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A Dissertation Submitted to Manipal University in
Partial Fulfilment for the Award of
AUGUST 2012
By
Neel Kamal BPT, FAGE
Under the guidence of
Dr. Ramachandra KamathProfessor and Head
Department of Public Health
Manipal University
Co-guides
Dr. Leonard Machado, MD Dr. Lesley Lewis, DCH, DNB
Associate Professor Professor
Department of Public Health Department of Paediatrics
Manipal University Manipal University
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Certificate
This is to certify that the Reserch Project entitled Availability of Neonatal
care Services in Udupi Taluk - A Cross-Sectional Study prepared by
Neel Kamal (102802004) under our supervision in partial fulfilment of the
requirement for Masters in Public Health, Manipal University has not
previously formed the basis for the award of any Degree or Diploma by this or
any other University and that, this work is a record of the candidates personal
work.
Guide
Dr. Ramachandra KamathProfessor and Head
Department of Public Health
Date: / / 2012
Place: Manipal
Co-guides
Dr. Leonard Machado, MD Dr. Lesley Lewis, DCH, DNB
Associate professor Professor
Depart of Public Health Department of Paediatrics
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Certificate
Manipal University Manipal University
Date: / /2012 Date: / /2012
Place: Manipal Place: Manipal
This is to certify that the dissertation entitled, Availability of Neonatal
care Services in Udupi Taluk, Karnataka, India is a bonafide work
done by Neel Kamal in the Department of Public Health, Manipal University,
under our direct supervision and guidance.
Guide
Dr. Ramachandra KamathProfessor and Head
Department of Public Health
Date: / / 2012
Place: Manipal
Co-guides
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Dr. Leonard Machado, MD Dr. Lesley Lewis, DCH, DNB
Associate professor Professor
Depart of Public Health Department of Paediatrics
Manipal University Manipal University
Date: / / 2012 Date: / / 2012
Place: Manipal Place: Manipal
DECLARATION
I hereby declare that the project entitled a study on Availability of Neonatal
care Services in Udupi Taluk, Karnataka, India has been submitted during
the year 2012-2013 under the valuable guidance and supervision of
Dr. Ramachandra Kamath, Professor and Head, Department of Public
Health in partial fulfilment of the requirements of the Master of Public Health
(MPH) degree of Manipal University. Further I extend my declaration that this
report is my original work and has not previously formed the basis for the award
of any degree or diploma.
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I am also gratified by the kind support from my colleague Smiksha Babbar.
Last but not the least I affectionately thank my family and friends for their prayers,
inspiration, guidance and support and to the God Almighty for everything and more.
Neel Kamal
CONTENTS
CHAPTER NO. CONTENTS PAGE NO:
1 Introduction 11-15
2 Aim and Objectives 16-17
3 Literature Review 18-24
4 Materials and Methods 25-28
5 Results and Discussion 29-57
6 Summary 58-59
7 Conclusions 60-61
8 Limitations 62-63
9 References 64-66
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10 Appendix 67-94
TABLES AND FIGURE
TABLES & FIGURE DESCRIPTIONS PAGE NO.
Table: 1 Types of Health Care Facilities 29
Figure: 1Distribution of Health Care Facilities 29
Tables: 2 Newborn Care Services 30
Table: 3AInfrastructure for Newborn Care 34
Table: 3B
Infrastructure for Newborn Care 35
Table: 3CInfrastructure for Newborn Care 35
Table: 4AEquipment for Management: 39
Table: 4BEquipment for Monitoring 40
Table: 4CEquipment for Investigation 42
Table: 4DEquipment for Resuscitation 44
Table: 4E Equipment for Disinfection 45
Table: 5A Human Resource for Newborn Care 49
Table: 5B Human Recourses with Training status 51
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Table: 6 Records of deliveries from last 3-months 54
Table: 7 Registers maintained for Newborns 55
LIST OF ABBREVIATIONS
NMR: Neonatal Mortality Rate
IMR: Infant Mortality Rate
MDGS: Millennium Developmental Goals
U5MR: Under Five Mortality Rate
SRS: Sample Registration System
LBW: Low Birth Weight
NBCC: Newborn Care Corner
NBSU: Newborn Stabilization Unit
SNCU: Special Newborn Care Unit
NICU: Neonatal Intensive Care Unit
CSSM: Child Survival & Safe Motherhood
RCH: Reproductive and Child Health
IMNCI: Integrated Management of Neonatal & Childhood Illness
F-IMNCI: Facility Based IMNCI
SC: Sub-Centre
PHC: Primary Health Centre
CHC: Community Health Centre
FRU: First Referral Unit
DH: District Hospital
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PH: Private Hospital
ENBC: Essential Newborn Care
FBNC: Facility Based Newborn Care
UNICEF: United Nation International Children Emergency Fund
TT: Tetanus Toxoid
IRC: International Rescue Committee
BEMOC: Basic Emergency Obstetric Care
EMOC: Emergency Obstetric Care
NGOS: Non-Governmental Organizations
AVD: Assisted Vaginal Deliveries
HCPS: Health Care Facilities
NNF: National Neonatal Forum
EAG: Empowered Action Group
IPHS: Indian Public Health Standard
OB/GYN: Obstetrician and Gynaecologist
OT: Operation Theatre
ECG: Electro Cardio Gram
24*7: 24 Hours Round The Clock
NSSK: Navjaath Shishu Suraksha Karyakram
SBA: Skilled Birth Attendant
ANM: Auxiliary Nurse Mid-Wife
MoHFW: Ministry of Health and Family Welfare
PIP: Project Implementation Plan
MCH: Maternal Child Health
NRHM: National Rural Health Mission
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HBNC: Home Based New born Care
GOI: Government of India
INTRODUCTION
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INTRODUCTION
Mortality rates are social indicators to determine the health status of any
country. Infant mortality is globally an important indicator of health as well as
standard of living of people in the community and the country 1 which indicates
the social and economic progress made by the nation and level of health care
available for the needy people. It also reflects the status of health programme &
policies implemented in the country2.
Though IMR is declining globally, but Neonatal mortality is being constant at
all levels. As compared to post neonatal infant deaths, there is 10-15 fold higher
risk of newborn dying in first month of life and neonates have approximately 30
fold greater risk of dying than young children (13-60 months). Inequality exists
for Neonatal mortality among various countries up to 30 folds, being highest in
sub-Saharan Africa. Though, regional average is low in Asia but it accounts for
almost 60% of global NMR. So, in order to get a sustained improvement for
neonatal health, care must be prioritized in these regions3.
To achieve Millennium Development Goal IV, Infant and Neonatal deaths
across the globe need to be reduced. Infant mortality showed an appreciable
decline during the 1980s and early 1990s. Thereafter, its pace of decline has
slackened considerably4. However, a special session was conducted to submit a
report for children in United Nations at New York in 2002, to high-lighten the
acceleration of MDGs for enduring child survival, Neonatal health
improvement, particularly in late foetal & neonatal period3.
Neonatal mortality accounts for almost 40% of under- five child mortality
worldwide i.e. four million deaths annually in the first month of life, out of
which, approximately 99% are occurring in low and middle income countries. 2
India contributes 20% of newborns to the World every year but accounts for 25-
30% of Neonatal deaths yearly and among those 45% die within first two days
of life5.
In India, nearly 50% of under-five (U5) mortality is contributed by Neonatal
deaths. Currently, Infant mortality rate of India is 50 per 1000 live births 5. Since,
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last many years, Neonatal mortality rate of India had been showing slow
decline, as in 2005, it was 37per 1000 live births (SRS 2005) and 34 (68%) per
1000 live births in 2009(SRS 2009); Whereas Karnatakas Infant mortality is 41
per 1000 live births4 and Neonatal mortality is 28.9(70.48%) per 1000 live
births6. Infant mortality of Udupi district is 8 per 1000 live births followed by
neonatal mortality of 4.5 (56.25%) per 1000 live births.7
So, from the above mentioned situation, we can infer that today also a greater
proportion of Infant deaths are accounted by neonatal deaths at all levels. A
review of ages at death during the first 28 days of life reveals that two-third of
deaths occur in the first week of life and two-third of these within the first 2
days of life4.
The major causes of death during this period are birth asphyxia, trauma,
problems related to low birth weight (LBW) (such as hypothermia, respiratory
problems, feeding and peri-partum infections) and malformations. Most of these
problems occur due to inadequate care during the antenatal period and during
labour. Inadequate care immediately after birth and inadequate care of LBW
infants within the first 48 hours may be contributing to the rest4. So, it is
important to focus on newborn care to sustain reduction in IMR & U5MR and
strengthening the care of sick, premature, LBW newborn at various levels of
health facility since birth through Neonatal period (0-28 days of life specially).
