Facility statistics
In 2016, 3,019 deliveries were recorded in District 1, 2,728 in District 2 and 6,275 in District 3. Neonatal mortality rates per 1,000 live births was 12 at District 1, 16 at District 2, and 7 at District 3 (see Table 1).
Table 1: Facility Statistics (2016)
|
District 1
|
District 2
|
District 3
|
Total
|
Number of deliveries
|
3019
|
2728
|
6275
|
12022
|
Number of live births
|
2919
|
2463
|
6112
|
11494
|
Rate of low birth weight newborn babies (< 2500 g)
|
5.8%
|
4.9%
|
10.7%
|
8.2%
|
Rate of very low birth weight newborn babies (< 1500 g)
|
1.1%
|
0.7%
|
0.6%
|
0.8%
|
Rate of extremely low birth weight babies (< 1000g)
|
0.6%
|
0.3%
|
0.3%
|
0.4%
|
Rate of deliveries: < 37 completed weeks
|
45.8%
|
17.5%
|
19.6%
|
25.8%
|
Rate of deliveries: < 32 weeks
|
1.7%
|
1.9%
|
1.9%
|
1.9%
|
Rate of deliveries: < 28 weeks
|
1.1%
|
0.5%
|
0.5%
|
0.6%
|
Rate of babies diagnosed with birth asphyxia
|
7.1%
|
8.0%
|
4.6%
|
6.0%
|
Rate of babies with Apgar score < 3 at 5 minutes
|
3.0%
|
4.1%
|
1.5%
|
2.4%
|
Facility neonatal mortality rate –deaths <28 days per 1000 live births (NMR)
|
12 (1.2%)
|
16 (1.6%)
|
7 (0.7%)
|
10 (1.0%)
|
Facility characteristics
Two of the three hospitals, District 2 and 3, had a separate ward for admitting newborns with 10-12 beds each. The hospital in District 1 admitted neonates to the labour and postnatal wards. However, nurseries at District 1 and 3 hospitals were under renovation at the time of assessment. The primary health centre did not admit newborns and specialized neonatal care (supportive care, case management, monitoring and follow-up of sick newborns, and neonates requiring specialized care) were referred to the Mission Hospital. The primary health facility did not have a separate nursery and facility data were collected in the general postnatal ward where babies were observed with their mothers for a few hours before discharge. Caesarean deliveries were separate from the labour ward in all three district hospitals; the primary health centre did not conduct caesarean deliveries.
None of the facilities had a full time obstetrician-gynaecologist. One hospital (District 1) had a clinical officer trained in obstetrics and gynaecology while the other three sites (District 2 Mission Hospital and primary health centre, District 3 hospital) had visits by an obstetrician approximately once a month. However, staff reported that the obstetrician had not been visiting of late at the hospital in District 3. Caesarean deliveries were done by clinical officers and general medical officers, in some cases, who had been trained ‘on the job.’ None of the facilities had a full time paediatrician. The primary health centre had a visiting paediatrician once a month while the three district hospitals did not have a visiting paediatrician. District level facilities were staffed by clinical officers, nurses/midwives and lay health workers.
