Need Assessment of Emergency Obstetric and Neonatal Care (EmONC) in Selected Health Care Facilities across Pakistan Dr Farah Rashid Siddiqui Associate.

Need Assessment of Emergency Obstetric and Neonatal Care

(EmONC) in Selected Health Care Facilities across Pakistan

Dr Farah Rashid SiddiquiAssociate Professor

Yusra Medical & Dental CollegeIslamabad

Background • The EmONC is a descriptive need assessment of

selected health facilities of Pakistan.

• The assessment by definition examined only facility-based services.

• The current needs assessment is designed to identify needs and gaps and to inform programmatic efforts for increasing quality, coverage, and utilization of EmONC services

Basic EmONC (B.EmONC )To qualify for a B. EmONC facility, the health centres and hospitals must have performed the following seven signal functions within the past 3 months (WHO, 2009)

1)administered parenteral antibiotics;2)administered parenteral anticonvulsants;3)administered parenteral oxtyocics;4)performed manual removal of placenta;5)performed removal of retained products (MVA)6)performed assisted vaginal delivery (with vacuum

extractor or forceps); and7)performed neonatal resuscitation with bag and

mask.

Comprehensive EmONC (C.EmONC• For a C.EmONC facility, the hospitals must have

performed following two additional signal functions besides above seven, within the past 3 months:

• Blood transfusion; and• Caesarean section.

Objective:• To assess the EmONC available in selected

Health Care Facilities across Pakistan with a view to identify gaps and suggest measures to bridge those gaps in service delivery.

• This needs assessment examined facility readiness, provider skills, the quality of services, coverage and utilization of EmONC services.

Selection of Health Facilities

• 31 Basic EmONC health facilities in 14 districts and

• 11 Comprehensive EmONC health facilities in 10 districts of;

• Punjab, Sindh, KPK, Balochistan and AJK

Table 1: Distribution of type of health facility by Province for B.EmONC

Province Type of health facility BHU RHC THQ Total

Punjab 9 2 1 12 Sindh 4 1 2 7 Khyber Pakhtoonkhwa 1 2 1 4 Balochistan 2 1 1 4 Azad Jammu & Kashmir 1 1 1 3

Table 2: Distribution of type of health facility by Province for C.EmONC

Province Type of health facility RHC THQ DHQ Total

Punjab 0 2 1 3 Sindh 1 1 1 3

Khyber Pakhtoonkhwa 0 1 2 3 Balochistan 0 0 1 1

Azad Jammu & Kashmir 0 1 0 1

Methodology &EmONC Assessment Tool:

• It was a cross-sectional survey conducted during 2010-2011. Data was collected on a structured checklist.

• Key Informant interviews with;– EDOH, – Medical Officer In charge, – dispensers and – community members; were conducted

Indicators 1 Infrastructure status 2 Staff availability 3 Basic Equipment

(Functional) 4 EmONC equipment

(Functional) 5 Knowledge of LHVs on

MNCH 6 EmONC signal functions 7 HIS stationary 8 Client satisfaction 9 Disaster Management

Plan 10 Blood transfusion

available 11 C-Section performed 12 Lab services available

Indicators B EmONC(%) C EmONC(%)

Infrastructure status 71.2 78.2Staff availability 92 86.4Basic Equipment (Functional) 46.7 96.4

EmONC equipment (Functional) 18.8 80.6

Knowledge of LHVs on MNCH 45.4 54.5

EmONC signal functions 69.2 86.8

HIS stationary 77.4 63.6Client satisfaction 70 80Disaster Management Plan 19.4 27.2

Blood transfusion available N/A 91

C-Section performed N/A 91Lab services available 38.7 82

Results

Comparison of the responses to the most important indicators information is presented in a consolidated manner

(%) for EDOH, MO and Community members

Indicators EDOH(%)

MO(%)

Community(%)

24/7 EmONC functionality 100 94 67

EmONC services availability 95.6 92 50

Staff well trained 84 91 71

Disaster responsiveness 69 50 46

B.EmONC health facilities- comparison of data for March 2010-11

March 2010 March 2011

ANC 56,904 57,172TT 32,906 33,237Deliveries 13,344 14,009PNC 12,487 14,593Children vaccinated for Measles 35,611 33,256