Hence, facility based newborn care at NBCC; NBSU & SNCU at all levels of
health system needs more attention8.
In India, several effective, low-cost interventions are being implemented
through various health programs like Child Survival and Safe Motherhood
(CSSM) Programme started in 1992 and Reproductive and Child Health (RCH)
Programme started in 1997. In the RCH II (2005), the IMNCI had been
incorporated in 359 Districts of India from 2010, as a major package for
intervention enabling the facilities to provide effective service to children and
neonates. By providing services through existing health facilities i.e.; PHCs,
CHCs/FRUs and District Hospitals, Essential newborn care (ENBC) and
Newborn Care Corner (NBCC) through facility based Neonatal care (F-IMNCI)
incorporated with integrated management of neonatal & childhood illness
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initiative (IMNCI) programme is expected to improve Neonatal survival.
Provision of newborn care at various levels of health facilities helps in
increasing the confidence of the community as well as the coverage of the health
services especially at the time of great emergency that is early days of life5.
Guidelines issued by Ministry of Health and Family Welfare, Govt. of
India/UNICEF toolkit for setting up SCNUs (special care newborn unit),
NBSUs (Newborn Stabilization unit), NBCCs (Newborn care corner) at District
Hospitals/Govt. Medical colleges and Hospitals, FRUs, 24*7 PHCs respectively
have been referred for establishing these facilities9.
Moreover, Siddarth Ramji has mentioned in his report on Newborn and Child
health in India: Problems and Interventions that there is a need to evaluate the
capacity of the health system and implementation of IMNCI and also
engagement of the health professionals at peripheral level to halve Neonatal
mortality and development, implementation, and monitoring of national action
plans for neonatal survival can be set as priority4.
Quality is one of the most important issues while child health concerned. Inspite
of approaching health care facilities, millions of children who need attention in
their sickness couldnt get an average level of care. Primary & secondary care
for newborn in low income or developing countries is lacking in terms of
availability of infrastructure, Human resources, basic laboratory services, drugs,
equipment & supply which makes health professionals to treat these children
with available resources10.
Though, the best possible newborn health care infrastructure is hard to
overcome several challenges regarding newborn care in terms of availability of
newborn care facility, adequate manpower, equipment & supply, yet regular
supervision and monitoring can be focused on to get better outcomes11.
Since independence, there has been a great expansion of health services through
Primary Health Centres (PHCs), Community Health Centres (CHCs) and Sub
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Centres (SCs) in India. Still the implementation and functioning of these
facilities according to the guidelines, is not up to the mark. This being so,
facility based newborn care is incorporated at primary, secondary and tertiary
levels.
Since the last 30 years, there has been significant progress in the socio-economic
development of Karnataka state and it seems to have achieved the expected
demographic goals. Udupi district in Karnataka has Infant mortality rate of 8 per
1000 live births. This is a good indicator for this district in Karnataka with
respect to other Districts and since many decades this may be a challenge for
other Districts to achieve this status. As compared to state Infant Mortality Rate
of 41 per 1000 live births (SRS2009) and country comparison of 50 per 1000
live births (SRS 2009), Udupi has a quite low IMR. Though infant mortality is
declining but the Neonatal mortality is being constant during last 10 years.
During April 2010 to March 2011, out of all infant deaths (118), Neonatal
deaths were (67) 56.77% and out of total Neonatal deaths, (52) 77.61% died
between 0-7Days7.
Moreover, a recent study in Udupi district explained that Neonatal deaths (55%)
were more as compared to post neonatal deaths (45%). Study also explained
about direct causes of mortality such as birth asphyxia (43%) was the most
common cause in early Neonatal period, sepsis (30%) contributed in late
neonatal period followed by pneumonia (13%) & prematurity (13%) whereas;
40% infants had LBW (less than 2 kg). If we look at other aspect, the same
study also focuses on indirect causes of infant mortality such as women literacy
rate of 93%, 81% registered pregnancies before 12 weeks, all mothers received
100% 2- dose of TT vaccine, & also recommended dose of Iron, folic acid &
calcium tablet, 64% were full term pregnancy, 60% had normal deliveries, 97%
institutional deliveries with 97% infants delivered by doctors, which is really
appreciable in Udupi district2
If above mentioned causes (direct) are looked carefully, it can be seen that most
of these are preventable8 despite of having support to indirect causes at greater
extent in Udupi district2. Since, implementation of facility based newborn care
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in Karnataka has already been incorporated in the health system; it can be
assumed that other causes may include gaps in availability or utilization of
resources through various levels of health care facility for newborn care.
However, valid & reliable information can give a good impact for decision
makers to undertake any intervention to improve effectiveness of the
programme; such information may be helpful for a district as well as
community. It may also give a better perception for any program planners, field
managers, researchers, field staff and organizations in the country for the
development of the programs. The external evaluation may help to find out
actual need of the program to improve its coverage at broader aspect and also to
get unbiased outcome for program managers20.
Not many studies were conducted in this regard, therefore limited literature was
available. As such, Facility based newborn care is also a new concept and the
Government of Karnataka is now looking on the same. Hence, it can be
expected that this study may contribute to knowledge in terms of Infrastructure,
Human resources, Health characteristics, Material resources, Record system &
transport facilities for Neonatal care in Udupi district.
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AIM AND OBJECTIVES
AIM
To assess the current situation of Neonatal care services in Udupi Taluk,
Karnataka.
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OBJECTIVES
Primary objectives:
To identify the available Neonatal care facilities in government &
private sectors.
To assess Human resources available for Neonatal care.
To assess the Infrastructure & Equipment available for Neonatal
care.
Secondary objective:
To find out records and registers maintained for Neonatal care.
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LITERATURE REVIEW
Global scenario:
Charles Opondo et al. (2009) 12
A study was conducted in eight first-referral level hospitals in Kenya to assess
the availability of essential basic care to newborns through direct observation,
using a checklist and self- administered questionnaire for the health care
workers. It was found that there was often lack of maintenance of safe hygienic
environment in the hospitals, poorly organized and insufficient staffing to
support the provision of care. Patient management guidelines were missing in all
sites and some key equipment, laboratory tests, drugs and consumables were not
available thus, providing insufficient newborn care.
Casey et al. (2009) 13
The study was conducted by international rescue committee (IRC) and CARE as
baseline assessments of public hospitals to evaluate their capacity to meet the
reproductive needs of the local population to determine the availability,
utilization and quality of reproductive services including emergency obstetric
care and family planning in nine general referral hospitals of democratic
republic of Congo. The information was attained through interviews,
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observations & clinical records review. It was found that most of the facilities
had shortage of staff, essential equipment, supplies and weak referral system.
Moreover, the facilities had poor infection prevention and poor monitoring of
reproductive health services related to EmOC.
Eugene J. et al. (2008) 14
Survey was conducted in all 73 health care facilities (13 hospitals and 60 health
centres) providing maternity services in central region of Malawi to establish
baseline for availability, utilization and quality of maternal and neonatal health
care services. They found that, there was a shortage of qualified staff, equipment
and supply in some facilities. Though there were adequate health facilities butthere was unequal distribution of the services.
Mike English et al. (lancet 2004, 364: 1622-29) 15
A cross sectional study to investigate the provision of paediatric care in
government district hospitals in terms of outcome of admission, infrastructure
resources, and views of hospitals staffs and caretakers of admitted children in 14
first referral level hospitals from seven of eight provinces in Kenya. It was
found that the basic laboratory services were available in at least 12 hospitals
but the bilirubin test was rarely found. Proper availability of drugs for
malnutrition, newborn feeds and anti- infective drugs were available at 11
hospitals. The staffs views regarding infrastructure and human consumable
resources indicated their dissatisfaction with the physical environment around
them.
Koyejo Oyerinde et al. (2011) 16
A needs assessment related cross-sectional study was conducted for emergency
obstetric care (EMoC) to address the maternal mortality indices. The study
included all public, private, mission and non-governmental organizations
(NGOs) hospitals providing maternal and child health services. Locally adapted
tool for data collection developed by Avertis maternal death and disability
program was used. It was found that there was adequate EmOC but it was
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poorly distributed. No hospital could be traced with basic EmOC and only few
facilities were able to provide assisted vaginal deliveries (AVD). In addition,
there was severe shortage of staff, equipment and supplies.
