January 2015
Changes that
improved
maternal and
neonatal health
in Delhi
Health facilities in
NCT of Delhi
where efforts to
improve care led to
this change package
Icons used in the change package and
how to read them
The ‘needle and syringe’ represents health service delivery or a
health product change ideas
ESI Hospital, Rohini
Baba Saheb Ambedkar Hospital
Sanjay Gandhi Memorial Hospital
Mongolpuri
Haidarpur
Bhagwan
Mahavir Hospital
Rohini, Sec-3
Hospitals
Yamuna Vihar
Jag Pravesh
Chandra Hospital
Seelampur
Rana Pratap Bagh
Rani Bagh
Shakurpur
Karawal Nagar
Tri Nagar
The ‘classroom’ icon represents change ideas that were primarily
related to classroom or on-the-job trainings, orientation and
sensitization sessions.
The ‘notice’ icon represents change ideas where materials were
created for ready reference or as reminders for action.
The ‘checklist’ icon represents change ideas that improved
services by enhancing quality of reporting, recordkeeping and
review.
The ‘box’ icon represents change ideas that improved
procurement of products and services.
The ‘two bustheads’ icon represents change ideas which were
either task shifting or was undertaken by introduction of a new
health professional.
The ‘clock’ icon represents change ideas that were related to
either increasing or reducing time of a service or product
administration.
The ‘two bust heads with an arrow sign’ icon represents change
ideas that were related to referral linkages.
Maternity
Homes
The ‘cart with goods’ icon represents change ideas that were
related to relocation or creation of a facility.
The ‘building’ icon represents change ideas that were
institutional and made integral to how the facility functions.
The ‘crossing arrow signs’ icon represents change ideas that
were related to supportive supervision.
The ‘people across a table’ icon represents change ideas that
were related to counseling practices.
The USAID ASSIST Project acknowledges the unwavering support of Dr. Rakesh Kumar, Joint Secretary (RCH),
Minstry of Health and Family Welfare, Government of India in development of this change package.
The USAID ASSIST Project also acknowledges contribution of facility managers and health service providers who, as members of the
quality improvement teams, initiated and implemented change ideas to improve quality of healthcare services in their facilities.
CONTEXT
Delhi state is spread over 1484 square kilometers and is home to 16.75 million people, translating into 11,297 persons living per square kilometer, making it
the most densely populated state in India1. 52 percent of Delhi residents live in slums, without basic services like water, electricity, sanitation, sewage system or proper
housing2. 97.5% of population in NCT of Delhi is classified urban3.
The infant mortality rate in Delhi has come down from 29 in 20014 and 30 per 1000 live births in 20105 to 24 per 1000 live births in 20136. The neonatal mortality declined from 20 in 20117 to 18 in
20138. Similarly, the analysis of deaths among babies admitted in the 14 Sick Newborn Care Units (SNCUs) show that majority of deaths during the early neonatal period were due to causes, which
were either preventable or could be managed by simple measures. An analysis of the Maternal Death Review (MDR) records for the year 2012-13 shows that among the total 415 maternal
mortalities, majority were due to excessive hemorrhage (22%) followed by Pregnancy associated Hypertension (15%), and Sepsis (15%). The Coverage Evaluation Survey (CES 2009) done by UNICEF
in the state shows that nearly two-thirds of women in Delhi registered their pregnancy with a health provider working in a Government system. The survey also shows that nearly 96 percent of the
pregnant women received at least one antenatal check but less than 42 percent received their full complement of antenatal care services9. Only 80 percent of the pregnant women had their blood
pressure checked and their blood tested for hemoglobin level10. The survey further showed that only 84 percent of the delivery in Delhi was with assisted by a skilled birth attendant11, which was
lower than many states in the country.
In order to accelerate reduction in maternal, neonatal and infant deaths in the state, the state government expressed their need for assistance in improving quality of maternal and newborn health
(MNH) services. The USAID ASSIST Project in the National Capital Territory (NCT) of Delhi is conceived with a mandate to improve quality of maternal and newborn care services by strengthening
the public health system in the state. The quality improvement12 (QI) teams from the USAID ASSIST Project, in consultation with public health facility managers and key health professionals in the
state, selected a set of catalytic, high impact interventions in antenatal, intranatal and postnatal care of mothers and essential care of newborns that would accelerate further reduction in MMR and
IMR in Delhi. These change ideas were introduced in two high priority districts of the state – the North East and the North West districts.
Gaps in quality of maternal and newborn health services
The QI teams used a mix of observations techniques and in-depth interviews on the maternal and newborn health interventions being practiced at select public health facilities in the state and
identified the following gaps in provision of quality maternal and newborn health services.
Gaps in maternal health services during ante-natal care (ANC) period
●
●
●
●
Hemoglobin (Hb) level was not being checked regularly for all pregnant women coming for ANC services, resulting in the facilities missing early detection of high risk pregnancies.
