MNH care services
Methodology• Round the clock availability of the providers were assessed by prospectively
assessing availability of each of the members of the MNH team by the three
different time slots i.e.
• Morning (8 am-2 pm)
• Evening (2 pm–9 pm)
• Night (9 pm–8 am)
• The observation were done for 30 days in three phases
• During daytime the timesheets were filled-up the by direct observation
• For presence of the providers in evening and night shift, the time-sheet were filled-
out either by direct observation or by interviewing a provider who was in duty in the
previous night
Availability of medical doctors in DH for attending patients by shift (Baseline)
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Consultant (Obs/Gynae)
(n=1)
Consultant (Paed)
(n=2)
RMO (n=2)
Pathologist (n=1)
Anaesthetist (n=1)
EMO (n=5)
Medical Offi-cer Indoor
(n=1)
Medical Offi-cer Outdoor
(n=2)
0
20
40
60
80
100
Present more than 3 hours Present less than 3 hours
On call but no emergency case On call with attending emergency cases
On call but not attending emergency cases
% o
f day
s ob
serv
ed
Availability of medical doctors in DH for attending patients by shift (Phase-1)M
orni
ng
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Mor
ning
Eve
ning
Nig
ht
Consultant (Obs/Gynae)
(n=2)
Consultant (Paed)
(n=2)
Consultant (Anaes-thesia) (n=1)
RMO (n=1)
Pathologist (n=1)
Anaesthetist (n=1)
EMO (n=4)
MO (Indoor) (n=1)
MO (Out-door)
(n=2)
0
20
40
60
80
100
Present more than 3 hours Present less than 3 hours
On call but no emergency case On call with attending emergency cases
On call but not attending emergency cases
% o
f d
ays
ob
serv
ed
Availability of medical doctors in different areas of DH for attending patients by shift (Baseline)
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Gynae ward (Cons/MO Indoor)
Paed ward (Both Consul-
tant)
Anaesthesia
(one Anaesthetist)
Gynae outdoor (MO Outdoor)
Paed outdoor (One Consultant)
Emergency (EMO/MO/RMO)
0
20
40
60
80
100
Present more than 3 hours Present less than 3 hours
On call but no emergency case On call with attending emergency cases
On call but not attending emergency cases
% o
f d
ay
s o
bs
erv
ed
Availability of medical doctors in different areas of DH for attending patients by shift (Phase-1)
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Mo
rnin
g
Eve
nin
g
Nig
ht
Gynae ward (Cons/MO Indoor)
Paed ward (Both Consul-
tant)
Anaesthesia Gynae outdoor (MO Out-
door)
Paed outdoor (One Consul-
tant)
Emergency (EMO/MO/RMO)
0
20
40
60
80
100
Present more than 3 hours Present less than 3 hoursOn call but no emergency case On call with attending emergency casesOn call but not attending emergency cases
% o
f da
ys o
bse
rve
d
Baseline Phase-1
Availability of Senior Staff nurses in Obs/Gynae ward
Morning Evening Night0
20
40
60
80
100
3 Nurses 2 Nurses 1 Nurse No Nurse
% o
f d
ay
s o
bs
erv
ed
Morning Evening Night0
20
40
60
80
100
3 Nurses 2 Nurses 1 Nurse No Nurse
% o
f d
ay
s o
bs
erv
ed
Baseline Phase-1
Availability of project-hired (MaMoni) nurses in Obs/Gynae ward
Morning Evening Night0
20
40
60
80
100
3 Nurses 2 Nurses 1 Nurse
% o
f d
ay
s o
bs
erv
ed
Morning Evening Night0
20
40
60
80
100
3 Nurses 2 Nurses 1 Nurse No Nurse
% o
f d
ay
s o
bs
erv
ed
Availability of nurses (combined) in Obs/Gynae ward
Morning Evening Night0
20
40
60
80
100
4+ Nurses 3 Nurses 2 Nurses 1 Nurse
% o
f d
ay
s o
bs
erv
ed
Morning Evening Night0
20
40
60
80
100
4+ Nurses 3 Nurses 2 Nurses 1 Nurse
% o
f d
ay
s o
bs
erv
ed
Baseline Phase-1
Baseline Phase-1
Availability of Senior Staff nurses in paediatrics ward