Youn-g Mi Kim et al. (2009) 17
A cross-sectional study was conducted in seventy eight first line referral
facilities of Afghanistan with the objective to assess the availability & utilization
of emergency obstetric and neonatal care (EMoC) facilities as defined by UN
indicators. After the study it was found that 42% of the peripheral health
facilities did not have sufficient facility to provide or deliver comprehensive
emergency obstetric and neonatal care (EMoNC) facilities and 31% of the
facilities were lacking for equipments & supplies and 77% of the facilities cited
lack of human resources. Services like c-sections were provided in 33% of
CHCs, 76% of district hospitals and all regional hospitals. Facility of blood
transfusion was reported from 33% of CHCs, 62% of district hospitals and
regional hospitals.
Charles Ameh et al. (2009) 18
A study was conducted in Somalia to provide and evaluate in service training in
(life saving skills) emergency obstructive & newborn care in order to improve
the availability of (EmoNC) in Somaliland. A total 222 health care providers
(HCPs) were trained within span of two years. Both quantitative and qualitative
methods were used for before and after evaluation of trainee reaction and
change, in knowledge, skills and behavior in addition to functionality of health
care facilities. It was found that training impacted positively on the availability
and quality of EmoNC and resulted in up skill of midwives performing skills of
medical doctors. But the lack of drugs, supplies, medical equipment and supply
policy were identified as barriers to use of new skills and knowledge acquired.
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Indian scenario:
Biswas A B et al. (2011) 19
A study was conducted in twelve first referral units of 6 Districts in West-
Bengal to assess the status of maternal and newborn care through record review,
interviews and observations using pre-designed proforma. The results showed
that there was inadequate infrastructure facilities (e.g. no sanctioned post of
specialist, no blood bank at rural hospital) and poor utilization of equipment like
neonatal resuscitation sets, radiant warmer, lack of training of service providers
were evident. Records/ registers were available but incomplete & referral
services were found to be almost non-existent. It was also reported that most of
the deliveries and immediate neonatal resuscitation was done by nurses (94.9%)
13.
B. Neogi Sutapa et al. (2011) 5
A cross- sectional study was conducted to assess the functioning of SNCU
(special newborn care unit) and availability of human resources, equipment and
quality care based on secondary data and cross sectional survey in 8 rural
districts of India that had been functioning for at least one year. The rate of
mortality among admitted neonates was taken as the key outcome to assess the
performance of the unit. It was found that the units had varying nurse to bed
ratio (1:05 to 1:1.3). Inadequate repair and maintenance of the equipment and
lack of human resources was also reported.
Srivastava V. K et al. (2009) 20
Another study was conducted for Rapid Assessment of Essential Newborn Care
Services and Rural Health Needs in National Mission Priority States of India to
see the availability of essential newborn care services and providers knowledge
and skills related to their provision in facilities at all levels of the government
health system.
The study was carried out in 10 states covering 11 districts including both EAG
and non-EAG districts. Out of 11 districts, seven had received training underNNF (in NNF districts) while four did not receive such training (in non NNF
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districts). It found that Essential newborn care infrastructure and laboratory
services were far from adequate at DHs and CHCs. PHCs were grossly deficient
for newborn care and Essential newborn care equipment was available in the
majority of DHs but CHCs and PHCs were not adequately equipped. Essential
drugs and supplies were available in most of the DHs. DHs had a pediatrician
compared to one-third of the CHCs. Staff nurses for essential newborn care
functions were available in almost all DHs and CHCs and one-half of the PHCs.
The doctors posted at DHs were more skilled compared to those posted at CHCs
and PHCs. No DH reported offering referral services since all facilities reported
providing complete essential newborn care services. The transport for referral of
patients to a higher-level health facility was available in a large number of the
CHCs and approximately half of the PHCs. Poor implementation of the program
were cited as the main reason for poor performance of the program by most of
the policy planners and state level program managers. Inadequate funds to
upgrade existing infrastructure was another reason given for the state of
newborn care services14.
Paul V.Ket al. (2000) 21
A survey was conducted in three states of India namely, Orissa, Himachal
Pradesh and Haryana. The study was carried out at district, sub-district and
primary health centres to assess status of neonatal care at these facilities. In
Orissa, the district and sub-district hospitals had median 100 and 30 deliveries
per month respectively. The study also found that most of these deliveries were
carried out by nurses and not by doctors. Neonates were generally kept for a day
in these facilities for supervision. Whereas; primary health centres seldom
admitted a sick neonate and rarely conducted any deliveries. Most of Caesarean
section deliveries were conducted at district hospital only.
D. K. Guha (1989) 22
A study was conducted on the existing facilities and concept of newborn care. A
questionnaire was sent to 135 hospitals. Most of the nurseries were found with
inadequate infrastructure for space. The nurse: baby and doctor: baby ratios
http://www.ncbi.nlm.nih.gov/pubmed?term=Paul%20VK%5BAuthor%5D&cauthor=true&cauthor_uid=10885212http://www.ncbi.nlm.nih.gov/pubmed?term=Paul%20VK%5BAuthor%5D&cauthor=true&cauthor_uid=10885212 -
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were improper as per recommended. Most of the NSCUs were found to have
gaps in maintenance of asepsis environment. Equipment, like incubators and
phototherapy units were inadequate. The higher morbidity and mortality was
among the LBW babies, those belonging to 1000-1500grms group.
P. R. Sodani (2011) 23
Another study was conducted in 13 community health centres of Bharathpur
District of Rajasthan, India. The main objective of study was to find out the
availability of infrastructure facility, human resources, laboratory service and
facility based newborn care service according to Indian public health standards
(IPHS). The process of data collection methods was through well- structured
questionnaire filled by service providers. Availability of infrastructure was
found to be adequate in most of CHCs but there was shortage of human
resource especially specialists. It was also observed that none of community
health centres were fully equipped to carry out facility based newborn care
service including newborn care corner (NBCC) and newborn stabilization unit
(NBSU).
Forhad Akhtar Zaman et al. (2008) 24
A cross-sectional study was carried out to find out and compare to what extent
the Indian Public Health Standards (IPHS) were followed by the PHCs of
selected EAG and non EAG states (Assam and Karnataka respectively). It was
found that all PHCs were rendering assured services of OPD, 24 hour general
emergency services and referral services but 24 hour delivery services were
provided by 80% of PHCs. Functional labor rooms were available in 90% of
PHCs and basic lab. services in 80% of them. So, the study revealed few
important deficiencies as per IPHS norms in the PHCs visited.
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Karnataka scenario:
Rao Arathi P (2011) 2
A study conducted on causes of infant mortality in Udupi District showed
Neonatal mortality of 56% of total Infant deaths, explaining that out of all places
of deliveries, 97.2% were institutional based, 30.8% of them were delivered in
private nursing homes, 20.6% were delivered in taluk hospitals, government
tertiary hospitals and private tertiary hospitals and 4.7% were delivered in health
centres (PHCs/CHCs). Out of the personnel who conducted the delivery, 97.2%
were doctors. So, after focusing on the study results, it can be assumed that there
may be lack of facility towards newborn care and trained health personnel as
well as some constraint towards availability of infrastructure and utilization to
carry out new born essential care specially immediately after birth(0-7 days) 2.
C M Lakshmanaet al. (2010) 25
A District wise analysis was done to take stock of overall healthcare
infrastructure for children in all 29 districts of Karnataka. It was found that
there were no permanent doctors at child outpatient departments in four districts.
Sixteen out of 53 posts of paediatrics were vacant. Only 5 districts had adequate
beds for children. NICU was found to be non-existent in eight districts including
Udupi. Medical equipment like fibre optics, ultrasound and microscope were
found non-existent in few of the districts. 25.
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MATERIALS AND METHODS
Study area:
Public and Private Hospitals in Udupi taluk.
District Hospital
Community Health centres
Primary Health centres
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Private Hospitals
Health Care Facilities, Udupi Taluk, Karnataka, India. Neel kamal. [internet].
[Cited 2012.August 14]. Available from:
https://maps.google.co.in/maps/ms?
msid=208588570602665024468.0004c72065bc4adb25dfb&msa=0&ll=13.37
0915,74.793549&spn=0.538431,1.347198
Study design:
Cross-sectional study.
Study population:
Public and Private Health care facilities providing delivery services in Udupi
taluk.
Sampling technique:
Complete enumeration of government & private hospitals in Udupi taluk.
