Assessing the quality of care for prevention, identification, and - PowerPoint PPT Presentation

Assessing the quality of care for prevention, identification, and management of maternal and newborn complications at the time of birth: Results from 5 country facility surveys Jim Ricca, MD, MPH Jhpiego

Acknowledgments  Ministries of Health and staff and patients of the study facilities in Ethiopia, Kenya, Madagascar, Rwanda, Tanzania, and Zanzibar  Study teams based in each country  Other U.S.-based study team members: David Cantor, Patricia Gomez, Barbara Rawlins, Heather Rosen, Linda Bartlett, Eva Bazant, Sheena Currie, Rebecca Levine, Bob Bozsa, and Joseph de Graft Johnson  Tandem consulting (Madagascar) 2

MCHIP Quality of Care Survey: QoC MNC Facility assessment examining the Quality of Care for prevention, identification, and management of common serious Maternal and Neonatal Complications at the time of birth, with a focus on:  Post-partum hemorrhage  Severe pre-eclampsia / Eclampsia  Essential newborn care and Resuscitation Current WHO guidelines for ANC and Labor and Delivery were used as the standard of care for assessment, especially the IMPAC series, including Managing Complications in Pregnancy and Childbirth

Objectives of QoC MNC survey 1. Guide quality improvement activities for maternal and newborn care at facility, regional and national levels. 2. Provide baseline estimates for countries to monitor improvements in care. 3. Develop indicators and data collection tools that can be used in multiple countries. 4

Data Collection Instruments  Tool 1: Health worker listing  Tool 2: Facility Inventory  Tool 3: Record review  Tool 4: ANC observation checklist  Tool 5: L&D observation checklist  Tool 6: Health worker interview with maternal and newborn knowledge tests  Tool 7: Policy review/key informant interview 5

QoC-MNC Assessment Countries • MCHIP QoC-MNC assessments implemented in 5 countries plus Zanzibar in 2009-2010 • Assessments in Zimbabwe and Mozambique are planned for 2011 6

Summary of Samples Assessed 597 facilities in 5 countries plus Zanzibar; observed 2164 deliveries and 2617 ANC consultations; interviewed 2440 health workers. Zanzibar Rwanda Mada- Sample Kenya Ethiopia Tanzania Total gascar Facilities 409 19 52 9 72 36 597 - Hospital 52% 100% 23% 56% 58% 75% 53% - Health Center/dispensary 48% 0% 77% 44% 42% 25% 47% Observations of care 2035 318 880 274 604 670 4781 - Deliveries 626 192 489 217 293 347 2164 *Initial assessment 452 107 306 106 187 268 1426 *3rd/4th stage of labor 563 117 415 201 225 288 1809 *Newborn care 571 115 419 203 225 336 1869 - ANC consults 1409 126 391 57 311 323 2617 Health workers 249 79 206 51 146 140 2440 interviewed 7

Data collection using mobile smart phones  Observers used Windows Mobile Smart Phones, for capturing data, enforcing quality checks and sending data 8

PREVENTION AND MANAGEMENT OF PRE- ECLAMPSIA & ECLAMPSIA

Screening for Pre-eclampsia during ANC 100% 71% 50% 90% 80% 70% 31% 29% 60% 50% 27% 40% 30% 20% 10% 0% Ask about headache or Ask about swollen Take client's BP with Both PE/E screening Perform or refer for blurred vision hands or face appropriate technique elements (ask about at urine test least 1 danger sign and Take BP) Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

Screening for PE/E during L&D Partograph use High (70-100%) Low (0-30%) Kenya Medium (40-60%) 100% Ethiopia 80% Tanzania Zanzibar Madagascar 90% Rwanda 80% 70% 60% 31% 50% 29% 25% 40% 30% 8% 20% 10% 0% Asks about signs of Initial blood pressure Both PE/E screening Tests urine for presence BP recorded at least PE/E* check elements of protein every 4hrs (when diastolic <90 mmHg) Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

Key Availability of MgSO4 in Delivery Room MgSO4 No MgSO4 Kenya Ethiopia 72% 16% 57% 70% 16% Hospital Health Center Hospital Health Center Tanzania Zanzibar 83% 75% 60% 47% 35% 67% Hospital Health Center Hospital Health Center Rwanda Madagascar 70% 55% 43% 46% 17% 4% Hospital Health Center

