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ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 25-30

Infection control practices at facilities providing monetary incentives for facility births: An assessment at selected labour and delivery rooms in two states of India


1 Department of Microbiology, Maulana Azad Medical College, New Delhi, India
2 Department of Sexual and Reproductive Health, Bhubaneswar, Odisha, India
3 Centre for Clinical Global Health Education, Johns Hopkins University, Baltimore, Maryland, USA
4 Department of Pediatrics, Children's National Medical Center, George Washington University, Children's Research Institute, Washington, DC, USA
5 Department of infectious Diseases, Mayo Clinic College of Medicine and Science, USA
6 Department of Pediatrics, Children's National Medical Center; Department Global Health and Epidemiology, George Washington University, Children's Research Institute, Washington, DC, USA

Date of Web Publication13-Aug-2019

Correspondence Address:
Dr. Vikas Manchanda
Department of Microbiology, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_5_19

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  Abstract 


Introduction: We report findings from an assessment of infection prevention and control (IPC) practices using a standardised assessment tool at five facilities in high maternal mortality areas of India.
Methods: This study was conducted in five public facilities in the two high-focus states ‒ Odisha and Rajasthan. Both the states registered a high uptake of the Janani Suraksha Yojana programme.
We surveyed facilities using the infection control assessment tool. The overall quality of those practices assessed in each section was as follows: A – excellent practices in this area (75%–100% of the possible total score); B – good practices in this area (from 50% to 75% of the possible total score) and C – poor practices needing immediate attention (<50% of the possible total score).
Results: The mean score for the hospital facility was 36% (27%–46%) in the C category. General ward facilities mean score was 83% (between 50% and 100%) in the A category. Biomedical waste management scored between 10% and 47% both in the C category. Adherence to policies regarding waste management scored 25%–50% in the C category. All the sites had dedicated labour rooms, and for all the modules, the mean score was <50% (22%–47%) in the C category. On general issues, staff education and labour and delivery service design, across the sites, the mean score was 30% (25%–50%) in the category C. Prophylactic antibiotics were used with a mean score of 67% (33% at one site 100% at four sites) for normal delivery and that was inappropriate. Post-partum care received mean score of 23% (20%–25%). The mean length of stay was 1–2 days following uncomplicated delivery and 5–7 days' post-C section delivery.
Conclusions: Our study reveals that basic core components of IPC practices were not being fully implemented for safe delivery of babies. Antibiotics were being used inappropriately for normal delivery. A robust IPC programme and antimicrobial stewardship programme should be implemented in labour and delivery rooms.

Keywords: Antimicrobial prophylaxis, caesarean infection rates, community health centre, infection control in labour and delivery, Janani Suraksha Yojana, limited resource setting, neonatal sepsis


How to cite this article:
Manchanda V, Prasad D, Randive B, Gearhart A, Huskins W C, Singh N. Infection control practices at facilities providing monetary incentives for facility births: An assessment at selected labour and delivery rooms in two states of India. J Patient Saf Infect Control 2019;7:25-30

How to cite this URL:
Manchanda V, Prasad D, Randive B, Gearhart A, Huskins W C, Singh N. Infection control practices at facilities providing monetary incentives for facility births: An assessment at selected labour and delivery rooms in two states of India. J Patient Saf Infect Control [serial online] 2019 [cited 2019 Nov 20];7:25-30. Available from: http://www.jpsiconline.com/text.asp?2019/7/1/25/264397




  Introduction Top


Women in low- and middle-income countries (LMICs) receive poor quality maternal care, which contributes to high rates of maternal mortality, especially among the poorest of women.[1] India contributes a fifth of all maternal deaths globally with the maternal mortality ratio (MMR) of 167.[2],[3] An analysis of MMR from Indian states found substantial variability in MMR among states, with the highest rates in poor states.[3],[4]