Morning Evening Night0
20
40
60
80
100
1 Nurse No Nurse
% o
f d
ay
s o
bs
erv
ed
Morning Evening Night0
20
40
60
80
100
2 Nurses 1 Nurse No Nurse
% o
f d
ay
s o
bs
erv
ed
Baseline Phase-1
Availability of Project-hired (MaMoni) nurses in paediatrics ward
Morning Evening Night0
20
40
60
80
100
2 Nurses 1 Nurse No Nurse
% o
f d
ay
s o
bs
erv
ed
Morning Evening Night0
20
40
60
80
100
2 Nurses 1 Nurse No Nurse
% o
f d
ay
s o
bs
erv
ed
Availability of nurses (combined) in paediatrics ward
Morning Evening Night0
20
40
60
80
100
3 Nurses 2 Nurses 1 Nurse
% o
f d
ay
s o
bs
erv
ed
Baseline
Morning Evening Night0
20
40
60
80
100
3 Nurses 2 Nurses 1 Nurse%
of
da
ys
ob
se
rve
d
Phase-1
Availability of Govt. nurses in OT
Morning Evening Night0
20
40
60
80
100
2 Nurses present 1 Nurse present 2 Nurses on call1 Nurse on call
% o
f d
ay
s o
bs
erv
ed
Morning Evening Night0
20
40
60
80
100
2 Nurses present 1 Nurse present
2 Nurses On-call 2 Nurses attending emergencies
1 Nurse attending emergencies
% o
f d
ay
s o
bs
erv
ed
Baseline Phase-1
Availability of other technical staff in DH (Baseline)
Morning Evening Night Morning Evening Night Morning Evening NightMedical Technologist (Lab/BT) Pharmacist Driver
0
20
40
60
80
100
Present On call but no emergency case On call with attending emergency cases
% o
f d
ay
s o
bs
erv
ed
Availability of other technical staff in DH (Phase-1)
Morning Evening Night Morning Evening Night Morning Evening NightMedical Technologist
(Lab/BT)Pharmacist Driver
0
20
40
60
80
100
Present On call but no emergency case On call with attending emergency cases
% o
f d
ay
s o
bs
erv
ed
Mean number of other support staff per day by shift available in DH
Other support staffMorning Evening Night
Baseline Phase-1 Baseline Phase-1 Baseline Phase-1
MLSS
(obs/gynae ward)0.6 1.00 0.3 1.00 0.2 1.00
Sweeper
(obs/gynae ward)1.0 1.00 1.0 1.00 0.8 1.00
Aya
(obs/gynae ward)0.8 0.76 0.8 0.79 0.8 0.52
Student Nurse
(obs/gynae ward)2.6 3.10 1.4 2.10 0.8 0.67
Student Nurse
(Paediatric ward)1.8 3.15 1.4 2.25 0.6 0.70
Medical doctorsPresent more than 3 hours (100% score) + Presence less than 3 hours (50% score) + Attending call (100 score) - Not attending call (100% score)
Nurses/FWVs for wardMorning shift = Presence of at least 3 nurses (100% score) + Presence of 2 nurses (67% score) +
Presence of presence of 1 nurse (33% score)
Evening shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score)
Night shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score)
Nurses/FWVs for OTPresence of at least 2 nurses/FWVs (100% score) + Presence of 1 nurse/FWV (50% score) + 2 on call nurses/FWVs with attending emergency cases (100% score) + 1 on call nurse/FWV with attending emergency cases (50% score) - On call nurses/FWVs but not attending emergency cases (100% score)
Other technical staff (MT/Pharmacist/ANA/Dai nurse)For each categoryPresence more than 3 hours (100% score)+ Presence less than 3 hours (50% score)+ On call attending emergency cases (100% score) - On call but not attending emergency cases (100% score)
Support staff (MLSS/Aya/Sweeper/Guard)Presence of at least 2 support staff (100 score) + Presence of at least 1 support staff (50% score)
Scoring system for availability of MNH care providers
Score on availability of providers in DH by assessment type
Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift
Baseline Phase-1Medical doctorsGynae ward 40.6 48.9Paed ward 28.9 32.2Emergency 100.0 100.0Anaesthesia 27.2 26.7
Average 49.2 51.9NursesGynae ward 95.8 93.3Paediatrics ward 65.4 68.5OT 31.1 25.6
Average 64.1 62.5Other Technical StaffMedical Technologist (Lab/BT) 84.4 66.7
