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

Acknowledgments
Country Ministries of Health and staff at the study health facilities in Ethiopia, 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

Summary of QOC Study Sample

Surveyed 643 facilities in 6 countries; Observed ~5600 deliveries and ANC consultations, and Interviewed ~1000 health workers
Sample Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar 36 75% 25% 670 347 336 Mozambique 46 46% 54% 828 525 508 Total

Facilities -Hospital -Health Center/dispensary Observations of care -Deliveries *newborn & postpartum care -Intrapartum complications *newborn resuscitation -ANC consultations Health workers interviewed

409 52% 48% 2035 626 571

19 100% 0% 318 192 115

52 23% 77% 880 489 419

9 56% 44% 274 217 203

72 58% 42% 604 293 225

643 53% 47% 5609 2689 2377

42 1409 249

18 126 79

37 391 206

12 57 51

44 311 146

49 323 140

28 303 186

230 2920 1057

Observation of Immediate Newborn Care

81%
100%
90% 80% 70% 60% 50% 40% 30% 20%

93% 63% 37% 43%

67%

10%
0% Immediately dries baby Discards wet towel and with towel covers with dry towel Kenya Ethiopia Cuts cord with clean blade Zanzibar Assists the mother to Places newborn skin to Ties/clamps cord when initiate breastfeeding skin pulsations stop or by 2within the first hour 3min after birth Rwanda Madagascar Mozambique

Tanzania

Inventory of Supplies for Immediate Newborn Care

69%
100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Disposable cord ties or clamps Kenya Ethiopia Towel or blanket to wrap baby Tanzania Zanzibar Sterile scissors or blade Rwanda Madagascar Mean score essential supplies Mozambique

89% 36%

65% (48% to 81%)

Inventory of Supplies for Management of Newborn Complications

Mean High Low

Bag and mask (infant size)

79.9%

100.0%

57.1%

Suction bulb Suction apparatus for use with catheter Resuscitation table for newborn
Gentamycin

66.2% 77.0% 68.3%

61.8%

95.1% 100.0% 88.9%

78.0%

26.7% 60.9% 51.4%

40.0%

Ampicillin Functioning incubator or other heat source Mean score supplies for complications

54.5% 52.7% 66.0%

73.7% 83.3% 81.2%

22.2% 26.0% 42.9%

Health Worker Knowledge of Immediate Newborn Care and Management of Complications

100% 90% 80% 70% 60%

61% 54% 43%

38%

28%

53%

50%
40% 30% 20% 10% 0% Equipment Kenya Ethiopia Immediate newborn care Tanzania Signs of sepsis in the newborn Zanzibar Rwanda Care of LBW newborn Madagascar Newborn resuscitation Mozambique

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

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* Values are mean score

Essential Newborn Care Cascade from Policy to Practice

100%
100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Policy (ENC in SDGs) Skilled birth attendance Kenya Ethiopia Supervised last 3/6 months Tanzania Zanzibar Score for essential supplies Rwanda Score for immediate Received all essential care knowledge newborn care elements Madagascar Mozambique

92% 61% 65% 51% 23%

Non-beneficial and Non-indicated Newborn Care Practices - Observation

100%
90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Slap newborn Kenya Ethiopia Hold newborn upside down Tanzania Zanzibar Milk newborns chest Rwanda Routine aspiration of newborn mouth and nose at birth Madagascar Mozambique

5%

10%

<1%

8%

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Newborn Resuscitation Simulation

Dry/position: drying, place on warm clean surface, head in slightly extended position (all items)

Dry/position

53%

Suction

84%

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)

Ventilation

34%

Adjustment

74%
0% Tanzania 20% 40% Zanzibar 60% Rwanda 80% 100% Madagascar

Management of Newborn Asphyxia Observations

Item
Cases of resuscitation observed

Number (n) 230

Steps performed correctly -Drying and positioning -Suction -Ventilation -Adjustment head position, mask seal
Outcome of newborn -Alive -Dead
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91 92 29 92

Steps are as described on previous page;

208 22

Malawi: Helping Babies Breathe Performance Evaluation

2012 Performance evaluation: conducted by MCHIP and Malawi MOH Findings are available from the first phase of data collection 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 & mask ventilation Observation of immediate essential newborn care Management of newborn asphyxia
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Inventory of Equipment for Newborn Care

Equipment Total facilities (n=81) Bag and mask (infant size) for resuscitation Tube and mask Incubator Other source of heat for premature newborn Newborn weighing scale Suction bulb for mucus extraction Suction apparatus for use with catheter Resuscitation table for newborn Disposable cord ties or clamps Towel or blanket to wrap newborn Observed n(%) Reported, not seen n(%)
5 (6.2) 4 (4.9) 4 (4.9) 1 (1.2) 3 (3.7) 2 (2.5) 3 (3.7) 5 (6.2)

Not available n(%)

21 (25.9) 25 (30.9) 62 (76.5) 55 (68.8) 3 (3.7) 28 (34.6) 12 (14.8) 21 (25.9) 7 (8.6) 56 (69.1)
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55 (67.9) 50 (61.7) 15 (18.5) 24 (30.0) 77 (95.1) 49 (60.5) 66 (81.5) 59 (72.8) 71 (87.7) 20 (25.0)

Assessment of Health Worker Skills Bag & Mask Ventilation (Simulation)

Respondents who completed each step (N=177) Checks equipment and selects the correct mask Tests function of bag and mask Makes sure mask fits the babys face Applies the mask to make a firm seal Extends the head Places mask on the chin then mouth and nose A firm seal permits chest movement when the bag is squeezed Ventilates at 40 breaths per minute Looks for chest movement Improves ventilation if the chest does not move Head- reapplies mask and repositions head Mouth- clears secretions and opens the mouth Bag- squeezes the bag harder Mean Number of steps done correctly SD Range Percent 43.3 64.4 88.2 84.3

66.3
51.7 74.2

59 50.6 28.1
6.1 2.4 0-10

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Observation of Immediate Newborn Care

120 100

80 P e r c 60 e n t 40

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0 Immediately dries baby with towel Discards wet towel Places newborn skin-to-skin with mother Initiate breast Ties/clamps cord Cuts cord with clean blade feeding within the when pulsations first hour stop, or within 23 minutes after birth (but not immediately after birth)

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

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Preliminary Findings for Management of Newborn Asphyxia

231 not breathing at birth 13 missing data 164 received stimulation 54 received no stimulation 1 w/o data 2 w/o data 68 with bag & mask 62 breathing 6 unsuccess ful 4 breathing 5 w/o bag & mask 1
unsuccessfu l

89 breathing

75 not breathing

47
breathing

6
unsuccessful
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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 newborn care for babies delivered at health facilities
A sizable proportion of health facilities included in the study have newborn resuscitation equipment but provider skills need further strengthening

Recommendations

Although countries are committed to making QOC improvements, 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 logistics management Have appropriate policies, service delivery guidelines/protocols Strengthen supervision and monitoring

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