To address this problem, India launched the Janani Suraksha Yojana (JSY) programme to reduce maternal and neonatal mortality in 2005. The JSY emphasises in-facility births as a means to increase access to safe delivery care. The JSY is a cash transfer programme wherein women are paid cash on delivering in a health facility.[5] During the first 10 year period of the JSY programme (2005–2015), the percentage of in-facility births increased from 26% to 78% in Odisha and from 23% to 87% in Rajasthan.[6] However, despite the dramatic increase in in-facility births, decreases in maternal mortality were proportionately much lower. The poor quality of care during facility births in the JSY programme is an important reason for this paradox.[7],[8]

Infection prevention and control (IPC) is an important aspect of quality of care and can have a major impact on the outcomes of care. Despite facility-based delivery, poor (IPC) practices lead to infection, which can, in turn, lead to mortality and morbidity among mothers and neonates. IPC in the JSY facilities has not been studied. We report findings from an assessment of IPC practices using a standardised assessment tool at five facilities in high maternal mortality areas of India.


  Methods Top


Study settings

This study was conducted in public facilities in two of the high-focus states ‒ Odisha in Northeast India and Rajasthan in Western India. Both the states registered a high uptake of the JSY programme.[8],[9] In these states, the public sector is the major provider of obstetric services, the private sector being small in size, located in urban areas and unaffordable to the majority of residents. The public facilities that provide the JSY scheme are primary health centres and their sub-centres, which provide basic physician and nurse midwife services, and community health centres (CHC), which provide specialist services and obstetric referrals when needed to district hospitals (DH), which provide specialist and emergency services. Services in all of these public facilities are free of cost or highly subsidised.

The JSY is a flagship programme started in the year 2005 under a health system reform initiative – the National Rural Health Mission launched in the year 2005 and continued under the subsequent National Health Mission.[5] The JSY focussed on states with poorer health and development indicators. The JSY pays a monetary incentive to women delivering at public or accredited private health facilities, irrespective of economic class and parity.

Study facilities and data collection

This pilot study was conducted at five facilities in the two states. The sites were selected by the state's United Nations Children's Fund office. We included one CHC, two subdivisions and two DHs. Permission to conduct the survey at each facility was provided by the facility director. The results of the assessment were summarised at the facility level. In each facility, the nurse manager and physician in charge were present during the assessment. The assessment was undertaken by co-authors (VM and NS) on 2 consecutive days in each of the two states during the normal working hours.

We surveyed facilities using the infection control assessment tool (ICAT). The ICAT was developed and field tested to assess health-care IPC programmes and practices in low-resource settings.[10],[11] The ICAT consists of 22 modules, each focuses on a topic or specific service area, used to conduct a comprehensive assessment IPC activities in health-care facilities. The purpose behind the modular structure is to allow users to tailor the assessment to specific local needs. In this case, we were focussed on IPC practices associated with childbirth, so we chose the three ICAT modules most relevant to this topic, including modules for health-care facility information, biomedical waste management and labour and delivery rooms [Table 1]. The surveyors (VM and NS) have previous experience using the ICAT in a variety of settings.[12]
Table 1: Modules and sections of Infection Control Assessment Tool modules that were used for assessment

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Each module consists of a standardised questionnaire with several sections and point values ranging from 0 to 3 assigned to each answer choice. Response formats include multiple choices or an observation checklist. The scoring allocated to each section was calculated by adding up the total points for the selected answers in the section and has been previously described.[12] The total assessment score for the module was the sum of each section, converted into a percentage by dividing by the total possible score for the module. The overall quality of those practices assessed in each section was as follows: A – excellent practices in this area (75%–100% of the possible total score); B – good practices in this area, (from 50% to 75% of the possible total score) and C – poor practices needing immediate attention (<50% of the possible total score).


  Results Top


Modules for the general hospital facility (H1–H5) information were conducted in three of the five participating facilities where information was available. Facility information was available in three health-care facilities (two in the state of Rajasthan and one in Odisha). The mean score for hospital facility was 36% (27%–46%) in the C category, which denotes poor practice in this area needing immediate attention. Water supply scored the lowest across 20% at three sites, as they had no purification of water prior to arrival to the facility and had no additional treatment of water such as chlorination or boiling. Two hospital sites (H1 and H5) were using municipal water, whereas one site (H2) was using bore well water. General ward facilities' mean score was 83% (between 50% and 100%) in the A category.

