| Quality of Primary Health Centers: ✓ Areas Improving X Areas Resistant/Slower to Change | Success Factors | Challenges |
|---|---|---|
| Clinical Practices | ||
| ✓ Better understanding and use of AMTSL ✓ Diminished use of labor augmentation ✓ Routine administration of vitamin K ✓ Use of radiant warmers for low birth weight newborns ✓ Better understanding of how to handle complications such as newborn resuscitation and postpartum hemorrhage X Postnatal check-ups at 15-minute intervals difficult to comply with X Objections by MOs who were not updated with latest clinical guidelines | • Rapport and trust between nurse mentors and staff nurses • Strengthening of nurses’ clinical skills through demonstrations, bedside teaching, case sheet reviews, and case studies | • High-volume PHCs require more support than low- or moderate-volume facilities • More difficult for mentors to engage with busy staff nurses • Cultural practices that undermine provision of comprehensive care (e.g., arriving in advanced stages of labor, discharge before 48 hours) |
| Availability of Equipment, Drugs, and Supplies | ||
| ✓ Procurement of needed equipment, drugs, and supplies ✓ Creation of MNCH complication kits ✓ Replacement of damaged equipment ✓ Increased availability of drugs and supplies X Deficiencies in basic infrastructure harder to address | • Quality improvement processes and tools, including team-based assessment and action plans • Access to government untied funds to procure needed supplies | • Absent or inadequate PHC (MO) leadership support discouraged teamwork in a small number of facilities |
| Referral Processes | ||
| ✓ Improved appropriate identification and pre-referral management ✓ PHCs posted referral directories ✓ Nurses called referral facilities in advance more often ✓ Nurses increasingly tracked referral outcomes X Automatic referral without prior assessment continued in some instances | • Use of case sheets to identify complications requiring referral • Case reviews and mentor reinforcement of referral guidelines | • Understaffed facilities and overworked staff find it hard to perform complete pre-referral management • Inadequate referral facilities • Patient and family member resistance to referral |
| Infection Prevention | ||
| ✓ Improved sterilization practices ✓ Greater cleanliness in labor rooms X Overall facility cleanliness still deficient X Deficiencies in basic infrastructure (water, toilets) | • Mentor reinforcement of infection prevention • Demonstration of infection prevention practices with all nurses and cleaners | • Cleaning staff resistant to changing practices • Long time needed to change ingrained attitudes and practices |
Abbreviations: AMTSL, active management of the third stage of labor; MNCH, maternal, newborn, and child health; MO, medical officer; PHC, primary health center.