Other Support Staff
(MLSS/Aya/Sweeper/Guard) 96.67 100.0
Overall Average 63.3 62.4
Score on availability of providers in DH by assessment type (excluding holidays)
Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift
Baseline Phase-1Medical doctors Gynae ward 48.8 56.5Paed ward 34.6 40.6Emergency 100.0 100Anaesthesia 30.2 33.3
Average 53.4 57.6NursesGynae ward 96.3 93.7Paediatrics ward 65.6 76.3OT 32.1 31.2
Average 64.7 67.1Other Technical StaffMedical Technologist (Lab/BT) 87.7 71.0
Other Support Staff
(MLSS/Aya/Sweeper/Guard) 96.3 100.0
Overall Average 65.7 67.0
Achievement of
targets
Type of providers BaselineLevel-I
Target Achieved
Medical doctors 49.2% 51.9%
Nurses 64.1% 62.5%
MT (lab/BT) 84.4% 66.7%
Support Staff 96.7% 100.0%
Overall 63.3% 70.0% 62.4%
Achievement of targets for availability of providers for
24/7 MNH care services in DH
Type of care BaselineLevel-I
Target AchievedFP services - - -
ANC 25.6% 35.6%
NVD 52.6% 65.2%
PNC 19.0% 76.9%
Sick newborn care 54.1% 28.1%
C-section delivery 65.6% 85.0%
Maternal complications management
77.0% 78.4%
Blood transfusion 80.3% 82.3%
Infection prevention 64.3% 83.2%
All procedures 54.8% 70.0% 66.9%
Achievement of targets for quality of care for
MNH services in DH
Findings from MCWC
Human resources (HR)
Name of the postSanctioned
post
In positionComment
Baseline Phase-1
Medical doctorsMO (clinic) 1 1 1 Trained in Obs/Gynae
MO (MCH-FP) 0 1 1Trained in Anaesthesia, Posted in Sadar Upazila FP office, attached in MCWC
Other support staffFWV 2 6 7 All are EOC trained
Staff nurse (Ma-Moni) 0 1 0 Maternity leave but no replacement was done
FMA 1 1 1
ANA/Dai nurse 2 3 3Pharmacist 0 1 1Driver 1 1 1
Peon cum chowkider 1 2 1
Sweeper 1 3 1 Two are temporary staff were found during baseline assessment
Aya 0 1 1Guard 0 4 - Two are from Ansar/VDP
Availability of HR in MCWC (No.)
Quality of care
• Technical competency of the providers for providing commonly performed maternal and newborn health care services were assessed by observation of the related medical procedures using standardized checklists of SBM-R
• These checklists were filled-up by trained female medical officer/paramedic
• In each of the health facilities these observation were done if respective procedure was available within 30 days
• For each of the procedures, the total target was estimated purposively
• Scoring was done as percentage of activities achieved among total number of activities in each procedure
Methodology
Total number of activities observed by procedure
Type of careNumber of activities observed per
procedure (Total score)Birth spacing/FP
Combined oral contraceptive (COC) pill 64Progesteron only pill (POP) -Depot medoxy progrsteron acetate (DMPA) 65Condom 40Insertion of Intra-uterine copper device (IUCD) 61Removal of Intra-uterine copper device (IUCD) 24Emergency contraceptive pill (ECP) -Sterilization 45Implant 58
ANC 81NVD 253PNC 103Sick newborn care
Preterm/LBW neoenate 20Neonatal sepsis 14Neonatal jaundice 14Umbilical infection
C-section delivery 152
Maternal complications management
Incomplete abortion 54Pre-eclampsia/Eclampsia 58PPH 71
Blood transfusion 24Infection prevention 156
Total number of procedures observed by type
Type of careNumber of procedure observed
Baseline Phase-1FP services
Combined oral contraceptive (COC) pill 15 4Progesteron only pill (POP) - - Depot medoxy progrsteron acetate (DMPA) 12 5Condom 8 3Insertion of Intra-uterine copper device (IUCD) 3 2Removal of Intra-uterine copper device (IUCD) 1 1Emergency contraceptive pill (ECP) - -Sterilization 11 8Implant 10 7
