operations research to improve 24/7 delivery and emonc services in public facilities by health...

Operations research to improve 24/7 delivery and EmONC

services in public facilities by health systems strengthening in

Bangladesh

A collaborative study among ICDDR,B,

DGHS, DGFP, EngenderHealth, MCHIP/Save the Children,

JHSPH

Date:13.07.2015

Principal Investigator

Mahbub Elahi Chowdhury

Scientist, ICDDR,B

Conceptual framework of the study

Health system input

(filling up the gaps in

infrastructure and

logistical supports

Increased

availability of

providers

Improved

quality of care

Increased

utilization of

delivery and

EmONC services

Policy advocacy to fill

up HR gap

Standard based

monitoring and

recognition (SBM-R)

Sharing of public

providers

Input Output

indicatorOutcome

indicator

Outline of the presentation• Specific objectives

• Methodology

• Preliminary findings of the baseline assessment

Availability of Infrastructure, Essential drugs and Equipment for MNH services

Availability of human resources (HR) based on sanctioned post

Quantity of careService record of last 6 month Daily service statistics (30 days observation)

Quality of care

Scores obtained by the providers of DH in different MNH care services

Availability of providers for MNH care services in 30 days’ observation period Percentage of days with availability of providers by type for MNH care in each

shift (morning, evening, night) Availability of mean number of other support staff for MNH care per shift per day Scoring on availability of providers

• Objective 1a. To test effectiveness of a health system strengthening intervention package (filling up the gaps in infrastructure and logistical supports; sharing/hiring of providers; policy advocacy to fill-up human resource gaps; strengthening of the monitoring and supervision; provision of non-financial group incentives to attain the set targets) in

• Increased availability of providers for offering MNH and

EmONC services at public health facilities

• Increased utilization of delivery and EmONC services • Improved quality of care for different components of EmONC services

Specific objectives

Methodology

Habiganj

1 District Hospital

& 1 MCWC

Study design & sites

Pre-post study design

Study sites

• A four member data collection team divided into two groups is engaged in quantitative data collection. Each data collection group consists of one female medical officer and one person with quantitative background trained in respective field

• Another medical officer was responsible for co-coordinating the overall quantitative data collection activities in the field.

• A team of two members were engaged in qualitative data collection.

Data collection team

• A monitoring and supervision team, consisting of the ICDDR,B investigators made unscheduled field visits to supervise the field activities.

• The qualitative investigator of the study was responsible for overall data collection, monitoring and supervision of the qualitative team.

Monitoring team

Monitoring visit

Data collection procedureBoth baseline and 1st periodic assessments were done in 3 phases for a duration of 30 days

Data collection tools

• EmONC needs assessment (cross-sectional)

− Face-to-face interview by using semi structured questionnaire

− Extraction of service record of last 6 months from registers

• 30 days prospective assessment on HR availability, admission and referral and services

• Assessment of quality of MNH care through observation (using checklist)

− ANC, NVD, PNC, FP services, Sick newborn care, C-section delivery, Maternal complications management, Blood transfusion, Infection prevention

• In depth interviews of program managers, providers and support staffs

Baseline Assessment Phase-1 Assessment

1st phase April 29-May o8, 2014 April 15-April24, 2015

2nd phase May 18-May 27, 2014 May 01-May 10, 2015

3rd phase June 07-June18, 2014 May 15-May 24, 2015

Snap shot of data collection

Human resources (HR)

Availability of HR in DH : Medical doctors (No.)

Medical doctorsSanctioned

post

In positionComment

Baseline Phase-1

Sr.Consultant (Obs/Gynae)

1 0 0Jr. Consultants of two UHCs are working through local management

Jr.Consultant (Anaesthesia)

1 0 1

Jr.Consuntant (Paediatrics)

1 2 2One consultant is placed against the post of Jr. Consultant (Eye)

RMO 2 2 1

Medical officer (Pathology)

1 1 1

Anaesthetist 1 1 1

Medical officer (BT) 2 0 0

Medical officer (MO) 14 8 8 One Obs/Gynae specialist One is trained in Obs/Gynae

EMO 3 1 1 Trained in Anaesthesia

Availability of HR in DH : Nurses and other technical staff (No.)