There was delay in reporting results of Hb test as well as post- diagnosis medical consultations, resulting in the facilities missing early detection of high risk pregnancies.
There was incomplete recording of pregnant women’s history in ANC cards, Mother and Child Tracking System (MCTS) and in ANC registers because pregnant women often went to different
facilities for their antenatal health check. This was limiting public health system’s ability to track and manage pregnancies identified as high risk.
The pregnant women were not getting counseled on all aspects of nutritional intake, birth preparedness, family planning and infant and young child feeding (IYCF) practices, which was an
essential component of ANC services.
Gaps in maternal health services during intra-natal period
●
●
Administration of Injection Oxytocin for prevention of post partum of hemorrhage (PPH) was inconsistent to the guidelines given by the Government of India (GOI) on active management of
third stage of labor (AMTSL)13.
Several of the facilities in the state selected for introducing change package were not documenting either the incidence of PPH or its management. As a result, medical officers in charge
(MOICs) of the facilities did not understand the burden of PPH in their facility and actions they need to prioritize to respond to PPH incidence.
Gaps in maternal health services during post-natal period
●
Repeated monitoring of vital parameters during immediate postpartum period was not being practiced across selected facilities, resulting in the facilities missing many high risk cases.
Gaps in newborn health services
●
●
Vitamin K injection was administered to only low birth weight newborn than to all newborns, which was inconsistent to the guidelines given by the Government of India.
Health providers were not counseling mothers on early initiation of breastfeeding resulting in delay by many mothers to initiate breastfeeding.
Delivering change in maternal and newborn health services
Checking and recording hemoglobin (Hb) levels in all four antenatal check-ups and detection and
management of severe anemia (<7 gm% Hb) among pregnant women
Sensitization of staffs
engaged in providing ANC
services on importance of
repeatedly checking Hb
levels of pregnant women
coming to the facility for
ANC services.
Logic for change
Hb testing was being done for all
pregnant women on her first ANC visit.
The promptness of subsequent Hb
testing(s) was not consistent across
different facilities and providers.
How the change happened
The QI teams, with support of ASSIST coaches,
sensitized facility staffs on importance of frequent
Hb testing and on how to use changes detected in
Hb levels in identifying high risk pregnancies and in
their timely management. The QI teams encouraged
the facility staffs to test Hb levels of pregnant
women at least four times during their antenatal
period.
In-house maintenance of
consolidated ANC records of
pregnant women coming to
the facility for ANC services
for tracking and managing
high risk pregnancies.
A new antenatal card was generated for
recording individual details and service
information every time the pregnant
woman went to a different facility for ANC
visit. As a result, ANC information was not
getting consolidated at one place, staffs
were neither able to track antenatal
history of pregnant women nor provide
timely interventions.
The staffs providing ANC services in the facilities
were provided with ANC register templates as
recommended by Government of India. The ANC
clinic staffs were assisted in creating a name based
list in the register of pregnant women coming to the
facility to record information by name for each of
the ANC visit a pregnant woman makes to the
facility. This led to reduction in duplication of
information.
Extension of laboratory
technician’s working days in
the facility from three days a
week to six days a week so
that lab investigations can
be done for all women
coming for ANC services
The lab technician in the facility was
available for only three days every week,
because of which he was not available
one of one of the two days scheduled for
ANC services every week. This was
resulting in the facility missing Hb testing
for many pregnant women.
The Chief District Medical Officer (CDMO) increased
the availability of the laboratory technician in the
facility to all six days of the week.
Facilitating a functional
system of continuous
tracking and follow-up of
severely anemic women by
staffs in maternity homes to
ensure compliance to
treatment advice.
The facilities did not have a functional
system of managing severely anemic
women, which also included tracking and
follow-up mechanisms. As a result, the
facilities were not able to ensure
compliance of treatment protocol by
many severely anemic women.
The ASISST coaches trained ANC clinic staffs to line
list14 severely anemic cases, in compliance with GOI
recommendation. The line lists in maternity homes
added name and contact of ANM servicing each
patient’s area to enable the system follow-up
severely anemic women and facilitate compliance to
treatment.
Facilitating a functional
system of continuous
tracking and follow-up of
severely anemic women by
facility staffs in hospitals to
ensure compliance to
treatment advice.
The MCTS in large Government hospitals
were getting updated selectively to
enable Janani Suraksha Yojana15. Heavy
ANC caseload further resulted in only a
fraction of ANC cases getting registered in
MCTS. As a result, many cases of severe
anemia were getting missed from the
monthly work plan that MCTS generated
for ANMs.
The Medical Superintendent instructed the MCTS
administrators in their facilities to register pregnant
women identified as severely anemic in the ANC
clinic to MCTS on priority. The monthly work plan
generated by MCTS, which now included names
and contacts of severely anemic women, aligned
them to the area ANM associated with the hospital.
