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, Postgradate !nstitte of "edical
#dcation and $esearc%, &%andigar% 1'0012
1"D, (enior $esident
2D", Professor
3"))(, Director, National $ral *ealt% "ission +N$*",, *ar-ana
134112
114
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.N/01#D2# 3ND P$3&4!&#( /5 *#314*&3$# P$/6!D#$( 3)/U4 #((#N4!31 N#0)/$N &3$# 7 1/U!( ET AL 118
3s per 2009 estimates, 979 million c%ildren die eac% -ear arond t%e :orld and more t%an %alf of t%is
mortalit- is contri;ted ;- neonatal deat%s17 !n !ndia, neonatal mortalit- acconts for '9< of t%e nder-8 mortalit-
as per National 5amil- *ealt% (r=e- +N5*(,-327 4%e leading cases of deat%s in t%e ne:;orn period inclde
prematrit-, perinatal asp%->ia and infections3-87 &are practices at and immediatel- follo:ing deli=er- contri;te to
neonatal mor;idit- and mortalit- and a pac?age of essential ne:;orn care +#N)&, practices %as ;een pro=en to
redce t%ese ris?s',77 4%ese practices inclde cleanliness
dring deli=er-, t%e se of clean sterilised ;lade to ct t%e cord and t-ing :it% clean string, immediate dr-ing and
:rapping of t%e ne:;orn and dela-ing of first ;at%, initiation of e>clsi=e ;reastfeeding :it%in an %or and prompt
resscitation of asp%->iated ne:;orns',97
!n !ndia, s;centres, primar- %ealt% centres +P*&s,, commnit- %ealt% centres +&*&s, and district %ospitals +D*s,
form t%e ;ac?-;one of t%e %ealt%care deli=er- s-stem7 (;centre is t%e most perip%eral otpost of t%is s-stem in
rral areas and is manned ;- a>iliar- nrse mid:i=es +3N"s,7 3N"s are t%e most perip%eral salaried %ealt%care
pro=iders, :%o pro=ide maternal and c%ild %ealt%care ser=ices inclding deli=er- care@7 4%is is follo:ed ;- P*&s
and &*&s :%ere staff nrses condct most
of t%e deli=eries7 Under $eprodcti=e and &%ild *ealt% Programme, p%ase 7 !! +2008-2010,+$&* !!,, s?illed ;irt%
attendant +()3, training :as started across !ndia, :%ic% mainl- trains 3N"s, lad- %ealt% =isitors +1*6s, and staff
nrses for monitoring of mot%ers dring la;or, acti=e management
of t%e la;or per se and also t%e essential care of ne:;orn7 4%e crrent instittional deli=er- rates in !ndia
are 4077<, and are rapidl- increasing ;ecase of t%e incenti=e ;ased sc%eme of t%e go=ernment7Aanani (ra?s%a
BoCana +A(B,2,107 *o:e=er, fnctional instittions are grossl- inadeDate in nm;er and often lac? enog% trained
manpo:er to ta?e care of t%e ne:;orns7 4%ere is a ris? t%at t%e gains of A(B ma- ;e :iped off, if t%e ne:;orn care
is not impro=ed simltaneosl-7 !t is important to assess t%e crrent le=el of training of t%e %ealt%care :or?ers
spposed to ta?e care of t%e neonates in t%ese instittions7 0it% t%is ;ac?grond, :e aimed to std- t%e ?no:ledge
and practices of %ealt% personnel :it% regards to management of ne:;orns in t%e deli=er- room and immediate
postnatal period7 4%is :old %elp to assess t%e effecti=eness of crrent training programs and t%e reDirements for
agmentation of t%ose7
4%e specific o;Cecti=e :as to assess t%e a:areness
among doctors and nrses regarding neonatal resscitation
and in pro=iding essential care to t%e ne:;orns in t%e
immediate postnatal period till disc%arge, in a district of
*ar-ana7
The Study :
4%is :as a cross-sectional Destionnaire ;ased std- done o=er a period of 1 mont% from 1st to 31st "a- 2010 in
