We have partnered with BTAST- Bihar to support the Department of Health & Family Welfare for Clinical Mentoring & Handholding support to enhance technical quality of care & facilitate responsive behavior of service providers in selected facilities covering 14 districts (56 facilities) in Bihar. The Project objectives were;

·         To assess gaps in Labour Room and Maternity ward functional status 

·         To identify the existing gaps in skills / knowledge relating to practice of standard clinical protocols 

·         To act as clinical mentors to facility staff helping in upgrading & in increasing their knowledge/skills and helping them adhere to evidence based protocols particularly for MNCH service delivery

Gap Analysis

Facility Assessment

A detailed study of the various levels of public health facilities against the set standards were measured in the 14 districts of Bihar. The assessment findings highlight the significant gaps, their causes and impact in the outcome of healthcare services. About 18 important gaps were identified in terms of service provision, infrastructure, supplies, infection control practices, clinical services and documentation practices. Recommendations to traverse every gap have been made in order to provide quality assured services to care seekers. The identified gaps were;

· Essential laboratory services & USG services are not available round the     clock in District Hospitals

· Limited or no Blood Transfusion services in most of the CEmONC centers

· There is no MTP service available in the facilities

· In most of the facilities, there is no maternal healthcare services readily   available for women with HIV positive

· There is no provision of separate examination and Pre - delivery room in    the facilities

· The number of delivery tables are not in proportion to the delivery load   and lack of space between the delivery tables

· Inadequate number of trays (Delivery tray, Episiotomy tray, immediate      newborn care tray & IUCD/PPIUCD tray)

·  Inadequate and irregular supply of consumables in the labour room

·  There is no regular supply of Essential & Emergency drugs

· Poor maintenance of equipment in the labour Room & NBCC

· Irregular supply of running water in the labour room & maternity ward

· There is no practice of sterilizing instruments in the Labour room

· Improper segregation of Biomedical Wastes in the labour room

· Nurses are not conducting deliveries as per the standards of procedures

· Poor practice of immediate newborn care

· Injudicious administration of Inj. Oxytocin

· Poor Postnatal Services

· Poor practice of documentation

Skill Assessment

The maternal and newborn care skills of nurses working at all levels of public health facilities were assessed using the “Skill Assessment Tool”. The skill assessment tool was developed by taking into consideration the government of India standards that are to be followed in the practice of maternal and newborn care services. The award of scores was based on the levels of performances of nurses and their skills were categorized as being “Satisfactory, Partially Satisfactory or Unsatisfactory”. The core skills assessed among nurses are;

1.    Medical Handwashing

2.    Wearing and Removing of Sterile Gloves

3.    Measuring Blood Pressure

4.    Abdominal Examination

5.    Monitoring Uterine Contractions

6.    Vaginal Examination

7.    Conduction of Labour

8.    Examination of Placenta

9.    Examination of Cervix, Vagina and Perineum

10.  Perineal Repair

11.  Immediate Care of the newborn

12.  Kangaroo Mother Care (KMC)

13.  Care of babies under Radiant Warmer

14.  IM Medication Administration

15.  IV Infusion

Findings

· Medical handwashing skills were assessed among nurses. The results revealed    that, the handwashing skills of 42.8% of nurses were unsatisfactory, those of  43.4% of nurses were partially satisfactory and those of 13.8% of nurses were  satisfactory

· With regard to the assessment of skills on wearing and removing of gloves, the  skills of 64% of nurses were unsatisfactory, those of 33.1% of nurses were    partially satisfactory and only those of 2.9% of nurses were satisfactory

· With regard to the level of skills that are required for measuring blood    pressure, the skills of 55.9% of nurses were satisfactory and those of 44.1% of    nurses were partially satisfactory. Around 44.1% of nurses did not record blood  pressure readings in women’s case records or partographs.

· The level of performance of nurses in abdominal examination was assessed    and the results showed that, the skills of 63% of nurses were unsatisfactory,  those of 30% of nurses were partially satisfactory and those of 7.1% of nurses  were satisfactory

· With regard to the assessment of uterine contractions, 9% of nurses’ skills      were unsatisfactory, 74.6% of nurses’ skills were partially satisfactory and only  16.4% of nurses’ skills were satisfactory.

· Nurses’ skills required for vaginal examination were assessed, the results  showed that 7.3 % of nurses’ skills were satisfactory, 78.1% of nurses’ skills  were partially satisfactory and 14.6% of nurses’ skills were unsatisfactory

· The skill of the nurses in the conduction of labour was assessed. 72.4% of  nurses’ skills were unsatisfactory and 27.6% of nurses’ skills were partially  satisfactory.

· Nurses in the facilities did not do the regular examination of placenta soon      after the conduction of delivery. Nurses are also ignorant of the importance of  placental examination and of the various steps involved in placental         examination

· The observation made on their performance while examining vagina, cervix  and perineum revealed that the skills of 96.2% of nurses were unsatisfactory  and those of 3.8% of nurses were partially satisfactory

· The practices followed by nurses while performing perineal repair were    assessed, the assessment showed that 22.2% of nurses skills were unsatisfactory  and 77.8% of nurses’ skills were partially satisfactory

· The skills of 83% of nurses were found to be unsatisfactory and those of 17% of nurses were found to be satisfactory.

· The keen observation made on the practices of kangaroo mother care among mothers revealed that 44.8% of KMC practices were unsatisfactory, 41.4% of KMC practices were satisfactory

· With regard to the care of baby under radiant warmer, the results showed  that 15.4% of nurses’ skills were satisfactory, 30.8% of nurses’ skills were  partially satisfactory and 53.8% of nurses’ skills were unsatisfactory

· The skills of nurses as revealed in IM medication administration were  observed. The study showed that 7.8% of nurses’ skills were unsatisfactory,  76.6% of nurses skills were partially satisfactory and only 15.6% of nurses skills  were satisfactory

·  With regard to IV infusion 54.5% of nurses’ skills were unsatisfactory, 9.1% of  nurses’ skills were partially satisfactory and only 36.4% of nurses’ skills were  satisfactory

Clinical Training & Mentoring of Nurses

A 3 day training and mentoring program for nurses / ANMs was conducted in all the 56 facilities to improve the knowledge and skills on maternal and neonatal core skills.

Outcome of the Project

· About 18 important gaps in the facilities were identified and  recommendations to traverse every gap have been 

· Enhanced nurses’ level of knowledge and skills in delivering adept maternal and neonatal health care

· Infection control measures was brought into regular practice

· Nurses have developed the capacity to identify and manage complications of mother and newborn

Project Recommendations

·  Strengthening manpower in the facilities based on IPHS

· Practice of standardized safe delivery checklist by healthcare providers to adhere to GoI protocols

· Strengthening Supply Chain Management to have uninterrupted services in the facility

·Continuous updating of the knowledge and skills of healthcare providers to

· Periodic Monitoring and Supportive Supervision of nurses/ ANMs

· Effective Implementation of Quality Management System