ANC 36 36NVD 20 20PNC 18 20Sick newborn care - - C-section delivery 14 15Maternal complications management
Incomplete abortion - 2Pre-eclampsia/Eclampsia - -PPH - -
Blood transfusion 0 2Infection prevention 5 5
Level of quality of care for different types of MNH-FP care services in MCWC
FP service
ANCNVD
C-section delive
ryPNC
Maternal comp. management
Sick newborn ca
re
Blood transfu
sion
Infection preventio
n
All proce
dures0
20
40
60
80
100
Baseline Phase-1
Per
cent
age
of s
core
Percentage of score obtained in different components of birth spacing by the providers of MCWC
Components of FP ServiceMCWC
Baseline Phase-1Counselling technique 39.9 80.3Support client's interest, needs and choice 19.4 70.8Providing information on all birth spacing methods and helping to choose suitable method 5.3 64.8
Counselling clients regarding postpartum contraception and lactational ammenorrhoea method (LAM) 3.7 25.0
Ruling out of the current pregnancy 18.8 85.1Return/follow-up visit of the client 26.6 75.9Combined oral contraceptive (COC) pill 13.6 41.1Progesteron only pill (POP) - - Depot medoxy progrsteron acetate (DMPA) 24.3 59.7Condom 15.0 45.1Insertion of Intra-uterine copper device (IUCD) 34.9 67.7Removal of Intra-uterine copper device (IUCD) 41.7 71.9Emergency contraceptive pill (ECP) Sterilization 36.6 82.2Implant 26.5 89.4Total 23.8 69.6
Percentage of score obtained in different components of antenatal care by the providers of MCWC
Components of Antenatal CareMCWC
Baseline Phase-1
Initial evaluation by the receiver 14.8 53.6
Cordial and respectful receiving by the provider 59.4 92.8
Obstetrical history taking 60.8 66.7
General medical history taking 17.7 37.4
Physical and obstetric examination 57.0 69.1
Individualized care based on findings and protocols 32.1 57.3
Birth planning 4.5 22.9
Care planning 48.9 76.7
Total 36.9 57.2
Percentage of score obtained in different components of normal vaginal delivery by the providers of MCWC
Components of Normal Vaginal DeliveryMCWC
Baseline Phase-1Initial assessment 46.7 96.1Explanation of services to be provided 73.6 93.6Review and filling-up the clinical history 57.9 76.6Physical examinations between contractions if time allows 55.7 63.6Obstetric examination between contractions if time allows 72.0 79.0Vaginal examination 74.6 77.3Use of partograph and make adjustments to the birth plan 11.0 42.1Preparation to assist birth 74.5 79.0Assist the woman to have a safe and clean birth 85.8 81.7Initial assessment of the newborn and provides immediate newborn resuscitation if needed 78.4 84.6
Active management of the third stage of labor 71.5 77.4Immediate postpartum care 89.7 90.7Disposal of used instruments and medical waste 76.5 79.0Monitoring of newborn in immediate postpartum period 33.6 60.6Close monitoring of the woman for at least two hours after the birth 54.8 56.7
Neonatal resuscitation if needed 100.0 100.0Total 59.8 72.2
Percentage of score obtained in different components of C-section delivery by the providers of MCWC
Components of C-section DeliveryMCWC
Baseline Phase-1
Information to the clients regarding indication, risks and benefit of caesarean section delivery 65.7 72.8
Ensure fitness for surgery through physical and laboratory examinations 81.4 77.0
Preparation of operation theatre and provider for surgery 83.8 70.0Preparation of the patient for surgery 88.8 74.3Provide anaesthesia 95.5 91.4Opening of abdominal layer 100.0 100.0Opening of uterus 92.0 100.0Delivery of baby 89.8 100.0Delivery of the placenta and exploration of the peritoneal cavity 68.0 93.3Closure of the uterus 96.0 96.7Closure of the abdominal wall 100.0 100.0Completion of all post-procedure tasks 77.7 41.3Post-operative monitoring and ensure postnatal care 79.2 66.2Monitoring of newborn in immediate postpartum period 33.8 50.1Resuscitation of newborn if needed 50.0 - Total 76.5 75.4