Total hospitals in Udupi Taluk= 48 [(Government=26) & (Private=22)]
Total hospitals in Udupi taluk providing delivery services = 44
[(Government=26) & (Private= 18)]
Total hospitals (44 from Udupi taluk)
--------------------------------------------------------------------
Government hospitals Private hospitals
(26) (18)
https://maps.google.co.in/maps/ms?msid=208588570602665024468.0004c72065bc4adb25dfb&msa=0&ll=13.370915,74.793549&spn=0.538431,1.347198https://maps.google.co.in/maps/ms?msid=208588570602665024468.0004c72065bc4adb25dfb&msa=0&ll=13.370915,74.793549&spn=0.538431,1.347198https://maps.google.co.in/maps/ms?msid=208588570602665024468.0004c72065bc4adb25dfb&msa=0&ll=13.370915,74.793549&spn=0.538431,1.347198https://maps.google.co.in/maps/ms?msid=208588570602665024468.0004c72065bc4adb25dfb&msa=0&ll=13.370915,74.793549&spn=0.538431,1.347198https://maps.google.co.in/maps/ms?msid=208588570602665024468.0004c72065bc4adb25dfb&msa=0&ll=13.370915,74.793549&spn=0.538431,1.347198https://maps.google.co.in/maps/ms?msid=208588570602665024468.0004c72065bc4adb25dfb&msa=0&ll=13.370915,74.793549&spn=0.538431,1.347198 -
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PHCs District hospital CHCs
(22) (1) (3)
Inclusion criteria:
All the PHCs, CHCs, District Hospital and Private Hospitals providing delivery
services in Udupi Taluk.
Study period:
The study was conducted from March 2012 to August 2012.
Study tools:
Standard checklist for Newborn care facility assessment. (Facility based
Newborn care operational guide 2011, MoHFW, GOI)
Data collection methods:
(1) Site assessment.
(2) Interview with head of the institution or the in charge of heath care facility.
(3) Reviewing the records/registers.
Site assessment:
The process based on observation of:
Infrastructure, Equipment & supply.
Interview:
To collect information on available facilities for Newborn care.
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Human resources with their training status for providing Newborn care
services.
Reviewing the records/registers
To collect information on newborn care indicators.
Data analysis:
Analysis has been done using SPSS 15 version. Data has been expressed in
frequency and percentage.
Ethical consideration:
The proposal was approved by Institutional Ethics Committee, Kasturba
Medical Hospital, Manipal.
Written permission from District Health officer (DHO), Udupi for
Primary Health centres and Community Health centres.
Written permission from District surgeon, Udupi for District (MCH)
Hospital.
Request letter from Indian Medical Association (IMA) President, Udupi
District for Private Hospitals.
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RESULTS AND
DISCUSSION
RESULTS AND DISCUSSION
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In the overall planning of facility based care, it is important to understand the
level of care that can be provided at the various facility levels. The present study
aimed to assess the availability of infrastructure, equipment, supply and Human
resource in all Health care facilities providing delivery services in Udupi Taluk.
Table 1: Types of Health care Facilities in Udupi Taluk
Types of Health Facilities Frequency (N) Percentage (%)
Primary Health Centres (PHCs)
Community Health Centres (CHCs)
District Hospital (DH)
Private Hospitals (PHs)
22
3
1
17
51.1
6.9
2.3
39.5
Total 43100
The table above shows the distribution of Health care facilities in Udupi taluk.Among the facilities visited, there were twenty two Primary Health Centres,
three Community Health Centres, one District Hospital and seventeen Private
Hospitals.
Figure: 1
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Tables 2: Table -Newborn Care Services:
S.NO VARIABLESCATEGORIES
TYPES OF HEALTH FACILITIES
PrimaryHealth Centre
(22)
N (%)
CommunityHealth Centre
(3)
N (%)
DistrictHospital
(1)
N (%)
1.
Is there 24hrs duty roster
observed andStaff present on-site?
Yes1 (4.5) 3 (100.0) 1 (100.0) 1
2.
Which type of delivery
services does the hospitalprovide?
No deliveryservice 3 (13.6) 0 (.0) 0 (.0)
Only Normal 19 (86.3) 3 (100.0) 0 (.0)
Normal, Manual,
Assisted and
C-section
0 (.0) 0 (.0) 1 (100.0) 1
3.
Does the hospital provide
essential newborn care
services?Yes
14 (63.6) 3 (100.0) 1 (100.0) 1
4.
Does the hospital provide
referral services?Yes
22 (100.0) 3 (100.0) 1 (100.0) 1
5.
Does the hospital havefunctional ambulance or
other vehicle on site of
Referral?
Yes 3 (13.6) 2 (66.7) 1 (100.0)
6.
Does the hospital provide
24hr coverage for deliveryand newborn care?
No 24 hr coverage 5 (22.7) 0 (.0) 0 (.0)
Only deliveries 16 (72.7) 0 (.0) 0 (.0)
both deliveries
and newborn care 1 (4.5) 3 (100.0) 1 (100.0) 1
7.
Is the person skilled inconducting deliveries
present at hospital or on call24-hrs a day including
weekend, to providedelivery care?
No skilled persons
observed 5 (22.7) 0 (.0) 0 (.0)
Yes present,schedule observed 1 (4.5) 0 (.0) 1 (100.0)
Yes, on call,schedule observed 16 (72.7) 3 (100.0) 0 (.0)
8.
Who attends the
complicated delivery at
hospital?
Obstetrician 0 (.0) 1 (33.3) 1 (100.0)
Obstetrician andPaediatrician 0 (.0) 0 (.0) 0 (.0)
Referred to higherservices 22 (100.0) 2 (66.7) 0 (.0)
9.Is there any post-partum
care offered at the hospital? Yes20 (90.9) 3 (100.0) 1 (100.0) 1
10.Does hospital immunizes
newborns?Yes 22 (100.0) 3 (100.0) 1 (100.0)
11.Does hospital have essential
laboratory services?Yes 22 (100.0) 3 (100.0) 1 (100.0)
12.Does hospital have blood
transfusion service?Yes Not applicable Not applicable 1 (100.0)
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Private Hospital (PHs)
All Private Hospitals have 24*7coverage with staff present with
observed duty roster.
But only 53% of Hospitals have skilled staff present for conducting
deliveries 24hours including weekend whereas; 47% of hospitals have on
call facilities for same.
All Private Hospitals have facilities to conduct deliveries in term of
normal as well as complicated.
All Private Hospitals provide referral, essential newborn care and post-
partum services but immunization services are unavailable in 23% PHs
and onsite vehicle not present in 29% PHs.
Two Private Hospitals do not have essential lab. services and one is
without blood transfusion facility.
Koyejo Oyerinde et al.16found that no hospital could be traced with basic EmOC
and only few facilities were able to provide assisted vaginal deliveries (AVD)
among public, private, mission and non-governmental organizations (NGOs)
hospitals providing maternal and child health services.
Youn-g Mi Kim et al.17also reportedthat 42% of the peripheral health facilities
did not have sufficient facility to provide or deliver comprehensive emergency
obstetric and Neonatal care (EMoNC) facilities and services like C-sections
were provided in 33% of CHCs, 76% of District Hospitals and all regional
hospitals of Afghanistan.
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Tables 3A: Table Infrastructure for Newborn Care
S.NO VARIABLES
TYPES OF HEALTH FACILITIES
Primary Health
Centre
(22)
Community Health
Centre
(3)
District
Hospital
(1)
Private
Hospita
(16)
Quantity N (%) Quantity N (%) N Quantity
1. Total no. of beds
0 1 (4.5)
30 3 (100.0) 79
15-50
1-3 10 (45.5) 51-100
4-6 11 (50.0) >100
2.
No. ofmaternity/postnatal
Beds
0 15 (68.2) 5 1(33.3)
50
0
1-3 6 (27.3) 6 1(33.3) 1-20
4 1 (4.5) 12 1(33.3) 21-40
3.No of newborn
beds
0 20 (90.9) 0 1(33.3)
29
0
1-4
1 2 (9.1) 1-6 2 (66.7)5-8
12
4. No. of labor room 1 22 (100.0) 1 3 (100.0) 1
1 1
2
5. No. of OT NA 1 3 (100.0) 1
1
2
3
6.No. of postnatal
ward NA 13 (100.0) 2
0
1 1
7. NBCC 1 1(4.5) 1 3 (100.0) 10
1 1
8. SNCU / NICU NA NA 1
0 1
1
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In the table above, one Private Hospital has been excluded as it is a Medical College & Teaching
Hospital with maximum no. of beds.
Tables 3B: Table- Infrastructure for Newborn Care
S.NO VARIABLES CATEGORIES
TYPES OF HEALTH FACILITIES
Primary Health
Centre
(22)
N (%)
Community
Health Centre
(3)
N (%)
District
Hospital
(1)
N (%)
Pr
H
N
1.
Where is the deliveryand neonatal
equipment located?
