1. The First Hours of Life Experiences of mothers and newborns in Bangladesh health systems Ishtiaq Mannan, Save the Children Sanwarul Bari, Abdullah Nurus Salam Khan, icddr,b

2. Context Achievements Challenges of health systems Preparedness Practice HR Physical National response Outline Capacity QI

3. CONTEXT

4. 16 21 42 32 Place of delivery

5. 42% Type of assistance at delivery

6. ACHIEVEMENTS

7. MDG 4

8. MDG 5

9. Health Systems Bottlenecks The Bangladesh paradox Governance, stewardship and accountability Financing HR Quality Logistics Measurement Equity

10. METHODS

11. Sites and Tools Data from on-site observation of deliveries conducted during the System Evaluation of Scaling up of HBB Sites: Sub-District hospital (16): 16 UHC Total 221 SBAs (Doc/Nurses/Paramedics): 7138 deliveries (1776 at baseline) Community component: (6 months of observation) Total: 39 CSBAs (332 deliveries) Tools: Observation of delivery and immediate newborn care Key informant interview (District hospital and MCWC)

13. KEY FINDINGS: PREPAREDNESS AND PRACTICES

14. Environment of the Delivery Room Environment delivery roomFacility N=1161 Adequate light in the delivery room62.6 (727) Adequate ventilation89.7 (1041) *Multiple responses

15. Availability of ENC Equipment Essential equipment*Facility N=1776 Community Two pieces of cloths94.4 (1677) 99.4 (330) Two gloves98.6 (1752) 98.8 (328) Umbilical clamps/threads98.5 (1749) 99.4 (330) Scissor/ blade98.4 (1747) 100.0 (332) Suction device80.6 (1432) 57.2 (190) Resuscitation bag66.2 (1176) 53.3 (177) *Multiple responses

16. Equipment: sterilization The nurse working in labor ward of district hospital said about sterilization of instruments: – “ We don’t use autoclave machines here. We use savlon water, clean with hexisol, that’s how we manage because we deliver a lot. We also use chlorine solution in OT for disinfection and also boil instruments. But we mainly clean with hexisol” More in the MCWC, the FWV uses the autoclaved instruments for cord clamping and cutting. The medical officer of MCWC described about the sterilizing practice there: – “We autoclave the instruments upstairs for OT (where autoclave room is situated). Actually in delivery room instruments are not always autoclaved. Mainly boiled.” A nurse from the district hospital mentioned: – “We don’t have dry sheet or clean cloth supply in the hospital, so we depend on what patients bring with them.”

17. Overall Preparedness for All Services is Very Poor Bangladesh Health Facility Preparedness Survey, 2014

18. Preparedness protocols Standard operating procedures – Specifications – Table of equipment Challenges: Preparedness

19. Preparing for Delivery and Newborn Care: Logistics

20. Preparing for Delivery and Newborn Care: Physical Examination

21. Handwashing Practices HandwashingFacility (N=1776) Community (N=332) Washed hands before delivery 44.1 (783) 46.0 (152) Washed hands with water only 8.0 (140) 2.1 (7) Soap and others 36.0 (643) 44.0 (145)

22. Managing the Delivery of Placenta

23. Did the SBA seek assistance to help resuscitate the newborn? 42.8 40.6 all newborns Facility Community 44.2 39.5 Facility Community newborns not crying at birth Assistance During Resuscitation

24. ENC Practices

25. Variable practice levels – not aligned with training or standards – Clinical competency – Retention – Lack of supervision Standard operating procedures Supervisory system and structure Challenges: Practices

26. Preparedness: Human Resources The consultant of gynecology of district hospital also described the scenario as: – “To tell you the truth the baby is managed by “Aya” here. Our nurses are busy in delivery and taking care of mother. If you go to Medical college hospitals nurses don’t even work there. All the care of the baby is taken care by Ayas.”

27. Quality and experience of care About the experience in labor room, 3 out of 4 mothers complained about the nurses not being sympathetic to the pain of the mothers. One of the mothers said: – “I was in lot of pain. They don’t understand and behave harshly. Home is better place to deliver as it is comfortable. But here people come in and out. I didn’t have any privacy.” Regarding the postnatal care, all 4 mothers mentioned they called nurses for help, but nobody responded. Two of the mothers mentioned their baby caught cold and got sick but no doctor came in for check-up until the next morning. But they also realize how busy they were and accepted it being in a govt. hospital. A mother from district hospital said: – “A doctor came in the morning. He said if there was any problem. But he didn’t ask about baby’s health and didn’t examine him”

28. Inappropriate, inadequate human resource organization and management Quality of care – Accountability – Dignity Challenges: Human resources

29. NATIONAL RESPONSE

30. Essential services package Shift towards facility delivery with continuum of care QI mechanism Real time measurement and monitoring The next HPN Sector Program (2016-21)

31. Health Systems issues to focus on HR related: – Dedicated birth attendants – midwives – Number of facilities providing delivery care – Human resource – Standardized competency based training Quality Improvement – SOPs (both clinical and physical standards) – QI mechanism – TQM and standards

32. Thank you!