Facility based newborn care in India: norms and standards

Dr Pavitra Mohan, MD, MPH

Health Specialist, UNICEF India

Regional Child Health Managers Meeting, November 2011

UNICEF

Institutional births: CES: 72%, DLHS-3: 47%

Govt. Facilities 47%

2

CES, 2009

UNICEF

Sick Neonate treated (OPD & Indoor) in Referral Hospitals in Orissa, 2004-2006

0

500

1000

1500

2000

2500

3000

3500

Baripada DHH Udala SDH Karanjia SDH Rairangpur SDH

2004

2005

2006

UNICEF

Newborn Stabilization

units

Newborn Corners

IMNCI /JSYreferrals

SCNU

ReferralsTraining inputs

UNICEF

Facility Based Newborn care in India: A Conceptual framework

Community

PHC

CHC

District Hospital

Newborn corner

(1 bed)

At Delivery Sick newborn

Stabilization units

(4 beds)

Special newborn care unit

(12-20 beds)

UNICEF

Facility Based Newborn Care

Essential Care to all Newborns

Special Care to Sick Newborns

Normal post-natal care to normal newborns

Follow-up of sick newborns

UNICEF

Status of Special Care Newborn Units in IndiaMore than 00 units “operational”, more than 100 in pipeline

Rapid expansion between 2005-2010Partnership between UNICEF/ NNF/ national and state governments

Plans to have at-least one SCNU in each districtSupported by network of Newborn Stabilization Units at first referral units, and newborn care corners in each “delivery-point”

UNICEF

BTL

SVP

SNI

SDH

SA

CDWBLG

CTP

KRG

RSN

MDL

STN

VDS

DHRJBA

PAN

SJP

KND

DMH

SHE

SOP

UJN

RJGSDL

DWS

JBP

HSB

GUNRWATKM

NSP

MDS

KTN

DDR

AKN

BHD

IDR

GLR

MRN

RTM

ANP

BRW

UMR

NMC

HRD

BHP

BPL

DTA

18 Functional

20 Under Construction

Status of Special Care New Born Units : Madhya Pradesh, India

Sanctioned for all 50

UNICEF

UNICEF

Assessment of 8 Special Care Newborn units in India

Assess the effectiveness in improving newborn survival

Understand the operational bottlenecks that affect their functioning and limit their effectiveness

Sieve out lessons for scaling up SCNUs in India and other similar settings

UNICEF

What are these districts like?Infant Mortality Rate: 48-73/1000 live births

Literacy rate among women: 36%-63%

% institutional deliveries: 22%-36%

% children fully immunized: 23%-65%

UNICEF

Results: Profile of newborns admitted in 8 SCNUs

No of admissions/100 births: 19.5 (4-39)

% of intramural admissions among all admissions: 68.5% (54%-90%)

% of boys among all admissions: 63.8% (58-70% )

% of babies with birth weight:Between 1500-2499: 35% (22-46%)

<1.5 kg: 6%

UNICEF

Admission Profile: Reasons for admission

UNICEF

Decline in mortality among admitted newborns after one year

District Decline in neonatal mortality after 1year

Tonk 4.5%

Dibrugarh 11.8%

Mayurbhanj 28.4%

Purulia 48.1%

Lalitpur -8.6%

Vaishali 43.0%

Guna 13.6%

Port Blair 16.2%

Current mortality among admitted newborns range from 5-15%

UNICEF

Where did the decline occur?

UNICEF

Adequacy of number of beds

Existing number of beds Required Number of Beds

Tonk 12 20

Dibrugarh 17 23

Mayurbhanj 12 25

Purulia 14 32

Lalitpur 12 25

Vaishali 13 32

Guna 20 32

Port Blair 14 10

UNICEF

Adequacy of beds: Average length of stay and bed occupancy rate

Name of the unit Average length of stay (in days)

Bed occupancy rate

Tonk 5.1 106%

Dibrugarh 4.4 137%

Mayurbhanj 4 155.3%

Purulia 15 100%

Lalitpur 3.4 52%

Vaishali 2.2 28.1%

Guna 5.5 130%

Port Blair 5.6 96%

UNICEF

Adequacy of Human resources

Name of the unit Total number of beds Nurse: bed ratio Doctor : bed ratio

Tonk 12 1: 1.5 1: 4.0

Dibrugarh 17 1: 0.8 1: 5.7

Mayurbhanj 12 1: 1.2 1: 4.0

Purulia 14 1: 0.7 1: 4.7

Lalitpur 12 1: 2 1: 6.0

Vaishali 13 1: 1 1: 2.6

Guna 20 1: 2 1: 6.7

Port Blair 14 1: 1.8 1: 7.0

UNICEF

Maintenance of Equipments

Name of the unit Reported time for repair of essential equipment (warners, phototherapy units)

Tonk 6 months

Dibrugarh 1.5 months

Mayurbhanj 6 months

Purulia 1.5 months

Lalitpur 3 months

Vaishali 1.5 months

Guna 0.5 month

Port Blair 6 months

UNICEF

Adequacy of asepsis practices

Name of the unit Asepsis score

Tonk 5

Dibrugarh 8

Mayurbhanj 3

Purulia 9

Lalitpur 5

Vaishali 5

Guna 7

Port Blair 9

UNICEF

Determinants of outcomes: Human resources

UNICEF

Determinants of outcomes: Asepsis practices

Norms and Standards

TOOL-KIT 2008 (UNICEF, NNF, WHO-CC):• Levels of newborn care• Services at each level• Infrastructure and design• Equipment: list, numbers and specs• Human resources• Training• Cost

UNICEF

Norms and Standards (2011)

Operational Guidelines (Ministry of Health and Family Welfare): 2011

Part-1: Setting up, costing and operational steps

Part-2: Key clinical & housekeeping protocols

Annexure 1.1: List of Equipment

Annexure 1.2: List of Dash board indicators

Annexure 1.3: Reporting format

Annexure 1.4: Checklist for facility assessment

Annexure 2.1: Working Definitions

Annexure 2.2: New born case record sheet

UNICEF

Norms and standards: how did they help?

Ready reckoner for the states and districts

Quality assurance: design, space, infrastructure

Procurement of equipment

Ensuring human resources

Budgeting in state and district plans

Less dependence on external support

Assessment against norms: policy briefs for advocacy

Consensus (in India?)

UNICEF

UNICEF

Acknowledgements

National Neonatology Forum and all members

Public Health Foundation of India

All the nurses and doctors who are making quality newborn care available in some of the remotest districts of the country, often in difficult circumstances…..