Emergency Obstrics Care

8/8/2019 Emergency Obstrics Care

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Emergency Obstetric Care (EmOC) at CHC of WardhaDistrict of Maharashtra State

A Project Proposal Submitted to

CHSJ, New DelhiPopulation Leadership program University of Washington,

Seattle, USAUNFPA India

Submitted by

Datta Meghe Institute of Medical Sciences UniversiySawangi (Meghe), Wardha

Maharashtra, India


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I N D E X

Sr No Content Page no

1 Introduction 1 2 Evaluation Question / Sub question / Objectives 2


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Emergency Obstetric Care (EmOC) at CHC of Wardha District ofMaharashtra State

Background:

Health care delivery in India has been envisaged at three levels namely primary,secondary and tertiary. The Community Health Centres (CHCs) which constitutethe secondary level of health care were designed to provide referral as well asspecialist health care to the rural population.

CHCs are established and maintained by the State Governments. Manned byfour specialists i.e. Surgeon, Physician, Gynecologist and pediatrician andsupported by 21 paramedical and other staff, a CHC has 30 indoor beds withone OT, X ray facility, a labour room and laboratory facility. It serves as a referralcentre for 4 PHCs. CHC thus catering to approximately 80,000 population intribal / hilly areas and 1, 20,000 population in plain areas. Currently there are

3222 Community Health Centres in the country and 8 in Wardha District ofMaharashtra state.

Service delivery in CHCs: Every CHC has to provide the following serviceswhich can be known as the Assured Services: 1. Care of routine and emergency cases in surgery:

This includes Incision and drainage, and surgery for Hernia, hydrocele,Appendicitis, haemorrhoids, fistula, etc. Handling of emergencies likeintestinal obstruction, haemorrhage, etc.

2. Care of routine and emergency cases in medicine:Specific mention is being made of handling of all emergencies in relation tothe National Health Programmes as per guidelines like DengueHaemorrhagic fever, cerebral malaria, etc. Appropriate guidelines are alreadyavailable under each programme, which should be compiled in a singlemanual.

3. 24-hour delivery services including normal and assisted deliveries4. Essential and Emergency Obstetric Care including surgical interventions like 5.Caesarean Sections and other medical interventions6. Full range of family planning services including Laproscopic Services7. Safe Abortion Services8. New-born Care9. Routine and Emergency Care of sick children10. Other management like nasal packing, tracheostomy, foreign body removal etc

11. All national health programs12. Facility for blood storageThese centres are however fulfilling the tasks entrusted to them only to a limitedextent. The launch of the National Rural Health Mission (NRHM) gives us theopportunity to have a fresh look at their functioning. We undertook this rapidassessment to find out of the CHC in Wardha District of Maharashtra state meetthe standards of NRHM.


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Evaluation Question:

Did the CHC / SDH for Wardha District of Maharashtra State meet theexpectation of NRHM with regards to EmOC?

Objectives (sub questions):1. Does the CHC/SDH of the meet the Indian Public Health Standard

given of NRHM for providing EmOC?2. What is the current utilization pattern of OB services with special

reference to EmOC at CHC/SDH?3. What are the constraints or facilitators in providing the EmOC at and

CHC/SDH level? (providers perspective)4. What are the barriers or facilitators for accessing the EmOC at

different levels? (clients perspective)

Operational definitions:

All the Definition will be as per the NRHM guidelines / Concept note

EmOC - are defined as Basic EmOC and Comprehensive EmOC

1. Basic EmOC: It is defined as obstetric care facilities available round theclock through out the year at the center with regards to

a. Parenteral administration of Antbioticb. Parenteral administration of Anticonvulsantsc. Parenteral administration of Oxytocicsd. Assisted Vaginal deliverye. Manual removal of Placenta.f. Removal of retained products of conception

2. Comprehensive EmOC: It is defined as obstetric care facilities availableround the clock through out the year at the center with regards to

a. Parenteral administration of Antbioticb. Parenteral administration of Anticonvulsantsc. Parenteral administration of Oxytocicsd. Assisted Vaginal deliverye. Manual removal of Placenta.f. Removal of retained products of conceptiong. Availability of blood and blood transfusion facility.h. Facility for Caesarian section for delivery of foetus in emergency

cases


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CHC:

CHCs are established and maintained by the State Governments. Manned byfour specialists i.e. Surgeon, Physician, Gynecologist and pediatrician andsupported by 21 paramedical and other staff, a CHC has 30 indoor beds with

one OT, X ray facility, a labour room and laboratory facility. It serves as areferral centre for 4 PHCs.