Technical and support staff Sanctioned post

In position EOC training

Baseline Phase-1 Baseline Phase-1

Nursing staffNursing supervisor 2 0 0 - -Senior staff nurse 38 31 28 4 2Staff nurse 16 0 1 - -Staff nurse (MaMoni) 10 10 - -Assistant nurse 5 4 4 - -

Technical staffSACMO 0 1 4 - -Medical Technologist (Lab.) 1 2 2 - -Medical Technologist (Rad.) 1 1 1 - -Medical Technologist (BT) 0 - -Pharmacist 3 2 2 - -

Other support staffDriver 2 2 2 - -MLSS 17 18 18 - -Ward Master 2 0 0 - -Stretcher bearer 4 2 2 - -Guard 4 1 5 - -Aya 10 7 8 - -Sweeper 19 13 14 - -

Quality of care

• Technical competency of the providers for providing commonly performed maternal and newborn health care services were assessed by observation of the related medical procedures using standardized checklists of SBM-R

• These checklists were filled-up by trained female medical officer/paramedic

• In each of the health facilities these observation were done if respective procedure was available within 30 days

• For each of the procedures, the total target was estimated purposively

• Scoring was done as percentage of activities achieved among total number of activities in each procedure

Methodology

Total number of activities observed by procedure

Type of careNumber of activities

observed per procedure (Total score)

ANC 81NVD 253PNC 103Sick newborn care

Preterm/LBW neoenate 20Neonatal sepsis 14Neonatal jaundice 14Umbilical infection

C-section delivery 152Maternal complications management

Incomplete abortion 54Pre-eclampsia/Eclampsia 58PPH 71

Blood transfusion 24Infection prevention 156

Total number of procedures observed by type

Type of careNumber of procedure

observedBaseline Phase-1

ANC 36 36NVD 20 20PNC 20 20Sick newborn care

Preterm/LBW neoenate 4 9Neonatal sepsis 7 7Neonatal jaundice 3 3Umbilical infection - -

C-section delivery 15 15Maternal complications management

Incomplete abortion 6 5Pre-eclampsia/Eclampsia 4 6PPH 5 4

Blood transfusion 10 15Infection prevention 5 5

Level of quality of care for different types of MNH-FP care services in DH

FP serviceANC

NVD

C-section delivery

PNC

Maternal comp. management

Sick newborn care

Blood transfusion

Infection preventio

n

All procedures

0102030405060708090

100

Baseline Phase-1

Per

cent

age

of s

core

Percentage of score obtained in different components of antenatal care by the providers of DH

Component of Antenatal CareDH

Baseline Phase-1

Initial evaluation by the receiver 15.5 9.3

Cordial and respectful receiving by the provider 57.1 33.1

Obstetrical history taking 57.1 54.3

General medical history taking 30.2 24.7

Physical and obstetric examination 15.3 35.4

Individualized care based on findings and protocols 32.7 60.0

Birth planning 1.5 19.9

Care planning 36.1 48.5

Total 25.6 35.6

Percentage of score obtained in different components of normal vaginal delivery by the providers of DH

Components of Normal Vaginal DeliveryDH

Baseline Phase-1Initial assessment 45.6 57.2Explanation of services to be provided 67.9 79.8Review and filling-up the clinical history 55.3 67.3Physical examinations between contractions if time allows 40.1 59.4Obstetric examination between contractions if time allows 58.0 61.0Vaginal examination 62.8 83.5Use of partograph and make adjustments to the birth plan 9.7 17.9Preparation to assist birth 42.7 64.1Assist the woman to have a safe and clean birth 80.8 87.0Initial assessment of the newborn and provides immediate newborn resuscitation if needed 78.6 88.1

Active management of the third stage of labor 63.0 69.4Immediate postpartum care 68.7 90.3Disposal of used instruments and medical waste 43.5 44.0Monitoring of newborn in immediate postpartum period 32.8 53.9Close monitoring of the woman for at least two hours after the birth 49.5 57.7Neonatal resuscitation if needed 86.7 97.5Total 52.6 65.2

Percentage of score obtained in different components of C-section delivery by the providers of DH

Components of C-Section DeliveryDH

Baseline Phase-1

Information to the clients regarding indication, risks and benefit of caesarean section delivery 51.7 75.6

Ensure fitness for surgery through physical and laboratory examinations 52.0 60.0

Preparation of operation theatre and provider for surgery 70.9 77.5Preparation of the patient for surgery 62.9 70.5Provide anaesthesia 84.0 92.4Opening of abdominal layer 84.2 100.0Opening of uterus 90.0 100.0Delivery of baby 80.0 100.0Delivery of the placenta and exploration of the peritoneal cavity 58.1 95.0Closure of the uterus 88.5 86.7Closure of the abdominal wall 98.9 100.0Completion of all post-procedure tasks 55.8 62.7Post-operative monitoring and ensure postnatal care 71.2 64.8Monitoring of newborn in immediate postpartum period 34.1 55.1Resuscitation of newborn if needed - 100.0Total 65.6 76.9

Percentage of score obtained in different components of postnatal care by the providers of DH