Biomedical waste management modules were evaluated at two sites H1 and H5, one in each state of Rajasthan and Odisha, and each of these sites scored between 10% and 47% both in the C category. Adherence to policies regarding the waste management scored 25%–50% in the C category. Neither site had written policies nor did procedures regarding waste management, and site's staff had only partial awareness of the biomedical waste management. In terms of segregation of contaminated Waste, these sites scored 11 - 22% at the H1 through H5 sites, in the C category. H1 site did not store infectious/ contaminated separately from routine waste. With regards to waste disposal, H1 received no credit (score zero) where as H5 received a score of 83% in the A category. At H1, non-infectious waste were disposed of on-site, contaminated solid waste was also usually disposed of on-site, contaminated solid waste dump or open landfill or contaminated solid waste were usually buried, incineration of contaminated solid waste usually occurred in open air, contaminated untreated liquid waste disposed of in drains and contaminated materials such as laboratory specimens, blood clots and placenta steam/pressure were not sterilised (autoclaved) before disposal. The H5 site achieved the aforementioned criteria with the exception for contaminated materials such as laboratory specimens, blood clots or placenta not being steam/pressure sterilised (autoclaved) before disposal.

Labour and delivery modules were evaluated at all five sites (H1–H5) with 10 sections [Table 2]. All the sites had dedicated labour rooms, and for all the modules, the mean score was <50% (22%–47%) in the C category. On general issues, staff education and labour and service design, across the sites, the mean score was 30% (25%–50%) in the category C. All sites lacked participation in education programmes specific to IPC practices at labour and delivery. There were no written policies and procedures for general hygiene practices and cleaning, and a score of 0% was given for this. Gloves were used for 75%–100% of the vaginal deliveries and were always worn for antepartum and post-partum vaginal examinations. However, gloves were not consistently changed between patients. Sterile gloves were always (100%) being used for C sections and changed between patients. Scrub for vaginal deliveries received a mean score of 16% (0%–33%); one site had no running water to scrub. Barriers worn for vaginal deliveries had a mean score of 26% (11%–44%).
Table 2: Assessment scores for infection prevention activities during labour and delivery process in different hospitals in Rajasthan and Odisha

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Doctor/nurse/midwife wore apron during the delivery, and one site (H5) was reusing gowns due to lack of supply and received a score of 0. The use of invasive devices received a mean score of 52% (20%–80%). Labour and delivery procedures received a mean score of 34% (18%–45%). Across the sites, suction devices were routinely used for cleaning of the nasopharynx or meconium; however, these devices were not always changed between the babies. There were insufficient numbers of delivery kits available for vaginal deliveries. Newborn's eyes were not treated after birth to prevent gonococcal infection. All the sites were performing one or fewer vaginal examinations during Stage 2 labour, consistent with best practices.

Prophylactic antibiotics were used with a mean score of 67% (33% at one site 100% at four sites) for normal delivery and that was inappropriate [Figure 1]. Different groups of antibiotics were being used among the similar category of patients even within a single health-care organisation. The antibiotic combination included a narrow spectrum such as cephalexin to broad-spectrum antibiotics such as carbapenem. Antimicrobials were used due to lack of hygiene and sanitation in delivery rooms per managers on site. Sites were aware of the appropriate use of prophylactic antibiotic use for caesarean (C) section deliveries. Post-partum care received a mean score of 23% (20%–25%). The mean length of stay was 1–2 days following uncomplicated delivery and 5–7 days' post-C section delivery. Following the study, based on an initial assessment, feedback and recommendations were provided to the stakeholders to enhance safe health-care delivery and ensure supplies for hand hygiene, delivery kits, provisions and utilisation for biomedical waste collection.
Figure 1: Assessment scores for infection prevention activities during labour and delivery process in different hospitals in Rajasthan and Odisha

