Practices of Auxiliary Nurse Midwives regarding care of baby at birth

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1 Practices of Auxiliary Nurse Midwives regarding care of baby at birth Jyoti Sarin, Jeeva S, Geetanjli, Poonam Sheoran Abstract : Despite various initiatives and efforts by government and other agencies, neonatal morbidity and mortality continues to be high in India. Among other reasons, newborn care practices are major contributors for such high rates. The aim of the study was to assess the expressed practices of Auxiliary Nurse Midwives (ANMs) regarding care of baby at birth including neonatal resuscitation. Community based exploratory survey was conducted in selected sub centres of Ambala district in Haryana. Sampling technique was Purposive and a Semi-structured; Interview schedule was used to interview 31 Auxiliary Nurse Midwives conducting delivery and rendering newborn care. Data was analyzed using descriptive statistics. Majority of the ANMs held the babies upside down & assessed for cry and colour to ascertain the life status of the babies. Cleaning & wrapping the baby in a warm towel was adopted correctly by majority of ANMs. When baby was not crying, most of the ANMs used unsafe practices of holding the baby upside down and slapping at the back and when the baby was not breathing; same number of ANMs gave mouth to mouth respiration. Some of them tried to resuscitate the baby for minutes; when unsuccessful they made a decision for referral to the nearest PHC/CHC/Hospital. There is an urgent need to reorient ANMs and to educate them on safe delivery practices and care of baby at birth including neonatal resuscitation. Key words : Expressed Practices, Auxiliary Nurse Midwives (ANMs), Care of baby, Neonatal resuscitation. Correspondence at : Jyoti Sarin Principal, MM College of Nursing, Mullana, Ambala Introduction Newborn mortality is one of the world s major health problems. Nearly 27 million babies are born in India each year; this accounts for 20% of global bir ths. It is estimated that globally four million newborns die before they reach one month of age and out of which India contributes 1.0 million which accounts for 25% of the total neonatal deaths worldwide. The Neonatal Mortality Rate (NMR) declined rapidly in the 1980s from 69 in

2 to 53 in However in recent years, the rate of fall of NMR has shown some slackening-form 48 in 1995 to 39 per 1000 live births in which accounts for nearly two third of infant mortality and half of under-five mortality rate. The slow declining trend is a cause of concern. About 40% of neonatal deaths occur on the first day of life, almost half within three days and nearly threefourth in the first week. The rate of neonatal mortality varies widely among the different states ranging from 11 per 1000 live births in Kerala to around 48 in Uttaranchal and 43 in Haryana. The NMR in rural areas is about one and half times of that in urban areas (42.5 vs per 1000 live births). Similarly, the NMR among the poorest 20% of the population is more than double the NMR of the richest 20 %( 48.4 versus 22 per 1000 live births). Globally, infections, asphyxia, and prematurity are the leading causes of neonatal death. A similar pattern is seen in India where the above mentioned causes contribute to 33%, 21%, and 15% of total neonatal deaths respectively 1,2,3,4.. India is committed to achieve Millennium Development Goals (MDGs) by year 2015 which calls for a 2/3 rd reduction in under-five child mortality rate from year 1990 to National Population Policy (NPP) is the framework for family planning, maternal health and newborn and child health programs for India. The NPP calls for the reduction of IMR to less than 30 per 1000 live birth by the year 2010; and MMR to less than 100 per 1,00,000 live births by this period. Another goal of NPP is to achieve institutional delivery rate of 80% and 100% of deliveries conducted by trained persons. Focusing on the rural population Government of India has launched an initiative National Rural Health Mission and Reproductive and Child Health Programme (RCH) under the umbrella of this programme. The main focus of RCH is to address the issue of IMR, MMR, and total fertility rate. The most important of these is Janani Suraksha Yojna, which has led to increase in institutional deliveries with in just four years; the number of beneficiaries has risen for 7.39 lakh per year in to about one crore in Massive training of ANMs and nurses for safe delivery and management of sick children have also helped in major way. In parallel to these effor ts the up gradation of health care facilities to provide obstetric care and to improve access to skilled birth attendants made a significant difference to health outcomes. Almost more than one lakh skilled health care providers have been financed under NRHM to public health work force 2,5. In addition different states have also taken many initiatives to improve the health services like in number of villages in Haryana, delivery huts have been established to ensure safe delivery for rural women by trained persons in hygienic conditions. Under the scheme, 435 delivery huts have been set up till date at the cost of Rs crores. Haryana govt has also star ted prominently Janani Suraksha Yojana and Janani Suvida Yojana 6. Despite of these all effort almost 60% of deliveries in India occur at home and only 111