Change site
Hospital
Maternity
home
Proportion of ANCs in which hemoglobin was checked and
recorded in Mongolpuri Maternity Home (August – November 2014)
100%
Percentage
Change idea
80%
60%
Lab technician
appointed for all
ANC days
Lab technician
on leave
40%
20%
0%
Number
AIM#1
Jul/14
Aug/14
Sep/14
Oct/14
Nov/14
Total number of ANC visits reviewed
600
300
0
Jul/14
Aug/14
Sep/14
Oct/14
ASSIST coaches training members of
quality improvement team
Orientation learning session conducted by
quality improvement teams
Nov/14
Delivering change in maternal and newborn health services
Checking and recording hemoglobin (Hb) levels in all four antenatal check-ups and detection and
management of severe anemia (<7 gm% Hb) among pregnant women
Linkage of severely anemic
cases from maternity homes
with ‘high risk’ clinic at the
government hospital for
seamless continuum of care.
Logic for change
How the change happened
The pregnant women identified as high
risk pregnancies, based on assessments
during their ANC visits to maternity
homes, were referred to larger hospitals
for further assessment and management.
Some of the referred cases were not able
to avail services due to delay caused by
time lost in locating the correct service
point in facility or long wait in absence of
a prior registration or them reaching the
facility on non ‘high risk’ clinic days.
The QI team members in the maternity homes
generated online OPD tickets for women with high
risk pregnancies by accessing the relevant
government hospital’s portal and setting their
appointments for ‘high risk’ clinic days and
encouraged them to take their ANC card along with
the online OPD registration receipt on their
appointed day. ASHAs or ANMs accompanied
women who required additional care to the ‘high
risk’ clinic These initiatives ensured that the referred
patients reach the referral facility and that check-up,
investigations and admissions are facilitated. The
ASHAs/ ANMs, who are assigned the task of tracking
high risk pregnancies using line list/ ANC registers,
frequently followed up the cases and report defaults
to MOICs.
Change site
Hospital
Maternity
home
Strengthening of referral linkages between Mongolpuri
Maternity Home and Sanjay Gandhi Hospital (July – November 2014)
Referral to
High Risk
Clinics
100%
Percentage
Change idea
50%
0%
Number
AIM#1
Provided
color
coded
cards
Jul/14
Provided pre-printed
OPD tickets through
online registration
Aug/14
Sep/14
Oct/14
Nov/14
Total number of ANC visits reviewed
30
15
0
Jul/14
Aug/14
Sep/14
Oct/14
Nov/14
Measuring and recording blood
pressure levels during every ANC visit
• Proportion of ANCs during which Hb was checked and recorded
• Number of women detected with severe anemia
• Proportion of women detected with severe anemia, who were managed appropriately
AIM#2
Recording of complete history of pregnant women during ANC visits for detecting high risk pregnancies
and their timely referral
Change idea
Sensitization and skill
development of staffs
engaged in providing ANC
services on the importance
of history taking (personal,
past, family, obstetric) and
how the collected
information should be used
for identifying high risk
pregnancies
Logic for change
The staffs providing ANC services were
not covering all elements of history taking
and were not using the information they
collected while recording history of
pregnant women for identifying women
with potential of becoming high risk
pregnancies.
How the change happened
The MOIC sensitized staffs providing ANC services
on information they should include while taking
history (personal, past, family, obstetric) of pregnant
women and to identify high risk cases on the basis
of adverse history. Staffs working in ante natal ward
underwent regular assessment of history taking
skills, using simulation technique, and were
provided support as needed to improve their
practice of history taking.
Change site
Hospital
Maternity
home
A senior staff made responsible to ensure
that no service is missed to a pregnant woman
Delivering change in maternal and newborn health services
Recording of complete history of pregnant women during ANC visits for detecting high risk pregnancies
and their timely referral
Logic for change
How the change happened
Sensitization and skill
development of staffs
engaged in providing ANC
services on the importance
of history taking and how
the collected information
should be used for
identifying high risk
pregnancies
The staffs providing ANC services were
not covering all elements of history taking
and were not using the information they
collected while recording history of
pregnant women for identifying women
with potential of becoming high risk
pregnancies.
Clearly visible display of a
printed checklist for history
taking of antenatal women
on the walls of ANC clinics
for quick and ready
reference.
The ANC clinic staffs were missing factors
while taking history of pregnant women,
which were essential for identifying
pre-existing conditions that may add risk
to pregnancy.
The five major areas that need to be covered when
taking history of a pregnant woman were displayed
on a wall in a clearly visible format, placed at a point
which was in line of sight of the staffs providing
ANC services at the facility to serve as a ready
reckoner.
Enhancing uniformity in
documentation of ANC
services by introducing use
of ANC Register
The OPD slips and the ANC card for
pregnant women in facilities were neither
compiled nor chronologically organized.
