Practitioners' Series
Knowledge and practices of healthcare providers
about essential newborn care and resuscitation in a
district of Haryana
Deepak Louis1, Praveen Kumar2, Ashish Gupta3
In India, institutionalisation of deliveries is happening at a fast pace. Evaluating the knowledge and
practices of healthcare providers in these institutions is a priority in this current scenario. The objective
of this study was to assess the knowledge and practices regarding essential newborn care and resuscitation
among healthcare providers in Panchkula district of Haryana. A cross-sectional questionnaire
based survey of healthcare personnel working in one district hospital, 2 community health centres, 5
primary health centres and 2 subcentres, each with at least 100 deliveries per year, was done. Fifty-eight
medical personnel comprising of 27 staff nurses, 11 auxiliary nurse midwives, 15 doctors and 5 multipurpose
health workers were interviewed. Of them, 33 (57%) had received training in newborn care, but
only 9 (16%) knew all the initial steps of resuscitation. Twenty-eight (48%) had knowledge of positive
pressure ventilation while 8 (13%) could provide chest compression or drugs during resuscitation.
Thirtythree (57%) practiced holding the baby upside down after delivery. Early and exclusive breastfeeding
including colostrum was advised by all. All practiced hand washing prior to delivery and kept the cord
clean and dry. At least one danger sign was told to the mother at the time of discharge by 48 (83%).
However, kangaroo mother care was rarely advised to mothers of preterm babies. It was found that
majority of healthcare personnel had good awareness about breastfeeding and clean practices while
conducting delivery. In contrast, knowledge about neonatal resuscitation and some aspects of essential
newborn care was poor. [J Indian Med Assoc 2013; 111: 114-7]
Key words : Essential newborn care, healthcare providers, knowledge, neonate, practices,
resuscitation.
Neonatal Unit, Department of Paediatrics, Postgraduate Institute of Medical
Education and Research, Chandigarh 160012
1MD, Senior Resident
2DM, Professor
3MBBS, Director, National Rural Health Mission (NRHM), Haryana
134112
114
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KNOWLEDGE AND PRACTICES OF HEALTHCARE PROVIDERS ABOUT ESSENTIAL NEWBORN CARE . LOUIS ET AL 115
A
s per 2008 estimates, 8.8 million children die each year around the world and more than half of this
mortality is contributed by neonatal deaths1. In India, neonatal mortality accounts for 68% of the under-5
mortality as per National Family Health Survey (NFHS)-32. The leading causes of deaths in the newborn
period include prematurity, perinatal asphyxia and infections3-5. Care practices at and immediately
following delivery contribute to neonatal morbidity and mortality and a package of essential newborn care
(ENBC) practices has been proven to reduce these risks6,7. These practices include cleanliness
during delivery, the use of clean sterilised blade to cut the cord and tying with clean string, immediate
drying and wrapping of the newborn and delaying of first bath, initiation of exclusive breastfeeding within
an hour and prompt resuscitation of asphyxiated newborns 6,8.
In India, subcentres, primary health centres (PHCs), community health centres (CHCs) and district
hospitals (DHs) form the back-bone of the healthcare delivery system. Subcentre is the most peripheral
outpost of this system in rural areas and is manned by auxiliary nurse midwives (ANMs). ANMs are the
most peripheral salaried healthcare providers, who provide maternal and child healthcare services
including delivery care9. This is followed by PHCs and CHCs where staff nurses conduct most
of the deliveries. Under Reproductive and Child Health Programme, phase . II (2005-2010)(RCH II),
skilled birth attendant (SBA) training was started across India, which mainly trains ANMs, lady health
visitors (LHVs) and staff nurses for monitoring of mothers during labour, active management
of the labour per se and also the essential care of newborn. The current institutional delivery rates in India
are 40.7%, and are rapidly increasing because of the incentive based scheme of the government.Janani
Suraksha Yojana (JSY)2,10. However, functional institutions are grossly inadequate in number and often
lack enough trained manpower to take care of the newborns. There is a risk that the gains of JSY may be
wiped off, if the newborn care is not improved simultaneously. It is important to assess the current level of
training of the healthcare workers supposed to take care of the neonates in these institutions. With this
background, we aimed to study the knowledge and practices of health personnel with regards to
management of newborns in the delivery room and immediate postnatal period. This would help to
assess the effectiveness of current training programs and the requirements for augmentation of those.