Table 2: Quality of care scores
|
District 1
|
District 2
|
District 3
|
Overall average
|
Infrastructure
|
3.0
|
3.7
|
3.9
|
3.6
|
Laboratory
|
4.0
|
4.0
|
4.0
|
4.0
|
Labour and delivery facilities
|
3.0
|
2.0
|
2.0
|
2.3
|
Caesarean section facilities
|
3.0
|
3.0
|
4.0
|
3.3
|
Prevention and management of preterm labour
|
4.2
|
3.9
|
3.6
|
3.9
|
Nursery facilities
|
2.5
|
3.5
|
3.9
|
3.4
|
Infection control
|
3.3
|
2.9
|
2.5
|
2.9
|
Supportive care of sick neonates
|
3.4
|
4.4
|
3.8
|
3.9
|
Neonatal care equipment and supplies
|
3.0
|
3.0
|
3.0
|
3.0
|
Routine neonatal care
|
4.1
|
3.5
|
3.8
|
3.7
|
Case management of the sick newborn
|
3.1
|
3.4
|
3.0
|
3.2
|
Monitoring and follow-up of sick newborns
|
4.2
|
3.8
|
2.8
|
3.6
|
Infrastructure
The overall average score for the four facilities was 3.6, indicating that all facilities required some need for improvement to meet standards of care. The sites ranged from scores of 3.0 to 3.9. Electricity was not continuously available in all four sites and back-up power systems were insufficient. For example, a solar power system in one site was not sufficient to operate heavy machines and an additional diesel generator was needed for the operating theatre and nursery. Another site noted that water was usually not available when there was a power cut. A third site noted that while a back-up power system was available, it was not in use most of the time. While there was often a functioning fridge available for drugs or vaccines, it may be located in a different department. There was a lack of soap and disinfectants in three out of the four facilities.
Laboratory
All of the laboratory facilities scored 4.0, placing them in the category of little improvement needed to meet standards of care. Most tests were available in the laboratory, including blood glucose, haemoglobin, HIV, syphilis, urine dipstick, urine microscopy and full blood count testing. There were some gaps for hematocrit (PCV) and bilirubin testing across sites and testing for blood grouping and Rhesus antibody was only available at the hospital facilities. However some key tests for management of sick newborns were missing - none of the four sites had blood gas analysis and blood cultures available. All available tests were reported to take under an hour. Space was frequently limited in the laboratory and one site noted that there was no back-up power for the laboratory in case of power cuts.
Labour and delivery, caesareans and nursery facilities
For labour and delivery facilities, the average score was 2.3, indicating considerable need for improvement to meet standards of care. The hospital in District 1 had a score of three while the other three sites scored two. Inadequate lighting, limited space and lack of sterile gloves, a heating source for neonates and equipment for neonatal resuscitation were areas of concern in the labour and delivery ward. In two of the three hospitals, the oxygen concentrator was shared by the whole maternity department or borrowed from the nursery. The average score for caesarean section facilities for the three hospitals was slightly better at 3.3, indicating some need for improvement to meet standards of care. District 3, where the most deliveries recorded, had a score of 4.0. Most equipment and supplies were available and at one site the theatre was well arranged. Heating lamps for newborns and an infusion pump were not available in all sites.
For nursery facilities, the average score was 3.4, indicating some need for improvement. There were considerable differences between the sites ranging from 2.5 to 4.1, with the Mission Hospital scoring the highest. Lack of running water was a problem in two of the three hospitals, leading to unclean toilets. Understaffing was explicitly highlighted in the comments in one hospital. Two of the three hospitals did not have mosquito nets in the nursery despite being a malaria endemic area. The Mission Hospital was clean but only the staff had access to handwashing stations.
Prevention and management of preterm labour
The overall average score for prevention and management of preterm labour was 3.9. District 1 scored over four, indicating little improvement needed, while District 2 and 3 facilities score 3.4-3.9, indicating the need for some improvement. When interviewed, staff were knowledgeable around managing preterm labour and the use of tocolytic drugs. Corticosteroids were given to the mother to improve foetal lung maturity and chances of neonatal survival, if less than 34 weeks gestation and medical staff were prepared to care for and resuscitate a preterm or low birth weight baby if necessary. However, protocols and guidelines on the management of preterm labour were largely not available, vacuum extraction was not avoided and most of the preterm labour was not being prevented. Additionally, records on preventing labour or antenatal administration of corticosteroid were not kept.