Absence of a single document to record
changes in parameters of each pregnant
woman accentuated the challenge of
using antenatal history to identify and
manage high risk cases.
In facilities which had ANC Register but were not
using it, registers were modified to include columns
for recording history, physical and laboratory
findings for each ANC visit, including observations
and advice given during ANC visits. QI teams drew
ANC register template on a commonly available
long notebook and began using it as an ANC
Register, wherever ANC Registers were not available.
Change site
Proportion of ANC cases identified as high risk pregnancies
on basis of history taking in Tri Nagar Maternity Home
(September – November 2014)
Maternity
Hospital
home
The MOIC sensitized staffs providing ANC services
on information they should include while taking
history (personal, past, family, obstetric) of pregnant
women and to identify high risk cases on the basis
of adverse history. Staffs working in ante natal ward
underwent regular assessment of history taking
skills, using simulation technique, and were
provided support as needed to improve their
practice of history taking.
10%
Percentage
Change idea
8%
6%
4%
Sensitization
of ANC clinic
staffs
Display of
printed checklist
for history taking
2%
0%
Sep/14
Oct/14
Nov/14
Total number of ANC visits reviewed
Number
AIM#2
75
50
25
0
Sep/14
Oct/14
Nov/14
Checking and recording hemoglobin levels during
all ANC visits
• Proportion of ANCs during which complete history (personal, past, family, obstetric, etc.) was taken.
• Proportion of high risk pregnancies identified and referred through history taking among all ANC cases.
AIM#3
Administration of Injection Oxytocin 10 International Units/intramuscular within one minute of
delivery to all the women for active management of third stage of labor (AMTSL)
Change idea
Orientation of staffs on use
of Injection Oxytocin for
PPH prevention as part of
AMTSL
Logic for change
How the change happened
Facilities were using a combination of
Oxytocics IM/IV to prevent PPH. This
practice was not in compliance to
Government of India guidelines, but was
being followed as the staffs were not
aware of the guidelines.
QI teams underwent an orientation on Government
of India guidelines on AMTSL. The members of QI
team tested the efficacy of Injection Oxytocin on a
select few cases before mentoring other staffs to
use Injection Oxytocin for prevention of PPH as per
GOI guidelines.
Line listing of severely anemic cases in ANC clinics of
the maternity homes
Change site
Hospital
Maternity
home
Delivering change in maternal and newborn health services
Administration of Injection Oxytocin 10 International Units/intramuscular within one minute of
delivery to all the women for active management of third stage of labor (AMTSL)
Change idea
Logic for change
How the change happened
Staffs in the facility were not using all the
parameters recommended for identifying
atonic PPH16 cases. Recording of atonic
PPH incidence in case sheets limited the
facility’s ability to get a single source view
of atonic PPH cases, assess severity of its
incidence in their facility and take
administrative actions as needed.
The staffs in labor room and postpartum ward were
re-oriented on guidelines for identifying atonic PPH,
which not only considered volume of blood lost but
also concomitant vital signs presented during the
postpartum period. Maintenance of record of atonic
PPH in patient wise notes in the labor room register
as well as the discharge register was instituted for
review and action planning.
Placement of a clock with
seconds hand on the wall of
the labor room to guide the
staffs on time of
administration of Injection
Oxytocin.
Staffs used to remove their wristwatch
before washing hands in preparation of
delivery. In absence of a clock in the labor
room and with several tasks competing
for their attention immediately post
delivery, they many-a-times missed
administering Injection Oxytocin within
one minute of delivery.
Medical Officer in the facility agreed to procure one
clock from funds given to the facility. The clock was
installed on a wall facing the doctor during delivery.
This helped in noting the time of birth and in
administration of Injection Oxytocin within one
minute of delivery of the baby.
Filling of Injection Oxytocin
(10 IU) at the time of
perineal bulging
The staffs in high caseload facilities, who
were simultaneously handling many
deliveries at a time, were not able to
administer Injection Oxytocin because
often the syringes were not kept ready for
use.
Staffs were trained to use the time of perineal
bulging to load Oxytocin into syringes and keep
them ready in the instrument tray. The syringe with
Oxytocin was marked with an “O” sign so that it is
easily identified. As soon as twin pregnancy was
ruled out, Injection Oxytocin was administered.
Clearly visible display of
actions staffs need to take
for administering Injection
Oxytocin on the walls of
labor room for ready
reference.
It was observed that the staffs in labor
room, even after orientation on
administration Injection Oxytocin,
required regular reminders and reference
to specific actions they need to take to
sustain the practice.
A note on administration of Injection Oxytocin in
easy-to-understand language and in large fonts was
put on paper. The written instructions were pasted
in the labor room, on the wall in front of the labor
table, which the nursing staffs could refer to on a
regular basis.