Components of Postnatal CareDH

Baseline Phase-1

Initial assessment 35.3 37.0


Verification of existed clinical records or opening of new one by appropriate history taking 41.3 13.5

Routine physical examination 13.6 11.7


Advices on danger signs of postpartum period 6.1 21.6

Referral of mother if needed 50.0 83.3

Assessment of the condition of newborn 25.9 40.1

Management of neonates and show breast feeding position 0.0 0.0

Counseling on care of baby 7.2 22.3

Advices on baby's danger signs 0.0 15.8

Total 19.0 28.1

Percentage of score obtained in different components of maternal complications management by the providers of DH

Components of Maternal Complications Management DH

Baseline Phase-1

General

management

Availability of drugs, equipment and supplies 89.5 82.4

Management of hypovolumic shock 81.9 83.8

Evaluation of patient's response and next step 67.7 70.0

Incomplete abortion Diagnosis of incomplete abortion 90.5 97.6

Management of incomplete abortion 68.8 83.9

Pre-eclampsia/

Eclampsia

Diagnosis of pre-eclampsia/Eclampsia 91.7 100.0

Management of severe pre-eclampsia and/or

eclampsia 76.0 82.4

PPH

Diagnosis of PPH 100.0 100.0

General management of PPH 62.3 86.9

Cause-specific management of PPH 49.0 100.0

Follow-up of the PPH patient 59.9 79.2

Total 77.0 85.0

Percentage of score obtained in different components of sick newborn care by the providers of DH

Sick newborn careDH

Baseline Phase-1

Receiving of the patient and explanation of the condition after history taking

70.0 75.3

Appropriate diagnosis of a pre-term/low birth weight neonate

31.7 75.9

If neonatal sepsis, proper diagnosis and appropriate referral

53.0 81.2

If neonatal jaundice, proper diagnosis and appropriate referral if required

51.9 76.4

If umbilical infection, proper diagnosis and appropriate treatment

- -

Total 54.1 78.4

Percentage of score obtained in different components of blood transfusion by the providers of DH

Components of Blood Transfusion ServicesDH

Baseline Phase-1

Cordial receive of the patient and response to any query 55.0 73.3

Assessment of the donor for fitness of blood donation 75.0 86.7

Blood collection procedure 91.7 91.1

Appropriate blood transfusion procedure 86.8 78.6

Total 80.3 82.3

Percentage of score obtained in different components of infection prevention by the providers of DH

Components of infection preventionDH

Baseline Phase-1Cleanliness of the facility and availability of clean running water 52.6 72.5Process to clean rooms wards and clinical areas 41.7 66.1

Labour room

Storage of equipment for reuse 48.0 76.0

Using of antiseptics 40.0 82.4Instrument cleaning area and prevention of cross-contamination 77.8 91.1

Decontamination of instruments and other articles 56.0 72.0

Process of cleaning instruments and other items 77.1 88.6

OT

Storage of equipment for reuse 80.0 80.0Using of antiseptics 60.0 94.3

Instrument cleaning area and prevention of cross-contamination 86.7 97.8

Decontamination of instruments and other articles 72.0 72.0Process of cleaning instruments and other items 80.0 82.9

Area for wrapping and packing instruments 60.0 100.0Process of packaging instruments and other items to be sterilized 80.0 100.0Sterilization process 71.8 93.2High level disinfection process 90.0 100.0Availability of antiseptics, disinfectants and other supplies 61.4 94.1Collection of soiled linen 26.7 66.7Following of general biosafety and infection prevention practices in the laboratory 97.1 79.5

Total 64.3 83.2

Round the clock availability of provider for

MNH care services

Methodology• Round the clock availability of the providers were assessed by prospectively

assessing availability of each of the members of the MNH team by the three

different time slots i.e.

• Morning (8 am-2 pm)

• Evening (2 pm–9 pm)

• Night (9 pm–8 am)

• The observation were done for 30 days in three phases

• During daytime the timesheets were filled-up the by direct observation

• For presence of the providers in evening and night shift, the time-sheet were filled-

out either by direct observation or by interviewing a provider who was in duty in the

previous night

Availability of medical doctors in DH for attending patients by shift (Baseline)

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Consultant (Obs/Gynae)

(n=1)

Consultant (Paed)

(n=2)

RMO (n=2)

Pathologist (n=1)

Anaesthetist (n=1)

EMO (n=5)

Medical Offi-cer Indoor

(n=1)

Medical Offi-cer Outdoor

(n=2)

0

20

40

60

80

100

Present more than 3 hours Present less than 3 hours

On call but no emergency case On call with attending emergency cases

On call but not attending emergency cases

% o

f day

s ob

serv

ed

Availability of medical doctors in DH for attending patients by shift (Phase-1)M

orni

ng

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Mor

ning

Eve

ning

Nig

ht

Consultant (Obs/Gynae)