Geographical Boundaries:

The proposed work rapid assessment will be conducted in 2 BLOCKS (Taluka) of Wardha District of Maharashtra State, India.

Study design:

This will be a cross-sectional study.Stakeholders and means for reaching them:

1. Civil Surgeon through appointment2. Medical Superintendent or In-charge of CHC/SDH or doctors at

CHC/SDH after approval from CS and through appointments3. Nurses : approval through MS/Officiating In-charge4. Mothers (who availed EmOC in last one year) List will procured through

CHC and they will be reached through Anganwadi worker at their homes(villages)

5. Community leader: in community through Pahchayat Samiti (BlockDevelopment Officer) or Panchayati Raj Institutions of the respectivevillage.

6. Doctors from Private sector- directly approaching them priorappointment will be taken.

Population and Phenomenon:

Population: Beneficiaries (mothers/couple who received EmOC services)Providers of EmOC at CHC/SDH

Phenomenon: EmOC Services at CHC/SDH

Ethical issue / Consent:

Study protocol will be get approved by the IRB before commencing the study.


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Data Elements (Variables)

(Note: Detail schedule is in annexure ____)

Mothers (Beneficiaries):

Predictors /independent variables1. Age of the respondents2. Education (of respondent and husband)3. Residence (distance from the nearest CHC/SDH)4. Income: (monthly per capita income)5. Family type:6. Age at marriage:7. Children ever born8. Number of living children Boy(s): Girl(s)9. Registered for ANC for recent pregnancy: (if Yes, where, which

trimester. Services received, whether identified as high risk, knewbefore hand where to go for delivery)

Main outcome variables:10. Delivery place:11. Pattern of referral (visit to various Health Care Providers) for OB

care and expenses incurred from detection of pregnancy tilldelivery.

12. EmOC received at CHC/SHD: (if yes, what services received)13. Delivery outcome14. Are you satisfied with the services received: (Likert Scale)

Provider (CS/MS/MO/In-charge):Predictors /independent variables

1. Age2. Highest level of qualification3. Designation4. Place of work (name of CHC)5. Experience (total and at current CHC/SDH)6. What are the EmOC services proposed by the NRHM at CHC level7. Is your staff trained in EmOC? If yes, where? what type of training

(curriculum/duration etc)? who trained them?Main outcome variables:

8. Do you receive patients for EmOC at your CHC/SDH? If yes,usually from which area / region?

9. Roughly what proportion of the ANC received EmOC at yourCHC/SDH in last 6 months or one year?

10. What are the constraints for providing EmOC at your center? Is itpossible to provide EmOC at your CHC level?

11. Are you satisfied with the EmOC provided through your CHC/SDH?12. What more would you need to provide EmOC better?


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Observational checklist: Annexure ___ (ref NRHM, IPHS standard for CHC level)

Secondary Data:Proportion (total) patients who received EmOC services at CHC/SDH?

Characteristics of patients receiving these servicesGeographical area from where the CHC is receiving the patients forEmOC

Data Collection Methods:

Key Informant Interview - CS/MS/Doc/Local leaderFGDIn-depth Interview /tracking the events Mother (User)Observation checklist facilitiesRecord revives (of CHC/SDH) for secondary data

Data Collection Instrument: (annexure -)Guides for InterviewChecklist for observationChecklist for extracting secondary data

Matrix for information needed to address the issues (answer research

question), its source and respondents

Issues Interview(29)

Observation/ Checklist

(2)

FGD(2)

Secondary datareview

(1 Dist.+2 Block)EmOC facilities atCHC as per theNRHM Standards

CHC (2) Review of districtdata

current utilizationpattern of EmOCat CHC

Review of DistrictMIS and 2 CHC

records(2 blocks)

Facilitators &barriers forproviding EmOC

CS (1)MO I/C of CHC (4)