Making the practice of using
Injection Oxytocin for
prevention of atonic PPH as
per GOI guidelines an
integral part of care for
mother’s in the facility
While the staffs were made aware of
Government of India guidelines, they
required an official instruction to begin
use of Injection Oxytocin as per GOI
guidelines for prevention of atonic PPH
Written instructions from MOIC on using Injection
Oxytocin within one minute of delivery and for
adhering to the standard operating procedures
began institutionalization of this practice. The
facilities also integrated AMTSL for preventing
atonic PPH into their orientation plan for new staffs.
The Medical Officers demonstrated use of Injection
Oxytocin immediately post delivery to prevent
atonic PPH. Senior staffs included review of
Injection Oxytocin usage in review of delivery cases
with in depth review of cases where the practice
was not followed.
Building capability of labor
room and postpartum ward
staffs to correctly identify
atonic PPH cases and
manage them.
Proportion of vaginal deliveries for which uterotonic was administered within one minute of birth
Change site
Hospital
Maternity
home
Proportion of mothers receiving AMTSL among all those
having vaginal delivery at BSA Hospital January 2014-May 2014
Proportion of mothers receiving AMTSL
AIM#3
100
80
Availability of prefilled syringes
Discuss advantages with staff
Congratulate staff on achievements
60
40
Baseline data collected
First QI team meeting
Sensitisation of staff in all shifts
Prefilled syringes in LR
20
0
650
325
0
Issue orders on
AMTSL Policy
Display policy & SOPs
Include AMTSL
in induction training
of new nurses & JRs
Jan/14
Feb/14
Mar/14
Apr/14
May/14
Total number of vaginal deliveries reviewed
Jan/14
Feb/14
Mar/14
Apr/14
May/14
QI team members reviewing in
Partograph for currectness and providing supervision
Administration of Injection
Oxytocin within one minute of delivery
Delivering change in maternal and newborn health services
Monitoring and documentation of vital parameters (blood pressure and pulse) in the
post partum period for timely identification and management of complication in mothers
Logic for change
How the change happened
Sensitization of medical and
paramedical staffs providing
obstetric care services on
GOI guidelines on PNC17,
with more focus on early
detection of post partum
complications.
As different cadres of staffs attend to
mothers during the immediate
postpartum period, it was essential to
build a common understanding among all
care providers on importance of
postpartum monitoring, the expected
level of performance and their own role in
implementing this service.
The MOIC facilitated a joint commitment by labor
room and postnatal ward staffs to improve quality
of postpartum care. The staffs decided to check vital
parameters of mothers at least six times in the first
six hours, thrice in labor room and another three
times in the postnatal ward. The QI team members
oriented nurses in labor room and postnatal ward to
use data to identify and manage complications.
Establishing an observation
room in the postpartum
ward of the facility.
Mothers, after delivery, were moved from
the labor room to postnatal ward, but
their beds were scattered all over the
ward. Significant amount of time was
being lost in searching for mothers who
needed postpartum monitoring, thus
preventing the staffs from giving quality
time to each case.
A cluster of beds in one section of the postnatal
ward was dedicated to transfer of mothers from
labor room. Each mother was kept in this section for
at least six hours post delivery. This clustering
helped provide better quality postpartum care as
the nursing staffs were able to give more time per
mother, BP appartus could be kept ready and case
sheets of mothers could be kept at one nursing
station to facilitate recording of observations.
Delivering a package of
services at every
opportunity of care with the
mother.
It was observed that most PNC services
were delivered one at a time, resulting in
many more visits to a delivered woman
than required.
QI team was oriented to use every opportunity to
assess the wellbeing of mothers. QI team started
doing postpartum monitoring of mothers along
with other routine activities, like checking on IV
line/urine output, providing medicines, etc.
Partnering with family
members accompanying the
delivered women about the
postpartum check schedule
and engaging them to
remind the postpartum
ward staffs to check vitals as
per schedule.
Due to high caseload and shortage of
staffs in the postnatal ward, the nursing
staffs at times missed measuring vital
parameters despite setting the schedule
for it. Mother’s attendants were available
beside the delivered women to facilitate a
reminder system.
QI team advised staffs in the postnatal ward to
inform the mother’s attendants about the post
partum vitals monitoring schedule and the danger
signs that present itself during immediate post
partum period. Family members were asked by
nursing staffs to remind them to monitor post
partum vitals as per the set schedule and also raise
an alarm in case they observed any danger sign.
Making the practice of
monitoring vital parameters
and management of
postpartum complications
as per GOI guidelines an
integral part of care for
mother’s in the facility
While the staffs were made aware of
Government of India guidelines, they
required an official instruction to put the
change in post partum monitoring of vital
parameters into practice.
Written instructions from the Deputy Medical
Superintendent to staffs for periodic monitoring of
vital parameters post partum (at least six times in
the first six hours of delivery) and management of
post partum complication began the
institutionalization of this practice. The facilities also
integrated monitoring of post partum vitals into
their orientation plan for all new staffs and in review
of cases where the practice was not followed.