(n=2)

Consultant (Paed)

(n=2)

Consultant (Anaes-thesia) (n=1)

RMO (n=1)

Pathologist (n=1)

Anaesthetist (n=1)

EMO (n=4)

MO (Indoor) (n=1)

MO (Out-door)

(n=2)

0

20

40

60

80

100




% o

f d

ays

ob

serv

ed

Availability of medical doctors in different areas of DH for attending patients by shift (Baseline)

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Gynae ward (Cons/MO Indoor)

Paed ward (Both Consul-

tant)

Anaesthesia

(one Anaesthetist)

Gynae outdoor (MO Outdoor)

Paed outdoor (One Consultant)

Emergency (EMO/MO/RMO)

0

20

40

60

80

100




% o

f d

ay

s o

bs

erv

ed

Availability of medical doctors in different areas of DH for attending patients by shift (Phase-1)

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Mo

rnin

g

Eve

nin

g

Nig

ht

Gynae ward (Cons/MO Indoor)

Paed ward (Both Consul-

tant)

Anaesthesia Gynae outdoor (MO Out-

door)

Paed outdoor (One Consul-

tant)

Emergency (EMO/MO/RMO)

0

20

40

60

80

100

Present more than 3 hours Present less than 3 hoursOn call but no emergency case On call with attending emergency casesOn call but not attending emergency cases

% o

f da

ys o

bse

rve

d

Baseline Phase-1

Availability of Senior Staff nurses in Obs/Gynae ward

Morning Evening Night0

20

40

60

80

100

3 Nurses 2 Nurses 1 Nurse No Nurse

% o

f d

ay

s o

bs

erv

ed


20

40

60

80

100


% o

f d

ay

s o

bs

erv

ed

Baseline Phase-1

Availability of project-hired (MaMoni) nurses in Obs/Gynae ward


20

40

60

80

100

3 Nurses 2 Nurses 1 Nurse

% o

f d

ay

s o

bs

erv

ed


20

40

60

80

100


% o

f d

ay

s o

bs

erv

ed

Availability of nurses (combined) in Obs/Gynae ward


20

40

60

80

100

4+ Nurses 3 Nurses 2 Nurses 1 Nurse

% o

f d

ay

s o

bs

erv

ed


20

40

60

80

100

4+ Nurses 3 Nurses 2 Nurses 1 Nurse

% o

f d

ay

s o

bs

erv

ed

Baseline Phase-1

Baseline Phase-1

Availability of Senior Staff nurses in paediatrics ward


20

40

60

80

100

1 Nurse No Nurse

% o

f d

ay

s o

bs

erv

ed


20

40

60

80

100

2 Nurses 1 Nurse No Nurse

% o

f d

ay

s o

bs

erv

ed

Baseline Phase-1

Availability of Project-hired (MaMoni) nurses in paediatrics ward


20

40

60

80

100


% o

f d

ay

s o

bs

erv

ed


20

40

60

80

100


% o

f d

ay

s o

bs

erv

ed

Availability of nurses (combined) in paediatrics ward


20

40

60

80

100

3 Nurses 2 Nurses 1 Nurse

% o

f d

ay

s o

bs

erv

ed

Baseline


20

40

60

80

100

3 Nurses 2 Nurses 1 Nurse%

of

da

ys

ob

se

rve

d

Phase-1

Availability of Govt. nurses in OT


20

40

60

80

100

2 Nurses present 1 Nurse present 2 Nurses on call1 Nurse on call

% o

f d

ay

s o

bs

erv

ed


20

40

60

80

100

2 Nurses present 1 Nurse present

2 Nurses On-call 2 Nurses attending emergencies

1 Nurse attending emergencies

% o

f d

ay

s o

bs

erv

ed

Baseline Phase-1

Availability of other technical staff in DH (Baseline)

Morning Evening Night Morning Evening Night Morning Evening NightMedical Technologist (Lab/BT) Pharmacist Driver

0

20

40

60

80

100

Present On call but no emergency case On call with attending emergency cases

% o

f d

ay

s o

bs

erv

ed

Availability of other technical staff in DH (Phase-1)

Morning Evening Night Morning Evening Night Morning Evening NightMedical Technologist

