Thursday, June 20, 2013

Institutional delivery: Despite of basic infrastructure, health centres show inertia towards using it

By Our Representative
In a major critique of the much tom-tommed Chiranjeevi Project, which seeks to provide institutional delivery to Gujarat’s rural population, a recent study, “Infection control in delivery care units, Gujarat state, India: A needs assessment” by senior scholars Rajesh Mehta, Dileep V Mavalankar, KV Ramani, Sheetal Sharma and Julia Hussein has said that “simply incentivizing the behaviour of women to use health facilities for childbirth via government schemes may not guarantee safe delivery.”
The study reports that, although 70% of respondents, who included doctors and nurses, said “standard infection control procedures were followed, a written procedure was only available in 5% of facilities.” Worse, “alcohol rubs were not used for hand cleaning and surgical gloves were reused in over 70% of facilities, especially for vaginal examinations in the labour room.”
Then, “most types of equipment and supplies were available but a third of facilities did not have wash basins with hands-free taps. Only 15% of facilities reported that wiping of surfaces was done immediately after each delivery in labour rooms. Blood culture services were available in 25% of facilities and antibiotics are widely given to women after normal delivery.”
The study no doubt states that “Gujarat performs comparatively well compared with the rest of the country on many maternal health indicators“ with “health centres, family welfare centres and general hospitals widely found in urban areas, while the public health infrastructure in rural areas consists of primary health centres and community health centres.” 
Yet the fact is, “serious shortages of health professionals characterise especially the rural public health system. Much of the health infrastructure does not function due to these chronic staff shortages, and also because of the lack of drugs, supplies and equipment.”
During the field survey in Ahmedabad and Surendranagar districts it was found that in the preceding year, the primary health centres conducted between 5 and 77 deliveries, intermediate health facilities (private and public) between 450 and 600 deliveries, first referral units (health facilities providing government designated obstetric services) 550 to 840 deliveries and tertiary hospitals 800 to 1800 deliveries. More than 400 deliveries were carried out annually in 60% of facilities.
Half of the facilities had more than 20 beds, although 10% did not have designated maternity beds. A separate antenatal ward was available in 70% of the facilities and a separate postnatal ward in 20%. Ninety percent of facilities had a separate operation theatre and labour room. Two facilities (10%) had a combined labour room and operation theatre.
The study found that most facilities did not keep systematic data on infection rates in the maternity units. Delivery registers were seen during observation. “The registers contained information about delivery date and time, sex and birth weight of newborn and type of delivery, although details pertaining to indicators of infection and other crucial information for data analysis of clinical conditions was lacking. Where data was available, infection rates were found to be between 3% and 5%.”
It added, “In almost all health care facilities, the respondents reported that they and their staff routinely washed their hands before and after procedures, although only 75% of respondents reported vigorous rubbing of hands before conducting what were supposed to be aseptic procedures. Eighty percent of respondents believed that the frequency of hand washing in their facility was good, while the rest believed their practices were average.”
The study further said, “Soap and sterile gloves were reported as being widely available in 80% or more of facilities. Surgical gloves were washed and prepared for reuse in more that 70% of facilities, reportedly to limit costs. New sterile gloves were not available in the labour room. Staff present during the observation exercise said that vaginal examinations in the labour room were conducted with reused, washed or autoclaved gloves.”
Then, “sterile gloves were generally reserved for the operation theatre. For vaginal examination in some places, gloves were used after simple washing without autoclaving. Alcohol rubs were not used at all and not seen during the observation exercise. Running water was available in labour rooms and operation theatres in almost all facilities, although a third of facilities were observed not to have wash basins with hands-free taps.”
The study further said, “Protective clothing such as aprons, gloves, caps and face masks were available in over 80% of facilities, although some items such as nail brushes were present in only about 5% of facilities. Sterile gowns, linen packs, delivery packs and packs for Caesarean section were found in only 40-65% of facilities. Sterile disposable delivery kits (Mamta Kit) which are supplied for home deliveries, were found in 40% of the facilities. Autoclave machines were available in most facilities, but indicator paper only in 65% of the facilities. A register for recording of autoclaving was maintained in most facilities.”
The study also found that “thermometers were only available in 65% of facilities. Evidence that recording of temperatures was monitored (by bedside charts, clinical notes) was found in only 45% of facilities . Staff reported that blood cultures could be taken in only 25% facilities. In one facility, the interview revealed that swabs were collected for culture from different areas in the operation theatres on a monthly basis.”
The scholars reported, “Respondents indicated that antibiotics were freely available at the majority of facilities. Antibiotics were observed to be available on the wards. Researchers were told that antibiotics were given to most of the women undergoing (even normal) delivery by the oral route for 14 days or as a single intramuscular injection. A few facilities (15%) reported occasional difficulty in procuring antibiotics.”
The scholars concluded, “Our study shows that infection control is likely to be suboptimal in many delivery units in Gujarat. There is lack of a systemic approach to infection control in facilities with no set procedures for recording, analysis or follow up action. This is evidenced by the lack of standard guidelines and infection control committees, and poor data availability, feedback and audit in the majority of facilities, even in a relatively well performing state like Gujarat.”
They added, “Given the lack of information, underreporting of puerperal sepsis and other infectious complications relating to childbirth is likely. Record keeping, analysis and feedback of data needs to be improved. Criteria for diagnosis of puerperal sepsis should be uniformly laid down and communicated. Notification of puerperal sepsis should be encouraged.”
Further, “Although the increasing institutional delivery rates in Gujarat is likely to benefit the safety of mothers and babies overall, there is need for 'watchfulness' in the light of the transition to facility based childbirth. Studies from several countries have demonstrated that mothers who had planned home deliveries had fewer infections than those who delivered in hospitals. Contracting infections during childbirth in health facilities is a risk in Gujarat and India that is poorly documented. A focus on infection control during delivery and puerperal sepsis may help to improve quality of maternity care.”

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