• Average numbers of times vitals (BP and pulse) are measured and recorded within six hours of delivery.
• Number of mothers detected with complications on basis of postpartum monitoring.
Change site
Hospital
Number of mothers detected with complications on
basis of postpartum monitoring in Bhagwan Mahavir Hospital
(January – November 2014)
Maternity
home
15
Numbers
Change idea
Improving the frequency of
monitoring
Involvement of doctors & nurses
Sharing of work between
labor room & post partum ward
Use of opportunity for care
10
5
0
Improving early pick-up of complications
under new system of care
Observation room
Partnering with patients’ attendants
Baseline
Jan/14
Feb/14
Mar/14
Apr/14
May/14
Jun/14
Jul/14
Aug/14
Sep/14
Oct/14
Nov/14
Average number of times vitals (BP and pulse) are monitored and recorded
10
Numbers
AIM#4
5
0
Jan/14
Feb/14
Mar/14
Apr/14
May/14
Jun/14
Jul/14
Aug/14
Sep/14
Oct/14
Nov/14
Monitoring vital parameters (BP and Pulse)
in the postpartum period
Recording of postpartum vital parameters (BP and Pulse)
in the delivery register
Delivering change in maternal and newborn health services
AIM#5
Administration of Injection Vitamin K to all newborns to prevent Vitamin K deficiency bleeding
Change idea
Logic for change
How the change happened
Orientation to medical and
nursing staffs on GOI
guidelines on
administration of Injection
Vitamin K to all neonates
There was a lack of awareness on GOI
guidelines for administration of Vitamin K
to newborns. In some places, it was being
given only to low birth weight babies.
The MOIC oriented staffs in the labor room and in
postnatal ward on the importance of Vitamin K
administration, the correct dosage, syringe
specifications, time of administration and the
procurement of injection Vitamin K as is
recommended in GOI guidelines.
Planned procurement (in
time and in adequate
quantity) of Injection
Vitamin K to ensure 24 x 7
availability
Vitamin K was being procured on
piecemeal basis instead of procurement
and stocking on the basis of delivery load
at the facility. There was no supply of
Injection Vitamin K from the district store.
Staffs involved in procurement were oriented to
calculate average delivery load of the facility and
keep at least one month stock of injection Vitamin K.
The MOIC used JSSK18 funds, which has provision for
such purchases, to procure Injection Vitamin K.
Placement of posters on
guidelines related to
Injection Vitamin K
administration pasted in
labor room in the facility, as
visual reminder.
Staffs in labor room, even after orientation
on Vitamin K administration to newborns,
required regular reminders to administer
Injection Vitamin K to newborns within six
hours of their birth.
Key points from the GOI guidelines on dosage and
timing of injection Vitamin K administration for
newborns were posted on the wall of the labor
room. Since the labor room staff worked in different
shifts, the poster also served as a reminder for them
to check whether or not Vitamin K has been
administered to a newborn in the previous shift.
Involvement of MOIC in
daily review of Vitamin K
administration to newborns
A process of reviewing, providing
feedback and handholding to staffs was
important to ensure correct practices are
established in the system.
The MOIC of the facility conducted regular review
with the staffs of the labor room and postnatal ward
on administration of Injection Vitamin K to
newborns. This was further verified by a review of
case sheets and labor room register.
Change site
Hospital
Maternity
home
IYCF counselor assisting mother’s in
initiating breastfeeding within 1 hour of birth
Baby tray kept ready in facilities
for emergency newborn care
Proportion of newborns administered Vitamin K within 24 hours of birth
AIM#6
Early initiation of breastfeeding in all newborns
Change idea
Orientation to nursing and
paramedical staffs on GOI
guidelines on infant and
young child feeding (IYCF)
practices and importance of
early initiation of
breastfeeding.
Logic for change
A few nursing and paramedical staffs were
facilitating the initiation of breast feeding
after the first hour of child’s birth. Staffs
lacked correct and updated knowledge
regarding initiation and continued
practice of breastfeeding among mothers,
solving common problems of the mothers
and on GOI guidelines.
Training to nursing staffs on administration
of Injection Vitamin K to all newborns within 24 hours of birth
How the change happened
Staffs were oriented on various aspects of
breastfeeding through multiple sessions. A
pediatrician oriented and demonstrated the correct
practices of breastfeeding and also on management
of common problems during breastfeeding.
The MOIC instructed the health facility staffs to
facilitate initiation of breastfeeding as per GOI
guidelines.
Change site
Hospital
Maternity
home
Delivering change in maternal and newborn health services
AIM#6
Early initiation of breastfeeding in all newborns
Change idea
Logic for change
How the change happened
Posters on early initiation,
correct practice and correct
placement of newborn for
breastfeeding pasted in the
wards as visual reminder for
mothers and their
attendants.
