|Year : 2016 | Volume
| Issue : 4 | Page : 341-346
Assessment of newborn care corners in selected public health facilities in Bihar
Monika Chauhan1, Jyoti Sharma2, Preeti Negandhi2, Siddharth Reddy3, Ghanashyam Sethy4, Sutapa B Neogi5
1 Project Associate, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
2 Associate Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
3 Health Officer Maternal and Newborn Health, UNICEF, Bihar, India
4 Health Specialist, UNICEF, Bihar, India
5 Additional Professor, Indian Institute of Public Health-Delhi, Public Health Foundation of India, India
|Date of Web Publication||15-Dec-2016|
Indian Institute of Public Health-Delhi, Public Health Foundation of India, Plot No. 47, Sector 44, Gurgaon, Delhi-NCR, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: A functional newborn care corner (NBCC) is critical to provide immediate care to newborns including resuscitation, warmth, and initial care to sick newborns. NBCC provides an acceptable environment for all infants at birth, and it is mandatory for all delivery points at all levels in the health system including operation theaters. Objective: The objective of this study was to find the status of availability of NBCCs and service provision in selected public health facilities of Bihar. Methods: A total of 57 NBCCs, having high delivery load (>100 deliveries/month), across 25 high-priority districts in Bihar, were selected purposively in consultation with the State Health Society, Bihar, for the assessment. These facilities were assessed for the availability and/or functioning of infrastructure, equipment maintenance, human resource, supply of drugs and consumables, adherence to protocols, and record keeping. Results: Only 22.8% of the NBCCs were found to be fully functional, majority (68.4%) were partially functional, and 9% were nonfunctional. Thirty-seven (64.9%) NBCCs were located inside the labor room premises. Approximately, one-third of the neonates delivered were kept in NBCCs. Equipment though available lacked the provision of annual maintenance contract. Essential drugs such as adrenaline (24.6%) and Vitamin K injection (42.1%) were not available in many facilities. Only 6.2% of the newborns had low birth weight, indicating underreporting. Majority of the health-care staff available were trained but possessed poor skills. Data recording and reporting was also suboptimal. Conclusion: The network of NBCCs needs to be strengthened across the state and linked with higher facilities to achieve the desired reduction in neonatal morbidity and mortality.
Keywords: Assessment, facilities, newborn care corners, newborns
|How to cite this article:|
Chauhan M, Sharma J, Negandhi P, Reddy S, Sethy G, Neogi SB. Assessment of newborn care corners in selected public health facilities in Bihar. Indian J Public Health 2016;60:341-6
|How to cite this URL:|
Chauhan M, Sharma J, Negandhi P, Reddy S, Sethy G, Neogi SB. Assessment of newborn care corners in selected public health facilities in Bihar. Indian J Public Health [serial online] 2016 [cited 2020 Jan 22];60:341-6. Available from: http://www.ijph.in/text.asp?2016/60/4/341/195863
| Introduction|| |
Facility-based newborn care (FBNC) refers to clinical services provided by skilled personnel at health facilities round-the-clock., With the launch of the National Rural Health Mission (NRHM), the focus on newborn care has become central to the child health strategy both at the community and facility level. UNICEF India played a lead role in partnership with state governments in the early operationalization of FBNC in the country. The operational guidelines were formulated to provide details of designing the special newborn care units (SNCUs) at district level, newborn stabilization units (NBSUs) at the first referral units, and newborn care corners (NBCCs) at all active delivery points in a district.,
NBCC is a space within the delivery room where immediate care is provided to all newborns. According to the Indian Public Health Standards, NBCCs provide an acceptable environment for all infants at birth, and it is mandatory for all delivery points at all levels in the health system including operation theaters. The following services should be available at every functional NBCC: resuscitation including provision of warmth, early initiation of breastfeeding, weighing the newborn, and initial care to sick newborns. According to the recent report, in June 2015, 14,441 NBCCs were functional in the country and 496 in Bihar. The study was conducted to find the status of availability of NBCCs and service provision in selected public health facilities of Bihar.
| Materials and Methods|| |
Based on the criteria of having high caseload (>100 deliveries/month), a total of 57 NBCCs from 25 high-priority districts in Bihar were selected purposively in consultation with the State Health Society, Bihar (SHSB). These facilities were visited by a team for a rapid assessment from May to June 2015.
A quality assurance checklist was developed to assess the availability and quality of services. This checklist assessed NBCCs on parameters that included infrastructure, equipment maintenance, human resources, supply of drugs and consumables, adherence to protocols, and record keeping. Information related to each parameter was obtained through observation, staff interview, and record review.
Field investigators with a prior experience of public health research were trained for 1 day at the outset to conduct the assessment. Before starting data collection, the tools were piloted and revised according to the results of the pilot study. The health manager, labor room staff, and medical officers were interviewed at each selected facility. Registers were checked to assess the completeness and accuracy of records. The availability and functionality of equipment and adherence to protocols and processes were assessed by direct observation. The data collection process was supervised by the research team.