(Lab/BT)Pharmacist Driver

0

20

40

60

80

100

Present On call but no emergency case On call with attending emergency cases

% o

f d

ay

s o

bs

erv

ed

Mean number of other support staff per day by shift available in DH

Other support staffMorning Evening Night

Baseline Phase-1 Baseline Phase-1 Baseline Phase-1

MLSS

(obs/gynae ward)0.6 1.00 0.3 1.00 0.2 1.00

Sweeper

(obs/gynae ward)1.0 1.00 1.0 1.00 0.8 1.00

Aya

(obs/gynae ward)0.8 0.76 0.8 0.79 0.8 0.52

Student Nurse

(obs/gynae ward)2.6 3.10 1.4 2.10 0.8 0.67

Student Nurse

(Paediatric ward)1.8 3.15 1.4 2.25 0.6 0.70

Medical doctorsPresent more than 3 hours (100% score) + Presence less than 3 hours (50% score) + Attending call (100 score) - Not attending call (100% score)

Nurses/FWVs for wardMorning shift = Presence of at least 3 nurses (100% score) + Presence of 2 nurses (67% score) +

Presence of presence of 1 nurse (33% score)

Evening shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score)

Night shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score)

Nurses/FWVs for OTPresence of at least 2 nurses/FWVs (100% score) + Presence of 1 nurse/FWV (50% score) + 2 on call nurses/FWVs with attending emergency cases (100% score) + 1 on call nurse/FWV with attending emergency cases (50% score) - On call nurses/FWVs but not attending emergency cases (100% score)

Other technical staff (MT/Pharmacist/ANA/Dai nurse)For each categoryPresence more than 3 hours (100% score)+ Presence less than 3 hours (50% score)+ On call attending emergency cases (100% score) - On call but not attending emergency cases (100% score)

Support staff (MLSS/Aya/Sweeper/Guard)Presence of at least 2 support staff (100 score) + Presence of at least 1 support staff (50% score)

Scoring system for availability of MNH care providers

Score on availability of providers in DH by assessment type

Note: Outdoor department and pharmacy were excluded in calculating availability score as only assigned for morning shift

Baseline Phase-1Medical doctorsGynae ward 40.6 48.9Paed ward 28.9 32.2Emergency 100.0 100.0Anaesthesia 27.2 26.7

Average 49.2 51.9NursesGynae ward 95.8 93.3Paediatrics ward 65.4 68.5OT 31.1 25.6

Average 64.1 62.5Other Technical StaffMedical Technologist (Lab/BT) 84.4 66.7

Other Support Staff

(MLSS/Aya/Sweeper/Guard) 96.67 100.0

Overall Average 63.3 62.4

Score on availability of providers in DH by assessment type (excluding holidays)


Baseline Phase-1Medical doctors Gynae ward 48.8 56.5Paed ward 34.6 40.6Emergency 100.0 100Anaesthesia 30.2 33.3

Average 53.4 57.6NursesGynae ward 96.3 93.7Paediatrics ward 65.6 76.3OT 32.1 31.2

Average 64.7 67.1Other Technical StaffMedical Technologist (Lab/BT) 87.7 71.0

Other Support Staff

(MLSS/Aya/Sweeper/Guard) 96.3 100.0


Achievement of

targets

Type of providers BaselineLevel-I

Target Achieved

Medical doctors 49.2% 51.9%

Nurses 64.1% 62.5%

MT (lab/BT) 84.4% 66.7%

Support Staff 96.7% 100.0%

Overall 63.3% 70.0% 62.4%

Achievement of targets for availability of providers for

24/7 MNH care services in DH

Type of care BaselineLevel-I

Target AchievedFP services - - -

ANC 25.6% 35.6%

NVD 52.6% 65.2%

PNC 19.0% 76.9%

Sick newborn care 54.1% 28.1%

C-section delivery 65.6% 85.0%

Maternal complications management

77.0% 78.4%

Blood transfusion 80.3% 82.3%

Infection prevention 64.3% 83.2%

All procedures 54.8% 70.0% 66.9%

Achievement of targets for quality of care for

MNH services in DH

Findings from MCWC

Human resources (HR)

Name of the postSanctioned

post

In positionComment

Baseline Phase-1

Medical doctorsMO (clinic) 1 1 1 Trained in Obs/Gynae

MO (MCH-FP) 0 1 1Trained in Anaesthesia, Posted in Sadar Upazila FP office, attached in MCWC

Other support staffFWV 2 6 7 All are EOC trained

Staff nurse (Ma-Moni) 0 1 0 Maternity leave but no replacement was done

FMA 1 1 1

ANA/Dai nurse 2 3 3Pharmacist 0 1 1Driver 1 1 1

Peon cum chowkider 1 2 1

Sweeper 1 3 1 Two are temporary staff were found during baseline assessment

Aya 0 1 1Guard 0 4 - Two are from Ansar/VDP

Availability of HR in MCWC (No.)

