WASH and CLEAN on the Labour Ward: A Situation Analysis in India & Bangladesh

1. WASH and CLEAN on the Labour Ward: A Situation Analysis in India & Bangladesh Team India Prof D V Mavalankar Prof K Vora Prof D Saxena

2. Latest SRS reports cites….. • MMR in India around 200 per 100,000 LB • Gujarat MMR about 142/100,000LB • Documented Increased use of health facilities • Institutional deliveries reduce the risks of infections but there are poor infection control practices in labour and delivery units , that can cause puerperal sepsis and other infections of childbirth.

3. Descriptive review from India shows that • Puerperal sepsis second most common cause after hemorrhage, accounting for approximately 15% of all maternal deaths. • Hemorrhage can also have infection as an underlying contributory factor . • Studies from northern India reveals sepsis responsible for over 35% of maternal deaths & leading cause of maternal death, responsible for 41.9% of deaths in Southern India.

4. Global evidences shows ….. • Robust evidence-based links between poor hygiene practices and environment at the time of birth contributing to life-threatening infections in mothers and babies. • Poor WASH and infection control in institutional facilities not only increases the iatrogenic risks to mothers, babies and indeed health care providers, but also impacts on women’s satisfaction with care at the time of birth.

5. To conclude…………………….. Health gain is seriously undermined if health facilities do not have capacity to cope with increased demand, in terms of trained healthcare workforce and physical environment including WASH , this can inevitably lead to an increase in infection-related morbidity and mortality. Misuse of antibiotics, particularly around childbirth, can also lead to significant drug resistance that can increase the healthcare costs.

6. Objectives 1 Situation analysis of the determinants, processes and effectiveness of cleaning practices on labour wards/ maternity units in India and Bangladesh

7. Objectives 2 Understand how the underlying determinants – both the contextual drivers, such as WASH, and those relating to individual actors can influence cleaning practice and drive cleanliness and safety of the birth environment and identify effective, acceptable and sustainable interventions in the longer-term.

8. Conceptual framework

9. Methodology Multi Site Study Gujarat State, India, and in Mymensingh District and Dhaka City, Bangladesh Project involves developing and pilot testing tools for capturing levels of cleanliness objectively and the determinants (structures), processes and outcomes of cleaning of the labor ward.

10. Methodology ……… • Application of tools to a small stratified sample of maternity units to the test determinants of WASH in terms of • Infrastructure, management, supervision and cleaning resources, • Individual drivers such as social norms (the structures), the cleaning practices in terms of who cleans what and how (the processes), • Effectiveness as measured satisfaction and acceptability of user and provider in terms of visual cleanliness, and • by basic microbiological assessment in terms of safety of the healthcare environment (the outcomes).

11. Three phases to current project 1. Formative : develop a “toolbox” to capture objectively levels of cleanliness and to reveal key determinants 2. Situation analysis : to apply toolbox to 8-12 maternity units in Gujarat State, and 10 units in Mymensingh District & Dhaka city in Bangladesh 3. Synthesis & communication : to revise toolbox & share findings (& prepare proposal for improvement intervention)

12. Methodology ………. • Mixed-methods approach, combining qualitative and quantitative • Formative phase - focused on 2 maternity units • Refinement of the conceptual framework • Stakeholder analysis • Development of photo methodology-Photovoice • Development of the processes and protocols • Focus group discussions with stakeholders • Qualitative assessment of key parameters of healthcare environment • Convening of synthesis workshop • Microbiology sample collection & culture

13. Photo Elicitation technique ………… • An innovative method have not been used previously in connection with healthcare environments including WASH. • Photo-elicitation asks participants to react to photographic prompts-generating discussion, debate, and insights not gained through more traditional “direct questioning” methods of data collection. • Furthermore, engaging participants in the photo-elicitation method has been found to have an impact in terms of empowerment and education, suggesting its relevance to future intervention work

14. Modules already designed for implementation …. • Head of Hospital Interviews • FGD (or interviews) with other relevant managers • Facility Document Capture & Review • Facility Questionnaire • Checklist/ Walk Through micro-biology and photography during walk-through by research associate • Participatory Photography Workshops – Cleaners/ Providers • Semi-structured, photo-prompted interviews or FGDs – Cleaners/ Healthcare Providers • Interviews/ FGD with women users Permission from State & IEC granted

15. Situation analysis • After formative phase and tool development • 8-12 maternity units will be included for situational analysis in Gujarat using tools developed during formative phase • Synthesis and communication of findings: • to revise toolbox & share findings (& prepare proposal for improvement intervention)

16. Proposed outcome of project • Findings of the study will be shared with stakeholders including government to help improving cleaning practices and infection control in labor rooms • Findings will also assist in better understanding of infection control in labour rooms and general cleanliness of hospitals. • Sample collection and culture of basic microbial samples can provide useful evidence to support the need for action and subsequently can be used to evaluate improvement interventions. • The study will explore the innovative method photo-elicitation in area of Public Health.

17. References: Hogan MC, Foreman KJ, Naghavi M, Ahn S, Wang J, Makela SM, Lopez AD, Lozano R, Murray CJL: Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010, 375:1609-1623.  PubMed Abstract | Publisher Full Text Kumar R, Sharma AK, Barik S, Kumar V: Maternal mortality inquiry in a rural community of north India.International Journal of Gynecology and Obstetrics 1989, 29:313-9. PubMed Abstract |Publisher Full Text Kausar R: Maternal Mortality in India - Magnitude, Causes and Concerns.Indian Journal for the Practising Doctor 2005, 2:2.  Anandalakshmy PN, Buckshee K: Maternal mortality in a referral hospital in northern India: a sixteen year review. Journal of Family Welfare 1997, 43:1-4.  Rajaram P, Agrawal A, Swain S: Determinants of maternal mortality: a hospital-based study from south India. Indian Journal of Maternal and Child Health 1995, 6:7- PubMed Abstract Special Bulletin on Maternal Mortality in India 2009-11

18. THANKS