The specific objective was to assess the awareness
among doctors and nurses regarding neonatal resuscitation
and in providing essential care to the newborns in the
immediate postnatal period till discharge, in a district of
Haryana.
The Study :
This was a cross-sectional questionnaire based study done over a period of 1 month from 1st to 31st May
2010 in the Panchkula district of Haryana in North India. The questionnaire comprised of 35 open ended
questions and it mainly covered various aspects of newborn care including resuscitation, care of newborn
immediately after delivery, cord and skin care, initiation of feeding and counselling at discharge (Fig 1).
This questionnaire was pilot tested on 10 staff nurses in the district hospital of Panchkula.
Haryana is one of the most industrialised states in the country and has the third highest per capita income
of all states in India. It ranks 18th among the list of states with high infant mortality. According to the
medical certification of causes of death in Haryana, 2007, birth asphyxia accounted for 20% of the total
neonatal deaths in the state11. Panchkula is one of the 21 districts of Haryana, located in its northern part.
The population of Panchkula district is about 4.68 lakhs which is nearly equally distributed between
rural and urban areas. The healthcare system in Panchkula comprises of 1 district hospital, 2 community
health centres, 9 primary health centres and 46 sub-centres. The number of deliveries occurring in this
district range from 12,000 to 13,000 every year. This survey was conducted in all health facilities of
Panchkula district which catered to at least 100 deliveries per year. This comprised of 1 district hospital
(DH), 2 community health centres (CHCs), 5 primary health centres (PHCs) and 2 subcentres.
A convenient sample size of 58 personnel was taken for the purpose of this study.
Data were obtained from the healthcare providers involved in neonatal care through direct interviews. An
informed consent was obtained from them and anonymity was maintained.
Statistical analysis :
For baseline clinical variables, descriptive statistics were used. Categorical variables were compared
using Chisquare test. For skewed continuous variables, Mann- Whitney U test was used. A p-value of <
0.05 was consideredsignificant.
Analysis :
Fifty-eight medical personnel were interviewed which included 27 staff nurses, 11 ANMs, 15 medical
officers, 4 multipurpose health worker females (MPHWF) and one multipurpose health worker male
(MPHWM). Medical officers comprised of 4 paediatricians and 11 MBBS doctors.
Deliveries were conducted by staff nurses at the PHCs, CHCs and DH, while ANMs conducted it at the
subcentre level. Thirty-three personnel (57%) had received some form of training in neonatal
resuscitation. Of them, 31 (53%) had attended the skilled birth attendant (SBA) training and 2 doctors had
attended the neonatal resuscitation program (NRP) course. The median time since their training
was 2 years (range 4 months to 15 years). Thirty-three healthcare workers (57%) had the practice
of holding the baby upside down (Table 1). The initial steps of resuscitation, which comprise of drying the
baby, suctioning and then stimulating, were also evaluated. All the 3 steps were known to only 9 (16%),
while 41 (71%) knew at least 1 of the 3 steps and 8 (13%) did not know any of these initial steps. Among
initial steps, 15 (26%) did not know how to stimulate the baby if he/she does not cry. Only 28 (48%) knew
about providing positive pres_______________________________________________________________________________________________
1 Serial number
2 Name of the health worker
3 Designation
4 Age
5 Educational qualification
6 Place of work
7 Duration in delivery room
8 Any training in neonatal resuscitation
9 Type of training
10 Period after training
11 How do you prepare prior to delivery ?
12 Do you do handwashing prior to conducting delivery ?
13 Who conducts the delivery at your centre ?
14 How do you hold the baby after delivery ?
15 When is cord tied ?
16 What is used for tying the cord ?
17 What is used for cutting the cord ?
18 Do you apply any thing on the cord ?
19 Have you heard about the 5 .C.s during delivery and
what are they?