3 46.6% of these are attended by ANMs. Keeping in view these factors the present study was conducted to find out the expressed practices of ANMs regarding care of baby at birth. Objective To assess the expressed practices of ANMs regarding care of baby at birth. Materials and Methods In the state of Haryana, there are 2465 Sub centres, 427 PHCs, 160, 24x7 PHCs, 91 CHCs, 86 FRU, 6 Mobile Units, 25 Sub Divisional hospitals and 21 district hospitals. Ambala district is one of the twenty one districts of Haryana.As of 2001 census Ambala district has a population of 10, 14,411 which is about 5 percent of the total population of Haryana. The PHCs are hubs for 5-6 sub-centres usually covering 3-4 villages, Sub centre is the most peripheral health unit and first contact point between the community and health care system at grass root level and are operated by an Auxiliary Nurse Midwife (ANM).They provide preventive, curative and promotional health care services. The study was conducted in selected sub centres of Ambala district, Haryana during the months of July-Sep 2009.These Sub centres fall under Community Health Centre of Mullana. There are six PHC out of which five were selected conveniently i.e., Mullana, Ugala, Barara, Nohani & Salmehri. In the present study a total of 31 ANMs were selected purposively. The number of sub centres under each PHC is as follows: Mullana (7), Ugala (6), Barara (7) Samlehri (6) Nohani (5).These Sub centres covers around 22 km radius in and around the community health centre of Mullana, Nohani (9 km) Samlehri (15km) Barara (9 km) Ugala (16km) with a population of 1, 59,783 people catering to health care needs of 125 villages. The infant mortality rate for the population covered under community health centre of Mullana is 46.6/1000 live bir ths. These sub centres are providing comprehensive health care services to the individuals, families and communities in this district. A semi structured Interview schedule was developed as data collection tool to assess the expressed practices of the ANMs regarding care of baby at birth including neonatal resuscitation. The interview schedule consists of items related to Demographic variables, Care of baby at bir th including neonatal resuscitation. The content validity of the tool was established by exper ts from the field of Nursing, Community Health Nursing, Obstetrics and Gynaecology, Nursing research, Department of preventive and social medicine. The purpose of the study was explained to the subjects, the confidentiality of the responses was assured & consent of the subjects was taken prior to the conduct of the study. The data was collected from subjects posted in sub centres. Semi str uctured interview schedule was administered to each sample. The sample subjects took about

4 30 minutes to give their responses. The data was analyzed using descriptive statistics & presented in the tables and figures. Results Table-1 discusses the Demographic variables of ANMs. As regard to education status 67.8% had education up to 10 th & 32.2% had above secondary education. With regard to years of experience in conducting delivery and care of baby at birth 38.7% of them had experience of yrs, 32.2% of them with yrs of experience and 22.8% with 1-10 yrs of experience where as 3.3% with yrs of experience. More than half of ANMs (58.6%) had antenatal mothers under their care and supervision, followed by 41.93% of them had 1-10 mothers under their care and supervision. Majority of the ANMs (99.7%) conduct 1-10 deliveries per month whereas 3.22% conduct deliveries in a month. Two third (67.7%) of the ANMs had attended refresher or training courses related to care of baby birth & resuscitation and rest did not attend any kind of training or course. The data also reveal that 100% of the antenatal mothers under the care and supervision of the health workers were registered. Majority of the ANMs (96.7%) preferred to conduct deliver y in an institutional setting due to availability of services and facilities to handle emergencies and only one (3.22%) among them preferred to conduct delivery at home. Table 1: Education, Experience & Maternal Care burden of the subjects variables Academic qualification of ANM f(%) Up to 10 th 21(67.7) Above 10 th 10(32.3) Years of experience in conducting delivery and care of baby at birth. 1-10yrs 08(25.8) 10-20yrs 12(38.7) 20-30yrs 10(32.2) 30-40yrs 01(3.3) No. of antenatal mothers under care (41.9) (58.1) Average no. of deliveries conducted per month (96.7) ( 3.3) Undergone any refresher course / training 21(67.8) Registration status of Antenatal mothers under care. 31(100) Prefer to conduct delivery at Institution 30(96.7) Home 01( 3.3) The data in Table-2 describes the expressed practices of ANMs related to measures carried out to establish respiration. Three forth (74%) of the ANM s held the babies upside down, 12.9% placed the baby on the mother s abdomen/chest, and positioned the baby in supine and 12.9% positioned the baby in supine with head turned to one side / left lateral. 113