t%e Panc%?la district of *ar-ana in Nort% !ndia7 4%e Destionnaire comprised of 38 open ended Destions and it
mainl- co=ered =arios aspects of ne:;orn care inclding resscitation, care of ne:;orn immediatel- after deli=er-,
cord and s?in care, initiation of feeding and conselling at disc%arge +5ig 1,7 4%is Destionnaire :as pilot tested on
10 staff nrses in t%e district %ospital of Panc%?la7
*ar-ana is one of t%e most indstrialised states in t%e contr- and %as t%e t%ird %ig%est per capita income of all
states in !ndia7 !t ran?s 19t% among t%e list of states :it% %ig% infant mortalit-7 3ccording to t%e medical
certification of cases of deat% in *ar-ana, 2007, ;irt% asp%->ia acconted for 20< of t%e total neonatal deat%s in
t%e state117 Panc%?la is one of t%e 21 districts of *ar-ana, located in its nort%ern part7 4%e poplation of Panc%?la
district is a;ot 47'9 la?%s :%ic% is nearl- eDall- distri;ted ;et:een
rral and r;an areas7 4%e %ealt%care s-stem in Panc%?la comprises of 1 district %ospital, 2 commnit-
%ealt% centres, @ primar- %ealt% centres and 4' s;-centres7 4%e nm;er of deli=eries occrring in t%is district range
from 12,000 to 13,000 e=er- -ear7 4%is sr=e- :as condcted in all %ealt% facilities of Panc%?la district :%ic%
catered to at least 100 deli=eries per -ear7 4%is comprised of 1 district %ospital +D*,, 2 commnit- %ealt% centres
+&*&s,, 8 primar- %ealt% centres +P*&s, and 2 s;centres7
3 con=enient sample siEe of 89 personnel :as ta?en for t%e prpose of t%is std-7
Data :ere o;tained from t%e %ealt%care pro=iders in=ol=ed in neonatal care t%rog% direct inter=ie:s7 3n informed
consent :as o;tained from t%em and anon-mit- :as maintained7
Statistical analysis :
5or ;aseline clinical =aria;les, descripti=e statistics :ere sed7 &ategorical =aria;les :ere compared sing
&%isDare test7 5or s?e:ed continos =aria;les, "ann- 0%itne- U test :as sed7 3 p-=ale of F 0708 :as
consideredsignificant7
Analysis :
5ift--eig%t medical personnel :ere inter=ie:ed :%ic% inclded 27 staff nrses, 11 3N"s, 18 medical officers, 4
mltiprpose %ealt% :or?er females +"P*05, and one mltiprpose %ealt% :or?er male +"P*0",7 "edical
officers comprised of 4 paediatricians and 11 "))( doctors7
Deli=eries :ere condcted ;- staff nrses at t%e P*&s, &*&s and D*, :%ile 3N"s condcted it at t%e s;centre
le=el7 4%irt--t%ree personnel +87<, %ad recei=ed some form of training in neonatal resscitation7 /f t%em, 31 +83<,
%ad attended t%e s?illed ;irt% attendant +()3, training and 2 doctors %ad attended t%e neonatal resscitation program
+N$P, corse7 4%e median time since t%eir training
:as 2 -ears +range 4 mont%s to 18 -ears,7 4%irt--t%ree %ealt%care :or?ers +87<, %ad t%e practice
of %olding t%e ;a;- pside do:n +4a;le 1,7 4%e initial steps of resscitation, :%ic% comprise of dr-ing t%e ;a;-,
sctioning and t%en stimlating, :ere also e=alated7 3ll t%e 3 steps :ere ?no:n to onl- @ +1'<,, :%ile 41 +71<,
?ne: at least 1 of t%e 3 steps and 9 +13<, did not ?no: an- of t%ese initial steps7 3mong initial steps, 18 +2'<, did
not ?no: %o: to stimlate t%e ;a;- if %eGs%e does not cr-7 /nl- 29 +49<, ?ne: a;ot pro=iding positi=e pres-
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
1 (erial nm;er
2 Name of t%e %ealt% :or?er
3 Designation
4 3ge
8 #dcational Dalification
' Place of :or?