C.EmONC health facilities- comparison of data for March 2010-11

March 2010 March 2011

ANC 23,179 26,462Deliveries 21,091 27,190C-section 531 647PNC 18,344 19,417Children vaccinated for Measles 54,173 65,329Maternal deaths 8 9Neonatal deaths 30 36

1. Infrastructure Figure 1.1 B.EmONC Figure 1.2 C.EmONC

73.75

65

87.5

82.5

56.25

71.25

0 20 40 60 80 100

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Infrastructure status at B-EmONC facilities (%)

100.0

55.0

83.3

60.0

85.0

78.2

0.0 20.0 40.0 60.0 80.0 100.0 120.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Infrastructure status at C-EmONC facilities (%)

2. Staff Availability

Figure 2.2 C.EmONCFigure 2.1 B.EmONC

94

92

100

94

0

92

0 20 40 60 80 100

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Human resource Availability on day of visit(%)

97.6

71.4

92.9

78.6

85.7

86.4

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Human resource Availability on day of visit(%)

3. Basic Equipment Availability & Functionality

45.0

16.7

73.3

45.0

83.3

46.7

71.7

86.7

76.7

75.0

83.3

75.0

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Basic Equipment Availability & Functionality (%)

Available

Functional

4. EmONC related Equipment Availability & Functionality

Figure 4.1 B.EmONC Figure 4.2 C.EmONC

13.8

20.0

35.0

20.0

0.0

18.8

42.5

40.0

45.0

38.8

0.0

40.6

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

B.EmONC related equipment Availability & Functionality (%)

Available

Functional

89.9

82.6

84.1

43.5

73.9

80.6

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

C.EmONC related equipment Functionality (%)

5. HMIS- Figure 5.1 B.EmONC Figure 5.2 C.EmONC

93.8

40

80

75

0

77.4

0 20 40 60 80 100

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

HIS Stationary Availability (%)

100

0

100

0

1

63.6

0 20 40 60 80 100

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

HIS Stationary Availability (%)

. 6. Availability of Essential drugs

Figure 6.1 B.EmONC Figure 6.2 C.EmONC

75.7

82.9

77.1

95.7

42.9

78.6

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Essential drugs availability at health facilties (%)

100.0

63.9

69.4

75.0

100.0

79.5

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Essential drug availability at health facilties (%)

7. Knowledge of LHV on MNCHFigure 7.1 B.EmONC Figure 7.2 C.EmONC

40.0

40.0

58.5

57.7

61.5

45.4

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Knowledge of LHVs on MNCH issues(%)

69.7

39.4

60.6

36.4

54.5

54.5

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Knowledge of LHVs on MNCH issues(%)

8. Knowledge of WMOs on C-section sterilization and post-op care

55.6

22.2

44.4

0.0

33.3

36.4

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Knowledge of WMOs on C-section, sterilization & post-op care (%)

9. Availability of EmONC services including all the signal functions

Figure 9.1 B.EmONCFigure 9.2 C.EmONC

63.1

66.2

83.1

78.5

84.6

69.2

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Availability of Basic EmONC services including signal functions (%)

100.0

90.0

65.0

95.0

95.0

86.8

0.0 20.0 40.0 60.0 80.0 100.0 120.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Availability of Comprehensive EmONC services including signal functions (%)

10.Disaster management plan for MNCH

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Yes No

27.2%

72.8%

Do you have a disaster management plan for B.EmONC

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Yes No

19.4%

80.6%

Do you have a disaster management plan for C.EmONC

The health facilities who shared the disaster management plan, had the following components covered;

• Extra beds are placed in the hospital for affectes

• Extra supplies are made available• Coordination is made with donors• Coordination is made with DGHS

11. Community SatisfactionFigure 11.1 B.EmONC Figure 11.2 C.EmONC

64.4

57.8

91.1

80.0

88.9

70.0

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Community Service users satisfaction (%)

88.9

70.4

88.9

55.6

88.9

80.8

0.0 20.0 40.0 60.0 80.0 100.0

Punjab

Sindh

KPK

Balochistan

AJK

Pakistan

Community Service users satisfaction (%)

Conclusion

• There is a need to provide improved EmONC services through Quality, Effectiveness, Acceptability, Accessibility and Affordability.

• District wise Disaster Management Plans should be

prepared with the active involvement of EDHOs, DHOs and other important stakeholders.