Percentage of score obtained in different components of postnatal care by the providers of MCWC
Components of Postnatal CareMCWC
Baseline Phase-1
Initial assessment 29.0 60.4
Cordial and respectful receiving by the provider 15.6 75.0
Verification of existed clinical records or opening of new one by appropriate history taking 19.4 79.2
Routine physical examination 18.3 50.4
Individualized care based on findings and protocols 37.4 67.9
Advices on danger signs of postpartum period 13.6 42.8
Referral of mother if needed - 100.0
Assessment of the condition of newborn 14.2 35.5
Management of neonates and show breast feeding position 5.9 26.9
Counseling on care of baby 34.0 43.3
Advices on baby's danger signs 22.0 51.1
Total 24.5 52.2
Percentage of score obtained in different components of maternal complications management by the providers of MCWC
Components of Maternal Complications Management MCWC
Baseline Phase-1
General management
Availability of drugs, equipment and supplies - 78.6
Management of hypovolumic shock - 100.0
Evaluation of patient's response and next step - 70.7
Incomplete abortion
Diagnosis of incomplete abortion - -
Management of incomplete abortion - -
Pre-eclampsia/Eclampsia
Diagnosis of pre-eclampsia/Eclampsia - -
Management of severe pre-eclampsia and/or eclampsia - -
PPH
Diagnosis of PPH - 100.0General management of PPH - 72.9
Cause-specific management of PPH - 85.7
Follow-up of the PPH patient - 79.2Total - 78.7
Percentage of score obtained in different components of blood transfusion by the providers of MCWC
Components of Blood Transfusion ServicesMCWC
Baseline Phase-1
Cordial receive of the patient and response to any query
- 100.0
Assessment of the donor for fitness of blood donation - 87.5
Blood collection procedure - 91.7
Appropriate blood transfusion procedure - 73.3
Total - 85.0
Percentage of score obtained in different components of infection prevention by the providers of MCWC
Components of infection preventionMCWC
Baseline Phase-1Cleanliness of the facility and availability of clean running water 91.2 96.9Process to clean rooms wards and clinical areas 70.4 62.6
Labour room
Storage of equipment for reuse 88.0 84.0Using of antiseptics 62.9 57.1Instrument cleaning area and prevention of cross-contamination 80.0 93.3Decontamination of instruments and other articles 84.0 60.0Process of cleaning instruments and other items 94.3 77.1
OT
Storage of equipment for reuse 100.0 92.0Using of antiseptics 82.9 74.3Instrument cleaning area and prevention of cross-contamination 91.1 88.9Decontamination of instruments and other articles 80.0 68.0Process of cleaning instruments and other items 94.3 89.3
Area for wrapping and packing instruments 66.7 86.7Process of packaging instruments and other items to be sterilized 95.0 100.0Sterilization process 91.6 93.3High level disinfection process 100.0 - Availability of antiseptics, disinfectants and other supplies 78.6 100.0Collection of soiled linen 40.0 53.3Following of general biosafety and infection prevention practices in the laboratory - -
Total 83.0 81.9
Round the clock availability of provider for
MNH care services
Methodology• Round the clock availability of the providers were assessed by prospectively
assessing availability of each of the members of the MNH team by the three
different time slots i.e.