7 Dration in deli=er- room
9 3n- training in neonatal resscitation
@ 4-pe of training
10 Period after training
11 *o: do -o prepare prior to deli=er- I
12 Do -o do %and:as%ing prior to condcting deli=er- I
13 0%o condcts t%e deli=er- at -or centre I
14 *o: do -o %old t%e ;a;- after deli=er- I
18 0%en is cord tied I
1' 0%at is sed for t-ing t%e cord I
17 0%at is sed for ctting t%e cord I
19 Do -o appl- an- t%ing on t%e cord I
1@ *a=e -o %eard a;ot t%e 8 7&7s dring deli=er- and
:%at are t%e-I
20 !f ;a;- does not cr-, :%at :ill -o do I
21 0%at are t%e initial steps in neonatal resscitation I
22 0%en s%old -o start c%est compressions and
positi=e pressre =entilationI
23 0%at is t%e indication for sing adrenaline I
24 0%ic% inCection is gi=en to all ;a;ies after deli=er- I
28 3re -o practising it and if no, :%- I
2' 0%at is t%e first feed to ;e gi=en to t%e ;a;- I
27 0%ic% mil? s%old ;e gi=en I
29 (%old colostrm ;e gi=en I
2@ 0%at feed do -o gi=e to ;a;ies ;orn ;- ceasarean section I
30 0%ere do -o ?eep t%e ;a;- immediatel- after deli=er- I
31 0%at are t%e complications t%at can de=elop in preterm ;a;ies I
32 0%at is ?angaroo mot%er care I
33 *o: is it done I
34 Do -o ad=ise t%e practice of ."& I
38 0%at do -o tell t%e mot%er at t%e time of disc%arge I
3' Do -o ?no: :%at are t%e danger signs I
5ig 1 7 (%o:ing Jestionnaire for t%e #=alation of .no:ledge
and Practices a;ot $esscitation and #ssential Ne:;orn &are
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11' A !ND!3N "#D 3((/&, 6/1 111, N/ 2, 5#)$U3$B 2013
sre =entilation sing self-inflating ;ag and mas?, :%ereas 80 +97<, did not ?no: a;ot c%est compression or a;ot
t%e se of drgs +adrenaline, in resscitation7 3ll %ad t%e practice of t-ing t%e cord immediatel- after deli=er-7 3ll
t%e 8 7&7s reDired for deli=er- ie, clean %ands, clean deli=er- srface, clean ;lade, clean cord and clean cord tie
:ere ?no:n to onl- 33 +87<,, :%ile 21 +3'<, did not ?no: an- of t%em7 5ift--si> of t%em +@'<, did not appl-
an-t%ing to t%e cord :%ile 2 of t%em applied ;etadine7 3ll of t%em did %and :as%ing prior to condcting t%e deli=er-
and sed sterile scissors for ctting t%e
cord7 3ll sed clean cord ties +4a;le 1,74%e practices of t%e %ealt%care personnel :%o %ad ndergone some special
training corses li?e ()3, N$P or ?angaroo mot%er care+."&, :ere compared :it% t%ose
:%o %a=e %ad no sc% training7 No significant differences :ere fond in an- of t%e practices ;et:een t%e
trained and t%e ntrained persons e>cept for t%e ?no:ledge a;ot ."&, :%ic% :as more in trained
personnel +pK07001, +4a;le 2,7 3mong doctors +nK18,, 12 +90<, ?ne: a;ot positi=e pressre =entilation,
:%ile among nrsesG3N"s +nK43, onl- 1' nrsesG 3N"s +43<, ?ne: it7 (imilarl-, 10 doctors +'7<, ?ne:
a;ot c%est compressions, :%ile onl- 3 nrses +7<, %ad t%is ?no:ledge +4a;le 3,7 4%e ?no:ledge and practices of
%ealt%care personnel :ere compared ;ased on t%eir lengt% of ser=ice in t%e deli=er- room7 3n ar;itrar- ct-off of 10
-ears :as ta?en for t%is7 *o:e=er, comparison ;et:een t%ese 2 grops did not re=eal an- difference in t%e =arios
%ealt%care practices +4a;le 4,7
4%e need of =itamin . for t%e ne:;orn :as ?no:n to 44 +7'<,, :%ile onl- 32 +88<, practiced it7 4%e main reason
for not sing =itamin . :as t%e non- a=aila;ilit- of t%e drg, especiall- in t%e P*&s and s;centres7 3fter deli=er-,
t%e practice of ?eeping t%e ;a;- :it% t%e mot%er :as follo:ed ;- 31 +83<, respondents :%ile t%e remaining ?ept
t%e ;a;- nder a radiant :armer7 #>clsi=e ;reastfeeding :as ad=ised ;- all of t%em in t%e first ' mont%s and
e>cept one, all ?ne: t%at e=en postcaesarean
mot%ers can and s%old ;reastfeed7 3ll of t%em practiced gi=ing colostrm to t%e ne:;orn ;a;- as t%e first feed7 3t