Quality of care

• Technical competency of the providers for providing commonly performed maternal and newborn health care services were assessed by observation of the related medical procedures using standardized checklists of SBM-R

• These checklists were filled-up by trained female medical officer/paramedic

• In each of the health facilities these observation were done if respective procedure was available within 30 days

• For each of the procedures, the total target was estimated purposively

• Scoring was done as percentage of activities achieved among total number of activities in each procedure

Methodology

Total number of activities observed by procedure

Type of careNumber of activities observed per

procedure (Total score)Birth spacing/FP

Combined oral contraceptive (COC) pill 64Progesteron only pill (POP) -Depot medoxy progrsteron acetate (DMPA) 65Condom 40Insertion of Intra-uterine copper device (IUCD) 61Removal of Intra-uterine copper device (IUCD) 24Emergency contraceptive pill (ECP) -Sterilization 45Implant 58

ANC 81NVD 253PNC 103Sick newborn care

Preterm/LBW neoenate 20Neonatal sepsis 14Neonatal jaundice 14Umbilical infection

C-section delivery 152

Maternal complications management

Incomplete abortion 54Pre-eclampsia/Eclampsia 58PPH 71

Blood transfusion 24Infection prevention 156

Total number of procedures observed by type

Type of careNumber of procedure observed

Baseline Phase-1FP services

Combined oral contraceptive (COC) pill 15 4Progesteron only pill (POP) - - Depot medoxy progrsteron acetate (DMPA) 12 5Condom 8 3Insertion of Intra-uterine copper device (IUCD) 3 2Removal of Intra-uterine copper device (IUCD) 1 1Emergency contraceptive pill (ECP) - -Sterilization 11 8Implant 10 7

ANC 36 36NVD 20 20PNC 18 20Sick newborn care - - C-section delivery 14 15Maternal complications management

Incomplete abortion - 2Pre-eclampsia/Eclampsia - -PPH - -

Blood transfusion 0 2Infection prevention 5 5

Level of quality of care for different types of MNH-FP care services in MCWC

FP service

ANCNVD

C-section delive

ryPNC

Maternal comp. management

Sick newborn ca

re

Blood transfu

sion

Infection preventio

n

All proce

dures0

20

40

60

80

100

Baseline Phase-1

Per

cent

age

of s

core

Percentage of score obtained in different components of birth spacing by the providers of MCWC

Components of FP ServiceMCWC

Baseline Phase-1Counselling technique 39.9 80.3Support client's interest, needs and choice 19.4 70.8Providing information on all birth spacing methods and helping to choose suitable method 5.3 64.8

Counselling clients regarding postpartum contraception and lactational ammenorrhoea method (LAM) 3.7 25.0

Ruling out of the current pregnancy 18.8 85.1Return/follow-up visit of the client 26.6 75.9Combined oral contraceptive (COC) pill 13.6 41.1Progesteron only pill (POP) - - Depot medoxy progrsteron acetate (DMPA) 24.3 59.7Condom 15.0 45.1Insertion of Intra-uterine copper device (IUCD) 34.9 67.7Removal of Intra-uterine copper device (IUCD) 41.7 71.9Emergency contraceptive pill (ECP) Sterilization 36.6 82.2Implant 26.5 89.4Total 23.8 69.6

Percentage of score obtained in different components of antenatal care by the providers of MCWC

Components of Antenatal CareMCWC

Baseline Phase-1

Initial evaluation by the receiver 14.8 53.6


Obstetrical history taking 60.8 66.7

General medical history taking 17.7 37.4

Physical and obstetric examination 57.0 69.1


Birth planning 4.5 22.9

Care planning 48.9 76.7

Total 36.9 57.2

Percentage of score obtained in different components of normal vaginal delivery by the providers of MCWC

Components of Normal Vaginal DeliveryMCWC

Baseline Phase-1Initial assessment 46.7 96.1Explanation of services to be provided 73.6 93.6Review and filling-up the clinical history 57.9 76.6Physical examinations between contractions if time allows 55.7 63.6Obstetric examination between contractions if time allows 72.0 79.0Vaginal examination 74.6 77.3Use of partograph and make adjustments to the birth plan 11.0 42.1Preparation to assist birth 74.5 79.0Assist the woman to have a safe and clean birth 85.8 81.7Initial assessment of the newborn and provides immediate newborn resuscitation if needed 78.4 84.6

Active management of the third stage of labor 71.5 77.4Immediate postpartum care 89.7 90.7Disposal of used instruments and medical waste 76.5 79.0Monitoring of newborn in immediate postpartum period 33.6 60.6Close monitoring of the woman for at least two hours after the birth 54.8 56.7

Neonatal resuscitation if needed 100.0 100.0Total 59.8 72.2

Percentage of score obtained in different components of C-section delivery by the providers of MCWC