5 In relation to the assessment carried out to ascertain the life status of the baby, (29%) assessed for cry breathing & colour, 22.6 % assessed for cry only and 22.6% of the ANMs assessed for cry, breathing and heart rate and 19.4% assessed only colour and breathing. Very few number of health workers 6.4% assessed for breathing and heart rate, cry, & colour. Two third of ANMs (67.7%)% maintained airway by cleaning the mouth with gauze followed by 32.3% maintained airway through suction. Table 2 : Practices of subjects in relation to establishment of Respiration. N=31 Establishment of Respiration f(%) Position immediately after birth Hold the baby Upside down 23(74.2) Place the baby on mother abdomen/chest 04(12.9) Supine with head turned to one side, left lateral. 04(12.9) Assessment of baby Only Cry 7(22.6) Colour and breathing 6(19.4) Cry, breathing and heart rate 7(22.6) Cry and breathing & colour. 9(29.0) Breathing, heart rate, Cry, & colour. 2( 6.4) Clearing of airway Clean mouth with gauz 21(67.7) Suction using mucus sucker 10(32.3) Table-3 describes the expressed practices adopted by ANMs for prevention of Hypothermia in Newborn. Most of them (90.32%) maintained temperature by cleaning and wrapping the baby, 61.2% of them motivated mothers to initiate breast feeding, 58.06% kept the baby warm in warm towel, 35.48% placed the baby on mother s chest/ abdomen, 25.80% kept the baby along with mother,19.35% kept room heaters in winter to keep the room warm, 6.45% switched off the Fan, only 3.22% of them placed the baby under radiant warmer and only 1(3.2%) delayed the bath. Table 3 : Practices of subjects regarding prevention of hypothermia. N=31 Prevention of hypothermia f(%) Keep on mother s abdomen / chest 11(35.9) Keep along with mother 8(25.8) Wrap in warm towel 28(90.3) Clean and wrap 18(58.1) Initiation of breast feeding 19(61.2) Keep room heater in winter to warm the room 6(19.4) Switch off the fan 2( 6.5) Delay Bath 1( 3.2) * More than are practice was practiced by subject. The data given in Table-4 describes the problems encountered by the ANMs in prevention of infection. Nearly half of them (48.4%) did not have delivery area adequately clean and disinfected whereas 9.68% of them had very less space available to conduct delivery, it was difficult to conduct deliveries on the cot/khat, only one of them (3.22%) had expressed that there is no separate area for baby care and 29% of them expressed no problems. 114