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  Discussion Top


Our study shows health-care infrastructure that needs improvement to provide quality of care for the pregnant women in two high-focussed states in India. With increased in-facility delivery in these states of Rajasthan and Odisha, health-care providers were delivering many poor women who otherwise were unable to access the health care with the launch of the JSY. Core components of IPC practice recommended by the World Health Organisation (WHO) were not being fully performed at our pilot study sites.[13] Compliance with hand hygiene was poor at many sites. Delivery rooms at our sites, sometimes, did not have running water or waterless gel dispensers which further inhibited adherence to IPC practices, thereby increasing the risk of acquisition of healthcare-associated infections (HAIs). Lack of hygiene, which included contaminated hands, soiled clothing and improper use of barrier precaution such as gowns or eyewear all, can contribute to the spread of infectious agents to other patients and health-care workers. Improper disposal of the biomedical waste management was another area of concern indicated lack of basic IPC core component. In addition, while all the staff were aware that there are biomedical waste guidelines, the guidelines were not clear to the ancillary staff.[14],[15]

Another area of concern was inappropriate use of prophylactic antibiotic for normal delivery use to compensate for poor implementation of IPC practices. In LMICs, the misuse of antibiotics is contributing to a high prevalence of antimicrobial resistant organisms.[16] Multidrug-resistant Gram-negative rods are emerging as a major challenge in neonates and young infants in India.[17],[18],[19]Klebsiella pneumoniae, Acinetobacter species, Pseudomonas aeruginosa and  Escherichia More Details coli have high degrees of antimicrobial resistance and are associated with high mortality and morbidity due to the scarcity of effective antibiotics. These factors hinder the achievement of the goal of JSY in reducing maternal and neonatal mortality. This requires an urgent call for action of the government in LMIC to ensure implementation of core IPC practices in health-care facilities, as the bacteria are becoming resistant to last-resort antibiotics. This step will be in line with the WHO's recent decision, emphasising an urgent need for addressing the growing prevalence of the antimicrobial resistant organisms.[20],[21]

The government of India has come up with the standards for labour rooms and deliveries.[22] These guidelines help standardisation of space and layout of labour and delivery room complexes. It also provides insights into the recommended items for labour room complexes and guides through the maintenance of centralised sterile supplies department. These can be adopted by many states to improve their infrastructure and patient flow processes. The four pillars of patient safety, namely health-care-associated IPC, surgical safety, medication safety and patient communication, are needed to be implemented to improve maternal and neonatal outcomes.[23]

The National Accreditation Board for healthcare and health-care organisation and Delhi State Health Mission has come up with hospital infection control guidelines, which can help contain the HAIs in these areas of healthcare units.[24],[25] Adoption in various states of such guidelines with appropriate training and monitoring system can help improving outcomes of hospital deliveries and newborn care. Labour room quality initiative has been launched by the Nation Health Mission, Ministry of Health and Family welfare, The government of India is another effort through which checklist for labour room and operation theatre has been provided along with the recommended minimum human resource for labour rooms.[26] It also provides guidance towards promoting respectful maternity care and cognitive development of the baby.

The limitations of the study include the ICAT measured the process of healthcare in delivery rooms at pilot sites and identified potential targeted areas for reducing the risk of HAI in patients; however, the outcomes for patients in the labour rooms were not measured. Our finding from this study is similar to IPC practices observed in another state in a government-funded hospital using the ICAT modules for the surgical module, antibiotic use, surgical equipment procedures, surgical area practices, sterilisation and disinfection of equipment and hand hygiene.[12] The study was conducted in the year 2012; the findings from our studies support capacity building for health-care professionals specifically trained in implementing IPC practices and major investment in IPC infrastructure in LMIC, especially in government-funded health-care facilities. IPC practices should be used for each patient, each time the health care is rendered. Although many guidelines and policy documents have been prepared from the study being conducted, the extent of implementation of these policies and guidelines remains to be seen.


  Conclusions Top


Our study reveals that basic core components of IPC practices were not being fully implemented for safe delivery of babies. Antibiotics were being used inappropriately for normal delivery. A robust IPC programme and antimicrobial stewardship programme should be implemented in labour and delivery rooms.

Acknowledgements

We are grateful to all the study sites that welcomed us and shared their experiences in health-care delivery process.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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