20 If baby does not cry, what will you do ?
21 What are the initial steps in neonatal resuscitation ?
22 When should you start chest compressions and
positive pressure ventilation?
23 What is the indication for using adrenaline ?
24 Which injection is given to all babies after delivery ?
25 Are you practising it and if no, why ?
26 What is the first feed to be given to the baby ?
27 Which milk should be given ?
28 Should colostrum be given ?
29 What feed do you give to babies born by ceasarean section ?
30 Where do you keep the baby immediately after delivery ?
31 What are the complications that can develop in preterm babies ?
32 What is kangaroo mother care ?
33 How is it done ?
34 Do you advise the practice of KMC ?
35 What do you tell the mother at the time of discharge ?
36 Do you know what are the danger signs ?
Fig 1 . Showing Questionnaire for the Evaluation of Knowledge
and Practices about Resuscitation and Essential Newborn Care
_____________________________________________________________________________________________________________________________________________________________
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116 J INDIAN MED ASSOC, VOL 111, NO 2, FEBRUARY 2013
sure ventilation using self-inflating bag and mask, whereas 50 (87%) did not know about chest
compression or about the use of drugs (adrenaline) in resuscitation. All had the practice of tying the cord
immediately after delivery. All the 5 .C.s required for delivery ie, clean hands, clean delivery surface,
clean blade, clean cord and clean cord tie were known to only 33 (57%), while 21 (36%) did not know any
of them. Fifty-six of them (96%) did not apply anything to the cord while 2 of them applied betadine. All of
them did hand washing prior to conducting the delivery and used sterile scissors for cutting the
cord. All used clean cord ties (Table 1).The practices of the healthcare personnel who had undergone
some special training courses like SBA, NRP or kangaroo mother care(KMC) were compared with those
who have had no such training. No significant differences were found in any of the practices between the
trained and the untrained persons except for the knowledge about KMC, which was more in trained
personnel (p=0.001) (Table 2). Among doctors (n=15), 12 (80%) knew about positive pressure ventilation,
while among nurses/ANMs (n=43) only 16 nurses/ ANMs (43%) knew it. Similarly, 10 doctors (67%) knew
about chest compressions, while only 3 nurses (7%) had this knowledge (Table 3). The knowledge and
practices of healthcare personnel were compared based on their length of service in the delivery room.
An arbitrary cut-off of 10 years was taken for this. However, comparison between these 2 groups did not
reveal any difference in the various healthcare practices (Table 4).
The need of vitamin K for the newborn was known to 44 (76%), while only 32 (55%) practiced it. The main
reason for not using vitamin K was the non- availability of the drug, especially in the PHCs and
subcentres. After delivery, the practice of keeping the baby with the mother was followed by 31 (53%)
respondents while the remaining kept the baby under a radiant warmer. Exclusive breastfeeding was
advised by all of them in the first 6 months and except one, all knew that even postcaesarean
mothers can and should breastfeed. All of them practiced giving colostrum to the newborn baby as the
first feed. At least one danger sign was told to the mothers at discharge by 48 (83%). Forty-five of them
(76%) knew at least some complications that preterms are prone to, including hypothermia, infection or
hypoglycaemia. Even though 39 personnel (67%) had heard about KMC, only 33 of them (57%) knew
how to do it and only 3 (5%) practiced it while managing small babies.
Comments :
In this survey of the health personnel posted at various health delivery centres in the Panchkula district of
Haryana, about knowledge and practices regarding resuscitation and essential newborn care, it was
found that there were some encouraging but many disconcerting findings. It was good to note that all
personnel practiced hand washing prior to conducting delivery and used sterilised scissors for cutting the
cord. All advised exclusive breastfeeding and giving colostrum, even when the mother had a caesarean
section.