Labor Room 16 (72.7) 3 (100.0) 1 (100.0) 8
Others 6 (27.3) 0 (.0) 0 (.0) 9
2.Does the hospital
have adequate light? Yes 18 (88.1) 3 (100.0) 1 (100.0) 17
3.
Which type of power
backup does thehospital have?
No powerbackup 5 (22.7) 1 (33.3) 0 (.0) 0
Generator 1 (4.5) 1 (33.3) 1 (100.0) 17
Inverter 16 (72.7) 1 (33.3) 0 (.0) 0
4.
Which type of water
source does thehospital have?
Open-well 5 (22.7) 1 (33.3) 0 (.0) 3
Bore-well 3 (13.6) 2 (66.7) 0 (.0) 1
Panchayat 9 (40.9) 0 (.0) 0 (.0) 1
Mix 5 (22.7) 0 (.0) 1 (100.0) 12
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Tables 3C: Table - Infrastructure for Newborn Care
S.NO VARIABLES CATEGORIES
TYPES OF HEALTH FACILITIES
District Hospital
(1)
N (%)
Private Hospital
(17)
N (%)
1.Area for Hand
washing Yes 1 (100.0) 17(100.0)
2.Area for mixing IV
fluid Yes 1 (100.0) 17(100.0)
3.
Area for boiling &
autoclaving Yes 1 (100.0) 15 (80.2)
4. Area for laundry Yes 1 (100.0) 17(100.0)
5. Clean utility area Yes 1 (100.0) 17(100.0)
6. Soiled utility area Yes 1 (100.0) 16 (94.1)
7. Store room Yes 1 (100.0) 17 (100.0)
8. Side lab Yes 0 (.0) 2 (11.1)
Primary Health Centres (PHCs)
Fifty percent of the PHCs are 4-6 bedded and one PHC has no beds.
Twenty seven percent of PHCs have 1-3 maternity beds and 68% PHCs
have not allotted any maternity beds whereas; only two PHCs are with
one Newborn bed. This can be explained as due to poor demand of the
services because most of the people prefer District and Private Hospitals
for birth of their children.
All PHCs have one labor room each but NBCC is available only in one
PHC.
Seventy three per cent of PHCs have placed the delivery and Neonatal
equipment in labor room whereas other 27% have kept in other than
labor room.
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Adequate light for examination is available in 88% PHCs.
Seventy three per cent PHCs use invertor whereas 28% are without any
power backup.
Primary Health Centres utilize water from different sources with 41%
using water from Panchayat source.
Community Health Centres (CHCs)
All Community Health Centres are thirty bedded with two CHCs having
5-6 maternity beds each and only one CHC with no bed for the
Newborns.
Designated area for one labor room, OT and one NBCC each available in
all CHCs.
All CHCs have placed delivery & neonatal equipment in labor room with
adequate light for examination.
One Community Health Centre has no power back up and water source
for two CHCs is from bore-well.
District Hospital (DH)
District Hospital has 50 maternity beds and 29 newborn beds.
Designated area for labor room, OT, NBCC in labor room, postnatal
ward and a separate SNCU available in District Hospitals.
Delivery and neonatal equipment are placed in labor room with adequate
light for examination.
District Hospital uses Generator as power backup and has multiple
sources for water supply.
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District Hospital has a separate ancillary area each for hand washing, IV
fluid mixing, autoclaving, utility and store room but no side lab.
Private Hospitals (PHs)
Nineteen per cent PHs are without maternity beds and 31.3% are without
newborn beds.
All Private Hospitals have designated area for labor room and OT.
Eighty seven per cent of PHs has one post natal ward each and 69% have
one NBCC in labor room but NICU is unavailable in 69% of PHs.
Delivery and Neonatal equipment are placed in labor room with
adequate light for examination in all PHs.
All Private Hospitals use Generator as power backup and 71% use
multiple sources for water supply.
All Private Hospitals have separate ancillary area each for hand washing,
IV fluid mixing, autoclaving, utility and store room but side lab was
present only in two Private Hospitals.
According to the guidelines on Facility Based Newborn Care (2011) formulated
by Ministry of Health and Family Welfare, Government of India, Newborn Care
Corner is mandatory for all health care facilities where deliveries are conducted
and SNCU is deemed compulsory at District level and above. The study
revealed that all health facilities visited provided delivery services except four
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PHCs but NBCC and SNCU/NICU services were available only at District
Hospital and few Private Hospitals (35%).
Casey et al. (2009)13 found that the facilities had poor infrastructure, infection
prevention and poor monitoring of reproductive health services related to EmOC
in a study conducted by International Rescue Committee (IRC) and CARE as
baseline assessments of public hospitals to determine the availability, utilization
and quality of reproductive services in nine general referral hospitals of
democratic republic of Congo.
Sutapa Neogi et al.5 findings concluded that the SNCUs visited in eight rural
districts of India had availability but inadequate repair and maintenance of
equipment and lack of Human resources. So, more research is still required to
evaluate the quality and monitoring of the health care facilities for a satisfactory
conclusion and planning of the programs and policies for newborn care in the
taluk.
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Tables 4A: Table Equipment for Management:
S.NO VARIABLES
TYPES OF HEALTH FACILITIES
Primary Health centres
(22)
Community Health
centres(3)
District
Hospital(1)
Private
Hospitals(16)
Quantity N (%) Quantity N (%) N Quantity N (%)
1. Radiant warmer
0 21 (95.5) 1 2 (66.7)
9
0 6 (37.5)
1 1 (4.5) 2 1 (33.3)
1-3 9 (56.2)
5 1 (6.3)
2.Phototherapy unitsingle head high
Intensity
NA
0 2 (66.7)
6
0 1 (6.3)
2 1 (33.3)
1-2 11 (68.7)
4 4 (25.0)
3. Incubator NA NA 0
0 9 (56.2)
1 6 (37.5)
2 1 (6.3)
In the table above one Private Hospital has been excluded as it was Medical College &
Teaching Hospital had maximum number of Equipment.
Primary Health Centres (PHCs)
Though 19 PHCs conduct deliveries (on call) but radiant warmer is
available in only one PHC.
Community Health Centres (CHCs)
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Three radiant warmers are required in each CHC but two CHCs have one
radiant warmer each and one CHC with two radiant warmers only.
One phototherapy unit is required in each CHC but two CHCs did not
have the same.
District Hospital (DH)
District Hospital has nine radiant warmers, six phototherapy units and no
incubator.
Private Hospitals (PHs)
Sixty nine percent Private Hospitals have radiant warmers, 94% have
phototherapy unit and 47% have incubator.
Tables 4B: Table - Equipment for Monitoring:
S.NO VARIABLES
TYPES OF HEALTH FACILITIES
Primary Health centres
(22)
Community Health
centres
(3)
District
Hospital
(1)
Private
Hospitals
(16)
Quantity N (%) Quantity N (%) N Quantity N (%)
1. Baby weighing scale 1 22 (100.0) 1 3 (100.0) 11 10 (62.5)
2 6 (37.5)
2. Thermometer 1 22 (100.0) 1 3(100.0) 8
1-3 12 (75.0)
4-6 4 (25.0)
3. Pulse oximeter NA NA 6
0 1 (6.3)
1-2 12 (75.0)
3 3 (18.7)
4. Stethoscope Neonates NA NA 13
0 1 (6.3)
1-3 12 (75.0)
4-5 3 (18.7)
5. Sphygmomanometer NA NA 1
0 2 (12.5)
1 5 (31.3)
2 9 (56.2)
6. Vital sign monitor NA NA 1
0 2 (12.5)
1 9 (56.2)2 5 (31.3)
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In the table above one Private Hospital has been excluded as it was Medical College &
Teaching Hospital with maximum number of Equipment.
Primary Health Centres (PHCs)
All PHCs have one mechanical baby weighing scale and one
thermometer each.
Community Health Centres (CHCs)
All Community Health Centres have one electronic baby weighing scale
and one thermometer each but four thermometers are required in each
CHC.
District Hospital (DH)
District Hospital has one electronic baby weighing scale in SNCU, eight
thermometers, six pulse oximeters, thirteen neonate stethoscopes, one
sphygmomanometer and one vital sign monitor but four electronic baby
weighing scales, twelve thermometers and six sphygmomanometers are
required.
Private Hospitals (PHs)
Fifty nine percent Private Hospitals have one baby weighing scale each
and 41% have two each.
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Seventy percent of Private Hospitals have atleast one thermometer each
and 30% have atleast 4 thermometers each.
Seventy percent of Private Hospitals have atleast one pulse oximeter and
one thermometer each and 30% have three of both each.