Descriptive analysis was conducted to assess the parameters mentioned above. The functional status of NBCC was the primary outcome of the study. The status of the functionality of NBCCs was categorized on the basis of the following criteria mutually decided by the SHSB and UNICEF [Table 1].
|Table 1: Criteria for categorization of newborn care corners as per their functional status|
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Permission for the study was obtained from the Institutional Ethics Committee of Indian Institute of Public Health-Delhi as part of the permission for undertaking the project on interventions related to the newborn care at the outset.
| Results|| |
NBCCs at district, subdistrict, and referral hospitals were assessed in the selected districts. Primary Health Centers (PHCs) with high delivery load were also included in the assessment. This included 32 (57%) NBCCs from district and subdistrict hospitals and referral units and 25 (43%) NBCCs from PHCs.
Status of newborn care corners
It is recommended that NBCCs should be located inside the labor room to avoid any delay in providing newborn care. The data showed that 64.9% (37) of the NBCCs were located inside the labor room, while rest were located outside the labor room. Out of 57 NBCCs, only 22.8% (13) were found to be fully functional, fulfilling all the five criteria. Majority (39; 68.4%) of the NBCCs were partially functional and five (9%) NBCCs were nonfunctional at the time of the assessment.
Status of service delivery
The service delivery data were collected from fully functional and partially functional NBCCs. The delivery load reported for the last quarter before assessment was 47,636 for all the 52 functional/partially functional NBCCs collectively (approximately 885 deliveries/facility in the past 3 months). Of these, 6.2% of the newborns were of low birth weight (LBW). Out of the total deliveries, approximately, one third of the newborns (31.02%) were kept in NBCCs. Only two facilities reported that they kept all newborns in NBCCs after birth.
Out of the total newborns kept in NBCCs, 23.5% were resuscitated and only a few (1.7%) were referred to SNCU [Table 2]. It is important to note that data on the number of newborns resuscitated were reported by only 44 facilities; 8 facilities reported zero figures and no records were available in 5 facilities.
Equipment and supplies
Neonatal equipment were available and functional in most of the NBCCs. Major gap between availability and functional status was observed for oxygen concentrator (92.9% vs. 74.1%) followed by radiant warmer (98.2% vs. 80.4%) and suction machine (84.2% vs. 85.4%). Nearly 75.4% of the NBCCs share voltage stabilizers. Annual maintenance contract (AMC) was not provisioned for almost all of the equipment [Table 3].
Essential drugs such as adrenaline and Vitamin K injection were not available in majority of the NBCCs. Almost all consumables were available in majority of the selected facilities except baby wrapping towel [Table 4].
Human resources availability
Availability of skilled health-care staff is the key for quality service provision. There were 232 medical officers, 359 staff nurses (SNs)/auxiliary nurse midwives (ANMs), and 82 ancillary staff. The observation revealed that not all medical and paramedical staff were trained in essential newborn care. Out of those available, 66.4% medical officers, 72.7% SNs/ANMs, and 62.2% ancillary staff were trained.
Despite receiving training, approximately, 20% of the medical officers and 15% of the SNs/ANMs were not able to use essential newborn care equipment such as Ambu bag, radiant warmer, oxygen concentrator, and suction machine. Moreover, they were not able to weigh the newborn correctly. It was also observed that trained ANMs were frequently transferred/interchanged between the health facilities affecting the provision of services. Almost all the ancillary staff showed satisfactory skills after training and were able to handle the bio-medical waste management process.
Adherence to protocols and standard operating procedures
The required standard operating procedures (SOPs) were not present in all the NBCCs. Besides availability, the display of these protocols was not as per the guidelines. Even if displayed, many were found to be faded and/or torn. One of the most important protocols for infection prevention, i.e., hand washing was not available in 21.6% of the NBCCs. Observations indicated that more than availability, it was the practice of adherence to the protocols, which needed improvement. Adherence to the protocols ranged between 55% and 75%. It was highest for breastfeeding protocol (75.4%) and lowest for bio-medical waste management (56.1%).
Recording and reporting
The assessment revealed that equipment register was not available in majority of the NBCCs (77.2%). Almost all the NBCCs (89.4%) were reporting the data on a monthly basis. Nearly 10% of the NBCCs were not reporting at all.
| Discussion|| |
This study is a cross-sectional assessment of the availability and quality of essential newborn care services delivered at NBCCs in selected facilities with high delivery load across 25 districts of Bihar.
Most of the NBCCs were either partially functional (68.4%) or nonfunctional (9%) highlighting the major gaps in providing essential newborn care at the primary and secondary level health facilities. Deficiencies were noted with regard to location of the NBCCs in the facility, availability of skilled human resource, supply of essential drugs and consumables, functionality of equipment, availability and adherence to SOPs, and recording and reporting of the data. Similar to the present findings, a quality assurance model study in Bihar also reported the infrastructural gaps in majority (63%) of the districts. The study reported that nearly 25% of the facilities had their NBCCs located outside the labor rooms, which defeated the purpose of having one. As per the quarterly monitoring report by the SHSB, in the year 2012, approximately, half of the NBCCs were found to be located outside the labor room. In the current study, this proportion has reduced to 35.1%. This indicates a positive change in the provision of essential newborn care services, although gradual, over a period of 3 years. In addition, it is possible that the facilities selected for the present study may be different from the ones selected for monitoring by the SHSB in 2012.