Components of C-section DeliveryMCWC

Baseline Phase-1

Information to the clients regarding indication, risks and benefit of caesarean section delivery 65.7 72.8

Ensure fitness for surgery through physical and laboratory examinations 81.4 77.0

Preparation of operation theatre and provider for surgery 83.8 70.0Preparation of the patient for surgery 88.8 74.3Provide anaesthesia 95.5 91.4Opening of abdominal layer 100.0 100.0Opening of uterus 92.0 100.0Delivery of baby 89.8 100.0Delivery of the placenta and exploration of the peritoneal cavity 68.0 93.3Closure of the uterus 96.0 96.7Closure of the abdominal wall 100.0 100.0Completion of all post-procedure tasks 77.7 41.3Post-operative monitoring and ensure postnatal care 79.2 66.2Monitoring of newborn in immediate postpartum period 33.8 50.1Resuscitation of newborn if needed 50.0 - Total 76.5 75.4

Percentage of score obtained in different components of postnatal care by the providers of MCWC

Components of Postnatal CareMCWC

Baseline Phase-1

Initial assessment 29.0 60.4


Verification of existed clinical records or opening of new one by appropriate history taking 19.4 79.2

Routine physical examination 18.3 50.4


Advices on danger signs of postpartum period 13.6 42.8

Referral of mother if needed - 100.0

Assessment of the condition of newborn 14.2 35.5

Management of neonates and show breast feeding position 5.9 26.9

Counseling on care of baby 34.0 43.3

Advices on baby's danger signs 22.0 51.1

Total 24.5 52.2

Percentage of score obtained in different components of maternal complications management by the providers of MCWC

Components of Maternal Complications Management MCWC

Baseline Phase-1

General management

Availability of drugs, equipment and supplies - 78.6

Management of hypovolumic shock - 100.0

Evaluation of patient's response and next step - 70.7

Incomplete abortion

Diagnosis of incomplete abortion - -

Management of incomplete abortion - -

Pre-eclampsia/Eclampsia

Diagnosis of pre-eclampsia/Eclampsia - -

Management of severe pre-eclampsia and/or eclampsia - -

PPH

Diagnosis of PPH - 100.0General management of PPH - 72.9

Cause-specific management of PPH - 85.7

Follow-up of the PPH patient - 79.2Total - 78.7

Percentage of score obtained in different components of blood transfusion by the providers of MCWC

Components of Blood Transfusion ServicesMCWC

Baseline Phase-1

Cordial receive of the patient and response to any query

- 100.0

Assessment of the donor for fitness of blood donation - 87.5

Blood collection procedure - 91.7

Appropriate blood transfusion procedure - 73.3

Total - 85.0

Percentage of score obtained in different components of infection prevention by the providers of MCWC

Components of infection preventionMCWC

Baseline Phase-1Cleanliness of the facility and availability of clean running water 91.2 96.9Process to clean rooms wards and clinical areas 70.4 62.6

Labour room

Storage of equipment for reuse 88.0 84.0Using of antiseptics 62.9 57.1Instrument cleaning area and prevention of cross-contamination 80.0 93.3Decontamination of instruments and other articles 84.0 60.0Process of cleaning instruments and other items 94.3 77.1

OT

Storage of equipment for reuse 100.0 92.0Using of antiseptics 82.9 74.3Instrument cleaning area and prevention of cross-contamination 91.1 88.9Decontamination of instruments and other articles 80.0 68.0Process of cleaning instruments and other items 94.3 89.3

Area for wrapping and packing instruments 66.7 86.7Process of packaging instruments and other items to be sterilized 95.0 100.0Sterilization process 91.6 93.3High level disinfection process 100.0 - Availability of antiseptics, disinfectants and other supplies 78.6 100.0Collection of soiled linen 40.0 53.3Following of general biosafety and infection prevention practices in the laboratory - -

Total 83.0 81.9

Round the clock availability of provider for

MNH care services

Methodology• Round the clock availability of the providers were assessed by prospectively

assessing availability of each of the members of the MNH team by the three

different time slots i.e.

