Logistical, cultural, and structural barriers to immediate neonatal care and neonatal resuscitation in Bihar, India

Abstract

BackgroundIn India, the neonatal mortality rate is nearly double the Sustainable Development Goal target with more than half of neonatal deaths occurring in only four states, one of which is Bihar. Evaluations of immediate neonatal care and neonatal resuscitation skills in Bihar have demonstrated a need for significant improvement. However, barriers to evidence based practices in clinical care remain incompletely characterized.MethodsTo better understand such barriers, semi-structured interviews were conducted with 18 nurses who participated as mentors in the AMANAT maternal and child health quality improvement project, implemented by CARE India and the Government of Bihar. Nurse-mentors worked in primary health centers throughout Bihar facilitating PRONTO International emergency obstetric and neonatal simulations for nurse-mentees in addition to providing direct supervision of clinical care. Interviews focused on mentors’ perceptions of barriers to evidence based practices in immediate neonatal care and neonatal resuscitation faced by mentees employed at Bihar’s rural primary health centers. Data was analyzed using the thematic content approach.ResultsMentors identified numerous interacting logistical, cultural, and structural barriers to care. Logistical barriers included poor facility layout, supply issues, human resource shortages, and problems with the local referral system. Cultural barriers included norms such as male infant preference, traditional clinical practices, hierarchy in the labor room, and interpersonal relations amongst staff as well as with patients’ relatives. Poverty was described as an overarching structural barrier.ConclusionInteracting logistical, cultural and structural barriers affect all aspects of immediate neonatal care and resuscitation in Bihar. These barriers must be addressed in any intervention focused on improving providers’ clinical skills. Strategic local partnerships are vital to addressing such barriers and to contextualizing skills-based trainings developed in Western contexts to achieve the desired impact of reducing neonatal mortality.

Assessment of Maternal Referral Systems in Dr. Sardjito General Hospital Using Phyo Referral Score: A Single-Center Preliminary Study

“…Comprehensive literature review was conducted to find variables or factors which affect maternal health referral system. Several factors were included in this instrument such as age, geographical access, indication for referral, referral staff, initial procedure/treatment prior referral, communication, transportation vehicle, insurance coverage, and distance for referral [4,5,6,7,8] Below was an instrument that we have already formulated entitled Phyo Referral Score (PRS) ( Table 1).…”

“…There are several important factors affecting the quality of referral system such as staff, protocols, transportation, communication, and geographical access/distance [4,5,6,7] that need to be concerned by the stakeholders which involved in the maternal and child health program. By evaluating the quality of referrals it can be found which factors that were not working optimally and could be considered for maternal and perinatal audit.…”

Successes, Challenges and Opportunities Towards Universal Health Coverage for Maternal and Child Health in South East Asian Countries: A Systematic Review

“…The main reason was the lack of recognition that a large proportion of maternal morbidity and mortality occurs in the postpartum period 39 . Another study revealed that cultural barriers include cultural norms such as preference over male infant and traditional clinical practices delays maternal care seeking among Indian women 38 .…”

“…Perceived low-quality services are barriers for delivery and postpartum care access for rural Indian and Nepal women 20,39,44,45 . Financial constrains due to poverty was detected as an overarching structural barrier for access 38,39,46 .…”

“…When considering the quality of MCH care, facility readiness was detected as poor for emergency obstetric care and newborn care in public and private health facilities including primary care facilities both rural and urban areas in India, Nepal and Bangladesh 21,31,47,56 . Several studies detected inadequate infrastructure leads to poor quality in maternal and child care including family planning services in the region 12,[22][23][24]26,28,38,45,51,52,56,60,65,73 . In addition to those problems, irregular supply of water and electricity, lessfunctioning of blood bank 12 , inadequate laboratory facilities 12,56,61 were detected as challenges.…”