Also, atleast one danger sign was told to the mothers prior to discharge by majority of the personnel.
However, the knowledge and practices related to resuscitation were grossly sub-optimal. This is alarming
because birth asphyxia is responsible for 20% of the neonatal deaths in Haryana11. The initial steps of
resuscitation like drying, suction, stimulation were known to only few of the personnel attending deliveries,
and the majority did not know about advanced resuscitation including chest compressions and drugs like
adrenaline. Also, 57% of them still had the practice of holding the baby upside down after delivery, which
could be dangerous, especially in a preterm baby. Even though many knew about the complications in
preterm babies including hypothermia, hardly any one practiced kangaroo mother care.
These findings are to be viewed along with the fact that 57% had undergone some form of training, with
the majority having undergone the SBA training. Promoting skilled attendance at birth through the SBA
training is an important strategy that has been adopted as part of the RCH-II programme. Implementation
of this strategy was meant to empower the ANMs, LHVs and staff nurses, not only in handling normal
deliveries, but also for actively managing the third stage of labour and providing the required
emergency care before referring any woman who develops complication during pregnancy or child birth
and
Table 1. Showing Knowledge and Practices Related
to Newborn Care among the Healthcare Providers
(n=58)
Knowledge and practices No of healthcare
workers (%)
Hand washing prior to conducting delivery 58 (100)
Clean cord tie 58 (100)
Application on cord 2 (3)
5 .C.s 33 (57)
Initial steps of resuscitation (all three) 9 (16)
At least one of the initial 3 steps 41 (71)
Holding baby upside down 33 (57)
Positive pressure ventilation 28 (48)
Chest compressions 8 (13)
Resuscitation drugs 8 (13)
Table 2 . Showing Comparison between Those Who Received
Special Training and Those Who Did Not
No of trained No of untrained p-value
personell (%) personell (%)
(n=33) (n=25)
Holding baby upside down 22(67) 11 (44) 0.35
Knew initial steps (all 3) 5 (15) 4 (16) 0.90
Knew indication for chest
compressions 6 (18) 2 (8) 0.41
Positive pressure ventilation 17 (51) 11 (44) 0.83
Knew about vitamin K 27 (81) 17 (68) 0.84
Knew about KMC 30 (90) 9 (36) 0.001
p<0.05 . significant
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KNOWLEDGE AND PRACTICES OF HEALTHCARE PROVIDERS ABOUT ESSENTIAL NEWBORN CARE . LOUIS ET AL 117
also essential newborn care.
The SBA training occurs over a period of 2 weeks and at a time, not more than 4 persons are trained.
During the training, core skills are taught and demonstrated, which includes monitoring the progress of
labour, augmenting labour, conducting normal delivery with aseptic technique, actively managing the third
stage of labour, and essential newborn care. The newborn part of the training mainly focuses on
asepsis prior to delivery like hand washing and preparing the delivery surface, temperature maintenance
in the newborn, care of the cord, skin, and eyes, exclusive breast feeding and counseling prior to
discharge including the danger signs. But, the major aspect of this training is focused on the mother so as
to prevent maternal mortality and only a small fraction (approximately 5%) of the entire module is
dedicated to newborn care. Also, this module does not train healthcare workers in the initial steps of
resuscitation and what steps are to be adopted in a baby who fails to breathe like stimulation or positive
pressure ventilation. The fact that there were almost no major differences in the knowledge and practices
of those who had undergone special training as compared to those without any special training suggests
that the training courses did not have the desired impact. The methodology and content of these courses
needs to be reviewed and provision for follow-up courses and knowledge support systems should be
made.
A study done by Paul et al in 1997 evaluated the newborn care practices along with the infrastructure
available in the district hospitals and sub-district hospitals of Orissa using a questionnaire12. They found
that between 70 to 75% of deliveries at these facilities were conducted by staff nurses and the remaining
by doctors. There was a high incidence of early initiation of breastfeeding, good cord care and colostrum
administration to the newborns.