There was a felt need to create a
mechanism of continuous reminders to
mothers and relatives to practice exclusive
breastfeeding, as one time counseling
sessions to mothers and their attendants
were not enough.
IEC materials were created and displayed in local
language informing the mothers on the benefits of
early initiation and exclusive breast feeding. Posters
showed proper positions of feeding the baby, time
of feeding and benefits. The materials were placed
at conveniently visible places in the labor room,
ANC clinics and in postnatal wards.
Initiation of breastfeeding,
right in the labor room,
immediately post delivery.
The practice was to initiate breastfeeding
once the mother and newborn were
shifted to the postnatal ward. Early
initiation was further delayed when family
members insisted on performing birth
rituals.
Labor room staffs were made responsible to
facilitate early initiation of breastfeeding before
shifting the newborn and mother out of the labor
room. Staffs counseled mothers in labor room on
benefits and proper method of breastfeeding.
Counseling on timely
initiation and exclusive
breastfeeding to mothers
from the time of her ANC
visits by medical and
paramedical staffs.
Pregnant woman and her family members
were not getting counseled on benefits of
colostrum, early and exclusive
breastfeeding, due to which their
misconceptions regarding newborn
feeding practices were not addressed.
Medical and paramedical staffs were oriented to
include counseling on breastfeeding along with
counseling on diet and nutrition, care during
pregnancy, birth preparedness, complication
readiness and family planning during ANC visits.
Engaging relatives of
mothers to facilitate
breastfeeding in cases
where it did not get initiated
in the labor room.
Mothers in law and husbands influence
mothers in initiating and sustaining
breastfeeding practice. The IYCF
counselors were not counseling family
members.
Relatives accompanying the women for ANC visits
and for delivery were counseled along with the
mother on breastfeeding and were encouraged to
support the mother in initiating breastfeeding
within one hour of delivery.
Involving IYCF counselors in
counseling pregnant
women in ANC clinics and
mothers and her attendants
in postnatal wards on early
initiation of breastfeeding.
IYCF counselors were placed with the
pediatric department and were not
engaged in counseling pregnant women
in ANC clinics or mothers in the postnatal
ward, which are under the gynecology
department.
The departments of pediatrics and gynecology
agreed to engage IYCF counselors to begin
continuum of care of infants and young children
from the antenatal period. IYCF counselors’
responsibility was expanded to include visits to ANC
clinic and postnatal wards to counsel and promote
early initiation and exclusive breastfeeding.
Reinforcing breastfeeding
messages through different
cadres of staffs working with
the postnatal ward.
Support staffs deputed to the postnatal
wards also interacted with mothers and
their attendants on regular basis. As
mothers and their attendants shared
many socio-cultural characteristics with
the support staffs, they found reiteration
of medical advice by them more
reasonable and acceptable.
QI team members organised a short sensitization
session for the support staff on early initiation and
exclusive breastfeeding. The support staffs were
encouraged to ask the mother and relatives “has the
baby been breastfed?” in each of their interaction
with the mother and their attendants. This helped
reinforcing the practice of breastfeeding among
mothers.
Proportion of newborns who were breast fed within one hour of birth
Change site
Hospital
Maternity
home
Trained nursing staffs giving breathing assistance to newborns
Trained nursing staff administering Injection
Vitamin K to a newborn
Poster reminding nursing staff to inject
Vitamin K after initiating breastfeeding to the newborns
Quality
Improvement
Approach
The USAID Applying Science to Strengthen and Improve Systems (ASSIST) is a USAID funded project managed by University Research Co., LLC (URC) to
support the government and to strengthen and improve the health system so that the quality of maternal & newborn care becomes better and more lives
are saved. URC’s global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard University School of Public Health; Health Research, Inc.;
Institute for Healthcare Improvement; Initiatives Inc.; Johns Hopkins University Center for Communication Programs; and Women Influencing Health
Education and Rule of Law, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write
assist-info@urc-chs.com.
The QI approach used in the USAID
ASSIST Project consists of seven steps19:
1. Defining the improvement aim
2. Forming the improvement team
3. Understanding the current system
4. Developing a measurement system
5. Developing changes
6. Testing changes
7. Implementing and sustaining changes
Model for improvement
What are we trying to
accomplish?
What change can we make that
will result in improvement?
How will we know that a
change is an improvement
Act
Plan
Study Do
Reference
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Census of India 2011. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.
Ibid reference 1
Ibid reference 1
SRS Bulletin, Volume 36 No.2, October 2002. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.
SRS Bulletin, Volume 45 No.1, January 2011. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.
SRS Bulletin, Volume 49 No.1, September 2014. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India.
SRS Statistical Report 2011. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India. Accessed from
http://www.censusindia.gov.in/vital_statistics/SRS_Reports_2011.html on 25 December 2014
SRS Statistical Report 2013. Sample Registration System. Officer of Registrar General of India and Census Commissioner, Ministry of Home Affairs, Government of India. Accessed from
http://www.censusindia.gov.in/vital_statistics/SRS_Reports_2011.html on 25 December 2014
All India Report, Coverage Evaluation Survey, United Nations’ Children’s Fund. 2009
Ibid reference 9.