• Vertical programs like National MNCH program should be

actively involved in Provincial and district disaster management plans for filling the gaps, training of staff and provision of Basic and Comprehensive EmONC services

10:59 AM 28

SECTION – V: AVAILABILITY OF LAB & DIAGNOSTIC SERVICES(Check, Observe And Report By Ticking Either “Yes” Or “No”)

Sr. Services Yes No

1. Hemoglobin

2. Blood Grouping

3. TB Lab smear diagnostic services

4. Routine blood examination services

5. X-Rays chest services (Radiological services)

SECTION – VII: DRUG STOCK OUTS (YES MEANS DRUG OUT OF STOCK)(Check, Observe And Report By Ticking Either “Yes” Or “No”)

Drug Items

At the day of VisitDuring Last 3

Months If yes, number of stock out days in last 3 months

Yes No Yes No

1. Antipyretic Syrups

2. Antibiotic Syrups

3. ORS

4. Zinc

5. Ferrous Sulphate

6. Deworming Syrups

7. Deworming Tablets

8. EmONC Drugs

9.RHZE (Rifampicin 150mg + Isoniazid 75mg + Pyrazinamde 400mg + Ethambutol 275mg)

10. HR (Isoniazid 100mg + Rifampicin 150mg)

11. Streptomycin (750mg)

SECTION – IX: QUALITY OF CARE INDICATORS Check The Appropriate “Yes” Or “No” Cell For Each Indicator After Thorough Observation.

Quality: Process Indicators Yes No

Maintenance and updating of records/ registers

Telemedicine sessions being held in the health facility

DEWS liaisoning center established

DEWS reporting systems functional in the health facility

Mobile clinics functional

Laboratory pick-up points functional

Health education MNCH, hygiene, sanitation, nutrition, breast feeding, home care of common illness developed, printed & available

Registration of Antenatal Cases complete

Antenatal cards available

Family planning 3 modern methods available

Five essential EmONC drugs available

Functional emergency newborn care unit available

Blood transfusion services available

C-Section services available

Maternal and newborn referral slips available

Facility functional 8/6 for preventive MNCH services

Facility functional 24/7 for basic EmONC Services

Facility functional 24/7 for comprehensive EmONC services

Child weights being plotted on growth charts

Children being vaccinated according to EPI protocol

Lab register maintained for STI tests

Obstetric register record updated with normal deliveries and complications

IUD cards available and filled for follow-up

Environmentally acceptable placenta disposal methods in place

Environmentally acceptable methods of risk waste disposal in place

Neonatal deaths investigate by clinical audit

Under 5 child deaths investigated by clinical audit

Maternal deaths investigated by clinical audit

Health facility has monthly performance review meeting

Health facility has quarterly performance review meeting

Quality Output/ Outcome Indicators (Ask, observe and check records) Yes No

SECTION – XAsk And Check The Figures For The Last 3 Months From Registers

Quality Outcome/ Outcome Indicators #

Number of women provided ANC

Number of MNCH health education sessions held in the community

Number of hygiene and sanitation health education sessions held in the community

Number of exclusive breast feeding and family planning health education sessions held in the community

Number of nutrition and home care of common illness health education sessions held in the community

Number of training sessions of health care providers carried out *

Number of women delivered in the health facility (Normal delivery)

Number of C-section deliveries in health facility

Number of women died during delivery

Number of women referred for delivery and complications

Number of children presented with diarrhea

Number of children with diarrhea who died

Number of children with presented with ARI

Number of children with ARI who died

Number of newborn referred

Number of newborn who died

Number of men (>18 years) diagnosed and treated through telemedicine

Number of women (>18 years) diagnosed and treated through telemedicine

Number of adolescents aged 5-18 years diagnosed and treated through telemedicine

Number of children under 5 years age diagnosed and treated through telemedicine

Knowledge of LHVs on MNCH issues

Serial no

Questions Pre-test evaluation Post-test evaluation

frequency %age frequency %age 1 How many antenatal

visits r recommended?

2 Skilled birth attendants are?

3 Danger signs during pregnancy

4 Hygiene during pregnancy

5 Danger signs after pregnancy

6 Child spacing between two pregnancy

7 Practices for clean cutting of cord

8 Myths of community in pregnancy

9 Ideal time to start breastfeeding

10 First bath to new born