However, this study did not evaluate the knowledge about the initial steps required in resuscitation and
confined their survey to DHs and sub-district hospitals. In Haryana, the IMR is 54 per 1000 live births and
75% of it is contributed by neonatal deaths. The contribution of asphyxia and low birth weight to neonatal
deaths in Haryana is around 20% and 23% respectively11. In Panchkula, despite the fact that it has a very
high percentage of institutional deliveries reaching near 95%, neonatal mortality contributes to 68% of
infant deaths. This is a reflection of the inadequate training and capacity building related to essential
newborn care and resuscitation. Hence, there is an urgent need to critically examine the current
training programs related to care of the newborn. Apart from augmentation of the program to ensure
coverage of all health personnel involved in looking after neonates, there may be a need to do some
redesigning of the content, duration or strategy.
To conclude, majority of the healthcare personnel of the district had good awareness about scientific
breastfeeding practices and were following at least some of the recommended clean practices during
delivery. However, their knowledge and practices related to neonatal resuscitation and some postnatal
aspects of newborn care were inadequate. There is an urgent need to strengthen the essential newborn
care training including the neonatal resuscitation component.
REFERENCES
1 Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al — Global, regional and national causes of child mortality
in 2008: a systematic analysis. Lancet 2010; 375: 1969-87.
2 DHS — National Fact Sheet. National Family Health Survey, India 2005-6. Mumbai: International Institute for Population
Sciences, 2007.
3 Hyder A, Morrow R, Wali S, McGuckin J — Burden of Disease for Neonatal Mortality in South Asia and Sub-Saharan Africa.
Washington DC: Save the Children Federation USA, 2001.
4 Bryce J, Boschi-Pinto C, Shibuya K, Black RE — WHO estimates of the causes of death in children. Lancet 2005; 365:
1147-52.
5 Anonymous — Saving Newborn Lives: State of the World’s Newborns. Washington DC: Save the Children US, 2001.
6 Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L — Evidence based cost-effective interventions: how
many newborn babies can we save? Lancet 2005; 65: 977-88.
7 World Health Organisation (WHO) — Essential Newborn Care. Geneva: WHO, 1996.
8 Bhutta Z, Darmstadt G, Hasan B, Haws R — Communitybased interventions for improving perinatal and neonatal health
outcomes in developing countries: a review of the evidence.
Pediatrics 2005; 115: 519-617.
9 Dadhich JP, Paul VK — State of India’s newborns. New Delhi: National Neonatology Forum, 2004.
10 Lim S, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E — India’s Janani Suraksha Yojana, a conditional
cash transfer programme to increase births in health facilities:
an impact evaluation. Lancet 2010; 375: 2009-23.
11 Government of National Capital Territory of Delhi — Report on Medical Certification of Causes of Deaths in Haryana. New
Delhi: Directorate of Economics and Statistics and office of
the Chief Registrar (Births and Deaths), Government of National
Capital Territory of Delhi, 2007.
12 Paul VK, Ramani AV — Newborn care at peripheral health care facilities. Indian J Pediatr 2000; 67: 378-82.
Table 3 . Showing Knowledge about Resuscitation among Doctors
and Nurses/ANMs
Practices No of doctors (%) No of nurses/
(n=15) ANMs (%)
(n=43)
Knew initial steps (all 3) 2 (13) 7 (16)
Knew positive pressure ventilation 12 (80) 16 (37)
Knew chest compressions 5(33) 3 (7)
Table 4 . Showing Knowledge about Healthcare Practices among
Healthcare Personnel based on Length of Service in Delivery Room
Practices Length of Length of p-value
service service
>10 years <10 years
(n=16) (n=42)
Holding baby upside down 8 (50) 23 (55)
Knew initial steps (all 3) 5 (31) 13 (31)
Knew positive pressure ventilation 8 (50) 19 (45) >0.05
Knew chest compressions 2 (12.5) 5 (12)
Knows KMC 7 (44) 31 (74)
Values in n (%), p <0.05 . significant