Transcript Slide 1

Facility Assessment of Quality of Care
for Immediate Newborn Care and
Neonatal Resuscitation
in selected African Countries
Dr. Joseph de Graft-Johnson,
MCHIP
Acknowledgments
 Ministries of Health and staff of the study facilities
in Ethiopia, Kenya, Madagascar, Rwanda,
Tanzania, and Zanzibar
 Study teams based in each country
 Study team: Jim Ricca, Barbara Rawlins, Linda
Bartlett, David Cantor, Heather Rosen, Patricia
Gomez, Eva Bazant, Rebecca Levine, Bob Bozsa,
and Joseph de Graft Johnson
 Tandem consulting (Madagascar)
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QoC-MNC study
 QoC-MNC study technical focus:
Maternal: PPH, PE/E, Prolonged/Obstructed
Labor and Sepsis
Newborn: Immediate newborn care and neonatal
resuscitation
 Tools: Inventory list, Knowledge test and Observation
checklist
Core of assessment is direct observation to assess quality of
care, both for ANC and Labor and Delivery.
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QoC-MNC Assessment Countries
• MCHIP QoC-MNC
assessments
implemented in 5
countries plus
Zanzibar in 2009-2010
• Results from
assessments in
Zimbabwe and
Mozambique not ready
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Summary of Samples
Assessed 597 facilities in 5 countries plus Zanzibar;
observed 2164 deliveries and 2617 ANC consultations;
interviewed 2440 health workers.
Facilities
409
19
52
9
72
Madagascar
36
- Hospital
- Health Center/dispensary
52%
48%
100%
0%
23%
77%
56%
44%
58%
42%
75%
25%
53%
47%
Observations of care
- Deliveries
*Initial assessment
*3rd/4th stage of labor
*Newborn care
- ANC consults
Health workers
interviewed
2035
626
452
563
571
1409
249
318
192
107
117
115
126
79
880
489
306
415
419
391
206
274
217
106
201
203
57
51
604
293
187
225
225
311
146
670
347
268
288
336
323
140
4781
2164
1426
1809
1869
2617
2440
Sample
Kenya
Ethiopia Tanzania Zanzibar Rwanda
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Total
597
Data collection using mobile smart phones
 Observers used Windows
Mobile Smart Phones, for
capturing data, enforcing
quality checks and
sending data
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Inventory of Supplies for Immediate Newborn Care
100%
88%
68%
90%
64%
80%
70%
36%
60%
50%
40%
30%
20%
10%
0%
Disposable cord ties or clamps Towel or blanket to wrap baby
Kenya
Ethiopia
Tanzania
Sterile scissors or blade
Zanzibar
Rwanda
Madagascar
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* In Kenya, facilities could have a delivery pack which included blade (not specified as sterile) and cord ties/clamps.
Mean score essential supplies
Inventory of Supplies for Management of Asphyxia
79%
61%
77%
68%
71%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Bag and mask (infant size)
Suction bulb
Suction apparatus for use Resuscitation table for
with catheter
newborn
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Kenya
Ethiopia
Tanzania
Zanzibar
Rwanda
Madagascar
Mean score resuscitation
supplies
Health worker knowledge of immediate newborn
care and management of complications
100%
Note: Values are mean score.
90%
80%
61%
70%
60%
54%
49%
38%
50%
33%
40%
30%
20%
10%
0%
Equipment and supplies
for immediate newborn
care
Immediate newborn
care
Kenya
Ethiopia
Signs of sepsis in the
newborn
Tanzania
Zanzibar
Newborn resuscitation Newborn resuscitation
test
simulation
Rwanda
Madagascar
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* In Madagascar, newborn knowledge questions were mistakenly omitted.
** Newborn resuscitation test for Kenya and Ethiopia only; newborn resuscitation simulation for Tanzania, Zanzibar, Rwanda, and Madagascar.
Observation of Immediate Newborn Care
80%
59%
92%
66%
100%
39%
90%
43%
80%
70%
24%
60%
50%
40%
30%
20%
10%
0%
Immediately dries Discards wet towel Cuts cord with Assists the mother Places newborn
baby with towel and covers with clean blade (2)*
to initiate
skin to skin
(1)*
dry towel *
breastfeeding
within the first
hour*
Kenya
Ethiopia
Tanzania
Zanzibar
Rwanda
(1) Kenya: no separate dries question
(2) Kenya and Ethiopia: cuts and ties/clamps cord, protecting newborn from blade or scissors
Ties/clamps cord Essential newborn
when pulsations care (all 4 items/3
stop or by 2-3min
Kenya)
after birth
Madagascar
Newborn Resuscitation Simulations
(1) Stimulation: drying, place on warm
clean surface, head in slightly
extended position, suction with bulb or
catheter in mouth or nose (all items)
51%
Stimulation (1)
Ventilation (2)
(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)
39%
74%
Adjustment (3)
0%
20%
Tanzania
40%
Zanzibar
60%
Rwanda
80%
Madagascar
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100%
(3) Adjustment is any proper
adjustment: check neck position, check
seal, repeat suction, squeeze harder
From Policy to Practice: Essential
Newborn Care Constraints Analysis
83%
93%
100%
90%
59%
64%
80%
54%
70%
60%
24%
50%
40%
30%
20%
10%
0%
Score for Policy
Ethiopia
Skilled birth
attendance
Supervision last 3
months
Tanzania
* In Madagascar, newborn knowledge questions were mistakenly omitted.
Score for essential
supplies
12
Zanzibar
Score for newborn Received all essential
knowledge
newborn care
elements
Rwanda
Madagascar
Management of Newborn Asphyxia
Item
Resuscitation
observations
Type of treatment
- Dry/position for
resuscitation
- Suction
n
%
202
185
92%
171
85%
- Use of bag and mask
100
50%
- Ventilate with oxygen
21
10%
22
11%
Outcomes
-Newborn deaths
A G1 P0 woman was observed starting with 1st stage of labor.
She was attended by a female nurse/midwife with graduate level
diploma at a health center. Progress was plotted on a new WHO
partograph but was not initiated at correct time. The action line on
the partograph was reached at 2:45pm, yet action was not taken
until 4:45pm, when provider prepared for assisted delivery.
Mother had an assisted SVD at 5:55.
Newborn was not crying/breathing:
• Provider slapped newborn and held upside down.
• Provider performed initial stimulation: dried/wrapped, placed
on back, neck tilted, suctioned airway.
• Newborn was still not breathing so provider ventilated with
bag and mask: squeezed the mask and adjusted it for a
correct seal. Provider ventilated but not at 40 breaths/minute;
• After 1 minute, the baby’s breathing was <30 breaths/minute.
Provider continued ventilating but there was no respiration.
• Ventilation stopped at 6:30pm and the baby was pronounced
dead
• Size 0 mask, suction catheter, and suction machine were laid
out and ready before delivery
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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
 Supportive national policies generally in place
 Lack of supplies for immediate newborn care
 A sizable percentage of health facilities had newborn
resuscitation equipment
 Supervision is not frequent in all facilities and the
content is variable
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
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