6 Regarding the problems concerning the articles (74.1%) had no problems but 16.1% faced problems like difficulty in maintaining sterilization and 9.8% had problems in getting the kits and necessary articles. Majority of the ANMs (96.7%) had stressed on the importance of having clean cloth for the mother, 93.5% of them had stressed on the clean place for conducting delivery. The data further revealed that moderate importance was given to; use of clean blade (25.8%), use of clean string (22.5%) whereas only 19.3% of them gave instr uction related to hand hygiene. Regarding eye care and cord care only 38.70% gave eye care to the baby, whereas 61.3% provided cord care by cleaning the cord and letting to air dry. Table 4 : Problems encountered by subjects & practices of prevention of Infection in Newborn. N= 31 Problems encountered &prevention of infection f(%) Problems encountered related to delivery area Delivery area is not clean and disinfected 15 (48.4) Delivery area is inadequate in size 3( 9.7) Difficult to conduct delivery on cot/khat 3( 9.7) No separate area for baby care 1( 3.2) No problems 9(29.0) Problems related to articles Difficulty in maintaining sterilization 5(16.1) Difficulty in getting the kit/articles 3( 9.8) No problems 23 (74.1) Prevention of infection while preparation for delivery Clean cloth for mother & baby 30 (96.7) Clean place 29 (93.5) Clean blade 8 (25.8) Clean string 7 (22.5) Clean hand 6 (19.3) Prevention of infection from Cord & eyes Eye care 12 (38.7) Cord care 19 (61.3) Further, the articles in the delivery kit of the ANM for conducting delivery most of them i.e. 87% carried sterile thread and 80.8% carried sterile blade in the delivery kit. Two third of them (64.5 %) carried soap for hand washing, 54.8% carried gauze, 41.9% carried ar tery forceps, scissor and gloves.another one third (32.2%) of respondents carried 115

7 cotton, and similar number ( 32.2%) carried other articles (nail brush, mackintosh, catgut), 22.5% carried cord clamp as shown in Fig-1. Articles in Delivery Kit 22.50% Cord Clamp 32.20% 41.90% Cotton, Gauze Scissors & Gloves 64.50% Soap 80.80% 87% Sterile Blade Sterile thread 0% 20% 40% 60% 80% 100% Figure-1: Articles in delivery kit The data in Table-5 describes the circumstances leading to neonatal resuscitation Table 5 : Practices related to neonatal resuscitation Practices related to Neonatal resuscitation viz. Baby not crying, /Not Breathing, / Excessive secretion in mouth, Blue /Gasping baby. When the baby is not crying, breathing or having excessive secretions in the mouth (70.96%) of the ANM s were holding the baby upside down and gave a slap on the back, 22.58% did the back rub, 48.38% cleaned the mouth & turned the head to one side & 16.12% administered oxygen. For the blue baby/ when baby is gasping 29.02% has given mouth to mouth respiration followed by 25.80% cleaned the mouth & 19.4% provided warmth, 25.8% administered oxygen. Baby not crying, /Not Breathing, /Excessive secretion in mouth Hold Upside down and slap back 22 (70.96) Back rub 7 (22.58) Clean mouth with gauze & turn head to one side 15 (48.38) Administer oxygen 5 (16.12) Blue /Gasping baby Mouth to mouth respiration 9 (29.00) Clean mouth with gauge 8 (25.80) Provide warmth 6 (19.40) Administration of oxygen 8 (25.80) Time taken for resuscitation 5-10 minutes 11 (35.48) minutes 12 (38.70) minutes 03 ( 9.67) Minutes 03 ( 9.67) Not answered 02 ( 6.45) Need for referral Blue baby 22 (70.96) Baby Not Breathing /Gasping/Not Crying 24 (77.41) Preterm, Low birth weight /large babies, 12 (38.70) Jaundice, Urine/Meconium not passed. 4 (12.90) * More than one answer was given by subjects f(%) 116

8 As regard to the time taken to resuscitate 38.70% had taken minutes after which they made the referral, 35.48% tried for 5-10 minutes, 9.67% of ANMs had taken minutes and similar number has taken minutes respectively, 6.45% did not give any response. The need for referral aroused in77.41% of ANMs when the baby not breathing not crying or gasping, when baby is blue (70.96%), in case of preterm neonates (38.70%), low birth weight or large babies, suspected case of pathological jaundice, baby not passing Meconium/urine (12.90%). Discussion Improving new born survival is a major priority in child health today. Specific programs for enhancing the maternal and child health have been in place since the early 1950 s till date, like MCH program, immunization, ORS for control of diarrhoeal diseases, anaemia, and vitamin A prophylaxis program, CSSM and current RCH-II. ANMs are considered as impor tant health team members in implementing these programmes. Hence it is important to study their practices related to care of mothers and babies before during and after birth. It is good to note that 100% of the antenatal mothers in the study area were registered with ANMs and 96.7% of ANMs opt for conducting delivery in the health centre. During majority of the deliveries (90.32%) conducted in health centre the new-borns was wrapped immediately after birth. Such a practice repor ted should be encouraged as it can lead to prevention of hypothermia in newborns. Bathing the new-born in the first hour after delivery results in significantly increased prevalence of hypothermia as repor ted in a randomized controlled trial conducted in Uganda so bathing should be delayed. 8 In present study only one ANM reported about delaying the bath. Only one third of the newborns delivered were weighed at birth. Whereas weighing at birth is considered an essential activity carried out to determine babies at higher risk and accordingly, determine need for extra care. The weighing of new-borns is also emphasized in Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and its importance have to be emphasized to the would-be-mothers during antenatal period besides monitoring the work of traditional birth attendants to make weighing at birth universal. It was further encouraging finding out that, rooming in was practiced in 61.28% cases. This practice needs to be increase further as it allows mother to observe the baby continuously and any unfavourable observation can be reported immediately. Hand hygiene practices were given less importance by the ANMs only 19.3% 117