The study districts catering to a total of 47,636 deliveries in previous quarter reported that 6% of the total newborns were born with LBW. This estimate is significantly lower than the reported figures from the Annual Health Survey 2012–2013 for Bihar state, according to which 21.9% of the children in Bihar are born with birth weight of <2.5 kg. This gross discrepancy points toward issues related to the practice of weighing all newborns, availability and functionality of calibrated weighing machines at the facilities, as well as accuracy of recording and reporting of birth weight. This reflects on the need to improve and maintain the upkeep of equipment for essential newborn care at the facilities, adherence to SOPs and monitoring and supervision of service delivery at the facilities. Further, the proportion of newborns requiring referral was quite less (2%) as against the standard estimates of about 10%–15% newborns requiring level II care, i.e., admission to SNCU after having a complication. The study results reveal issues either with the recording of data related to referrals or lack of referral linkages with higher facilities, which need to be strengthened. In an earlier study conducted in Bihar, it was observed that the implementation of referral policy was challenging given the absence of display of protocols, absence of clear admission and referral guidelines, nonavailability of vehicles, refusal by the families to take their newborns to higher level facilities, and absence of financial support.
Suboptimal newborn care service delivery highlights two major issues: lack of availability of staff in the facilities and lack of competence among available staff to deliver essential newborn care. Many trained staff members were not able to demonstrate the correct use of Ambu bag, a potential lifesaving device, as also some of the other newborn care equipment in the NBCCs. Huge deficiencies in performance skills among all cadres of personnel have also been reported from other studies.,,,, Although the available staff members get trained on various aspects of child health, this cannot translate into improved quality of services, owing to the shortage of staff at the facilities in proportion to the delivery load and complications demanding immediate management. Shifting of trained health-care workers from one facility to the other was another factor responsible for the shortage of trained staff. Although the health-care workers have gone through many training programs during the past few years, yet they are not able to achieve the required competencies. Therefore, the process of capacity building needs to be reviewed to appropriately design need-based training package for different levels of health-care personnel. The facility-based refresher training programs and posttraining follow-ups should be ensured through institutional mechanisms.
Although with the launch of the NRHM, the availability of the equipment has been taken care of, their functionality and maintenance have still remained a concern. This warrants attention toward need for the provision of AMC to maintain the functionality of neonatal care equipment. Other logistics should also be in tandem with provisions for newborn care. Previous assessment of essential newborn care units also raised a similar concern that nonfunctional equipment results either in suboptimal or nonutilization of NBCCs in most of the facilities.,, Although the phototherapy units have an important role to play in the management of neonatal jaundice, their requirement in NBCCs is negligible. However, during this assessment, it was observed that phototherapy units were available in many NBCCs at the PHCs which eventually remain nonutilized and hence, a wastage of valuable equipment.
During this assessment, the absence of essential drugs such as adrenaline was quite alarming since this drug should be available in all facilities and at all times to handle emergencies. Furthermore, as per the national guidelines for the administration of injection, Vitamin K is mandatory for all newborns; however, this was not available in a majority of the facilities at the time of the assessment. In addition, as far as the consumables are concerned, most of them were available except for the baby wrapping towel, a very critical item to be used soon after birth. These findings indicate the need for strengthening of management of drugs and consumables.
Further, suboptimal data recording and reporting echo the need to strengthen the health management information system in the state. This has a bearing on the overall statistics related to performance indicators which serve as yardsticks for further improvement.
While availability of newborn care facilities continues to be an issue, focus is now also on functionality and utilization. This study is a first of its kind, wherein the assessment of NBCCs has been conducted and analyzed across a vast majority of districts involving large number of facilities at different levels. However, this assessment focused only on certain structural aspects related to NBCCs; knowledge, skills, behaviors, and practices related to essential newborn care were not assessed. Another limitation was that we could not assess the trends of availability, functionality, and utilization of either of these parameters over a period of time as this was a cross-sectional study. Although almost two thirds of the districts across the state were included in the assessment, they may not be representative of the remaining districts in the state.
| Conclusion|| |
Under the aegis of the NHM, there has been a significant progress in the provision of services with regard to newborn care. This study highlights the further scope in improvement in the functioning of NBCCs, not only in Bihar but also in other similar settings. The network of NBCCs needs to be strengthened across the state and linked with higher facilities to achieve the desired reduction in neonatal morbidity and mortality. The available resources should also be utilized effectively to strengthen NBSUs and SNCUs across the state to maximize the gains. The momentum gained as a result of these efforts needs to be accelerated further to realize the desired goals.
Financial support and sponsorship
Financial support for the study was provided by UNICEF Bihar.
Conflicts of interest
Ghanashyam Sethy and Siddharth Reddy are affiliated to UNICEF Bihar (sponsor of the study and supplement). The views expressed in this paper are those of individuals and not of the organizations they represent.
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[Table 1], [Table 2], [Table 3], [Table 4]
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