• Morning (8 am-2 pm)

• Evening (2 pm–9 pm)

• Night (9 pm–8 am)

• The observation were done for 30 days in three phases

• During daytime the timesheets were filled-up the by direct observation

• For presence of the providers in evening and night shift, the time-sheet were filled-

out either by direct observation or by interviewing a provider who was in duty in the

previous night

Availability of medical doctors in MCWC for attending patients by shift (Baseline)

Morning Evening Night Morning Evening NightMedical Officer (Clinic) Medical officer (MCH-FP)

0

20

40

60

80

100



% o

f da

ys o

bse

rve

d

Availability of medical doctors in MCWC for attending patients by shift (Phase-1)

Morning Evening Night Morning Evening NightMedical Officer (Clinic) Medical officer (MCH-FP)

0

20

40

60

80

100

Present more than 3 hours Present less than 3 hours On call but no emergency case On call with attending emergency cases

% o

f d

ay

s o

bs

erv

ed

Availability of FWVs in MCWC


20

40

60

80

100

3+ FWVs 2 FWVs 1 FWV

% o

f fa

ys

ob

se

rve

d

Baseline Phase-1


20

40

60

80

100

3+ FWVs 2 FWVs 1 FWV

% o

f d

ay

s o

bs

erv

ed

Availability of other technical staff in MCWC

ANA/Dai nurse

FMA Pharmacist Driver0

20

40

60

80

100

Morning Evening Night

% o

f d

ay

s o

bs

erv

ed

ANA/Dai nurse

FMA Pharmacist Driver0

20

40

60

80

100

Morning Evening Night

% o

f d

ay

s o

bs

erv

ed

Baseline Phase-1

Mean number of other support staff per day by shift available in MCWC

Other support staff

Baseline Phase-1

Morning Evening Night Morning Evening Night

Peon cum Chowkider 0.5 0.5 0.0 1.03 0.27 0.60

Sweeper 1.0 0.5 0.6 1.03 0.53 0.43

Aya 0.5 0.3 0.4 0.37 0.07 0.23

Night Guard 1.7 0.6 1.1 0.93 0.81 0.44

Medical doctorsPresent more than 3 hours (100% score) + Presence less than 3 hours (50% score) + Attending call (100 score) - Not attending call (100% score)

Nurses/FWVs for wardMorning shift = Presence of at least 3 nurses (100% score) + Presence of 2 nurses (67% score) +

Presence of presence of 1 nurse (33% score)

Evening shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score)

Night shift = Presence of at least 2 nurses (100% score) + Presence of 1 nurse (50% score)

Nurses/FWVs for OTPresence of at least 2 nurses/FWVs (100% score) + Presence of 1 nurse/FWV (50% score) + 2 on call nurses/FWVs with attending emergency cases (100% score) + 1 on call nurse/FWV with attending emergency cases (50% score) - On call nurses/FWVs but not attending emergency cases (100% score)

Other technical staff (MT/Pharmacist/ANA/Dai nurse)For each categoryPresence more than 3 hours (100% score)+ Presence less than 3 hours (50% score)+ On call attending emergency cases (100% score) - On call but not attending emergency cases (100% score)

Support staff (MLSS/Aya/Sweeper/Guard)Presence of at least 2 support staff (100 score) + Presence of at least 1 support staff (50% score)

Scoring system for availability of MNH care providers

Score on availability of providers in MCWC by assessment type


Baseline Phase-1

Medical doctors

Obs/Gynae 31.7 34.4

Anaesthesia 36.1 30.0

Average 33.9 32.2

FWVs/Nurse 71.1 66.5

Other Technical Staff

ANA/Dai nurse 63.3 70.0

Other Support Staff

MLSS/Aya/Sweeper/Guard 93.9 87.2


Score on availability of providers in MCWC by assessment type (Excluding holidays)


Baseline Phase-1

Medical doctors

Obs/Gynae 32.1 42.0

Anaesthesia 35.8 39.1

Average 34.0 40.6

FWVs/Nurse 84.8 73.2

Other Technical Staff

ANA/Dai nurse 72.8 69.6

Other Support Staff

MLSS/Aya/Sweeper/Guard 93.2 87.0


Achievement of

targets

Type of providers BaselineLevel-I

Target Achieved

Medical doctors 33.9% 32.2%

FWVs/Nurse 71.1% 66.5%

Other technical staff 63.3% 70.0%

Support Staff 93.9% 87.2%

Overall 59.2% 70.0% 57.6%

Achievement of targets for availability of providers for

24/7 MNH care services in MCWC

Type of care BaselineLevel-I

Target Achieved

FP service 23.8% 69.6%

ANC 36.9% 57.2%

NVD 59.8% 72.2%

PNC 24.5% 75.4%

Sick newborn care - 52.2%

C-section delivery 76.5% 78.7%Maternal complications management -

Blood transfusion - 85.0%

Infection prevention 83.0% 81.9%

All procedures 50.7% 70.0% 71.5%

Achievement of targets for quality of care for

MNH services in MCWC

icddr,b also thanks its Core Donors

Acknowledgements

This project was funded by the Traction project of USAID

operations research to improve 24/7 delivery and emonc services in public facilities by health...

Documents

qualitative data collection

data collection group

overall data collection

member data collection

hr availability

providers of dh

emonc services policy

supervision team