1. Facility Assessment of Quality of Care for Immediate Newborn Care and Neonatal Resuscitation in selected African Countries Dr. Joseph de Graft-Johnson, MCHIP

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

3. QoC-MNC study  QoC-MNC study technical focus: Maternal: PPH, PE/E, Prolonged/Obstructed Labor and Sepsis Newborn: Immediate newborn care and neonatal resuscitation  Tools: Inventory list, Knowledge test and Observation checklist Core of assessment is direct observation to assess quality of care, both for ANC and Labor and Delivery. 3

4. QoC-MNC Assessment Countries 4 MCHIP QoC-MNC assessments implemented in 5 countries plus Zanzibar in 2009-2010 Results from assessments in Zimbabwe and Mozambique not ready

5. 5 Summary of Samples Assessed 597 facilities in 5 countries plus Zanzibar; observed 2164 deliveries and 2617 ANC consultations; interviewed 2440 health workers. SampleKenyaEthiopiaTanzaniaZanzibarRwanda Mada- gascar Total Facilities409195297236597 - Hospital52%100%23%56%58%75%53% - Health Center/dispensary48%0%77%44%42%25%47% Observations of care20353188802746046704781 - Deliveries6261924892172933472164 *Initial assessment4521073061061872681426 *3rd/4th stage of labor5631174152012252881809 *Newborn care5711154192032253361869 - ANC consults1409126391573113232617 Health workers interviewed 24979206511461402440

6. Data collection using mobile smart phones  Observers used Windows Mobile Smart Phones, for capturing data, enforcing quality checks and sending data 6

7. Inventory of Supplies for Immediate Newborn Care 7 * In Kenya, facilities could have a delivery pack which included blade (not specified as sterile) and cord ties/clamps. 36% 88% 64% 68%

8. Inventory of Supplies for Management of Asphyxia 8 79%61%77%68%71%

9. Health worker knowledge of immediate newborn care and management of complications 9 Note: Values are mean score. * In Madagascar, newborn knowledge questions were mistakenly omitted. ** Newborn resuscitation test for Kenya and Ethiopia only; newborn resuscitation simulation for Tanzania, Zanzibar, Rwanda, and Madagascar. 38% 54% 61% 33% 49%

10. 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 80%59%92% 39%43% 66% 24%

11. Newborn Resuscitation Simulations 11 (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 51% 39% 74%

12. * In Madagascar, newborn knowledge questions were mistakenly omitted. From Policy to Practice: Essential Newborn Care Constraints Analysis 12 93% 64% 54% 59% 24% 83%

13. Management of Newborn Asphyxia 13 A G1 P0 woman was observed starting with 1 st stage of labor. She was attended by a female nurse/midwife with graduate level diploma at a health center. Progress was plotted on a new WHO partograph but was not initiated at correct time. The action line on the partograph was reached at 2:45pm, yet action was not taken until 4:45pm, when provider prepared for assisted delivery. Mother had an assisted SVD at 5:55. Newborn was not crying/breathing: Provider slapped newborn and held upside down. Provider performed initial stimulation: dried/wrapped, placed on back, neck tilted, suctioned airway. Newborn was still not breathing so provider ventilated with bag and mask: squeezed the mask and adjusted it for a correct seal. Provider ventilated but not at 40 breaths/minute; After 1 minute, the baby’s breathing was <30 breaths/minute. Provider continued ventilating but there was no respiration. Ventilation stopped at 6:30pm and the baby was pronounced dead Size 0 mask, suction catheter, and suction machine were laid out and ready before delivery Itemn% Resuscitation observations 202 Type of treatment - Dry/position for resuscitation 18592% - Suction17185% - Use of bag and mask10050% - Ventilate with oxygen2110% Outcomes -Newborn deaths2211%

14. Conclusions Assumption that skilled birth attendance equals quality newborn care is obviously not true There is a need to improve the quality of newborn care for infants delivered at health facilities  Supportive national policies generally in place  Lack of supplies for immediate newborn care  A sizable percentage of health facilities had newborn resuscitation equipment  Supervision is not frequent in all facilities and the content is variable Routine monitoring of newborn care in health facilities, in addition to periodic comprehensive health facility assessments, will assist in addressing some of the observed deficiencies

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