Infection control
None of the district-level facilities met standards of care for infection control and the average score was 2.9, indicating considerable need for improvement. The scores ranged between 2.5-3.3. At the three public health facilities, hand hygiene was not followed usually and soap/disinfectants were not available. Though the private mission hospital had a well organized handwashing station and guidelines posted, hand hygiene was still not practiced regularly. Gloves were sometimes used instead of hand hygiene. Sterile gloves were not available at the primary health centre. While infection control policies were sometimes available, they were rarely put into practice. Routine disinfection of the premise were scheduled but irregularly preformed due to staff shortages. Additionally, one site noted that disinfection was compromised by facilities remaining open. In the three hospitals, a routine policy of changing dress and footwear by staff in the operating room was not observed.
Essential drugs, equipment and supplies for neonatal care
The three hospitals each scored 3.0, indicating some need for improvement. Incubators, heated mattress cots, multi-function monitors and appropriately sized nasogastric tubes for preterm babies were not available. A radiant warmer and digital scale were available at the hospital in District 3 but located in the labour ward. One phototherapy lamp was available, one to two functioning oxygen concentrators, appropriate sized face masks, and one to two functioning CPAP machines, pulse oximeter and suction apparatus were available at each hospital. Glucometers were available but at one site there were no reagents to perform the test. Some oxygen concentrators and CPAP machines were not functioning and not all staff were trained to use the CPAP machine. Appropriate-sized self-inflating bags were available though of insufficient number and not always functional. Thermometers were reported to be available but mostly staff kept their own personal thermometers.
Of the drugs penicillin, ceftriaxone and gentamicin were the most available antimicrobials, and phenobrbitone the available anticonvulsant. IV glucose and ferrous sulphate were most readily available. Drugs that were available were not close to expiry but there was often minimal stock. Vancomycin, surfactant, sodium bicarbonate, chlorohexidine for cord care, vitamin D and IV calcium were not stocked at the district hospitals. Most of the drugs are kept at the pharmacy rather than in the nursery.
Routine neonatal care
The overall average score for routine neonatal care was 3.7, indicating some need for improvement to meet standards of care. The hospital in District 1 scored 4.1 while the other districts scored between 3.5 - 3.8. Early and exclusive breastfeeding (4.6), neonatal resuscitation (4.0), screening, prevention and management of vertically transmitted infectious diseases (4.0), and counselling for mothers (4.0) met standards of care with minor improvements needed. However, newborn assessments were not complete and newborns’ breathing and body temperatures were irregularly monitored. Additionally, there were failures to document breastfeeding, jaundice and mothers’ health profiles.
Supportive care, case management, monitoring and follow-up of sick neonates
The three hospitals had an average score of 3.9 in supportive care for sick neonates, indicating the need for some improvements. Only the private mission hospital met the standards of care with little improvements needed (4.4). The provision of IV fluids and blood transfusions were rare and none were observed during the assessments. However, staff reported that IV fluid use and blood transfusions were used when indicated. Drugs were also given with a clear indication and routine use of sedatives was not the norm. Blood glucose was poorly monitored.
The three hospitals had an average score of 3.1, ranging between 3.0-3.4, for case management of sick neonates, indicating the need for some improvements. In particular, there was poor recognition and treatment of jaundice and management of convulsions. There were also problems in diagnosing neonatal sepsis because of the lack of blood and urine cultures. Guidelines for management of convulsions and jaundice were not available and feeding sick neonates were not recorded or monitored routinely. The wards practiced kangaroo mother care and there was good maintenance of room temperature at 25-28C.
The three hospitals had an average score of 3.6 in monitoring and follow-up of sick newborns, indicating that some improvements are needed. However, there was variation across the three sites. The hospitals in District 3 scored 2.8, District 2 scored 3.8 and District 1 scored 4.2 indicating substantial, some and little need for improvement, respectively. Monitoring by nurses met the standards with little improvement required (4.0) but reassessment by physicians required substantial improvements to meet standards of care (average score = 2.9). Daily reassessments by a doctor were not completed, and with the exception of the Mission Hospital in District 2, though a doctor did not review sick neonates or new admissions on weekends and holidays.