PP (4)Facilitators &barriers forAccessing EmOC

Mothers (16)Local leader (4)

Mother(2)

Figures in parenthesis are quantity of activities


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Network Dynamics for field work:

Objective: To have a fastest mode of communication between various level and

solving problems

Network structure:

Networking in field :

Level Manpower per team No of teams

1 Field Level One SIThree RA

1

2 DMIMSU Principal investigatorSupport Staff

-

3 - CHSJ New Delhi -

1. Field Level

2 RCO

3. CCO

Day 1 SI & 3 RA - Meetings &Preparations

Day 2 3 RA Observation of facility

SI - Interview of 1 M/SDay 3 SI Secondary data collection &

Record review1st RA - 2 Community Leaders2nd & 3 rd RA Interview of 8 user mother

Day 4 to Day 7 All RA - 2 FGDSI - Interview of PP - 1

SI will check the all schedule for completeness and signTransfer the schedule to RCO & log sheet aftercompletion of block

Will receive the schedule on Saturday of each week andcheck the schedule for the completeness

Tran scripter will check the transcript and triangulate thewritten one with the recorded one

Update RCO Dailyevening at 6.00 pmby telephone aboutthe status of work.Communicateproblem if anyDispatch scheduleon eight day toRCO

Receivehe call

daily andsort outproblemf any

Feedback o fieldeam

Update CCO on emailweekly about the status

Communicate problem if any

Send log sheet on firstMonda of each month

Feed-back


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HUMAN RESOURCE:

Sr N Position Post % effort in project

1 Principal Investigator 1 10

2 Co Investigator (one for each field team& total two field team)

2 50

3 Research Associates (Three for eachfield team & total two field team) 3 100


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central coordinating office(CCO) dailySchedules will be check for completenessData will be collated at CCOData will be analyzed at CCO

complete and consistent# schedule complied andanalysis done

Report writing Preparing the draft reportGet if vetted from the maincoordinating center Prepared a final report &dissemination

Final report ready for thedissemination

Time line

Activities M1 2 3

Linkages and coordination with Main coordinating office (CHSJ)Development of the Data Collection tools and pilot testing.Finalization / plan of the field workTaking needed approvals (IRB and District health officials)Selection and training the research associates (RA)Key Informant Interview CS/MS/Doc/Local leaderIn-depth Interview /tracking the events Mother (User)Observation checklist facilitiesRecord review (of CHC/SDH) for secondary data

Data Compilation and analysisReport writing


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* User of the services

** Non User of the services

DeliveryOccur

Availed *EmOC

Do Notavail

EmOC

Place of EmOC

Need**EmOC

Do NotNeed

EmOC

?

? - Reason / Barrie

Yes

Yes - Reason for u

CONCEPTUAL FRAMEWORK


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Threats for evaluation: (measure to overcome)

1. Instrument error instrument will be pilot tested. Final instrument willbe translated in local language and then retranslated into English.

2. Interviewer Bias Will be overcome by training the interviewer for

common understanding of the study objectives and hands onexperience for data collection.3. Recall bias for mother however since the event is from last one year

and very much related life of the women we assume the recall biascould be minimum.

Storage of data

Optimum care will be taken for storage safety of data and will be taken from thestart of the study from carrying to the field of the proformas/ interview forms/ taperecorder to coming back from the field in the appropriate files in the bag.

Analysis plan:

The data entry, processing and analyzing data will be done using SPSSpackage.

1. Data Coding: Before entering data, the raw information will betransformed for tabulation and analysis. Non-numerical data that are to beanalyzed quantitatively will be converted into numerical codes. Qualitativedata will be analyzed appropriately.

2. Data Entry and Editing Coded data need to be entered into the computer with a minimum oftyping errors and then edited to correct any errors in the data.

To ensure data quality: Researcher will verify the data and check for thefollowing types of errors:

1. Omissions2. Illegal Codes3. Logical Inconsistencies4. Improbabilities

Field editing will always be done by the supervisors whenever there is a chancethat the error can be converted by talking with the data gatherer or perhaps re-interviewing the respondent for clarification.

Variable transformation1. Recodes2. Counts3. Conditional Transformation4. Other Mathematical Transformation

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Emergency Obstrics Care