least one danger sign :as told to t%e mot%ers at disc%arge ;- 49 +93<,7 5ort--fi=e of t%em +7'<, ?ne: at least some
complications t%at preterms are prone to, inclding %-pot%ermia, infection or %-pogl-caemia7 #=en t%og% 3@
personnel +'7<, %ad %eard a;ot ."&, onl- 33 of t%em +87<, ?ne: %o: to do it and onl- 3 +8<, practiced it
:%ile managing small ;a;ies7
Comments :
!n t%is sr=e- of t%e %ealt% personnel posted at =arios %ealt% deli=er- centres in t%e Panc%?la district of *ar-ana,
a;ot ?no:ledge and practices regarding resscitation and essential ne:;orn care, it :as fond t%at t%ere :ere some
encoraging ;t man- disconcerting findings7 !t :as good to note t%at all personnel practiced %and :as%ing prior to
condcting deli=er- and sed sterilised scissors for ctting t%e cord7 3ll ad=ised e>clsi=e ;reastfeeding and gi=ing
colostrm, e=en :%en t%e mot%er %ad a caesarean section7
3lso, atleast one danger sign :as told to t%e mot%ers prior to disc%arge ;- maCorit- of t%e personnel7
*o:e=er, t%e ?no:ledge and practices related to resscitation :ere grossl- s;-optimal7 4%is is alarming
;ecase ;irt% asp%->ia is responsi;le for 20< of t%e neonatal deat%s in *ar-ana117 4%e initial steps of resscitation
li?e dr-ing, sction, stimlation :ere ?no:n to onl- fe: of t%e personnel attending deli=eries,
and t%e maCorit- did not ?no: a;ot ad=anced resscitation inclding c%est compressions and drgs li?e
adrenaline7 3lso, 87< of t%em still %ad t%e practice of %olding t%e ;a;- pside do:n after deli=er-, :%ic% cold ;e
dangeros, especiall- in a preterm ;a;-7 #=en t%og% man- ?ne: a;ot t%e complications in
preterm ;a;ies inclding %-pot%ermia, %ardl- an- one practiced ?angaroo mot%er care7
4%ese findings are to ;e =ie:ed along :it% t%e fact t%at 87< %ad ndergone some form of training, :it% t%e
maCorit- %a=ing ndergone t%e ()3 training7 Promoting s?illed attendance at ;irt% t%rog% t%e ()3 training is an
important strateg- t%at %as ;een adopted as part of t%e $&*-!! programme7 !mplementation of t%is strateg- :as
meant to empo:er t%e 3N"s, 1*6s and staff nrses, not onl- in %andling normal deli=eries, ;t also for acti=el-
managing t%e t%ird stage of la;or and pro=iding t%e reDired
emergenc- care ;efore referring an- :oman :%o de=elops complication dring pregnanc- or c%ild ;irt% and
4a;le 17 Showing Knowledge and Practices Related
to Newborn Care among the Healthcare Proiders
!n"#$%
.no:ledge and practices No of %ealt%care
:or?ers +<,
*and :as%ing prior to condcting deli=er- 89 +100,
&lean cord tie 89 +100,
3pplication on cord 2 +3,
8 7&7s 33 +87,
!nitial steps of resscitation +all t%ree, @ +1',
3t least one of t%e initial 3 steps 41 +71,
*olding ;a;- pside do:n 33 +87,
Positi=e pressre =entilation 29 +49,
&%est compressions 9 +13,
$esscitation drgs 9 +13,
4a;le 2 7 Showing Com&arison between Those 'ho Receied
S&ecial Training and Those 'ho (id Not
No of trained No of ntrained p-=ale
personell +<, personell +<,
+nK33, +nK28,
*olding ;a;- pside do:n 22+'7, 11 +44, 0738
.ne: initial steps +all 3, 8 +18, 4 +1', 07@0
.ne: indication for c%est
compressions ' +19, 2 +9, 0741
Positi=e pressre =entilation 17 +81, 11 +44, 0793
.ne: a;ot =itamin . 27 +91, 17 +'9, 0794
.ne: a;ot ."& 30 +@0, @ +3', 07001
pF0708 7 significant
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also essential ne:;orn care7
4%e ()3 training occrs o=er a period of 2 :ee?s and at a time, not more t%an 4 persons are trained7 Dring t%e
training, core s?ills are tag%t and demonstrated, :%ic% incldes monitoring t%e progress of la;or, agmenting
la;or, condcting normal deli=er- :it% aseptic tec%niDe, acti=el- managing t%e t%ird stage of la;or, and essential