The Government of India considers the skilled birth attendant as a person who can handle common and major obstetric and neonatal emergencies as well and recognizes when the situation reaches a
point beyond his/her capability and refers the woman or the newborn to a First Referral Unit/appropriate facility without delay. GOI. Handbook for ANMs, LHVs and staff nurses as a skilled birth attendant.
New Delhi: Department of Family Welfare, Ministry of Health and Family Welfare; 2006. Accessed http://mohfw.nic.in/NRHM/MH/Facilitors_Guide.pdf on 12 December 2014
Quality Improvement team consisted of select medical and paramedical staffs of the participating public health facility.
Guidelines for Antenatal Care and Skilled Attendance at Birth by ANMs/ LHVs/SNs, 2010. Maternal Health Division, Ministry of Health & Family Welfare, Government of India.
A line list is a table that summarizes information about persons who may be associated with a health event. Each row represents a single individual, and each column represents a specific characteristic
about that person. Column information includes identifying, demographic, clinical, and other epidemiologic information, including risk factors possibly related to the illness.
Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission (NHM). It is being implemented with the objective of reducing maternal and neonatal mortality by
promoting institutional delivery among poor pregnant women. Accessed from http://nrhm.gov.in/nrhm-components/rmnch-a/maternal-health/janani-suraksha-yojana/background.html accessed on 27
Dec 2014.
Ibid reference 15
Ibid reference 15
Janani Shishu Suraksha Karyakram is a national initiative to provide free and cashless services to pregnant women including normal deliveries and caesarean operations and sick newborn (up to 30 days
after birth) in Government health institutions in both rural & urban areas. Accessed from http://www.nhp.gov.in/health-programmes/national-health-programmes/janani-shishu-suraksha-karyakaram-jssk
on 15 Jan 2015
Langley GJ et al. the Improvement Guide – a Practical Approach to Enhancing Organizational Performance. Second Edition. 2009
Abbreviations
AMTSL
ANC
ANM
ASHA
ASSIST
BP
BPL
CDMO
CHC
DLHS
GOI
Hb
IM
Active Management of Third Stage of Labor
Antenatal care
Auxiliary Nurse Midwife
Accredited Social Health Activist
Applying Science to Strengthen and Improve Systems
Blood Pressure
Below Poverty Line
Chief District Medical Officer
Community Health Center
District Level Household Survey
Government of India
Hemoglobin
Intramuscular
IMR
IU
IYCF
JSSK
JSY
MCTS
MMR
MOIC
NCT
OPD
PPH
QI
USAID
List of contributors (in alphabetical order)
• Akhilesh Patel, District Improvement Coordinator, North East District, the USAID ASSIST Project,
URC CHS
• Enisha Sarin, Senior Advisor, Research and Evaluation, the USAID ASSIST Project, URC CHS
• Mirwais Rahimzai, Deputy Country Director, the USAID ASSIST Project, URC CHS
• Mona Chopra, District Improvement Coordinator, North West District, the USAID ASSIST Project,
URC CHS
•
•
•
•
•
Infant Mortality Rate
International Units
Infant and Young Child Feeding
Janani Shishu Suraksha Karyakram
Janani Suraksha Yojana
Mother and Child Tracking System
Maternal Mortality Ratio
Medical Officer In-Charge
National Capital Territory
Outpatient Department
Postpartum Hemorrhage
Quality Improvement
United States Assistance for International Development
Neerja Arora, State Improvement Coordinator, NCT of Delhi, the USAID ASSIST Project, URC CHS
Nigel Livesley, Country Director, the USAID ASSIST Project, URC CHS
Subir Kole, Data and Research Manager, the USAID ASSIST Project, URC CHS
Vandana Naidu, Senior Improvement Advisor, the USAID ASSIST Project, URC CHS
Vikas Kanthwal, District Improvement Coordinator, North West District, the USAID ASSIST
Project, URC CHS
For more information, contact: Dr. Mirwais Rahimzai, Deputy Country Director
USAID ASSIST India. University Research Co., LLC
Alps Building, 1st Floor, 56 Janpath, New Delhi - 110001. TEL 91-11-48987700
www.usaidassist.org / www.urc-chs.com / mrahimzai@urc-chs.com
Disclaimers
This ‘Change Package’ is made possible by the generous support of the American people through USAID’s Bureau for Global Health, Office of Health Systems. The
contents are the sole responsibility of University Research Co., LLC (URC) and do not necessarily reflect the views of USAID or the United States Government. The
USAID ASSIST Project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101.
Many change ideas mentioned in this change package were context and facility specific. They may not necessarily be applicable across the board in their current
form and may require modifications to achieve desired results.