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Essential Newborn Care (ENC) services
- Bihar Experiences
State Health Society Bihar
National Review on Child Health
22-23 October 2012
BIHAR TEAM
Our Challenges
State Health Society Bihar
OUR CHALLANGES
Gaps in Infrastructure
(as per IPHS )
Health Institutions Required Present Shortfall
Medical Colleges 18 11 7 (39%)
District Hospitals 38 36 2 (6%)
Sub-Divisional
Hospitals 101 76 25(25%)
Referral Hospital 622 70 552 (88%)
PHC 2489 533 1956 (78%)
Additional PHC 2787 1243 1544 (55%)
Sub-Health
Centers 16576 8858 7718 (46%)
Source ; SHSB
Trend of IMR in Bihar
61 60
58
56
52
48
44
0
10
20
30
40
50
60
70
2005 2006 2007 2008 2009 2010 2011
State Health Society Bihar
Source ; SRS
Background
2010-Year of Newborn :
A defining YEAR for NB in Bihar
• A number of initiatives aimed at
improving the newborn care
facilities in the Bihar
• Setting up SNCU, NBSU, NBCC
has been a part of these initiatives
• KEY Initiative : All Health Facilities
in the state provide Essential
Newborn Care services through
NBCC and have Mamta workers
Declaration by Hon’ble Chief Minister Bihar,
Shri Nitish Kumarji on 25th Feb. 2010
State Health Society Bihar
So far there are 11 SCNUs, 1 NBSU and 464 NBCCs have been set up in
the state
27 SCNUs,41 NSUs and 50 NBCCs are in the process of getting set up by
the state government
Initiatives institutionalized
State level Newborn Care Committee
headed by Health Secretary and District
Newborn care Core Committees formed
in all districts for coordination of all
activities for newborn care.
State Health Society Bihar
State government provided Newborn
Kit to all mothers in government
hospitals(Baby Shirt; Baby Bed
Sheet; Baby Blanket; Baby Napkin;
Sanitary Pads for mother)
Initiatives institutionalized...cont..
Introduction of Labour Room Registers in all
Facilities conducting delivery to record the
information related to mother and newborns
State Health Society Bihar
MIS for SNCU set up and
SCNU Registers
Introduction of NBCC Registers in all
Facilities conducting delivery to record the
information related to newborns
Newborn Care Corner (NBCC) operational
status
46
164
464
0
100
200
300
400
500
600
2010 2011 2012 (April)
No of NBCC operational Expon. (No of NBCC operational)
Source: Monthly NBCC report
External Monitoring report
The Stepping Stones
2010 Year of Advocacy
State’s Year of Newborn
2011 Year of Establishment
Setting up of SNCU, NBSU
and NBCC
2012 Year of Consolidation
Quality Management
of FBNC
State Health Society Bihar
QM in FBNC
Immediate objective
– To provide quality services to newborn through FBNC in the state.
Long term goal
– Develop a pool of doctors, nurses and managers having the knowledge and
skill for running a FBNC.
– Develop a pool of Technical Quality Supervisors (TQS) capable of
providing monitoring and supervision support to FBNCs.
– Develop Medical colleges as the hub of newborn care and regional
centres of excellence for newborn care capable of training and mentoring
new generation of doctors, nurses and managers on newborn care.
State Health Society Bihar
Strategy: Quality Assurance Initiatives
Assuring quality with internal
intervention
• Internal QA by the practicing
staffs (MOs / Staff nurses /
ancillary staffs) themselves
using a protocol checklist –
Self-Assessment Tool (SAT)
This serves the dual purpose of on
the job capacity development of the
staff as well as monitoring and
reporting on QA.
Assuring quality with external
intervention
• External monitoring for QA done
using an External Assessment
Tool (ExAT) by RPMU, SIHFW,
MC who have been successfully
practicing the protocols of QA
This helps validation of the
protocols followed by the internal
staff as well as sharing of good
practices and cross learning.
State Health Society Bihar
Quality Assurance
Quality Assessment Quality
Improvement
Systematic
monitoring
Identify gaps –
recommend action Follow up on
recommendations
Quality Assurance Model
State Health Society Bihar
Protocol Indicators
INPUT PROCESSES OUTPUT
• Infrastructure
• Staff- training
• Posting incentives
• Equipment- O&M
• Drugs and
consumables
• Hand holding /
mentoring support
• Adherence to protocol and
guidelines
• Hand washing- before entering
and touching every baby
• Client provider interaction
• Record Keeping
• On the job training of staff
• Timely action for repair of the
equipment
• Breast feeding of admitted babies
• KMC
• Providers’ perspective-
(Quality)
Admission rates
Morbidit
Mortality
Referral to higher
centres
LAMA
• Clients’ perspective-
(Satisfaction)
Care provided by staff
Treatment
Behavior
Expenditure on
treatment
State Health Society Bihar
Scheme
SAT-based
Internal
assessment
Report
identifying action
points
Compilation of all SATs
generates action for
the CS/DHS
Action required at
the state level
intimated to SHS
Conduct Quarterly
visits to all facilities
using External
Assessment Tool
(ExAT)
Analyze and validate monthly SAT reports.
Provides mentoring support.