Twenty nine percent Private Hospitals have one sphygmomanometer
each and 59% have atleast two each.
Fifty three percent of Private Hospitals have one vital sign monitor each
and 35% have atleast five each.
Tables 4C: Table- Equipment for Investigation:
S.NO VARIABLES
TYPES OF HEALTH FACILITIES
Primary Health centres
(22)
Community Health
centres
(3)
District
Hospital
(1)
Private
Hospitals
(16)
Quantity N (%) Quantity N (%) N Quantity N (%)
1.
Centrifuge,
hematocrit
benchtop, up to12000 rpm,
including rotator
0 1 (4.5) 1 2 (66.7)
2
0 2 (12.5)
1 21 (95.5) 2 1(33.3)1 5 (31.3)2 9 (56.2)
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2. Microscope
1 21 (95.5) 1 2 (66.7)
2
0 2 (12.5)
2 1 (4.5) 2 1 (33.3)1-2 8 (50.0)
2-3 6 (37.5)
3.Bilirubinometer,total bilirubin,
capillary based
0 20 (90.9) 0 2 (66.7)1
0 7 (43.8)
1 2 (9.1) 1 1 (33.3) 1 9 (56.2)
4. Glucometer
0 3 (13.6) 1 2 (66.7)
2
0 2 (12.5)
1 19 (86.4) 2 1 (33.3)1-2 13 (81.2)
6 1 (6.3)
5. ECG unit portable NA NA 0 0 3 (18.7)
1 9 (56.2)
2 5 (31.3)
6. X-ray mobile NA NA 00 5 (31.3)
1 11 (68.7)
In the table above one Private Hospital has been excluded as it was Medical College
& Teaching Hospital had maximum number of Equipment.
Primary Health Centres (PHCs)
Ninety five percent PHCs have one centrifuge and one microscope each.
Eighty six percent have one glucometer each but 91% of PHCs do not
have bilirubinometer.
Community Health Centres (CHCs)
All CHCs have atleast one centrifuge, one microscope and one
glucometer each but bilirubinometer is not available in two CHCs.
District Hospital (DH)
District Hospital has two centrifuges, two microscopes; two glucometer
(three required) and one bilirubinometer but no portable ECG (desired)
and mobile X-ray (desired) could be traced.
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Private Hospitals (PHs)
Fifty nine percent of Private Hospitals have atleast two centrifuges and
two PHs do not have it.
Forty seven percent of PHs have atleast one microscope each and 41%
have atleast two microscopes each.
Fifty-nine per cent have atleast one bilirubinometer and 81% have atleast
one glucometer.
Eighty eight percent have portable ECG unit and 69% have mobile X-ray
facility.
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Tables 4D: Table- Equipment for Resuscitation:
S.NO VARIABLES
TYPES OF HEALTH FACILITIES
Primary Health centres
(22)
Community Health
centres
(3)
District
Hospital
(1)
Privat
Hospit
(16)
Quantity N (%) Quantity N (%) N Quantity
1.Resuscitator, hand
operated 500ml
0 18 (81.8)
0 3 (100.0) 11 1
1 3 (13.6)
2 1 (4.5) 2
2.Resuscitator, hand
operated 250ml
0 11 (50.0)1 3 (100.0) 4
1 1
1 11 (50.0) 2
3.Pump suction, foot
operated
0 8 (36.4) 1 2 (66.7)
1
0 1
1 13 (59.1)2 1 (33.3) 1
2 1 (4.5)
4.Suction pump
portable,
220v.w/access
NA 0 3 (100.0) 21 1
2-4
5.Laryngoscope sets,
NeonatesNA
1 2 (66.7)5
1-2 1
2 1 (33.3) 3-4
In the table above one Private Hospital has been excluded as it was Medical College &
Teaching Hospital had maximum number of Equipment.
Primary Health Centres (PHCs)
Fifty per cent of the PHCs have at least one 250ml resuscitator each and
one foot operated pump suction was available in 60% of PHCs each
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whereas; resuscitator 500ml is available (1 required in each PHC) only in
18% of PHCs.
Community Health Centres (CHCs)
All CHCs have atleast one 250ml resuscitator each and one pump-
suction foot operated each. Whereas; resuscitator 500ml is not available
(2 required in each CHC) in any of CHCs.
District Hospital (DH)
District Hospitals has four resuscitator 250ml, one foot operated suction,
two portable suction pumps and five laryngoscope sets.
Private Hospitals (PHs)
All PHs have at least one resuscitator 250ml, one portable suction pump
and one laryngoscope set each but foot operated suction is available only
in 31% PHs.
Tables 4E: Table- Equipment for Disinfection:
S.NO VARIABLES
TYPES OF HEALTH FACILITIES
Primary Health centres
(22)
Community Health
centres
(3)
District
Hospital
(1)
Private
Hospitals
(16)
Quantity N (%) Quantity N (%) N Quantity N (%)
1.Syringe hub cutter
1 17 (77.3) 2 1 (33.3)1
0 9 (56.3)
2-5 5 (22.7) 3 2 (66.7) 1 7 (43.7)
2.Sterilizing drum
165mm diameter
1 21 (95.5)1 3 (100.0) 5
1-3 4 (25.0)
2 1 (4.5) 4-6 12 (75.0)
3. Electric sterilizer
0 2 (9.1)
1 3 (100.0) 0
0 3 (18.7)
1 20 (90.9)1 11 (68.8)
2 2 (12.5)
4. Gowns
0 3 (13.6) 6 2 (66.7)
25
1-10 7 (43.7)
3 19 (86.4) 9 3 (33.3)11-20 7 (43.7)
21-30 2 (12.5)
5. Washable slippers 0 6 (27.3) 2 1 (33.3) 12 1-6 7 (43.7)1-3 13(59.1) 3 1 (33.3) 7-12 7 (43.7)
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4 3 (13.6) 4 1 (33.3) >=20 2 (12.5)
6. Washing machine 0 22 (100.0) 0 3 (100.0) 10 8 (50.0)
1 8 (50.0)
In the table above one Private Hospital has been excluded as it was Medical College &
Teaching Hospital had maximum number of Equipment.
Primary Health Centres (PHCs)
All PHCs have at least one syringe hub cutter, one sterilizing drum and
one electric sterilizer each.
Gowns and washable slippers were not available in three and six PHCs
respectively.
Community Health Centres (CHCs)
All Community Health Centres have one sterilizing drum, one electric
sterilizer and atleast six gowns each.
District Hospital (DH)
District Hospital has one syringe hub cutter, five sterilizing drums, 25
gowns and 12 washable slippers but no electric sterilizer because it has
separate autoclave facility.
Private Hospitals (PHs)
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Twenty four percent Private Hospitals have atleast one sterilizing drum
each and 76% have atleast four each.
Syringe hub cutter is unavailable in 53% of PHs because waste disposal
is handled by a local based company.
All Private Hospitals have electric sterilizer, gowns and washable
slippers except no electric sterilizer in three private hospitals as these
hospitals have separate autoclaving facilities.
General Equipment:
Four syringe pumps were available in District Hospital whereas 62.5%
of Private Hospitals did not have any syringe pump. In addition, surgical
instruments were found in all Private Hospitals as well as District
Hospital.
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All health care facilities had one computer with printer each except 20%
Private Hospitals.
All health care facilities were equipped with atleast one refrigerator,
stabilizer and wall clock each. In addition, air conditioner was not
present in any CHC and 12.5% of PHs.
Sixty nine percent of Private Hospitals were lacking with infanotometer
plexi and no room heater was available in any of health facilities except
one Private Hospital.
Measuring tape, kidney basin, dressing tray and infusion stand were
available in District Hospital and all Private Hospitals.
Spot lamp was available in two CHCs, District Hospital and all Private
Hospitals.
Charles Opondo et al12 also found lack of hygienic environment and some key
equipment in first referral units of Kenya, which is also a developing country.
Sara E Casey et al13 also reported shortage of equipment, essential drugs and
poor infection prevention in public hospitals of Congo.
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A B Biswas et al19 showed that there was inadequate infrastructure facilities (e.g.
no sanctioned post of specialist, no blood bank at rural hospital) and poor
utilization of equipment like neonatal resuscitation sets, radiant warmer, lack of
training of service providers were evident. It was also reported that most of the
deliveries and immediate Neonatal resuscitation was done by nurses (94.9%) 19
in first referral level hospitals in six Districts of West Bengal.
Neogi Sutapa et al. (2011) 5 also reported inadequate repair and maintenance of
the equipment in eight rural districts of India. Most of the NSCUs were found to
have gaps in maintenance of asepsis environment.
