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)

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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.

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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

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QoC-MNC Assessment Countries

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• MCHIP QoC-MNC

assessments implemented in 5 countries plus Zanzibar in 2009-2010

• Assessments in

Zimbabwe and Mozambique are planned for 2011

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Summary of Samples

Assessed 597 facilities in 5 countries plus Zanzibar;

• bserved 2164 deliveries and 2617 ANC consultations;

interviewed 2440 health workers.

Sample Kenya Ethiopia Tanzania Zanzibar Rwanda Mada- gascar Total 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 interviewed 249 79 206 51 146 140 2440

Data collection using mobile smart phones

• Observers used Windows

Mobile Smart Phones, for capturing data, enforcing quality checks and sending data

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PREVENTION AND MANAGEMENT OF PRE- ECLAMPSIA & ECLAMPSIA

Screening for Pre-eclampsia during ANC

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Ask about headache or blurred vision Ask about swollen hands or face Take client's BP with appropriate technique Both PE/E screening elements (ask about at least 1 danger sign and Take BP) Perform or refer for urine test

Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

29% 27% 71% 31% 50%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Asks about signs of PE/E* Initial blood pressure check Both PE/E screening elements Tests urine for presence

• f protein

BP recorded at least every 4hrs (when diastolic <90 mmHg)

Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

29% 80% 25% 8%

Medium (40-60%) Zanzibar Low (0-30%) Ethiopia Madagascar High (70-100%) Kenya Tanzania Rwanda

Partograph use

Screening for PE/E during L&D

31%

Availability of MgSO4 in Delivery Room

70%

Kenya

72% 57% Hospital Health Center 47%

Tanzania

83% 35% Hospital Health Center 43%

Rwanda

70% 4% 67%

Zanzibar

46%

Madagascar

55% 17% Hospital Health Center 16%

Ethiopia

16% Hospital Health Center 60% 75% Hospital Health Center

MgSO4 No MgSO4

Key

From Policy to Practice: PE/E Constraints Analysis

87% 93% 59% 48% 42% 25% 31%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Score for Policy Skilled birth attendance Supervision last 3 months Magnesium sulfate in DR Score for PE/E knowledge Received both PE/E screening elements at ANC Received both PE/E screening elements at L&D Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

PREVENTION & MANAGEMENT OF POSTPARTUM HEMORRHAGE

* In Kenya, timing is based on data collector’s estimate. All other countries, data collectors recorded actual times for birth and uterotonic administration.

Practice of AMTSL According to FIGO/ICM Definition

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any uterotonic given (+) correct timing 1 min (+) Controlled cord traction (+) Uterine massage = FIGO/ICM standard AMTSL Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

95% 56% 45% 29%

Note: Values are additive moving from left to right

Availability of Oxytocin in Delivery Room

87% 93% Hospital Health Center 88% 12%

Kenya

100 % 76% Hospital Health Center 67% 33%

Tanzania

100 %

Zanzibar

100 % 100 % Hospital Health Center 84% 16%

Ethiopia

79% 21%

Madagascar

73% 100 % Hospital Health Center 87% 13%

Rwanda

95% 78% Hospital Health Center 96% Hospital Health Center Oxytocin No oxytocin

Key

From Policy to Practice: PPH Constraints Analysis

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Score for Policy Skilled birth attendance Supervision last 3 months Oxytocin in DR Score for PPH knowledge Received AMTSL within 1 minute Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

96% 93% 59% 84% 41% 29%

IMMEDIATE NEWBORN CARE AND MANAGEMENT OF BIRTH ASPHYXIA

Observation of Immediate Newborn Care

(1) Kenya: no separate dries question (2) Kenya and Ethiopia: cuts and ties/clamps cord, protecting newborn from blade or scissors

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Immediately dries baby with towel (1)* Discards wet towel and covers with dry towel * Cuts cord with clean blade (2)* Assists the mother to initiate breastfeeding within the first hour* Places newborn skin to skin Ties/clamps cord when pulsations stop or by 2-3min after birth Essential newborn care (all 4 items/3 Kenya) Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

80% 59% 92% 39% 43% 66% 24%

Newborn Resuscitation Simulations

20 (1) Stimulation: drying, place on warm clean surface, head in slightly 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 bag with 2 fingers or hand – appropriately, ventilate at 40 breathes/min (all items) (3) Adjustment is any proper adjustment: check neck position, check seal, repeat suction, squeeze harder

0% 20% 40% 60% 80% 100% Stimulation (1) Ventilation (2) Adjustment (3) Tanzania Zanzibar Rwanda Madagascar

51% 39% 74%

Inventory of Supplies for Management of Asphyxia

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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Bag and mask (infant size) Suction bulb Suction apparatus for use with catheter Resuscitation table for newborn Mean score resuscitation supplies Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

79% 61% 77% 68% 71%

* In Madagascar, newborn knowledge questions were mistakenly omitted.

From Policy to Practice: Essential Newborn Care Constraints Analysis

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93% 64% 54% 59% 24% 83%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Score for Policy Skilled birth attendance Supervision last 3 months Score for essential supplies Score for newborn knowledge Received all essential newborn care elements

Kenya Ethiopia Tanzania Zanzibar Rwanda Madagascar

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

Overall Conclusions

• Performance of AMTSL improves when using “relaxed”

definition (uterotonic within 3 minutes). Given the difficulty for a lone provider to care for the newborn and quickly give

• xytocin, it would be advisable to study the health effect (if

any) that this more realistic standard would have.

• Some findings could only have been obtained in an
• bservational study like this(e.g., the fact that partographs

are sometimes only filled out AFTER the birth occurs) .

• Some losses of quality are due to “softer” and not easily

quantifiable management issues and not that would not be delineated in a more usual facility readiness assessment (e.g., not having all resuscitation equipment ready and accessible before birth).