From Policy to Practice: PE/E Constraints Analysis 87% 93% 100% 59% 48% 90% 80% 70% 42% 31% 60% 25% 50% 40% 30% 20% 10% 0% Score for Policy Skilled birth Supervision last 3 Magnesium Score for PE/E Received both Received both attendance months sulfate in DR knowledge PE/E screening PE/E screening elements at ANC elements at L&D Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

PREVENTION & MANAGEMENT OF POSTPARTUM HEMORRHAGE

Practice of AMTSL According to FIGO/ICM Definition 95% Note : Values are additive moving 100% from left to right 90% 56% 80% 45% 70% 29% 60% 50% 40% 30% 20% 10% 0% Any uterotonic given (+) correct timing 1 min (+) Controlled cord traction (+) Uterine massage = FIGO/ICM standard AMTSL Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar * In Kenya, timing is based on data collector’s estimate. All other countries, data collectors recorded actual times for birth and uterotonic administration.

Key Availability of Oxytocin in Delivery Room Oxytocin No oxytocin Kenya Ethiopia 96% 93% 12% 16% 87% 88% 84% Hospital Health Hospital Health Center Center Tanzania Zanzibar 100 100 100 % 76% % % 33% 67% 100 % Hospital Health Center Hospital Health Center Madagascar Rwanda 100 95% % 73% 78% 13% 21% 79% 87% Hospital Health Center Hospital Health Center

From Policy to Practice: PPH Constraints Analysis 96% 84% 93% 100% 90% 59% 80% 70% 29% 60% 41% 50% 40% 30% 20% 10% 0% Score for Policy Skilled birth Supervision last 3 Oxytocin in DR Score for PPH Received AMTSL attendance months knowledge within 1 minute Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

IMMEDIATE NEWBORN CARE AND MANAGEMENT OF BIRTH ASPHYXIA

Observation of Immediate Newborn Care 80% 59% 92% 66% 100% 39% 43% 90% 80% 70% 24% 60% 50% 40% 30% 20% 10% 0% Immediately dries Discards wet towel Cuts cord with Assists the mother Places newborn Ties/clamps cord Essential newborn baby with towel and covers with clean blade (2)* to initiate skin to skin when pulsations care (all 4 items/3 (1)* dry towel * breastfeeding stop or by 2-3min Kenya) within the first after birth hour* Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar (1) Kenya: no separate dries question (2) Kenya and Ethiopia: cuts and ties/clamps cord, protecting newborn from blade or scissors

Newborn Resuscitation Simulations (1) Stimulation: drying, place on warm clean surface, head in slightly 51% Stimulation (1) extended position, suction with bulb or catheter in mouth or nose (all items) (2) Ventilation: place correct size mask covering chin, moth and nose, squeeze Ventilation (2) 39% bag with 2 fingers or hand – appropriately, ventilate at 40 breathes/min (all items) 74% (3) Adjustment is any proper Adjustment (3) adjustment: check neck position, check seal, repeat suction, squeeze harder 0% 20% 40% 60% 80% 100% Tanzania Zanzibar Rwanda Madagascar 20

Inventory of Supplies for Management of Asphyxia 79% 61% 77% 68% 71% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Bag and mask (infant size) Suction bulb Suction apparatus for use Resuscitation table for Mean score resuscitation with catheter newborn supplies 21 Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

From Policy to Practice: Essential Newborn Care Constraints Analysis 83% 93% 100% 59% 64% 90% 80% 54% 70% 60% 24% 50% 40% 30% 20% 10% 0% Score for Policy Skilled birth Supervision last 3 Score for essential Score for newborn Received all essential attendance months supplies knowledge newborn care elements 22 Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar * In Madagascar, newborn knowledge questions were mistakenly omitted.

Overall Conclusions  “Skilled birth attendant” does not necessarily mean skilled care is being provided. Areas of strength and weakness in performance were identified.  A combination of factors, some explored in “constraint analysis” in this study, inhibit the provision of quality care:  Supportive national policies were generally in place but lacking more for PE/E than other areas  Medicines, equipment and supplies were lacking in some cases in the service delivery areas, e.g., MgSO4 at the health center level and in Ethiopian hospitals, oxytocin in health centers in Tanzania  Provider knowledge and skills appear to be inadequate in key areas  Supervision is not frequent in all facilities and the content is variable