D. K. Guha (1989) 22 reported that equipment, like incubators and phototherapy
units were inadequate in most of the health facilities.
Srivastava V. K et al. (2009) 20 found that Essential newborn care equipment was
available in the majority of DHs but CHCs and PHCs were not adequately
equipped. Essential drugs and supplies were available in most of the DHs. Poor
implementation of the program were cited as the main reason for poor
performance of the program by most of the policy planners and state level
program managers in eleven Districts of India.
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Tables 5A: Table - Human Resource for Newborn Care
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In the table above one Private Hospital has been as it was Medical College & Teaching Hospital
with maximum number of Human Recourses.
Primary Health Centres (PHCs)
S.NO VARIABLES
TYPES OF HEALTH FACILITIES
Primary Health
Centre
(22)
Community Health
Centre
(3)
District
Hospital
(1)
Private
Hospital
(16)
Quantity N (%) Quantity N (%) N (%) Quantity N (%)
1 Paediatrician
Permanent NA 1 1 (33.3) 2 (100.0) 10 7 (43.7)
Contractual NA 0 (0) 0 (.0) 25 9 (56.3)
2. OB/GYN
Permanent NA 1 1 (33.3) 1 (100.0)
0 4 (25.0)
1 10 (62.5)
2-5 2 (12.5)
Contractual NA 0 (.0) 0 (.0)
0 7 (43.7)
1 4 (25.0)
2-4 5 (31.3)
1. Medical
officers
Permanent 21 21(95.5) 3 3 (100.0) 0 (0)0 3 (18.7)
1-5 13 (81.3)
Contractual 1 1 (4.5) 0 (0) 3 (100.0)0 15 (93.7)
4 1 (6.3)
2. Staff nurse
Permanent 10 10(45.5)14 3 (100.0)
0 (0)
4-8 10 (62.5)
9-16 5 (31.2)
24 1 (6.2)
Contractual 4 2 (9.1) 4 2 (66.7) 12 (100.0) 0 (0) 0 (0)
4.Lab.
Technician
Permanent 20 20(90.9) 3 3 (100.0) 1 (100.0) 36 14 (87.5)
Contractual 2 2 (9.1) 0 (.0) 0 (.0) 0 2 (12.5)
5. Data manager
Permanent 0 (.0) 3 3 (100.0) 1 (100.0) 24 13 (81.2)
Contractual 0 (.0) 0 (.0) 0 (.0) 0 3 (18.7)
6.Supporting
staff
Permanent 23 17(77.3) 10 3 (100.0) 4 (100.0) 73 15 (93.7)
Contractual 6 5 (22.7) 0 (.0) 0 (.0) 15 1 (6.2)
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Three Private Hospitals do not have Medical officers and all PHs have
permanent staff nurses working in the hospitals.
All PHs have permanent Lab. technicians, Data manager and supporting
staff.
Tables 5B: Table - Human Recourses with Training status
CODES FOR TRAINING STATUS DAYS OF TRAINING ATTENDED
A. IMNCI: for medical officer/ staff nurse 8 Days
B. F-IMNCI: for medical officer/ staff nurse 11 Days
C. NSSK: for medical officer/ staff nurse/ANM 2 Days
D. Facility based newborn care: for medicalofficer/staff nurse posted in SNCU
3 Days
E. SBA for ANMs/LHVs & Staff nurse 2-3 Days
F. SBA/BEmOC for Medical officer 9 Days
G. Observership 2 Weeks
H. Neonatology 3 months
S.NO VARIABLES
TRAINING STATUS
N
o
T
r
a
i
n
i
n
g
B C F B
&
C
B
&
F
C
&
F
E
&
G
B
,
C
&
G
B
,
C
&
F
B
,
E
&
G
B
,
C
&
D
C
,
E
&
G
C
,
E
&
F
PHC
(22)Medicalofficers
Permanent(21)
2 3 0 2 9 3 0 0 0 1 0 1 0 0
Contractual
(1)1 0 0 0 0 0 0 0 0 0 0 0 0 0
Staff
nurse
Permanent(10)
1 1 0 0 1 0 0 0 1 0 2 0 0 0
Contractual(4)
1 0 0 0 0 0 0 2 0 0 0 0 0 0
CHC
(3)
Medical
officers
Permanent
(3)0 0 0 1 0 0 1 0 0 1 0 0 0 0
Staffnurse Permanent(14) 0 0 1 0 2 0 0 2 0 0 3 0 3 0
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Contractual(4)
0 0 0 0 0 0 0 0 0 0 1 0 2 0
In the District hospital, out of 3 only 1 Medical Officer and all 12 staff
nurses were trained in Neonatology.
In all Private Hospitals, neither Medical officers nor Staff nurses were
trained, except two Paediatricians trained with one year fellowship in
Neonatology.
Primary Health Centres (PHCs)
Most of the Medical officers in PHCs were trained with F-IMNCI and
NSSK.
Staff nurses in most of the PHCs were trained with F-IMNCI, NSSK,
SBA and observer-ship.
Community Health Centres (CHCs)
In all CHCs, Medical officers were trained with BEmOC and NSSK.
District Hospital (DH)
In the District Hospital, out of 3 only one Medical Officer and all 12
staff nurses were trained in Neonatology for 3 months.
Private Hospitals (PHs)
In all Private Hospitals, neither Medical officers nor Staff nurses were
trained, except two paediatricians trained with one year fellowship in
Neonatology.
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Sara E Casey et al.13 also reported shortage of staff in public hospitals of Congo.
Charles Opondo reported that there was often lack of poorly organized and
insufficient staffing to support the provision of care at eight first referral level
hospitals in Kenya.
Charles Ahmeh et al.18 evaluated the baseline and after training, performance
and confidence of the Human resource for emergency obstetric and Newborn
care (life- saving skills). They concluded that though there was improvement in
confidence, knowledge and skills of the trained staff but the training of the staff
alone cant contribute sufficiently to obstetric and newborn care if there is
inadequacy of the equipment, supply and drugs. Moreover, sufficiently available
infrastructures, equipment, supply and Human resource can be left unused if the
staffs are not trained with the knowledge and skills required for obstetric and
Newborn care.
In addition, Koyejo Oyerinde et al.16 reported that there was severe shortage of
staff, equipment and supplies in his study.
Youn-g Mi Kim et al.17 found that 77% of the facilities cited lack of Human
resources in first referral level Hospitals in Afghanistan.
Biswas A B et al.19reported that most of the deliveries and immediate Neonatal
resuscitation was done by nurses (94.9%)in six Districts of West Bengal.
Neogi Sutapa et al.5 cited lack of Human resources in 8 rural Districts of India.
Srivastava V. K et al.
20
found that
DHs had a paediatrician compared to one-thirdof the CHCs. Staff nurses for essential newborn care functions were available in
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almost all DHs and CHCs and one-half of the PHCs. The doctors posted at DHs
were more skilled compared to those posted at CHCs and PHCs in 11 Districts
of India whereas; C M Lakshmanaet al.25 cited sixteen out of 53 vacant posts of
paediatrics in 29 districts of Karnataka.
Tables 6: Table Records of deliveries from last 3-months
S.NO VARIABLESTYPES OF HEALTH FACILITIES
District Hospital
(1)
Private Hospital
(15)
N (%) N (%) COUNT N (%)
1.
Normal/ Assisted
deliveries 414 (65.0) 391 (60.6)
0 1 (6.6)
1-50 12 (80.0)
51-100 1 (6.6)>100 1 (6.6)
2. C-section deliveries 219 (35.0) 255 (39.4)1-25 10 (66.7)
26-50 5 (33.3)
3. Total deliveries 633 646
1-50 10 (66.7)
51-100 4 (26.7)
>100 1 (6.6)
4. Total newborn deaths 6 51 3 (20.0)
2 1 (6.6)
5. Total live births 627 641
1-50 10 (66.6)
51-100 4 (26.7)
>100 1 (6.6)
In the table above two Private Hospitals have been excluded as they were Medical College& Teaching Hospitals with maximum number of deliveries.
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Primary Health Centres (PHCs)
No PHC has conducted any deliveries in last three months except one
PHC with 12 normal deliveries and one PHC with one normal delivery.
Community Health Centres (CHCs)
Out of three CHCs, one conducted four normal deliveries and one CHC
conducted one normal delivery.
District Hospital (DH)
District Hospital has conducted 65% normal & 35% C-section deliverieswith neonatal mortality of 9.57 per 1000 live births in last three months.