Quarterly consolidated report prepared
containing the recommendations of SAT and QAT
reports
Tagging of local Health
Officials with the TQS
resulted in their gradual
capacity development
Medical College as Hub of Newborn
Care (operate as the Secretariat of
QAFBNC, training, verbal autopsy)
Internal exercise
The journey so far
• QA being practiced internally in 11 SNCUs, 1 NBSU and 464 NBCCs
• A pool of TQS created (RPMU/MC/SIHFW/SHS/STF)- 82 State & 150
District (2 MOs & 2 SNs /district)
• All these facilities being monitored externally for validation of
adherence to protocols and providing hand holding support
– Cross sharing and learning across the state through quarterly documentation of
outcome of internal and external QA mechanisms.
– Quarterly grading of facilities (one of the key indicator for ranking of districts in
Bihar)
• Hub in MC
• UNICEF supported State Task Force for QA-FBNC providing technical
support at all levels.
State Health Society Bihar
Essential criteria for Grading of NBCC
Functional status of
equipment
Following five neonatal equipment along with Voltage Stabilizer need to be
in working condition
1. Radiant Warmer
2. Oxygen Concentrator
3. Suction Machine
4. AMBU Bag
5. Weighing Scale
Availability of Trained and
Skilled staff
All staff need to be trained on NSSK/NBCC training and Possess the required
skill for handling newborn babies
(Skills are assessed by direct observation & demonstration on mannequin)
Asepsis maintained &
Adherence to protocols
Cleansing of labor room and NBCC areas at least 3 times daily and NBCC
equipment once daily
Staff need to practice at least the following 5 protocols:
1. Hand wash
2. Resuscitation
3. KMC
4. Breast Feeding (EBF, position)
5. BMW management
Proper Record keeping
Timely &Complete reporting to
SHS
Maintaining and updating NBCC register & sending report monthly to
SHS
Care of Baby (Essential
Newborn Care)
1. Early initiation of breastfeeding
2. Weighing the newborn
3. Provision of Warmth (Drying & wrapping, KMC, delayed bathing)
4. Prevention of infection (hygienic cord care/eye care)
5. Immunization (Birth dose Polio, BCG and Hepatitis-B)
Availability of Essential Life
Saving drugs
NBCCs should have at least these 5 essential drugs
1.Adrenaline
2. Normal Saline
3. Inj. Vitamin-K
4. Dextrose 5% or 10%
5.Inj. Antibiotics
Availability of Consumables
NBCCs need to have the following items
1. Sterile Gloves
2. Disposable Syringes & Needle
3.Baby Wrapping towel
4. Soap & Towel for wash basin
5. Color coded bags & bins
Essential criteria for Grading of NBCCs…..cont…
Grading of NBCCs/Facilities -
3 categories with color coding
Fully Functional
(Fulfilling all 5 criteria)
A. Newborn Care: Newborn babies provided with Essential
Newborn Care
B. Other parameters
1. Equipment : All equipment are functional
2. Human Resources :All staff are trained & skilled
3. Adherence to Protocol :Asepsis maintained & Protocols
followed strictly
4. Records & reports :Record keeping good & report sent to SHS
regularly
Partially Functional
A. Newborn Care: Newborn babies provided with Essential Newborn
Care
B. Problem in anyone of the above B criteria.
Non-Functional Babies NOT provided with ENC
But equipment/ trained HR/ other logistics available
Grading: 1st Quarter Vs 2nd Quarter of 2012
Sl.
No. Status April 2012 Sept 2012 Change
1 Fully Functional 125 (27%) 167(36%)
2 Partially Functional 311 (67%) 288 (62%)
3 Non-Functional 28 (6%) 9 (2%)
Total 464 464
State Health Society Bihar
Overall changes-Functional Status
Sr
No
Major changes in Functional Status Number of
NBCC
comment
1 Upgraded from Partial to Fully
functional NBCC 48
2 Upgraded from Non-functional to
Partial Functional NBCC 19
3 Downgraded from Fully to Partial
functional NBCC 6 Mainly due to non-
functional neonatal
equipment
4 Downgraded to Non-Functional NBCCs
0
State Health Society Bihar
Findings: 1st Quarter Vs 2nd Quarter
Newborns reached
State Health Society Bihar
1 Total number of Live Birth 1,53,152
a
No. of Babies received Initial Steps of
Resuscitation56200 (36%)
b
No. of Babies received Bag and Mask
Ventilation11704 (7.6%)
c No. of Babies referred to higher facility 1169
2 Total number of Still Birth 2835
3 Total number of Newborn Death 363
Source : MPR-NBCC , SHSB
Newborn Care at NBCCs- Apr to June 2012
Source: Reported data (YNB format) for 2010
NBCC Monitoring & Mentoring Report
Early Initiation of breastfeeding
….within one hour of birth
39
72 79
0
10
20
30
40
50
60
70
80
90
2010-11 Q1 (April 2012) Q2 (Sept 2012)
Early initiation of Breastfeeding
Correct weight recording of Newborn at
Health Facilities
11%
22%
25%
2011 2012 (1st Quarter) 2012 (2nd Quarter)
Correct weight recording at health facility
NBCC Monitoring & Mentoring Report
N- 2918 newborn
Web Based NBCC reporting
State Health Society Bihar UNICEF
Challenges
– Managing facilities where staff nurses are not
available and only ANMs are present.
– Weak O&M support from the suppliers of the
equipment – challenge of spread – 464 NBCC/38
districts/connectivity challenges
– Changing behaviour and age-old practices of staff
– Timely replenishment of Drugs, consumables and
supplies
State Health Society Bihar
State Health Society Bihar UNICEF