9 gave advices related to hand hygiene, even the use of clean string (22.5%) and clean blade (25.8%) was in the least category. This can lead to introduction of infection. Unsafe Cord cutting and improper cord care practices have been identified as risk factors for neonatal deliveries. Studies suggest low coverage of clean cord care & practices among deliveries in South Asia. 1 The ANMs were holding the baby upside down and gave a slap at back to stimulate the baby to cry which is also a harmful practice that should be discouraged. Similarly, in a study in Uttar Pradesh found that 38% of the newborns were hanged baby upside down and slapped immediately after birth to clean the airway The practice of positioning the baby in upside down position immediately after birth was done by majority of the ANM s (74.1%) whereas studies conducted revealed such a practices may damage the brain tissues. Only very less number (3.22%) of health workers assessed for breath, colour, cry and heart rate to ascertain the life status of the baby which serves as a baseline criteria for initiating the resuscitation measures. Review studies have noted the lack of cost-effectiveness studies for strategies to improve clean delivery practices including training of ANMs. The findings presented here suggest that home visits by ANMs AWWs & other forms of antenatal counselling may improve clean delivery practices. The cost effectiveness of this strategy has to be examined. In spite of the fact that most deliveries are conducted in health facilities & all the Antenatal mothers under the care of ANMs were registered, harmful / unsafe newborn care practices were common. Besides traditions, community practices also seem to be impor tant contributors for such practices. There is an urgent need to educate mothers and train health care providers including ANMs and Anganwadi workers on newborn and early neonatal care. Various behavioural change communication strategies through mass media and interpersonal education during antenatal visits may be studied for their effectiveness. Prevailing unhealthy/unsafe practices in the area also should be discussed with health care providers including dais and local practitioners, so that they take special action in preventing these. There is therefore the need for training and retraining of ANMs on safe delivery and good practices. This will go a long way in lowering the high maternal and neonatal mor tality with subsequent lowering of perinatal mortality rates. References 1 Parlato RP, Darmstadt GL, Tinker A. Saving Newborn Lives. Initiative. Washinton DC Paul VK. Teaching Aids: Newborn Health; Newborn health in India. WHO Collaborating Centre for Research and Training in Newborn Care. 1st edition

10 3 WHO.World Health Report. Geneva, Ministry of heath and family welfare. Health indicators of Haryana. Available from URL http// mohfw.nic.in/nrhm/state%20files/ haryana.htm accessed on September Government of India Ministry of Health and family welfare. Annual Report to the People on Health. September Government of Haryana. Concept of Delivery Huts. Available from URL http// www. Haryanagov.in accessed on September Darmstadt GL, Syed U, Patel Z, Kabir N: Review of Domiciliary Newborn-care Practices in Bangladesh. Journal of Health, Population and Nutrition 2006, 24(4): Bergstrom A, Bvaruhanga R,Okong P. The impact of newborn bating on prevalence of hypothermia in Uganda. A randomized control trial. Acta Paediatr 2005; 94: Pratibha Gupta, VK Srivastava,Vishwajeet Kumar et.al Newborn care practices in urban slums of Luknow City,UP.Indian Journal of community medicine.2010;35(1): Singh D. A study of Knowledge, Attitude and Practices regarding care of the neonate in rural community: Thesis submitted to faculty of medical sciences, University of Delhi