Private Hospitals (PHs)
Private hospitals have conducted 61% normal & 39% C-section
deliveries with neonatal mortality of 7.8% per 1000 live births in last
three months.
Tables 7: Table - Registers maintained for Newborns
S.NO VARIABLES CATEGORIES
TYPES OF HEALTH FACILITIES
Primary Health
Centre
(22)
N (%)
Community
Health Centre
(3)
N (%)
District
Hospital
(1)
N (%)
Priv
Hosp
(1
N (
1.Does the hospital
maintaindelivery and type
of birthregisters?
Yes 10 (45.5) 2 (66.7) 1 (100.0) 17 (10
2.Does the hospital
maintain OT
register?Yes 0 (0) 0 (0) 1 (100.0) 16 (9
3.Does the hospital
maintainnewborn
register?
Yes 6 (27.3) 0 (0) 1 (100.0) 5 (29
4.Does the hospital
maintain wardregister? Yes 12 (54.5) 3 (100.0) 1 (100.0) 14 (8
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5.Does the hospital
maintain
monthlyreports/HMIS?
Yes 20 (90.9%) 3 (100.0) 1 (100.0) 16 (9
6.Does the hospital
maintain labor
room register?
Yes 11 (50.0) 3 (100.0) 1 (100.0) 17 (10
7.Does the hospital
maintain birthregister?
Yes 7 (31.8) 1 (33.3) 1 (100.0) 10 (5
8.Does the hospital
maintain
neonatal deathregister?
Yes 12 (54.5) 1 (33.3) 1 (100.0) 6 (35
9.Does the hospitalmaintain circular
issue?Yes 20 (90.9) 3 (100.0) 1 (100.0) 17 (10
10.Does the hospital
maintainpartogram?
Yes 10 (45.5) 3 (100.0) 1 (100.0) 4 (23
11.Does the hospital
maintain birth
charts?Yes 17 (77.3) 3 (100.0) 1 (100.0%) 4 (23
The table above shows that:
All registers enlisted in the checklist were available and maintained by
District Hospital and two Private Hospitals only.
Delivery and type of birth register, ward register, Neonatal death register
and partogram were maintained by only 50% of PHCs, all CHCs andmost of the Private Hospitals except neonatal death register and
partogram maintained only by few Private Hospitals (35.3% and 23.5%
respectively)
None of the PHCs and CHCs maintained OT register and 94% of Private
Hospitals maintained the same.
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SUMMARY
SUMMARY
Health services depend, to a large extent, on the availability of both Human
resources and properly equipped health facilities. Maternal and Newborn care
services particularly depend on health facilities with the equipment and skilled
staff to provide the essential lifesaving services required for mothers with
complicated deliveries and ill Newborns. Hence, this cross-sectional study was
conducted to assess the availability of Neonatal care services in terms ofinfrastructure, equipment and Human resource in all 43 Health care facilities
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providing delivery services in Udupi taluk of Karnataka. The data was collected
through site assessment using a standard checklist, interviews and review of
records and registers by the single investigator. Collected data was entered and
analysed separately according to the objectives, to produce the results in form of
categorised variables and respective percentages. It was found that only one
Primary Health Centre was working 24 hours and conducted maximum
deliveries in last three months. Though two CHCs had specialists but the
complicated deliveries were handled only by the District hospital and Private
Hospitals. However, satisfactory referral services, postpartum care,
immunization services and essential laboratory services were available in all the
health care facilities visited.
Infrastructure was observed to be available in most of the PHCs, CHCs, District
Hospital and Private Hospitals. Equipment for management and investigation
equipment were unavailable in most of the facilities. However, monitoring
equipment was found to be available in most of the health facilities visited.
Government health facilities had more availability of resuscitation equipment as
compared to the private hospitals. Equipment for disinfection were available in
most of the health care facilities except the syringe hub cutter being unavailable
in 50% of Private Hospitals. Syringe pump and infanotometer plexi were
unavailable in high percentage of Private Hospitals.
The permanent and trained staffs were available more in the government health
facilities than Private Hospitals. Through the records, it can be concluded that
most of the deliveries were normal and conducted in District Hospital and
Private Hospitals in last three months. Complete records and registers enlisted in
the checklist were available and maintained by only District Hospital and two
Private Hospitals.
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CONCLUSION
CONCLUSION
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The present study assessed all the forty three health care facilities providing
delivery services in Udupi taluk of Karnataka. Through the results of the survey
it was revealed that out of all 22 PHCs, only one was working 24x7 as it handled
the maximum deliveries among all Primary Health Centres in the Taluk. Though
out of three, two CHCs had specialists but complicated deliveries were handled
only by the District Hospital and Private Hospitals in the area. However,
satisfactory referral services, postpartum care, immunization services and
essential lab. Services were available in all the health care facilities visited. Only
six Primary Health Centres had allotted beds for mothers and Newborns as
compared to requirement in all of the centres.
Infrastructure in terms of no. of beds, equipment location, power back up and
water source, was observed to be available in most of the PHCs, CHCs, District
Hospital and Private Hospitals. Equipment for management of Newborns like
radiant warmers and phototherapy units and investigation equipment like
Bilirubinometerwere unavailable in most of the facilities. However, monitoring
equipment was found to be available in most of the health facilities visited.
Government facilities had more availability of resuscitation equipment as
compared to the Private Hospitals. Oxygenation facility deemed as very
important for Newborn care, was found in all health care facilities. Equipment
for disinfection were available in most of the health care facilities except the
syringe hub cutter being unavailable in 50% of Private Hospitals.
The permanent and trained staffs were available more in the government sector
than Private sector. Most of the deliveries were normal and conducted in District
hospital and Private Hospitals in last three months. Estimated Neonatal mortality
rate was found to be 9.57 per 1000 and 7.8 per 1000 in District Hospital and
Private Hospital respectively in last three months. Complete records and
registers enlisted in the checklist were available and maintained by only District
hospital and two private hospitals.
Hence, it can be concluded that the health care facilities providing delivery
services in Udupi taluk need to be strengthened and further research on the
quality of the available services is required for successful planning and
implementation of the measures planned.
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LIMITATIONS
All the private hospitals could not be covered as one private hospitals
authorities were not willing to participate in the study.
During data collection, some of the private hospitals did not allow to
observe the NICU area, therefore the collected information is based on
the interviews only.
The present study is cross-sectional therefore more of analytical studies
can provide with detailed information and associations.
Lastly, the present study focussed on the availability of neonatal care
services in the taluk. The quality of the available services can be further
assessed by continued research and thus, reliable conclusion can be
achieved.
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APPENDIX
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Annexure 2
Ethical Committee Approval Certificate
Steps March
2012
April 2012 May
2012
June
2012
July
2012
August
2012
Problem
selection
Review of
literature
Preparation of
research
proposal
Ethical
committee
clearance
Protocol
presentation
Data collection
Data Analysis
Submission of
first Draft
Submission of
final draft
Submission of
manuscript
Final
presentation
Final submission
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Annexure 3
Request letter from IMA President Udupi District
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Annexure 4
Permission Letter from District Health Officer (DHO) Udupi
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Annexure 5
QUESTIONNAIRE FOR PRIMARY HEALTH CENTRES
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Availability of Neonatal care facilities in Udupi Taluk, Karnataka
Checklist for Newborn facilities Survey:
SECTION 1
01. Types of health facility: Primary
Health centre
02. Date of the Assessment:
03. Name of facility Institution:
04. Location of the facility Institution:
...
Signature of In-charge
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SECTION: 2
AVAILABILITY OF NEWBORN CARE SERVICES
Yes No
05. Is there 24- hours delivery and newborn care coverage?
If yes, specify;
A. Yes 24-hours duty roster observed or staff present onsite
B. Yes 24-hours coverage but no duty roster observed & no staff present onsite
06. Does hospital provide following delivery service?
If yes, specify;
A. Normal deliveries B. Manual removal of Placenta
C. Assisted deliveries D. Caesarean section
(E.g. forceps/vacuum) (C- section) delivery
E. Administration of parental oxytocics/antibiotics/inj.
Magnesium sulphate/Management of PPH/others complications
07. Does hospital have essential newborn care services?If yes; specify
A. Resuscitation B. Thermal care
C. Breast feeding support services
08. Does the hospital provide referral services?
09. Does the hospital provide 24-coverage for delivery &newborn care
Services? If yes; specify
A. Only deliveries services B. Only newborn care services
C .Both deliveries & newborn care services
10. Is the person skilled in conducting deliveries present at the hospital or
on call 24-hours a day, including weekends, to provide delivery care?
A. Yes present, schedule observed B. Yes present, schedule reported, n