ne:;orn care7 4%e ne:;orn part of t%e training mainl- focses on
asepsis prior to deli=er- li?e %and :as%ing and preparing t%e deli=er- srface, temperatre maintenance in t%e
ne:;orn, care of t%e cord, s?in, and e-es, e>clsi=e ;reast feeding and conseling prior to disc%arge inclding t%e
danger signs7 )t, t%e maCor aspect of t%is training is focsed on t%e mot%er so as to pre=ent maternal mortalit- and
onl- a small fraction +appro>imatel- 8<, of t%e entire modle is
dedicated to ne:;orn care7 3lso, t%is modle does not train %ealt%care :or?ers in t%e initial steps of resscitation
and :%at steps are to ;e adopted in a ;a;- :%o fails to ;reat%e li?e stimlation or positi=e pressre =entilation7 4%e
fact t%at t%ere :ere almost no maCor differences in t%e ?no:ledge and practices of t%ose :%o %ad ndergone special
training as compared to t%ose :it%ot an- special training sggests
t%at t%e training corses did not %a=e t%e desired impact7 4%e met%odolog- and content of t%ese corses needs to ;e
re=ie:ed and pro=ision for follo:-p corses and ?no:ledge spport s-stems s%old ;e made7
3 std- done ;- Pal et al in 1@@7 e=alated t%e ne:;orn care practices along :it% t%e infrastrctre a=aila;le in
t%e district %ospitals and s;-district %ospitals of /rissa sing a Destionnaire127 4%e- fond t%at ;et:een 70 to 78<
of deli=eries at t%ese facilities :ere condcted ;- staff nrses and t%e remaining ;- doctors7 4%ere :as a %ig%
incidence of earl- initiation of ;reastfeeding, good cord care and colostrm administration to t%e ne:;orns7
*o:e=er, t%is std- did not e=alate t%e ?no:ledge a;ot t%e initial steps reDired in resscitation and confined
t%eir sr=e- to D*s and s;-district %ospitals7 !n *ar-ana, t%e !"$ is 84 per 1000 li=e ;irt%s and
78< of it is contri;ted ;- neonatal deat%s7 4%e contri;tion of asp%->ia and lo: ;irt% :eig%t to neonatal deat%s in
*ar-ana is arond 20< and 23< respecti=el-117 !n Panc%?la, despite t%e fact t%at it %as a =er- %ig% percentage of
instittional deli=eries reac%ing near @8<, neonatal mortalit- contri;tes to '9< of infant deat%s7 4%is is a reflection
of t%e inadeDate training and capacit- ;ilding related to essential ne:;orn care and resscitation7 *ence, t%ere is
an rgent need to criticall- e>amine t%e crrent
training programs related to care of t%e ne:;orn7 3part from agmentation of t%e program to ensre co=erage of all
%ealt% personnel in=ol=ed in loo?ing after neonates, t%ere ma- ;e a need to do some redesigning of t%e content,
dration or strateg-7
4o conclde, maCorit- of t%e %ealt%care personnel of t%e district %ad good a:areness a;ot scientific
;reastfeeding practices and :ere follo:ing at least some of t%e recommended clean practices dring deli=er-7
*o:e=er, t%eir ?no:ledge and practices related to neonatal resscitation and some postnatal aspects of ne:;orn
care :ere inadeDate7 4%ere is an rgent need to strengt%en t%e essential ne:;orn care training inclding t%e
neonatal resscitation component7
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4a;le 3 7 Showing Knowledge abo)t Res)scitation among (octors
and N)rses*ANMs
Practices No of doctors +<, No of nrsesG
+nK18, 3N"s +<,
+nK43,
.ne: initial steps +all 3, 2 +13, 7 +1',
.ne: positi=e pressre =entilation 12 +90, 1' +37,
.ne: c%est compressions 8+33, 3 +7,
4a;le 4 7 Showing Knowledge abo)t Healthcare Practices among
Healthcare Personnel based on Length o+ Serice in (elier, Room
Practices 1engt% of 1engt% of p-=ale
ser=ice ser=ice
L10 -ears F10 -ears
+nK1', +nK42,
*olding ;a;- pside do:n 9 +80, 23 +88,
.ne: initial steps +all 3, 8 +31, 13 +31,
.ne: positi=e pressre =entilation 9 +80, 1@ +48, L0708
.ne: c%est compressions 2 +1278, 8 +12,
.no:s ."& 7 +44, 31 +74,
6ales in n +<,, p F0708 7 significant