• Morning (8 am-2 pm)
• Evening (2 pm–9 pm)
• Night (9 pm–8 am)
• The observation were done for 30 days in three phases
• During daytime the timesheets were filled-up the by direct observation
• For presence of the providers in evening and night shift, the time-sheet were filled-
out either by direct observation or by interviewing a provider who was in duty in the
previous night
Availability of medical doctors in MCWC for attending patients by shift (Baseline)
Morning Evening Night Morning Evening NightMedical Officer (Clinic) Medical officer (MCH-FP)
0
20
40
60
80
100
Present more than 3 hours Present less than 3 hours
On call but no emergency case On call with attending emergency cases
% o
f da
ys o
bse
rve
d
Availability of medical doctors in MCWC for attending patients by shift (Phase-1)
Morning Evening Night Morning Evening NightMedical Officer (Clinic) Medical officer (MCH-FP)
0
20
40
60
80
100
Present more than 3 hours Present less than 3 hours On call but no emergency case On call with attending emergency cases
% o
f d
ay
s o
bs
erv
ed
Availability of FWVs in MCWC
Morning Evening Night0
20
40
60
80
100
3+ FWVs 2 FWVs 1 FWV
% o
f fa
ys
ob
se
rve
d
Baseline Phase-1
Morning Evening Night0
20
40
60
80
100
3+ FWVs 2 FWVs 1 FWV
% o
f d
ay
s o
bs
erv
ed
Availability of other technical staff in MCWC
ANA/Dai nurse
FMA Pharmacist Driver0
20
40
60
80
100
Morning Evening Night
% o
f d
ay
s o
bs
erv
ed
ANA/Dai nurse
FMA Pharmacist Driver0
20
40
60
80
100
Morning Evening Night
% o
f d
ay
s o
bs
erv
ed
Baseline Phase-1
Mean number of other support staff per day by shift available in MCWC
Other support staff
Baseline Phase-1
Morning Evening Night Morning Evening Night
Peon cum Chowkider 0.5 0.5 0.0 1.03 0.27 0.60
Sweeper 1.0 0.5 0.6 1.03 0.53 0.43
Aya 0.5 0.3 0.4 0.37 0.07 0.23
Night Guard 1.7 0.6 1.1 0.93 0.81 0.44
Medical doctorsPresent more than 3 hours (100% score) + Presence less than 3 hours (50% score) + Attending call (100 score) - Not attending call (100% score)
Nurses/FWVs for wardMorning shift = Presence of at least 3 nurses (100% score) + Presence of 2 nurses (67% score) +
Presence of presence of 1 nurse (33% score)
Evening shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score)
Night shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score)
Nurses/FWVs for OTPresence of at least 2 nurses/FWVs (100% score) + Presence of 1 nurse/FWV (50% score) + 2 on call nurses/FWVs with attending emergency cases (100% score) + 1 on call nurse/FWV with attending emergency cases (50% score) - On call nurses/FWVs but not attending emergency cases (100% score)
Other technical staff (MT/Pharmacist/ANA/Dai nurse)For each categoryPresence more than 3 hours (100% score)+ Presence less than 3 hours (50% score)+ On call attending emergency cases (100% score) - On call but not attending emergency cases (100% score)
Support staff (MLSS/Aya/Sweeper/Guard)Presence of at least 2 support staff (100 score) + Presence of at least 1 support staff (50% score)
Scoring system for availability of MNH care providers
Score on availability of providers in MCWC by assessment type
Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift
Baseline Phase-1
Medical doctors
Obs/Gynae 31.7 34.4
Anaesthesia 36.1 30.0
Average 33.9 32.2
FWVs/Nurse 71.1 66.5
Other Technical Staff
ANA/Dai nurse 63.3 70.0
Other Support Staff
MLSS/Aya/Sweeper/Guard 93.9 87.2
Overall Average 59.2 57.6
Score on availability of providers in MCWC by assessment type (Excluding holidays)
Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift
Baseline Phase-1
Medical doctors
Obs/Gynae 32.1 42.0
Anaesthesia 35.8 39.1
Average 34.0 40.6
FWVs/Nurse 84.8 73.2
Other Technical Staff
ANA/Dai nurse 72.8 69.6
Other Support Staff
MLSS/Aya/Sweeper/Guard 93.2 87.0
Overall Average 63.7 62.2
Achievement of
targets
Type of providers BaselineLevel-I
Target Achieved
Medical doctors 33.9% 32.2%
FWVs/Nurse 71.1% 66.5%
Other technical staff 63.3% 70.0%
Support Staff 93.9% 87.2%
Overall 59.2% 70.0% 57.6%
Achievement of targets for availability of providers for
24/7 MNH care services in MCWC
Type of care BaselineLevel-I
Target Achieved
FP service 23.8% 69.6%
ANC 36.9% 57.2%
NVD 59.8% 72.2%
PNC 24.5% 75.4%
Sick newborn care - 52.2%
C-section delivery 76.5% 78.7%Maternal complications management -
Blood transfusion - 85.0%
Infection prevention 83.0% 81.9%
All procedures 50.7% 70.0% 71.5%
Achievement of targets for quality of care for
MNH services in MCWC
icddr,b also thanks its Core Donors
Acknowledgements
This project was funded by the Traction project of USAID